Helen H. Moore's Blog, page 61

“Visualizing Disease” is an illuminating history of how we started to see medicine

AP Photo/Elaine Thompson, file

This article originally appeared on Massive

Leo Tolstoy famously wrote that “All happy families are alike; each unhappy family is unhappy in its own way.” According to the science historian Domenico Bertoloni Meli, the same can be said of disease. A human body in good health has its quirks – a long nose, a crooked thumb – but these are mere noise, variants around a mean. Disease, on the other hand, is the disruption of an ideal: a gnarled tumor blossoms over a bone; skin erupts in a patchwork of sores as turbulent as a dry riverbed.

Meli’s new book, "Visualizing Diseases" (out in January), guides readers on a tour of the art and science of illustrating human pathology that spans several hundred years. At its core is the premise that the practices of rendering healthy and sick bodies evolved separately. This occurred not only thanks to technical constraints that made it challenging to effectively depict pathology (imagine trying to convey skin disease before color printing), but because physicians didn’t always think these images had practical value. From our modern vantage point, where medical imaging technologies like fMRI, CT scans, and X-rays are a standard part of patient care, it’s curious to imagine an age when pinpointing the seat of a malady — a tumor, a lesion, or hardening of tissue — had little relevance to treatment.

I remember a protracted experience I had with doctors when I was a teenager, trying to identify the cause of a mysterious fatigue. Nothing ever surfaced in the numerous tests and scans I had. Soon I became afraid that the absence of a lesion implied I was fabricating the symptoms. Seeing disease has the power to validate it, and ever since my experience growing up, I’ve come to feel a slight relief when receiving an abnormal test result from a nurse. Ah, there really was something there. What I wanted to know, and what I wish this book had taken more time to discuss, was how the existence of illustrations of disease changed the practice of medicine. Did a picture of a diseased lung ever evoke pity, or understanding, that sicknesses could lie unseen and blameless beneath the skin?

Indeed, the prevalent theory of the Middle Ages, that imbalanced humors gave rise to sickness, left little room for organs and yet-undiscovered cells in the model of health. Furthermore, Meli argues convincingly, pre-Enlightenment physicians may not have appreciated how destructive structural changes inside the body, such as lesions and organ cancers, could be because they seldom operated on patients. For centuries, he explains, surgeons and physicians belonged to separate guilds, hardly intersecting in their day-to-day practice or cross-pollinating with their hard-won perspectives.

One of the book’s strengths is that it impresses upon the reader how the state of technology, both scientific and artistic, perpetually guided the nascent field of pathological illustration. Like so much else, the story of anatomical illustration is one of economy as well as medicine: to produce a folio of images, there needed to be printers, engravers, artists, a hospital or government institution to provide access to bodies, and of course, a medical professional.

Bone diseases were among the very first pathological illustrations, and Meli proposes that’s both because bones were the easiest body part to preserve and collect (which some physicians did by the hundred, gathering enough to make private museums in their homes), and because bones could be clearly represented before the advent of color printing. Internal organs could not be satisfactorily rendered until printing had sufficiently advanced to allow cost-effective coloring, and even then, their development was hindered by the difficulty of keeping an organ around long enough to draw: among the most enjoyable moments in the book are when Meli remarks that artists would sometimes be called at odd hours to attend an autopsy, or might be delivered a liver at random.

It’s both a testament to the author’s eye for detail, and a challenge for a non-specialized reader like myself, that this work reads like a doctoral thesis. Meli’s survey takes place almost exclusively in European epicenters of medicine such as Leiden, London, and Paris, taking a magnifying glass to the practitioners and artists who gave Western pathology its foundational pictures. The cast of characters is long, and the book functions as an encyclopedia of the working lives and academic lineages of these men (and it is only men).

While the scope of this work must be appreciated – I can only imagine the labor it took to compile this biographical information – it is dry and has long stretches of text that read like records more than a narrative. Although the book is beautifully printed, with an inviting cover bearing accolades about the accessibility of the story, I struggled to identify who outside of medical historians would find this book so accommodating. Frequently, Meli references diseases by their historical names (like phthisis and fungus haematodes) without explaining their modern translations or welcoming the unacquainted reader with descriptions. The work is a worthy contribution to the history of medicine, but Meli takes few pains to initiate the layman.

What I craved most from "Visualizing Disease," and what I was disappointed not to find, is a connection with the pathological illustrations themselves. Many of the prints left me in want of a story, most of all a post-mortem drawing of a man with the skin of his abdomen and neck peeled away to reveal an abundance of small tumors, like fleshy barnacles on his organs. He looks like he is sleeping peacefully, with this window cut out to peer inside, and then I realize that those pale little nodules are the very thing that choked out his life. For a book of its size, the images receive sparingly little discussion or explanation of their content. Their powers are never fully invoked, leaving it to the reader to forge a distant kinship with these long-ago wounded bodies.

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Comsat launch bolsters China’s dreams for landing on the Moon’s far side

Getty/Giuseppe Cacace

This article was originally published by Scientific American

The latest phase of China’s bid to become a dominant space power is underway as the nation’s new robotic mission hurtles toward an orbit overlooking the far side of the moon. The relay satellite Queqiao, or “Magpie Bridge” — a reference to Chinese folklore — departed Earth atop a Long March 4C booster on Monday local time (Sunday evening in North America) from the Xichang Satellite Launch Center. The outbound trip will take a little over a week, although Queqiao will only reach its final orbit two months from now.

The mission will act as a vital link in China’s burgeoning network of robotic spacecraft around and on the moon while also performing novel scientific experiments that could lead to new discoveries in cosmology, astrophysics and astrobiology.

Queqiao will be positioned 40,000 miles (roughly 60,000 kilometers) above the moon’s far side in an orbit that lets it relay signals between Earth and China’s Chang’e 4 farside lander/rover, expected to be lofted in December. Together with Queqiao, two microsatellites — Longjiang 1 and  2, developed by China’s Harbin Institute of Technology — hitched a ride for release into lunar orbit to investigate radio bursts from the sun.

From the lunar far side to cosmic dawn

One of the premier scientific instruments onboard the farside relay spacecraft is the Netherlands–China Low-Frequency Explorer (NCLE), built by a team of Dutch scientists and engineers.

Mounted on the satellite’s chassis, NCLE is the first Dutch-made scientific instrument to be sent on a Chinese space mission, and is the result of a 2016 agreement between the Netherlands Space Office and the China National Space Administration. When the satellite settles into its final orbit months from now, it will wait for Chang’e 4’s arrival at the moon in early 2019. Then NCLE’s three five-meter-long antennas will be rolled out and the scientific work will start.

Built to carry out cutting-edge radio science and astronomy, the radio antennas’ top duty is to precisely measure radio waves originating from the period immediately after the big bang—the so-called “dark age” of the cosmos, when the universe was bereft of stars. Through its studies NCLE could help pinpoint when the dark age ended in a “cosmic dawn,” as the first stars began to shine. “NCLE is a stepping-stone towards a larger radio array in space,” says project leader Albert-Jan Boonstra, an astronomer at ASTRON Netherlands Institute for Radio Astronomy. That array could be “either a radio interferometer on the farside surface of the moon or a slowly drifting constellation of many small satellites.”

A moon garden

All this is a prelude to China’s Chang’e 4 lander/rover mission, expected to be sent moonward by a Long March 3B booster this December. A candidate landing region for Chang’e 4 is the southern floor of Von Kármán, a 180-kilometer-wide crater within the South Pole — Aitken impact basin — the largest of its kind on the moon.

Chang’e 4 will carry a cluster of international payloads from Germany, the Netherlands, Saudi Arabia and Sweden. The lander will also tote a “lunar mini biosphere” experiment, designed by 28 Chinese educational institutions led by Chongqing University. Weighing roughly seven pounds, this experiment will attempt to germinate seeds from potatoes and Arabidopsis, a small flowering plant related to cabbage and mustard. It may additionally include a number of silkworm eggs. The biosphere package also contains water, air and nutrients, which will hopefully allow the seeds and eggs to briefly flourish in their protective capsule on the lunar surface. A tiny camera and data transmission system will allow researchers to see when and if the seeds blossom.

