With help from tech startups, the concept of timeshare vacation homes is shaking off its stodgy old image. Even commitment-phobes might be tempted.
Learning to Listen to Patients’ Stories
Narrative medicine programs teach doctors and other caregivers “sensitive interviewing skills” and the art of “radical listening” to improve patient care.
Waclawa “Joanne” Zak, who now lives in Oxford, Wis., fought in the Polish resistance during World War II. As a teenager, she served as a scout, assessing German troop strength and positions. Later in the war she trained as a nurse and was liberated from a German P.O.W. camp. She told her story as part of the “My Life, My Story” program at the William S. Middleton Memorial Veterans Hospital in Madison, Wis.Credit…Andy Manis for The New York Times
The pandemic has been a time of painful social isolation for many. Few places can be as isolating as hospitals, where patients are surrounded by strangers, subject to invasive tests and attached to an assortment of beeping and gurgling machines.
How can the experience of receiving medical care be made more welcoming? Some say that a sympathetic ear can go a long way in helping patients undergoing the stress of a hospital stay to heal.
“It is even more important now, when we can’t always see patients’ faces or touch them, to really hear their stories,” said Dr. Antoinette Rose, an urgent care physician in Mountain View, Calif., who is now working with many patients ill with Covid.
“This pandemic has forced many caregivers to embrace the human stories that are playing out. They have no choice. They become the ‘family’ at the bedside,” said Dr. Andre Lijoi, a medical director at York Hospital in Pennsylvania. Doctors, nurses and others assisting in the care of patients “need time to slow down, to take a breath, to listen.”
Both doctors find their inspiration in narrative medicine, a discipline that guides medical practitioners in the art of deeply listening to those who come to them for help. Narrative medicine is now taught in some form at roughly 80 percent of medical schools in the United States. Students are trained in “sensitive interviewing skills” and the art of “radical listening” as ways to enhance the interactions between doctors and their patients.
“As doctors, we need to ask those who come to us: ‘Tell me about yourself,’” explained Dr. Rita Charon, who founded Columbia University’s pioneering narrative medicine program in 2000. “We have fallen out of that habit because we think we know the questions to ask. We have a checklist of symptom questions. But there is an actual person in front of us who is not just a collection of symptoms.”
Columbia is currently offering training online for medical students like Fletcher Bell, who says the course is helping to transform the way he sees his future role as healer. As part of his narrative medicine training, Mr. Bell has kept in touch virtually with a woman who was being treated for ovarian cancer, an experience of sharing that he described as being both heartbreaking and also beautiful.
“Simply listening to people’s stories can be therapeutic,” Mr. Bell observed. “If there is fluid in the lungs, you drain it. If there is a story in the heart, it’s important to get that out too. It is also a medical intervention, just not one that can be easily quantified.”
This more personalized approach to medical care is not a new art. In the not-so-distant past, general practitioners often treated several generations of the same family, and they knew a lot about their lives. But as medicine became increasingly institutionalized, it became more rushed and impersonal, said Dr. Charon.
The typical doctor visit now lasts from 13 to 16 minutes, which is generally all that insurance companies will pay for. A 2018 study published in the Journal of General Internal Medicine found that the majority of doctors at the prestigious Mayo Clinic didn’t even ask people the purpose of their visit, and they frequently interrupted patients as they spoke about themselves.
But this fast-food approach to medicine sacrifices something essential, says Dr. Deepu Gowda, assistant dean of medical education at the Kaiser-Permanente School of Medicine in Pasadena, Calif., who was trained by Dr. Charon at Columbia.
Dr. Gowda recalls one elderly patient he saw during his residency who suffered from severe arthritis and whom he experienced as being angry and frustrated. He came to dread her office visits. Then he started asking the woman questions and listened with interest as her personal history unfolded. He became so intrigued by her life story that he asked her permission to take photographs of her outside the hospital, which she granted.
Dr. Gowda was particularly struck by one picture of his patient, cane in hand, clutching onto the banister of her walk-up apartment. “That image represented for me her daily struggles,” he said. “I gave her a copy. It was a physical representation of the fact that I cared for who she was as a person. Her pain didn’t go away, but there was a lightness and laughter in those later visits that wasn’t there before. There was a kind of healing that took place in that simple human recognition.”
While few working doctors have the leisure time to photograph their patients outside the clinic, or to probe deeply into their life history, “people pick up on it” when the doctor expresses genuine interest in them, Dr. Gowda said. They trust such a doctor more, becoming motivated to follow their instructions and to return for follow-up visits, he said.
Some hospitals have started conducting preliminary interviews with patients before the clinical work begins as a way to get to know them better.
Thor Ringler, a family therapist, started the “My Life, My Story” program at the William S. Middleton Memorial Veterans Hospital in Madison, Wis., in 2013. Professional writers are hired to interview veterans — by phone and video conference since the onset of the pandemic — and to draft a short biography that is added to their medical record and read by their attending physician.
“My goal was to provide vets with a way of being heard in a large bureaucratic system where they don’t always feel listened to,” Mr. Ringler said.
The program has spread to 60 V.A. hospitals, including in Boston, where more than 800 veteran stories have been compiled over the past three years. Jay Barrett, nurse manager at the VA Boston Healthcare System, said these biographies often provide critical information that can help guide the treatment.
“Unless they have access to the patient’s story,” Ms. Barrett said, “health care providers don’t understand that this is a mother who is taking care of six children, or who doesn’t have the resources to pay for medication, or this is a veteran that has severe trauma that needs to be addressed before even talking about how to manage the pain.”
Dr. Lewis Mehl-Madrona, a family doctor who teaches at the University of New England in Biddeford, Maine, has been studying veterans who were undergoing treatment for pain. Those who were asked to tell about their lives experienced less chronic pain and rated the relationship with their physician higher than those who had not. The doctors who solicited the stories also reported more job satisfaction and were subject to less emotional burnout, which has become an especially worrisome problem during the Covid pandemic.
Demands have never been greater on health care workers’ time. But narrative medicine advocates say that it only takes a few moments to forge an authentic human connection, even when the communication takes place online, as it often does now. Dr. Mehl-Madrona argues that remote videoconferencing platforms like Zoom can actually make it even easier to keep track of vulnerable people and to solicit their stories.
