Vox: All Posts by Keren Landman, MDhttps://cdn.vox-cdn.com/community_logos/52517/voxv.png2024-03-25T09:45:33-04:00https://www.vox.com/authors/keren-landman/rss2024-03-25T09:45:33-04:002024-03-25T09:45:33-04:00Is measles back?
<figure>
<img alt="A hand wearing a surgical glove holds a vaccine vial that says “Measles Mumps Rubella Vaccine.” A syringe is visible in the background." src="https://cdn.vox-cdn.com/thumbor/ieenMLqNy8vpuyAwtGGHv4C5MgU=/288x0:4640x3264/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/73204793/GettyImages_1126559052.0.jpg" />
<figcaption>Getty Images</figcaption>
</figure>
<p>Is measles making a US comeback? Here’s what you need to know.</p> <p id="pOwCri">As of March 21, the Centers for Disease Control and Prevention (CDC) <a href="https://www.cdc.gov/measles/cases-outbreaks.html">reports</a> 64 measles cases have been identified so far in the US this year across 17 jurisdictions. That’s more than in the entirety of<strong> </strong>2023, when 58 cases were reported over the full calendar year.</p>
<p id="yxCARO">It’s been nearly 25 years since measles was officially eliminated in the US. The declaration meant the infection hadn’t been transmitted continuously anywhere in the country for more than a year. However, it doesn’t mean measles couldn’t come back: <a href="https://academic.oup.com/cid/article/75/3/416/6443449">Under certain conditions</a> — lots of cases imported from abroad, not enough people vaccinated against the infection, and not enough tools to fight back — measles could re-entrench itself stateside.</p>
<p id="S3yfmf">That’s why <a href="https://www.vox.com/public-health" data-source="encore">public health</a> authorities monitor measles cases and vaccination rates against the infection. And why, when cases rise while vaccination rates drop, they fret.</p>
<p id="sDMG2T"><a href="https://www.cdc.gov/measles/about/parents-top4.html">Measles</a> is a viral infection that causes fever, rash, and cough, which can be complicated by severe, life-threatening infections of the ears, lungs, and brain. It’s particularly likely to cause severe disease in children under 5 years old and in immunocompromised people. To make matters worse, it’s one of the most contagious diseases out there: Infectious particles can hang out in the air or on surfaces for <a href="https://www.who.int/news-room/fact-sheets/detail/measles#:~:text=Transmission,for%20up%20to%20two%20hours.">hours</a>, and, on average, each infected person infects another <a href="https://pubmed.ncbi.nlm.nih.gov/28757186/#:~:text=For%20measles%2C%20R0%20is,determinants%20of%20measles%20R0.">12 to 18 people</a>. </p>
<p id="Ihltwg">When measles turns up in the US, it’s because it was brought to the country from the outside — more often than not, by <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6788396/">US residents</a> returning from travel abroad. There’s a lot of measles in the world: In 2022, the infection caused more than 9 million cases and killed more than <a href="https://jamanetwork.com/journals/jama/fullarticle/2813426#:~:text=Yet%2C%20in%202022%2C%20more%20than,World%20Health%20Organization%20(WHO).">136,000 people</a> globally, most of them children. Although countries in Eastern Europe, the Middle East, and South Asia currently top the list of <a href="https://www.cdc.gov/globalhealth/measles/data/global-measles-outbreaks.html">measles cases globally</a>, there have also been multiple outbreaks in <a href="https://www.ecdc.europa.eu/sites/default/files/documents/measles-eu-threat-assessment-brief-february-2024.pdf">Western Europe</a> over the past year. </p>
<p id="6l5lCk">There’s a highly effective vaccine to prevent measles — but to protect the youngest babies and immunocompromised people in any population, everyone around them needs to have been vaccinated. Part of what’s keeping US public health experts up at night is that, increasingly, that’s not the case. Still, it’s a situation people can do something about if they know how and understand the stakes.</p>
<p id="QubwpY">Here’s what you need to know.</p>
<h3 id="b6tLyL">1) Who’s at highest risk from a measles infection, and what does an infection look like?</h3>
<p id="Xe3wQU">Unvaccinated children and immunocompromised people — especially those receiving certain <a href="https://www.astctjournal.org/article/S1083-8791(19)30506-3/pdf">cancer treatments</a> — face the highest risk when measles is in circulation.</p>
<p id="lpEeGh">“Even an uncomplicated case of measles is really awful,” said Sarah Lim, an <a href="https://www.vox.com/infectious-disease" data-source="encore">infectious disease</a> doctor and medical specialist at the Minnesota Department of Health, during a press conference on March 12. Measles infections are so often severe that about <a href="https://www.nfid.org/infectious-disease/measles/#:~:text=Measles%20can%20be%20serious%3A,children%20with%20measles%20gets%20pneumonia">one in five</a> unvaccinated people who get infected are hospitalized, and between <a href="https://www.cdc.gov/measles/symptoms/complications.html">one and three</a> of every 1,000 measles infections end in death. </p>
<p id="wZRWUv">In its early stages, measles infection can cause a range of symptoms, including high fevers, cough, runny nose, red eyes, and full-body rash. About <a href="https://www.cdc.gov/vaccines/pubs/pinkbook/meas.html#:~:text=Approximately%2030%25%20of%20measles%20cases,subacute%20sclerosing%20panencephalitis%2C%20and%20death.">one-third</a> of infected kids get complications, which can include severe diarrhea, ear infections, and pneumonia. Brain infection that can lead to brain damage and epilepsy, called encephalitis, occurs in about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6788396/">one of every 1,000</a> kids who get infected with measles.</p>
<p id="58vr5N">Measles can also do something else that few other infections are known to do: It can <a href="https://www.vox.com/2019/11/1/20943217/measles-outbreak-2019-vaccine">wipe out kids’ immune memory</a>, leaving them unprotected from other bacterial and viral pathogens. That effect, and the increased susceptibility to other infections that comes with it, can last for years after infection.</p>
<p id="8WJY6P">Travel to parts of the world where measles circulates widely increases the risk of infection. That makes it important to ensure you and your family are protected from measles — in addition to <a href="https://wwwnc.cdc.gov/travel/page/travel-vaccines">all the other things</a> — prior to travel.</p>
<h3 id="vSDiSf">2) How is this year’s measles outbreak in the US different from past outbreaks?</h3>
<p id="yqoVoo">The biggest number of measles cases the US has seen over the past 25 years was in <a href="https://www.cdc.gov/mmwr/volumes/68/wr/mm6817e1.htm">2019</a>, when nearly 1,300 infections were reported over the course of the year. That year, nine out of every 10 cases occurred in unvaccinated people living in close-knit communities. A single outbreak in an Orthodox Jewish community in New York involved <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1912514">649 cases</a>; another outbreak involving 71 cases occurred in a <a href="https://www.vox.com/2019/3/19/18263688/measles-outbreak-2019-clark-county">Washington State</a> community of recent immigrants from the former Soviet Union.</p>
<p id="afl9Z0">What’s different so far about this year’s US measles cases is that they’re occurring in “lots of little sparks across the nation,” as epidemiologist Katelyn Jetelina put it in her recent <a href="https://yourlocalepidemiologist.substack.com/p/state-of-affairs-march-12">newsletter</a>. “The more embers, the more likely it is that they find unvaccinated pockets and spread like wildfire,” she wrote.</p>
<p id="pmUrvO">We don’t yet know whether spread among close-knit communities is contributing to transmission in the US. Although the CDC is reporting where cases are taking place, it hasn’t reported the ages or any other demographic information about the people who’ve been infected. An agency representative declined to share this information with Vox when we reached out on March 12.</p>
<p id="7SUunl">Another concerning feature about this year’s cases is that they’re happening at a time when a relatively large proportion of kids are going unvaccinated against measles. In a November publication, CDC scientists reported <a href="https://www.cdc.gov/mmwr/volumes/72/wr/mm7245a2.htm">7 percent</a> of kindergarteners hadn’t been vaccinated against measles during the 2022-2023 school year. At the same time, vaccine exemptions reached an all-time high, with more than 5 percent of kids exempted in 10 states.</p>
<p id="CIV3wb">To make matters worse, according to recent <a href="https://www.latimes.com/california/story/2024-03-11/parents-delaying-kids-vaccines-posing-risk-to-toddlers">reporting</a> in the LA Times, a lot of parents are choosing to delay measles vaccination in their infants, which increases vulnerability to the most severe effects of measles in a group that’s already at the highest risk of complications. </p>
<p id="GflYpX">The World Health Organization (WHO) <a href="https://www.who.int/news/item/23-11-2022-nearly-40-million-children-are-dangerously-susceptible-to-growing-measles-threat">cautions</a> that the risk of a measles outbreak increases dramatically if more than 5 percent of people in a community aren’t vaccinated, which makes these numbers pretty concerning. What’s even more alarming is that these numbers are averages: In some states, as many as <a href="https://www.cbsnews.com/news/measles-outbreaks-schools-vaccination-rates-decline/">22 percent</a> of people are unvaccinated, and that number is likely much higher in some smaller geographic pockets. </p>
<p id="AobEG3">“That’s where you’re really talking about throwing a match [into a pile of kindling] and having a large fire,” says Jane Zucker, an infectious disease doctor and epidemiologist who retired in 2023 after 30 years in public health, including more than 20 with the New York City health department’s Bureau of Immunization. “That’s what you’re really most anxious about.”</p>
<h3 id="WbFxbt">3) Who should get vaccinated, revaccinated, or tested for immunity?</h3>
<p id="psMnsM">There’s no medicine to treat measles infection once it’s taken hold, which makes prevention the main strategy for avoiding the virus’ worst effects.</p>
<p id="4KPCCZ">The best news about measles — and the reason most of us have no idea what it looks like — is that the vaccine that prevents it is extremely effective and safe.</p>
<p id="BhaWaM">That vaccine, called MMR — because it protects children from measles, mumps, and rubella — is what experts call a “<a href="https://www.hhs.gov/immunization/basics/types/index.html#:~:text=Rabies-,Live%2Dattenuated%20vaccines,and%20long%2Dlasting%20immune%20response.">live-attenuated</a>” vaccine. That means it’s made using a weakened version of the measles virus that can’t actually cause the disease. Because they so closely replicate the actual virus, these kinds of vaccines induce the strongest and longest-lasting response of any type of vaccine — including Covid-19 vaccines. MMR vaccines are <a href="https://www.cdc.gov/vaccines/vpd/mmr/public/index.html">97 percent effective</a> at preventing symptomatic measles infections. </p>
<p id="o1rVuw">These vaccines can even protect people <em>after </em>they’re exposed to measles if they’re given within 72 hours of exposure, and they’re <a href="https://www.cdc.gov/vaccinesafety/vaccines/mmr-vaccine.html">extraordinarily safe</a>.</p>
<p id="OOvuNL">Who should get vaccinated against measles? Babies (lifelong immunity comes after two shots, the first at 12 months old and the second at 4 to 6 years of age) and almost everyone else who doesn’t have proof that they’ve been vaccinated before should get vaccinated, according to the <a href="https://www.cdc.gov/vaccines/vpd/mmr/public/index.html">CDC</a>. </p>
<p id="A557PQ">That’s especially true if those people without vaccination proof work in health care or are about to travel to places where there’s lots of measles in circulation — which these days includes Europe, says Zucker. Babies 6 to 12 months should also get an MMR shot if they’re going to be traveling; because their immune systems aren’t mature enough at that age for the vaccine to “take,” they’ll still need another two-shot series after their first birthday.</p>
<p id="UT8AX1">Many adults who’ve already been vaccinated won’t ever need another measles vaccine. That’s because all the versions of measles vaccines in use since 1968 have been strong enough to give lifelong protection against infection. So long as you’re certain you’ve had two vaccines in the years since then — that is, it’s documented somewhere in your medical record that you got them — you don’t need a repeat. The exception is for adults who only got vaccinated between 1963 and 1967: Because the version used during those years was too weak to give lifelong immunity, they’re not considered protected unless they’ve gotten at least one dose of a newer version of the vaccine.</p>
<p id="zBJyYm">Another group that doesn’t need to worry about vaccination is most adults over 65. Measles was so common before the vaccine was available that experts assume people born in those years were exposed and are immune. So if you were born before 1957, you don’t need a vaccine unless you’re in a high-risk situation — for example, you work in health care or you’re about to travel to a place where there’s a lot of measles in circulation.</p>
<p id="F95ddU">There are some people who should wait to get an MMR vaccine if they’re unvaccinated or if their vaccine history isn’t clear. Live vaccines like this one are typically not recommended for people with weakened immune systems, which include pregnant folks and some immunocompromised people. Some other conditions also make it sensible to hold off on vaccination — have a look at the CDC’s answers to “Who Should Not Get MMR Vaccine?” <a href="https://www.cdc.gov/vaccines/vpd/mmr/public/index.html">here</a> and talk to a health care provider if you’re not sure what to do. </p>
<p id="pJjycf">A blood test called a measles serology can measure the level of measles antibodies in a person’s blood. If the level is high, it’s safe to assume that person is immune to measles, either as a result of vaccination or past infection. But low scores on these tests may not be very meaningful, says Zucker: Many people with low levels of measles antibodies actually have measles protection due to prior vaccination, making it a bad test for determining whether immunizations documented a long time ago are still providing protection. For that reason, the <a href="https://www.cdc.gov/measles/lab-tools/serology.html#:~:text=Serologic%20testing%20for%20measles%20in%20low%20prevalence%20setting,-Ongoing%20measles%20activity&text=Detection%20of%20specific%20IgM%20antibodies,or%20recent%20measles%20virus%20infection.">CDC</a> says a history of vaccination supersedes a serology result when it comes to determining whether a person is protected from measles.</p>
<p id="urHVFC">Health experts sometimes administer these tests in outbreak settings and during pregnancy, but the results are typically used in ways specific to those scenarios. So you don’t need a serology to prove you’re vaccinated if the shots are documented in your medical record — and in any case, it’s harmless to get a repeat vaccination even if you’ve been vaccinated before. “If you don’t know if you’re immune,” says Zucker, “it’s easier to just get yourself vaccinated.” </p>
<h3 id="lmyJdG">4) How bad is this outbreak likely to get?</h3>
<p id="3U9Yz2">Where US measles cases go is really up to us. </p>
<p id="J8YfgI">There’s hope for controlling measles’ damage in the US if more parents opt to vaccinate their babies as soon as they’re eligible, if they keep unvaccinated kids home from school, and if they vaccinate their unvaccinated children as soon as they hear about a potential exposure.</p>
<p id="Vxmbxf">It’ll also help if public health authorities have adequate support and staffing to educate the public about measles, provide and document vaccination — as with <a href="https://www.cdc.gov/vaccines/programs/iis/index.html">immunization registries</a> — and intervene when outbreaks happen.</p>
<p id="Sv7IDs">However, last year’s national debt ceiling deal resulted in <a href="https://www.gpb.org/news/2023/07/06/cdc-reduce-funding-for-states-child-vaccination-programs">cuts to states’ child vaccination programs</a>. Furthermore, the wild nonsense on vaccines that <a href="https://www.publichealth.columbia.edu/news/vaccine-misinformation-outpaces-efforts-counter-it">pervades social media</a> — and, occasionally, official messaging, as in the case of <a href="https://www.nytimes.com/2024/02/23/well/family/florida-measles-outbreak-joseph-ladapo.html?unlocked_article_code=1.cU0.YcRd.P45F3u6Lg7Fr&smid=url-share">Florida’s surgeon general</a> — makes it challenging for many parents to disentangle the common-sense guidance from the crap. </p>
<p id="RR67J1">Joshua Barocas, an infectious disease doctor at the University of Colorado, said during March 12’s press conference that pushing back against measles is a team effort and that removing shame from the equation is key. “Parents are flooded with tons of information, some of that [being] misinformation — and so if you are a parent who’s been on the fence, now is the time to catch up on your kids’ delayed vaccines,” he said.</p>
<p id="P0XDXJ">“I would also encourage health care workers to welcome people with open, non-judgmental arms,” Barocas said.</p>
<p id="gP7haL"><em><strong>Correction, March 15, 11:45 am ET: </strong></em><em>A previous version of this story incorrectly stated the number of years Jane Zucker worked for the New York City health department’s Bureau of Immunization. </em></p>
<p id="mAaHRG"><em><strong>Update, March 25, 9:45 am ET: </strong></em><em>This story was originally published on March 13 and has been updated to include newly identified cases.</em></p>
https://www.vox.com/even-better/24099783/measles-mmr-united-states-cdc-vaccineKeren Landman, MD2024-03-20T06:00:00-04:002024-03-20T06:00:00-04:00Abortion influences everything
<figure>
<img alt="A row of wooden blocks set up like dominoes is about to topple one by one, as the first block leans into the second." src="https://cdn.vox-cdn.com/thumbor/kZ5zSLRp8t_5--JotdiC5N-6-6Y=/0x0:7092x5319/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/73219885/GettyImages_1339787713.0.jpg" />
<figcaption>Getty Images</figcaption>
</figure>
<p>By inhibiting drug development, economic growth, and military recruitment, as well as driving doctors away from the places they’re needed most, bans almost certainly harm you — yes, you.</p> <p id="SkcKmT">Last year in Texas, federal Judge Matthew Kacsmaryk <a href="https://www.vox.com/politics/2023/3/16/23642927/supreme-court-abortion-matthew-kacsmaryk-mifepristone-texas-trump">ruled</a> that, based on his read of some <a href="https://www.npr.org/sections/health-shots/2024/02/09/1230175305/abortion-pill-mifepristone-retraction-supreme-court">very bad science</a>, the Food and Drug Administration (FDA) needed to withdraw its approval of the <a href="https://www.vox.com/policy/23678597/mifepristone-safety-abortion-pill-ruling-misoprostol-kacsmaryk-fda-rems">safe</a> and widely used <a href="https://www.vox.com/abortion" data-source="encore">abortion</a> drug <a href="https://www.vox.com/2023/4/10/23677220/texas-abortion-pills-usa-updates-mifepristone-misoprostol-kacsmaryk" data-source="encore">mifepristone</a>. He claimed that the FDA hadn’t adequately considered its safety (<a href="https://www.vox.com/policy/23678597/mifepristone-safety-abortion-pill-ruling-misoprostol-kacsmaryk-fda-rems">it had</a>) and that the lack of restrictions on the drug (<a href="https://www.acog.org/news/news-articles/2023/02/mifepristone-in-the-courts#:~:text=ACOG%2C%20along%20with%20the%20American,oppose%20burdensome%20restrictions%20on%20mifepristone.">there were plenty</a>) had led to many deaths and severe adverse events (<a href="https://www.contraceptionjournal.org/article/S0010-7824(12)00643-9/fulltext">demonstrably false</a>). </p>