Little steps, big goals

China’s cislunar (the area of space between Earth and its moon) exploration program is designed to be conducted in three phases: The first is simply reaching lunar orbit, a task completed by Chang’e 1 in 2007. The second is landing and roving on the moon, as Chang’e 3 did in 2013. The third is snagging lunar samples and rocketing them back to Earth—a challenging objective meant to be incrementally advanced by Chang’e 4 and two follow-up missions, Chang’e 5 and 6. “China’s launch of the Queqiao relay satellite ushers in a new era of lunar infrastructure that will enable full exploration of the moon, including the poorly known lunar far side,” says James Head, a planetary scientist at Brown University. “Similar to the way in which GPS and communications satellites on the Earth provide an infrastructure for our activities in orbit and on the ground here,” he adds, “the Queqiao relay satellite underlines the robustness of China’s comprehensive plans for lunar exploration, including the upcoming Chang'e 4 farside lander and rover, the Chang'e 5 nearside sample-return mission, and lunar polar exploration beyond.”

Paul Spudis, a planetary scientist at the Lunar and Planetary Institute, views China’s robotic missions as “part of a long-term, sustained effort to establish Chinese cislunar presence.” He suggests the Chinese relay satellite, after first serving its assigned tasks, might later be useful for more speculative and visionary missions.

“In the case of Chang’e 4, after its main mission is complete I would move the relay satellite to a high ‘storage’ orbit and have it become part of a future comsat network,” Spudis says.

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How I used my research skills to help diagnose myself

akindo via iStock

This article originally appeared on Massive

High school ended around 2:30 pm, but field hockey practice didn’t start until 4, so I would go home and nap for an hour. It seemed excessive — I was getting around eight hours of sleep a night — but it was necessary. In college, my schedule became even crazier. I let my night owl tendencies take over, but still slept eight to nine hours a night, sometimes even 12,by avoiding early morning classes. I napped most days, too. If I wanted to get work done in the evening, I had to gamble: Do I nap so I can focus later on? But if I nap, there’s a chance I’ll be too groggy to work.

I was a science major in college, so rather than just keep sleeping, I started to think more critically — more scientifically — about my situation. I tried to study my sleeping patterns to make observations to help me overcome my sleeping issues. But nothing seemed to help. No matter what I tried, I was always exhausted.

I started to research extreme fatigue because if something was wrong with me, I could hopefully get medication and treat the issue. I scoured the internet for diseases related to fatigue, and fact checked each claim with a variety of sources.

In my experience, a lot of scientists approach their own lives and health like this — even the most basic aspects of our lives sometimes get treated like an experiment. And if something is wrong, we take a scientific approach to solving it. I think we do this because our training in science also trains our minds for this kind of thought, which leaks out into our everyday life. Sometimes it just leads to excessive research into the best mattress or haircare product. In this instance, it was my wellbeing.

Doctors are similar to scientists and, in theory, should be doing research for their patients. Unfortunately, some doctors don’t approach patient problems like a scientist but, rather, like cookie-cutter cases. Whether this is because of lack of time, inherent problems in the medical system, or even a lack of proper scientific training, the upshot is that health is heavily dependent on personal experience. My background serves me well in this respect, but most people aren’t trained research scientists.

At the start of my search, the first obvious result that came up was hypothyroidism. I did experience a lot of the symptoms: increased sensitivity to cold, dry skin, hair loss, a terrible memory. But I didn’t have the hallmark side effect of the disease — issues with weight gain. Chronic fatigue syndrome seemed like a possibility, but what did that really mean? It’s a diagnosis by exclusion, and nothing had been excluded. I tried to avoid the WebMD catch-all answer of cancer. I wasn’t depressed. I didn’t have anxiety. My mom had been recently diagnosed with fibromyalgia, but that didn’t seem like my problem. I did test low for hemoglobin when donating blood, so maybe I was anemic? Nothing really seemed to make sense. No condition associated with fatigue seemed to hold up as a valid hypothesis. However, no disease presents all the common signs or symptoms.

The summer before graduate school, nearly six years after I started having fatigue symptoms, I went a primary care physician to get tested. My thyroid-stimulating hormone levels (TSH) were above the normal range. If you have too much TSH in your blood, it’s an indicator of hypothyroidism. The range is debated and likely dependent on the individual. The doctor did not want to prescribe me medication until I started gaining excess weight. I wasn’t satisfied. If I had clinical indications of disease with life-affecting symptoms, I thought medication should at least be an option. At the time, I let it go. I wasn’t sure if I was right. I mean, I wasn’t the expert.

Nondiagnosis, over-diagnosis, self-diagnosis

Shortly after, I moved away to start graduate school. In my first two months, I ended up making two trips to urgent care for kidney stones. I spent a lot of time there on an IV to increase my fluids. It was slow day and I started complaining to the doctor, concerned with my persistent need to nap and how this might affect me in graduate school. She was incredulous about the fact that I was denied medication; she tested me to be sure and then immediately prescribed some.

The downside about medication for hypothyroidism is it takes a while to kick in. But about two months later I had this ah-ha moment: I wasn’t napping everyday. In fact, I hadn’t napped at all week!

A few years later, I started to run into the opposite problem. I wasn’t sleeping. I had trouble falling asleep, staying asleep, and getting restful sleep. Over the period of a year, I worked with my doctors to adjust my medication dosage and even try a new one, but this only helped somewhat.

Again, I did a little light research into the problem. I can’t remember how I came across the subject, but I ended up down a rabbit hole on vitamin D deficiency. There are many, many, many studies on the health impacts of vitamin D deficiency. A few of these overlapped with symptoms of thyroid disorders, particularly sleep quality. Skipping the doctor altogether, I looked into the amount of vitamin D that can be consumed regularly without risking overdosing, then started taking supplements regularly. Within a month, I noticed I was waking up less and less restless in the middle of the night and feeling more rested.

This approach to self-diagnosis has personally served me well; I frequently take a scientific approach to most aspects of my life. Albeit, that isn’t always the best option. Pro tip: Not every friendship or relationship problem is best approached analytically. Presenting a “research” proposal to your husband on why you should get more plants even though there is no more space in your apartment, is probably not a good idea. Hey, they’re good for you! NASA says so.

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Why medicine leads the professions in suicide, and what we can do about it

hikrcn/Shutterstock

This article was originally published on The Conversation.

Earlier this month, one of us visited a prominent U.S. medical school to give a lecture on the topic of burnout and how physicians can find more fulfillment in the practice of medicine. Sadly, that very day, a fourth-year medical student there took her own life.

The problem was not personal failure. She had recently matched into a competitive residency program at the one of the nation’s most prestigious hospitals. Yet apparently, she still found the prospect of the life ahead more than she could bear.

This is hardly an isolated incident. A study reported earlier this month at the annual meeting of the American Psychiatric Association revealed that among U.S. professionals, physicians have the highest suicide rate. According to the researchers, the suicide rate in medicine is more than twice that of the general population, resulting in at least one physician suicide per day in the U.S. In fact, the actual number is probably higher, as the stigma of suicide results in underreporting.

The news gets even worse. There is good reason to think that when it comes to distress among physicians, suicide is only a particularly noticeable indicator of a much larger problem. For every physician who attempts suicide, many others are struggling with burnout and depression. One recent survey found that 42 percent of U.S. physicians are burned out, with rates of 38 percent among men and 48 percent among women. Such distress manifests in other ways, such as alcoholism, substance abuse and poor patient care.

High stress, but high rewards

From one point of view, these findings are not surprising. Medicine has long been recognized as a stressful profession, characterized by competitiveness, long hours and lack of sleep. Many physicians work each day with the knowledge that a mistake could lead to the death of a patient, as well as the frustration that, despite their best efforts, some patients will elect not to comply with medical recommendations and others, despite doing so, will still get sicker and die.

And yet physicians seem to have much to be grateful for. Compared to Americans in other lines of work, they are highly educated and well compensated. They enjoy a relatively high level of respect and trust. And their work provides them with regular opportunities to make a difference in the lives of patients, families and communities. They are privileged to care for human beings in some of their most memorable moments, such as in birth and death, and they may occasionally save someone’s life.

Test pilots

Why then might suicide rates among physicians be so high?

While there are undoubtedly many factors, ranging from problems in the health care system to individual circumstances, the recent death of novelist Tom Wolfe at age 88 has inspired us to look at the problem from a different perspective. The author of numerous works of both fiction and nonfiction, Wolfe’s best-selling book was 1979’s “The Right Stuff,” which chronicled the early days of the U.S. space program.

Chuck Yeager in the cockpit of an NF-104 on Dec. 4, 1963.

U.S. Air Force Photo

“The Right Stuff” is populated by two very different sets of heroes. First there are the test pilots, represented by Chuck Yeager, a former flying ace who in 1947 became the first person to break the sound barrier during level flight in his X-1 rocket-powered jet.