Derek McCracken, a lecturer at Columbia University who helped develop training protocols for using narrative techniques in telehealth, agrees. “Telehealth technology can be a bridge,” he said, “because it’s an equalizer, forcing both parties to slow the conversation down, be vulnerable and listen attentively.”
The critical point for Dr. Mehl-Madrona is that when people are asked to talk about themselves — whether that happens in person or onscreen — they are “not just delivering themselves to the doctor to be fixed. They become actively engaged in their own healing.”
“Doctors can be replaced by computers or by nurses if they think their only role is just to prescribe drugs,” he added. “If we want to avoid the fate of the Dodo bird, then we have to engage in dynamic relationships with patients, we have to put the symptoms in the context of people’s lives.”
Vaccine Hesitancy in Cancer Patients
Living With Cancer
“If I accept the vaccine,” one cancer patient says, “it will be with a strong feeling of guilt that at best I will be prolonging my life for a few months or years.”
Do the vaccines against the coronavirus offer cancer patients the same hope that they hold out to healthy people? The women in my cancer support group expressed hesitancy as the vaccines started to be administered to health care workers.
Lucy Cherbas, in chemotherapy for recurrent ovarian cancer and in the over-70 population slated to receive the vaccine next, described the moral impediment that some healthy people also confront in a different variant.
“If I accept the vaccine,” she said, “it will be with a strong feeling of guilt that at best I will be prolonging my life for a few months or years, while others behind me in line still have full lives to live if they don’t succumb to Covid-19.”
Lucy’s altruism reminds us how many people have responded to the pandemic with grace and grit. I talked about her guilt with Dr. Timothy Lahey, a medical ethicist and infectious disease specialist at the University of Vermont Medical Center. He pointed out that at a personal level, “Lucy has no duty to endanger herself for others.” As long as she meets vaccine eligibility criteria, he said, “she should feel no compunction about claiming her vaccine.”
According to Dr. Lahey, “altruism is admirable because it is not compulsory.”
Even at a population level, with vaccine prioritization designed to minimize death and suffering, Lucy has “every right to trust the system and receive the vaccine when her number is called.” Of course, she can give up her place, but, Dr. Lahey said, “such a decision would do little to improve the efficiency of the overall distribution system.”
Lucy was also concerned about the physical issues that play a more prominent role in medical conversations. Because she is on a chemo drug that kills dividing cells, Lucy worried that the vaccine would be ineffective. “The development of an immune response involves a lot of cell division, and that seems unlikely to happen in the presence of anti-mitotic chemo agents,” she said. (Before she retired, Lucy was a molecular geneticist.) Since her oncologist continued to advise her to take the vaccine, Lucy has overcome her misgivings and has made an appointment.
Like Lucy, cancer patients need to discuss their unique cases with their physicians. According to Dr. Otis Brawley, past medical and scientific officer of the American Cancer Society and currently a professor of oncology at Johns Hopkins University, “no guidance has come out from the usual nongovernmental groups.”
He added that authorities like the Food and Drug Administration, the Centers for Disease Control and Prevention and the Medical Research Council of Britain “leave it up to individual doctors, but suggest that it should be safe.”
Ideally, those cancer patients who want the shot could get it at their cancer centers rather than in a mass distribution site. But a bumpy rollout and age restrictions have frustrated many people with cancer. Still, if the shot is offered, Dr. Brawley recommends it to his patients in active therapy and to those in follow-up. Certainly, they may not have as strong a response as someone who has an intact immune system; however, they will get some protection and will not be harmed because the current vaccines from Moderna and Pfizer are not produced from live virus (as measles, rubella, mumps and smallpox had been). Live virus vaccines must be avoided by the highly immunocompromised.
The Moderna and Pfizer coronavirus vaccines, Dr. Brawley explains, are made from messenger ribonucleic acid, or mRNA, by means of a new technology. Its genetic material causes the vaccinated person to create the same proteins that are found in the spikes of the novel coronavirus.
“The vaccinated person’s immune system then recognizes these proteins as foreign and produces antibodies against them,” Dr. Brawley said. “Another immune cell called a dendritic cell also records the proteins as foreign.”
Dr. William Nelson, director of the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, agreed that “the worst that could happen” to cancer patients inoculated with the coronavirus vaccine “is a poor response.” The poorest responses will probably occur with people in treatment for B-cell lymphomas and multiple myeloma, he explained, because regimens for these diseases often involve agents targeting antibody-producing cells in the body. “For folks undergoing bone marrow transplants,” Dr. Nelson advised, vaccinations should probably be timed at three to six months after the transplant to ensure that immune recovery has occurred.
As important as the vaccines are, Dr. Nelson urged people with cancer as well as their families and friends to “remain vigilant about mask-wearing, social distancing, hand washing, etc.” Because cancer patients often experience low white-blood cell counts, their symptoms — fever, muscle aches, headache, dry cough — can be indistinguishable from those of Covid-19. “Now these patients will also need to be rapidly tested for the coronavirus and isolated in a suitable facility to get their intravenous antibiotics infused.”
When the health authorities in my state, Indiana, announced they would inoculate people over 70, I had no problem signing up online for an appointment. When I went for my first shot at a small medical facility, it was abuzz with people buoyed by high hopes for widespread, so-called herd immunity. My own optimism was shadowed by periodic news stories this winter about mask-less receptions, rallies, protests, parties and raves, and by personal conversations with people scared of inoculation in general.
As Eula Biss explained in her brilliant pre-pandemic book “On Immunity,” fear of the government, of the medical establishment, and of public intrusions into the private body can inhibit the collective trust that achieving immunity requires. Because fearfulness often afflicts cancer patients, they might be especially susceptible to these sorts of trepidations.
In a period of rampant disinformation, anti-vaccine campaigners have emerged to decry what they call a “scamdemic.” They will feed and fuel vaccine anxiety unless they are vigilantly countered by scientific authorities in the media.
Head of McKinsey, Kevin Sneader, Voted Out as Firm Faces Reckoning on Opioid Crisis
Partners decided not to keep Kevin Sneader in the top job. Weeks earlier, McKinsey had reached a historic settlement agreement in the U.S. over its advice to drugmakers.
