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Should Biden take a cognitive test? Here's what it would — and wouldn't — tell us

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Should Biden take a cognitive test? Here's what it would — and wouldn't — tell us

It seemed like a sensible suggestion for assessing the capabilities of an 81-year-old man seeking voters’ approval to remain in the White House until January 2029.

To reassure the American people, ABC’s George Stephanopoulos asked President Biden, would he be willing to take a cognitive test and share the results with the American people?

Biden demurred. In carrying out his duties as leader of the free world, he said, “I have a cognitive test every single day.”

Though the president dismissed the suggestion, medical experts said the idea of having Biden — along with his 78-year-old challenger, former President Trump — take some kind of cognitive exam had merit.

“Let’s give it to both of them,” said Dr. Louise Aronson, a geriatrician at UC San Francisco.

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Kevin Duff, a neuropsychologist at the Oregon Health & Science University’s Alzheimer’s Disease Research Center, likened the proposal to the long-standing practice of asking presidential contenders to release their tax returns.

There would be several types of tests to choose from. A simple screening exam could involve just a handful of questions and be completed in minutes. An in-depth evaluation could take a full day.

When former White House physician Dr. Ronny Jackson evaluated Trump in 2018, he opted for the popular Montreal Cognitive Assessment, or MoCA Test. Over the course of about 15 minutes, patients are asked to recall a list of five words, draw a clock with its hands set to a particular time, do subtraction with double-digit numbers, and come up with the names of animals in a drawing, among other tasks. At the time, Trump scored a perfect 30 out of 30.

Whether long or short, a good test measures multiple “domains of cognition,” Aronson said. There’s short-term memory and long-term memory. There’s the ability to communicate through both spoken and written language. There’s attention, comprehension, judgment, reasoning, problem-solving, decision-making and more.

“If a person completely aces a test, that tells you something,” said Dr. Laura Mosqueda, a professor of family medicine and geriatrics at USC’s Keck School of Medicine. “And if they bomb a test, it tells you something.”

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A score that’s somewhere in between can be trickier, experts say.

An abnormal result on a cognitive test doesn’t necessarily mean that a patient has a true cognitive problem. In about 10% of cases, it can be chalked up to a side effect of medications, an infection, a thyroid problem, a vitamin deficiency, a mood disorder such as anxiety or depression, or something else that’s reversible.

“The thing we see constantly as geriatricians are medication reactions,” Aronson said. “I can’t tell you how often we withdraw medications and then the person goes back to normal.”

Sometimes it’s even simpler than that.

“I’ve seen people diagnosed with dementia who’ve actually had a hearing problem but didn’t want to admit it,” Mosqueda said. “They couldn’t hear the questions and so they were giving weird answers.”

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Some cognitive changes are a normal part of the aging process. Thinking speed is a prime example.

“As we age, we will do things more slowly,” Aronson said. That isn’t necessarily a sign of cognitive impairment, she said, recalling a 101-year-old patient who missed only one point on a test but needed extra time to complete it.

If a patient’s cognitive problems persist, or if caregivers want to get a better handle on the subtleties of their condition, a more in-depth assessment may be in order.

The tasks are more challenging, Duff said. For instance, instead of seeing whether a patient can remember five words after five minutes, a neuropsychologist might give a patient 15 words and see how many they recall half an hour later.

On the MoCA Test, a score of 25 or lower is considered abnormal regardless of any other factors. With a more sensitive test, the results are compared with the performance of other people of the same age, educational background, career history and other characteristics, Duff said.

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A person with Biden’s background would probably perform well on a MoCA test even if his cognition has declined, experts agreed.

“In certain patients who are particularly verbal, they won’t remember the word they want but they can work their way around it,” Aronson said. In such cases, a normal score on the test “would not necessarily rule out cognitive impairment.”

Duff said it would be like having an IndyCar driver who wants to compete in the Indianapolis 500 take the same behind-the-wheel test that the DMV uses for 16-year-olds.

“My concern is that a relatively easy test still doesn’t mean you’re up to the challenge of leading one of the most powerful countries in the world,” he said.

This isn’t an issue limited to presidential candidates. It may be appropriate to ask airline pilots, bus drivers, surgeons and other people with jobs that entail a high degree of responsibility to take cognitive tests as they get older, experts said.