By Wolfe’s account, the test pilots were men of daring who regularly pushed the limits of human flight, placing themselves in hazardous situations where failure to respond to problems in a split-second could result in mission failure and even death. In his introduction to the 1983 edition, Wolfe reports a pilot mortality rate of 23 percent. During the 1950s, this translated into about one death per week.

Yet morale and camaraderie among the test pilots were high. They believed that they were promoting patriotism, expanding the human capacity for exploration, and bravely breaking what were thought to be unbreakable human limits. Said Yeager, “What good does it do to be afraid? It doesn’t help anything. You better try and figure out what is happening and correct it.”

Astronauts

Through no choice of their own, the later Mercury astronauts were a very different breed, Wolfe found. Though many had experience as both combat and test pilots, their role in space exploration would resemble that of passengers more than pilots. For example, they were selected based less on their bravery, judgment or skill than on their ability to withstand a battery of grueling and sometimes humiliating tests that included nausea-inducing centrifuge rides and castor-oil enemas.

Mercury 7 astronauts, including John Glenn, second from left, examine what NASA called their ‘couches,’ or their seats that had been molded to fit plaster casts of their bodies.

In other words, the astronauts functioned less as test pilots than test subjects. The work of piloting the flights would largely be done by computers and ground control, and the astronauts’ role was largely to endure them. When it came to the design of the Mercury capsule, they had to fight for a window through which they could see where they were going, a hatch that they could open from the inside, and even minimal manual control over the rocket.

The astronauts and their families were revered by the American public, who marveled at the courage it took to ride a rocket into the unknown, but it was not enough for the men themselves. They longed to do something. In “The Right Stuff,” Yeager captures much of their frustration when he turns away from the project saying, “Anyone who goes up in that damn thing is going to be spam in a can.”

Physicians: Test pilots or astronauts?

The contrast between pilots and astronauts captures nicely some of the disappointments and frustrations facing U.S. physicians. Having entered medicine believing that their own knowledge, compassion and experience would help make the difference between health and illness and even life and death for their patients, they have found themselves inhabiting a very different reality, one that often leaves them feeling more like passengers than pilots.

Consider how physician performance is assessed. In the past, physicians sank or swam based on their professional reputations. Today, by contrast, the work of physicians tends to be evaluated by the quality of their documentation, their compliance with policies and procedures, the degree to which their clinical decision-making conforms to prescribed guidelines, and satisfaction scores. Over the past few decades, the physician has become less of a decision-maker and more of a decision implementer.

Why is this discouraging? Just as only the test pilot knows what is happening in the cockpit from second to second, a physician is often the only health professional who gets to know patients as people, including each one’s particular needs and concerns. Being assessed by metrics promulgated by economists, policymakers and health care executives who have never met the patient gives the practice of medicine a hollow feel.

Most physicians don’t want to be astronauts, hurtling uncontrollably into a health care future they cannot see. Instead they want to be pilots – professionals who exemplify why having eyes and ears on the patient is far more important than mastering a computer system or billing code. They don’t want to be astronauts, stuck in a can that dictates their every move and provides no opportunity to make the kind of difference for patients that generates personal challenge and growth.

The situation is summed up nicely by a crayon drawing by a six-year-old patient we saw recently. Entitled, “My Visit to the Doctor,” it depicts a young patient seated on an examination table, facing the doctor. The doctor, however, is across the room at a desk, facing away from the patient, bent down over a computer into which he is entering data. The implicit message of this simple image? The computer is more important to the doctor than the patient.

If we want to stem the tide of burnout, depression and suicide in medicine, we need to enable doctors to be good doctors – not mere “health care providers” – and to practice medicine in a way they can be proud of. We must allow and even encourage them not merely to manage health information but to care for human beings. Like the early astronauts, physicians, especially the best among them, cannot thrive if they remain relegated to the role of Ham the Astrochimp, America’s first chimpanzee astronaut.

Richard Gunderman, Chancellor's Professor of Medicine, Liberal Arts, and Philanthropy, Indiana University and Peter Gunderman, First-year Resident at IU Health Ball Memorial Hospital, Indiana University

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When is insurance not really insurance? When you need pricey dental care

AP

This article originally appeared on Kaiser Health News.

I’m 61 years old and a San Francisco homeowner with an academic position at the University of California-Berkeley, which provides me with comprehensive health insurance. Yet, to afford the more than $50,000 in out-of-pocket expenses required for the restorative dental work I’ve needed in the past 20 years, I’ve had to rely on handouts — from my mom.

This was how I learned all about the Great Divide between medicine and dentistry — especially in how treatment is paid for, or mostly not paid for, by insurers. Many Americans with serious dental illness find out the same way: sticker shock.

For millions of Americans — blessed in some measure with good genes and good luck — dental insurance works pretty well, and they don’t think much about it. But people like me learn the hard way that dental insurance isn’t insurance at all — not in the sense of providing significant protection against unexpected or unaffordable costs. My dental coverage from UC-Berkeley, where I have been on the public health and journalism faculties, tops out at $1,500 a year — and that’s considered a decent plan.

Dental policies are more like prepayment plans for a basic level of care. They generally provide full coverage for routine preventive services and charge a small copay for fillings. But coverage is reduced as treatment intensifies. Major work like a crown or a bridge is often covered only at 50 percent; implants generally aren’t covered at all.

In many other countries, medical and dental care likewise are segregated systems. The difference is that prices for major procedures in the U.S. are so high they can be out of reach even for middle-class patients. Some people resort to so-called dental tourism, seeking care in countries like Mexico and Spain. Others obtain reduced-cost care in the U.S. from dental schools or line up for free care at occasional pop-up clinics.

Underlying this “insurance” system in the U.S. is a broader, unstated premise that dental treatment is somehow optional, even a luxury. From a coverage standpoint, it’s as though the mouth is walled off from the rest of the body.

My humbling situation is not about failing to brush or floss, not about cosmetics. My two lower front teeth collapsed just before my 40th birthday. It turned out that, despite regular dental care, I had developed an advanced case of periodontitis — a chronic inflammatory condition in which pockets of bacteria become infected and gradually destroy gum and bone tissue. Almost half of Americans 30 and older suffer from mild to severe forms of it.

My diagnosis was followed by extractions, titanium implants in my jaw, installation of porcelain teeth on the implants, bone grafts, a series of gum surgeries — and that was just the beginning. I’ve since had five more implants, more gum and bone grafts and many, many new crowns installed.

At least I’ve been able to get care. The situation is much worse for people with lower incomes and no family support. Although Medicaid, the state-federal insurer for poor and disabled people, covers children’s dental services, states decide themselves on whether to offer benefits for adults. And many dentists won’t accept patients on Medicaid, child or adult, because they consider the reimbursement rates too low.

The program typically pays as little as half of what they get from patients with private insurance. For example, as Kaiser Health News reported in 2016, Medicaid in Colorado pays $87 for a filling on a back tooth and $435 for a crown, compared with the $150 and $800 that private patients typically pay.

“It’s really a labor of love to do it,” said Dana Lubet, a recently retired dentist in Madison, Wis., who estimated Medicaid paid only a third of his costs. Accepting too many, he said, “could easily kill your practice.”

A few years ago, while in his mid-50s, Nick DiGeronimo, a facility maintenance worker at a New Jersey sports center, obtained private insurance coverage through the Affordable Care Act, hoping to get treatment for progressive tooth decay.

He needed two implants but, to his dismay, the plan did not cover them. To pay the $10,500 bill, he had to take out loans. “Dental insurance is basically useless,” said DiGeronimo. “It’s a sham, a waste of money, and another case of the haves versus the have-nots.”

As for older Americans, many lose employer-based dental coverage when they retire even as they suffer from increasing dental problems. Among those 65 and older, 70 percent have some form of periodontal disease, according to the Centers for Disease Control and Prevention. Yet basic Medicare plans do not include dental coverage, although options exist for seniors to purchase it.

Overall, in 2015, almost 35 percent of American adults of working age did not have dental insurance. By contrast, only about 12 percent of American adults under 65 did not have medical insurance in 2016. That lack of coverage and treatment can diminish economic and social opportunities — for instance, it can be costly at work or in a job interview not to smile because of unsightly or missing teeth.

Eventually, poor prevention and treatment can become a medical problem — leading to serious, and occasionally deadly, health consequences. In an infamous 2007 case — described by Mary Otto in her book “Teeth: The Story of Beauty, Inequality and the Struggle for Oral Health in America” — Deamonte Driver, a 12-year-old boy in Maryland, died after a tooth infection spread to his brain. The family’s Medicaid coverage had lapsed.