Partners at McKinsey & Company voted out the consulting firm’s top executive, Kevin Sneader, this week as it continues to face blowback over its role in fueling the opioid crisis.
The decision to deny Mr. Sneader a second three-year term as global managing partner came in a vote by more than 600 senior partners, according to a company executive. Earlier this month, McKinsey had agreed to pay 49 states a historic settlement of almost $600 million because of sales advice the company had given to drugmakers.
It is highly unusual for a sitting managing partner at McKinsey to be refused a follow-on term. The last time a firm leader was denied a second term was in 1976, according to the company’s internal history book.
Mr. Sneader, 54, did not even make it to the final round of balloting, according to the company executive, who spoke on the condition of anonymity. The final candidates for Mr. Sneader’s replacement are Bob Sternfels, based in San Francisco, and Sven Smit, based in Amsterdam. The shake-up at the prestigious consulting firm was first reported by The Financial Times.
Mr. Sneader’s term was turbulent from the start, as he tried to deal with controversies stemming from client work that had been undertaken during the nine-year tenure of his predecessor, Dominic Barton, now Canada’s ambassador to China. The issues Mr. Sneader had to reckon with went far beyond the deadly opioid crisis.
Days into his new job in July 2018, Mr. Sneader flew to South Africa to apologize for the firm’s work with a state-owned power provider. McKinsey’s lucrative contract, found to be in violation of South African contracting law, involved the use of a local intermediary tied to a corruption scandal that brought down the country’s president. McKinsey has returned tens of millions of dollars in fees it earned in South Africa.
“We came across as arrogant or unaccountable,” Mr. Sneader said at the time. “To be brutally honest, we were too distant to understand the growing anger in South Africa.”
That month, he had to defend McKinsey after a New York Times report revealed that it was working with the U.S. Immigration and Customs Enforcement agency — even in the midst of widespread fury over the Trump administration’s separation of migrant children from their parents.
At the same time, the fuse was lit for what became the biggest scandal of McKinsey’s 95-year history: its extensive work with Purdue Pharma to “turbocharge” sales of OxyContin in the middle of a national opioid epidemic that has contributed to the deaths of more than 450,000 people over the past two decades.
On July 4 of that year, two McKinsey senior partners on the Purdue account exchanged emails discussing possibly “eliminating all our documents and emails” to head off repercussions the firm might face. That exchange was a key part of the settlement states made with McKinsey this month. McKinsey did not admit wrongdoing in the settlement, but both senior partners — who would have been voting in the election of Mr. Sneader’s successor — were fired.
“We deeply regret that we did not adequately acknowledge the tragic consequences of the epidemic unfolding in our communities,” Mr. Sneader said this month. “With this agreement, we hope to be part of the solution to the opioid crisis in the U.S.”
During his watch, Mr. Sneader oversaw the introduction of measures aimed at preventing controversial projects, including new procedures on reviewing prospective clients. But he could also be a staunch defender of McKinsey in the wake of scandal, including its extensive work in Saudi Arabia, which came under intense scrutiny in late 2018 after The Times disclosed that a McKinsey employee, in a written report, had identified influential critics of the Saudi government and that several of those critics or their family members were later arrested.
Mr. Sternfels — who, like Mr. Barton, was a Rhodes scholar — runs many of the firm’s technology-focused initiatives and is also the senior partner overseeing McKinsey’s bankruptcy restructuring practice. That work has been the focus of lawsuits in recent years. In 2019, the firm agreed to pay $15 million in a settlement with the Justice Department to resolve allegations that it failed to properly disclose potential conflicts of interest stemming from its bankruptcy work.
Mr. Smit is a co-chairman of the McKinsey Global Institute, the firm’s in-house think tank.
A spokesman for McKinsey wouldn’t comment on the specifics of the election, saying in a statement: “The election, which is conducted by an independent third-party firm, is now underway and we will announce the result after the election concludes.”
Walt Bogdanich contributed reporting.
Will Tiger Woods Play Golf Again? Doctors Predict a Difficult Recovery
After a serious car crash on Tuesday, he risks infections, bones that do not heal, and foot and ankle injuries that impede walking.
Even before Tuesday’s crash, Tiger Woods’s career had been hampered by injuries in his neck, back, knee and lower legs.Credit…Illustration by Tim Oliver/The New York Times; Photograph by Rob Carr/Getty Images
The serious lower leg injuries Tiger Woods sustained in a car crash on Tuesday typically lead to a long and perilous recovery, calling into question his ability to play professional golf again, according to medical experts who have treated similar injuries.
Athletes with severe leg injuries thought to doom their careers have managed to come back — the quarterback Alex Smith returned to playing football last season after a gruesome leg break, and the golfer Ben Hogan returned decades ago after a car accident.
But Woods’s injuries are more extensive, and his path to recovery is strewn with serious obstacles. Infections, inadequate bone healing and, in Woods’s case, previous injuries and chronic back problems may make a monthslong or even yearslong recovery more difficult, and may reduce the chances that he will play again.
In the accident near Los Angeles, Woods’s lower right leg was smashed and his right foot severely injured, and his leg muscles swelled so much that surgeons had to cut open the tissue covering them to relieve pressure, Dr. Anish Mahajan, the chief medical officer at Harbor-U.C.L.A. Medical Center, where Woods, 45, was treated, wrote in a Twitter message posted on Woods’s account.
Doctors also inserted a rod into Woods’s shin bone, and screws and pins into his foot and ankle. Physicians familiar with these kinds of injuries described the complications they typically bring.
The injuries are frequently seen among drivers involved in car accidents, said Dr. R. Malcolm Smith, the chief of orthopedic trauma at UMass Memorial Medical Center in Worcester, Mass. Usually they occur when the driver frantically stomps on the brake as a car careens out of control.
When the front end of the car is smashed, immense force is transmitted to the driver’s right leg and foot. “This happens every day with car crashes in this country,” Dr. Smith said.
Such lower-leg fractures on occasion bring “massive disability” and other grave consequences, said Dr. Smith. “A very rough estimate is that there is a 70 percent chance of it healing completely,” he added.
