In the Nursing Home, Empty Beds and Quiet Halls

For more than 40 years, Morningside Ministries operated a nursing home in San Antonio, caring for as many as 113 elderly residents. The facility, called Chandler Estate, added a small independent living building in the 1980s and an even smaller assisted living center in the 90s, all on the same four-acre campus.

The whole complex stands empty now. Like many skilled nursing facilities in recent years, Chandler Estate had seen its occupancy rate drop.

“Every year, it seemed a little worse,” said Patrick Crump, chief executive of the nonprofit organization, supported by several Protestant groups. “We were running at about 80 percent.”

Staff at the Chandler Estate took pride in its five-star rating on Medicare’s Nursing Home Compare website. But by the time the board of directors decided it had to close the property, only 80 of its beds were occupied, about 70 percent.

Revenue from independent and assisted living couldn’t compensate for the losses incurred by the nursing home.

In February, the last resident was moved out. Morningside Ministries operates two other retirement communities in the San Antonio area; they took in the independent living and assisted living residents and about 30 nursing home patients, absorbing most of the staff as well.

But more than 40 older people had to relocate to other nursing facilities or move out of town closer to family, and 30 staff members lost their jobs.

“There was some real sadness, tears, frustration,” Mr. Crump said. “It’s hard knowing you won’t be providing services to those older folks.”

ImageThe locked doors of Chandler Estate. At the time of its close, only 80 of its beds were occupied, about 70 percent.CreditIlana Panich-Linsman for The New York Times

At least the organization has the cold comfort of knowing that nursing homes across the country are grappling with the same problem.

The most recent quarterly survey from the National Investment Center for Seniors Housing and Care reported that nearly one nursing home bed in five now goes unused.

Occupancy has reached 81.7 percent, the lowest level since the research organization began tracking this data in 2011, when it was nearly 87 percent.

“It’s a significant drop,” said Bill Kauffman, senior principal at the center. “The industry as a whole is under pressure, and some operators are having difficulty.”

Such national statistics mask considerable local differences.

“The best facilities still have 100 percent occupancy and waiting lists — that’s how you know they’re good,” said Nicholas Castle, a health policy researcher at the University of Pittsburgh.

But in 2015, the National Center for Health Statistics reported that more than a third of beds were empty in some states, including Illinois, Iowa, Nebraska, Oklahoma and Utah. Texas wasn’t far behind.

Nationally, “200 to 300 nursing homes close each year,” Dr. Castle said. The number of residents keeps shrinking, too, from 1.48 million in 2000 to 1.36 million in 2015, according to federal data.

Given an aging population, you’d think nursing homes would be coping with the opposite problem — surging demand for their services.

But they also face growing financial strains and regulatory requirements intended to control costs, Mr. Kauffman pointed out.

Under the Affordable Care Act, for instance, hospitals face financial penalties for readmissions, and some have responded by designating patients as “under observation,” rather than admitting them as inpatients. After discharge, Medicare won’t cover skilled nursing care for these patients.

(Generally, Medicare pays for short-term rehabilitative care in nursing homes following a hospital stay; however, Medicaid, administered by the states, covers long-term care.)

Moreover, “certain surgeries are migrating from inpatient to outpatient surgical centers,” Mr. Kauffman said. Medicare won’t cover skilled nursing for those patients, either.

The growth of Medicare Advantage plans, which now cover a third of Medicare beneficiaries, also plays a role.

“They have a keen interest in lowering costs, so maybe they divert people from skilled nursing to home care,” Mr. Kauffman said. “If you do go to a nursing facility, instead of a 30-day stay, maybe the plan wants the patient out in 17 days.”

At the same time, nursing homes face stiffening competition. As their operators sometimes say themselves, they’re selling a product nobody wants to buy.

“You have increased alternatives, like assisted living, and other ways for people to stay at home,” said Ruth Katz, senior vice president of public policy at Leading Age, which represents nonprofit senior service providers. “When people find community alternatives, they use them whenever possible.”

Federal policy has helped propel this shift. For years, advocates protested that Medicaid covered care in nursing homes but not in the places people much preferred to live. Congress paid attention and passed legislation in 2005.