Research has demonstrated links between periodontal infections and chronic conditions like diabetes and cardiovascular disease. Studies have found associations between periodontitis and adverse pregnancy outcomes, such as premature labor and low birth weight. Tooth problems also hinder chewing and eating, affecting nutritional status.

The split between the medical and dental professions, however, has deep roots in history and tradition. For centuries, extracting teeth fell to tradesfolk like barbers and blacksmiths — doctors didn’t concern themselves with such bloody surgeries.

In the U.S., the long-standing rift between doctors and dentists was institutionalized in 1840, when the University of Maryland refused to add training in dentistry and oral surgery to its medical school curriculum — leading to the creation of the world’s first dental school.

Dentists have in some ways benefited from the separation — largely escaping the corporate consolidation of American medicine, with many making good livings in smaller practices. Patients often willingly pay out-of-pocket, at least to a point.

Some people deliberately forgo dental coverage, considering it less urgent than having insurance against medical catastrophes. “You might not get a job as hostess at the restaurant, but by the same token people that have a lot of missing teeth live to tell the tales,” Lubet said.

With fluoridation and advances in treatment, many Americans have come to take the health of their teeth for granted and shifted their attention to more cosmetic concerns. And the dental field has profited from the business.

In my experience, which includes extensive travel in other countries, Americans often seem disoriented or even horrified when confronted with imperfect dentition. During my period of intense dental care here, I hated wearing temporaries and often braved the public with missing front teeth. I found myself routinely reassuring people that, yes, I knew about the gap, and yes, I was having it dealt with.

Meanwhile, the bold line between what is covered or what is not often strikes patients as nonsensical.

Last fall, Lewis Nightingale, 68, a retired art director in San Francisco, needed surgery to deal with a benign tumor in the bone near his upper right teeth. The oral surgeon and the ear, nose and throat doctor consulted and agreed the former was best suited to handle the operation, although either one was qualified to do it.

Nightingale’s Medicare plan would have covered a procedure performed by the ear, nose and throat doctor, he said. But it did not cover the surgery in this case because it was done by an oral surgeon — a dental specialist. Nightingale had no dental insurance, so he was stuck with the $3,000 bill.

If only his tumor had placed itself just a few inches away, he thought.

“I said, what if I had nose cancer, or throat cancer?” Nightingale said. “To separate out dental problems from anything else seems arbitrary. I have great medical insurance, so why isn’t my medical insurance covering it?”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Forced to choose between a job — and a community

AP

This article originally appeared on ProPublica.

John Arnett chose Adams County, Ohio, as his home long before he was old enough to vote, drink beer or drive a motorcycle along the Ohio River. After his parents split up, Arnett opted at age 10 to spend most of his time with his grandmother in Adams County, along the river 70 miles southeast of Cincinnati, rather than with his parents in the Dayton area. He liked life on the tobacco farm his grandfather had bought after retiring early from General Motors Co. in Dayton. And his grandmother, who became a widow when her husband died in a tractor accident, welcomed the companionship.

After high school, Arnett joined the U.S. Marine Corps, in 1999. His unit, the 1st Battalion, 7th Marines — the storied Suicide Charley — took him to the other side of the world: South Korea, Japan, Thailand. In the spring of 2003 he was an infantryman in the invasion of Iraq, spending five months in country — Baghdad, Tikrit, Najaf.

Once back in Ohio, he settled in Adams County with his future wife, Crystal, and started taking classes in criminal justice at the University of Cincinnati, figuring he’d follow the well-worn path from the military to law enforcement. One day, though, Crystal alerted him to an ad in the paper for jobs right in Adams County, at the coal-fired power plants down on the river. He jumped at the chance. The Dayton Power & Light Co. plants had been there for years — the larger, 2,400-megawatt J.M. Stuart Station, opened in 1970 as one of the largest in the country, and the 600-megawatt Killen Station followed 12 years later, 14 miles to the east — and weren’t going anywhere: Ohio was getting 80 percent of its electricity from burning coal.

Arnett started out in 2004 making $12 an hour, handling heavy machinery in the yard where the coal was offloaded from barges coming up the river from mines in southern Indiana and Illinois. He soon moved inside the plant, operating the boiler and turbines, and finally became an operator chemist in charge of monitoring water quality, making about $38 per hour. He got active in the union that represented the plants’ 380 hourly employees, Local 175 of the Utility Workers Union of America; eventually he was elected its vice president. He and his wife started a family and in 2009 bought a larger home, a repossessed rancher they got for $130,000, in Manchester, the community nearest to Stuart. Occasionally he still got out for rides on his Harley, but life was taken over by family and youth sports, which was fine with him. He liked how he could call up his sister-in-law to watch his kids on a snow day when he was at the plant and his wife was in classes for her physical therapy degree. He liked how, at high school football games, he could send his 7-year-old off to buy himself a hot dog. “I can look over to the concession stand and I’ll know someone over there,” he said.

In mid-November of 2016, a few days after the election of Donald Trump, the president of Local 175, Greg Adams, called Arnett with news: Dayton Power & Light, which had been bought in 2011 by the global energy company AES Corp., had notified the state that it intended to close Stuart and Killen in June 2018. The plants were by far the largest employer and taxpayer in Adams County, population 28,000, which by one measure of median family income is the poorest county in Ohio. The announcement left the county with just a year and change to figure out how it was going to make do without them.

And it provided just a year and change for Arnett and hundreds of other workers — there were more than 100 management employees and 300 contractors in addition to the 380 union workers — to answer the question being asked in other deindustrializing places all over the country: Stay or go?

It was a hard question to confront, one the workers would be left to answer almost entirely on their own. Ohio was facing more retirements of coal-fired power plants than anywhere else in the country. Yet nobody in government — not in the state, not in Washington — was doing anything to grapple comprehensively with the challenge that Adams County and other areas were facing. It wasn’t just the economy that was leaving so many places behind.

America was built on the idea of picking yourself up and striking out for more promising territory. Ohio itself was settled partly by early New Englanders who quit their rocky farms for more tillable land to the west. Some of these population shifts helped reshape the country: the 1930s migration from the Dust Bowl to California; the Great Migration of blacks to the North and West, which occurred in phases between 1910 and 1960; the Hillbilly Highway migration of Appalachian whites to the industrial Midwest in the 1940s and ‘50s.

In recent years, though, Americans have grown less likely to migrate for opportunity. As recently as the early 1990s, 3 percent of Americans moved across state lines each year, but today the rate is half that. Fewer Americans moved in 2017 than in any year in at least a half-century. This change has caused consternation among economists and pundits, who wonder why Americans, especially those lower on the income scale, lack their ancestors’ get-up-and-go. “Why is this happening?” New York Times columnist David Brooks asked in 2014. His answer: “A big factor here is a loss in self-confidence. It takes faith to move.” Economist Tyler Cowen wrote last year that “poverty and low incomes have flipped from being reasons to move to reasons not to move, a fundamental change from earlier American attitudes.”

The reluctance to move is all the more confounding given how wide the opportunity gap has grown between the country’s most dynamic urban areas and its struggling small cities and towns, a divide driven by a mix of factors that include technology, globalization and economic concentration. According to a new Brookings Institution report, the largest metro areas — those of 1 million or more people — have experienced 16.7 percent employment growth since 2010, and areas with 250,000 to 1 million have seen growth of 11.6 percent, while areas with fewer than 250,000 residents have lagged far, far behind, with only 0.4 percent growth. The question has taken on a stark political dimension, too, given how much Trump outperformed past Republican candidates in those left-behind places.

For policymakers, the low rates of migration to opportunity present a conundrum. Should there be a wholesale effort to revitalize places that have lost their original economic rationale? Or should the emphasis be on making it easier for people in these places to move elsewhere?

The country has a long tradition of place-based investment, most notably the New Deal, which, through the Tennessee Valley Authority and similar grand-scale projects, sought to raise up Appalachia and the South. Yet there’s strikingly little support these days for similar efforts, anywhere on the political spectrum. Kevin Williamson put it most caustically in a March 2016 essay in National Review. “So the gypsum business in Garbutt ain’t what it used to be,” he wrote. “The truth about these dysfunctional, downscale communities is that they deserve to die.” Paul Krugman was more charitable, but hardly effusive, in a blog post last year. “There are arguably social costs involved in letting small cities implode, so that there’s a case for regional development policies that try to preserve their viability,” he wrote. “But it’s going to be an uphill struggle.”

