Category: Health

Did you know that arthritis is the number one cause of disability in the United States? According to the Centers for Disease Control and Prevention (CDC), the condition affects nearly 60 million people in the U.S. each year, or about 24% of the population.

With over 100 types of arthritis and related conditions, the causes and symptoms can vary from person to person. But what everyone with arthritis has in common is joint pain.

Maybe your hands hurt sometimes when the weather changes. Or perhaps your joints are stiff when you wake up in the morning. Learning more about arthritis can help you recognize the symptoms and find the right care to help manage it and improve your quality of life.

What is arthritis?

Arthritis refers to soreness, and often inflammation (swelling), in one or more joints. Joints are the places where your bones connect together and move. When someone has arthritis, those joints can become painful, and in some cases, swollen.

Arthritis is often mistaken for its own standalone disease, but it’s really a joint condition with many different causes. There are two main categories of arthritis: noninflammatory arthritis (which is the case for osteoarthritis) and inflammatory arthritis (usually related to a rheumatological condition). We’ll explain more about the types below.

The primary symptoms of arthritis are joint pain, stiffness, swelling and decreased range of motion. These symptoms can vary from mild to severe and might be constantly present or come and go.

Arthritis tends to affect women more than men, and it’s often associated with aging as our joints experience more wear and tear. But it affects people of all ages because it can be caused by a variety of underlying conditions, including sports injuries and autoimmune disorders which lead the body’s immune system to attack its own healthy joints (rheumatoid arthritis).

Types of arthritis

Experts believe arthritis can have nearly 100 different causes, and more is being learned about them over time. Here are some of the most common types of arthritis:

Osteoarthritis

Osteoarthritis is the most common form of arthritis, affecting about 80% of adults over the age of 55. It’s sometimes known as degenerative joint disease (DJD) or wear-and-tear arthritis because it happens when the cartilage in your joints breaks down.

Our bones have cartilage on the ends, serving as a cushion to help them move smoothly and avoid the friction of rubbing together. When someone has osteoarthritis, the cartilage in their joints has worn down. Without that layer of protection, the bones can grind together painfully. Cartilage itself has no nerves, but the bones underneath have lots of nerves, which cause the joint pain.

Osteoarthritis can be caused by typical wearing as you age, injuries to joints that damage the cartilage, and repetitive motions in your work or daily activities that put force on your joints. It can affect a variety of different joints in the body, but it usually happens with the ones you use the most, like your hands, wrists, shoulders, knees or feet. (That also means it’s a little different for everyone.)

Osteoarthritis can be treated by a primary care doctor, an orthopedic specialist or a physical therapist through medication, cortisone injections, physical therapy and, in some cases, surgery.

Rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune rheumatic disease. These diseases cause one’s immune cells to attack and damage the body’s own healthy joint tissues, leading to pain, swelling and stiffness. Rheumatoid arthritis commonly affects the hands, wrists and knees, making everyday tasks like writing or taking stairs difficult. If left untreated, it can damage other organs and systems, including your heart, lungs and eyes.

With this form of arthritis, it’s important to see a rheumatology specialist. They can help you understand the diagnosis and create a personalized treatment plan to improve symptoms and protect your health long-term.

Psoriatic arthritis

Psoriatic arthritis is connected to psoriasis, a chronic skin condition that causes uncomfortable red patches, often with a silvery scale-like layer on top. Most people will experience the skin symptoms of psoriasis long before developing psoriatic arthritis, which causes the joint pain, swelling and stiffness of similar arthritis conditions.

There’s no cure for psoriatic arthritis, but people often experience periods of flare ups and remission. It’s typically treated by a rheumatologist with a combination of medication, and physical and occupational therapies. If left untreated, psoriasis and psoriatic arthritis can be debilitating, so it’s important to continue care with a rheumatologist and often a dermatologist.

Gout

Gout is a condition caused by high levels of uric acid in your bloodstream. Uric acid is a waste product left behind when your body breaks down chemicals called purines. It usually dissolves, but when you eat foods that are high in purines over time, urate crystals collect in your joints. This can lead to intense pain and swelling.

Uric acid crystal deposition and gout are more likely in people with obesity, those on diuretics, and those with poor kidney function. Gout flare-ups usually happen suddenly. Rheumatologists use medications as the main treatment and can also help prevent future gout attacks.

