The Role of Psychological Distress in Long Covid

A Study Finds a “Strong” Association

In a study published last month in the journal JAMA Psychiatry, investigators from the Harvard T.H. Chang School of Public Health and Harvard Medical School reported that among individuals followed up for more than a year starting in April 2020 the presence of several types of psychological distress at baseline and before COVID-19 infection was “strongly associated” with subsequent development of Long Covid.  What these researchers are reporting on is a strong association between preinfection psychological distress and symptoms of Long Covid, the illness that occurs in about 30% of people after they have recovered from COVID-19. Other data already suggest that patients who have survived COVID-19 are at increased risk to develop psychiatric illnesses like depression and anxiety disorders.

         We all know and agree that association is not causality and therefore the authors of this study were appropriately careful not to say that psychological distress is a cause of Long Covid. Unpacking the study, however, makes it clear that this could be one possibility in some cases. The researchers used data from three large ongoing epidemiological surveys and included 54,960 participants in the study. They assessed these study participants for psychological distress before they reported being infected with SARS-CoV-2, the virus that causes COVID-19. They used a careful statistical analysis that controlled for many potentially confounding variables to find a strong association between depression, anxiety, worry, loneliness, and stress and subsequent Long Covid.

A Caveat from the Authors

         Knowing that this finding is bound to spark controversy, the authors made a curious statement in the discussion section of their paper: “Our results should not be misinterpreted as supporting a hypothesis that post-COVID-19 conditions are psychosomatic.” They list several reasons for that assertion including:

·  More than 40% of the participants who developed Long Covid did not report psychological distress prior to developing COVID-19.

·  Symptoms of Long Covid “differ substantially” from symptoms of mental illness.

·  More than half of the patients reported relapses after physical exercise, whereas physical exercise has been shown to be protective against relapses of many forms of psychiatric illness. 

They go on to explain potential biological links between psychological distress and Long Covid involving the immune system and inflammation, which we will return to in a bit. Somehow, the authors seem to want to reassure their readers that they do not regard Long Covid as in any way a “mental illness” or merely “psychosomatic.” Rather, they want us to be clear, there is biology underlying the association between psychological distress and Long Covid and therefore Long Covid must be a “real” illness.

What the authors are obviously responding to here is the long-standing debate about the causes of conditions that sociologists have called “contested illnesses,” a list that includes chronic Lyme disease, fibromyalgia, and chronic fatigue syndrome/myalgic encephalomyelitis. These are illnesses for which there is often disagreement between traditional medical experts and patients about their “nature, causes, and treatments.”  The authors of the JAMA Psychiatry paper noted that “Prior studies have further suggested that distress is associated with long-term symptoms after Lyme infection and in functional syndromes, eg. chronic fatigue syndrome and fibromyalgia, that have symptoms similar to those of post-COVID-19 conditions, such as fatigue, headache, and muscle pain. Yet any suggestion that these “functional” syndromes are linked in any way to psychological factors brings out an immediate outcry from patient advocacy groups, who say that making such a link is akin to asserting that these illnesses are “all in the head” and therefore not real.

Advocates for people with conditions like Long Covid, chronic Lyme disease, and chronic fatigue syndrome are absolutely right to insist that the very real suffering these conditions impose must be fully recognized by the medical profession and that patients who have them should be taken seriously and offered appropriate medical tests and interventions. But it is important to remember that the same is also the case for people suffering from depression, anxiety disorders, and other sources of significant psychological distress.  Trying to negate the possibility that conditions associated with psychological distress might be one cause of Long Covid has the effect of minimizing the reality of psychiatric illness.

Positing a Biological Basis

   The authors of the JAMA Psychiatry paper do not want anyone to think that Long Covid is a “psychosomatic” disorder, a term that is usually taken to mean a psychological condition in which the presence of physical symptoms are unexplained by a known medical illness. To counteract this possible misunderstanding of their findings, they stated that “Inflammation and immune dysregulation may link psychological distress with post-COVID-19 conditions” and mention evidence that stress, as well as depression and other psychiatric illnesses, may activate a biological system called the hypothalamic-pituitary-adrenal axis. This is a system that links a brain region, the hypothalamus, to the pituitary gland that sits at the base of the brain, to the adrenal glands, which are located on top of each kidney. The result of activation of this axis is an increase in several hormones linked to stress, including the adrenal hormone cortisol. Interestingly, cortisol suppresses immune function and has recently been shown to be decreased in patients with Long Covid. Hence, whether there really is a link among hypothalamic-pituitary-adrenal axis function, psychological distress, and Long Covid remains very much an open question.

   Somehow, there is the idea here that if we can find a “medical” or “biological” reason for the association between psychological distress and Long Covid (or any other illness where psychological distress is relevant), then we have removed the association from the realm of mental illness. The fact is, however, that we don’t actually know for sure what is the “biological” basis of either psychiatric conditions or of Long Covid. We have lots of data addressing this issue and it is likely that some answers, at least in the case of Long Covid, will emerge soon. We do know that both are accompanied by significant suffering and disability. We also know that both require careful attention from healthcare professionals. If it turns out that having a history of depression, anxiety disorder, or some other form of psychological distress increases the risk for Long Covid, we should be cautious in offering unproven hypotheses to explain that association. Rather, the new study tells us that psychiatrists, psychologists, and other behavioral healthcare professionals will undoubtedly play an important role in understanding and treating Long Covid.

Dismal U.S. Life Expectancy Statistics From the CDC

An August report from the U.S. National Center for Health Statistics, a branch of the Centers for Disease Control and Prevention (CDC),  paints a glaringly disturbing picture of life expectancy for the American population.  For the years 2020 and 2021 the U.S. experienced its sharpest decline in life expectancy in 100 years, falling especially heavily on American Indians and Alaskan Natives. In 2021, the average American could expect to live 76.1 years, a decline from 2020 of 0.9 years. Worse, there was a decline of 1.9 years in that period for American Indians and Alaskan Natives to levels not seen since 1944.

         Deaths from Covid-19 account for most of that decline, but a substantial amount also came from unintentional accidents, mostly overdoses. These data are dismaying on their own, but behind them are other disturbing facts. A New York Times article published just after the release of the CDC mortality report extensively quoted Dr. Steven Woolf, director emeritus of the Center on Society and Health at Virginia Commonwealth University, who noted that the decline in life expectancy in the U.S. was more severe and is continuing for longer than in other high-income countries. Quoting from the article:

“None of them experienced a continuing fall in life expectancy like the U.S. did, and a good number of them saw life expectancy start inching back to normal,” Dr. Woolf said.

Those countries had more successful vaccination campaigns and populations that were more willing to take behavioral measures to prevent infections, such as wearing masks, he said, adding: “The U.S. is clearly an outlier.”

         It thus appears that the portion of the steep decline in life expectancy that is attributable to Covid-19 is worse in the U.S. than in other high-income countries and this can be ascribed to our general lack of preparedness and to the political divisiveness that made following public health recommendations a matter of partisan ideology instead of evidence-based practice. Many Americans sadly have fallen for misinformation about the pandemic and believe that face masks don’t reduce the risk of transmitting and acquiring disease (they do) and that vaccinations are unsafe and ineffective (they are in fact both safe and effective). The price Americans are paying for listening to misinformed voices is obviously profound.