<p id="YMCYg6">That case didn’t go away: On March 26, the US <a href="https://www.vox.com/scotus" data-source="encore">Supreme Court</a> will <a href="https://www.politico.com/news/2023/12/13/supreme-court-to-decide-whether-abortion-pill-will-remain-widely-available-00131504#:~:text=The%20justices%20announced%20Wednesday%20they,Congress%20and%20the%20White%20House.">hear arguments</a> on whether one judge’s take supersedes that of an agency full of scientific experts. Although mifepristone remains available by mail and in <a href="https://www.vox.com/even-better/2024/3/5/24091215/mifepristone-abortion-cvs-walgreens-drugstores-retail-pharmacies-prescribers">some retail pharmacies</a> — and will at least until the court issues its ruling in June — there’s already a lot of concern about how the decision could reverberate throughout the rest of American society. Not only are there concerns about access to the drug among people who need it for other reasons, but many also fear the case could threaten the FDA’s ability to do its job, which would in turn jeopardize the entire drug innovation ecosystem — a <a href="https://www.cbo.gov/publication/57126">major contributor</a> to the American <a href="https://www.vox.com/economy" data-source="encore">economy</a>.</p>
<p id="TzLoHd">The notion of a “butterfly effect” is sometimes used to describe situations where tiny, incremental events (like the flapping of a butterfly’s wings) have enormous and sometimes unpredictable downstream consequences (like a tornado). It’s a useful framework for thinking about the fallout of abortion policies: Although changes to these policies might not always be incremental, their consequences can be dramatic and often surprising — and can touch people, issues, and industries that go well beyond individual pregnancy terminations. </p>
<p id="puOuAb">The last time the Supreme Court heard an argument on abortion was in 2022. That June, the court’s opinion in <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf"><em>Dobbs v. Jackson Women’s Health Organization</em></a> overturned the constitutional right to abortion, and experts say we’re only just beginning to see the repercussions of that decision. </p>
<p id="FO0Zkx">“What happened in <em>Dobbs</em> has just opened the door for so many other things beyond reproductive care,” said <a href="https://www.americanprogress.org/people/sabrina-talukder/">Sabrina Talukder</a>, who directs the Women’s Initiative at the Center for American Progress.</p>
<p id="dUbT2D">Restricting abortion means removing women’s control over not only their bodies, but also their futures — and giving that control to someone else. In a nation where <a href="https://www.guttmacher.org/fact-sheet/adolescents-teens-receipt-sex-education-united-states">sex education</a> and <a href="https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states?gad_source=1&gclid=CjwKCAjw7-SvBhB6EiwAwYdCAT2mjv9yWd_7egP0kGV9i0DT8cKQrruvP-75zUMQPlGNb1ys1ljo9xoCN-YQAvD_BwE">contraception access</a> are already spotty and about half of all pregnancies are <a href="https://health.gov/healthypeople/objectives-and-data/browse-objectives/family-planning">unplanned</a>, that act is a population-level assault on women’s autonomy. The result is a psychic wound even to those who aren’t seeking abortions. </p>
<p id="NfVkti">On a more individual level, it also means many women are forced to carry unwanted pregnancies to term — an estimated <a href="https://www.npr.org/2023/11/24/1215152734/after-the-dobbs-decision-birth-rates-are-up-in-states-with-abortion-ban-states">30,000</a> of them annually in the US, according to a recent estimate. Without being able to control their fertility, women are forced into a different set of educational and professional choices than they might otherwise make.</p>
<p id="V2Y8XF">But that’s not where the impact ends. The tactics anti-abortion activists use to achieve their goals themselves constitute an assault on the American institutions and conventions that form the bedrock of many of our most trusted systems.</p>
<p id="0o8xVV">Some predictions of the consequences of restricting abortion are hypothetical. That doesn’t mean they’re not reasonable; it’s just that contemporary Americans have never lived in a world where our courts were so willing to subvert our institutions in service of anti-abortion ideology. Imagining the impacts of that subversion isn’t fantasy, it’s forethought. </p>
<p id="IblWv4">To see real-world effects, we only need to compare states. Although the right to abortion was constitutionally guaranteed for a half-century after <em>Roe, </em>many state governments nevertheless systematically made abortions hard to get by enacting so-called targeted regulation of abortion provider laws, otherwise known as TRAP laws. These laws force abortion clinics to comply with all kinds of burdensome requirements to stay open, limiting abortion access in states that enacted them, and creating a sort of real-world laboratory allowing experts to compare outcomes in states with and without straightforward abortion access.</p>
<p id="lPtzD7">Here are nine repercussions that could follow — and in some cases, have already happened due to — the efforts of US anti-abortion activists. </p>
<hr class="p-entry-hr" id="Da56su">
<h3 id="tqmnll">1) They complicate miscarriage treatment and access to other health care</h3>
<p id="oskWoI">Although attacks on mifepristone center on its use in abortions, the drug is also used in treating miscarriages once they’re already in progress. Theoretically, it should be legal and accessible for miscarriage treatment even in states where abortion is now banned.</p>
<p id="joduLt">However, because the drug has been so politicized, women prescribed the drug to reduce bleeding and the need for surgical intervention after a miscarriage <a href="https://stateline.org/2023/10/20/many-women-cant-access-miscarriage-drug-because-its-also-used-for-abortions/">often can’t get it</a>. This means that although the American College of Obstetricians and Gynecologists recommended mifepristone as part of miscarriage treatment in its 2018 <a href="https://pubmed.ncbi.nlm.nih.gov/30157093/">guidelines</a>, only <a href="https://jamanetwork.com/journals/jama/fullarticle/2807775">2.5 percent</a> of women having miscarriages were getting mifepristone from their <a href="https://www.vox.com/health-care" data-source="encore">health care</a> providers in 2020. Given how much its profile has risen since then, it’s <a href="https://stateline.org/2023/10/20/many-women-cant-access-miscarriage-drug-because-its-also-used-for-abortions/">unlikely</a> access has improved much today.<strong> </strong></p>
<p id="QGwNWS">Other effects on health care access result from OB-GYNs’ willingness to practice in states that restrict abortions. After all, it’s not only pregnant people who need OB-GYN care. These doctors also provide other types of care to women: They diagnose and treat sexually transmitted infections, cancers of the female reproductive tract, menopause, and a range of other conditions. Americans need OB-GYNs to help check out-of-control transmission of <a href="https://www.vox.com/science-and-health/23392423/std-syphilis-sti-maternal-prenatal-care-sexually-transmitted">syphilis</a> from mothers to babies. </p>
<h3 id="X3xMKb">2) They undermine FDA authority</h3>
<p id="Vk9Nui">One of the biggest fears experts have about the potential fallout of the Kacsmaryk case is about what the decision could mean for the FDA’s authority. In this case, a lower court judge used junk science — since <a href="https://www.nature.com/articles/d41586-024-00556-0">retracted</a> by the journals that published it — to make conclusions that he then substituted for the scientific and medical expertise of the FDA, said <a href="https://www.linkedin.com/in/amanda-banks-md-0abb8744">Amanda Banks</a>, a physician and biotechnology entrepreneur, speaking at a press conference on March 14. If his decision holds, it will set a precedent “that anyone with an ideological or other disagreement, coupled with a scientifically untrained judge, can undo the scientific and medical expertise of the agency,” she said.</p>
<p id="d28xWM">To be clear, among federal agencies, the FDA is no upstart pipsqueak. It’s not perfect, but the agency’s depth of expertise and its rigor in evaluating the risks and benefits of drugs and products set a global gold standard. </p>
<p id="hTGeZD">Allowing such a respected federal agency’s authority to be challenged — and cutting access to a drug it has approved — on the basis of an activist judge in a lower court would have consequences well beyond mifepristone, Banks said. The biggest immediate risks would likely be to products considered politically fraught, like contraception and IVF. Down the line, there would also be risks to products that are developed using certain living cells, among them many <a href="https://academic.oup.com/ajhp/advance-article-abstract/doi/10.1093/ajhp/zxae031/7606814?redirectedFrom=fulltext">vaccines and therapies</a> used to treat cancer and immune system diseases.</p>
<p id="3hMw8U">If successful, Kacsmaryk’s appeal could lead to sudden changes in other drugs’ availability due to lawsuits brought by people who object to those drugs on their own ideological grounds — or even by companies that might be seeking to remove a competing product for commercial gain. “There is a slippery slope here,” said Banks.</p>
<h3 id="2lqNgF">3) They chill pharmaceutical innovation</h3>
<p id="1jOocx">Developing one new drug typically costs a pharmaceutical company a minimum of <a href="https://www.cbo.gov/publication/57126">a billion dollars</a>. However, companies are willing to make that investment if there’s a good chance of proving the drug works, then selling it to a lot of people. The FDA is a key partner in making that happen.</p>
<p id="HSjXMD">If the Supreme Court lets Kacsmaryk’s decision stand, though, it would mean that other FDA decisions could easily be undermined by lower courts. That would inhibit investment and new research and development in the pharmaceutical industry, warned Banks. More than 700 biopharmaceutical executives have signed an <a href="https://urldefense.com/v3/__https:/docsend.com/view/2ahvmwy8djzxax3g__;!!H9nueQsQ!4ZNgTF4ZL71py8bJhZf8hc2nDCt8V5J4feZquCpyvbSSpCfLDVxlrlMyvpmmz-0ZaJ1NphPDWcNNv2FDc26x6CnJKrf5yYQ$">open letter</a> in support of the FDA’s authority; that “was entirely about the effect that this could have on the industry as a whole,” she said. </p>
<p id="lISz3j">“The regulatory process that we rely upon as an industry is rigorous,” Banks said, and without a guarantee that the outcome of that rigorous process will stand once the FDA comes to it, galvanizing internal support for investing in risky therapies, diagnostics, and tests will be challenging for pharmaceutical companies, as will raising capital from <a href="https://www.vox.com/venture-capital" data-source="encore">venture capital</a> or other private investors. </p>
<p id="Dk6hEN">“In an uncertain world, the investment also becomes quite uncertain — and so it threatens the innovation potential of our industry,” she said.</p>
<h3 id="6DHRR6">4) They raise infant and maternal mortality</h3>
<p id="TTJBLq">As part of providing pregnancy care, OB-GYNs sometimes have to terminate pregnancies due to complications that affect the viability of the fetus, the health of the mother, or both. In states that ban abortion, OB-GYNs cannot perform terminations without the risk of breaking the law. As a result, many of these specialists are <a href="https://www.nytimes.com/2023/09/06/us/politics/abortion-obstetricians-maternity-care.html">leaving states</a> with the most severe abortion restrictions. Additionally, <a href="https://www.washingtonpost.com/education/2023/10/13/obgyn-training-abortion-restrictions/">medical trainees</a> are <a href="https://www.axios.com/2023/04/18/abortion-ban-states-drop-student-residents">avoiding these states</a> because they know that in a state that does not permit abortion, they won’t get training in a key part of pregnancy care.</p>
<p id="pRteSF">The lack of OB-GYNs is a major problem in the US, especially in rural areas. Where there aren’t enough OB-GYNs, there isn’t enough maternity care, which raises the risk of both <a href="https://www.vox.com/23952456/syphilis-mortality-death-infant-newborn-congenital-babies-prenatal-maternity-pregnancy-desert">infant</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/33069560/">maternal</a> <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2800629">mortality</a>. </p>
<p id="5IKI8x">In a nutshell, banning abortion creates untenable working conditions for the exact health care providers whose job it is to preserve the lives of mothers and babies. </p>
<h3 id="7pAzNL">5) They reduce educational achievement and earnings, especially for Black women</h3>
<p id="nnWKqN">When women have unplanned pregnancies in their teens and early 20s, it often derails their educational or career plans. Abortion access allows them more control over the timing of their fertility, which also gives them more agency to see their aspirations through. Indeed, since abortion was legalized in the early 1970s, rising access has <a href="https://aura.american.edu/articles/online_resource/At_a_Crossroads/23857644">increased</a> women’s likelihood of starting college by 41 percent and raised their chances of graduating by 72 percent.</p>
<p id="vh1zuA">The link between abortion access and educational attainment is particularly pronounced for Black women, as are <a href="https://www.vox.com/2022/6/29/23187002/black-women-abortion-access-roe">many of the worst consequences</a> of obstructing abortion access. In this population alone, abortion access increases the likelihood of starting college by up to 200 percent and significantly <a href="https://pubmed.ncbi.nlm.nih.gov/7720849/">increases</a> the number of years spent in school. </p>
<p id="limnXw">Lower educational achievement means lower earnings. Pre-<em>Dobbs</em>, researchers estimated that for women living in abortion-restricting states, the gender pay gap widens an additional <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4048004">5 to 6.5 percent</a> for every TRAP law put in place.</p>
<p id="unTkF4">When she imagines the fallout of abortion bans, “I think about people being able to feed their families, I think about patients that literally don’t have housing,” said <a href="https://medicine.iu.edu/faculty/23603/wilkinson-tracey">Tracey Wilkinson</a>, a pediatrician who specializes in reproductive health issues at Indiana University’s medical school. “The ripple effects are just so profound for families and communities.”</p>
<h3 id="wdRhbg">6) They decrease workforce participation and economic growth</h3>
<p id="V4wFBK">Although creating children often involves both women and men, it should be news to zero people that historically, women have borne a <a href="https://www.vox.com/2018/2/19/17018380/gender-wage-gap-childcare-penalty">much greater share</a> of the parenting burden. The more women are forced to carry more pregnancies to term, the more women spend their time caring for children rather than working.</p>
<p id="M203t7">While mothering children is an option many women choose joyfully, a significant proportion opt to either delay or forgo that option when given the choice. Instead, many of these women choose to pursue other ambitions, often as part of the labor force. </p>
<p id="ooh3TJ">Abortion restrictions remove that choice for many women, with real, large-scale economic consequences. In 2021, the Institute for Women’s Policy Research (IWPR) <a href="https://iwpr.org/costs-of-reproductive-health-restrictions/">estimated</a> abortion restrictions were costing state economies $105 billion annually by keeping women of childbearing age out of the labor force, lowering their earnings, and increasing job turnover and time away from work. Conversely, they found that eliminating abortion restrictions would increase the growth of the US labor force by an additional 500,000 women, leading to an increase in private sector earnings growth of more than 9 percent.</p>
<p id="vCtPR5"><a href="https://iwpr.org/member/nina-besser/">Nina Besser Doorley</a>, who oversees policy and strategy for the IWPR, said her organization has just begun analyzing data from 2023 that will show how much impact <em>Dobbs</em> has already had on women’s workforce participation and earning potential. “We have every indication that the impacts of this decision have been absolutely massive on an individual level, as well as on a systemic level,” she said, “so I would be hugely surprised if any research that we got at this point showed anything else.” </p>
<h3 id="Cfhco1">7) They threaten military readiness</h3>
<p id="gKkqvv">Limiting access to mifepristone as a means of having a safe and private abortion would create big barriers to recruiting women to the US Armed Forces, as three former Army, Navy, and Air Force secretaries recently <a href="https://www.washingtonpost.com/opinions/2024/02/01/supreme-court-abortion-pill-mifepristone/">wrote</a> in a Washington Post editorial. Without mifepristone, women who are deployed would have to miss multiple days of work or travel long distances to get an abortion — a difficult thing to explain to an (often male) commanding officer, said <a href="https://www.wcl.american.edu/community/faculty/profile/caldera/bio">Louis Caldera</a>, former secretary of the Army and director of the White House Military Office, at the March 14 press conference. “The need for women to leave their units to go try to take care of their reproductive health care needs hurts their units,” and it could also hurt their promotion opportunities, he said.</p>
<p id="GLdbCC">As male interest in joining up has <a href="https://www.defense.gov/News/News-Stories/Article/article/3369472/vice-chiefs-talk-recruiting-shortfalls-readiness-issues/">waned</a>, the armed forces are facing a severe recruitment crisis. Women already make up 20 percent of the military, and as they are increasingly in recruiters’ sight lines, that number will likely rise. </p>
<p id="Cu5eZT">But not if the cost is being unable to end an unwanted pregnancy, said Caldera. “When we put those kinds of barriers, it makes it harder to recruit, it makes it harder to retain, it makes it harder to keep and promote the very people we’ve invested in — who we need in the senior ranks.”</p>
<h3 id="t87LJ0">8) They increase the number of kids living in poverty and entering foster care</h3>
<p id="Xp9YBb">In the <a href="https://bmcwomenshealth.biomedcentral.com/articles/10.1186/1472-6874-13-29">Turnaway Study</a>, which gathered data between 2008 and 2010, 40 percent of women said they were seeking an abortion due to financial considerations related to the cost of raising a child. When financially strained women are forced to carry pregnancies to term instead of getting abortions when they know they cannot afford to have a child, the result is that babies are born into under-resourced homes. That raises the risk that those children, or other children in the home, will live <a href="https://www.vox.com/poverty" data-source="encore">in poverty</a> or ultimately enter the foster care system.</p>