Juvenile arthritis

Also called pediatric rheumatic disease, juvenile arthritis (JA) is a term that describes a number of autoimmune or autoinflammatory diseases affecting children under 16. Similar to the effects of rheumatoid arthritis, this condition causes the immune system to release inflammatory chemicals that damage healthy tissues, including joints. Although JA can be a life-long disease, it’s possible to experience periods of remission or to have it completely resolve.

Treated by rheumatologists in partnership with a child’s pediatrician, the usual treatment for JA includes a combination of medication, lifestyle modifications, and sometimes integrative therapies like acupuncture.

Where is arthritis most common in the body?

One question people often have is, Where is arthritis most common in the body? The answer is that there isn’t one specific area that’s the most commonly affected. If you have arthritis, it typically affects more than one joint. But it’s true that the joints we use the most in our daily lives can be the most noticeably affected by pain or stiffness. Those joints typically include our knees, hands, wrists, feet, ankles, hips and shoulders.

Is arthritis hereditary?

Research and genetic studies show that arthritis can be hereditary, especially if your parent or someone in your close family has osteoarthritis or rheumatoid arthritis. It’s important to note that even if you’ve inherited those genes, not everyone will develop an arthritic condition or experience the same symptoms.

It’s just as common for arthritis to develop outside of genetic causes. It can happen as a result of the normal aging process, wear and tear from repeated stress on a joint, your unique anatomy, and a variety of other factors. Your doctor will look at your health history, symptoms and any imaging or examination findings to provide a diagnosis and help you understand the most likely cause.

Is arthritis always a chronic (long-term) condition?

No, arthritis isn’t always a chronic condition. For example, if it’s caused by an underlying illness that resolves, then arthritis symptoms may go away along with it.

But unfortunately, it’s much more common for arthritis to be a long-term condition that people need to manage with ongoing treatments, like medication and lifestyle changes. This is especially true in the case of osteoarthritis, the most common type. When you have wear and tear on your joints and the cartilage has degenerated, the cartilage cannot grow back. But variables such as your age, weight and history of joint injuries can determine the severity of the condition over time.

Long-term effects of untreated arthritis

The long-term effects of arthritis highly depend on the type, or cause. For moderate arthritis associated with joint wear and tear, treatment may not be needed. You can make lifestyle adjustments to make your daily activities more comfortable. For example, if you have sore knees, you might change your usual exercise plan to taking a walk rather than using the stair climber machine at the gym. Non-weight bearing exercise like biking and water aerobics can allow supportive muscle strengthening without worsening joint pain in weight-bearing joints like hips, knees, ankles and feet.

However, when autoimmune conditions like rheumatoid arthritis are left untreated, you can face more serious health risks, including deformed joints, permanently injured joints, and even damage to other organs and systems throughout the body. For that reason, it’s important to talk with your doctor about any symptoms you notice and learn what’s causing them.

Think you might have arthritis? Talk to your doctor

A little joint soreness here and there can be normal as we go through our lives. But if you’re experiencing recurring pain in your joints, whether it’s sudden or increasing as you age, it’s a good idea to talk to your doctor.

Primary care doctors can listen to you about your symptoms, look at your health history and help you understand what you’re experiencing. Depending on the diagnosis, they may suggest treatments that can help, or recommend that you see a rheumatologist or an orthopedist for more specialized care.

Make a primary care appointment

In 1988, the World Health Assembly announced a very ambitious goal: Polio was to be vanquished by the year 2000. It was a reach, sure, but feasible. Although highly infectious, polioviruses affect only people, and don’t hide out in wild animals; with two extraordinarily effective vaccines in regular use, they should be possible to snuff out. Thanks to a global inoculation campaign, infections had, for years, been going down, down, down.

But 2000 came and went, as did a second deadline, in 2005, and a third, in 2012, and so on. The world will almost certainly miss an upcoming target at the end of 2023 too. In theory, eradication is still in sight: The virus remains endemic in just two countries—Pakistan and Afghanistan—and two of the three types of wild poliovirus that once troubled humanity are gone. And yet, polio cases are creeping up in several countries that had eliminated them, including the United Kingdom, Israel, and the United States. Earlier this year, New York detected America’s first paralytic polio case in nearly a decade; last week, the governor declared a state of emergency over a fast-ballooning outbreak.