         A second sad truth that can be gleaned from the CDC life expectancy data concerns the fate of American Indians and Native Alaskans. Again quoting the New York Times story:

Average life expectancy in these populations is now “lower than that of every country in the Americas except Haiti, which is astounding,” said Noreen Goldman, professor of demography and public affairs at the Princeton School of Public and International Affairs.

         While it is true that the bulk of the reason for the decline in life expectancy among American Indians and Native Alaskans is due to the Covid-19 pandemic, that doesn’t explain why these communities suffered a much greater effect than other groups. Experts explain that the reason for this is that American Indians and Native Alaskans have higher rates of underlying conditions like diabetes and obesity, which make Covid-19 deadlier. Once again from the New York Times story:

Longstanding health problems — rooted in poverty, discrimination and poor access to health care — left Native Americans and Alaska Natives particularly vulnerable to the virus, said Dr. Ann Bullock, former director of diabetes treatment and prevention at the federal Indian Health Service agency and a member of the Minnesota Chippewa Tribe.

As of 2019, 5.7 million people were classified as American Indian or Alaskan Native, groups of people who experience some of the worst health outcomes in the U.S. As Dr. Bullock explains in the quote above, this is largely due to structural racism and adverse social determinant of health, like crowded living conditions and poor access to healthcare.

In 2019, an American could expect to live to be 79 on average. In 2021 that average lifespan was down to 76. Black Americans had a life expectancy of only 71 in 2021; American Indians and Native Alaskans even lower at 65. While other countries’ mortality statistics have rebounded from Covid-19, the U.S. continues to have high death rates, due in part to vaccine hesitancy. We also do worse than other high-income countries in surviving heart disease, chronic liver disease, and cirrhosis and we have experienced an outbreak of drug overdoses and suicides, the latter fueled in part by our refusal to control private gun ownership.

         The health of Americans compared to citizens of comparable countries is not good. Our fragmented, profit-driven healthcare system makes accessing healthcare difficult for millions, even those who have health insurance. We place the highest burdens on minority groups, offering them the worst access to healthcare and depriving them of many things that are associated with improved health outcomes. Our Critica readers will agree that this situation is morally wrong and intolerable. We can hope that the Covid-19 pandemic taught us that we need to be better prepared for the next infectious disease outbreak, but even accomplishing that will not fix the fundamental reasons that groups like the American Indians and Alaskan Natives living among us have the most dismal healthcare outcomes and the highest mortality rates. Perhaps the fact that we are dying younger in recent years will persuade us that it is time to make major structural changes in our healthcare system and the way we treat marginalized communities.

Monkeypox and a Dilemma of Science Communication

Monkeypox is hardly a new viral infection. It has been endemic to countries in Central and Western Africa for decades, even before 1970 when it was first identified in the Democratic Republic of the Congo. What is new is an outbreak in 82 newly affected countries globally that began several months ago and is challenging our ability to effectively communicate about health and science to the public.

         In the Monkeypox outbreak in newly affected countries, like the U.S., about 95% of the reported cases have occurred among men who have sex with men (MSM). Epidemiological trends confirm that most of these cases often occurred in MSM with multiple partners. It might seem logical, then, that public health communications should be directed mainly to the community most affected by monkeypox.

         However, such a strategy raises at least two problems for public health communicators. First, we know from the HIV epidemic how easy it is to stigmatize sexual minority communities by targeting only them with health information. We don’t want to make the mistake of facilitating anyone falsely labeling monkeypox a “gay disease” as happened with HIV. The pain and suffering this caused members of the MSM community is still incalculable.

         Second, monkeypox is biologically capable of infecting anyone who comes in close physical contact with an infected person or animal, regardless of their sexual orientation. In previously affected African countries where monkeypox has caused outbreaks for years, more common modes of exposure to the virus and possibly transmission are either from animal bites—the monkeypox virus is found in a variety of animals including rodents—or from preparing animal products intended for human consumption . This is not a “gay disease,” but rather an infectious outbreak that is currently affecting the MSM communities and social networks the hardest.

Reluctant Public Health Messengers

         Because of understandable skittishness around how best to walk these fine lines, public health communicators began by seemingly not trying too hard to communicate about monkeypox at all. It took time, for example, for the World Health Organization (WHO) to advise the MSM community to limit sexual contacts, especially anonymous ones, and consider keeping covered during intimate encounters. The U.S. Centers for Disease Control and Prevention (CDC) took even longer to issue that guidance, not offering direct advice to the MSM community until August 5, a week after the WHO.  Furthermore, Fenit Nirappil commented in the Washington Post that “The CDC did not widely promote its new guidance after rereleasing it online…A tweet and accompanying video linking to the changes did not mention the new recommendations to reduce exposure, including limiting partners.”

Predictably, misinformation and disinformation have flourished on the internet and social media platforms. Our colleagues at the University of Pennsylvania’s Annenberg Public Policy Center found in a survey that there is widespread misunderstanding about monkeypox among the U.S. respondents. For example, two-thirds of people were either not sure or did not believe there is a vaccine for monkeypox (there are two, see below) and 12% believe it is probably or definitely true that the monkeypox virus was bioengineered in a lab. In its most egregious form, a Twitter post identified by the Annenberg team alleged that parents should keep their children away from gay caretakers for fear of spreading monkeypox to them, a totally baseless claim. That tweet has since been taken down.

         In a critique of the CDC’s handling of the monkeypox outbreak last month in the New York Times, columnist Ross Douthat wrote:

And then along with these failures came an absurd ideological spectacle, in which health officials agonized about how to state the obvious — that monkeypox at present is primarily a threat to men who have sex with men — and whether to do anything to publicly discourage certain Dionysian festivities associated with Pride Month. As the suffer-no-fools writer Josh Barro has exhaustively chronicled, public-health communication around monkeypox has been an orgy of euphemism and wokespeak, misleading and baffling if you don’t understand what isn’t being said.

         Douthat’s critique here may be excessively harsh; we empathize with the dilemma CDC faced under these circumstances. But he is right that communication about monkeypox specifically to the MSM community and to the broader public was slow, confusing, and generally inadequate. CDC is an outstanding agency for the detection of infectious agents, but  is repeatedly falling short in communicating appropriate guidance to the public.

A Bit About the Monkeypox Virus

         Monkeypox is caused by a virus in the orthopoxvirus genus and belongs to the same group as its more lethal close relative, variola, the causal agent of smallpox. There are two main strains of the virus, now called Clade I and Clade II. Clade II, formerly known as the West African clade, has been detected in cases from the ongoing outbreak in newly affected countries. It  causes less severe disease (2-3% mortality) than Clade I, which is endemic to Central Africa’s Congo Basin, and has a mortality rate of as high as 10%.

People who get monkeypox experience a variety of flu-like symptoms like swollen lymph glands, fever, and muscle aches, but the hallmark of monkeypox is the large, crusted, lesions that form on the skin where the virus concentrates. In the current outbreak in newly affected countries, atypical presentations with a predominance of painful in oral, genital, and anal lesions have been noted, likely a reflection of transmission through close intimate contacts facilitated by sex playing a key role in new infections in the current outbreak

   

The hallmark of monkeypox is typical pox-like skin lesions in which the virus concentrates. Close and prolonged contact with these lesions is the main mode of transmitting the virus from one person to another (image: Shutterstock).