Thirty years ago, 90 percent of Medicaid dollars for long-term care flowed to institutions and only 10 percent to home- and community-based services. Now, the proportions have flipped, and nursing homes get only 43 percent of Medicaid’s long-term care expenditures.

A report from the federal Government Accountability Office earlier this year pointed out, for example, that Medicaid covers assisted living for 330,000 people. A demonstration program called Money Follows the Person has moved more than 75,000 residents out of nursing homes and back into community settings.

It’s good news for consumers — but not so good for nursing homes. The 31 largest metropolitan markets have 13,586 fewer nursing home beds now than in late 2005, the investment center reports.

This could prove a temporary crisis. When the baby boomers enter their 80s and need residential care, occupancy could pick up again.

Even now, nursing homes can turn a profit with lower occupancy by attracting more patients for short-term rehab. Medicare reimburses for those stays at higher rates than Medicaid pays for long-term care. (About 80 percent of American nursing homes are for-profit.)

Facilities are bracing for some tough years ahead, nonetheless. In casting about for additional revenue, they’re trying tactics like opening pharmacies and home care agencies, and accepting sicker patients, including those on ventilators, at higher reimbursement rates.

They’re experimenting with 12-hour staff shifts, allowing them to hire fewer employees but offer more flexible schedules. Some may convert shared rooms to private ones, a popular move with residents.

Whether emptier and fewer nursing homes benefit older adults and their families remains an open question. On the plus side, people have more choices when they need help, a long-sought goal, said Robyn Grant, director of public policy and advocacy for the National Consumer Voice for Quality Long-Term Care.

“You no longer have to go to a nursing home because it’s the only game in town,” she said.

But what about those who already live in nursing homes, or will move in over the coming years, because they need the round-the-clock supervision no other kind of facility offers?

“From what I’ve observed, as occupancy goes down, so will staff levels,” Ms. Grant said. With most nursing home staffs already stretched too thin, that could hurt.

Despite extensive federal regulations, including new rules adopted in the waning months of the Obama administration, nursing homes have no federal minimum staffing requirements (though some states have requirements).

“You can cut with impunity,” Ms. Grant said, and with financial pressures mounting, she worries that facilities will.

So families with relatives in nursing homes might want to pay particular attention. If occupancy falls, maybe your loved one gets a private room. Or maybe the call button takes even longer to answer.

The new federal rules require more accurate staffing information posted on Nursing Home Compare, using time-cards rather than facilities’ self-reports. That’s one way families can keep tabs on how empty beds may affect care.

“Monitor the data,” was Ms. Grant’s recommendation. “Talk to staff and residents. Definitely keep an eye out.”

[1] https://www.nytimes.com/2018/09/28/health/nursing-homes-occupancy.html?partner=rss&emc=rss

Syphilis Rises Sharply Among Newborns

The number of babies born with syphilis has more than doubled in the past four years and last year reached a 20-year high, according to the Centers for Disease Control and Prevention.

Syphilis may be passed from a pregnant mother to her unborn baby through the placenta. The infection can cause miscarriages and stillbirths, and infants born with it may suffer a wide variety of serious health problems, including deformities, seizures, anemia and jaundice.

Congenital syphilis can be treated with penicillin, but the damage caused by the disease can last a lifetime.

Elimination of syphilis had almost been achieved by 2000, said Dr. Gail Bolan, director of S.T.D. prevention at the C.D.C. “There was support from Congress — they even argued that our work in S.T.D.s would prepare us for bioterrorism,” she said.

“Cost analysis showed that billions would be saved by investing in elimination, and we had a much more robust public health system at that time,” she continued. “We really got syphilis down to a low level.”

But, the new report said, “progress has since been unraveled.”

There were 101,567 cases of syphilis reported in 2017. Of these, 30,644 were primary and secondary cases — the earliest and most infectious stages of the disease.

This represents a 10.5 percent over the rate in 2016, and a 72.7 percent increase since 2013. The number of syphilis cases has increased every year since 2013.

Along with this, the number of cases of congenital syphilis has also steadily increased, to 918 cases in 2017 from 362 in 2013, a national rate of 23.3 per 100,000 live births in 2017.