This is the cruel logic of viruses: Give them enough time—leave enough hosts for them to infect—and they will eventually find a way to spread again. “You have to stop transmission everywhere, all at the same time,” says Kimberly Thompson, a health economist and the president of the nonprofit Kid Risk. Which means eradication will demand a near-perfect syncing of vaccine supply, access, equity, political will, public enthusiasm, and more. To beat the virus, population immunity must outlast it.

Right now, though, the world’s immunological shield is too porous to stop polio’s spread. At the center of the new epidemics are vaccine-derived polioviruses that have begun to paralyze unimmunized people in places where immunity is low—a snag in the eradication campaign that also happens to be tightly linked to one of its most essential tools. Vaccine performance has always depended on both technology and human behavior. But in this case especially, because of the nature of the foe at hand, those twin pillars must line up as precisely as possible or risk a further backslide into a dangerous past.

In the grand plan for eradication, our two primary polio vaccines were always meant to complement each other. One, an ultra-effective oral formulation, is powerful and long-lasting enough to quash wild-poliovirus transmission—the perfect “workhorse” for a global vaccination campaign, says Adam Lauring, an evolutionary virologist at the University of Michigan. The other, a supersafe injectable, sweeps in after its colleague has halted outbreaks one country at a time, maintaining a high level of immunity in post-elimination nations while the rest of the world catches up.

For decades, the shot, chaser approach found remarkable success. In the 1980s, wild poliovirus struck an estimated 300,000 to 400,000 people each year; by 2021, the numbers had plummeted to single digits. But recently, as vaccine coverage in various countries has stalled or slipped, the loopholes in this vaccination tactic have begun to show themselves and grow.

The oral polio vaccine (OPV), delivered as drops in the mouth, is one of the most effective inoculations in the world’s roster. It contains weakened forms of polioviruses that have been altered away from their paralysis-causing forms but still mimic a wild infection so well that they can stop people from spreading wild pathogens for years, even decades. In the weeks after people receive the vaccine, they can also pass the weakened virus to others in the community, helping protect them too. And OPV’s transportability, low price point, and ease of administration make it a “gold standard for outbreak interruption,” says Ananda Bandyopadhyay, the deputy director for the polio team at the Bill & Melinda Gates Foundation. Since its mid-20th-century debut, OPV has helped dozens of countries—including the U.S.—eliminate the virus. Those nations were then able to phase out OPV and switch to inoculating people with the injected vaccine.

But OPV’s most potent superpower is also its greatest weakness. Given enough time and opportunity to spread and reproduce, the neutered virus within the vaccine can regain the ability to invade the nervous system and cause paralysis in unvaccinated or immunocompromised people (or in very, very rare cases, the vaccine recipient themselves). Just a small handful of genetic modifications—three or fewer—can spark a reversion, and the mutants, which are “better at replicating” than their kin, can take over fast, says Raul Andino, a virologist at UC San Francisco. In recent years, a few thousand cases of vaccine-derived polio have been detected around the world, far outstripping the toll of wild viruses; dozens of countries, the U.S. now among them, are battling such outbreaks, and the numbers seem to be only going up. Vaccine-derived polio is still a true rarity: Billions of oral vaccines have been delivered since the global campaign began. But it underscores “the real problem” with OPV, Lauring told me. “You’re fighting fire with fire.”

Read: The epidemic that preyed on children

The injected polio vaccine, or IPV, which contains only chemically inactivated versions of the virus, carries none of that risk. To purge all polio cases, “you have to stop using oral polio vaccine,” Thompson told me, and transition the entire globe to IPV. (Post-eradication, countries would need to keep IPV in their routine immunization schedule for at least 10 years, experts have said.) But the injected vaccine has a different drawback. Although the shot can very effectively stave off paralysis, IPV doesn’t elicit the kind of immunity that stops people from getting infected with polioviruses and then passing them on. In places that rely on injected vaccines, “even immune individuals can participate in transmission,” Thompson told me. Which opens up a vulnerability when too many people have skipped both types of vaccines: Paralyzing polioviruses erupt out of communities where the oral vaccine is still in use—then can spread in undervaccinated areas. It might be tempting to blame OPV for our troubles. But that’s not the main threat, Bandyopadhyay told me. “It’s the lack of adequate vaccination.”