The most common mode of transmission is clearly via close and extended physical contact with active pox lesions. Other modes of transmission like prolonged contact with contaminated objects such as bedding or clothing and droplets/aerosol are possible but not considered to be the primary modes of transmission. Although monkeypox virus has been isolated from seminal fluid, it is not officially described as a “sexually-transmitted infection” because actual transmission by exchange of semen has not been definitively documented. Similarly, although monkeypox virus can be found in large respiratory droplets like those that originate from a cough or sneeze, it is not clear how much if any transmissions occur by inhalation of infectious droplets. Household transmission appears uncommon, and the risk of transmission by aerosolized respiratory droplets in a manner similar to the Covid-19 virus is considered very low.  Hence, it is not likely that one can become infected with monkeypox simply by being in the same room as someone who has it; close and sustained contact with the actual lesions appears to be by far the most common mode of transmission.

Vaccines and Medication Are Available

         Prevention of monkeypox begins of course with limiting physical contact with people already infected. Two vaccines are authorized for monkeypox prevention in the U.S. One is a smallpox vaccine called ACAM2000, which contains a less virulent orthopoxvirus (vaccinia virus) that is capable of replication. It can cause adverse side effects in people who receive it, especially in immunocompromised people for which it is contraindicated , including people with HIV who are not on antiretroviral  treatment . There is also the Jynneos vaccine, which contains a modified vaccinia virus that does not replicate. It is manufactured in Denmark, has fewer adverse side effects, and can be used in immunocompromised individuals but is in short supply. To expand the supply, the CDC recently recommended giving it in lower doses and using a different injection method than originally authorized. Finally, the antiviral drug Typoxx, also in short supply, can be used to treat monkeypox.

Equitable Treatment is Lacking

         We have stressed that monkeypox is not a new illness to highlight that once again a virus has only gotten attention only when it affects high-income countries. As Critica Chief Scientific Advisor B.K. Titanji, an infectious disease specialist at Emory University, recently Tweeted: “Mixed emotions again vaccinating and protecting folks and their communities amidst a global outbreak…Knowing fully well it could be years before communities in Africa, S. America, and Asia are able to do the same. We need EQUITY in Global Health.”

         Even in the U.S. there are clear inequities in infection rates and treatment, with Black MSM in certain southern states having higher rates than white men and having more difficulty accessing preventative services and treatment.

         So there are two imperatives for controlling monkeypox. One is to pay immediate attention to the disease in Africa by getting vaccines and other preventative and treatment measures to people who have been dealing with monkeypox for decades.  Similarly, we need to get vaccines and treatments to people at high-risk for monkeypox in non-endemic countries, especially MSM from minority communities. Equitable attention and access to treatment globally and within the U.S. are clear moral and medical imperatives.        

The other imperative is to learn from our science communication mistakes once again, as we have been forced to do with the Covid-19 pandemic. It should not be so difficult for public health agencies to figure out early messaging that can deal with difficult situations, like that presented by monkeypox. We need to ensure that the community most affected by monkeypox gets reliable information, and that means communicating directly with the MSM community with facts and options. Guidance should not be hedged but must be explicit in explaining what kinds of contacts are most likely to spread disease and what preventative measures most likely to offer protection. At the same time, it must be made clear to the general population that monkeypox is not a “gay disease,” but rather one that can affect anyone. The aim here is not to generate public hysteria; it is unlikely that monkeypox will spread through the U.S. population the way Covid-19 has. Rather, it is to make clear that everyone must take monkeypox seriously and care about those most likely to be affected. More than anything else, it is a plea to public health agencies like CDC to develop better policies and practices around public communication, making them more rapid, relevant to specific communities, and effective in shaping health-promoting behaviors.

Despite Working for Many, We Still Don’t Know How Antidepressants Work

A Paper About the “Serotonin Hypothesis” Stokes Controversy

Even though depression is one of the most common conditions in the world and we know many of the things that increase the chances of getting it (e.g., early life stress, being female, serious medical illness, grief and loss), scientists still do not understand precisely what causes it. When it comes to treating depression, we have many effective interventions, including a range of evidence-based psychotherapies and antidepressant medications, but once again knowledge about exactly how any of these work to alleviate depression is lacking.

         A recent paper and subsequent commentaries that seemed to debunk one theory about how antidepressant medications work received a lot of attention and led its authors to decry the use of these medications. Written by European authors, the paper is a systematic “umbrella” review of the “serotonin theory of depression.” The authors conclude that there is little evidence supporting the serotonin hypothesis and therefore that a whole class of antidepressant drugs, called selective serotonin reuptake inhibitors (SSRIs), may not actually work. In a bold statement the authors of the review paper concluded “Our study shows that [the serotonin theory] is not supported by scientific evidence. It also calls into question the basis for the use of antidepressants.” This is a classic example of authors of a paper making conclusions that go well beyond their data.

The Serotonin Hypothesis of Depression

         What is the serotonin hypothesis of depression? Many antidepressant drugs have the property of quickly increasing the amount of a neurotransmitter in the brain called serotonin or 5-HT. Serotonin then binds to specific receptors in the brain, one type of which is also the site where the SSRIs and other types of antidepressants bind. This raised the question decades ago in scientists’ minds of whether low brain levels of serotonin or some decreased ability to utilize serotonin might be a cause of depression. As the paper by Joanna Moncrieff of University College, London and colleagues published in the journal Molecular Psychiatry showed, efforts to measure serotonin in blood, urine, and cerebrospinal fluid of patients with depression have failed to show any deficits, but this is not surprising because the levels of neurotransmitters in the brain are poorly reflected by levels in these peripheral bodily fluids. Moncrieff and colleagues also reviewed studies of various receptors and genes connected to the serotonin system and once again did not find any evidence supporting the simplistic serotonin hypothesis. In the Molecular Psychiatry paper, they concluded “Our comprehensive review of the major strands of research on serotonin shows there is no convincing evidence that depression is associated with, or caused by, lower serotonin concentration or activity.”

         So far, Moncrieff and co-authors make a reasonable case that low levels or activity of serotonin is probably not the cause of depression, nor do SSRIs and other antidepressants work simply by increasing the amount of serotonin in the brain. Yet, this conclusion is hardly news: very few scientists actually subscribe to such a simplistic version of the serotonin theory at this point. From the very beginning, even before SSRI antidepressants were first approved in 1987, scientists noted that the drugs increase serotonin levels after just a few doses, but it takes weeks of administering them before depression symptoms actually begin to respond. Obviously, something other than simply low levels of serotonin must be involved. All Moncrieff et. al. did was to accumulate years of research about this in one paper, a useful service perhaps but not a novel observation. Where things get controversial is in the conclusions they draw from their review.

Overreaching from Data to Conclusions

         “There is no other accepted pharmacological mechanism for how antidepressants might affect depression,” Moncrieff and co-author Mark A. Horowitz write about in a paper about their research in The Conversation. “If antidepressants exert their effect as placebos, or by numbing emotions, then it is not clear that they do more good than harm…We conclude that it is impossible to say that taking SSRI antidepressants is worthwhile, or even completely safe.”