The highest rate of congenital disease was found in Louisiana, with 93.4 cases per 100,000 births. Rates were also high in Nevada, California, Texas and Florida.

The C.D.C. recommends that all pregnant women be screened for syphilis during the first prenatal visit, with additional testing at the start of the third trimester for women at increased risk or who live in a community with high syphilis prevalence.

Treatment with penicillin is inexpensive and effective, but Dr. Bolan said that about 34 percent of women who give birth to babies with syphilis have had no prenatal care at all.

“Congenital syphilis is a needless tragedy,” she said. “It is going to take all sectors of our society to help if we’re going to be able to reverse these trends — the health care and public health sectors, communities, decision makers, researchers and industry.”

[1] https://www.nytimes.com/2018/09/28/science/congenital-syphilis-infants.html?partner=rss&emc=rss

Review: A Slain Journalist’s Voice Resounds in ‘Intractable Woman’

Just the facts.

Here is a partial record of what one Russian journalist saw after a suicide bombing in Grozny, Chechnya, on a winter day in the early 21st century: burning vans, shredded clothes, car hoods, one human head, a radio, a leg, taxi meters, an arm, a hand, flags on their flagpoles, plastic bags, billboards, two dead dogs, bottles, puke, one child.

This catalog includes more than 50 items, each given the same, neutral weight by the woman reciting it. The sample I’ve chosen above skews toward sensationalism more than the list’s creator would have approved.

That’s the title character of “Intractable Woman: A Theatrical Memo on Anna Politkovskaya,” a cool, carefully composed and frightening work by Stefano Massini, which opened on Sunday night at 122CC, Second Floor Theater in the East Village. Politkovskaya was a reporter for the newspaper Novaya Gazeta who, she said, never wrote “commentary, or opinion, or speculation.”

Yet her unvarnished accounts of the war in Chechnya antagonized many powerful people in the Russian military and government, who regarded her descriptions of acts of savagery committed by their country’s soldiers as “unpatriotic.” She was assassinated in the elevator of her Moscow apartment building in 2006.

Of course, the selection of details inevitably provides its own slanted commentary, as Politkovskaya well knew. This makes her an ideal subject for Mr. Massini, who subjects this intrepid journalist to the same sort of clinical scrutiny that she brought to her war reporting.

And somehow this steady accumulation of individual details, taken from Politkovskaya’s own writing and rearranged into subliminally hypnotic patterns, creates a vivid portrait of a woman as well as of her times. Mr. Massini understands the consciousness-altering power of repetition and hidden cadence, which is expertly captured by Paula Wing’s English translation.

Occasionally, the language slides into a fluid impressionism that summons the surreal nature of Politkovskaya’s world. That description of the detritus of the bombing in Grozny is framed by the softly spoken words “blood, snow, blood, snow, blood, snow.”

Easy empathy is not part of the program here. How could it be when Ms. Politkovskaya’s voice is divided by three? She is portrayed by Nadine Malouf, Nicole Shalhoub and Stacey Yen, who are dressed almost identically in dark pantsuits and pale shirts but are not physically interchangeable.

In level voices, inflected just enough to remind us that the speakers are human and capable of fear and anger, these actresses take turns in describing what Politkovskaya witnessed in Chechnya. That includes acts of violence and terrorism perpetrated by the Russian military, the Chechen government and native dissidents.

Sometimes the performers will assume the roles of Politkovskaya’s interview subjects or of the state officials (from both sides) who regularly interrogated her, with threats open and veiled, on her activities and sources. These other lives are rendered with understated physical tics.

No one, not even the military official who arranges a mock execution of Politkovskaya, comes across as a monstrous caricature. Nor when describing her own life, in the war zone or at home in Moscow, does this journalist strike extreme emotional notes or heroic poses, demanding our compassion or admiration.

Only naked words paint the pictures, which develop into images as horrifying as anything from Goya’s Disasters of War series. Marsha Ginsberg’s institutional set evokes a courtroom, a place for the presentation of evidence after the fact.

Its furnishings include an interrogation table with a microphone and about 20 chairs, which are periodically rearranged, though without any of the self-conscious cleverness associated with story theater. Changes in lighting (by Masha Tsimring) and in a barely perceptible, nagging soundscape (by Stowe Nelson) become deeply disturbing. When a door quietly opens by itself, it registers with the shock of an explosion.