<p id="Oguut8">A recent <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2811533">study</a> examined the likely consequences of the <em>Dobbs</em> decision by looking at what happened in foster care systems pre-<em>Dobbs</em> in states with TRAP laws. </p>
<p id="WMnrFl">When the researchers compared states with and without TRAP laws, they found foster care placements increased 11 percent in states with these restrictions in the years after the laws were enacted.</p>
<p id="GkF7Nh">That’s not only a tragedy for families and children, but also an expensive burden for taxpayers. Child welfare services, including foster care, currently cost the federal government <a href="https://cms.childtrends.org/wp-content/uploads/2023/05/ChildWelfareFinancingSFY2020_TitleIV-E.pdf">billions of dollars</a>; the more children who need those services, the more taxpayer money gets spent providing them.</p>
<h3 id="3DJKFH">9) They damage mental health</h3>
<p id="SHFDj6">In a survey conducted before the <a href="https://www.vox.com/scotus">Supreme Court</a> overturned the constitutional right to abortion, women living in states with more abortion restrictions had <a href="https://www.sciencedirect.com/science/article/pii/S2352827323000939?via%3Dihub">higher rates of mental distress</a>. In another study, states enforcing abortion restrictions between 1974 and 2016 had <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2799597?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jama.2023.26816">higher suicide rates</a> in women of childbearing age in particular.</p>
<p id="mlDXo3">Post-<em>Dobbs</em>, these trends are unfortunately holding up: A <a href="https://www.vox.com/24071802/abortion-roe-overturn-trigger-ban-states-mental-health">recent study</a> suggested that in states with trigger bans, anxiety and depression have risen while symptoms of these conditions have simultaneously decreased in states without these bans.</p>
<p id="9jLDic">This is happening at a time when Americans are living in an age of broadly unmet <a href="https://www.vox.com/mental-health" data-source="encore">mental health</a> care needs: <a href="https://data.hrsa.gov/topics/health-workforce/shortage-areas">122 million Americans</a> live in areas with provider shortages, and only <a href="https://www.inseparable.us/AccessAcrossAmerica.pdf">one-third</a> of people diagnosed with a behavioral health condition get the care they need.</p>
<hr class="p-entry-hr" id="cPLAz5">
<p id="SMZles">Even if you’re not seeking an abortion and you don’t think you ever will, it’s worth taking a moment to see what it looks like when a nation systematically undervalues women’s bodily autonomy. The examples here aren’t a complete list, experts told me — and anti-abortion advocates have no intention of stopping at abortion restrictions; advocates are already using many of the same tactics to <a href="https://www.vox.com/24087411/anti-abortion-roe-dobbs-birth-control-contraception-ivf">undermine contraceptive access</a> as they used to chip away at abortion access.</p>
<p id="F50MHy">“It isn’t about abortion, it’s about control — abortion was just the first thing. And now that the floodgates are open,” said Wilkinson, “I’m surprised by how quickly the other side is moving.”</p>
https://www.vox.com/even-better/24106111/abortion-mifepristone-kacsmaryk-fda-economic-military-readiness-mortality-mental-health-povertyKeren Landman, MD2024-03-12T08:00:00-04:002024-03-12T08:00:00-04:00How to talk to boys so they grow into better men
<figure>
<img alt="An adult and a child hold hands, in silhouette-form, separated by a gap. " src="https://cdn.vox-cdn.com/thumbor/fBhHvjL3pVaAPt4OC2M4MK3WKDw=/158x0:4835x3508/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/73200506/GettyImages_1483667121.0.jpg" />
<figcaption>Westend61 via Getty Images</figcaption>
</figure>
<p>Counteracting the Andrew Tate effect isn’t just the purview of parents and teachers.</p> <p id="rgYmCE"></p>
<p id="CVN73q"></p>
<p id="y089kr"></p>
<p id="vGESrx"></p>
<p id="o2CbEs"></p>
<p id="5OMBRB"></p>
<p id="TXzo3D"></p>
<p id="gWrgHF">Men are <a href="https://www.vox.com/the-gray-area/23813985/christine-emba-masculinity-the-gray-area">not okay</a>.</p>
<p id="DbrqSE">They’re less likely to <a href="https://www.brookings.edu/articles/boys-left-behind-education-gender-gaps-across-the-us">graduate high school and go to college</a> than women, have <a href="https://www.vox.com/the-highlight/23323556/men-friendship-loneliness-isolation-masculinity">dwindling circles of friends</a>, and are <a href="https://www.frbsf.org/research-and-insights/publications/economic-letter/2023/10/mens-falling-labor-force-participation-across-generations/">sitting out of the labor market</a> at startling rates. Compared with women, they’re two to three times likelier to die of <a href="https://www.nih.gov/news-events/news-releases/men-died-overdose-2-3-times-greater-rate-women-us-2020-2021">drug overdoses</a> and nearly four times likelier to die by <a href="https://afsp.org/suicide-statistics/">suicide</a>. The disadvantages are particularly marked for working-class men and men of color.</p>
<p id="RKoF9K">The problem begins in boyhood — and so should the solution, says award-winning health educator <a href="https://www.mrhealthteacher.com/about">Christopher Pepper</a>, writer of the <a href="https://www.teenhealthtoday.com/">Teen Health Today newsletter</a> and co-author of the forthcoming book <a href="https://www.talktoyourboys.com/"><em>Talk To Your Boys</em></a>. In his view, a future where men are healthier and happier starts with better conversations with boys.</p>
<p id="YInQya">Technology has made those conversations harder to have. Back when family phones were in kitchens or living rooms — and casual communication usually involved talking to each other — more of the conversations kids were having with their friends and peers happened within earshot of parents and teachers. That gave adults more opportunities to coach kids on how to talk to each other, says Pepper. Now, kids learn to communicate on cell phones and social media largely out of view of adults during the key years they’re building social skills. </p>
<p id="Aut8pH">Boys suffer the social consequences of that more because while adults typically emphasize social skills in teaching girls how to interact with each other, there’s less of an imperative to guide boys in that way, Pepper says. That might explain why <a href="https://www.tandfonline.com/doi/full/10.1080/10888691.2021.1890592?scroll=top&needAccess=true">researchers</a> have found that on average, girls demonstrate better <a href="https://www.nytimes.com/2014/04/29/upshot/a-link-between-fidgety-boys-and-a-sputtering-economy.html">social skills</a> than boys as early as kindergarten — and that advantage widens over the course of elementary school as boys’ <a href="https://www.tandfonline.com/doi/full/10.1080/10888691.2021.1890592?scroll=top&needAccess=true">social abilities decline</a>. </p>
<p id="1oqOxR"> “Boys often don’t really learn the basics of social relationships and responsibility and communication,” says Pepper. Social skills adults may take for granted, like all the steps involved in making plans to meet a friend, are skills that aren’t necessarily taught. The consequences for boys aren’t good: As they grow up, they often <a href="https://onlinelibrary.wiley.com/doi/10.1111/jora.12047">lose close friendships with other boys</a>, even though they really want them.</p>
<p id="tJ2Q3z">The absence of clear guidance for many boys on how to be and act creates massive opportunities for internet misogynists like <a href="https://www.vox.com/culture/2023/1/10/23547393/andrew-tate-toxic-masculinity-qa">Andrew Tate</a>, says Pepper. “Tate has figured out that boys are actually really interested in talking about gender, talking about masculinity, and thinking about what it means to be a successful man,” says Pepper. Many boys don’t get much other messaging on these issues from their families or schools, leaving a void easily filled by charismatic jerks.</p>
<p id="z59ZnT">Bad behavior among students is <a href="https://www.edweek.org/leadership/student-behavior-isnt-getting-any-better-survey-shows/2023/04">worse</a> <a href="https://www.city-journal.org/article/confronting-the-student-behavior-crisis">now</a> than it was pre-pandemic, perhaps <a href="https://www.theguardian.com/society/2023/feb/02/andrew-tate-twisted-ideology-infiltrated-british-schools">especially among boys</a>. Although the causes are unclear, adults often blame increased social isolation and screen time, plus the popularity of figures like Tate and the viral spread of various dumb <a href="https://www.scarymommy.com/parenting/kids-mewing-in-class-tiktok-explained">TikTok</a> <a href="https://www.npr.org/2021/09/17/1038378816/students-are-damaging-school-bathrooms-for-attention-on-tiktok">trends</a>. </p>
<p id="PRTu2l">On a broader scale, though, Tate’s popularity shows what boys are missing, says Pepper: “There’s a real opening for adults to step up to more positive conversations about masculinity and what it means to be a man, and how they would like men to be in the world.”</p>
<p id="G2MFjG">I asked Pepper what those conversations could and should look like. Below is what he told me, in his own words, edited for length and clarity.</p>
<h3 id="ums8Px">Make it clear you’re a trustworthy adult <em>before</em> you need to have difficult conversations</h3>
<p id="YpCwoR">Depression, suicide, substance abuse — these can be scary things to learn about or to talk about. Sometimes adults have the impulse to rush into a conversation about a difficult topic and be very prescriptive and authoritarian — to say, “These are all the things you should not do.” </p>
<p id="eeNeZd">But shame and judgment tend to really shut off conversation. So instead, I would lean into curiosity in conversations before you get to the difficult stuff. When a boy invites you into his world, even in a little way, take that opening. Like if he’s talking about a song, or a funny meme, or a video game that he’s playing that he loves, be curious about it. And really listen, reflect back what he’s saying. Make sure you’re understanding where he’s coming from, and just do what you can to keep those conversations open so that when more challenging topics come up, you still have those lines of communication open — you’re still interested in hearing from each other.</p>
<h3 id="mjsIEz">Model, celebrate, and reinforce taking care of other people and experiencing a full range of emotions —<em> </em>especially if you’re a father</h3>
<p id="JE3uEY">Another thing you can do — and this is especially for fathers, but really, for any parents — is <a href="https://www.vox.com/even-better/23421467/parenting-good-influence-role-model-kids-mistakes">be reflective on your own life</a>: Are you making time to actually see your friends and be a good support, and to let the boys in your life see you doing that? Do you talk about your friends and the people you care about? </p>
<p id="oepVQs">One of the things that happens as boys are growing up is they learn about a very restrictive version of masculinity, a list of things that you’re not allowed to do or say. Particularly around emotions: You’re allowed to be angry, and you might be able to cry if something’s really bad — like a sports team you’re on loses a really important game, or someone died. But part of being a full human is being able to access and express a fuller range of emotions. So for adults, it’s important to ensure it’s safe for boys to do that, that you’re not criticizing them or judging them for it. If you hear other kids making fun of them for showing their emotions, stick up for them and say, “Hey, it’s actually good and positive to be connected to your feelings and to be able to show them.”</p>
<p id="pE2brs">When boys are showing care and concern and support for other people, celebrate it in the same way that you might celebrate more traditional things that are celebrated for boys, like sports victories or catching a big fish. You want to celebrate when they care for friends or family, too — like, “I saw how responsible you were with your little sister today when she was upset and really helped our family get through dinner,” for example. Really recognize and celebrate those things. They might be coded as feminine, but they’re really life skills that will help them grow into men who are good fathers, good partners, and good friends.</p>
<h3 id="BSoThI">When conversations get complicated: Notice signals that they don’t understand, know your own mind, and get comfortable with do-overs</h3>
<p id="yJWpPM">When boys blame girls or feminism for the problems in the world, that’s a big red flag — it often happens when they learn about issues from social media. </p>
<p id="ZUJvSm">If you hear a boy talking along these lines, it’s a good moment to engage him in some critical thinking. But rather than saying, “Oh, you’re totally wrong,” try something like, “I was surprised to hear you say that. Can you tell me more about what you’re thinking?” And if they mention learning something from a video, you can ask them to watch the video together and talk about it. </p>
<p id="4EiXzC">Boys often dismiss especially questionable or offensive statements as jokes — Peggy Orenstein got into this in her recent book, <a href="https://www.peggyorenstein.com/boysandsex"><em>Boys & Sex</em></a>. For example, they’ll say something about rape or the Holocaust and follow it up with, “Can’t you take a joke?” That’s often a signal that they want to learn more about something, or that they don’t understand it. </p>
<p id="sQvLtH">It can make an impact when an adult takes those jokes seriously — especially when men do. You could say: “Joking about <a href="https://www.vox.com/sexual-harassment" data-source="encore">sexual harassment</a> or rape is a red line, is not okay with me, and I want to tell you why.” For some boys, hearing from an adult man that the subject is serious and that they want to be able to talk about it — that will feel different than hearing it from a woman. Saying these things is a skill that gets easier with practice, and I think is an important thing for adults to get better at.</p>
<p id="PHlSk5">When adults are having these conversations, it’s good for them to get clear about their own values. Think through what you believe about <a href="https://www.vox.com/gender" data-source="encore">gender equality</a>, yourself, and what you understand about racism or sexism or homophobia. Recognize they can be hard but important things to talk about. </p>
<p id="qfA8LF">Being able to talk about these issues will be super useful to boys as they’re going through their lives. When they repeat things they hear online, they’ll be better able to decide if that’s something they actually believe.</p>
<p id="GoAnuC">Remember that as a parent, you have lots of chances — so it’s OK if you get it wrong the first time! If you have a conversation that kind of goes sideways, you can come back to it and say, “Hey, we talked about this yesterday and I thought about it later and realized I kind of misspoke. I wonder if we can talk about that again.” You can apologize to young people for getting angry; you can ask for a do-over of tough conversations, for a do-over of trying to understand them. In fact, asking for a do-over helps model and develop self-reflection and taking responsibility for a mistake in a way that can help boys be successful in their own lives.</p>
<h3 id="RLcVoF">Create places where boys can grow socially and emotionally </h3>
<p id="bu9ixt">More schools should have boys’ groups. </p>
<p id="QalNeV">It’s pretty easy for a boy to go through a whole school day and not talk to anyone, except maybe about the assignments that are due, or to maybe have some sort of surface-level conversation about a sports game or a video game. The surgeon general has said <a href="https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf">loneliness is a national crisis</a> — but on the whole, schools haven’t been putting a lot of effort into the social and emotional lives of boys. Schools often don’t have spaces where boys can talk reflectively to other boys and talk to a trusted adult about what’s going on in their lives. </p>
<p id="EycEgT">When they create these spaces — groups where boys can talk to other boys about what it is like to be a boy today and what’s going on in their lives, and get help with the day-to-day struggles in navigating the social and emotional side of the world — boys love them. </p>
<p id="Um7Ysx">There are great models of this all over the place. A Canadian nonprofit called <a href="https://www.nextgenmen.ca/">Next Gen Men</a> has a free curriculum — in addition to their in-person groups, they have one online on Discord. In Oakland, where I live, there’s a group called the <a href="https://everforwardclub.org/">Ever Forward Club</a>, and in New York, there’s <a href="https://www.acalltomen.org/">A Call to Men</a>, which has a free curriculum. Other programs engage coaches of boys’ sports teams in teaching healthy masculinity to their players. [See the sidebar below for more resources.]</p>
<p id="7MkDay">I’d like to see these kinds of programs expanded into more schools, just to encourage boys to really think about the world they’re living in, how they treat people, how to <a href="https://www.vox.com/friendship" data-source="encore">make friends</a>, and to get support when they need it.</p>
<div class="c-float-right"><div id="2RjafY"><div data-anthem-component="aside:12276056"></div></div></div>
<h3 id="jmouio">Even if you don’t live or work with boys, treating them like caring humans helps</h3>
<p id="XV0q4S">There are still lots of ways you can help boys develop into better men [if you’re not a parent or someone who works closely with them]. There are formal mentoring and tutoring programs, but on a more day-to-day basis, I think trying to recognize the humanity of boys is meaningful. Sometimes, the way adults talk about teenage boys, it’s like they’re really scary, or a different species. There are a lot of jokes about how terrible teenage boys are.</p>
<p id="ArnakI">It’s helpful if we recognize they’re human beings who will grow up to be men in our world. These are going to be our co-workers and neighbors. It’s often easier to build relationships with teenage boys individually, rather than trying to do so with a whole group of kids you don’t know. </p>
<p id="NHXMf3">So treat them as individual people and be curious about them. </p>
<p id="JXyonI">That could mean building a mentoring relationship, but it could also mean hiring somebody for a job, like to be the dog walker, or thinking about boys as possibly being babysitters or people who can take care of things. I would encourage people to kind of check their stereotypes about who can do that kind of care work — it’s not only teenage girls who could be good babysitters. Recognize everybody’s different. </p>
<p id="lB3248"></p>
<p id="ExSyqj"></p>
https://www.vox.com/even-better/24097641/andrew-tate-masculinity-teens-boys-men-talk-conversationsKeren Landman, MD2024-03-05T16:35:00-05:002024-03-05T16:35:00-05:00Abortion meds can now be sold in drugstores. Here’s why that’s so important.