As things stand, the goal in the endemic countries of Pakistan and Afghanistan remains achieving sufficiently high vaccine coverage, Bandyopadhyay said. But many of the communities in these nations are rural or nomadic, and tough to reach even with convenient drop-in-the-mouth vaccines. Civil and political unrest, misinformation, natural disasters, and most recently, the COVID pandemic have raised additional hurdles. So have intermittent bans on house-to-house vaccination in Afghanistan, says John Vertefeuille, the chief of the polio-eradication branch at the CDC. Cases of wild polio have experienced a recent jump in Pakistan, and have also been imported into the non-endemic countries of Malawi and Mozambique.

But the toll of those outbreaks—all featuring type 1 polio—currently pales in comparison with those featuring vaccine-derived type 2. The last case of wild type 2 polio was detected in 1999, but that version of the virus has persisted in its modified form in oral polio vaccines. And when it reverts to its dangerous form, it gains particularly infectious oomph, allowing it to spread unchecked wherever immunity is low. Some 30 countries around the world are battling outbreaks of poliovirus whose origin can be traced back to the oral inoculations; vaccine-derived type 2 is what’s been circulating in Jerusalem, London, and New York, where it ultimately paralyzed an unvaccinated young man. The extent to which the virus is churning in other parts of the country isn’t fully known; routine immunization has dropped since the COVID pandemic’s start, and the U.S. hasn’t regularly surveyed its wastewater for the pathogen.

The success of these vaccine-derived viruses is largely the result of our own hubris—of a failure, experts told me, to sync the world’s efforts. In 2016, 17 years after the last wild type-2 case had been seen, officials decided to pivot to a new version of OPV that would protect against just types 1 and 3, a sort of trial run for the eventual obsolescence of OPV. But the move may have been premature. The switch wasn’t coordinated enough; in too many pockets of the world, type-2 polio, from the three-part oral vaccine, was still moseying about. The result was disastrous. “We opened up an immunity gap,” Thompson told me. Into it, fast-mutating vaccine-derived type-2 viruses spilled, surging onto a global landscape populated with growing numbers of children who lacked protection against it.

A new oral vaccine, listed for emergency use by the WHO in 2020, could help get the global campaign back on track. The fresh formulation, developed in part by Andino and his colleagues, still relies on the immunity-boosting powers of weakened, replicating polioviruses. But the pathogens within have had their genetic blueprints further tweaked. “We mucked around” with the structure of poliovirus, Andino told me, and figured out a way to make a modified version of type 2 that’s far stabler. It’s much less likely to mutate away from its domesticated, non-paralyzing state, or swap genes with related viruses that could grant the same gifts.

Technologically, the new oral vaccine, nicknamed nOPV2, seems to be as close to a slam dunk as immunizations can get. “To me, it’s just super cool,” Lauring told me. “You keep all the good things about OPV but mitigate this evolutionary risk.” In the year and a half since the vaccine’s world premiere, some 450 million doses of nOPV2 have found their way into children in 22 countries—and a whopping zero cases of vaccine-derived paralysis have followed.

But nOPV2 is “not a silver bullet,” Andino said. The vaccine covers just one of the three poliovirus types, which means it can’t yet fully replace the original oral recipe. (Trials for type-1 and -3 versions are ongoing, and even after those recipes are ready for prime time, researchers will have to confirm that the vaccine still works as expected when the three recipes are mixed.) The vaccine’s precise clinical costs are also still a shade unclear. nOPV2 is a safer oral polio vaccine, but it’s still an oral polio vaccine, chock-full of active viral particles. “You can think of it as more attenuated,” Thompson said. “But I don’t think anybody expects that it won’t have any potential to evolve.” And nOPV2’s existence doesn’t change the fact that the world will still have to undergo a total, coordinated switch to IPV before eradication is won.

As has been the case with COVID vaccines, and so many others, the primary problem isn’t the technology at all—but how humans have deployed it, or failed to. “Vaccine sitting in a vial, no matter how genetically stable and how effective it is, that’s not going to solve the problem of the outbreaks,” Bandyopadhyay said. “It’s really vaccination and getting to that last child in that last community.”