Some calls are easier than others. It’s hard to argue that, say, a town that sprang up for a decade around a silver mine in Nevada in the 1870s needed to be sustained forever once the silver was gone. Where does one draw the line, though? If all of southern Ohio is lagging behind an ever-more-vibrant Columbus, should people there be encouraged to seek their fortunes in the capital? What would it look like to write off an entire swath of a state?

This has all become particularly urgent in places that are home to coal-fired power plants. These utilities get less media attention than actual coal mines, but they are far more widespread, employ almost half as many — some 20,000 — and are experiencing a much more immediate decline. Whereas coal mines have been shedding jobs for decades, coal-fired plants are experiencing their biggest crisis right now, squeezed by both competition from cheap natural gas and government constraints on their copious carbon emissions. At least 14 coal-fired plants are scheduled to close this year alone, many in remote places where they’re the big employer in the area.

Adams County is a classic example. The plants dominate the landscape — not just the towering stacks along the river but also the moonscapes that have been carved out of the nearby land to hold waste from the plants in so-called ash ponds. The good-paying jobs at the plants — a total $60 million in annual payroll — drew skilled workers to the county and to Maysville, Kentucky, the picturesque former tobacco hub across the river. The plants fattened the tax base. Despite the high poverty rate, the Manchester schools became some of the state’s best-funded, with high teacher salaries and an ambitious football program.

In theory, once the plants were closed, Adams County could revert to farm country. But it hadn’t been farm country for almost a half-century.

After Arnett got word from Greg Adams of the planned closure, they went to Stuart Station to discuss it with the operations manager, Mark Miller. The two men say Miller asked them to keep word of the closure to themselves. The reason seemed plain to Arnett and Adams: The company didn’t want so many workers leaving for new jobs that the plants would lack manpower to operate in the interim. They had no intention of observing the request. They found it irksome that the plants had recently hired new workers away from other jobs, some of them from hundreds of miles away, despite the imminent closure. The union leaders knew other colleagues who were on the verge of buying new trucks or farms, assuming their jobs were safe as ever.

So that same day, they gathered workers in the vast parking lot outside Stuart Station and, speaking from the back of a pickup, told them what was happening. Some in the crowd scoffed openly, saying it was surely a tactic for upcoming labor negotiations. In the months that followed, though, the reality became undeniable. AES began moving management employees to other locations around the country. Needed repairs started going unattended. And in the spring of last year, the company signed off on a final agreement with state regulators that gave it the rate hike it was seeking and also required it to provide some transition funding for workers and the county: a grand total of $2 million.

Desperate to save their members’ jobs, the local union leaders, as well as their counterparts at the national level, began to seek a buyer for the plants. This did not seem out of the question. The plants were still making money, they had been upgraded with expensive scrubbers just a decade ago and the company had recently cleared out a whole hollow above Stuart Station for a new ash pond.

The union did manage to find some potential buyers, but AES appeared reluctant to entertain offers. This fed workers’ suspicion that the closure was part of a deal involving Ohio’s largest utilities, under which those companies agreed not to oppose AES’s recent request to state regulators for a rate hike in exchange for AES closing Stuart and Killen, thereby removing competition from the field. Asked about its reasons for shuttering the plants, the company said simply, “It became clear that, without significant changes in market conditions, the plants would not be economically viable beyond mid-2018.”

Meeting with so little success on this front, the union leaders reached out to their elected representatives. In May 2017, a half-dozen of them drove to Washington, where they were joined by two Adams County commissioners. The group met with both Ohio senators, Republican Rob Portman and Democrat Sherrod Brown, and what struck Arnett was how similar they were in their unsatisfying responses. “If you put them in a room, you couldn’t tell a difference, Republican or Democrat,” he says. “Both of them had their people coming in saying they had another meeting.” Three months later, County Commissioner Ty Pell, whose father had worked at Stuart Station, returned to meet with Vice President Mike Pence and several cabinet secretaries. But the one who would’ve been the most helpful to meet with, U.S. Secretary of Energy Rick Perry, was in Houston, where flooding from Hurricane Harvey had become a crisis. Once back in Ohio, Pell and others made repeated attempts to reach Perry, to no avail.

More confounding, though, was the response they met with closer to home. If they couldn’t stop the plants from closing, they concluded, they could at least start making the pitch to the state of Ohio for the single best substitute: a pipeline (at an estimated cost of $25 million) to hook up the county to natural gas, which now bypasses it, making it far less appealing for potential employers. Despite months of trying, neither the workers nor county officials could get a meeting with Gov. John Kasich, a Republican, even though Ty Pell had been county chairman of his gubernatorial campaign. They settled for one meeting with Kasich’s policy director, which produced nothing tangible.

The meeting that most stuck out for Arnett was the one he landed with the state senator representing Adams County, Joe Uecker. They met at a Panera Bread in the Cincinnati suburbs. Arnett asked Uecker, a Republican in his sixth term in the Legislature, what Uecker might be able to do to forestall the closing or, failing that, to ease the transition for the county. He described to him what a huge impact the closing would have, not least on his kids’ schools.

He was startled by the advice Uecker offered in response: “You need to move,” the senator said. Uecker confirms this exchange: “I did say, ‘Sometimes you have to do what’s best for your family.’” The man elected to represent Arnett’s community was telling him the most responsible thing he could do was leave it.

It took no time for the fallout to hit. In late 2016, as plant workers were getting word of the closures, the county found out its own way: The state alerted it that the valuation of the plants had dropped by $56 million because of the planned closure. This meant a loss of $218,400 in tax revenue for the county general fund, which has an annual budget of about $8 million to pay for public works, the sheriff’s office, the jail, the courthouse, and social services, along with much else. The next valuation reduction came late last year, and a third is expected late this year. All told, the annual loss for the general fund is expected to be $787,800.

County officials are planning to make up some of that by using a final influx of money from a statewide Medicaid managed-care sales tax. That money will be gone in 2019. They are finding efficiencies wherever possible — the county treasurer is sharing an employee with the county recorder, an election board employee is filling a vacancy in the commissioner’s office — but at some point, the math just doesn’t work. A third of the county budget now goes toward the sheriff’s office and jail. Both already operate at levels bordering on negligence. The jail, built to hold a maximum of 38 inmates, often houses as many as 75, the result of both the opioid epidemic that’s beset southern Ohio and the state government’s push to cut its own budget by putting more inmates in county jails. Not infrequently, one officer monitors more than 60 inmates.

The county spreads over 583 square miles. To patrol that territory, there are only 22 public safety officers between the sheriff and the five municipal police departments. During certain shifts, Sheriff Kimmy Rogers has only two deputies on duty to cover the entire county. At his small, windowless office inside the jail, where he keeps a cardboard box of battered toys by his desk to give to needy kids, he contemplates what he could possibly spare to help make up a huge drop in tax revenue from the plants. “I just don’t know how I could cut,” he says. “We’re bare-bones.” That’s a standard line from department heads. In this case, it seems hard to deny.

Ten miles down Route 136, Brian Rau, superintendent of the Manchester Local School District, is looking at numbers no less incomprehensible. The district — essentially a single campus serving K-12 — was carved out from the countywide school system in 2004, when tax revenue from the plants was flowing freely. Until recently, it spent about $12,000 per pupil, among the highest in the state. As a result of the plant closures, the district is expected to lose at least $4.5 million of its annual funding, more than a third of its $11 million budget. Under Ohio rules, the state will ramp up its funding for Manchester, which will become, in a flash, a high-needs district: State funding will jump to 80 percent of its total budget, from 20 percent now. But the state will make up only so much of the loss; spending in the district will drop to $8,000 per pupil, among the lowest in the state. The loss of enrollment as a result of the closure will mean even less per capita funding. To begin to adjust to the new reality, the district has laid off several employees, cut its school psychologist back to part time (which Rau already regrets), barred the band and cheerleaders from traveling to distant away games, and, to Rau’s chagrin, started favoring less experienced teachers in job searches, since they cost less.

That’s easy compared with the 1996 bond issue hanging over the district. Rau sketches out different scenarios for paying off the debt if plant revenue vanishes. Under one scenario, residents would see their property taxes quintuple in the final year of the bond, 2021. “It’s ludicrous,” Rau says.

Lee Anderson, director of governmental affairs at the national Utility Workers Union, has spent years trying to get elected officials around the country to grapple with what’s happening in places such as Adams County. But there’s just no political will, he says. There’s support on the left for public investment in struggling areas, but less so, he says, when it comes to communities that are increasingly voting Republican — Adams County among them — and whose decline is linked to fossil fuels. On the right, he says, there’s no appetite for public investment, period. Not to mention that the scale of the challenge is so huge and the potential solutions so expensive.