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“I think you can argue this is a job where your brain should be working pretty well,” Aronson said.

There is no expert consensus on whether to screen all older adults for cognitive impairment. The U.S. Preventive Services Task Force weighed the issue in 2020 and determined there wasn’t enough evidence to make a broad recommendation one way or the other.

One of the reasons for the hesitation is that screening tests aren’t good enough, said Dr. Colleen Christmas, a geriatrician at the Johns Hopkins School of Medicine.

“You’re going to catch a lot of people who don’t have issues, and you’re going to miss a lot of people who do,” she said.

There’s also the fact that the aging process varies greatly from person to person.

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“It’s incredibly heterogeneous,” Christmas said. “There’s no way to say 80 equals old whereas 75 equals young.”

Besides, no test, no matter how sensitive, can provide a full picture of a patient’s cognitive function. Doctors also need the results of blood tests, brain scans, and information from family members, among other things. If an MRI revealed evidence of several small strokes in parts of the brain that align with the patient’s cognitive deficits, for example, it would suggest a diagnosis of vascular dementia.

“It’s like putting a puzzle together,” Mosqueda said.

Biden may be in a unique position, but his bristling reaction to the idea of taking a cognitive test was pretty typical, Christmas said.

“I think people are so afraid of the diagnosis of dementia that it’s upsetting to have your doctor or a family member suggest that you need cognitive testing,” she said. “It’s a really scary prospect.”

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This Scientist Has a Risky Plan to Cool Earth. There’s Growing Interest.

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This Scientist Has a Risky Plan to Cool Earth. There’s Growing Interest.

David Keith was a graduate student in 1991 when a volcano erupted in the Philippines, sending a cloud of ash toward the edge of space.

Seventeen million tons of sulfur dioxide released from Mount Pinatubo spread across the stratosphere, reflecting some of the sun’s energy away from Earth. The result was a drop in average temperatures in the Northern Hemisphere by roughly one degree Fahrenheit in the year that followed.

Today, Dr. Keith cites that event as validation of an idea that has become his life’s work: He believes that by intentionally releasing sulfur dioxide into the stratosphere, it would be possible to lower temperatures worldwide, blunting global warming.

Such radical interventions are increasingly being taken seriously as the effects of climate change grow more intense. Global temperatures have hit record highs for 13 months in a row, unleashing violent weather, deadly heat waves and raising sea levels. Scientists expect the heat to keep climbing for decades. The main driver of the warming, the burning of fossil fuels, continues more or less unabated.

Against this backdrop, there is growing interest in efforts to intentionally alter the Earth’s climate, a field known as geoengineering.

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Already, major corporations are operating enormous facilities to vacuum up the carbon dioxide that’s heating up the atmosphere and bury it underground. Some scientists are performing experiments designed to brighten clouds, another way to bounce some solar radiation back to space. Others are working on efforts to make oceans and plants absorb more carbon dioxide.

But of all these ideas, it is stratospheric solar geoengineering that elicits the greatest hope and the greatest fear.

Proponents see it as a relatively cheap and fast way to reduce temperatures well before the world has stopped burning fossil fuels. Harvard University has a solar geoengineering program that has received grants from the Microsoft co-founder Bill Gates, the Alfred P. Sloan Foundation and the William and Flora Hewlett Foundation. It’s being studied by the Environmental Defense Fund along with the World Climate Research Program, an international scientific effort. The European Union last year called for a thorough analysis of the risks of geoengineering and said countries should discuss how to regulate an eventual deployment of the technology.

But many scientists and environmentalists fear that it could result in unpredictable calamities.

Because it would be used in the stratosphere and not limited to a particular area, solar geoengineering could affect the whole world, possibly scrambling natural systems, like creating rain in one arid region while drying out the monsoon season elsewhere. Opponents worry it would distract from the urgent work of transitioning away from fossil fuels. They object to intentionally releasing sulfur dioxide, a pollutant that would eventually move from the stratosphere to ground level, where it can irritate the skin, eyes, nose and throat and can cause respiratory problems. And they fear that once begun, a solar geoengineering program would be difficult to stop.