         Does the fact that a theory about the mechanism of action of a medication turns out to be unsupported mean that the medication is ineffective or unsafe? Obviously, this is not automatically the case and the conclusions that Moncrieff and Horowitz reached are themselves unsupported by any data they provide. The FDA approves antidepressants if there is sufficient evidence they are superior to placebo in clinical trials. All the available antidepressants in the U.S. have met that test. That doesn’t mean of course that antidepressants work for every patient with depression, that they are sufficient to completely eliminate depression even in patients for whom they have some benefit, or even that they are the best treatment for depression. Many patients with depression will do better receiving psychotherapy than medication; some need a combination of the two interventions; and some will do best with antidepressants alone. Nor does the fact that the antiquated serotonin hypothesis is not likely to explain how antidepressants work have any relevance to the issue of their safety. Moncrieff and Horowitz seem to believe that antidepressants merely “numb” emotions and are no better than sugar pills, but nothing in their review paper substantiates that claim.

         In another commentary, Srijan Sen, head of the University of Michigan’s Depression Center, asks “Do we need to understand exactly how a drug or a non-drug treatment works in order to use it? No — if that were true we would have no treatments for depression, whether it’s drugs, like SSRIs, psychotherapies like cognitive therapy, or lifestyle changes like more consistent sleep patterns.” And Sen notes that “by coincidence” another study was published at around the same time as the Moncrieff paper that does show evidence for involvement of the serotonin system as a cause of depression. That paper, published in the journal Translational Psychiatry, is quite technical and did not garner media attention. Yet it suggests that a combination of adverse life experiences and mutations in a serotonin receptor gene does seem to be involved in why some people become depressed.

         Although Moncrieff and co-authors are careful to caution people on antidepressants not to stop them without discussing with their prescribers, their warnings seem half-hearted. Implicit in their comments is the message that if what they misunderstand to be a prominent hypothesis about how antidepressants work—correcting low levels of serotonin in the brain—doesn’t hold up then maybe the use of antidepressant medication is called into question. Media seemed intrigued by that message, which is clearly not a logical conclusion. What they have simply provided us with is another reminder that the human brain is incredibly complex and difficult to study and that in many instances treatments for human diseases, especially when they involve the brain, work without our knowing why they work. The easiest thing to do here is to call for more research, which of course we do and will happen. More to the immediate point, however, is to urge scientists to be cautious in leaping to conclusions and the media to put things in the correct perspective.

Is It “Medical Gaslighting” or Are You Really Just Okay?

A 24-year-old man makes a visit to his primary care doctor because of a severe headache that has been bothering him for 24-hours. The doctor takes a history and learns that the man has otherwise been in good health, exercises regularly, does not smoke or use drugs, and has no significant family history relevant to headaches. A physical examination is also normal including a normal blood pressure. The doctor tells the patient that it is unlikely that there is anything seriously wrong with him, inquires whether he has been under an unusual amount of stress lately, and advises him to take an over-the-counter pain medication (acetaminophen) and to call if the headache does not subside over the next 24 hours.

         This is a typical scenario for a primary care visit and the overwhelming odds are that this young man indeed has nothing seriously wrong with him, is suffering from a tension headache because of stress, and will feel much better after a few doses of the painkiller and a few hours. Yet in many cases patients do not feel satisfied with an encounter like this. In this instance, our patient feels that his doctor did not appreciate the severity of his symptoms or consider all the possible underlying causes for them. So he goes home and searches the internet for causes of headaches. He reads that a type of brain tumor called glioblastoma multiforme (GBM) is the most common form of brain cancer, that it is virtually incurable, and that severe headache is one of the early symptoms. Our patient wants a magnetic resonance imaging (MRI) scan of his head without delay. He leaves a message with the doctor’s office making that request and becomes very frustrated when a day later he has not heard back. Fortunately, at that point his headache is better, so he now resolves to find a neurologist who will order the MRI scan he thinks he needs.

Article Identifies Medical Gaslighting

         A recent article in the New York Times by Christine Caron highlights instances in which people do not feel their doctors are listening to them. “The experience of having one’s concerns dismissed by a medical provider, often referred to as medical gaslighting, can happen to anyone,” Caron wrote in the article published last July. Caron writes about people whose symptoms were dismissed by medical professionals, only to turn out to have serious illnesses. “A recent New York Times article on the topic,” she explains, “received more than 2,800 comments: Some recounted misdiagnoses that nearly cost them their lives or that delayed treatment, leading to unnecessary suffering. Patients with long Covid wrote about how they felt ignored by the doctors they turned to for help.” She also notes that the problem of “medical gaslighting” appears to be worse for “women, people of color, geriatric patients and L.G.B.T.Q. people.”

         To read the article by Caron, one might get the impression that there is a widespread breakdown of communication between patients and their doctors, and that dismissal of symptoms is a common phenomenon. Furthermore, the article implies that doctors routinely miss real disease because they don’t take what patients tell them seriously.

         Caron cites a study “using data from 2006 and 2007 [that] estimated that approximately 12 million adults were misdiagnosed in the United States every year and about half of those errors could be harmful.” When we looked at that study, however, we also noted that the rate of those errors, which involved colon and lung cancer cases that were not initially diagnosed, was 5.08%. In other words, no misdiagnosis was detected in almost 95% of the cases the investigators examined. While finding misdiagnoses in 1 out of 20 patients is very far from trivial, it does put in perspective the sense from the article that misdiagnoses are common. We believe that a more common problem is the breakdown of communication between patients and their healthcare providers. Let’s look first at what was probably on the mind of the doctor who saw the patient in our fictional example.

Using Pretest Probability to Make Medical Decisions

         When a physician or other healthcare provider is faced with a set of symptoms reported by a patient, one of the very important things they consider is the “pretest probability” of different potential diagnoses. In the case of our young man with a headache, for example, we know that the rate of GBM is 3.19 per 100,000 people and that the median age of diagnosis is 64. Thus, the chances that a 24-year-old man with a normal neurological examination has a GBM are vanishingly small. Much more likely are other types of headaches, like tension and migraine headaches. MRI scans are expensive and unhelpful in detecting the causes of most headaches and health insurers balk at paying for unnecessary medical procedures. Finally, waiting a few days to see if the headache goes away would have minimal consequences if our patient really did have a brain tumor. In this case, the doctor’s advice on a plan of action was entirely reasonable.

         Yet it did not seem so to our patient. Indeed, a survey published last year found that “Three in 4 Americans leave the doctor confused and dissatisfied for reasons that include disappointment in the level of Q & A they have with their doctor, confusion about their health, and a need to do more research…” Nearly half of people research their doctors’ suggestions after a visit. A breakdown in communication between healthcare providers and patients seems to be at the root of this issue.

         And a key cause of this breakdown is probably the fact that primary care providers, and many other healthcare professionals, find themselves overloaded by the demands made on them, particularly by the need to record every aspect of a patient encounter in the electronic health record (EHR). A study published last July in the Journal of General Internal Medicine showed that primary care doctors would need 26.7 hours a day to complete all the work that is asked of them. This problem spills over into many aspects of healthcare: in a recent visit to an emergency department at a major urban teaching hospital, a member of the Critica team witnessed scores of doctors and nurses huddled in front of computer screens trying to complete EHR requirements while patients waited for hours to be seen. While anecdotal evidence like this must be taken lightly, it is consistent with many reports we have heard and with the Journal of General Internal Medicine study showing that doctors simply don’t have enough time to spend providing direct care to patients. It is hardly surprising, then, that some people feel their doctors aren’t listening to them or sufficiently addressing their questions and concerns. Many are turning to the internet for information, where they may or may not obtain accurate information.