But this doesn’t mean inaction is excusable or that it’s enough to tell people to find work elsewhere, Anderson says. “The problem here is trying to treat people like interchangeable widgets,” he says. “They’re not. They’re human beings embedded in communities. We’re forcing cultural and social change on people, and people don’t like that. They don’t move three states away for a hypothetical job. They want to live where they are because their parents are in the same town, and their grandmother is in the next town, and they go to church there. Just picking people up and relocating them, it doesn’t work like that. And on the flip side, even if it did work out for an individual, consider what you left behind: What is the ramification for your family and community, now that you’re gone for good?”

One by one, the plant workers started leaving — to a natural gas plant in Huntington Beach, California, to coal-fired plants in Kentucky, Oklahoma and Hawaii. Some of them had little farewell meetups at a bar. Others just vanished.

Randy Rothwell left with his wife, Tiffany, and their two sons last summer, after landing what seemed like a dream offer: a high-paying federal job with great benefits at the Grand Coulee Dam in Washington state. It wasn’t easy leaving Adams County, where their older son had recently started kindergarten, where Tiffany had belonged to a church for 25 years, where the boys’ cousins were their best friends. The Grand Coulee job was hard to pass up, though. The Rothwells managed to sell their house — thereby overcoming one of the major hurdles in leaving a struggling area such as Adams County — and moved in late July.

They lasted half a year. The job was fine, but they didn’t realize just how much they’d miss Adams County. The landscape of central Washington state was more desolate than they were prepared for. The nearest Walmart and McDonald’s were almost an hour away. Flights back home were expensive. Tiffany had almost no contact with other adults when Randy was at work.

Late last year, Randy got word of a job at Adams County’s second-largest private employer, an engine-testing facility for GE Aviation. He applied and got an offer. The position was nonunion and paid only $22 per hour, half of what he was making in Washington state and also much less than the $35 per hour he made at Killen Station. He took it anyway. The family came back to Adams County in a rented truck and, because they’d sold their house, moved in with Tiffany’s mother while they looked for a place.

It was different being back now, without a home of their own and with Randy bringing in so much less. Tiffany might have to find work, which won’t be easy. “That sense of security is gone,” she says. Still, they’re confident moving back was the right thing to do. “I know some people think, ‘What are you thinking?’ For us, it was family, wanting our children to grow up knowing their family and not being strangers to everyone around them,” Tiffany says. Randy agrees. “The American dream is kind of to stay close to your family, do well and let your kids grow up around your parents,” he says. It was a striking comment: Not that long ago, the American dream more often meant something quite different, about achieving mobility — about moving up, even if that meant moving out.

Others keep leaving, bound for Wyoming, Florida and Nebraska. Those left behind are keenly aware not only of the sheer tally but also of the kinds of people leaving. Over the years, the plants had brought a new cohort of families to the county, led by the sort of skilled workers who were able to get good-paying jobs at the plant. The kids from those families tend to share their parents’ traits and habits. Now those sorts of people are leaving and will no longer be arriving. “You’re going to lose a lot of your brightest youth,” says Rogers, the sheriff. “We’ve got a lot of bright kids here, and I’d hate to see them leave. But it will happen.” Chris Harover, executive vice president at one of the two local banks, shares the same worry. “You’re going to lose a big influx of good people,” he says. “There’s going to be no more moving in.”

At the plants, the departures were causing a more immediate problem: There were barely enough people left to keep things running. By February the unionized head count had dropped from 380 to less than 260. Under the union’s safety standards, there are supposed to be eight power plant operators for each of the four shifts at Stuart, for a total of 32; by February there were only 15 total.

A couple of groups of potential buyers came by to tour the plants, but nothing seemed to be coming of it. The company sent official notice that it wasn’t planning to put any power on the grid after June. A proposal by Rick Perry to subsidize ailing coal-fired plants was shot down by the Federal Energy Regulatory Commission; given the imminence of the plants’ closure, it would likely not have helped anyway.

Meanwhile, county officials were getting no answers from the company or state officials about the plans for the plants and ash ponds after the closure. Because fly ash isn’t categorized as hazardous, the moonscape could in theory remain a blot along the river in perpetuity. The company, which owned seven miles of riverfront, started ceding hundreds of acres to land conservancies. This handoff sounds benign, but if the company did so with all 5,000 of its acres, it would wipe it all from the tax base for good.

By early March, the union and county still hadn’t even gotten a firm closure date from AES. “We have no dialogue between the company and the county at all,” said Pell, the county commissioner.

On the first day of March, the state’s workforce development agency set up a “transition center” inside DP&L’s training facility in Manchester. There were computers to search for jobs and brochures on “Using Social Media to ‘Net a Job’” and “Untangling the Internet.” A week later the agency held an open house there, with a state employee tasked with explaining how to apply for unemployment and representatives from several local technical schools. There was a chance the workers could qualify for federal trade adjustment assistance, which would help pay for tuition.

About 100 plant workers showed up. There were free “OhioMeansJobs” tote bags and a spread of sandwiches, pasta salad and banana pudding. There was also a door prize: a thumb drive. Officials from Shawnee State University, in nearby Scioto County, were promoting their video game design program. The Southern Hills Career & Technical Center advertised training for nursing assistants. A woman from the Kentucky Career Center had a list of available jobs that included Hampton Inn receptionist, Dollar General sales associate and Domino’s Pizza driver.

The workers milled about uncertainly. Dean Toller expressed some interest in a six-month welding program in Kentucky that cost $15,000. Brandon Grooms said he was thinking of moving to North Carolina to work for a friend who sold engines for private jets. Missy Hendrickson, the controller for the two plants, was desperately hoping to transfer to another AES facility — she had been with the company 26 years, and if she didn’t make it to 30, she’d lose almost half her pension.

John Arnett was there, too. He said he and his wife were still torn about what to do. They were very worried about what the closure would mean for the Manchester schools, which their kids attended. But it was still painful to contemplate leaving. They were as deep in the local rhythms as ever. Youth baseball season was starting up. Soon it would be turkey hunting season, followed by squirrel season, then deer season — the whitetail was legendary in Adams County. “It’s just home,” he said. “I’ve been a bunch of different places, different countries. I’ve been across the equator. And now this is where I want to be, or I’d have stayed somewhere else. It’s the most beautiful place in the world, these hills.”

All these thoughts had led Arnett to lean toward trying to get transferred to one of AES’s jobs as a lineman in the Dayton area, even if it came with a pay cut and meant driving almost two hours to work. Many other workers were also considering this kind of commute. Rumors started swirling that a potential buyer has belatedly emerged for Killen Station, the smaller and younger plant: an IT staffing and consulting company in Atlanta called American CyberSystems Inc. In theory, Arnett could use his seniority to get one of the 100-odd jobs that would remain at Killen if it stays open, but taking a job as a lineman in Dayton seemed safer than banking on a new owner with zero experience in running a coal-fired plant.

He wasn’t sure about the lineman job, though, so at the open house, he drifted over to the man pitching the Kentucky welding program. The man talked about how much demand there is for welders and how good the money is. Arnett asked if there were jobs to be had here, in Adams. Not so much, the man conceded — although, he added brightly, one could do pretty well by traveling elsewhere for temporary stints, several weeks or months at a time.

Arnett turned away, unconvinced. “The issue is traveling,” he said under his breath. “I’d be able to get a job. I’m not concerned about that. But that doesn’t help the community.”

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Why we need to rethink how to teach the Holocaust

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This article was originally published on The Conversation.

A recent national survey reported that millennials are struggling with their knowledge of the Holocaust. The survey results show that 22 percent of millennials have not heard of, or are not sure if they have heard of the Holocaust, and that 66 percent could not identify Auschwitz.

As a scholar of Holocaust education and teacher education, I argue that knowledge of specific facts is only a small part of knowing about any historical event, including the Holocaust. A more important question to consider is: What do we want students to learn from the Holocaust, and given there are fewer and fewer survivors alive to tell their story, is there a need to rethink how it is taught?

Why learn about Holocaust?

History educator Sam Wineburg argues that history as a discipline has the unique capacity to humanize us. More specifically, scholars Keith Barton and Linda Levstik argue that history education can and should promote reasoned judgment, help students develop an expanded view of humanity, and encourage deliberation of the common good.

From this perspective, the most important rationale for Holocaust education would be to create a better society. Indeed, when studying the Holocaust learners need to grapple with complicated moral issues that blur the lines between right and wrong. It also challenges ideas about how individuals could (or should) act in society. In other words, the Holocaust provides lessons in human rights and human conduct.