The crash caused a cascade of injuries. It smashed Woods’s shin bones, with primary breaks in the top and bottom parts of the bones and a scattering of bone fragments. When the bones in Woods’s shin shattered, they damaged muscles and tendons; pieces poked from his skin.
The trauma caused bleeding and swelling in his leg, threatening his muscles. Surgeons had to quickly cut into the layer of thick tissue covering his leg muscles to relieve the swelling. Had they not, the tissue that covers swelling muscle would have acted like a tourniquet, constricting blood flow. The muscle can die within four to six hours.
It is possible that some muscle died anyway, between the accident and the surgery, Dr. Smith said: “Once you lose it, you cannot get it back.”
Tiger Woods is the greatest golfer of his generation and one of the most recognizable athletes in the world. But his car accident on Tuesday was the latest setback in a career full of them.
Here’s a look at some of Woods’s highs and lows →
In 1997, a year after turning professional, Woods, at 21, became the youngest person and the first person of color to win the Masters. He became the face of golf, even as he faced racial slurs and death threats.
Tiger Woods Rewrites Masters’ History
From 1997 through 2008, Woods won 14 major titles: four Masters, four PGA Championships, three United States Opens (above, in 2002) and three British Opens.
Woods Looks Back at First U.S. Open Win
Woods’s marital infidelities spilled out in public in 2009. After a domestic dispute with his wife, he slipped behind the wheel of his car with Ambien in his system and collided with a fire hydrant yards from his house.
The 2009 Crash That Rocked Woods’s Career
His injuries took a toll in recent years. He underwent his fourth back operation in April 2017, a spinal fusion surgery that he called “a last resort.” A fifth back operation sidelined him from competition in early 2021.
How Woods Became a ‘Walking Miracle’
Another middle-of-the-night incident, in May 2017, revealed an opioid addiction. Woods was arrested by the police after he was found alone and asleep in his car on the side of a road with the engine running.
Woods Arrested and Charged With D.U.I.
Woods made an astounding comeback in 2019: At 43, he won a fifth Masters for his 15th major title. He had yet to announce if he’d compete in this year’s Masters, but after the car accident his golf career is in jeopardy.
Woods Captures the Masters at 43
Woods may need months or years to recover from the crash.
Patients who have this procedure must remain in the hospital until the muscle swelling goes down. That can take a week or more. Sometimes, even after several weeks the swelling has not receded enough to close the wound, so surgeons have to graft skin over the opening.
Dr. Kyle Eberlin, a reconstructive surgeon at Massachusetts General Hospital, said that to close the holes where bones poke out of skin, doctors often must transplant skin from the thigh or back, a procedure called a free flap. They cut pieces of skin as large as a football and, using a microscope, carefully reconnect tiny blood vessels — about a millimeter in diameter — from the skin transplant to the blood vessels near the wounds.
Infection is a risk with fractures that break through the skin and following surgery to insert rods and pins into bones, with amputation in the worst cases, Dr. Smith said. The likelihood of infection depends on the degree of contamination and the size of the wound.
In car accidents, gravel and sometimes dirt can get into wounds, increasing the odds of infection, Dr. Eberlin said.
And opening the covering of muscles can raise the risk of infection, said Dr. Reza Firoozabadi, an orthopedic trauma surgeon at Harborview Medical Center in Seattle.
At major trauma centers like Massachusetts General or U.C.L.A., the free flap procedures are performed within 48 hours. But it is more typical to operate within a week of the injury, Dr. Eberlin said.
Rehabilitation will be long and onerous. If Woods required a free flap — which, trauma surgeons said, seems likely — “it will be months and months before he can bear weight on his leg again,” Dr. Eberlin said.
Woods also risks fractures that do not heal or that grow together only very slowly, Dr. Firoozabadi said. “To get things to heal, you need good blood flow,” he said. “With an injury like this, blood flow is disrupted.”
As a result, he said, it may take five to 14 months for Woods’s lower leg bones to grow together, assuming they do so at all.
The biggest hurdle will be his foot and ankle injuries, Dr. Firoozabadi and others said. Regaining range of motion and strength can take three months to a year. Depending on the extent of those injuries, even after rehabilitation Woods may barely be able to walk.
His rehabilitation may be complicated by back surgery in December. Woods also has gone to rehabilitation for an addiction to painkillers; pain management during his recovery now may be difficult.
Still, a few athletes have come back from grave injuries. Smith, the Washington Football Team quarterback, had a similar injury to his leg and returned to play in October. But it took two years and 17 surgeries, and along the way he developed an infection of the wounds and sepsis, a life-threatening condition. And Smith did not have injuries to his foot and ankle.
Hogan, the golfer, broke his collarbone, pelvis, left ankle and a rib. The injuries were serious but not comparable to Woods’s injuries.
With his foot and ankle injuries and the serious injuries to his leg, Woods “may never play golf again,” Dr. Smith said.
Woman Dies After Getting Covid-19 From Transplanted Lungs
In what appears to be the first case of its kind, a pair of donated lungs led to Covid-19 in an organ recipient, according to doctors at the University of Michigan.
A woman in Michigan died 61 days after she received a pair of lungs from an organ donor who had been infected with the coronavirus, according to a case report published this month.
There was no indication that the donor, a woman fatally injured in a car accident, had Covid-19. A radiograph of her chest had seemed clear, and a nasal-swab test for the coronavirus had returned a negative result.
But the doctors who worked with the lung recipient at University Hospital in Ann Arbor, Mich., last fall began to question those results when their patient’s condition worsened. They concluded that the donor did indeed have Covid-19 — and that her lungs had infected not only the transplant patient, but also the surgeon.
It was the first confirmed case of a patient contracting the virus from the patient’s organ donor, according to the authors of the peer-reviewed report, which was published in The American Journal of Transplantation on Feb. 10. Kaiser Health News and NBC News reported on the case on Saturday.
“We want the transplant community to be aware that this can happen, and also that there may be things we can do to improve our success in screening patients for Covid,” said the surgeon, Dr. Jules Lin, an author of the report and the surgical director of the lung transplant program at Michigan Medicine, the health system of the University of Michigan.