Solutions for Medical Gaslighting

         In her New York Times article Caron lists six signs of medical gaslighting, most of which center on poor communication style, including “You feel that your provider is being rude, condescending or belittling.” One of the six is “Your provider will not order key imaging or lab work to rule out or confirm a diagnosis,” but as we have pointed out, that one is not always a sign of gaslighting but is more likely to be a question of a physician applying pretest probability logic to make a decision that expensive or invasive tests are unlikely to contribute information that would influence a course of treatment.

         Caron also offers suggestions for how patients can advocate for themselves and steps to take if a person still feels ignored, including switching providers and joining a support group. The latter is also more complicated that she suggests, however, because support groups may or may not be sources of accurate medical information. Some can help patients through difficult situations and offer valuable advice, but others create an adversarial relationship between doctors and patients and promote interventions that are not evidence-based.

         Solutions to the medical gaslighting problem should not rest solely on patients’ shoulders of course. While Caron’s suggestions are mainly good ones, they do not go far enough. Two things need to happen on the healthcare providers’ side of the issue. First, it is now abundantly clear that the age of the EHR and other changes in medicine have put ridiculous demands on healthcare providers that force them away from their most important task, interacting directly with patients. This needs urgent attention and reform. While the EHR offers a multitude of advantages over old-fashioned handwritten charting, it now places an impossible workload on doctors and nurses and needs to be fixed. Second, much more attention needs to be paid to training doctors and other healthcare workers how to communicate with patients. While this may seem obvious, it is not necessarily a routine part of medical training. Caron paints a bleak picture of doctors who don’t answer questions, condescend to patients, and ascribe symptoms to mental health issues without offering any actual mental health help. Relieving some of the administrative burden on doctors should make it easier for them to spend more quality time with patients but teaching doctors how to communicate effectively is also needed.

         It is unclear how common medical gaslighting is and it is critically important that we not encourage unnecessary medical testing and procedures. Still, Caron does an important service in identifying a growing rift between doctors and their patients. We believe that a large portion of the cause of that rift rests in unreasonable demands on doctors’ time and lack of training in how to communicate with patients. Both are remediable issues that require our attention.

Don’t Just Look Where the Light Is Shining

Switching Focus on Treatments for Alzheimer’s disease

There is an old joke in science about a police officer walking his beat one dark and gloomy night when he comes upon a man furiously searching for something beneath a streetlight. “What are you looking for?” the officer asks the man. “I lost my car keys,” the man replies. “Is this the area where you lost them?” the officer queries. “No, but it is the only place on the whole block where there is any light,” is the man’s answer.

         Those keys could, of course, be anywhere, and the decision to limit the search to the place where the streetlight shines strikes us as clearly irrational and a bit funny. Not so funny, however, when logic like this seems to inhibit progress in learning the causes of and treatments for a life-limiting disease. This, unfortunately, appears to be what has happened in the case of Alzheimer’s disease research. We wrote a year ago about the then recently U.S. Food and Drug Administration (FDA)-approved drug Aduhelm, which is essentially an antibody directed against an abnormal protein called beta-amyloid that is found in plaques on postmortem examination of brains from people who had Alzheimer’s dementia during their lifetimes.

         It has always been unclear if Aduhelm actually works to prevent or reverse memory loss in patients with Alzheimer’s disease. There has been a strong outcry from the scientific community protesting the FDA approval of the drug because the evidence that it does more good than harm for people with Alzheimer’s disease is thin. Because there are currently no effective treatments for Alzheimer’s disease, it might be understandable that an agency would want to err on the side of approval. The FDA, however, is supposed to make its decisions based on solid scientific evidence for efficacy and lack of harm, not out of sentiment. Why, in the face of very little solid evidence for efficacy, was this anti-amyloid drug approved? Why do scientists and regulators persist in pursuing the anti-amyloid strategy at all?

Amyloid Plaques Seem a Likely Culprit

Ever since Alois Alzheimer first described changes in the brains of people that had the disease that bears his name, scientists have focused on the idea that the buildup of amyloid plaques in the brain is the cause of the severe memory loss experienced by patients with Alzheimer’s disease and reckoned that eliminating them would somehow improve cognitive function and slow the inevitable progression of the disease to death. Directing antibodies against the proteins that are the main ingredients of the amyloid plaques seems like a logical idea. In a recent STAT piece, Howard M. Fillit, a neuroscientist and geriatrician at the Icahn School of Medicine at Mount Sinai and co-founder and chief scientific officer of the Alzheimer’s Drug Discovery Foundation, explained that “When Alzheimer’s disease was believed to be caused solely by the accumulation of amyloid protein in the brain, pinning all hopes on an amyloid-targeting drug like Aduhelm…made sense.”

Amyloid plaques build up between neurons in the brains of people with Alzheimer’s disease. They have been the target of enormous amounts of research and clinical trials, but it is now seeming less likely that they are the central cause of the illness (image: Shutterstock).

         Indeed, enormous amounts of research funding and effort have been expended on understanding the biology of the amyloid plaque and trying to figure out how to eliminate it from the brain. Amyloid plaques collect between neurons in the brains of people with Alzheimer’s disease and there is no question that they are toxic to brain function. On autopsy, amyloid plaques are easy to see under a light microscope and extracting the proteins that make them also relatively straightforward. This makes them an ideal research target. It is, after all, where the light seems to be shining.

Anti-amyloid Drugs Persistently Fail

But there have always been signals that the buildup of amyloid plaques is probably not the only cause of Alzheimer’s, if it is even one of the causes at all. For example, Alzheimer’s disease generally begins in a part of the brain called the entorhinal cortex, a brain region critical for short-term memory and navigation through physical space. Yet, plaques are “not primarily observed in the entorhinal cortex.”  One attempt after another to prevent or treat cognitive function loss in Alzheimer’s disease by targeting amyloid plaques has failed. One thought that occurred to scientists after the first few failures was that perhaps by the time a patient has advanced disease it is too late to induce improvements by trying to reduce the amyloid plaque burden. So, researchers decided to pursue clinical trials with anti-amyloid drugs involving people with the earliest signs of Alzheimer’s disease.

         This strategy, unfortunately, also seems like a dead end. In June, the Roche drug company announced the failure of its experimental drug crenezumab in a much anticipated study. The study involved people with a relatively rare genetic mutation that causes early-onset Alzheimer’s disease. Crenezumab is another antibody-based medication that targets amyloid plaque protein, and in this trial it was compared to placebo in study participants with the mutation who did not yet have signs of the disease. Yet crenezumab did no better than placebo in preventing onset of or slowing cognitive decline, indicating that even addressing Alzheimer’s disease in its earliest stages with anti-amyloid drugs does not seem to work.

         The perseverance of interest in amyloid plaques as the main treatment target for Alzheimer’s disease, while understandable, represents one not uncommon problem with research, perhaps especially relevant when it involves diseases of the brain. Despite the ever-increasing sophistication of methodology in neuroscience and human brain imaging, the brain remains relatively impenetrable compared to other organs of the body. Sometimes psychiatrists and neurologists who are specialists in brain disorders think that even black holes in outer space are easier to study than the human brain. When something pops up that seems to make sense, scientists grab hold and invest all their time and money to study it in every possible aspect.

These MRI scans show the severe loss of brain tissue that occurs in patients with Alzheimer’s disease. Research now suggests that there are probably multiple different causes of the illness and clinical trials are beginning to address some of them (image: Shutterstock).