<figure>
<img alt="A lit-up, red CVS Pharmacy sign attached to the side of a building." src="https://cdn.vox-cdn.com/thumbor/OiLiXsUHuJ34Th5VovpxJ_Gznbo=/0x0:2667x2000/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/73183938/GettyImages_1993770588.0.jpg" />
<figcaption>Joe Raedle/Getty Images</figcaption>
</figure>
<p>Some actually good news about Americans’ abortion access.</p> <p id="e0XI8x">On March 1, the New York Times <a href="https://www.nytimes.com/2024/03/01/health/abortion-pills-cvs-walgreens.html">reported</a> that over the following few weeks, some retail pharmacies owned by <a href="https://www.walgreensbootsalliance.com/walgreens-mifepristone-resource-hub">Walgreens</a> and <a href="https://www.npr.org/2024/03/01/1235265078/abortion-pill-cvs-walgreens-mifepristone">CVS</a> will begin dispensing <a href="https://www.vox.com/2023/4/10/23677220/texas-abortion-pills-usa-updates-mifepristone-misoprostol-kacsmaryk" data-source="encore">mifepristone</a>, a key drug used in medication abortions.</p>
<p id="1FV1Og">It’s a big change: Before the pandemic, people could only obtain the drug in-person at the office or clinic of the health care provider who prescribed it. But in 2021, the Food and Drug Administration (FDA) <a href="https://www.acog.org/news/news-articles/2022/03/understanding-the-practical-implications-of-the-fdas-december-2021-mifepristone-rems-decision#:~:text=On%20December%2016%2C%202021%2C%20the,dispense%20mifepristone%20must%20be%20certified.">removed</a> that in-person dispensing requirement, opening the door to getting <a href="https://www.vox.com/abortion" data-source="encore">abortion</a> medications through the mail — an important second option for people seeking an abortion. At the same time, the agency said it would create a pathway for retail pharmacies to get certified to dispense mifepristone, giving Americans a third way to access the drug. </p>
<p id="iF46oI">In early 2023, less than a year after the US <a href="https://www.vox.com/scotus" data-source="encore">Supreme Court</a> overturned the constitutional right to abortion, the FDA <a href="https://www.nytimes.com/2023/01/03/health/abortion-pill-cvs-walgreens-pharmacies.html">finalized</a> changes to its rules that newly allowed brick-and-mortar pharmacies to dispense the drug. (Although the FDA can’t decide in which states abortion is legal or whether there’s a national right to abortion, it <a href="https://www.kff.org/report-section/legal-challenges-to-the-fda-approval-of-medication-abortion-pills-appendix/">can and often does modify</a> its rules that determine who can prescribe drugs used in having an abortion; who can dispense them; and what hoops prescribers, patients, and pharmacies have to jump through when they’re used.) Late last year, <a href="https://www.politico.com/news/2023/10/06/pharmacies-begin-dispensing-abortion-pills-00120397">independent pharmacies</a> began dispensing the drug, and last week’s news indicates national pharmacy chains are also getting on board. </p>
<p id="06tQ6D">This moment might feel like the culmination of something, but it’s really just the start, says Kirsten Moore, who directs the Expanding Medication Abortion Access Project. “We have finally reached the end of the beginning phase of expanding access,” she says. </p>
<p id="bWNQTJ">In the short term, the move gives Americans another avenue for accessing a critical medication. But it will likely have even more important effects on improving abortion access in the long term, says <a href="https://www.aclu.org/bio/julia-kaye">Julia Kaye</a>, an attorney with the American Civil Liberties Union who led the litigation culminating in the FDA’s 2021 loosening of mifepristone restrictions.</p>
<p id="OYmfaE">Before these changes were set into motion, health care workers had to “effectively act as both the prescriber and the pharmacist,” Kaye says. Now, however, prescribers will be able to either use a mail order pharmacy or send a prescription to a local pharmacy for the patient to pick up — just as they would any other equally safe drug. </p>
<h3 id="G4Y9Cp">Anti-abortion activists have throttled mifepristone access from the start by burying it under piles of arbitrary restrictions</h3>
<p id="UYwZXT"><a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/questions-and-answers-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation">Mifepristone</a> works by blocking the progesterone hormone. During pregnancy, progesterone helps keep the lining of the uterus intact; without it, a pregnancy cannot go on. In the context of an abortion, mifepristone is usually used in conjunction with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760893/">misoprostol</a>, a drug that relaxes the opening to the uterus and helps the uterus contract and empty itself. (Misoprostol can already be legally dispensed in drugstores.)</p>
<p id="ekNczQ">The FDA’s official <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/020687s020lbl.pdf">labeling</a> for mifepristone indicates it’s approved for inducing abortions and, in a <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/202107s000lbl.pdf">different formulation</a>, treating a hormonal condition called Cushing’s syndrome. But like many other drugs, <a href="https://www.contraceptionjournal.org/article/S0010-7824(15)00259-0/fulltext">mifepristone</a> also has <a href="https://www.contraceptionjournal.org/article/S0010-7824(15)00259-0/fulltext">“off-label”</a> uses. An important one: It can speed up miscarriages once they’ve already begun, which helps reduce the need for surgery in these cases. </p>
<p id="OB1KVJ">When mifepristone was first <a href="https://www.accessdata.fda.gov/drugsatfda_docs/appletter/2000/20687appltr.pdf">FDA-approved for abortions in 2000</a>, it had already been in use in France since 1988. (Notably, France <a href="https://www.thecut.com/article/france-enshrines-abortion-rights-in-constitution.html">enshrined abortion rights</a> in its constitution this week.) Back then, there was already a fair amount of <a href="https://www.ncbi.nlm.nih.gov/books/NBK234199/">data</a> suggesting the drug, in combination with a medication like misoprostol, effectively ended pregnancies in 95 percent of the people who took it for that purpose. Additionally, its side effects were <a href="https://www.nejm.org/doi/full/10.1056/nejm199003083221001">mild</a>, including nausea and vomiting, dizziness, weakness, abdominal pain, and headache. </p>
<p id="89kUjR">Moore participated in the initial effort to get mifepristone FDA-approved for use in the US. “My boss at the time was like, ‘This is it — we finally turned the corner,’” she said. She thought the availability of medication abortion would mean people who wanted to end a pregnancy would be able to get a prescription from their primary care doctor or OB-GYN, pick up the medication from a pharmacy like any other medication, and take it in the comfort and safety of their own home. That meant more than just convenience — it meant people no longer had to subject themselves to the <a href="https://feminist.org/our-work/national-clinic-access-project/monitoring-clinic-violence/">harassment and violence</a> that has long plagued people working and seeking care at abortion clinics and that has <a href="https://prochoice.org/our-work/provider-security/2022-naf-violence-disruption/">worsened</a> in the wake of the Supreme Court’s decision to overturn<em> Roe v. Wade</em>.</p>
<p id="N29Q8k">But because mifepristone made abortion simpler — and increased privacy and safety for people seeking one — anti-abortion activists saw mifepristone as a huge threat. In the decades since the drug was approved, these <a href="https://www.brennancenter.org/our-work/analysis-opinion/follow-money-behind-anti-abortion-laws">activists</a>, and the legislators and justices they <a href="https://www.opensecrets.org/news/2022/07/abortion-rights-groups-consistently-spent-more-on-lobbying-and-political-contributions-than-their-counterparts-so-what-happened/">lobby</a> and <a href="https://www.opensecrets.org/news/2021/09/texas-largest-anti-abortion-group-spent-millions-on-public-campaign-lobbying-in-past-decade/">fund</a>, have responded by pushing for a <a href="https://www.guttmacher.org/article/2016/06/public-health-implications-fda-update-medication-abortion-label">web of regulation</a> aimed at reducing mifepristone access in numerous ways. (In some cases, these restrictions were justified with ham-fisted research conducted by anti-abortion researchers who did not always disclose their conflicts of interest; some of this research is now being <a href="https://www.nature.com/articles/d41586-024-00556-0">retracted</a> by the journals that initially published it.)</p>
<p id="jolt8G">Reams of data, however, have emerged proving mifepristone’s <a href="https://www.vox.com/policy/23678597/mifepristone-safety-abortion-pill-ruling-misoprostol-kacsmaryk-fda-rems">safety</a>. In <a href="https://www.guttmacher.org/article/2016/06/public-health-implications-fda-update-medication-abortion-label">2016</a>, the FDA began loosening some of its restrictions on the drug, raising the gestational age at which it could be used for an abortion from seven to 10 weeks and allowing it to be prescribed by a broader range of health care providers. The changes that allow the drugs to be mailed and now dispensed by retail pharmacies followed in 2021 and 2023. </p>
<p id="E5XNOL">Anti-abortion activists have continued to push back: After the 2023 FDA rule change, 20 attorneys general from red states wrote a <a href="https://apnews.com/article/abortion-missouri-state-government-west-virginia-united-states-us-food-and-drug-administration-a1b1a387788bb5aaa39c9ce4128d77ab">letter</a> to CVS and Walgreens threatening legal action if the chains sold mifepristone by mail, and a Texas judge <a href="https://www.vox.com/policy/2023/4/7/23593396/medication-abortion-pills-mifepristone-misoprostol-pregnancy-texas">suspended</a> the FDA’s approval of the drug. That latter decision has been <a href="https://www.vox.com/scotus/2023/12/13/23992173/supreme-court-abortion-ban-mifepristone-danco-fda-alliance-hippocratic-medicine">appealed</a>, and the US Supreme Court is expected to hear the case on <a href="https://www.supremecourt.gov/">March 26</a>.</p>
<p id="FJqkGx">“They’re trying to put the genie back in the bottle and they know they can’t,” says Moore.</p>
<h3 id="Bmfn9P">The biggest impact of this change may be to increase the number of mifepristone prescribers</h3>
<p id="DliFYV">The short-term impact of this change will be limited to a few states. Initially, Walgreens will make it available only at a few of its pharmacies in a <a href="https://www.walgreensbootsalliance.com/walgreens-mifepristone-resource-hub">handful of states</a> where abortion is still legal — New York, Pennsylvania, Massachusetts, California, and Illinois — and CVS will dispense the drug only at its pharmacies in Massachusetts and Rhode Island.</p>
<p id="Qt92A7">In states where abortion is illegal, retail pharmacies will still be unable to dispense mifepristone to patients if it’s prescribed to induce an abortion. However, they should be able to dispense the drug for other, off-label uses, at least to the extent they were before the Supreme Court’s decision. Most importantly, patients in these states who are prescribed mifepristone to <a href="https://apnews.com/article/miscarriage-mifepristone-abortion-pill-83166b25c71f6e62dcf2967064fdfec8">prevent complications of a miscarriage</a> should now be able to get the drug in retail pharmacies.<strong> </strong>Many, though, are probably not able to do so: In 2020, only <a href="https://jamanetwork.com/journals/jama/fullarticle/2807775">2.5 percent</a> of women having miscarriages were getting mifepristone from their health care providers — despite 2018 <a href="https://pubmed.ncbi.nlm.nih.gov/30157093/">guidelines</a> from the American College of Obstetricians and Gynecologists. It’s <a href="https://stateline.org/2023/10/20/many-women-cant-access-miscarriage-drug-because-its-also-used-for-abortions/">unlikely</a> access has improved much since.<strong> </strong>GenBioPro, the company that produces a generic version of mifepristone, maintains a <a href="https://genbiopro.com/roster">list</a> of independent pharmacies that stock the drug. </p>
<p id="Mro8KP">It’s not yet clear how much demand there will be for the drug at retail pharmacies, nor how patients can identify which Walgreens outlets can dispense it for use in an abortion. For now, Moore recommends that people considering an abortion visit <a href="https://www.ineedana.com/">I Need an A</a> or <a href="https://www.abortionfinder.org/">Abortion Finder</a> to identify prescribers.</p>
<p id="fEkr99">People who favor online ordering might not immediately grasp why a retail pharmacy pick-up may be more convenient than receiving the drug in your mailbox. “Obtaining mifepristone by mail is not a realistic option for some patients,” said Kaye, including unhoused or unstably housed people without permanent mailing addresses, or people who aren’t able to confidentially receive mail at home because they live with a controlling or abusive partner (or just have a nosy family). A pharmacy pickup also makes it possible to take the drug the same day it’s prescribed, rather than wait a few days for it to show up in the mail.</p>
<p id="rJSmHL">The bigger impact of this change will likely be to increase the number of mifepristone prescribers. Under the old rule, the health care provider “had to be both doctor and pharmacist — meaning they had to pre-purchase the medication and stock it in their clinic in order to hand it over to a patient,” says Moore. Now, although prescribers will still have to get certified to prescribe mifepristone, they won’t also have to deal with everything that dispensing it entails. </p>
<p id="Ugha5m">That would open the door to many more health care providers — including OB-GYNs and, in many states, primary care providers and other generalists who comfortably prescribe other reproductive health medications like birth control — to provide a fuller spectrum of women’s health care.</p>
<p id="KF9JnO">Kaye says it’s important for people who favor increased abortion access to give positive feedback to the pharmacies that are helping to do that. “Folks who are opposed to abortion do not stay quiet about their feelings on increased access, and so those of us who believe that patients should have access to all critical medications they need for reproductive health care should make our voices heard,” she says.</p>
<p id="9S3v2S">Moore also suggests that people who favor increasing abortion access ask their own health care providers to become certified mifepristone prescribers — and, in turn, to ask the pharmacies where they send prescriptions to dispense mifepristone. </p>
<p id="YOvGiy">Although barriers to mifepristone access remain in many settings, these chains’ decision to expand mifepristone dispensing is “still a really BFD” — a big fucking deal — says Moore. Whatever the caveats, she says, it means major industry players “are saying, ‘We do in fact, think this drug should be treated like other FDA-approved medications. And we’re ready to do that.’”</p>
<p id="dgszUt"><em><strong>Update, March 5, 4:35 pm ET: </strong></em><em>This story was published on March 5 and has been updated to include more information about how few people are prescribed mifepristone for miscarriages.</em></p>
https://www.vox.com/even-better/2024/3/5/24091215/mifepristone-abortion-cvs-walgreens-drugstores-retail-pharmacies-prescribersKeren Landman, MD2024-03-04T09:55:00-05:002024-03-04T09:55:00-05:00What do Americans want from their food? The answers are in Trader Joe’s recalls.
<figure>
<img alt="A Trader Joe’s logo on a shopping cart handle in orange and white." src="https://cdn.vox-cdn.com/thumbor/sHlpmXKf6AYc8dN-NR0H3SSiIcg=/222x0:3779x2668/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/72504064/1236969291.0.jpg" />
<figcaption>Signage on a shopping cart at a Manhattan Trader Joe’s grocery store in New York in December 2021. | Photographer: Jeenah Moon/Bloomberg via Getty Images</figcaption>
</figure>
<p>Leaving food safety to private enterprise has risks.</p> <p id="aAabha">On March 2, Trader Joe’s announced a chicken soup dumpling <a href="https://www.traderjoes.com/home/announcements?category=recalls&id=268982835">recall</a> because the products are potentially contaminated with plastic fragments of <a href="https://apnews.com/article/trader-joes-chicken-soup-dumpling-recall-74d677e020d8f55bab6635508305e459">permanent marker</a>. It’s hardly the first time something like this has happened, and not even the first time it’s happened this year: In early February, the company <a href="https://www.traderjoes.com/home/announcements/food-safety-overview">recalled</a> a frozen pilaf meal due to the possible presence of foreign material (<a href="https://www.realsimple.com/trader-joes-recalls-chicken-lentil-caramelized-onion-pilaf-8559465">maybe rocks?</a>). And <a href="https://www.traderjoes.com/home/announcements/food-safety-overview">last summer</a>, it announced recalls for cookies, broccoli-cheddar soup, falafel, and crackers due to the possibility they were contaminated with insects, rocks, or metal. </p>
<p id="8gqe1I">It’s “really very problematic” for the company, said Melvin Kramer, a food safety expert and president of the <a href="https://www.ehagroup.com/">EHA</a> environmental and <a href="https://www.vox.com/public-health" data-source="encore">public health</a> consulting group, when we spoke to him about the 2023 recalls last August. It’s also a concerning reminder for consumers about the fallibility of mechanisms meant to ensure our food supply doesn’t cause disease (or in this case, tooth breakages and what Kramer calls “the yuck factor”).</p>
<p id="KSNkdz">In all cases, it appears Trader Joe’s issued the recalls voluntarily, as most companies do in the case of a contaminated food product: The US government’s oversight system leaves a lot of food safety assurance in the hands of private companies. Companies are incentivized to get ahead of food safety concerns — rather than wait for the government to shut them down — in order to maintain consumer confidence and profitability. But the more globalized our food system becomes, the harder it gets to ensure its safety.</p>
<p id="LvfoXX">It’s not clear why so many<strong> </strong>of these recalls have<strong> </strong>happened so close together, and to what extent globalization and the relative lack of federal food oversight have<strong> </strong>played in the goods’ contamination. But when there is a recall, one of those issues is often the culprit.</p>
<p id="8Onjmb">“You could say it’s bad luck,” Kramer said. In a statement to Vox last summer, Trader Joe’s said the cluster of recalls back then<strong> </strong>was “a coincidence.” But another possibility, said Kramer, is that the same features that make Trader Joe’s products so appealing to so many people — essentially, its blend of global and local foods made by small-batch producers — raise its risk of running into more safety problems compared with grocery stores that only source food from large-scale producers.</p>
<p id="COpOKp">A US food retailer with more than <a href="https://www.scrapehero.com/location-reports/Trader%20Joes-USA/">500 stores</a> nationwide, Trader Joe’s has earned cult status among many Americans for selling taste-bud-thrilling, local specialty foods on a massive scale — and for telling compelling stories about its brands in unusually shrewd, zeitgeisty ways. (How many grocery stores have a branded <a href="https://podcasts.apple.com/us/podcast/inside-trader-joes/id1375630453">podcast</a> that’s actually good?)</p>
<p id="zmeXZf">But in the context of the US’s somewhat porous food safety system, the grocer’s embrace of idiosyncratic tastes means recalls like the latest one are occasionally going to happen. </p>
<h3 id="Ugrxcz">Different types of US food get different levels of scrutiny</h3>
<p id="WFBHk4">Two government agencies are responsible for overseeing food safety in the US. And while one has fairly close oversight over products within its jurisdiction, the other isn’t required to be quite so meticulous. That creates the opportunity for problems. </p>
<p id="4YEWby">The <a href="https://www.fsis.usda.gov/">Food Safety and Inspection Service</a> (FSIS), a branch of the US Department of Agriculture (USDA), oversees meat and egg products, and conducts continuous inspections of plants where these products are made. (That means inspections are supposed to take place daily; it’s a <a href="https://www.reuters.com/article/us-usa-meat-usda/usda-admits-skipped-meat-plant-checks-for-30-years-idUSN2930654720070329">scandal</a> when a meat or egg plant goes two weeks without an FSIS visit.)</p>
<p id="F7zLDr">The Food and Drug Administration (FDA) oversees <a href="https://nationalaglawcenter.org/food-recalls-what-are-they-and-how-do-they-work/">everything else</a>, which translates to the vast majority of the US food supply, nearly 80 percent of all the products Americans consume. However, the FDA only inspects the manufacturers it supervises once every three to five years.</p>
<p id="yK41zp">That means the FDA simply doesn’t have the power to catch problems with most of the food it oversees before it hits grocery store shelves. As a consequence, problems with much of our food supply only get caught when a manufacturer or a consumer notices it.</p>
<p id="glihzc">This also means that the agencies have different mechanisms for keeping unsafe products off of consumers’ plates. Although the FSIS can keep meat or eggs from getting to stores if it detects a problem, the FDA largely relies on recalls to reduce people’s exposure to an unsafe food product. </p>
<p id="w2X5pK">Waiting for a problem to occur in order to intervene on a food safety issue is a pretty passive approach to something with potentially high stakes for consumers’ health. When a consumer product causes a health problem, it can destroy the public’s trust in food producers — and that can in turn have a huge impact on a company’s profits. So food distributors are incentivized to take a more active approach to food safety than what’s required by the FDA.</p>
<p id="c6Mahf">For that reason, many supermarkets and other food retailers <a href="https://www.fdareader.com/the-food-producers-guide-to-third-party-audits-part-1">hire independent companies</a> to verify the safety practices of their suppliers. These companies, often called third-party auditors, check to ensure the suppliers adhere to certain <a href="https://mygfsi.com/what-we-do/harmonisation/">global food safety standards</a>. However, food retailers can (and often do) also require that the suppliers adhere to other sets of standards that set a higher bar for food safety.</p>
<p id="ioLCym">The key here is that to some degree, it’s up to the food retailer — in this case, Trader Joe’s — to set the standards they require their food suppliers to meet. </p>
<h3 id="D0V4j6">Embracing artisanal and nonseasonal foods increases food safety risks — which some people are happy to take</h3>
<p id="NAxvom">As any lover of salty-crunchy foods within snacking distance of a Trader Joe’s will tell you, the retailer does some things differently from other large grocery chains. </p>
<p id="zxaWvh">The company carries a range of products from “a lot of smaller, more local companies that may not have some of the sophistication that some of the larger companies do,” said Kramer.</p>
<p id="ETG5Hq">After all, food retailers like Trader Joe’s have some leeway in determining which standards their suppliers are required to adhere to. It’s possible the company’s vendor certification process is not as stringent as other grocers’ are, said Kramer — a risk the company balances with being able to offer its shoppers more unique, artisanal food experiences. </p>
<p id="M8Rctm">In response, a Trader Joe’s representative wrote in an email last summer that the company buys “only products that are produced in FDA or USDA licensed and approved commercial manufacturing facilities that possess a variety of food safety certifications,” including two <a href="https://www.who.int/teams/health-product-policy-and-standards/standards-and-specifications/gmp#:~:text=GMP%20defines%20quality%20measures%20for,the%20production%20of%20pharmaceuticals%20and">widely</a> <a href="https://www.fda.gov/food/guidance-regulation-food-and-dietary-supplements/hazard-analysis-critical-control-point-haccp#:~:text=HACCP%20is%20a%20management%20system,Dairy%20Grade%20A%20Voluntary%20HACCP">accepted</a> food quality assurance systems.</p>
<p id="L1h7M2">“A lot of their clients like these experiences. And unfortunately, this goes with it,” Kramer said, referring to the recalls.</p>
<p id="1yyeks">Food safety is vastly improved now compared with 20 or 30 years ago, said Kramer. However, our collective appetite for unusual and often out-of-season foods translates to persistent food safety risks. </p>
<p id="Mfyz18">Consider the raspberry: Although these fruits were for many years broadly unavailable in the US in wintertime, the demand for year-round raspberries created a market for international imports. As a consequence of <a href="https://academic.oup.com/cid/article/31/4/1040/372808">shipping the fruit to the US from abroad</a>, “We had basically the introduction of [the gastrointestinal parasite] Cyclospora into our country,” said Kramer. </p>
<p id="j3tMik">It’s not that food production is necessarily less safe outside the US than within its borders; Kramer has seen good and bad practices all over the world, including in the US. But the reality is that more complexity in our food systems means more risk.</p>
<p id="xN100G">“That’s what comes with a global economy,” said Kramer: We are a global community of food — and “we are very demanding people.”</p>
<p id="yUtj2g"><em><strong>Update, March 4, 2024, 9:55 am ET: </strong></em><em>This story was originally published August 1, 2023, and has been updated to include additional recalls from Trader Joe's. </em></p>
https://www.vox.com/23815696/trader-joes-recalls-falafel-cookies-soup-food-safety-fda-broccoli-cheddar-rocks-insectsKeren Landman, MD2024-03-01T17:40:02-05:002024-03-01T17:40:02-05:00The CDC has finally loosened Covid isolation guidelines. Here’s why that’s a good thing.