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“The whole notion of spraying sulfur compounds to reflect sunlight is arrogant and simplistic,” the Canadian environmentalist David Suzuki said. “There are unintended consequences of powerful technologies like these, and we have no idea what they will be.”

Raymond Pierrehumbert, an atmospheric physicist at the University of Oxford, said he considered solar geoengineering a grave threat to human civilization.

“It’s not only a bad idea in terms of something that would never be safe to deploy,” he said. “But even doing research on it is not just a waste of money, but actively dangerous.”

Shuchi Talati, the founder of a nonprofit organization called the Alliance for Just Deliberation on Solar Geoengineering, called the technology “a double-edged sword.”

“It could be a way to limit human suffering,” she said. “At the same time, I think it can also exacerbate suffering if used in a bad way.”

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In a series of interviews, Dr. Keith, a professor in the University of Chicago’s department of geophysical sciences, countered that the risks posed by solar geoengineering are well understood, not as severe as portrayed by critics and dwarfed by the potential benefits.

If the technique slowed the warming of the planet by even just one degree Celsius, or 1.8 degrees Fahrenheit, over the next century, Dr. Keith said, it could help prevent millions of heat-related deaths each decade.

A planet transformed by solar geoengineering would not be noticeably dimmer during the daytime, according to his calculations. But it could produce a different kind of twilight, one with an orange hue.

He agrees that nations should stop burning coal, oil and gas, period. But Dr. Keith believes in going further.

Lean and athletic at 60, with glacier-blue eyes, Dr. Keith has spent his life outside the lab rock climbing, sea kayaking and skiing in the Arctic. He is deeply troubled by the myriad ways climate change is disrupting the natural world.

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By lowering global temperatures, solar geoengineering could help restore the planet to its preindustrial state, recreating conditions that existed before enormous amounts of carbon dioxide were pumped into the atmosphere and began to cook the Earth, he said.

If there were a global referendum tomorrow on whether to begin solar geoengineering, he said he would vote in favor.

“There certainly are risks, and there certainly are uncertainties,” he said. “But there’s really a lot of evidence that the risks are quantitatively small compared to the benefits, and the uncertainties just aren’t that big.”

The only thing more dangerous than his solution, he suggested, may be not using it at all.

To understand just how contentious Dr. Keith’s work can be, consider what happened when he tried to perform an initial test in preparation for a solar geoengineering experiment known as Scopex.

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Then a professor at Harvard, Dr. Keith wanted to release a few pounds of mineral dust at an altitude of roughly 20 kilometers and track how the dust behaved as it floated across the sky.

A test was planned in 2018, possibly over Arizona, but Dr. Keith couldn’t find a partner to launch a high-altitude balloon. When details of that plan became public, a group of Indigenous people objected and issued a manifesto against geoengineering.

Three years later, Harvard hired the Swedish space corporation to launch a balloon that would carry the equipment for the test. But before it took place, local groups once again rose up in protest.

The Saami Council, an organization representing Indigenous peoples, said it viewed solar geoengineering “to be the direct opposite of the respect we as Indigenous Peoples are taught to treat nature with.”

Greta Thunberg, the Swedish climate activist, joined the chorus. “Nature is doing everything it can,” she said. “It’s screaming at us to back off, to stop — and we are doing the exact opposite.”

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Within months, the experiment was called off.

“A lesson I’ve learned from this is that if we do this again, we won’t be open in the same way,” Dr. Keith said.

Behind the scenes, the Harvard team and its advisory committee became mired in finger pointing over who was to blame for the collapse of the project. Dr. Talati, a member of the Scopex advisory board, said it was “the moment of peak chaos.”

It didn’t help that there were personality conflicts. Several committee members said Dr. Keith could be ornery and headstrong, correcting colleagues in casual conversation and belittling those with whom he disagreed.

“I can be abrasive and difficult,” Dr. Keith acknowledged. “I am sometimes inappropriately forceful in making my point. I’m intense.”

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Opponents of solar geoengineering cite several main risks.

They say it could create a “moral hazard,” mistakenly giving people the impression that it is not necessary to rapidly reduce fossil fuel emissions.

“The fundamental problem is that we think we’re so smart that we don’t have to pay attention to nature’s boundaries,” Dr. Suzuki said. “But we haven’t dealt with the root cause of the problem, which is us.”

The second main concern has to do with unintended consequences.