Suppressing the performer’s natural urges to charm and to enlist sympathy can’t have been easy for the cast here. And it takes its members a while to achieve a confident rhythm.

Yet by the end, almost without your knowing it, they have given us a profound assessment of the toll taken by witnessing and chronicling what Politkovskaya saw. Look into the eyes of each of those self-contained faces, and you’ll see a full, agonizing scream waiting to erupt.

[1] https://www.nytimes.com/2018/09/23/theater/review-intractable-woman-stefano-massini-politkovskaya.html?partner=rss&emc=rss

Spare Your Friends: Make a Mini-Movie of Your Fabulous Vacation

TECH TIP

Showing all of the videos from your travels can be cumbersome. Instead, stitch them together into a short highlight reel.

ImageVisitors relax on deckchairs in the sunshine on the beach by Brighton Pier in Brighton, Britain, June 28, 2018.CreditCreditHenry Nicholls/ReutersJ. D. Biersdorfer

Let’s be honest, no one wants to see all of your little vacation video clips one at a time on your phone.

Sure, grabbing a quick video instead of snapping a photo is second nature now to many travelers — a slow pan around that medieval castle or that gorgeous ocean sunset. It’s a dynamic way to preserve those memories for yourself.

But the videos — and photos — add up quickly and showing them all off is cumbersome. Rest assured, everyone else just wants to see a highlight reel.

Never edited a movie before? Not to worry, as there’s a wide variety of beginner-friendly video apps that will stitch your snippets into share-worthy vacation “trailers” with just a few taps or clicks on your part. And here’s the best news of all: Making a video can take less than an hour. Here’s how to do it.

Step 1: Pick an app that works for you

You’ll want an app that does everything you want to do in your movie, like the ability to add photos or audio, but not so complicated that it is tough to use.

You may even have one already. Good options include Microsoft’s Movie Maker 10 for Windows, Cyberlink ActionDirector for Android, Apple’s iMovie for macOS and iOS, Adobe Premiere Clip for Android and iOS — or any of the dozens of video apps in the Google Play and iOS App Store. Read the reviews or dabble around until you find one you like.

While the design of these apps vary, most work the same way — once you add clips to your project, you put them in the order you want to see them by dragging them around a visual timeline. (But if that sounds like too much work, look for an app like Magisto that automatically combines a batch of clips to crank out an instant movie.)

ImageDozens of video-making apps are available for mobile and desktop systems, and most of them work the same way, with a timeline for arranging your clips.CreditJ.D. Biersdorfer/The New York TimesStep 2: Import your video clips

If you’re working on the smartphone you used to film your scenes, this is easy. Just open your video-editing app, create a new project or movie, look for an Import or Create button and select the clips you want to use.

If you’d rather do your editing on a tablet or desktop system because it’s easier to see what you’re doing, it’ll take another step or two because you’ll need pull in the clips there from your camera or smartphone. You can do this in several ways: connecting the devices by USB cable; wirelessly slinging them with Apple’s AirDrop, Android Beam or Bluetooth; or transferring them via cloud drive.

To get started, open your chosen editing app, create a new project or movie and then select clips from your phone or computer video library.CreditJ.D. Biersdorfer/The New York TimesStep 3: Arrange your scenes

The timeline or storyboard area in a video-editing app shows the sequence of the separate scenes in your movie. Once you add the clips to the timeline, you can drag them into a different order, trim off the boring parts and the beginning and end, or split one clip into two.

As you move the different parts around, think of the narrative you want to show your audience as each scene passes by. Do you want to go in chronological order or mix it up? And keep in mind, long scenes where not much happens can be boring for the viewer. (Vimeo has a blog full of tips for video newbies.)

On your app’s timeline, drag the clips into the order you want to see them. In many apps, tap a clip to get an editing tool for trimming the dull beginnings or ends of scenes.CreditJ.D. Biersdorfer/The New York TimesStep 4: Mix in other visual elements

Video-editing apps like iMovie and Windows Movie Maker include text tools so you can insert title cards and add identifying captions. Some can apply Hollywood-style transitions (like wipes, fades and dissolves) to glide between scenes, too.