Read: How the poor get blamed for disease

If dwindling vaccination trends don’t reverse, even our current vaccination strategies could require a rough reboot. In 2013, health officials in Israel—which had, for years prior, run a successful IPV-only campaign for its children—detected wild type-1 virus, imported from abroad, in the country’s sewage, and decided to roll out another round of oral vaccines to kids under 10. Within a few weeks, nearly 80 percent of the targeted population had gotten a dose. Even “polio-free countries are not polio-risk-free,” Bandyopadhyay told me. The situation in New York is different, in part because type-1 polio causes paralysis more often than type-2 does. But should circumstances grow more dire—should substantial outbreaks start elsewhere in the country, should the nation fail to bring IPV coverage back to properly protective levels—America, too, “may have to consider adding OPV as a supplement,” says Purvi Parikh, an immunologist and a physician at NYU, “especially in rural areas” where emergency injected-vaccine campaigns may be tough. Such an approach would be a pretty extreme move, and a “very big political undertaking,” Thompson said, requiring a pivot back to a vaccine that was phased out of use decades ago. And even then, there’s no guarantee that Americans would take the offered oral drops.

The CDC, for now, is not eager for such a change. Noting that most people in the U.S. are vaccinated against polio, Katherina Grusich, an agency spokesperson, told me that the CDC has no plans to add OPV or nOPV to the American regimen. “We are a long way from reaching for that,” she said.

But this week, the U.S. joined the WHO’s list of about 30 nations with circulating vaccine-derived-poliovirus outbreaks. The country could have avoided this unfortunate honor had it kept shot uptake more uniformly high. It’s true, as Grusich pointed out, that more than 90 percent of young American children have received IPV. But they are not distributed evenly, which opens up vulnerabilities for the virus to exploit. Here, the U.S., in a sense, had one job: maintain its polio-free status while the rest of the world joined in. That it did not is an admonition, and a reminder of how unmerciful the virus can be. Polio, a fast mutator, preys on human negligence; the vaccines that guard against it contain both a form of protection and a catch that reinforces how risky treating these tools as a discretionary measure can be.

Over the past week, an average of 491 Americans have died of COVID each day, according to data compiled by The New York Times. The week before, the number was 382. The week before that, 494. And so on.

For the past five months or so, the United States has trod along something of a COVID-death plateau. This is good in the sense that after two years of breakneck spikes and plummets, the past five months are the longest we’ve gone without a major surge in deaths since the pandemic’s beginning, and the current numbers are far below last winter’s Omicron highs. (Case counts and hospital admissions have continued to fluctuate but, thanks in large part to the protection against severe disease conferred by vaccines and antivirals, they have mostly decoupled from ICU admissions and deaths; the curve, at long last, is flat.) But though daily mortality numbers have stopped rising, they’ve also stopped falling. Nearly 3,000 people are still dying every week.

We could remain on this plateau for some time yet. Lauren Ancel Meyers, the director of the University of Texas at Austin’s COVID-19 Modeling Consortium, told me that as long as a dangerous new variant doesn’t emerge (in which case these projections would go out the window), we could see only a slight bump in deaths this fall and winter, when cases are likely to surge, but probably—or at least hopefully—nothing too drastic. In all likelihood, though, deaths won’t dip much below their present levels until early 2023, with the remission of a winter surge and the additional immunity that surge should confer. In the most optimistic scenarios that Meyers has modeled, deaths could at that point get as low as half their current level. Perhaps a tad lower.

Read: How did this many deaths become normal?

By any measure, that is still a lot of people dying every day. No one can say with any certainty what 2023 might have in store, but as a reference point, 200 deaths daily would translate to 73,000 deaths over the year. COVID would remain a top-10 leading cause of death in America in this scenario, roughly twice as deadly as either the average flu season or a year’s worth of motor-vehicle crashes.

COVID deaths persist in part because we let them. America has largely decided to be done with the pandemic, even though the pandemic stubbornly refuses to be done with America. The country has lifted nearly all of its pandemic restrictions, and emergency pandemic funding has been drying up. For the most part, people have settled into whatever level of caution or disregard suits them. A Pew Research survey from May found that COVID did not even crack Americans’ list of the top 10 issues facing the country. Only 19 percent said that they consider it a big problem, and it’s hard to imagine that number has gone anywhere but down in the months since. COVID deaths have shifted from an emergency to the accepted collateral damage of the American way of life. Background noise.

On one level, this is appalling. To simply proclaim the pandemic over is to abandon the vulnerable communities and older people who, now more than ever, bear the brunt of its burden. Yet on an individual level, it’s hard to blame anyone for looking away, especially when, for most Americans, the risk of serious illness is lower now than it has been since early 2020. It’s hard not to look away when each day’s numbers are identically grim, when the devastation becomes metronomic. It’s hard to look each day at a number—491, 382, 494—and experience that number for what it is: the premature ending of so many individual human lives.