         This of course runs the risk of overlooking other areas that might be more fruitful for scientists to pursue. Fortunately, scientists, perhaps reeling from all the failures of anti-amyloid drugs, finally seem willing to look at other pathways to ameliorate Alzheimer’s disease. As Fillit notes, “More than three in four treatments currently in clinical development work against non-amyloid targets.  These include drugs to reduce inflammation in the brain, improve blood flow, clear misfolded proteins, improve how the brain metabolizes energy, and more.” In fact, scientists have long known that there are multiple things wrong with the brains of people with Alzheimer’s disease besides the accumulation of amyloid plaques. Amyloid plaques might even be a reaction to one of these other disease processes. For example, Alzheimer himself identified another abnormal protein in the Alzheimer’s disease brain, called hyperphosphorylated tau protein. Misfolded tau proteins form what are called neurofibrillary tangles that collect inside of neurons and may be more central to the cause of Alzheimer’s disease than amyloid plaques. Drugs that rid the brain of neurofibrillary tangles are now under investigation.

         There is also strong interest in the likelihood that Alzheimer’s disease involves some abnormalities in the brain’s blood circulatory or vascular system. This is because many of the same factors that increase the risk for heart disease and stroke also appear to increase the risk for Alzheimer’s disease, including high blood pressure (hypertension), elevated cholesterol levels, smoking, diabetes, and obesity. Exercise and healthy diets may help reduce cognitive decline. So might social engagement and mentally challenging pursuits.

         Scientists, like everyone else, can have trouble abandoning what seems like a very good idea, even when experience should be telling us it is time to move on. In the case of anti-amyloid drugs, so much money has been invested in researching them and so many scientific careers devoted to their biology that moving on to new areas of work has clearly been difficult. Yet it seems it is time to do so. Unless we are surprised by an anti-amyloid drug that really shows strong clinical evidence for being effective, the FDA should stop approving drugs that target amyloid plaque proteins and the NIH and other funding bodies should begin to switch their grant-making priorities to other, more promising avenues. It is time to acknowledge that just because there happens to be a streetlight at one spot along a long block doesn’t mean that’s where our lost keys are to be found.

What If Your Doctor is Spreading Disinformation? 

A surprising trend among some doctors is harming the American public.

Physicians are sometimes thought to be on the front lines of fighting medical misinformation because they are in the advantageous position of interacting very closely with a wide range of patients. Lately, some physicians have even taken to debunking medical misinformation online, and in some cases, unfortunately, they are even attacked on social media. Some estimates suggest that as many as 1 in 4 physicians who address medical misinformation on social media are attacked in response. Renewed efforts have focused on training physicians to respond in a calm, effective manner when this happens. 

But what if the physicians themselves are spreading disinformation? This is actually not as unusual as it might sound. In June of 2022, the American Medical Association deemed it enough of a problem to adopt a new policy. The policy includes measures such as educating physicians to be debunkers of disinformation and educating the American public to recognize disinformation. Many of the action steps in this policy are unfortunately vague, such as “address disinformation disseminated by health professionals via social media platforms and address the monetization of spreading disinformation on social media platforms” and “consider the role of health professional societies in serving as appropriate fact-checking entities for health-related information disseminated by various media platforms.” 

The most important provision in the policy has to do with the power of state medical boards to take disciplinary action when doctors spread disinformation. But more needs to be done here: a coordinated effort between states and medical societies like the AMA is needed to identify and have a clear set of disciplinary actions in place for doctor-led disinformation. Some form of surveillance mechanism and set of clear and consistent disciplinary actions for various types of actions involving disinformation need to be established. This process should be led by the AMA. In addition, the general public needs to be better educated about how to spot physician-led disinformation, and, importantly, how to report propagators of this false information to state medical licensing boards. It is probably the case that most members of the American public would not know how to do this. 

Importantly, we need more information about the motivation behind the spread of disinformation among doctors and the methods that can be used to control the spread of this information online. As many have noted, a lot of physician-led disinformation can be traced back to just 12 individuals, who are often called the “Disinformation Dozen.” The Disinformation Dozen is responsible for 65% of the false anti-vaccine information shared on social media surrounding the COVID-19 vaccines in particular. While not all of them are physicians, some certainly are and have been peddling false information about vaccines and other topics on Facebook for years while often selling supplements and other products. The question then arises as to why Facebook is only now beginning to take down some of their accounts and why they are taking action so slowly, banning some of them but not all of them. Facebook is probably in the best position to surveil where disinformation is coming from on the platform and should be much more active in banning people who become superspreaders. While many have posited that profit is what is mostly behind the Disinformation Dozen’s and others’ spread of lies about health and medicine, there are probably also potent ideological and political motivations here as well. We should not dismiss the possibility that these may be the primary motives in many cases and that some physicians are leading a coordinated attack on our democratic values and our sense of who and what we can trust. 

Finally, what does it mean for physicians and other members of society to become adept at dispelling disinformation? These claims can be quite powerful and are not always so easily “debunked.” We suggest that physicians be trained in various methods of dismantling mis- and disinformation, such as motivational interviewing, prebunking, and inoculation methods. These and other sophisticated methods that exist in the now vast literature on misinformation should be something that all doctors can call upon as they encounter dis- and misinformation online and in the clinic. The AMA should be at the center of this effort as well as efforts to surveil social media for signs of viral disinformation if they are truly serious about doing something about this terrible problem.

 

Our Short Attention Span About Gun Violence

What Will It Take to Sustain Our Interest in Gun Control?

Two days after the May 24 Uvalde school massacre that claimed the lives of 21 people, two major league baseball teams did an unusual thing. Instead of tweeting about the game they were playing against each other, the New York Yankees and Tampa Bay Rays chose to tweet a series of facts about gun violence, including “Firearms were the leading cause of death for American children and teens in 2020 ” and “Every day, more than 110 Americans are killed with guns, and more than 200 are shot and injured.” Each statement was accompanied by a citation from a credible source, like the Centers for Disease Control and Prevention (CDC).

         Every time there is a mass shooting involving school children, we see a spike in media attention to gun violence and an increase in calls by politicians for federal gun control legislation. What the Yankees and Rays baseball teams did was laudable, but it raises the question of whether this kind of recitation of facts about gun violence immediately following an incident has any impact. At the time, we wondered whether the latest surge in interest in gun violence would last, whether it would lead to any action, and exactly what kind of action might actually work to decrease gun-related deaths and injuries.

Politicians Wait Out Public Outcries Against Guns

         Here’s a fact about guns: according to Monika L. McDermott of Fordham University and David R. Jones of Baruch College, CUNY, “Nearly half of the public lives in a household with a gun.” That’s the U.S. public, of course. Most other high-income countries have much stricter gun laws than the U.S. and far lower rates of gun-related deaths and injuries. McDermott and Jones point out that although a “slim majority” of Americans favor stricter gun control legislation, “that support tends to spike in the short term after events like the recent mass shootings [Buffalo and Uvalde].” Congress can thus size up that a lot of people own guns and only a small majority favors restricting access to them. To avoid taking any action it can just wait a bit until the furor over the most recent killings subsides. That means that a gesture like that taken by the baseball teams has a short-lived effect that won’t translate into any meaningful action.

         As we move farther away from highly publicized gun violence incidents like those in Uvalde, Texas and Buffalo, New York we see more and more doubts expressed about whether gun control legislation would even be effective in reducing gun violence. After all, there are already millions of guns in the hands of Americans—an estimated 120.5 for every 100 citizens—so some argue further restricting sales and access will have no meaningful impact.