The report said that medical professionals should consider testing lung donors for the coronavirus using a sample from their lower respiratory tract, which extends into the lungs — beyond the reach of a nasal swab. That kind of testing, which is invasive and not recommended for the general public, is not always available; currently, only about one-third of donated lungs are tested this way.
Dr. David Klassen, the chief medical officer at the United Network for Organ Sharing, the nonprofit organization that manages the nation’s organ transplant system, said the case in Michigan was “very significant” despite its rarity.
“We want to minimize any chances of this reoccurring,” he said.
Every organ donor in the United States is tested for the coronavirus in some way, Dr. Klassen said. The tests are not conducted by transplant surgeons; instead, they are typically overseen by nonprofit groups known as organ procurement organizations, which operate across the United States.
The Association of Organ Procurement Organizations referred questions to Gift of Life Michigan, which was not involved in this case. Its chief clinical officer, Bruce Nicely, said that many labs had refused to run samples from the lower lungs early in the pandemic, fearing that the procedure could contribute to the spread of the coronavirus.
“In response to the recommendations of the study, we are all for recommendations that improve safety and reduce the risk of infection,” Mr. Nicely said, adding that his organization has found a laboratory partner that is able to conduct testing of the lower respiratory tract.
When organs become available, time is of the essence. Some health facilities don’t have the resources to test donors’ lower respiratory tracts quickly for Covid-19. Given those constraints, there is no requirement that lung donors be tested this way.
“We could mandate it,” Dr. Klassen said. “But that might have the downstream effect of severely limiting the lungs that could be used for transplantation.”
Of the nearly 40,000 organ transplants performed in the United States last year, the operation in Michigan was the only confirmed instance of a recipient contracting the coronavirus from a donor.
“It’s important to emphasize that this is, fortunately, a rare event,” said Dr. Daniel R. Kaul, an author of the study and an infectious disease specialist at Michigan Medicine. The case, he said, should not dissuade people from getting transplants that could save their lives.
He added that the organ recipient, who had suffered from chronic obstructive lung disease, appeared to have had a successful operation until her condition worsened a few days later.
“All of a sudden, she had fever, low blood pressure, pneumonia,” Dr. Kaul said. “I wasn’t sure what was going on.”
When further testing showed that the woman had Covid-19, the doctors looked to the lung donor. Her nasal-swab test had come back negative before the transplant, but those tests don’t catch everything. The doctors needed to find a way to test the donor again.
As it turned out, they had exactly what they needed: a specimen from the deceased woman’s lower respiratory tract. Michigan Medicine regularly collects such samples from lung donors to test them — not for Covid-19, but for ureaplasma, bacteria that can cause a rare syndrome.
The doctors found that they still had enough of the donor’s sample to test for the coronavirus. The result showed that the donor had indeed been infected with the virus, and gene-sequence analysis showed that the patient had contracted the virus from the donor’s lungs.
So had Dr. Lin, who had been wearing a surgical mask during the transplant operation. (The report he co-wrote recommends that transplant centers consider the benefits of wearing N95 masks throughout the hourslong procedure, even if the donor has tested negative for the coronavirus.) He spent a couple of weeks recovering from the infection at home, he said, adding that the infection had not spread to his colleagues or his family members.
The patient, vulnerable in the wake of a major operation, did not recover despite doctors’ attempts to save her with a series of treatments including convalescent plasma, steroids and remdesivir. The doctors now hope that her case report will persuade more medical professionals to strengthen their coronavirus testing standards for organ donors, despite the logistical difficulties.
“I think these are barriers that we have to work to overcome,” Dr. Lin said, “for the safety of our patients.”
Travel Quarantines: Enduring the Mundane, One Day at a Time
Running a half-marathon in your hotel room. Hearing the sea, but not seeing it. Fixating on food. Here’s how some travelers passed the time during their mandatory quarantines.
May Samali knew she’d reached her limit when she saw a tentacle emerging from her hotel dinner in Sydney, Australia.
“I called downstairs and said, ‘I’m a vegan now, thank you!’” she said. “It was just so much fish. I’d gotten to the point where even thinking about it made me gag.”
Ms. Samali swore off the seemingly unlimited seafood while in the middle of a required quarantine in the Hotel Sofitel in Sydney this December and early January. An executive coach, she was repatriating back to Australia after her U.S. work visa expired. In addition to an excess of fish, Ms. Samali was confined to her room all day, forbidden from stepping outside, for two weeks.
Air travelers around the world are finding themselves in similar situations, enduring mandatory government quarantines in hotels as they travel to countries that are very serious about containing the coronavirus.
Their quarantine is not the cushy experience of shorter-term quarantines or “resort bubbles” found in some destinations like Kauai and the British Virgin Islands, where you are able to roam relatively freely on a resort’s expansive grounds while waiting for a negative coronavirus test.
This is the more extreme, yet typical experience of quarantine life. These mandatory quarantines involve confinement to your room, 24 hours a day, for up to two weeks (assuming you test negative, that is). And with some exceptions, you are footing the bill — quarantine in New South Wales, Australia, for example, costs about $2,300, or 3,000 Australian dollars for a two-week quarantine for one adult, and up to 5,000 Australian dollars for a family of four to quarantine for two weeks (in January, Britain announced a mandatory 10-day quarantine from high-risk areas with a similar cost of about $2,500 for one adult).
Travelers now journeying to countries with mandatory hotel quarantines, which also include New Zealand, mainland China and Tunisia, generally must have compelling reasons to do so — visiting ailing family members, “essential” business travel or permanent relocation.
Most accept the inconvenience and inevitable claustrophobia of the quarantine as the price of traveling. But while there can be comfort in establishing some kind of routine resembling normal life, travelers find themselves craving human connection, fresh air and, well, different food (the staff at the Sofitel happily accommodated Ms. Samali’s request; she is still off fish).
In general, people are still traveling but far less — the first two months of 2021 have seen fewer than half the number of air passengers as the same period in 2020, according to checkpoint travel numbers released by the Transportation Security Administration, which includes all domestic and international departures from the United States.
Travel quarantine might seem manageable, even familiar, for those who have been living in places with shelter-in-place orders and working from home. Pete Lee, a San Francisco-based filmmaker, wasn’t concerned about the quarantine when he flew to Taiwan for work and to visit family.