People grow accustomed to these daily tragedies because to not would be too painful. “We are, in a way, victims of our own success,” Steven Taylor, a psychiatrist at the University of British Columbia who has written one book on the psychology of pandemics and is at work on another, told me. Our adaptability is what allowed us to weather the worst of the pandemic, and it is also what’s preventing us from fully escaping the pandemic. We can normalize anything, for better or for worse. “We’re so resilient at adapting to threats,” Taylor said, that we’ve “even habituated to this.”

Read: America was in an early-death crisis long before COVID

Where does that leave us? As the nation claws its way out of the pandemic—and reckons with all of its lasting damage—what do we do with the psychic burden of a death toll that might not decline substantially for a long time? Total inurement is not an option. Neither is maximal empathy, the feeling of each death reverberating through you at an emotional level. The challenge, it seems, is to carve out some sort of middle path. To care enough to motivate ourselves to make things better without caring so much that we end up paralyzed.

Perhaps we will find this path. More likely, we will not. In earlier stages of the pandemic, Americans talked at length about a mythic “new normal.” We were eager to imagine how life might be different—better, even—after a tragedy that focused the world’s attention on disease prevention. Now we’re staring down what that new normal might actually look like. The new normal is accepting 400 COVID deaths a day as The Way Things Are. It’s resigning ourselves so completely to the burden that we forget that it’s a burden at all.

In the time since you started reading this story, someone in the United States has died of COVID. I could tell you a story about this person. I could tell you that he was a retired elementary-school teacher. That he was planning a trip with his wife to San Diego, because he’d never seen the Pacific Ocean. That he was a long-suffering Knicks fan and baked a hell of a peach cobbler, and when his grandchildren visited, he’d get down on his arthritic knees, and they’d play Connect Four, and he’d always let them win. These details, though hypothetical, might sadden you—or sadden you more, at least, than when I told you simply that since you started this story, one person had died of COVID. But I can’t tell you that story 491 times in one day. And even if I could, could you bear to listen?

One thing few people have been talking about since Roe v. Wade was overturned is how abortion restrictions will affect young girls across the United States.

Around the time of their first period, many young people learn the basic mechanics of managing their periods, such as how to put on a pad or tampon and that it happens once a month. Traditionally they might also receive some admonishment to keep their period hidden. Young people may get information about menstruation from a family member, friends or a teacher, or by searching on the internet.

But often it is only later that they learn and truly understand the more complex details about the menstrual cycle. This includes guidance around regular and irregular patterns and when to seek medical care for any shifts in timing, duration or the overall experience, including the severity of menstrual pain or heavy bleeding. These conversations also have clear implications for ovulation and pregnancy prevention.

Now, with the overturning of Roe v. Wade, young people who begin to menstruate will also need to learn early on how to recognize a missed period as soon as possible. In the past, a young person’s delay in mentioning that a period was late or skipped a few months might not have presented any particular urgency. However, going forward, in contexts where a ban on abortions beyond a very short period of weeks exists, even one missed period could have serious implications for a young person’s life.

Conversely, it’s critical that young people know that irregular periods can be normal and that it’s not always cause for alarm.

I have been researching young people’s experiences with menarche — the onset of menstruation — around the world for almost 20 years. In 2018, my team began to explore the experiences of American girls with their periods, including their recommendations for what all young girls need to know as they enter puberty and begin to menstruate.

Based on those suggestions and insights, we published A Girl’s Guide to Puberty & Periods, a body-positive illustrated graphic novel-style book that includes first-period stories, advice and questions written by girls.

Globally, I have learned that girls growing up in Africa, Asia and here in the U.S. often receive inadequate information and support about their periods.

Information about menstruation is inadequate

Menstrual health literacy, or a person’s understanding of the menstrual cycle and its intersection with one’s health and well-being, is essential from the time leading up to the first menstrual period through menopause.

Both the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics have recommended that just as doctors and nurses check someone’s blood pressure or temperature at each visit, they should also ask about periods.

These professional societies suggest that health care providers prepare girls and their families for the onset of menstruation and ensure that they understand the variation in menstrual patterns.

My team’s U.S. study focused on adolescent girls in Los Angeles, New York and Chicago. Our findings, along with research on state-level menstruation education standards across the country, suggest that the U.S. is a long way from delivering menstrual health literacy to the population. Our research indicated that many girls received no guidance before their first period or had been given information that felt dated and hard to relate to. Think educational videos made in the 1990s.