<figure>
<img alt="An illustration of a sitting person wearing a mask and looking at virus particles through a window." src="https://cdn.vox-cdn.com/thumbor/KAAsK5yoTQ6pomvCZFL3nMN4lUk=/0x0:5000x3750/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/73140460/GettyImages_1284429703.0.jpg" />
<figcaption>Maria Stavreva/Getty Images</figcaption>
</figure>
<p>Isolation policies haven’t stopped Covid’s worst outcomes. Other, better policies might. </p> <p id="RtB92V">Today, the Centers for Disease Control and Prevention (CDC) <a href="https://www.cdc.gov/media/releases/2024/p0301-respiratory-virus.html">changed</a> its <a href="https://www.vox.com/coronavirus-covid19" data-source="encore">Covid-19</a> guidance in a big way: People infected with the virus, or with other respiratory viruses, no longer need to isolate for five days before going back to work or school, the agency said. </p>
<p id="eepxQm">Instead, the agency advises that<strong> </strong>people can leave home if they’ve been fever-free for at least 24 hours (without fever-reducing medicine like ibuprofen or acetaminophen) and have improving symptoms. </p>
<p id="sUR3q2">The <a href="https://www.cdc.gov/respiratory-viruses/guidance/respiratory-virus-guidance.html">new guidance</a> does encourage people to take extra steps to prevent spreading their infections to others once they’ve resumed their usual activities, like <a href="https://www.cdc.gov/respiratory-viruses/prevention/immunizations.html">getting immunized</a> against preventable infections (which include Covid-19, flu, and RSV), <a href="https://www.cdc.gov/respiratory-viruses/prevention/hygiene.html">washing hands frequently, coughing and sneezing into elbows</a>, and using <a href="https://www.cdc.gov/respiratory-viruses/prevention/air-quality.html">air-filtering and ventilation strategies</a> — all of which are considered core strategies under the new recommendations. Meanwhile, <a href="https://www.cdc.gov/respiratory-viruses/prevention/masks.html">masking</a>, <a href="https://www.cdc.gov/respiratory-viruses/prevention/physical-distancing.html">keeping a distance from others</a>, and <a href="https://www.cdc.gov/respiratory-viruses/prevention/testing.html">testing</a> are in a lower-urgency “additional recommendations” category. </p>
<p id="4TgxEC">“It’s a reasonable move,” said <a href="https://www.southnassau.org/sn/find-a-doctor/glatt-aaron-e-md-macp-fidsa-fshea-chair-department-26">Aaron Glatt</a>, an <a href="https://www.vox.com/infectious-disease" data-source="encore">infectious disease</a> doctor and hospital epidemiologist at Mount Sinai South Nassau Hospital on Long Island. “When you’re doing <a href="https://www.vox.com/public-health" data-source="encore">public health</a>, you have to look at what is going to be listened to, and what is doable.” </p>
<p id="HERh34">Guidelines that adhere to the highest standards of infection control might please purists in public health who don’t have to make <a href="https://www.vox.com/policy" data-source="encore">policies</a> for the real world. However, guidelines that seem to acknowledge that workers often don’t have paid sick leave and emergency <a href="https://www.vox.com/child-care" data-source="encore">child care</a>, and that social interactions are important to folks, are more likely not only to be followed but to engender trust in public health authorities.</p>
<h3 id="u3iJn9">This change likely won’t increase exposure risk for the people most vulnerable to severe Covid-19</h3>
<p id="Yy3vdL">It’s important to note that the new recommendations are aimed toward the broader community and the people who live, work, and go to school in it — not toward hospitals, nursing homes, and other facilities whose residents are both less socially mobile and more vulnerable to the virus’s worst effects. </p>
<p id="nXDsCc">That means the people who are at higher risk of getting severely ill or dying if they get infected — people who are older and sicker at baseline — are subject to different, more conservative guidelines. Which makes sense, said Glatt: “It’s not the same approach in a 4-year-old kid as it is in a nursing home. It shouldn’t be.”</p>
<p id="YwzoSV">Covid-19 hospitalization rates among adults 65 and over are at least <a href="https://www.cdc.gov/coronavirus/2019-ncov/covidnetdashboard/de/powerbi/dashboard.html">four times</a> what they are in other age groups, and rates are particularly high among adults <a href="https://www.cdc.gov/surveillance/resp-net/dashboard.html">75 and over</a>, according to the CDC. In a <a href="https://www.cdc.gov/mmwr/volumes/72/wr/mm7240a3.htm">study</a> published in October, the agency reported that those 65 and older constituted nearly 90 percent of Covid-19 deaths in hospitals. </p>
<p id="a4cBls">The older adults getting hospitalized and dying with Covid-19 now are not the otherwise well people with active work and social lives who were getting severely ill earlier in the pandemic, said <a href="https://www.tuftsmedicine.org/doctor/shira-doron">Shira Doron</a>, an infectious disease doctor and hospital epidemiologist at Tufts Medicine in Boston. They’re people with severe underlying illness and compromised immune systems — and for many, it’s not even clear Covid-19 is what’s causing their decline. “I’m really struck by how totally different the Covid inpatient population — even the Covid death population that I’m seeing — is from 2020, or even 2021,” she said. </p>
<p id="LUUUwo">It’s hard to tell exactly how many of the worst-affected adults are infected in facilities like hospitals and nursing homes — in other words, how many of them would be relatively unaffected by a revised set of guidelines. It’s also hard to tell how many older adults, aware of their higher risk, take more measures to protect themselves in public, like wearing masks and gathering outdoors.</p>
<p id="U94m05">However, it’s worth noting the experiences of states that have already loosened recommendations. Since <a href="https://www.oregon.gov/oha/covid19/pages/index.aspx">Oregon</a> loosened its guidelines in May 2023, the state has not seen unusual increases in transmission or severity; <a href="https://covid19.ca.gov/isolation/#guidelines">California</a> made similar changes in January 2024. In revising their recommendations, state officials hoped to reduce the burdens on workers without sick leave and reduce disruptions on schools and workplaces, according to <a href="https://www.washingtonpost.com/health/2024/02/13/covid-isolation-guidelines-cdc-change/">reporting</a> in the Washington Post.</p>
<p id="fdEgWv">Doron said the reason loosened isolation guidelines haven’t led to mayhem in Oregon — nor in <a href="https://www.ecdc.europa.eu/en/publications-data/covid-19-guidance-discharge-and-ending-isolation">Europe</a>, where the recommendations began to loosen two years ago — is because isolation never did much to reduce transmission to begin with. “This has nothing to do with the science of contagiousness and the duration of contagiousness. It has to do with [the fact that] it wasn’t working anyway,” she said. </p>
<p id="y41xfE">Leaning away from what doesn’t work to reduce the virus’s impact — and toward what <em>does</em> work — is a smarter way forward, she said.</p>
<h3 id="zfTI3W">Revising testing guidelines would free up resources for interventions that actually work</h3>
<p id="8bN2Qp">Isolation guidelines haven’t been effective in mitigating Covid-19 harms because so many people simply do what they want, regardless of whether they’re sick — and they may avoid reporting symptoms to avoid being forced to comply with an isolation policy.</p>
<p id="PBFhty">Imagine a workplace or school policy adheres to the <a href="https://www.cdc.gov/coronavirus/2019-ncov/your-health/isolation.html">current CDC guidelines</a>, which recommend that people who test positive for Covid-19 infection stay home for at least five days. That policy creates a “perverse incentive” for some people who have symptoms to avoid getting tested, Doron said, because they don’t want to miss school, work, or a social event. Because so many people don’t have paid sick time, acknowledging even mild symptoms can lead to real financial losses when it means missing a week of work. </p>
<p id="Z4TLRw">At the same time, because these guidelines build testing into their protocols, they lead lots of other people — and the federal government — to spend money on at-home tests, which are often <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10701347/">inaccurate early in infection</a>. That’s a waste of resources that could save more lives if they were instead spent on providing tests to people likeliest to benefit from <a href="https://www.vox.com/even-better/2024/1/8/24026652/cold-flu-influenza-covid-rsv-season-respiratory-virus-cough-sneeze">Paxlovid</a> and getting them treated, said Doron.</p>
<p id="CLcdt3">“You should only be testing when it will change something, and that should be because you need Paxlovid or an antiviral,” Doron said. (Clarity and greater focus on who qualifies for Paxlovid would also be helpful, she said — current CDC recommendations are too broad.) </p>
<p id="hKBcx5">The updated guidelines clarify that <a href="https://www.cdc.gov/respiratory-viruses/prevention/testing.html">testing</a> is most useful for making choices about prevention or treatment — “even better than what I was expecting,” said Doron.</p>
<h3 id="gmMy1y">In the long term, CDC guidelines should normalize being considerate</h3>
<p id="YJhUOd">While the CDC’s guidelines are<strong> </strong>recommendations, not requirements, employers and state and local health departments often use them to guide their own policies.</p>
<p id="AV7Dci">In February, before the guidelines had been published,<strong> </strong><a href="https://www.siga.com/about-siga/#:~:text=Jay-,Varma,-Executive%20Vice%20President">Jay Varma</a>, an epidemiologist and biotechnology executive with extensive experience in state and federal public health practice, said one area where a new set of guidelines could make a big difference is in elevating and normalizing masking. He hoped the new recommendations would<strong> </strong>lean heavily into putting forth masking in public as a matter of routine for people who leave home as soon as they feel well.</p>
<p id="vcTcSA">“CDC should be thinking of this as a decades-long effort to promote cultural acceptance that being in public with a mask is similar to washing your hands, wearing a condom, or smoking outdoors: It’s a form of politeness and consideration for others,” Varma wrote in an email to Vox.</p>
<p id="RXhvV0">After all, in the long term, it’s a lot easier to change social norms around masking than it is to get people used to giving up their social lives for days or weeks at a time.</p>
<p id="8tlmXR">After the guidelines were released on Friday, Varma wrote on <a href="https://www.threads.net/@drjayvarma/post/C3-1Ymdu5TL">Threads</a> that public health officials should’ve advised individuals “that you don’t only use ventilation, hygiene, masks ‘when you’re home sick’ but when also you in public for at least 5 days after symptoms resolving.” He also wrote that organizations should improve ventilation and make N95 masks and antigen tests more broadly available to staff and visitors. </p>
<p id="NxApN4">It would also be helpful for public health officials to encourage people to factor in <em>who </em>gets exposed if they leave isolation soon after a Covid diagnosis, said Glatt. The revised guidelines do note that it’s especially important to use prevention strategies when you’ll be around people who have <a href="https://www.cdc.gov/respiratory-viruses/risk-factors/index.html">risk factors for severe illness</a> — for example, if they take high-dose immunosuppressive medications, are either older adults or young children, or are pregnant.</p>
<p id="HaKlb2"><em><strong>Update, March 1, 5:40 pm ET: </strong></em><em>This story, originally published on February 14, has been updated to note the CDC’s revised guidelines on respiratory virus prevention.</em></p>
https://www.vox.com/2024/2/14/24073306/isolation-covid-guidelines-cdc-changeKeren Landman, MD2024-02-27T09:30:23-05:002024-02-27T09:30:23-05:00A guide to starting your mental health journey
<figure>
<img alt="A drawing of a silhouetted head with its skull open like a lid. A disembodied hand is pulling a string from inside the tangle in the head." src="https://cdn.vox-cdn.com/thumbor/NVNPywuK4L6alHstL4472vWsdcA=/54x0:5774x4290/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/73167506/GettyImages_1934506289.0.jpg" />
<figcaption>Getty Images</figcaption>
</figure>
<p>From choosing the right therapist to figuring out how to pay.</p> <p id="84zQ0B">I wanted to start seeing a therapist long before I finally did. </p>
<p id="ShPEQx">For many years, my biggest obstacle was a near-total lack of free time, then a lack of insurance coverage for <a href="https://www.vox.com/mental-health" data-source="encore">mental health</a> care, then a range of positions that made seeking mental health care a <a href="https://www.vox.com/health/23921266/mental-health-doctors-physicians-depression-burnout">professional liability</a>. Even once I finally had a job with decent benefits and a list of therapists recommended by trusted friends, it took months to overcome another big obstacle to picking up the phone: my fear that during my first conversation with a prospective provider, I’d end up crying on the phone to a stranger. </p>
<p id="htwsyd">I’m not alone. In scientific studies, people who’d benefit from mental health care<strong> </strong>give rich and varied reasons for not seeking it, among them <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3128692">thinking it’s unnecessary</a>, fear others will <a href="https://pubmed.ncbi.nlm.nih.gov/15943655">think less of them</a> for getting it, and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9315193/#:~:text=Barriers%20may%20include%20high%20cost,Cohen%20Veterans%20Network%2C%202018).">cost</a>. At the same time, the US mental health care system isn’t structured to make treatment broadly available: Last year,<strong> </strong><a href="https://www.commonwealthfund.org/publications/explainer/2023/may/understanding-us-behavioral-health-workforce-shortage">160 million Americans</a> lived in areas with provider shortages and insurance denials, and in 2021,<strong> </strong>only <a href="https://www.inseparable.us/AccessAcrossAmerica.pdf">one-third</a> of people diagnosed with a behavioral health condition got the care they needed. Recent efforts to strengthen <a href="https://www.vox.com/2023/8/4/23815827/mental-health-therapy-services-health-insurance">laws aimed at improving access</a> might eventually help, but it’s not going to happen overnight. </p>
<p id="JwgmTB">If you’re considering getting care for your mental health needs, just getting started can feel daunting, and the landscape of payment, providers, and your progress can feel like a minefield. It’s especially hard to begin if you embark on this journey when you’re at a low point. </p>
<p id="LtoxWt">I speak from experience: I did wind up having the teary conversation I’d dreaded. But it turned out to be more clarifying than mortifying, and the therapist on the other end of the line<strong> </strong>was a keeper. </p>
<p id="wiePfJ">People face a range of common obstacles when seeking mental health care. Here’s how to navigate a few of them.</p>
<h3 id="pmWaAH">How do I start looking for help when I’m not sure what’s wrong with me?</h3>
<p id="OVy8Ar">People across the spectrum of okayness access mental health care at different times in their lives, and there’s huge variation in what leads them to do so, says <a href="https://www.linkedin.com/in/rochfordmegan">Megan Rochford</a>, who oversees the National Alliance on Mental Illness’s (NAMI’s) national <a href="https://nami.org/help">helpline</a>. No matter your situation, keep in mind that you don’t need to know what you need to start getting care.</p>
<p id="Kecmxu">If a sense of shame is keeping you from seeking mental health care, know that you’re not alone and help is out there, says Rochford. Calls to helplines like NAMI’s and the care that licensed professionals provide are confidential, she says, and their goal is to give you what you need to be your best and strongest self. Furthermore, getting mental health support might not look the way you imagine it: The vocabulary of modern mental health care goes beyond therapists’ couches and medications and includes <a href="https://www.vox.com/the-highlight/23402638/mental-health-psychiatrist-shortage-community-care-africa">options</a> like <a href="https://www.mhanational.org/bipoc-mental-health/community-care">community care</a> models (including healing circles and peer support)<strong> </strong>that feel more welcoming for some people. </p>
<p id="plB0gV">Although the people you consult as you’re seeking care might be the experts on the resources available to you, you’re ultimately the expert on your own experience, and you get to decide what feels right for you, says <a href="https://www.mhanational.org/niya-mccray-brown">Niya McCray-Brown</a>, a licensed professional counselor who directs community engagement at the education and advocacy nonprofit Mental Health America (MHA). </p>
<p id="73vAgU">Some people find themselves seeking mental health care in a moment of crisis. For example, they’re losing control of their ability to work, go to school, or be present for loved ones, or are in danger of harming themselves or other people. In these cases, finding care is urgent — and it’s now a comparatively straightforward process, said Rochford: The <a href="https://988lifeline.org/">988</a> suicide and crisis lifeline, which rolled out nationally in <a href="https://www.samhsa.gov/find-help/988/lifeline-timeline">July 2022</a>, provides around-the-clock emotional support to people in distress and, if needed, connects people with services and facilities in their area. If you are in crisis, you can dial 988 from any phone, access the chat feature from the 988 <a href="https://988lifeline.org/">website</a>, or text MHA to the number 741741.</p>
<p id="fdzjX8">For people who aren’t in crisis, the symptoms that lead them to seek mental health care may include both emotional and physical sensations. Many people seeking mental health care for the first time offer reasons including feeling particularly sad or overwhelmed, sensing constant worry, or being unable to turn off an internal voice, says <a href="https://www.apa.org/practice/office-independent-practice">Marnie Shanbhag</a>, a psychologist based in Winter Park, Florida, who works for the American Psychological Association. Others report trouble concentrating, trouble sleeping, or low energy.</p>
<p id="gNQvb3">People may also seek care to help change or get through specific moments in life, said Rochford. You might want to understand why you make certain choices or how to think through a problem you’re facing. Maybe you want help managing some unhealthy coping skills, like relying too much on alcohol or drugs, or working through some conflicts in a romantic or family relationship. Or perhaps you’re interested in seeing if you’d benefit from medication or getting a diagnosis.</p>
<p id="rSXM9J">The toolkit for treating mental health concerns is large, and you don’t need to know exactly which tools you need in order to start getting care. However, it can be helpful to have an objective in mind, says Rochford: “Give some thought to what your goals are, and then give some thought to how to best go about meeting those needs,” she says. </p>
<p id="hTye7v">Websites like <a href="https://www.nami.org/Your-Journey">NAMI’s</a> and <a href="https://screening.mhanational.org/mental-health-101/">MHA’s</a> can help you put words to feelings or symptoms that are difficult to describe. There are also lots of mental health “warmlines,” free and confidential support lines that provide help over the phone: NAMI runs a national <a href="https://nami.org/help">helpline</a>, and many states run their own <a href="https://nami.org/Support-Education/NAMI-HelpLine/NAMI-Warmline-Directory">warmlines</a>. These are different from hotlines like 988 in that they’re geared less toward supporting people through a crisis and more toward connecting people with resources for future care.</p>
<p id="bnwwaZ">These websites and helplines can also help you get oriented to the array of resources people with mental health concerns can access. Although many people may think of talk therapy and medications as the cornerstones of care, there are also self-help and <a href="https://www.mhanational.org/find-support-groups">support groups</a>, peer support and other community care approaches, and a range of nonmedication treatments that can be helpful in lots of situations. For certain serious mental illnesses that are harder to treat, <a href="https://www.psychiatry.org/patients-families/ect">electroconvulsive therapy</a> may play a role, and a range of <a href="https://www.vox.com/future-perfect/23721486/ketamine-dmt-lsd-psychedelics-magic-mushrooms-legalization-recreation-psilocybin">psychedelic drugs</a> are showing a lot of promise.</p>
<div><aside id="FcCdA9"><q>Mental health professionals are generally pretty comfortable helping you find the right place to start, even if it means connecting you to a different provider with the best expertise for your specific need</q></aside></div>
<p id="rcKK9m">If you’re not sure how to proceed even after some research, consider running your concerns past your primary care provider, says Rochford. “It can be very helpful to talk to somebody you trust who can kind of serve as a compass,” she says. Primary care providers likely know of mental health providers in your area, and can often start and manage medications for mental health complaints. Plus, it’s wise to rule out the possibility that a physical condition is contributing to your symptoms. </p>
<p id="5Pr8E3">Ultimately, mental health professionals are generally pretty comfortable helping you find the right place to start, even if it means connecting you to a different provider with the best expertise for your specific need, says Shanbhag. </p>