         We also see other doubts about the effectiveness of gun control laws cropping up. For example, in an analysis in the Washington Post, Glenn Kessler concluded from work done by gun researchers that “mass shooters are very determined individuals and that even with an average of seven or eight mass shootings a year, new laws might only reduce the number by one a year.” Later in the article, Kessler does acknowledge a now lapsed law banning large-capacity magazines “may have been effective in reducing the death toll” and that universal background checks “could have an impact on mass shootings.” Still, the tone of the article casts doubt on the likely impact of some of the most prominently proposed gun control laws, like bans on assault weapons.

         It is not only politicians who lose interest in gun control legislation over time, but all of us. We are shocked and horrified by the deaths of innocent children during a mass school shooting, we talk about nothing else for several days, and then the memory fades and we move on to other pressing topics. “A dramatic event like a shooting attracts reporters’ attention, provokes a great deal of coverage, and then fades from view when the news media move on to the next big event,” wrote Sarah Binder last May in the Washington Post. “What’s more, public pressure for change typically fades as well, letting opponents off the hook.”

The Science About Guns Is Clear

         But the fact remains that the Uvalde shooter purchased his guns legally just days before the massacre, right after his 18th birthday. Laws banning the purchase of assault weapons and raising the legal age to buy a gun from 18 to 21 across the country might have prevented him from obtaining the weapons he used. We can debate the likely effectiveness of gun controls laws endlessly, but perhaps what we need more of are headlines like the one that appeared on May 26 in Scientific American: “The Science is Clear: Gun Control Saves Lives.” Scientists love to debate all the details and nuances of available data on every topic, and pieces like the one cited above in the Washington Post that carefully dissect the evidence supporting gun control laws are important. Still, what we need to know is that scientific consensus supports gun control. The piece by the Scientific American editors does not equivocate:

The science is abundantly clear: More guns do not stop crime. Guns kill more children each year than auto accidents. More children die by gunfire in a year than on-duty police officers and active military members. Guns are a public health crisis, just like COVID, and in this, we are failing our children over and over again.

The clear gun science the article’s headline refers to is summarized as follows:

…in 2015, assaults with a firearm were 6.8 times more common in states that had the most guns, compared to the least. More than a dozen studies have revealed that if you had a gun at home, you were twice as likely to be killed as someone who didn’t. Research…tells us that states with higher gun ownership levels have higher rates of homicide.  Data even tells us that where gun shops or gun dealers open for business, killings go up…The science must not be ignored.

         We need definitive, bold statements like those made in the Scientific American article. While of course we always need more research on almost every topic and gun violence research has been woefully underfunded for many years because of federal funding restrictions, we have enough data right now to justify consideration by Congress of steps like renewing the bans on assault weapons and large capacity magazines, universal background checks for gun purchase, and raising the age limit for gun purchases from 18 to 21. It is true that so long as U.S. residents who are not active military or law enforcement personnel are permitted to have guns, none of these laws will eliminate gun homicides or suicides. The data tell us they may, however, reduce the number of gun-related deaths and injuries and that should be more than ample justification for pursuing them.

         What we will need to make federal gun control legislation happen is to keep our attention level about this issue sustained at a high level. We must not think that gun violence is isolated to the relatively rare school massacre: according to Pew Research, in 2020, the most recent year for which complete data are available, “45,222 people died from gun related injuries in the U.S.,” slightly more than half of which were suicides. The Pew report from last February also notes that “Regardless of the definition being used, fatalities in mass shooting incidents in the U.S. account for a small fraction of all gun murders that occur nationwide each year.” Firearm-related deaths and injuries occur daily in communities across the U.S.

         Media attention to every gun-related death in a community runs the risk of inuring the public to these tragedies and blunting our resolve to do something about them. Rather, we need sustained, targeted attention throughout the year to the problem. Articles like the one we cited above in Scientific American need to appear on a regular basis throughout traditional and digital media, not just after mass shootings involving children. Unless we remain outraged about gun violence and press for new gun control laws, Uvalde will simply fade away from our memories. It is for this reason that we are writing about gun violence and the data supporting gun control legislation two months after the Uvalde school massacre. We hope the Yankees and Rays and lots of other influential organizations will tweet and post about this problem again and again. Critica will do what we can to keep our attention focused on the gun violence issue and its potential solutions.

The Climate Crisis: Urgent and Not Hopeless

How many crises can people handle at the same time? The Covid-19 pandemic continues; there is a war in Ukraine; inflation is out of control; and people who are refugees, members of marginalized communities, or live in occupied territories continue to suffer around the world.

         Looming over all of this is global warming and the ongoing climate crisis. As massive floods, unprecedented heat waves, and other environmental disasters become ever more common across the globe, we seem to put this at the bottom of our list of concerns when we respond to surveys and vote for elected officials. Yet this problem is not going away—indeed it is getting worse, with more carbon dioxide being pumped into the environment now than ever before. Why are we so willing to look the other way when it comes to the climate emergency we are now facing?

It Isn’t Hopeless

         One reason is the sense of hopelessness and despair engendered by just what we wrote in the paragraph above, that the climate crisis is getting worse. It now seems inevitable that we will exceed the threshold of an increase in global temperature of 1.50 Celsius over preindustrial levels and that will surely bring us more floods, heatwaves, and misery. If it is hopeless, then the best we think we can do is to try not to think about it at all.

         Yet in fact hopelessness in the face of the climate crisis is entirely misplaced because scientists assure us that we now have the technologies necessary to operate our power grids with clean, sustainable energy from fossil-free sources. In a heartening article published in Physics in April, Mark Z. Jacobson of Stanford University noted that “10 countries—Iceland, Norway, Costa Rica, Albania, Paraguay, Bhutan, Namibia, Nepal, Ethiopia, and the Democratic Republic of the Congo—produced 97.5 to 100% of all their electricity from WWS [wind-water-solar] resources. Some of these countries even produced excess electricity that they could sell to their neighbors.”

Wind, water, and solar (WWS) energy are now powering the electric grids of whole countries and could be used to replace fossil fuel-derived power in most countries in the world right now according to scientists (image: Shutterstock).

The cost of wind and solar power have declined dramatically in recent years to the point that it is now practically and economically viable to develop them as our main energy producers. Fears that without burning fossil fuels the lights will go out all over the world are unsupported by the facts: Jacobson tells us “I’ve studied the use of [renewable energy] technologies in 143 countries and 50 states and found that the grid can stay stable everywhere in the world with 100% WWS.”  Iowa, for example, now gets most of its power from the wind. Batteries to store electricity generated by wind, hydro (water), and solar sources are also becoming increasingly more sophisticated and cheaper, although there are issues with the environmental and human effects of mining the minerals like cobalt and lithium that are needed for them.

Just as climate scientists give us the disheartening news about the devastations we face if we continue to extract and burn coal, oil, and gas, they are giving us increasingly upbeat news that we absolutely have the technology right now to rectify the situation and move to fossil-free energy.