A recent publication from the U.S. Centers for Disease Control and Prevention found that the median age of onset of menstruation decreased from 12.1 years old in 1995 to 11.9 by 2017. This means that nowadays, many girls are in elementary school when they get their first period.

For this reason, it’s clear that young people in fourth or fifth grade need to be receiving health education that addresses menstruation. Girls who do not receive education and support — particularly those who get their first period at a young age — are more likely to experience depression and low self-esteem. Low-income and minority girls are particularly vulnerable.

Yet many American girls still do not learn the basic facts about their menstrual cycles at home or school or from health care providers. As our study found, parents are often uncomfortable discussing periods, perhaps because it feels too linked to sexuality.

Our research also captured American girls’ first-period stories across 25 states and found that many young people are afraid and ashamed and do not know whom to ask for advice when their menstruation starts.

Missed opportunities abound

The internet and social media, which are important sources of news and guidance for many young people, may deliver misinformation or reinforce menstrual stigma. And a 2020 study of members of the American Academy of Pediatrics found that 24% of pediatricians surveyed do not regularly provide guidance before the first period. Furthermore, 33% do not discuss periods with their menstruating patients. Male pediatricians were also less likely to assess a patient’s menstrual cycle and provide information, perhaps because of discomfort with the topic.

Schools also may not be delivering the necessary guidance. In New York state, where I work, there is no requirement for the provision of menstrual health education, and sex education is not required to be taught or to be medically accurate. Only 30 states and Washington, D.C., mandate sex education in schools, but not all of them require medical accuracy.

It’s hard to know if many states are even including menstrual health in the curriculum, as data is limited and public information is not always available. I believe that, given the critical importance of some menstrual health literacy by late elementary school, schools could consider delivering puberty education — including menstrual health — separate from sex education. This is particularly true in states that are hesitant to mandate sex education.

Menstrual health literacy translates to health literacy

One survey of women of childbearing age suggested that only about 50% knew the average number of days of a regular menstrual cycle. Not knowing what is normal or not normal in relation to an average menstrual cycle — ranging from how often you get your period to the extent of bleeding or pain experienced — increases the health risk for an adolescent girl or woman.

Health — including menstrual health — is a basic human right. For those who menstruate, this means a right to menstrual health literacy, along with being able to seek care for the myriad menstrual and reproductive health disorders. These range from dysmenorrhea, or severe pain, to endometriosis, a condition in which endometrial tissue grows outside the uterus and can cause menstrual irregularities and significant discomfort. Both require diagnosis and treatment.

Menstruation is an issue of public health and one long overdue for increased attention and resources, starting with — but not limited to — menstrual health literacy. The fall of Roe adds urgency to this public health priority.

This story was originally published in the online magazine The Conversation. Marni Sommer is an associate professor of sociomedical sciences at Columbia University and receives funding from the Bill & Melinda Gates Foundation to develop guidance on indicators and related measures for improving national-level monitoring of progress on menstrual health and hygiene globally.

Late last month, Northwestern University and Johns Hopkins University announced they had received about $37 million from the National Heart, Lung and Blood Institute to study a new approach to stroke prevention in patients with atrial fibrillation, an irregular heart rhythm.

The funds will support the Rhythm Evaluation for AntiCoagulaTion (REACT-AF) trial, a seven-year study that will provide some patients with an Apple Watch to monitor for AFib. They’ll be able to take blood thinners in response to a prolonged episode, while patients in the control group will receive the current standard of care, continuously taking the drug to reduce stroke risk.

Dr. Rod Passman, director of the Center for Arrhythmia Research at Northwestern’s Feinberg School of Medicine and principal investigator of the study, sat down with MobiHealthNews to explain the upcoming research and how consumer devices could improve patient care. 

MobiHealthNews: Can you explain the study design and what you’re hoping to learn from this research?

Dr. Rod Passman: We’re looking at the major problem of the most common abnormal heart rhythm, which is atrial fibrillation. We know that people with atrial fibrillation, particularly those with other cardiovascular risk factors like high blood pressure, are at a substantially increased risk of stroke. 