<p id="Kfw1IB">For more information about mental health diagnoses and types of treatment and support, check out:</p>
<ul>
<li id="dOH9DY">MHA’s <a href="https://mhanational.org/b4stage4-get-help">Common Treatment Types and Managing Expectations</a>
</li>
<li id="Muoeuh">NAMI’s list of <a href="https://www.mhanational.org/find-support-groups">support groups</a> and <a href="https://www.mhanational.org/bipoc-mental-health/community-care">community care organizations</a>
</li>
<li id="bLsfTZ">NAMI’s <a href="https://nami.org/Support-Education/NAMI-HelpLine/NAMI-Resource-Directory">Resource Directory</a>, one of many <a href="https://nami.org/help">resource lists</a> on the organization’s website</li>
</ul>
<h3 id="ONMdtR">How do I pay for therapy and other mental health treatments? </h3>
<p id="Dx2mbz">Cost is always a concern when accessing any kind of health care; mental health care is no exception.</p>
<p id="RmN0ub">If you’re insured, look at your plan details (or call the 800 number on your insurance card) to figure out what kinds of treatment your insurer covers. There may be a deductible — that is, a portion of the cost that you pay regardless of the total cost — and that amount may vary quite a bit between plans. Some plans also fully cover a certain number of visits with a provider before you start paying out of pocket. </p>
<p id="E6dpWH">The upshot is that there’s a ton of variation between plans, so if you’re insured, avoid surprises by checking with your insurer before seeking care.</p>
<p id="UyzJA8">Many insurance plans have a network of providers whose services cost less to people in the plan than providers outside the network. Typically, these providers live in your state — although in the case of some online-only providers, they may live in another state but be licensed in yours. Many plans will pay some percentage of the total cost for providers in their network, and a lower percentage (or nothing) for providers out of network.</p>
<p id="EmKPMF">Even if you do have insurance, getting your mental health care paid for is often different from getting physical health care paid for. Many therapists give you their bill directly, which you pay and then submit to your insurer for reimbursement. </p>
<p id="myJVjt">If you don’t have health insurance, you still have options. If you want therapy, paying full price out of pocket may be an option. It’s costly, typically ranging from <a href="https://www.psychologytoday.com/us/basics/therapy/cost-and-insurance-coverage">$100 to $200</a> for a<strong> </strong>session. Some providers offer therapy on a sliding scale — which means lower costs for people with less ability to pay — so it’s worth asking.</p>
<p id="LjoueG">Additionally, many <a href="https://www.verywellmind.com/best-online-therapy-4691206">online-only providers</a> provide services to people paying out of pocket (some also accept certain insurance plans).</p>
<p id="vMlTZQ">There are also low- and no-cost options, both for therapy and for other types of treatment. Rochford suggests looking for universities with graduate programs training people to provide psychotherapy; these often offer treatment for free. Additionally, self-help and support groups are typically free to attend. </p>
<p id="0lkS04">For more information on the financial side of mental health treatment, check out:</p>
<ul>
<li id="ezewbg">
<a href="https://nami.org/Blogs/NAMI-Blog/April-2020/Strategies-to-Afford-Mental-Health-Treatment">This article</a> on NAMI’s website</li>
<li id="Qqig15">MHA’s <a href="https://mhanational.org/paying-care">Paying for Care</a> page</li>
</ul>
<h3 id="ydCH9T">How do I find a therapist?</h3>
<p id="uDJcou">For many people with a mental health concern, psychotherapy — treatment that involves talking with a therapist to help identify and change bothersome feelings, thoughts, and behaviors — is part of the treatment plan. Looking for a therapist, though, can easily lead to more questions than answers: The acronyms describing different treatment approaches and skill sets may be confusing to people, and it might not be clear how to determine the cost-effectiveness of choices upfront.</p>
<p id="y1ZR84">To start a search, it can be helpful to begin by considering your finances. If cost is a priority and you’re insured, it’s worth starting with the list of in-network providers your insurer maintains. You can search online for the names of individual providers to get some information about the populations and issues they typically focus on in their practice, or you can call individual providers to ask whether they have experience dealing with people whose concerns are similar to yours. Psychology Today maintains a large <a href="https://www.psychologytoday.com/us/therapists">directory</a> where therapists can pay to be listed alongside details about their practice, as do several other websites, or you can simply plug their name and “therapist” into a search engine.</p>
<p id="YpfvzY">Among the lower-cost therapy options available for both insured and uninsured people are the mental health services many local health departments and community-based organizations may offer. For people of faith, clergypeople may serve as a good resource, and for children, check to see if a school guidance counselor can provide some help.</p>
<p id="kifKQK">Although some therapists see patients only in person or online, many offer both as an option. “The pandemic changed the way we thought about telehealth,” says <a href="https://education.gsu.edu/profile/jeff-ashby/">Jeff Ashby</a>, a psychologist and professor at Georgia State University who researches stress and trauma. “What we discovered — consistent with previous research — is that a whole lot of issues can be treated using telehealth.”</p>
<p id="brSfFf">There might be some small advantages to in-person therapy: It allows your therapist to read your body language, not just your facial expressions, and makes building a therapeutic relationship a little easier. In part for that reason, <a href="https://education.gsu.edu/profile/catherine-chang/">Catharina Chang</a>, a professor and counselor at Georgia State University, recommends having at least one or two in-person sessions before switching to virtual interactions. But the best modality for accessing therapy really is the one that gets you the help you need. “The important thing is that you get help, and have a way you can get the help,” she says. If that means using a virtual-only platform, that’s fine!</p>
<p id="lsQvTQ">Lots of text-based therapy platforms have popped up in the past few years. Although these platforms offer what feels like an easy way to access support, experts advise approaching them with caution. State psychotherapist licensing boards, which accredit therapists based on their adherence to evidence-based best practices, haven’t approved text-based therapy, says McCray-Brown of MHA. “I would just caution folks to understand the implications of that, both in terms of the quality of service that they’re getting and what payment options are available to them,” she says. In other words, you’ll probably be paying out of pocket for text-based therapy — and there isn’t yet great evidence that it actually helps.</p>
<p id="khTtTz">For more tips on finding a therapist, check out:</p>
<ul>
<li id="7fvVXq">NAMI’s <a href="https://nami.org/Your-Journey/Individuals-with-Mental-Illness/Finding-a-Mental-Health-Professional">Finding a Mental Health Professional</a> page</li>
<li id="XwHgsn">
<a href="https://www.npr.org/sections/health-shots/2023/07/02/1185661348/start-therapy-find-therapist-how-to">This helpful guide</a> from NPR Shots </li>
</ul>
<div class="c-float-right"><aside id="o9pU4O"><q>The best modality for accessing therapy really is the one that gets you the help you need</q></aside></div>
<h3 id="u0AYVr">What do all the degrees and job titles mean?</h3>
<p id="QTHS10">If you’re choosing a therapist from a list, the array of letters following providers’ names can feel dizzying. It’s wise to keep a few things in mind as you look at credentials.</p>
<p id="njSpsq">First, there’s a difference between therapists who’ve been licensed by the state or states they practice in and those who haven’t. Licensed providers have to complete thousands of hours of supervised training before hanging up a shingle, have been extensively trained in diagnosing and treating mental health disorders, and are bound to keep your information confidential by HIPAA laws and ethical standards. </p>
<p id="GKw6Zw">None of this is guaranteed with unlicensed providers. The experts I spoke with suggested that unless you’re receiving therapy from a clergyperson under the umbrella of pastoral care, seeking out licensed providers is the safest route. </p>
<p id="BkQNpC">Second, the paths to becoming a licensed therapist include getting a master’s degree (in counseling, social work, or marriage and family therapy) or a doctoral degree (typically in psychology). They also include a minimum of two years of supervised experience providing therapy. Although the degree alone doesn’t convey much in the way of a therapist’s fit or even their experience, a few differences may be of interest to potential patients:</p>
<ul>
<li id="D3ftCz">
<strong>Psychologists</strong> (i.e., therapists with either a PhD in psychology or PsyD and at least three to five years of supervised experience) are trained in assessing a variety of mental disorders, which may be helpful for people seeking a diagnosis or treatment of a particular condition.</li>
<li id="olaPNx">
<strong>Clinical social workers </strong>(i.e., therapists with a master’s degree in social work and at least two years of supervised experience) have experience in managing stressors related to housing, employment, and other social issues. When these issues overlap with mental health concerns, a therapist with this training can function as a “one-stop shop” in many ways, says <a href="https://www.socialworkers.org/About/Staff">Mirean Coleman</a>, who directs clinical practice at the National Association of Social Workers.</li>
<li id="2a3DLN">
<strong>Licensed professional counselors</strong> (i.e., therapists with a master’s degree in counseling and at least two years of supervised experience) have training in diagnosis and can provide one-on-one and group counseling. Some have focused training in rehabilitation and school counseling.</li>
<li id="cQ1hmH">
<strong>Licensed marriage and family therapists</strong> (i.e., therapists with a master’s degree in counseling and at least two years of supervised experience) also have training in diagnosis, along with additional training in family systems and how close interpersonal relationships work.</li>
<li id="mZsXLR">
<strong>Psychiatrists</strong> are medical doctors with training in diagnosing and treating many types of mental illness. They less commonly provide talk therapy nowadays, but unlike most other therapists, they can prescribe medication. Typically, if a therapist determines a patient would benefit from medication, they refer them to a psychiatrist (or a psychiatric nurse practitioner) to prescribe and manage the medication, and stay on as the provider of psychotherapy for the patient. </li>
</ul>
<p id="oMe2x6">So as long as your therapist has experience in the issue you need help with, it makes sense to put more weight into whether you “click” with the person you’re seeing and less into what letters they have following their name.</p>
<p id="gqGDzC">Beyond differences in their degrees, there’s a ton of other variations among therapists: </p>
<ul>
<li id="8uve3s">Many develop expertise in working with certain populations — for example, older adults, or <a href="https://www.vox.com/lgbtq" data-source="encore">LGBTQ</a> people. </li>
<li id="4P1Lv5">Some get special training in caring for people with certain diagnoses or experiences (like obsessive-compulsive disorder, eating disorders, or trauma).</li>
<li id="l2T3IC">Different therapists often specialize in several of a variety of treatment <a href="https://www.nami.org/About-Mental-Illness/Treatments/Psychotherapy">methods</a>, like cognitive behavioral therapy (used for a range of conditions, including depression, anxiety disorders, bipolar disorder, eating disorders, and schizophrenia), dialectical behavioral therapy (a frequent treatment for borderline personality disorder), <a href="https://www.psychologytoday.com/us/therapy-types/acceptance-and-commitment-therapy">acceptance and commitment therapy</a> (also used for a broad range of conditions, including obsessive-compulsive, eating, and substance use disorders), and eye movement desensitization reprocessing therapy (often used for treating post-traumatic stress disorders).</li>
</ul>
<p id="62W900">It’s not uncommon for people with certain identities — like those with certain racial, ethnic, religious, gender, or sexuality affiliations — to seek out therapists who share that identity. “It’s natural, healthy, and valid that folks want to work with a clinician or work with a mental health care worker that has a similar experience to them,” says McCray-Brown of MHA.</p>
<p id="ziprDQ">That doesn’t mean that a mismatch is a bad thing. In fact, says McCray-Brown, “you might be able to find a sense of confidence and empowerment in educating others about your experience.” Additionally, good providers should have enough cultural humility to validate the experiences you bring to the table as part of your identity.</p>
<p id="ZY6cbW">For people who prefer to see a therapist with some cultural overlap but are struggling to find one, it’s reasonable to prioritize seeing someone who otherwise has the skills and fit that works for you rather than waiting. Don’t let perfect be the enemy of the good here — but at the same time, don’t hesitate to ask for changes if your experience isn’t affirmed and validated, says McCray-Brown. </p>
<p id="g1fGa5">For more information on types of mental health professionals, check out:</p>
<ul><li id="mI4284">MHA’s <a href="https://www.mhanational.org/finding-right-mental-health-care-you">Finding the Right Clinical Mental Health Care For You</a>
</li></ul>
<div class="c-float-right"><aside id="Uv3tuF"><q>Don’t let perfect be the enemy of the good here — but at the same time, don’t hesitate to ask for changes if your experience isn’t affirmed and validated</q></aside></div>
<h3 id="rkSmYP">How do I decide if a therapist is the right one for me — and can I fire them if they’re not?</h3>
<p id="R75q7V">The fit between a patient and their therapist is the most important thing in determining whether therapy will be productive, says Ashby. But it can be difficult to predict what kind of person you’ll click with in therapy. “Think about it as shopping,” he says. “There may be really talented therapists for whom you’re not a good fit,” and if that only becomes clear after you’ve been seeing them a while, you’re still absolutely within your rights — and not in violation of any norms — to move on to someone who’s a better fit.</p>
<p id="H6VOjC">“Good therapists only want to work with clients who are good matches because no one wants to be unsuccessful,” says Ashby.</p>
<p id="qxNk6u">As you start looking for a therapist, it’s key to remember that therapists are aware of the importance of fit between themselves and their clients, and they’ll know it’s totally normal for you to talk to a few people before settling on someone to work with. You shouldn’t be getting a hard sell from a therapist: Instead, you should get a clear sense that they’re well-qualified and open to working with you, but that it’s your choice to work with them.</p>
<p id="80ib5s">McCray-Brown suggests asking prospective therapists for a 10- or 15-minute consultation call to get to know them and their practice. Questions that can help you get a feel for how you might work together include:</p>
<ul>
<li id="1b3YC3">What types of clients have you worked with before? </li>
<li id="S5cK9W">Have you ever talked to somebody who’s dealing with the things I’m dealing with? </li>
<li id="UoZXdX">What type of approach do you use in your therapy? </li>
<li id="MUZvzj">How often will we be meeting? </li>
<li id="tVJEj5">How long are individual therapy sessions?</li>
<li id="lTQGU3">How would you handle it if I had a crisis?</li>
<li id="7dl3Os">How long does treatment for a condition like mine typically take?</li>
</ul>
<p id="QOcCSB">For help finding local providers, have a look at:</p>
<ul><li id="JatxXq">MHA’s guidance on <a href="https://www.mhanational.org/finding-therapy">finding a therapist</a>.</li></ul>
<h3 id="q3Bnvb">How will I know when I’ve gotten everything I can out of therapy or other mental health treatment? </h3>
<p id="yKSqgc">Getting therapy for mental health problems can be uncomfortable even when things are going well. Chang, of Georgia State University, suggests checking in with yourself after the first visit to determine if the fit is right. She recommends asking yourself if you felt heard, if the therapist seems like someone you can open up to, and if you were encouraged to talk about the goals and outcomes you want out of counseling.</p>
<p id="JCWREb">As psychiatrist <a href="https://vivo.weill.cornell.edu/display/cwid-rafriedm">Richard A. Friedman</a> recently <a href="https://www.theatlantic.com/health/archive/2024/02/therapy-vacation-long-term/677336/">wrote</a> in the Atlantic<em>, </em>most types of mental health therapy — and many mental health medications — have a common goal: “to eventually end treatment because you feel and function well enough to thrive on your own.” While some people with chronic conditions may need pharmacotherapy and individual or group support indefinitely, the majority of people who seek mental health care should consider it to be something they will eventually no longer need, or need only sporadically.</p>
<p id="muwjB9">The duration of therapy — and other types of mental health care — varies among people and conditions. Sometimes, a few sessions fix whatever was wrong, but more often, therapy uncovers the tip of an iceberg, says Ashby. Sure, you might “hassle around and finally find somebody and see somebody for two or six sessions and say, ‘I think I got it, I think these are the aches and pains of life,’” and feel like you’ve got it sorted out, he says. </p>
<p id="gtR4Db">But more commonly, people have been spending a lot of emotional energy holding issues at bay by the time they finally seek treatment for a mental health concern, and it takes time to unpack things. Even then, writes Friedman, therapy typically lasts a few years at most, not indefinitely.</p>
<p id="TuuBiF">Rochford suggests talking to your provider early on about what it will look like when you’ve reached your goals. Then, as you work together to figure out what you need, you’ll both know what an endpoint might look like. </p>
<p class="c-end-para" id="zj8D1g">Some people may be ready for a deep dive into something that’s been impairing their function, like a history of trauma and a current major depressive disorder, says Rochford. Others might just want a few months of work on reducing burnout, setting better boundaries, or having a stronger relationship. The goals of mental health care look different for different people, she says: “You’re the expert on what you need, what’s going to work best for you, what you’re ready for.”</p>
https://www.vox.com/even-better/24084051/mental-health-care-how-to-find-the-right-therapist-community-careKeren Landman, MD2024-02-20T07:30:00-05:002024-02-20T07:30:00-05:00Living in an abortion ban state is bad for mental health
<figure>
<img alt="Rows of women march in front of the US Capitol building, the front row carrying an orange banner." src="https://cdn.vox-cdn.com/thumbor/oj6OH3QirEZDFRuJ2yGf2UJ1XNM=/487x0:8072x5689/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/73151211/1242000690.0.jpg" />
<figcaption>From left, Democratic Reps. Nydia Velázquez, Ilhan Omar, Jackie Speier, and Carolyn Maloney make their way to the Supreme Court for a sit-in to protest the decision to overturn <em>Roe v. Wade</em>, on July 19, 2022. | Tom Williams/CQ-Roll Call, Inc via Getty Images</figcaption>
</figure>
<p>Worsened anxiety and depression is a predictable (and costly) effect of abortion bans.</p> <p id="Qx3KsU">The false idea that getting an <a href="https://www.vox.com/abortion" data-source="encore">abortion</a> makes women irreparably depressed and anxious, that it causes a deep psychic wound, has <a href="https://www.guttmacher.org/gpr/2006/08/abortion-and-mental-health-myths-and-realities">for decades</a> been used by anti-abortion activists to support abortion restrictions.</p>
<p id="ktf4gd">But the argument is entirely based on anecdotes, personal beliefs, and vibes. <a href="https://pubmed.ncbi.nlm.nih.gov/19014789/">No good science</a> has demonstrated this link.</p>
<p id="61c1r7">That’s not because nobody’s tried to answer the question of what the <a href="https://www.vox.com/mental-health" data-source="encore">mental health</a> impacts of abortion are on the women who obtain them. It’s because the answer to that question, over and over again, is: none. In <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2592320?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jama.2023.26816">study</a> after <a href="https://pubmed.ncbi.nlm.nih.gov/24402590/">study</a>, researchers have consistently shown that getting an abortion does not cause mental health problems.</p>
<p id="hyWCxi">What does<em> </em>reliably worsen women’s mental health, however, is banning or restricting abortion access. </p>
<p id="juDb4B">A wealth of research has shown that when people are forced to carry unwanted pregnancies, it <a href="https://www.ansirh.org/research/ongoing/turnaway-study">negatively impacts</a> their <a href="https://pubmed.ncbi.nlm.nih.gov/31958829/">physical health</a> and <a href="https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2017.304247r">finances</a> — and mental health. In a survey conducted before the US <a href="https://www.vox.com/scotus" data-source="encore">Supreme Court</a> overturned the constitutional right to abortion, women living in states with more abortion restrictions had <a href="https://www.sciencedirect.com/science/article/pii/S2352827323000939?via%3Dihub">higher rates of mental distress</a>. In another study, states enforcing abortion restrictions between 1974 and 2016 had <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2799597?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jama.2023.26816">higher suicide rates</a> in women of childbearing age in particular. </p>