To add a title or transition between scenes, look in your app’s toolbar for the appropriate element and drag the icon for a title or transition you want onto the timeline between scenes. Click a clip with the text tool to add a caption. Got a gorgeous photograph you want to add to the video tour? If your app supports photos, add it to your timeline and set it to linger for a few seconds to vary the video’s pace.

When you get your clips in order, add title cards, captions and scene transitions from the program’s toolbox. Your app’s on-screen manual can guide you.CreditJ.D. Biersdorfer/The New York TimesStep 5: Add audio

KineMaster for Android and iOS and iMovie are among the apps that let you record your own documentary-style narration.

Look for a menu item or button to add an audio track along your timeline. For better audio quality, consider getting a USB microphone. You can also add a song as a soundtrack, but be mindful of copyright when using someone else’s music.

Some programs allow you to make a soundtrack from music on your device, but you can also record your own documentary-style narration. Just look for a microphone icon. The audio track is displayed along the timeline under the video clips.CreditJ.D. Biersdorfer/The New York TimesStep 6: Preview, compress and share

Once you get all the elements in order, preview your creation within the program and make any last-minute adjustments before you finalize the project. When you’re satisfied, save the video and select an output size if asked. Just a few minutes of high-definition or 4K video can make for a hefty file, but you can pick a smaller output size for sharing or streaming.

When the app pops out your finished masterpiece, share away. And now you can start planning for your next vacation.

When you finish editing your video, save it, export it or post it to your favorite sharing site so friends and family can see your vacation in action.CreditJ.D. Biersdorfer/The New York Times

J.D. Biersdorfer has been answering technology questions — in print, on the web, in audio and in video — since 1998. She also writes the Sunday Book Review’s “Applied Reading” column on ebooks and literary apps, among other things. @jdbiersdorfer

[1] https://www.nytimes.com/2018/09/26/technology/personaltech/how-to-make-mini-vacation-movie.html?partner=rss&emc=rss

A New Class of Voting Rights Activists Picks Up the Mantle in Mississippi

“The methods have become more sophisticated, but the broader issues are still in play,” said Jim Kates, one of the Freedom veterans who, along with others, returned to Mississippi to assist Ms. Bennett and the other young organizers.

A Lesson of Fear and Hope

Part of what made Freedom Summer, first called the Mississippi Summer Project, so successful was that it exposed the horrors blacks faced trying to assert basic citizenship. Those experiences were exported to the masses in stark news dispatches. The volunteers, recruited by the Student Non-Violent Coordinating Committee and Congress of Racial Equality activists, trained at an Ohio college, then traveled some 800 miles south by bus or car.

At great personal risk, hundreds of black families hosted the volunteers in their homes. In turn, the volunteers met at black churches, to distribute registration information, helped to fill out forms and escorted them to the courthouses.

The veterans remembered a summer wrapped in fear but also hope. The volunteers were harassed by both the police and white residents. They were arrested and jailed. Beaten. Firebombed. And they were murdered. In the first week of the project, three activists — Andrew Goodman, Michael Schwerner and James Chaney — were abducted and shot just outside Philadelphia, Miss. Their corpses, brutalized and buried, were discovered two months later.

“You never really felt safe. And you never knew if some kind of harassment was going to turn into something more,” said Benjamin Graham, 73, who left the University of California, Berkeley, to spend that summer in Mississippi.

Mr. Graham, who later became a doctor specializing in internal medicine, still remembers with chilling clarity lying in bed one summer night in the house of a Batesville family. It was his first night back in Mississippi after a quick return trip to California. Suddenly, around 2 a.m. his chest began to tighten. His breath had shortened and he was wheezing.

[1] https://www.nytimes.com/2018/09/25/us/freedom-summer-mississippi-votes.html?partner=rss&emc=rss

To Get to the Boston Marathon, Run Faster, and Faster

For thousands of runners, that dream of running in the Boston Marathon just got a little more far-fetched.

Boston is a rare marathon that admits most runners based on merit. To qualify, runners must complete another marathon during the year or so leading up to the registration under a certain time, dependent on their age and gender. For men 35-39, for example, the time is 3 hours 10 minutes; women 60-64 must run in 4:25.