The current approach is to take a blood thinner. If you apply the criteria for being on a blood thinner to the U.S. population with atrial fibrillation, maybe 80-plus percent of patients who have atrial fibrillation would be on these anticoagulants for the rest of their lives. We sort of have a one-size-fits-all approach. We treat people who are continuously in the abnormal rhythm with the same daily blood thinner as we do the individual who has one episode a year, or who has no further episodes because they’ve had an ablation done, or they’re on a drug, or they’ve lost weight, or they’ve stopped drinking alcohol. 

So, I think this one-size-fits-all approach doesn’t make a lot of sense in an era where we can monitor people to see whether they’re truly having episodes. So, the goal here was to evaluate a paradigm shift, right? Instead of looking at individuals at risk, can we look at periods of risk? Can we treat at-risk patients with a targeted approach to being on a blood thinner, where they take it only for a few weeks and only in response to a multi-hour episode of atrial fibrillation?

MHN: If this method of continuous monitoring is validated by the study, how do you think this would improve upon the current standard of care?

Passman: From our estimates, this approach may apply to maybe half the population with atrial fibrillation. And what this means is that we can reduce the exposure to these medications, which are very effective at reducing stroke risk but are also contributors to both major and minor bleeding. 

So, if we can protect people against stroke and minimize the exposure to the risks of the blood thinners, then we can improve the lives of our patients. And this has other implications, right? Not only would this be protective against stroke and reduce bleeding risk, but this would also, we believe, improve their quality of life because many patients curtail their activities. They may not go mountain biking or skiing because of the risks of trauma. 

We also believe that this would be a cost savings to the healthcare system because these blood thinners can be costly and the cost of bleeding on these blood thinners is a major expense. So, if you can buy a device at your local electronics store for a fraction of the cost, this could not only improve quality of life, but do so at a lower cost.

MHN: Why did you choose to use a consumer device, the Apple Watch, for the study, as opposed to a clinical monitoring system?

Passman: We did two pilot studies, one using implantable cardiac monitors, and one using pacemakers and defibrillators. Those devices are very accurate in detecting atrial fibrillation. The problem is, the cost of using an implantable monitor for this indication is not scalable to the tens of millions of people around the world who may benefit from this approach. 

More importantly, these devices are not patient-facing, they’re physician-facing. As your doctor, I may get the data from your implantable monitor, and I may get it a day later. A consumer electronics device is much more scalable, and the patient gets alerted when they have an episode. 

Those issues allow us to ultimately make this point-of-care. This will be like a diabetic who checks their blood sugar, knows how much insulin to take in response to a particular level and can do that task without ever having to call their doctor. If this is a positive study, we hope that stroke prevention and atrial fibrillation follow a similar path.

MHN: You’ve done other research and written about wearables and digital health technology for this type of monitoring. What do you think are some of the obstacles to using these kinds of tools more broadly within the healthcare system?

Passman: From a patient perspective, there are still costs involved that may create barriers for some individuals. I do think that the healthcare system is not necessarily well-equipped to deal with the deluge of data that may be coming from these wearable devices that we may be asked to assess. 

And I think in many cases, the technology is out there, but the pivotal trials showing that the use of this technology improves lives is still lacking. So, we believe that this study is a major step in critically evaluating a consumer-grade electronics device to show how we can leverage this technology that you can buy at Best Buy to save your life, reduce cost, and improve both how long you live and how well you live.

MHN: Some digital health technologies have clinical evidence behind them, but a lot of them do not. From a clinician’s perspective, does that make it difficult to recommend these tools to patients?

Passman: In the case of Apple, they and many companies have gone through rigorous evaluation of the technology to assess the accuracy. So, in many cases, these devices do perform in the way that we want them to. The Apple Heart Study and the Fitbit study are massive trials that I think did a really good job of evaluating can these devices do what they’re supposed to be doing. 

But how we integrate this into care, and how we prove that giving patients these powerful tools impacts their journey through the healthcare system, those kinds of studies are lacking. I think that, in many cases, this technology has appeared faster than our ability to figure out how to integrate this into care. 

The example I give is, in the traditional healthcare system, a doctor orders tests and then we get the results and we discuss with the patient. Digital health allows patients to give us the results of a test that we didn’t order. And we need to prove, as I suspect that we will, that that allows us to diagnose disease earlier to keep people at home and to manage their disease remotely. 

But that will challenge the traditional healthcare system, where people come to an office appointment when they’re feeling well or an emergency department when they’re feeling poorly. We need to create the systems that allow us to take this information and manage patients remotely, and make sure that we are allowing this technology to keep patients away from the healthcare system.