It is not surprising that more state legislatures are now requiring Holocaust and genocide education as a way of dealing with the increase in hate crimes. Noting a spike in anti-Semitism, on May 7, 2018, the Connecticut House followed their Senate colleagues and voted unanimously to require Holocaust and genocide education in Connecticut schools. Kentucky also recently passed a Holocaust education law, increasing the total number of states with such requirements to 10.

Connecticut and Kentucky were among the 20 states last year whose lawmakers pledged to mandate Holocaust education in their states.

The changing context for Holocaust education

While for many states the position appears clear, for educators, it is not so simple. Teaching the Holocaust is an evolving and challenging context.

Foundational to the work of Holocaust educators and many teachers have been the survivors, whose presence — physically, emotionally, intellectually – has shaped every aspect of Holocaust education and representation.

Holocaust survivors are the ones who provided the moral and political will to create many of the Holocaust museums and memorials that exist today. Many Holocaust education programs were designed in collaboration with survivors and rely on survivor testimony as a key element.

This education, however, is nearing an end. In 2001, there were estimated to be over 160,000 survivors in the U.S.. That number is expected to drop to about 67,000 by 2020 with more than half over the age of 85.

Historian Sam Wineburg reminds educators of the important difference between lived memory and learned memory. Survivors, and their lived memory of having experienced the event, help young people connect to the past and make learning about the Holocaust relevant. Without survivors, the Holocaust will pass into being taught strictly from learned memory.

It is difficult to imagine a more powerful experience in Holocaust education than hearing from the people who survived. Interactions with survivors helps learners to personally connect to the Holocaust and develop empathy. The Holocaust, which may seem distant to many students today, becomes more real with eyewitness experiences.

The future of Holocaust education

This raises important dilemmas for teachers, curriculum developers and museum professionals about the future of Holocaust education. How do educators inform future generations? And how do they recreate the powerful empathetic moments?

Museums are taking the lead in adapting Holocaust education to a post-survivor world. One example is the Forever Project at the National Holocaust Centre and Museum in England, where staff are taking video of survivors in 3D and students can watch survivor testimony, and using the latest technology, ask questions and listen to answers.

The Shoah Foundation in the U.S. has a similar project working with Holocaust museums and using multidimensional video recordings of Holocaust survivors. The Anne Frank Center for Mutual Respect in New York is working on applying the lessons of the Holocaust to today, including its 50 State Genocide Education Project, which aims to encourage all 50 states to teach about the Holocaust and genocide with specific connections between events in the past and the present.

Holocaust education has the potential to encourage young people to think about how to improve humanity through individual and group actions. Its real test lies in how young people live out their daily lives. What happens, for example, when they see someone being bullied? How do they respond to a political leader whose words or policies promote stereotyping or hatred?

The effectiveness of Holocaust education is not one that we can readily measure, but it is more important than ever.

Alan Marcus, Associate Professor, University of Connecticut

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In the possum, the new animal meme du jour, the internet finds its soulmate

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Anyone who spends time on the Internet is aware of the prolific nature of dog and cat memes. Indeed, these household pets have become the internet’s unofficial mascots, with their own respective slangs — “lolcat” and “doggo” speak.

Now, the internet seems to have moved on to a new, more unusual animal meme du jour: the possum. Embittered, small, screaming at itself, his face wrapped in a perpetual grimace, the possum even has its own slang-talk — ”possum-speak” or "pösspeak," akin to doggo or lolcat tongues. It’s a weird animal to be so popular, granted, but its popularity might be related to our politics.

First, some background: One of the first viral possum memes, shared on Reddit in 2017, features a triptych of images of our furry friend, each accompanied by some descriptive text: “He have class / He give sass / But most importantly, he scream at own ass,” it reads. (Yes, in the final image, the possum does seem to be screaming at his ass.)

The six-pane image gained notoriety and several spinoffs, including a possum-ese rendition of the “Grease” song Summer Loving.

https://twitter.com/rageneggert/statu...

That specific tweet (which may not be original to that poster) has, to date, over 19,000 retweets and 39,000 likes. It is largely nonsensical, as many memes are, but the combination of rhyme and imagery seems to have struck a nerve online.

The possum is also making waves on Facebook; a page entitled “possumcore” has over 169,000 likes and shares possum memes daily. Recently, an image of a possum being interviewed struck a similar nerve and prompted hundreds of thousands of riffs, variations and digital nods of approval.

I HAVE HAD A LONG DAY... I AM VERY SMALL... AND I HAVE NO MONEY, SO YOU CAN IMAGINE THE KIND OF STRESS AM UNDER pic.twitter.com/up80o54JsU

— professor jiggly (@kallokisser) February 16, 2018

Popular Twitter account @own___ass has helped expand and popularize the “pösspeak” lexicon. Unlike doggo-speak or lolcat speak, pösspeak is very umlaut-heavy, perhaps mimicking a possum’s facial expression, which appears wreathed in perpetual shock or horror.

With over 45,000 followers, @own___ass is a major purveyor of possum memes, while also contributing to the growth of possum meme slang. Generally, @own___ass posts consist of images of cute possums paired with wholesome pösspeak text, like “u make me a smïleyböy !” and “you can do anything if you take life one stëp at a time !”

Whether screaming at his own ass or suffering through a spastic interview, the possum appears perpetually uneasy, both mentally and physically. Given this, it seems inevitable that the possum would become a mental health advocate. Indeed, during Mental Health Awareness Month, the @own___ass account shared positive messages and encouraged people to donate to National Alliance for Mental Health.

I have two theories as to why millennials love sharing the possum meme. First and foremost, we identify with him. We’re frustrated, often miserable and altogether sorely misunderstood creatures fumbling through life trying to make sense of our own daily lived realities against the backdrop of global crises. There’s an underlying existential dread present in the possum’s ass-screaming and permanently stunned expressions. Often, you’ll find a possum meme about eating trash and wanting to get hit by a car accompanied by the phrase “big mood,” a self-deprecating joke about the nihilism that accompanies depression. The possum is going nowhere fast and doesn’t feel great, but he’s still just trying to do his best, bless him.

Like the possum, aren't we all just stumbling awkwardly through existence? The possum is not a traditionally “cute” animal, but his semi-frazzled presence is kinda adorable. It’s an anxious yet authentic animal, in other words — which is exactly why he’s so endearing.

Virtual reality is revolutionizing how luxury apartments are sold

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This article originally appeared on GearBrain.

The future of the property marketing suite — the show apartment to you and me — will be a 'sensory space' with virtual reality, temperature changes, artificial smell, accurate textures and spatially mapped sounds.

That is the prediction of the Byrne brothers, co-founders of VMI Studio, a computer-generated imaging company based in South-West London. The pair use the Unreal video game engine to produce stunningly lifelike renders of luxury apartments yet to be built.

But while these images, which can take weeks or even months to create, are hugely impressive, VMI's party trick is how they can turn these renders into a virtual reality (VR) experience. Anyone interesting in buying an apartment, perhaps even before the show flat is built, can put on a VR headset, take hold of a game controller, and walk around the property as if they are actually there.

Building such VR environments takes a long time. Nicholas Byrne described spending weeks on a single CGI image as "very quick," adding that months-per-image is a more accurate timescale. The detail is simply staggering. When I ask if a bookshelf in one apartment is made from photographs of the real thing, the brothers both quickly say no, before Nicholas explains how each book is an individually-constructed 3D model.

But such attention to detail pays off, as people who visit a show apartment with an interest to buy spend far longer looking at the rooms through VR than when they flick through a brochure or look at a scale model. Fergus Byrne says: "People spend a lot longer looking [with VR]. With a brochure you get people looking for five seconds, but in this you get people playing for half an hour."

Capturing and maintaining a potential buyer's attention is key, especially when the properties VMI Studio works with can sell for millions of dollars. One such development, where the former BBC headquarters, Television Centre, is being turned into luxury apartments, hired VMI Studio to turn four different styles of apartment (created by four different architects, a quirk of the development) into four VR experiences for buyers to explore.

Fergus says: "They'd sold a lot of the one- and two-bedroom apartments but were struggling to sell their more premium offerings, the ones listed for £3.5m ($2.5m). They wanted to give customers at that price point extra vision for the scheme...to show the USP of each architect, because even to the discerning customer the differences perhaps aren't common knowledge. They had CGIs and the normal ways of showing buyers around [brochures, models, animated 'flyovers'] but wanted something more...something that would help push [a sale] across the line."