But in recent years, Boston has been getting more qualified applicants than it can handle, since its permit limits the size of its field. It solves this by admitting the fastest runners, while turning away those who only barely met the notional qualifying time. And the problem keeps getting worse.

Boston announced Thursday that only those who bettered the qualifying times by 4:52 would be accepted for 2019. Suddenly that man in his late 30s who thought his 3:09:59 got him into the race found that he really needed to have run 3:05:08.

The marathon said that 30,458 qualified applications had been received; of those, 7,384 were turned away because their times were not 4:52 better than the standard.

Why 4:52 and not an even five minutes? Those eight little seconds mattered: 433 runners who would not have made it if the cutoff had been five minutes sneaked into that tiny window.

The times that runners need to receive an invitation are dropping by more than a minute per year of late. For 2018, the figure was 3:23. In 2017, it was 2:09.

The marathon also announced that in view of the increased applications and faster times, the official qualifying times would all be made fully five minutes faster for 2020.

About 80 percent of the field of 30,000 qualifies on merit, and some elite runners get special invitations. The rest get in as part of charity programs. A few hundred who have completed 10 straight Boston Marathons also get in.

The news was a blow to many runners who had been buzzing in recent days with hope that they would get into the race. There has been much speculation on where the cutoff would fall this year, with many close qualifiers, sometimes known as “squeakers,” holding out hope they would sneak into the race.

Boston is for many lay runners the ultimate American marathon, and running in it can be a career pinnacle, a moment that in some runners’ minds separates the serious marathoner from the hobbyist.

Many runners are finding their dream keeps slipping away, by a minute or so every year.

[1] https://www.nytimes.com/2018/09/28/sports/boston-marathon-qualifying.html?partner=rss&emc=rss

In Hong Kong, Hepatitis E Strain Jumps From Rats to Humans

HONG KONG — A man in Hong Kong has been found to have a strain of hepatitis E that had been seen previously only in rats, researchers said on Friday.

While rats have passed on several other illnesses to people, this was the first discovery in humans of the rat variation of hepatitis E, a liver disease. Researchers at the University of Hong Kong identified the infection last September in a 56-year-old man who had received a liver transplant in May 2017.

He was cured of the disease in March, after which they verified their findings before announcing the case.

Dr. Yuen Kwok-yung, chairman of the infectious diseases section of the microbiology department at the University of Hong Kong, called the case “a wake-up call.”

And Dr. Siddharth Sridhar, a clinical assistant professor in the university’s department of microbiology, said it suggested that Hong Kong needed to work harder on rodent control, as the city did during the SARS epidemic of 2003 and 2004.

In densely populated areas like Hong Kong, “infections that jump from animals to humans must be taken very seriously,” Dr. Sridhar said. “For these kinds of rare infections, unusual infections, even one case is enough to make public health authorities and researchers very alert about the implications of the disease. One is all it takes.”

Although the patient had received a liver transplant, researchers ruled out infection from his blood and organ donors, which all tested negative for the disease. The researchers instead highlighted rat droppings, piles of uncovered garbage and open passageways found near the patient’s home as major risk factors in rodent-borne diseases.

The researchers said that routine hepatitis E testing would have failed to identify the strain, which is significantly different from the one that typically infects humans. They detected the source of the patient’s infection in this case after finding similarities with infected rats in Vietnam.

When they tested rodent samples that health officials had collected in his neighborhood in recent years, they found hepatitis E in at least one rat.

It is not unusual for diseases to pass between animals and humans — the Ebola virus most likely originated in an infected animal, for one. But scientists have struggled to measure the threat from rats and how they spread diseases.

Rat-borne infections are relatively rare. There have been just four in Hong Kong this year, and nine last year.

The World Health Organization estimates that the human variation of hepatitis E infects 20 million people each year, most commonly in East and South Asia. About 44,000 people died from it in 2015.

Most human cases of hepatitis E, which typically causes mild symptoms including nausea and diarrhea, resolve themselves within six weeks, but they can be more serious for patients with weakened immune systems. The disease is most common in areas with substandard sanitation and water supply.