<p id="jBCUo5">But when the court <a href="https://www.vox.com/2022/6/24/23181720/supreme-court-dobbs-jackson-womens-health-samuel-alito-roe-wade-abortion-marriage-contraception">decided to overturn <em>Roe v. Wade </em>in 2022</a>, it wasn’t making a decision grounded in science. </p>
<p id="k3s3Ky">Now we’re more than a year and a half into living with the consequences. And when it comes to women’s mental health, the fallout is following the exact pattern scientists predicted.</p>
<h3 id="8rmKun">Research shows the thing we thought was true is, in fact, true </h3>
<p id="UBPy9E">In a <a href="https://jamanetwork.com/journals/jama/article-abstract/2814133">study</a> published last month, researchers at Johns Hopkins University found that people living in states that banned abortion in the immediate wake of the Court’s decision have worse symptoms of anxiety and depression than those who live in states without bans. </p>
<p id="92LXlx">Using data gathered as part of US Census <a href="https://www.census.gov/data/experimental-data-products/household-pulse-survey.html">Household Pulse</a> surveys, the researchers looked at respondents’ self-reported anxiety and depression scores from about six months before and six months after the Court overturned the constitutional right to abortion. They compared scores on a scale of zero to 12 among people in states with and without <a href="https://www.vox.com/2022/6/25/23182753/roe-overturned-abortion-access-reproductive-rights-trigger-laws">trigger bans</a>, abortion restrictions that went into effect as soon as the Supreme Court issued its ruling. </p>
<p id="q1NiKd">What they found was, frankly, predictable: Before the Court’s decision, anxiety and depression scores were already higher in trigger states — a population-wide average of 3.5 compared with 3.3 in non-trigger states. After the decision, that difference widened significantly, largely due to changes in the mental health of women 18 to 45, what the authors defined as childbearing age. Among this subgroup, anxiety and depression scores subtly <a href="https://publichealth.jhu.edu/2024/analysis-of-us-census-survey-data-reveals-uptick-in-anxiety-and-depression-among-women-in-states-with-trigger-laws-post-dobbs-abortion-decision">ticked up</a> in those living in trigger states (from 4.62 to 4.76) — and dropped in those living in non-trigger states (from 4.57 to 4.49). There was no similar effect in older women, nor in men. </p>
<p id="kjZxxp">These differences were small but statistically meaningful, especially since they sampled the entire population, not just women considering an abortion. Moreover, they were consistent across trigger states, whether their <a href="https://www.vox.com/policy" data-source="encore">policies</a> and political battles around abortion had been high- or low-profile. Even when the researchers omitted data from states with particularly severe restrictions on women’s reproductive health (<a href="https://www.vox.com/2023/8/5/23820360/texas-abortion-ban-medical-exception">looking</a> <a href="https://www.vox.com/23997727/kate-cox-texas-abortion-ban">at</a> <a href="https://www.vox.com/scotus/2024/1/3/24023889/abortion-supreme-court-emtala-fifth-circuit-texas-becerra">you</a>, <a href="https://www.vox.com/policy/2023/4/7/23593396/medication-abortion-pills-mifepristone-misoprostol-pregnancy-texas">Texas</a>), the results held up. </p>
<p id="FpvKhM">It’s notable that the different levels of mental distress across states after <em>Roe </em>was overturned weren’t just a consequence of worsened anxiety and depression in states with trigger bans. Also contributing: an improvement in these symptoms in states without these bans. We can’t tell from the study exactly why that is, but it seems plausible that women living in states that protect their right to access necessary <a href="https://www.vox.com/health-care" data-source="encore">health care</a> simply <a href="https://jamanetwork.com/journals/jama/article-abstract/2814160">feel some relief</a>. </p>
<h3 id="FkyBPu">Americans don’t need more mental health stressors right now</h3>
<p id="S5mVyz">In bird’s-eye-view studies like this, it can be hard to pick apart the nuances behind a finding. For example, it’s possible other <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9654574/">social</a> or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737478/">cultural</a> factors are more likely to disproportionately affect women in trigger states — like variability in gender equity, interpartner violence, abortion stigma, and mental health care access.</p>
<p id="batPOg">Still, it should set off our alarm bells when high-quality research finds a causal relationship between big societal shifts and worsening depression and anxiety on a population-wide level. </p>
<p id="j1Vdft">People who sense limitations to their personal freedom and autonomy feel a sense of “violation and powerlessness,” says Benjamin Thornburg, a health economics PhD student who led the study. It stands to reason that the opposite of that, a sense of freedom and autonomy, would improve people’s overall mental health.</p>
<p id="CRqSCO">Anxiety and depression rates are reaching <a href="https://news.gallup.com/poll/505745/depression-rates-reach-new-highs.aspx">record highs</a> and are especially pronounced among <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2812389#:~:text=Both%20chronic%20and%20recent%20stress,and%20depression%20symptoms%20and%20disorders.&text=Indeed%2C%20high%20levels%20of%20anxiety,increase%20from%20prior%2Dyear%20levels.">young adults</a>, and suicide deaths are <a href="https://www.kff.org/mental-health/issue-brief/a-look-at-the-latest-suicide-data-and-change-over-the-last-decade/">ticking up</a>. At the same time, Americans are living in an age of broadly unmet mental health care needs: <a href="https://www.commonwealthfund.org/publications/explainer/2023/may/understanding-us-behavioral-health-workforce-shortage">160 million Americans</a> live in areas with provider shortages and insurance denials, and only <a href="https://www.inseparable.us/AccessAcrossAmerica.pdf">one-third</a> of people diagnosed with a behavioral health condition get the care they need. </p>
<p id="pkRZNw">Policymakers need to understand “there could be an increase in the need for mental health services in states where these bans have happened,” says Thornburg. </p>
<p id="IFBcbk">But it’s not at all clear they do. </p>
<p id="5RA2W6"><em>This story appeared originally in </em><a href="https://www.vox.com/today-explained-podcast"><em><strong>Today, Explained</strong></em></a><em>, Vox’s flagship daily newsletter. </em><a href="https://www.vox.com/pages/today-explained-newsletter-signup"><em><strong>Sign up here for future editions</strong></em></a><em>.</em></p>
https://www.vox.com/24071802/abortion-roe-overturn-trigger-ban-states-mental-healthKeren Landman, MD2024-02-06T07:30:00-05:002024-02-06T07:30:00-05:00How to get the medication you need when it’s out of stock
<figure>
<img alt="Empty blister packs sit on a pink background." src="https://cdn.vox-cdn.com/thumbor/BZtl0uEaJANrDbVVz2a_BlftSWE=/342x0:5707x4024/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/73115287/GettyImages_1387042817.0.jpg" />
<figcaption>Aitor Diago for Getty Images</figcaption>
</figure>
<p>The pharmaceutical supply chain is broken, but if you’re facing a drug shortage, you have more power than you think.</p> <p id="F7Rlik">By the time people get to <a href="https://www.angelsforchange.org/story">Laura Bray</a>, they’ve been failed<em> </em>by the US government, all of its agencies, and the entire global pharmaceutical supply chain. </p>
<p id="6n9CMU">So when someone calls her at <a href="https://www.angelsforchange.org/">Angels for Change</a>, the patient advocacy organization she founded in 2019 with a mission of ending drug shortages, one of the first things Bray does is reassure them that they’re not the problem. “I want you to know that drug shortages are real. You deserve access to the medicine,” she tells them. “And it’s not their fault, and somebody should have done better. And they all cry,” she says.</p>
<p id="AnUIKJ">Bray gets it. When her young daughter was getting leukemia treatment, one of the chemotherapy drugs she needed was unavailable due to a global shortage. She was stunned: A professor of business in Tampa, Florida, she knew other distribution channels weren’t nearly so brittle. A bank about to run out of cash would never be allowed to fail. Redundancy and resilience is built into our monetary, food, and oil supply chains, she thought, “but it’s just not there for pharmaceuticals. Why?”</p>
<p id="DzSfcH">Five years later, drug shortages in the US are at a 10-year high. The putative reasons are manifold: As the Food and Drug Administration has scrambled to catch up on inspections of routine drug manufacturing facilities in the wake of pandemic closures, the deficits they’re finding — and the production delays they’re leading to — are piling up all at once, says <a href="https://pharmacyservices.utah.edu/residency/drug-info-staff">Erin Fox</a>, a doctor of pharmacy and medication shortage specialist at the University of Utah, whose drug information service provides content to a drug shortage database run by the <a href="https://www.ashp.org/drug-shortages/current-shortages/drug-shortages-list?page=All&loginreturnUrl=SSOCheckOnly">American Society of Health-System Pharmacists</a> (ASHP). Simultaneously, a large <a href="https://ascopost.com/issues/december-10-2023/on-mark-cuban-and-the-chemotherapy-crisis/#:~:text=Two%20common%20chemotherapy%20agents%E2%80%94cisplatin,product%20and%20more%20dramatic%20shortage.">chemotherapy drug plant </a><a href="https://www.washingtonpost.com/business/2023/06/27/cancer-drug-shortage-generics/">shut</a><a href="https://ascopost.com/issues/december-10-2023/on-mark-cuban-and-the-chemotherapy-crisis/#:~:text=Two%20common%20chemotherapy%20agents%E2%80%94cisplatin,product%20and%20more%20dramatic%20shortage."> down</a> due to quality problems; opioid settlement rules have reduced pharmacy ordering capacity for controlled substances, <a href="https://www.vox.com/policy/2023/4/10/23671128/adhd-medication-adderall-shortage-2023#:~:text=Bloomberg%20reported%20this%20week%20that,pharmacy%20with%20an%20Adderall%20order.">including ADHD drugs</a>; and rising rates of syphilis are chewing through an already-low supply of <a href="https://www.statnews.com/2023/06/22/bicillin-syphilis-pfizer-penicillin-shortage/">injectable penicillin</a>.</p>
<p id="JuJcGz">The real reason shortages keep happening, says Bray, is because patient outrage never reaches the supply chain. She’s on a quest to change that: After thousands of phone calls eventually got her daughter the treatment she needed, she created an organization aimed not only at serving individuals’ medication needs but at unifying their voices to <a href="https://democrats-energycommerce.house.gov/committee-activity/hearings/hearing-on-examining-the-root-causes-of-drug-shortages-challenges-in">demand better</a>. </p>
<p id="hZsxdy">Few people have the time or the background to spend hours on the phone with hospitals, pharmacies, lawmakers, and pharmaceutical companies to get a medication. And while there’s been more awareness about drug shortages in the past year than the US has seen in some time, they’re not going away any time soon. </p>
<p id="6F30Hw">You can and should get hopping mad about drug shortages. And if you’re affected by one yourself, you have more power than you might think when it comes to getting the medication you need. </p>
<h3 id="rsSt1X">Broken financial incentives and a lack of transparency are at the heart of drug shortages</h3>
<p id="zWOnfQ">Fundamentally, shortages are related to problems that decrease a drug’s supply and increase its demand. Most shortages are rooted in supply problems — and in about two-thirds of cases that the FDA reports in its own <a href="https://www.accessdata.fda.gov/scripts/drugshortages/default.cfm">drug shortage database</a>, Fox says, quality problems at a manufacturing facility are at the heart.</p>
<p id="PyL4bd">Many of the quality problems affect the production of generic drugs, which are both most commonly used and cheapest for consumers. “It’s just a race to the bottom with these companies trying to gain market share,” says Fox. Pharmaceutical companies make so little money on generics that many eventually either stop making them, cut corners on quality, or opt not to upgrade the facilities that produce them. All of that makes production lines that produce generic drugs particularly vulnerable to shutdown — which, because the drugs are used so widely, ends up affecting a <em>lot</em> of people.</p>
<p id="SZZNlM"><em>[Related: </em><a href="https://www.vox.com/policy/2023/4/10/23671128/adhd-medication-adderall-shortage-2023"><em>The ongoing, unnecessary Adderall shortage, explained</em></a><em>]</em></p>
<p id="WbgJkx">Profit considerations also have a lot to do with the other one-third of drug shortages that the FDA reports, says Fox, which include related production stoppages unrelated to quality. For example, if a manufacturer can produce a more profitable drug in the same plant where it produces a less profitable drug, it might simply choose to make more of the one that nets more money. <a href="https://www.nytimes.com/2023/12/06/opinion/drug-shortages-pharmaceuticals.html">Nobody can force the company</a> to make the less profitable drug.</p>
<p id="V17JHV">Production problems related to raw material shortages or <a href="https://www.vox.com/natural-disaster" data-source="encore">natural disasters</a> — like <a href="https://www.theguardian.com/us-news/2018/jan/10/hurricane-maria-puerto-rico-iv-bag-shortage-hospitals">Hurricane Maria</a>, which shut down a Puerto Rico factory that made bags of saline, and a <a href="https://www.usp.org/supply-chain/pfizers-rocky-mount-facility-tornado-damage-impact-on-pharmaceutical-supply-chain">tornado</a> that hit a Pfizer plant in North Carolina — can also cause big disruptions in the drug supply.</p>
<p id="mhYRdY">These shortages would be a problem even if there were a robust system for reallocating the drugs they affect. But that system doesn’t exist, says <a href="https://publichealth.jhu.edu/faculty/3523/mariana-p-socal">Mariana Socal</a>, a physician and researcher who studies the US pharmaceutical industry at Johns Hopkins University’s Bloomberg School of Public Health. Part of the reason: Nobody outside the FDA knows exactly where the problems are. </p>
<p id="5s3nNR">“There’s no transparency” around what triggers any one shortage because private entities are allowed to keep that information under wraps, says Socal. She thinks about drug shortages every time she unpacks her groceries: “A box of fruit or vegetables says ‘Produced in California’ or ‘Origin: Mexico,’” she says, but you have no idea where a container of generic Tylenol came from or whether you can feel confident in the product.</p>
<p id="iK2X3p">The opaqueness of the production system, and the absence of a method for equitably allocating drugs when there is a shortage, means that only the savviest pharmacies get what’s left of a drug supply when it’s running low. “It’s like Hunger Games,” says Fox. “Whoever can order ahead, whoever has the most resources to kind of hear about a shortage first, to try to put in as many back orders with different companies as possible — those places are more likely to get some product in.”</p>
<p id="UJkGeY">Fox has tried to change this herself. Ten years ago, when there was a spate of pediatric cancer drug shortages, she asked the FDA and pharmaceutical companies to reserve the remaining drug supply for sale only to pediatric cancer centers. “Everyone was like ‘Oh, it’s a free market — we can’t tell these manufacturers what to do,’” she says.</p>
<p id="ZlERr7">So when waves of illness increase the demand for certain drugs — as surging syphilis rates have done for penicillin, and as cold and flu season does for <a href="https://www.npr.org/sections/health-shots/2022/12/03/1140185521/children-fever-medicine-tylenol-motrin-hard-to-find">fever reducers</a> and <a href="https://www.vox.com/policy-and-politics/23484040/rsv-flu-amoxicillin-tamiflu-abuterol-drug-adderall-shortages">amoxicillin</a> — consumers are left holding the (empty) bag.</p>
<p id="iCpyey"><a href="https://www.mcw.edu/find-a-doctor/ehrenfeld-jesse">Jesse Ehrenfeld</a>, a physician and current president of the American Medical Association, says solving drug shortages requires a multipronged approach. Any fix should prioritize developing more capacity for producing key medications, putting plans in place to minimize supply chain disruptions, creating a larger pool of generic drug manufacturers, and changing FDA processes to allow more drugs into the marketplace.</p>
<p id="mSr1lW">There’s hope for seeing some of this happen: Despite the US government’s reluctance to regulate private business — especially in industries with <a href="https://www.vox.com/2023/6/16/23760650/medicare-big-pharma-prescription-drug-prices-lawsuit">powerful</a> <a href="https://www.vox.com/policy-and-politics/2017/1/31/14453740/trump-medicare-prescription-drugs">lobbies</a> — Fox says there’s been more advocacy before <a href="https://www.vox.com/congress" data-source="encore">Congress</a> on drug shortages this year than she has seen in her two decades following the issue. </p>
<p id="0O7zbf">Much of the draft legislation is what Bray describes as “pet projects”: bills too narrowly focused on one part of the supply chain to really fix the problem. However, she was pleased to see a more robust approach in a <a href="https://www.finance.senate.gov/imo/media/doc/white_paper_preventing_drug_shortages.pdf">white paper</a> the Senate finance committee recently released and says the Senate energy and commerce committees have also been doing good work.</p>
<p id="bhhcn9">Bray also says the <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2023/11/27/fact-sheet-president-biden-announces-new-actions-to-strengthen-americas-supply-chains-lower-costs-for-families-and-secure-key-sectors/">White House plan to address drug shortages</a> announced in late 2023 is a good start. Notably, that plan proposed designating a government employee to provide the service Bray has been providing for people who reach out for help. Currently, she is the only person she knows of who directly links people affected by drug shortages with emergency supplies of their medications — and she’s a private individual, effectively a one-woman operation, alone in a Tampa office park except for a single employee who helps her with social media. “I could do it so much better if I had more people,” she says. </p>
<h3 id="2RlpAZ">What to do if there’s a shortage of a drug you need</h3>
<p id="TL8BpL">Bray gets an average of four requests a day, and depending on who’s calling, the work she does in response may help anywhere from a handful to thousands of patients. Although many of her calls come from clinics, hospitals, and manufacturers, she often hears from individual patients — and when she does, she suggests they take the series of steps outlined below, which I’ve interspersed with tips from the other experts I spoke with. </p>
<p id="Rip6mI">Although it’s easy to feel a sense of panic when facing down a shadowy tangle of dysfunctional institutions, take a deep breath and know that there is a path forward, and there are resources and advocates out there that can help.</p>
<p id="eGwPwQ">It’s obviously less stressful to have a few days to deal with a drug shortage rather than a few hours. When you can, plan ahead: If you’re reupping a drug you’re already taking, “give it a few extra days as opposed to waiting until the last minute to request a refill,” says <a href="https://ncpa.org/newsroom/qam/2022/03/18/ncpas-beckner-named-publication-advisory-board">John Beckner</a>, a pharmacist who directs strategic initiatives at the <a href="https://ncpa.org/">National Community Pharmacists Association</a> (NCPA).</p>
<p id="wbU17i">Before you do too much work, it’s worth seeing whether an independent pharmacy in your area can locate a supply of the drug you need. They’re less likely to just say “We’re out of stock — we can’t get it,” says Beckner. “They’re going to explore other means to try to obtain that drug.” That may mean calling around to smaller drug wholesalers or buying a small quantity of a medication that might not be on the radar of a drugstore that buys medications by the pallet. You can find a local independent pharmacy using the NCPA’s <a href="https://ncpa.org/pharmacy-locator">pharmacy locator</a> website.</p>
<p id="7bVooB">If you’re still unable to get the medication you need, here’s what Bray counsels people to do. Parts of this process are things patients must do on their own, but Bray is happy to help people who get stuck at any point along the way and welcomes contact by <a href="https://www.angelsforchange.org/contactus">phone or email</a>.</p>
<p id="QiiSaa"><strong>1) Look for the generic form of the drug in the two drug shortage databases</strong> that contain all the information available to the American public about specific medicines’ availability: the one maintained by the <a href="https://www.accessdata.fda.gov/scripts/drugshortages/default.cfm">FDA</a> and the one run by the <a href="https://www.ashp.org/drug-shortages/current-shortages/drug-shortages-list?page=All&loginreturnUrl=SSOCheckOnly">ASHP</a>. They’re similar, although the ASHP database has a lower threshold for reporting a shortage, says Bray. </p>
<p id="A8ZmmB">This first step helps patients determine not only which brands and dosages of a drug are unavailable, but also which <em>are</em> available.</p>
<p id="Et8F6Y"><strong>2) Call your insurance company</strong>, ask to speak with a manager, explain that you are affected by a drug shortage, and ask them to give you coverage for whatever alternative form, brand, or dose of the drug you might be able to get access to.</p>