While computer-made images of upcoming buildings and digitized 'flyovers,' where a virtual camera sweeps through a computer rendering as if on a low-flying drone, have been used by property developers for years, VR is seen as a game changer. Customers can explore the area at their own pace, looking wherever they like and getting up close with the smallest details in a way not previously possible. The wealthiest of buyers can ask to have their own furniture and art collections added to the VR rooms, to make sure everything fits and looks just so.

Even before they sample the VR, potential buyers are intrigued. When I first met VMI Studio in the marketing suite of a London apartment block in 2016, to see what was at the time their first foray into VR, the receptionist's phone rang. When told the show apartment wasn't ready yet, the caller was about to hang up, but quickly changed their mind when offered the chance to experience it in VR instead. They booked a viewing right away.

Two years on, and the interest in VR is still strong. The technology may not have set the gaming world on fire like many had hoped, but for practical applications like this, it's a no-brainer.

The lighting created by VMI Studio's latest creations is simply gorgeous; it reacts dynamically as you approach shiny objects and can be adjusted so potential buyers get to see how shadows shift through the property each day. Clouds pass by overhead and spatially-mapped sounds mean the noise of running water can be heard when walking past the virtual bathroom, or the sound of a nearby airport flightpath can be added above the balcony.

I ask Nicholas to show me an imperfection in one of VMI's images, a tell-tale sign that this is a render and not a real photograph. He looks around his computer screen, zooms in closely, pans around for a while then finally spots a small blemish in the way a shadow is cast where a wall meets the ceiling.

As anyone who has used a VR headset will know, the resolution on offer isn't a match for a regular television viewed from across the room, let alone a PC monitor just a few inches away. But this will change. The brothers told me of their excitement for the recently announced HTC Vive Pro, which has a resolution 78 percent higher than the regular Vive, meaning more pixels to show off their renders. Even higher VR resolutions are coming soon, offering a 4K display for each eye and a wider field of view.

"There's so much more you can do," Fergus says, explaining how the property industry is often slow to adopt new technologies like those of VMI. "Normally when you say to a developer we do the whole thing in VR, they say 'oh it's going to look like The Sims, isn't it?'...Unfortunately, I think sometimes in this [property] sector there's a bit of nerves around doing something that's different."

Although these photorealistic virtual properties can be loaded onto a smartphone and navigated with a pair of on-screen virtual joysticks — again, like a video game — the Byrne brothers believe the future is in taking VR to the next level by adding touch and smell to their renderings.

A full-size model of an apartment could be built to the exact dimensions of a VR experience. Potential buyers would then be given VR headsets and computers in backpacks (making the system completely wireless), before walking around the real and virtual world at the same time. This way, they can still reach out and touch the kitchen counter, but then the entire decor could be changed in VR to give the same layout a completely new look. On top of this, VMI wants to add elements of smell (maple syrup on bacon, suggests Fergus), and temperature, where a well-placed heater in the real world can mimic the log burner seen in VR.

"We've started to explore more sensory reality," Fergus says. "Experiences around smells and sounds. We believe the future of the property marketing suite will be sensory spaces that you can go into...something where you don't just walk around and see the apartment, you smell it."

He adds: "It's all about giving the customer more and getting them interested in the product. Visuals are great, copy is great, brochures and all those other things are great - but if you can give the client a little bit more, it's a clincher."

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How Christian media is shaping American politics

Getty/Alex Wong

This article was originally published on The Conversation.

For Americans growing up between the 1950s and the 1980s, religion was not a regular presence on television. Aside from Sunday morning shows or occasional commercials, religious programming issued end-time warnings, sought monetary contributions, or staged faith healings. But it did not cover news.

Today is different, however. Not only are there entire networks devoted to religious broadcasting,

but also Christian television has moved directly into covering news and politics, reaching millions of Americans daily with a conservative perspective on current events.

As a scholar of religion and politics in America, I believe it is important to understand the impact of the medium at this point of time as well as how it came to have such influence.

The growth of Christian media

American Christians have historically used new media to spread the gospel. In the 19th century, evangelicals used pamphlets and advertising techniques. The early 20th century produced a religious radio subculture that is still thriving in programs like the ones offered by Focus on the Family or Moody Radio.

By the early 1950s, preachers like Fulton Sheen, Robert Schuller or Billy Graham took to television.

While there was occasionally a political overtone to these programs, most of them refrained from explicit commentary. This changed beginning in the 1970s, in large part, because of two related political trends:

One, since the late 1970s, largely fundamentalist Protestant organizations like the Moral Majority took to popularizing Christian conservatism. These organizations rallied national support to influence politicians to oppose abortion rights and the Equal Rights Amendment, among other causes.

Two, around the same time, beginning with Ronald Reagan’s presidency, conservative politicians started to harness evangelicals as a voting bloc. As a result, many of these politicians began paying closer attention to Christian media for indications of this bloc’s concerns. This gave Christian media further influence in the political world.

The televangelists

The above political changes were reflected in the rapid growth of Christian shows on cable television.

Pat Robertson’s longstanding talk show “The 700 Club,” the end-times prophecy show “Jack Van Impe Presents” and others began to address what was happening in the news from a Biblical perspective. They claimed they were providing viewers with “real” explanations that media and liberal politicians covered up. These shows also reinforced conservative talking points as objective facts.

It is true that during this period, American “televangelists” experienced several withering scandals. Evangelist Jimmy Swaggart, for example, was discovered with a prostitute, and televangelist Jim Bakker was convicted of fraud. This led some scholars to suggest that religious television “went underground” because of this disrepute.

On the contrary, as the data shows, religious broadcasting grew hugely in the 1990s and 2000s. Christian media increasingly commented on current events. And, critically, it began to have an influence on the wider culture.

For example, from the mid-1990s, popular films and novels like “Left Behind” suggested that viewers with the “wrong” religious or political beliefs would suffer damnation. Such films and literature attracted tens of millions of viewers and readers.

Furthermore, Christian media was used to advance conservative biases. Authors and advocates of textbooks and curricula, for example, downplayed the women’s movement in American history or referred to slavery as “involuntary immigration.” Such changes were adopted in some Christian schools and their authors were often featured in Christian media. Even when the influence was indirect, the media, schools and entertainment mutually reinforced each others’ ideas.

There is considerable evidence, then, of the connections between evangelical media broadly speaking, Christian news specifically, and a conservative Republican base that sought steady support and advocacy from it.

Why this matters

The power of these programs is more than simply the stories covered or guests interviewed – it is their social impact on religious beliefs.

Christian news is effective in conveying its views because it repeats claims that viewers already believe, and provides them with particular emotional experiences that are described as facts. This way of viewing the world has moved closer to the center of conservative politics since the 1980s, a period of time when the Christian right acquired more influence in American politics.

The themes central to Christian television were more consistently those of the Republican Party. Consider how in the 1980s, Ronald Reagan began to be depicted as God’s agent on Earth. In the 1990s, the growth of multinational corporations and trade deals was decried as part of a demonic “new world order.” And today, when Islamophobia is on the rise, Christian television channels depict and celebrate President Trump as the fighter-in-chief, who defends Christians despite his personal faults.

These attitudes are reflected in the contemporary news programs themselves.

For example, Robert Jeffress of Dallas’ First Baptist Church has called Islam a “false religion” that is demonically inspired. Such claims have been widespread since September 11, 2001, but on Jeffress’ “Pathway to Victory” program, with an audience estimated in the millions, they are given a vast reach without the facts of Islam ever being addressed.

Further, Christian Broadcasting Network news regularly features stories about Christians persecuted in Turkey or India. While such persecution clearly does occur in places across the world, it is often cited by CBN and other outlets to support the idea that American Christians are censored or otherwise embattled by liberalism or secularism.

Amplifying one view?

The growing regularity of such examples has significant implications for American politics.

First, assertions that religious liberty is being violated around the world are put out endlessly in what I call “the resonance chamber of American public life,” in which repetition, aided by social media, helps claims to achieve legitimacy. Second, stories on the Christian news channels are constantly tailored to the idea that viewers are being persecuted.

By presenting itself as authoritative, trustworthy journalism, Christian news reassures viewers that they do not need to consult mainstream media in order to be informed. More dangerously, it authorizes a particular, often conspiratorial way of viewing the world. It denounces neutrality or accountability to multiple constituencies as burdensome or even hostile to Christian faith.

Sadly, tens of millions of its viewers are left without a sense of two of democracy’s most necessary foundations: the value of multiple viewpoints and shared political participation.

Jason C. Bivins, Professor, North Carolina State University

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