The rat variation of hepatitis E was discovered in 2010 in Germany, researchers said. It has been found in rats worldwide, including the United States.

A version of this article appears in print on , on Page A10 of the New York edition with the headline: In Hong Kong, Hepatitis E Strain Makes Jump From Rats to Humans. Order Reprints | Today’s Paper | Subscribe

[1] https://www.nytimes.com/2018/09/28/science/hepatitis-e-rats-hong-kong.html?partner=rss&emc=rss

The New Birds and Bees: Teaching Kids About Boundaries and Consent

Don’t treat body parts as shameful

Shame about body parts, Ms. Van der Doef says, comes from a child’s environment: they learn from their caregivers when to be squeamish and embarrassed. By normalizing all body parts and speaking of them regularly and straightforwardly with correct language, we send the message that every part of a person’s body is healthy, wholesome and worthy.

As I learned from the Dutch example, normalization goes beyond talk: day-to-day nonsexual nudity — in homes, picture books, mixed-gender school bathrooms, kids’ television programs, and public changing areas and wading pools — reinforces the tenet that bodies are nothing to be ashamed of and nothing we can’t discuss (in words any caregiver, teacher or health provider will recognize) if need be.

As we respond to kids’ natural, healthy curiosity about the human form, we can instill in them the idea that all people are born with wonderful bodies capable of feeling pleasure and pain.

Teach the importance of consent

It can be daunting to explain the emotional and relational aspects of human sexuality. Yet this is our richest opportunity to instill empathy, consent, inclusiveness and egalitarianism.

Preschool is the age to teach children the hallmarks of a healthy, trusting friendship. Children at this age can be made aware of the gender-role stereotypes they’ve absorbed (for example, girls like pink and boys have short hair). A simple role-play with stuffed animals in which a “girl” teddy bear wants to play football and a “boy” animal wants to wear a dress can teach it’s hurtful to limit one anther’s opportunities.

Preschoolers and even toddlers can learn rules for playing contact games with friends such as tickling, chase and “doctor”: everyone must agree happily to the game; no hurting allowed; anyone can say “no” or change their mind. As adults, we can model the importance of consent when children want to climb on us by reminding them to ask first. We can model respect for the importance of consent, too, when a child is reluctant to give a high-five, hug or kiss — especially to an adult, and this does include Grandma — by suggesting a contact-free alternative like a verbal greeting or a wave.

Elsbeth Reitzema, a sex education consultant and curriculum author for the sexual health institute Rutgers in the Netherlands, says it’s impossible to warn children of every scenario and impossible, too, to protect them 100 percent of the time. Specific scenarios such as the lap-patting relative or lollipop-offering stranger can be good to mention, but it’s most important to instill an understanding of consent. This goes for friends, relatives, teachers and even physicians. When children expect to ask, give and deny consent at their own discretion, sexual transgressions stick out as clear violations.

[1] https://www.nytimes.com/2018/09/27/well/family/the-new-birds-and-bees-teaching-kids-about-boundaries-and-consent.html?partner=rss&emc=rss

Killer Whales Face Dire PCBs Threat

Most people thought the problem of polychlorinated biphenyls — known as PCBs — had been solved. Some countries began banning the toxic chemicals in the 1970s and 1980s, and worldwide production was ended with the 2001 Stockholm Convention.

But a new study based on modeling shows that they’re lingering in the blubber of killer whales — and they may end up wiping out half the world’s population of killer whales in coming decades.

“It certainly is alarming,” said Jean-Pierre Desforges, a post-doctoral researcher at Aarhus University in Denmark and the lead author on the new study published Thursday in the journal Science.

Whales sit at the top of their food chain. Chemicals like PCBs are taken up by plankton at the base of the food chain, then eaten by herring and other small fish, which are themselves eaten by larger fish, and so on. At each step in this chain, PCBs get more and more concentrated. The most at-risk killer whales are those that eat seals and other animals that are themselves fairly high on the food chain and quite contaminated, Dr. Desforges said.

Killer whale populations in Alaska, Norway, Antarctica and the Arctic among other places, where chemical levels are lower, will probably continue to grow and thrive, the study found. But animals living in more industrialized areas, off the coasts of the United Kingdom, Brazil, Hawaii and Japan, and in the Strait of Gibraltar are at high risk of population collapse from just the PCBs alone — not counting other threats.