The Climate Situation is Life and Death

Relieving the world of the pollution caused by fossil fuel combustion is in fact as much a life and death emergency as is getting the Covid-19 pandemic under control and ending the war in Ukraine. In vulnerable neighborhoods around the world, people breathing in the pollutants emitted by truck and car exhaust and from incinerators and other polluting facilities suffer a plethora of adverse health outcomes, including lung and heart disease. Low-income neighborhoods are especially burdened by pollutants emitted from vehicles and facilities. That creates the impression that poverty is the cause of this environmental injustice, but studies show that the real cause is racism.  As reported in Nature, Dylan Bugden of Washington State University in Pullman found in a survey that “Most Americans do not think that Black people are any more likely to be affected by pollution than white people, despite significant evidence that racism is a root cause of environmental injustice in the United States…” Neighborhoods with high concentrations of Black people were subjected to redlining by federal authorities for almost 40 years, a practice that resulted in restricted mortgages to those neighborhoods and concentration of highways, incinerators, and other pollution-causing facilities.

Racist policies have led to the placement of pollution-emitting facilities in Black neighborhoods, contributing to environmental injustice and poor health outcomes (image: Shutterstock).

Here again, there is some hope on the horizon. New Jersey now has the strictest regulations in the U.S. to limit this kind of environmental insult by taking into consideration a community’s cumulative burden in granting permits to facilities that will cause pollution. At the federal level, President Biden’s Justice 40 initiative mandates that 40% of the government’s investment in climate and clean energy will go to disadvantaged communities.

Technologies exist to mitigate the climate crisis and thereby save lives. The situation is urgent, especially for people living in vulnerable neighborhoods who are the victims of racist practices that concentrate polluting vehicles and facilities in their communities. The issue is whether we and our elected officials have the will to take advantage of these technologies and of the examples set up by all the countries that are already using them to put an end to fossil fuel combustion and bring us renewable energy. We also need to see whether other states will take New Jersey’s example and move boldly to restrict further placement of pollution-causing facilities in already overburdened communities.

As an editorial in Nature recently put it “World leaders must listen to the research community, and accept the evidence and narrative offered to help them to navigate meaningful change. Environmental sustainability does not impede prosperity and well-being—in fact, it is vital to them. People in power need to sit up and take notice.”

The Many Myths About Abortion

When a person contemplates terminating a pregnancy by induced abortion they may go online for information. There, they will find an incredible array of misinformation and disinformation.  Online platform companies like Meta, the parent company of Facebook, Twitter, and Google, struggle to monitor and police online misinformation in general, but those challenges seem especially complex for them when it comes to abortion. These platforms claim to encourage free speech and because abortion is felt by some to be a political, religious, and ethical issue the platforms appear confused about when something posted is in fact misinformation.

The online platforms often neglect to recognize that induced abortion is a medical issue and that there are many things being posted about it that are clearly incorrect. “Perhaps no medical procedure is subject to more misinformation than abortion,” wrote Jenna Sherman in the Scientific American in June, “and social media and search engine companies have been too stagnant in their efforts to stop the spread.”

         So it is important to get the facts straight about abortion and then to do all we can to counteract misinformation and disinformation about it. There are two ways to accomplish an induced abortion, by taking medication and by surgery. Despite what one may read on the internet, both are safe. In fact, having an abortion is safer than having a baby. A study published ten years ago showed that a woman is 14 times more likely to die during childbirth than from complications of having an abortion.

Half of Induced Abortions are Medical

         About half of induced abortions in the U.S. are now accomplished by medication according to the Guttmacher Institute and that rate may go up with the recent overturning of the Roe v. Wade decision by the U.S. Supreme Court. Contrary to misinformation often posted on the internet, the “morning after pill” is not the same as the “abortion pill.” Experts agree that morning after pills, which contain the hormone progestin and must be taken within a few days of unprotected intercourse, interfere with ovulation and fertilization and do not cause abortion. Medical abortion on the other hand involves taking two drugs, mifepristone and misoprostol, and is approved by the FDA for use up to 10 weeks of pregnancy. Medical abortions are safe and effective.

         There is some concern that medications for preventing pregnancy and for medical abortion will become less available in the U.S. after the recent Dobbs decision that overturned the constitutional right to an abortion. There has been an increase in online chatter about alternatives to FDA-approved medications for abortion, including a variety of herbs. However, no herb has ever been proven to be an effective abortifacient and in fact taken in high doses there have been reports of severe toxicity and even deaths.

It is important that people contemplating an induced abortion have access to accurate scientific information. We know from extensive studies that both medical and surgical abortions are safe procedures that are not associated with any long-term adverse physical or mental outcomes (image: Shutterstock).

         The alternative to medical abortion is surgical abortion. More than 90% of surgical abortions in the U.S. are performed before the 13th week of pregnancy by an aspiration procedure. Fewer than one percent of induced abortions occur in the third trimester, although these abortions later in pregnancy seem to get the most attention from anti-abortion activists. Abortions after 21 weeks are sometimes done because of the detection of severe fetal abnormalities or because the life of the mother is threatened.

Medical and Surgical Abortions Are Both Safe Procedures

         Claims that induced abortion increases the risk for infertility, breast cancer, and mental health problems are incorrect. We know this from many studies, the most important of which is probably the Turnaway Study, which followed more than 1000 pregnant women for five years, beginning in 2007. Prior to the Turnaway Study, a number of reports in the literature suggested that there were increased mental health risks for women who had undergone elective abortion, but these studies were all fatally flawed. A key reason for the problem with them is that they did not control for preexisting mental health problems in women who underwent abortion and therefore could not determine if the abortion itself was really associated with any increase in risks. The Turnaway Study handled this problem in a very creative way: by comparing women who had an abortion to women who sought an abortion but were denied one because their pregnancies had gone beyond the time limit that the facility where they sought an abortion allowed, the investigators were able to assemble very well-matched groups for comparison.

The leader of the study, Diana Greene Foster, professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco, recently wrote about the findings of the study in the journal Science: “Women unable to obtain an abortion said they had more symptoms of anxiety lower self-esteem, and lower life satisfaction. They were more likely to report ‘fair or poor’ health than those who had received abortions.”  In a series of more than 50 papers published by Turnaway Study investigators, Foster noted it was also shown that women who were denied abortions were more likely to have lasting financial problems, to be unemployed, and to live below the federal poverty line compared to women who were able to obtain abortions. There is no link between having an abortion and future fertility problems and abortion does not increase the risk for breast cancer.

         One thing that is also clear is that restricting access to abortion will have its greatest adverse effect on people who belong to traditionally marginalized groups. According to scientists from the University of Pennsylvania, “it is well-established that anywhere from a quarter to a third of people who receive an abortion annually are Black, and the majority are low income.” The maternal mortality rate for Black women in the U.S. is more than double the rate for white women, meaning that unwanted pregnancies among Black women will cause, among other adverse outcomes, a disproportionate increase in maternal deaths.

         Regardless of one’s political, religious, and moral opinions about induced abortion, there are several things we know from research studies that belie rampant misinformation. Both medical and surgical abortions are effective and safe. There is no increase in maternal physical or mental health problems associated with having an abortion. In fact, childbirth is far riskier than having an abortion. Women who are denied an abortion suffer increased risks for unemployment, poverty, and ongoing financial and other social problems. The adverse outcomes associated with being denied an abortion disproportionately affect women of color, women with low-income, and members of traditionally marginalized groups.

         While there will be differences of opinion about induced abortion, it is critically important that the available science not be distorted in these debates. Evidence tells us that abortion is safe, and that restricting abortion causes physical and mental health problems as well as a host of poorer socioeconomic and life satisfaction outcomes. We hope that people contemplating an elective abortion will have access to accurate scientific information and that this information plays a prominent role in legislative and judicial proceedings about abortion.