“I was a little bit cocky when I first heard about the requirement,” said Mr. Lee, during his eighth day at the Roaders Hotel in Taipei, Taiwan. “I was inside my San Francisco apartment for 22 out of 24 hours a day! But it’s a surprisingly intense experience. Those two hours make a big difference.”
Much of quarantine life is determined by your hotel. And depending on where you are traveling, you may get to choose your quarantine hotel, or you may be assigned upon arrival. Mr. Lee, in Taiwan, was able to choose and book his quarantine hotel from a list compiled by the Taiwanese government, complete with information about location, cost, room size and the presence (or lack thereof) of windows. He also footed the bill.
Similarly, Ouiem Chettaoui, a public policy specialist who splits her time between Washington, D.C., and Tunisia, was able to choose a hotel for her weeklong quarantine when returning to Tunis with her husband in September; she based her selection, the Medina Belisaire & Thalasso on price and proximity to the Mediterranean Sea (“We couldn’t see it, but we could hear it … at least, we told ourselves we could!” she said).
Brett Barna, an investment manager who relocated to Shanghai with his fiancée in November, could select a district in the city, but not the hotel itself. In an attempt to improve their odds, Mr. Barna chose the upscale Huangpu district where, he hoped, the hotels would be higher quality.
“There were four possible hotels in the district, three of which were nice enough. And then there was the budget option, the Home Inn,” he said. Mr. Barna and his fiancée, to their dismay, ended up paying for quarantine in that option, which had peeling wallpaper and bleach stains on the floor thanks to aggressive cleaning protocols.
In Australia and New Zealand, there’s no choice in the matter — upon landing, your entire flight is bused to a quarantine hotel with capacity. In most instances, travelers do not know where they are going until the bus pulls up at the hotel itself.
Joy Jones, a coach and educator who is based in San Francisco, traveled to New Zealand with her husband, a New Zealand citizen, and two young daughters in January. She learned before their departure that they would have no say where in the country they would be quarantined.
“That was probably the hardest part,” she said. “I could put together a bag of activities for my older daughter, and plan on doing laundry in the sink. But not having an answer to where we’d be — after more than 21 hours of flying, with masks — would we have to get another flight? A three-hour bus ride?” They didn’t. Ms. Jones and her family were taken to Stamford Plaza in Auckland, just 25 minutes from the airport.
Pim Techamuanvivit and her New Zealander husband, however, were not so lucky. After arriving in Auckland from San Francisco, they were promptly directed to board another flight to Christchurch, and to the Novotel Christchurch Airport hotel. “At that point, we just really, really wanted to get to the hotel!” said Ms. Techamuanvivit, the chef-owner of Nari and Kin Khao restaurants in San Francisco and the executive chef of Nahm in Bangkok.
Relief at arriving — finally — might be the initial reaction, but it doesn’t take long for reality to set in. The hotel room is all that you’ll see for a not insignificant period of time.
As Adrian Wallace, a technology project manager who was quarantined at the Sydney Hilton in August after visiting his ailing father in Britain, put it: “That moment when the door slams … it’s reminiscent of the opening scene of ‘The Shawshank Redemption’!” Mr. Wallace said, referring to the 1994 prison movie with Tim Robbins and Morgan Freeman.
The challenge is managing the tedium. Working remotely helped pass the time for a number of the travelers, including Tait Sye, a senior director at the Planned Parenthood Federation of America, who traveled to Taipei, Taiwan, from Washington, D.C. in November. Mr. Sye attempted to maintain East Coast hours for the majority of his quarantine at the Hanns House Hotel, working from 10 p.m. to 6 a.m.
Mr. Wallace ran a half marathon around his Sydney hotel room (he was unable to adjust the in-room air-conditioner and got very sweaty). Mr. Barna and his fiancée in Shanghai had date nights on Zoom, since official policy required them to quarantine in separate rooms. A major highlight of their days came when a hotel employee, clad in full, hazmat-style P.P.E., knocked on the door and pointed an infrared thermometer at their heads. They were not allowed outside.
In New Zealand, travelers who test negative for the virus are allowed on the hotel grounds for supervised constitutionals after checking in with guards at multiple checkpoints (masks and distancing are still required, and the rules can quickly change if there is any threat of an outbreak in the country). The ability to get fresh air and walk was crucial for Ms. Jones, and a key part of the routine she created for her family. Other aspects included morning yoga, remote school, nap times, playtime and art projects (her husband worked remotely from the bathroom).
“We decorated a paper horse that we hung in our window — every day, a different part of it — that was a favorite activity. We’d have dance parties. And we’d watch a movie every night. We did what we could to bring some fun into it,” Ms. Jones said.
Meals become very important in quarantine life, to mark the passing of the time and as regular occurrences to break up the monotony of the day. Food quality, though, varies widely, as Mr. Sye learned in Taipei, where meals were ordered from nearby restaurants.
He recounted the highs of a Michelin-starred meal from Kam’s Roast Goose and the thoughtfulness of a Thanksgiving dinner decorated with a paper turkey to the low of an absolutely terrible pizza (at least it was accompanied by a beer).
For Ms. Techamuanvivit who documented her quarantine in Christchurch on Twitter, ordering food and grocery delivery was a life-saver. “I’m a chef. I suppose I am, shall we say, a snob!” she said. “As a restaurateur, I don’t have much love for UberEats. But ordering Indian takeaway proved to be important.” (Others who had delivery options available similarly cited them as game-changing).
Ms. Techamuanvivit spiced up hotel meals with leftover Indian pickles and found that Greek tzatziki sauce ordered from the grocery store worked well as a salad dressing. She and her husband also treated themselves to nice bottles of wine from the hotel restaurant’s wine list (In Australia and New Zealand, quarantined guests were limited to a delivery of six beers or one bottle of wine per person per day, perhaps to ward off belligerence. In Shanghai, alcohol was not allowed).
There are Facebook groups dedicated to hotel quarantine, by region and even by specific hotel, where members share tips for boiling eggs using in-room kettles and “cooking” with an iron. They were also a source of community; Mr. Wallace, who learned of the Sydney Hilton’s Facebook group while on the bus from the airport, participated in a daily Zoom call with members of the group (the meals of the day were a constant topic of conversation).