<p id="leaqkS">The reason to do this is that insurance companies cut deals with various drug intermediaries — called <a href="https://www.vox.com/2023/5/10/23709448/what-are-pbms-pharmacy-benefit-managers-bernie-sanders">pharmacy benefit managers</a> — for specific medicines within each class of drugs and specific dosages of those medicines. Ostensibly, they do this so they can buy those specific medicines in bulk quantities at a discount and cover most of their cost when they are prescribed to you. The list of medicines and dosages an insurance company covers, its hot list of sorts, is called its formulary.</p>
<p id="WDn1hz">But where there’s a hot list, there’s a not list: If you’re prescribed a dosage or brand of a medicine that isn’t on your insurer’s formulary, or a similar medicine that isn’t on its formulary, the company won’t cover it — and you’ll have to pay for it out of pocket, which can be wildly expensive.</p>
<p id="z4KEjZ">Patients can ask their insurers to temporarily cover a drug that isn’t on their formulary in a shortage situation like this, says Bray. “Say, ‘I’m going to be talking to my physician about giving me access to the [forms, brands, or dosages of the drug] that are available here and changing my prescription. Can you ensure that you open up the formularies while this shortage is happening so that I can get access to any of them?’”</p>
<p id="xneDbG">Bray suggests explaining that you would not be asking for this change if the on-formulary drug were available to you, but it’s not. The conversation — one patients or their policy holders must have with their providers themselves — is usually successful, she says.</p>
<p id="esBSe5"><strong>3) Contact the health provider who prescribes the unavailable drug</strong>, let them know there’s a shortage, and ask which of the available alternatives they can prescribe you. Bray suggests sending them a link to these alternatives. They’re easy to find in the <a href="https://www.ashp.org/drug-shortages/current-shortages/drug-shortages-list?page=All&loginreturnUrl=SSOCheckOnly">ASHP database</a> — just click on the name of the drug in shortage and scroll down to “Available Products.”</p>
<p id="rutza9">Providers are often aware of shortages and generally want to do the right thing to help patients get through them, says Ehrenfeld. </p>
<p id="k75vje">If your provider sends the alternative prescription to your pharmacy (or a hospital’s pharmacy, if you’re calling on behalf of a hospitalized patient) and the drug is in stock, this might be the triumphant end of your road. If not …</p>
<p id="W4EVGm"><strong>4) Seek an alternative pharmacy. </strong>If your usual pharmacy is part of a large chain, staff may be able to check the inventory of other local chain outlets, either online or over the phone — just ask.</p>
<p id="9wDayv">Again, nimbler independent mom-and-pop pharmacies may be better able to fill in drug availability gaps. In addition to having access to different supply lines, their staff may have more time to make calls about small quantities of scarce medications or their alternatives. In general, says Beckner, your pharmacist — whether independent or at a chain — “can really become your advocate and confidant,” especially if you’ve established a good relationship.</p>
<p id="8hwesZ"><strong>5) Call Angels for Change </strong>if you’re still struggling to find the medication you need after all of this, urges Bray. She can work to identify the supply map for a medication, and she can reach out to its manufacturers to inquire about any emergency supply they may have on hand and clarify the timeline for having more supply available. </p>
<p id="zZDKh8">It might be tempting to look online for a medication when you’re affected by a shortage, either on social media or by ordering from a sketchy internet pharmacy. All of the experts I spoke to recommend against this approach. You never know whether the medication was stored properly or whether it’s counterfeit, and you’re at risk for being price-gouged, says Fox. </p>
<p id="z5yF5V">Bray’s strategy is one “that requires sophistication and a lot of work that just should not be necessary in this day and age, with all the technology that we have and all of the resources in the nation,” says Ehrenfeld. “It’s because we have erected barriers to getting people the care that they need.”</p>
<p id="KEHPCb"></p>
https://www.vox.com/even-better/24062409/medication-shortage-drug-stock-medicine-pharmaceutical-supply-chain-angels-for-changeKeren Landman, MD2024-01-29T08:00:00-05:002024-01-29T08:00:00-05:00A guide to health care providers, from doctors to nurse practitioners
<figure>
<img alt="A grid on a white background shows colorful graphic depictions of various people dressed in medical work attire, like white coats, scrubs, masks, and stethoscopes." src="https://cdn.vox-cdn.com/thumbor/v0CMC_uDXyvBAxgvL_EfDmqV0pQ=/715x0:3386x2003/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/73093469/GettyImages_1162026234.0.jpg" />
<figcaption>Getty Images</figcaption>
</figure>
<p>You’re likelier than ever to get care from a physician assistant or nurse practitioner. Here’s what you need to know.</p> <p id="gufMKD">In 2021, Nicole Barbosa, a media relations specialist in Austin, Texas, moved back to the US after more than a decade abroad. Getting medical care established stateside was a priority for her — but when she tried to make an appointment with a primary care doctor at a local <a href="https://www.vox.com/health-care" data-source="encore">health care</a> system she trusted, she was surprised to find herself at the end of a months-long wait list. </p>
<p id="sTNWgg">Meanwhile, a physician assistant in the same practice was available within days. At first, Barbosa wasn’t sure how physician assistants were different from doctors. Still, she booked the appointment, and when she saw the provider the following week, she was delighted by the unhurried pace. “She answered all my questions without me feeling like she was rushed or needed to quickly move on to her next appointment or task,” she says.</p>
<p id="5Jm0z4">The care was so good that when her provider left the practice, Barbosa signed up to see another physician assistant. During visits, “I just always feel valued and seen,” she says.</p>
<p id="JFMfCZ">Americans seeking health care are increasingly likely to get it from people who aren’t doctors. The reasons are partly related to supply and demand: A nationwide physician shortage has been mounting for decades. And while the pipeline for producing more doctors hasn’t widened — something that would literally <a href="https://www.vox.com/22989930/residency-match-day-physician-doctor-shortage-pandemic-medical-school">require an act of Congress</a> — schools that train nurse practitioners (NPs) and physician assistants (PAs) have proliferated. As a result, nurse practitioner numbers <a href="https://www.bls.gov/oes/current/oes291171.htm">have tripled</a> <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00686">since 2010</a>, and there are nearly <a href="https://www.bls.gov/ooh/healthcare/physician-assistants.htm#tab-3">twice as many</a> physician assistants now <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3151188/#:~:text=Results,(total%20n%3D6%2C776).">as then</a>. In primary care clinics, emergency departments, operating rooms, and medical specialty offices, these medical professionals are now doing a lot of the same tasks doctors do.</p>
<p id="gPf8iO">These changes may be imperceptible to many people, but if you’ve noticed them and you’re wondering how to think about it, you’re not alone. Maybe you, like Barbosa, are trying to choose a primary care provider and want to know more about the professions. Or maybe your health system has assigned you to see a nurse practitioner or a physician assistant and you’re wondering what that means. </p>
<p id="PIYZOZ">Whatever your situation, it’s worth understanding the strengths each profession brings to the work of patient care, and what makes for a good fit between providers and people; just keep in mind that within each role, there’s a lot of variation in practice style based on personality differences and variability between practices. </p>
<h3 id="oCv0RO">Questions for yourself</h3>
<p id="QLZtbB"><strong>What do I want from a visit with my provider?</strong></p>
<p id="miR73a">The differences in the training that doctors, NPs, and PAs get before entering practice has a lot to do with how they approach patient care — and those differences can have a big impact on what happens during your visits.</p>
<p id="6xUPSJ">Doctors and physician assistants are trained in the medical model, explains <a href="https://profiles.ucsf.edu/joanne.spetz">Joanne Spetz</a>, a health economist at the University of California San Francisco who studies the nursing workforce. “A lot of medicine is around understanding body systems, understanding diseases — basically understanding how body systems get screwed up,” she says. People trained in these models focus largely on how to diagnose and treat illness and injury, and also to some degree on how to prevent illness.</p>
<p id="3LquVK">The nursing model is more holistic, says Spetz. The nursing paradigm, which guides nurse practitioners’ training, considers not only the physical needs and ailments of the patient, but also other factors like the patient’s personal goals and situation. For example, she says, if a patient has pain, a nurse would seek to identify the physical causes but also understand how the pain is impacting the patient’s social and emotional function — whether they can eat, whether the pain makes them withdraw from family, whether other stressors make it difficult to manage the pain. </p>
<p id="YPlMWW">Another important distinction is in the cost to employ members of each profession: While physician assistants and nurse practitioners earn around $125,000 annually, physicians earn about $230,000. Because doctors’ time costs their employers more than other providers’ time, many health care systems allot less of it to the patients they see.</p>
<p id="XjT0Bc">Together, these factors mean that NPs and PAs may be scheduled for longer visits than doctors are with the patients they see in primary care settings, which means more time to answer questions and provide patient education. </p>
<p id="Ageufg">It’s not clear if these visits are actually longer, says <a href="https://apps.smhs.gwu.edu/smhs/facultydirectory/profile.cfm?empName=Tamara%20Ritsema&FacID=2046529481">Tamara Ritsema</a>, a physician assistant and professor at George Washington University’s PA program. Due to a quirk in documenting PA and NP visits within the US health care system, it’s hard to gather data on differences in visit length between provider types. It’s possible patients just <em>feel </em>like some visits are longer because of variations in providers’ styles. </p>
<p id="MlnZQ1">“We hear this all the time from people: ‘My PA or my NP spends more time with me,’” says Ritsema. “We do not know if that is true or if they are leveraging better communication strategies, such as sitting down while they talk to the patient, or using more patient-friendly language.”</p>
<p id="OaAcSw">Because they’re trained in the nursing model, NPs in particular are primed to do patient-centered coaching. This includes helping patients near the end of life prioritize quality of life as they see it, says Spetz — to “elicit what your personal bucket list is before we start recommending all of these treatments.” Nurse practitioners’ holistic approach is a specific asset in <a href="https://pubmed.ncbi.nlm.nih.gov/37979946/">addiction medicine</a>, according to some of Spetz’s research. Other studies have shown patients are more likely to get <a href="https://journals.lww.com/lww-medicalcare/abstract/2017/06000/a_comparison_of_nurse_practitioners,_physician.11.aspx">health education and counseling services</a>, including advice on quitting smoking, from NPs and PAs than physicians. </p>
<p id="GGwKjl"><strong>How medically complicated am I? </strong></p>
<p id="diZ1yz">The road to becoming a doctor is substantially longer than the paths to other medical professions. Before they can practice independently, doctors spend four years in medical school and three to seven years in an on-the-job training program called residency; meanwhile, typical physician assistant and nurse practitioner training programs take two to three years to complete. (All of these programs require undergraduate degrees for admission; NP programs require an undergraduate nursing degree.)</p>
<p id="sVQ17b">During medical school, doctors take a range of courses on the invisible mechanisms that keep the body working — and that underpin disease — in coursework that includes biochemistry, pharmacology, <a href="https://www.vox.com/genetics" data-source="encore">genetics</a>, microbiology, and other hard sciences. Once they start taking care of patients, a lot of their education is aimed at connecting the dots between those complex mechanisms and the diseases they’re seeing in clinics and on hospital wards. By the time the least experienced doctor enters the workforce, they’ve had at least 10,000 hours of clinical experience.</p>
<p id="hjToX8">Physician assistants take an abbreviated version of this educational path, and like medical school graduates, finish their programs prepared to work in any medical setting. Also like medical school graduates, they need more on-the-job training before they’re considered competent in their field, says Ritsema. But while that training is formalized for doctors as a residency program with clear requirements, it’s less formally prescribed for PAs, she says. A PA fresh out of school has a minimum of 2,000 clinical experience hours under their belts. Because many PA programs require prior health care work as a prerequisite, many of these professionals hit the workforce with substantially more clinical experience.</p>
<p id="hXM8Cq">Nurse practitioner trainees also take a variety of didactic courses that overlap to some degree with PAs’ classes. However, they choose which population they want to work with while they’re still in school — whether that’s all comers or newborns, children, women, older adults, people with mental illness — and their clinical training prepares them to work with that population in particular. By the time they graduate from NP school, these professionals have completed at least 1,000 clinical experience hours — a figure that may be higher depending on what state they’re in.</p>
<p id="w4jJvY">These differences in training mean that if you “have super-complex medical conditions and all your drugs are interacting with each other,” a doctor caring for you has an advantage over other providers, says Spetz. After all that practice caring for complicated patients, physicians are used to puzzling out how dysfunction at the microscopic level can cause disease, and choosing diagnostic strategies to untangle a web of confusing symptoms or laboratory results.</p>
<p id="7xocNR">Not everyone’s a medical mystery. Plenty of research studies have shown that for less complex patients — people without multiple chronic conditions who aren’t taking tons of medications — the care NPs and PAs provide is <a href="https://pubmed.ncbi.nlm.nih.gov/28234756/">just as</a> <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00014">safe</a> and cost-effective as the care doctors provide.</p>
<p id="7jkgZk">NPs and PAs who work as part of collaborative and supportive teams are most likely to have good outcomes, says <a href="https://publichealth.gwu.edu/departments/health-policy-and-management/candice-chen">Candice Chen</a>, a pediatric doctor and researcher who studies primary care workforce issues at George Washington University. An environment that enables them — and doctors — to ask for and receive help when they need it is a key ingredient of quality care. </p>
<p id="mLluiV">There’s currently a lot of behind-the-scenes tussling among professional societies and state medical boards over how much care NPs and PAs should be able to provide without a physician collaborator. But these professions are not interchangeable with doctors, says Candice Chen. Although NP and PA care is in many cases equivalent or even better than doctors’ care, a recent <a href="https://www.nber.org/papers/w30608">study</a> suggests NPs caring for more complex patients at Veterans Health Administration emergency departments had worse outcomes than doctors. </p>
<p id="GPz42z">On teams where providers can easily ask for help, patients who need providers with certain skills are more likely to get seen by those providers. “The question becomes, how do you put those teams together so that everybody knows where their limits are, and knows where to get help?” says Candice Chen. More experienced professionals are also more likely to deliver high-quality care, even to complex patients, says Spetz. Research backs her up: In the VA study, “performance differences between the two professions become smaller as provider experience increases,” says <a href="https://econ.uic.edu/profiles/chen-yiqun/">Yiqun Chen</a>, a University of Illinois Chicago health economist who coauthored the report. </p>
<p id="YaeZsN">Regardless of who’s providing your care, it’s not just education and experience that determine whether that care is good, says Ritsema. The best NPs, PAs, and doctors all know when they’re in over their heads, and need to call for help. “The people that make me feel secure are the ones that put my care above their ego,” she says.</p>
<p id="Idh5cY">That means being open to asking questions of the other members of their teams — and to being asked questions by you.</p>
<h3 id="4BJU0A">Questions to ask a provider to see if they’re a good fit</h3>
<p id="4mmlzF"><strong>What’s your training and background?</strong></p>
<p id="um0ufe">In general, Americans can be fairly confident that their provider has been trained to a high standard, says Ritsema. But because PAs’ and NPs’ on-the-job training is less formalized than that of physicians, it may be harder to determine the level of experience these providers have just by looking them up on a website. </p>
<p id="QSrFtQ">It’s okay to ask your provider what their training and experience is, says Ritsema: “To be honest, if your provider, whoever that is — doctor, PA, NP — is unwilling to answer that in an uncomplicated way, that might raise a red flag to me,” she says. </p>
<p id="ReVb9n"><strong>Where would you go if you needed help with my care?</strong></p>
<p id="8yBBRH">Good providers know what they don’t know, are unafraid to ask for help when they need it, and have resources they can draw on in those situations — regardless of their degree, says Candice Chen. But as a patient, it can be hard to determine whether your provider and the practice setting they’re in meet that description.</p>
<p id="MQEYmW">If the practice has a website, you can look in advance to see what the mix of providers looks like, as their colleagues will probably be their first stop for support. You can also ask a new provider what happens if something serious comes up, or if you need a referral.</p>
<p id="ko3cnL">It’s harder to determine whether a practice truly has a collegial and supportive environment where providers are encouraged to seek help. Here’s where it’s useful to talk to any people in your social network who work in health care, says Ritsema. “Health professionals recognize those characteristics of humility in other health professionals, and they know who the cowboys are” — that is, which ones to avoid, she says.</p>
<p id="1tXtcF">Watching how providers interact when you’re at the practice can also be incredibly informative, says Spetz. “The medical assistants are like your canaries in the coal mine,” she says: If the providers are brusque and condescending toward these and other support staff in the office, it can be a sign of a dysfunctional hierarchy — not the kind of functional team that encourages requesting support and insight from others.</p>
<p id="TZuElT"><strong>Are you the right person to answer this question?</strong></p>
<p id="BJuy01">Medicine is not a field that any single health care provider can know everything about: Increasing specialization and rapid changes in technology means even the best providers will have substantial knowledge gaps about conditions they don’t see on a regular basis. </p>
<p id="O0E8yt">So while it’s reasonable to expect a certain level of knowledge from your health care provider, expecting them to answer questions that aren’t in their purview can set you up for disappointment, and lead you to misjudge a good provider as incompetent. If you ask a primary care provider about the intricacies of a vascular surgery, “the PA or NP in primary care — and, frankly, the doc in primary care — is not going to have the answer to that,” says Ritsema.</p>
<p id="ohp4he">It’s okay if you don’t know who to ask about what subject — and it’s okay to ask who to ask! Just be aware that hearing “I don’t know” from a provider doesn’t always indicate a knowledge deficiency that would be fixed if you switched providers. Sometimes, they’re not the right person to answer that question in the first place.</p>
<p id="wL5JmW"><strong>You can change providers</strong></p>
<p id="O5QlaV">If your provider isn’t able to get answers to your questions within their specialty, or their repeated efforts to diagnose or treat a medical condition don’t seem to be going anywhere, it’s okay to ask for a second opinion from a different provider, either in the same practice or in a different one. “One of the things we probably need to do is to empower people to not let politeness be the enemy of advocating for themselves,” says Candice Chen.</p>
<p class="c-end-para" id="XtXJ9V">Ritsema agrees. “If you don’t have confidence in your medical provider for whatever reason,” she says, “schedule an appointment with somebody else who you think will make you feel more confident.” </p>
<p id="iNCFgH"></p>
https://www.vox.com/even-better/24050901/nurse-practitioner-physician-assistant-doctor-health-care-qualityKeren Landman, MD