Dave Duffus, who directs the whale research lab at the University of Victoria in Canada and was not involved in the new research, said its conclusions are “shocking, but I don’t doubt them.”

Whales near him in the Pacific Northwest are surrounded by contaminants, face changes in their food supply and are continually bombarded with noise. “You can see the downtrend in their population,” Dr. Duffus said.

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The researchers used blubber samples to estimate the amount of PCB contamination in killer whales around the world. They also developed a model to forecast the amount of PCBs passed on to calves through the placenta and breast milk as well as from eating prey. Researchers then compared these concentrations to the known damage that can come from different amounts of PCBs.

According to their calculations, roughly half of the killer whale populations in the world will stop expanding and then will shrink in coming decades. Dr. Desforges said he could not be certain how long it would take for these populations to collapse, but his team estimated the impact of contamination over a century — and the clock started ticking about 40 years ago when PCB exposure levels were at their highest, he said. PCB exposures declined with the bans, but levels have stopped falling in long-lived marine predators like killer whales, he said. The whales only very slowly metabolize the PCBs during a life span of 50 to 80 years in the wild, Dr. Desforges said.

PCBs remain the highest chemical contaminant in the whales’ blubber, and are known to disrupt the whales’ reproductive, endocrine, thyroid and immune systems, harm their brains and trigger cancer. Other chemicals are also present, but in lower concentrations and with far less known about their potential hazards, he said.

“We’re looking at one contaminant among many, and this is one risk factor among many,” Dr. Desforges said.

Despite the depressing results, Dr. Desforges said he remained hopeful about the future of killer whales.

“It’s not a dead-end story. There’s still lots we can do about this,” Dr. Desforges said. Many countries are not living up to their commitments to dispose of old, PCB-contaminated equipment appropriately by 2028, he said, so more could be done to keep new PCBs from entering the oceans.

He said he hoped that policy makers would do more to help protect them, with the study helping to persuade them as well as the substantial appeal orcas have with the public.

“If killer whales can’t do it in the water, like pandas on terrestrial sites, I don’t know who will,” he said.

[1] https://www.nytimes.com/2018/09/27/science/killer-whales-pcbs.html?partner=rss&emc=rss

Should You Give Birth at a Birth Center?

Sometimes birth centers “have a comfortable agreement with the nearby hospitals and midwives have privileges there, and that’s fine,” said Dr. Woo, who has advocated for improved integration of birth centers. “Other times, they have no relationship, and then that often is what leads to bad outcomes, because there will be delays in transfer of care,” she said.

In the United States, about 22 percent of women planning to give birth at a birth center end up transferring to a hospital during labor or soon after giving birth with 2 percent being emergency situations.

Unfortunately, Dr. Tarr was one of these. She unexpectedly hemorrhaged after her daughter was born and had to go by ambulance to a hospital. It was scary, but she got appropriate medical attention in time, and the admitting nurse told her that the midwife had done everything right. Still, Dr. Tarr isn’t sure she would choose a birth center if she had another child. “I am happy with the birth experience I had there, but I am also more scared of what can happen, with no warning, even if you’re low risk.”

Giving birth outside of a hospital doesn’t mean it’s more dangerous, said Dr. Calvin, who specialized in high-risk obstetrics for 25 years before opening a birth center.

Wherever you give birth, your safety depends on what Dr. Calvin calls your “perinatal safety net.” How far are you from an operating room, an anesthesiologist, a blood bank, if something catastrophic happens? Consider that distance in miles, in minutes, and in the vigilance of the people you’ve trusted with your care. Ideally, a birth center should be within 10 to 15 minutes of a hospital, with a well-defined plan for transport, he said.

Dr. Calvin also points out that access to these medical resources is not a given in the United States, even in hospitals. A California study found that just 50 percent of community hospitals had 24-hour anesthesia availability and only 56 percent could perform an emergency C-section within 30 minutes.

[1] https://www.nytimes.com/2018/09/25/well/family/should-you-give-birth-at-a-birth-center.html?partner=rss&emc=rss