Mr. Lee moderated filmmaking conversations on Clubhouse, an invitation-only social media app, and spent time on Tinder while in quarantine; he connected with a woman who was nearing the end of her confinement in another hotel across town.
Ms. Jones documented her family’s quarantine experience on her private Instagram account, showing forts made of blankets, paper airplane competitions and “bowling” with water bottles and a crumpled ball made of paper. She was touched that friends and family, both in New Zealand and in the United States, sent her family meals, treats and toys for her daughters in response to her posts.
“It was a really cool way to feel love, and connection, from such an isolated space,” she said.
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Can Zapping Our Brains Really Cure Depression?
New research suggests that stimulating neurons in the brain can address psychological issues with surprising speed and precision.
The brain is an electrical organ. Everything that goes on in there is a result of millivolts zipping from one neuron to another in particular patterns. This raises the tantalizing possibility that, should we ever decode those patterns, we could electrically adjust them to treat neurological dysfunction — from Alzheimer’s to schizophrenia — or even optimize desirable qualities like intelligence and resilience.
Of course, the brain is so complex, and so difficult to access, that this is much easier to imagine than to do. A pair of studies published in January in the journal Nature Medicine, however, demonstrate that electrical stimulation can address obsessive-compulsive urges and symptoms of depression with surprising speed and precision. Mapping participants’ brain activity when they experienced certain sensations allowed researchers to personalize the stimulation and modify moods and habits far more directly than is possible through therapy or medication. The results also showed the degree to which symptoms that we tend to categorize as a single disorder — depression, for example — may involve electrical processes that are unique to each person.
In the first study, a team from the University of California, San Francisco, surgically implanted electrodes in the brain of a woman whose severe depression had proved resistant to other treatments. For 10 days, they delivered pulses through the electrodes to different areas of the brain at various frequencies and had the patient record her level of depression, anxiety and energy on an iPad. The impact of certain pulses was significant and nuanced. “Within a minute, she would say, ‘I feel like I’m reading a good book,’” says Katherine W. Scangos, a psychiatrist and the study’s lead author. The patient described the effect of another pulse as “less cobwebs and cotton.”
The researchers also recorded what type of unmediated brain activity coincided with periods of low mood or energy. The aim was to use those responses to guide the placement of another set of electrodes that would deliver what is known as deep-brain stimulation — a technique that can restore lost function to neurons by zapping them with a consistent, high-frequency electrical pulse. To date, it has been employed most commonly to treat movement disorders, like Parkinson’s. It has also shown promise for depression. “But because depression presents differently in different people, it likely involves multiple neural circuits,” Scangos says. She and her colleagues wondered if a “more personalized approach” might make the treatment more effective. Based on their mapping of the patient’s brain activity, they programmed the electrodes to detect her depressed states and deliver stimulation in response, much the way a pacemaker acts on the heart. That experimental treatment will continue long term as the patient goes about her daily life.
Deep-brain stimulation is too invasive to use except in extreme circumstances. But in the second study, researchers used a noninvasive technique called transcranial alternating current stimulation to deliver electrical pulses through electrodes placed on participants’ scalps. The goal was to try to curb obsessive-compulsive behaviors. Past studies have suggested that the orbital frontal cortex, an area in the brain’s reward network, might play a role in reinforcing such behaviors, by regarding them as beneficial. So the researchers attached the electrodes to 64 volunteers and recorded the frequency in hertz at which their orbital frontal cortex fired when they won a monetary reward in a game.
Crucially, it was noted, the frequency varied slightly by individual. Using that personal frequency, the researchers next stimulated the same area in each participant for 30 minutes a day for five days in a row. Doing so, they found, reduced the number of obsessive-compulsive behaviors in the volunteers by an average of nearly 30 percent over the following three months. (None of the volunteers had an obsessive-compulsive disorder diagnosis. All of them, however, reported varying degrees of repetitive tendencies, and those whose symptoms were most intense got the most relief.) The researchers hypothesize that the stimulation helped the orbital frontal cortex maintain its optimal rhythm, thereby improving its coordination with other areas in the reward network.
The findings reinforced the idea that personalized brain stimulation requires determining not just the right area to target but also the right rhythm at which to do so. “The neural code — it’s frequency-specific,” says Robert M.G. Reinhart, one of the study’s authors and the director of the Cognitive and Clinical Neuroscience Laboratory at Boston University. “The channel of information-processing in the brain is just like a channel you might tune in to on the radio.” The study also illustrated that traits like compulsivity exist on a spectrum. Currently, a person for whom those traits are bothersome but not disabling might not seek treatment, particularly if it comes with side effects, as medications often do. Brain stimulation, though, could one day remedy all kinds of conditions we now target inexactly with drugs, Reinhart says. “If you want to get futuristic, you can imagine someone giving themselves a zap to get over a trans-Atlantic flight. What people use coffee for today.”
Psychiatrists won’t be prescribing brain stimulation to the masses anytime soon. But by identifying the neural circuits that give rise to particular symptoms, and by showing that alterations to the timing of their firing can change those symptoms, they offer new ways to think about what psychiatric disorders are. “There’s still a lot of stigma around depression that a lot of patients feel,” Scangos says. The subject of her study was no exception: “The fact that there was such an immediate response when we stimulated made her feel like, It’s not something I’m doing wrong; it’s something in my brain that can be addressed.”
Giving a collection of symptoms a diagnostic label like “depression” is useful because it helps doctors more efficiently find a successful treatment, currently a lengthy process of trial and error. “The million-dollar question is how to match the best treatment to the patient and how to avoid treatments that won’t work,” says Helen Mayberg, a neurologist and director of the Nash Family Center for Advanced Circuit Therapeutics at the Icahn School of Medicine at Mount Sinai; she was co-author of a commentary on the two studies. As neuroscientists map the brain activity of more and more patients, they’re getting closer to being able to offer a battery of tests that show, Scangos says, “you have this type of depression, you’ll respond best to this medication.”
Ultimately, if we could address those symptoms directly, we might be able to get rid of diagnostic categories altogether, says Alvaro Pascual-Leone, medical director of the Wolk Center for Memory Health at Hebrew SeniorLife and a professor of neurology at Harvard Medical School. Rather than applying a default label of depression or obsessive-compulsive disorder, Pascual-Leone says, doctors could instead ask, “What is the disabling symptom that this person presents?” And then treat it specifically.
For now, what these studies offer everyone is additional evidence that “our brains are plastic,” says Shrey Grover, a graduate student and a co-author of the Boston University study. “And we can rewire the brain in different ways.” Those include psychotherapy and pharmacology. Our neural activity also changes as we learn; it changes as we age. This means we can improve how our minds work at any point in our lives, even without advanced technology.
But the brain’s plasticity makes it all the more puzzling that certain psychological states can be so hard to dispel. Research into personalized brain stimulation also probes at the larger question of why moods or habits that are mild or circumstantial in some people — carefully rechecking a tax form, say, or feeling deep sadness at the death of a loved one — are chronic and debilitating in others. “There’s nothing that gets right at the cause,” Reinhart says. “It’s like the water in the sink is running, and you can mop up the floor, but no one’s turning off the faucet.”
Kim Tingley is a contributing writer for the magazine.
Exercise vs. Diet? What Children of the Amazon Can Teach Us About Weight Gain
What we eat may be more important than how much we move when it comes to fighting obesity.
A young girl carries harvested food, part of the traditional hunting and gathering lifestyle of the Shuar of Amazonian Ecuador.Credit…Samuel S. Urlacher, Ph.D.
When children gain excess weight, the culprit is more likely to be eating too much than moving too little, according to a fascinating new study of children in Ecuador. The study compared the lifestyles, diets and body compositions of Amazonian children who live in rural, foraging communities with those of other Indigenous children living in nearby towns, and the results have implications for the rising rates of obesity in both children and adults worldwide.
The in-depth study found that the rural children, who run, play and forage for hours, are leaner and more active than their urban counterparts. But they do not burn more calories day-to-day, a surprising finding that implicates the urban children’s modernized diets in their weight gain. The findings also raise provocative questions about the interplay of physical activity and metabolism and why exercise helps so little with weight loss, not only in children but the rest of us, too.
The issue of childhood obesity is of pressing global interest, since the incidence keeps rising, including in communities where it once was uncommon. Researchers variously point to increasing childhood inactivity and junk food diets as drivers of youthful weight gain. But which of those concerns might be more important — inactivity or overeating — remains murky and matters, as obesity researchers point out, because we cannot effectively respond to a health crisis unless we know its causes.
That question drew the interest of Sam Urlacher, an assistant professor of anthropology at Baylor University in Waco, Texas, who for some time has been working among and studying the Shuar people. An Indigenous population in Amazonian Ecuador, the traditional Shuar live primarily by foraging, hunting, fishing and subsistence farming. Their days are hardscrabble and physically demanding, their diets heavy on bananas, plantains and similar starches, and their bodies slight. The Shuar, especially the children, are rarely overweight. They also are not often malnourished.
But were their wiry frames a result mostly of their active lives, Dr. Urlacher wondered? As a postgraduate student, he had worked with Herman Pontzer, an associate professor of evolutionary anthropology at Duke University, whose research focuses on how evolution may have shaped our metabolisms and vice versa.
In Dr. Pontzer’s pioneering research with the Hadza, a tribe of hunter-gatherers in Tanzania, he found that, although the tribespeople moved frequently during the day, hunting, digging, dragging, carrying and cooking, they burned about the same number of total calories daily as much-more-sedentary Westerners.
Dr. Pontzer concluded that, during evolution, we humans must have developed an innate, unconscious ability to reallocate our body’s energy usage. If we burn lots of calories with, for instance, physical activity, we burn fewer with some other biological system, such as reproduction or immune responses. The result is that our average, daily energy expenditure remains within a narrow band of total calories, helpful for avoiding starvation among active hunter-gatherers, but disheartening for those of us in the modern world who find that more exercise does not equate to much, if any, weight loss. (Dr. Pontzer’s highly readable new book on this topic, “Burn,” will be published on March 2. )
Dr. Pontzer’s work focuses primarily on Hadza adults, but Dr. Urlacher wondered if similar metabolic trade-offs might also exist in children, including among the traditional Shuar. So, for a 2019 study, he precisely measured energy expenditure in some of the young Shuar and compared the total number of calories they incinerated with existing data about the daily calories burned by relatively sedentary (and much heavier) children in the United States and Britain. And the totals matched. Although the young Shuar were far more active, they did not burn more calories, over all.
Young Shuar differ from most Western children in so many ways, though, including their genetics, that interpreting that study’s findings was challenging, Dr. Urlacher knew. But he also was aware of a more-comparable group of children only a longish canoe ride away, among Shuar families that had moved to a nearby market town. Their children regularly attended school and ate purchased foods but remained Shuar.
So, for the newest study, which was published in January in The Journal of Nutrition, he and his colleagues gained permission from Shuar families, both rural and relatively urban, to precisely measure the body compositions and energy expenditure of 77 of their children between the ages of 4 and 12, while also tracking their activities with accelerometers and gathering data about what they ate.
The urban Shuar children proved to be considerably heavier than their rural counterparts. About a third were overweight by World Health Organization criteria. None of the rural children were. The urban kids also generally were more sedentary. But all of the children, rural or urban, active or not, burned about the same number of calories every day.
What differed most were their diets. The children in the market town ate far more meat and dairy products than the rural children, along with new starches, like white rice, and highly processed foods, like candy. In general, they ate more and in a more-modern way than the rural children, and it was this diet, Dr. Urlacher and his colleagues conclude, that contributed most to their higher weight.
These findings should not romanticize the forager or hunter-gatherer lifestyle, Dr. Urlacher cautions. Rural, traditional Shuar children face frequent parasitic and other infections, as well as stunted growth, in large part because their bodies seem to shunt available calories to other vital functions and away from growing, Dr. Urlacher believes.
But the results do indicate that how much children eat influences their body weight more than how much they move, he says, an insight that should start to guide any efforts to confront childhood obesity.
“Exercise is still very important for children, for all sorts of reasons,” Dr. Urlacher says. “But keeping physical activity up may not be enough to deal with childhood obesity.”
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