“This is a really dangerous path to go down,” said Beatrice Rindevall, the chairwoman of the Swedish Society for Nature Conservation, which opposed the experiment. “It could shock the climate system, could alter hydrological cycles and could exacerbate extreme weather and climate instability.”

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And once solar geoengineering began to cool the planet, stopping the effort abruptly could result in a sudden rise in temperatures, a phenomenon known as “termination shock.” The planet could experience “potentially massive temperature rise in an unprepared world over a matter of five to 10 years, hitting the Earth’s climate with something that it probably hasn’t seen since the dinosaur-killing impactor,” Dr. Pierrehumbert said.

On top of all this, there are fears about rogue actors using solar geoengineering and concerns that the technology could be weaponized. Not to mention the fact that sulfur dioxide can harm human health.

Dr. Keith is adamant that those fears are overblown. And while there would be some additional air pollution, he claims the risk is negligible compared to the benefits.

“There’s plenty of uncertainty about climate responses,” he said. “But it’s pretty hard to imagine if you do a limited amount of hemispherically balanced solar geo that you don’t reduce temperatures everywhere.”

Last year, after the failure to launch the Scopex experiment in Sweden, Dr. Keith made a move that stunned his colleagues. He announced he was closing the door on 13 years at Harvard and taking his ambitions to the University of Chicago, where he would build a new program around climate interventions, including solar geoengineering.

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“I don’t know whether that stuff will ever get used,” said Mr. Gates, a major investor in climate technology. “I do believe that doing the research and understanding it makes sense.

Dr. Keith’s career can be traced to his father, Tony Keith, a wildlife biologist who attended the first global gathering to address threats to nature, the 1972 United Nations Conference on the Human Environment in Stockholm.

Dyslexia prevented him from learning to read until late in 4th grade, but when he was finally able to make sense of written words, he became a voracious reader. He also loved camping and, at 17, hiked a stretch of the Appalachian Trail solo.

After graduating from the University of Toronto, he spent months rock climbing. Looking for a way to get paid to live in the wilderness, he got a job studying walruses in the Canadian Arctic.

Dr. Keith eventually enrolled in a doctoral program at the Massachusetts Institute of Technology to study experimental physics.

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In 1992, he published an academic paper, “A Serious Look at Geoengineering,” that raised the questions that would shape his career: Who should authorize the use of these technologies? Who is liable if something goes wrong?

His academic career took him from Carnegie Mellon University to the University of Calgary, where he began investigating ways to capture and store carbon dioxide. The next stop was Harvard, where he got serious about solar geoengineering.

In 2006, a mutual acquaintance introduced him to Mr. Gates, who wanted to learn more about technologies that might help fight global warming. The two men discussed climate and technology in a series of meetings over the next 10 years.

Then in 2009, Dr. Keith founded Carbon Engineering, a company that developed a process for pulling carbon dioxide from the atmosphere. Investors included Mr. Gates, Chevron and N. Murray Edwards, who made billions pumping oil from the Canadian oil sands.

Last year Carbon Engineering was acquired by Occidental Petroleum, a major oil and gas producer based in Texas, for $1.1 billion. Dr. Keith owned about 4 percent of the company at the time of the sale, delivering him a personal windfall of about $72 million.

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Occidental is now building a series of enormous carbon capture plants. It plans to sell carbon credits to big companies like Amazon and AT&T that want to offset their emissions. Critics say that will only delay the phaseout of fossil fuels while allowing an oil company to profit.

“Of course I’m uncomfortable about it being sold to an oil company, no question,” Dr. Keith said, adding that he plans to give away most of his profits from the sale of Carbon Engineering, perhaps to a conservation group.

On a summer Monday in Cambridge, Mass., the Harvard campus was mostly quiet. But inside one classroom, a standing-room-only crowd listened as experts discussed the merits and risks of solar geoengineering.

Among those featured was Frank Keutsch, Dr. Keith’s former collaborator on the Scopex experiment.

Dr. Keutsch is less sanguine than Dr. Keith when considering its potential risks.

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“I compare stratospheric solar geoengineering with opiates,” he said on the panel. “They only treat the symptom and not the actual cause. You can get addicted to it if you don’t actually address the cause. In addition, like any painkiller, you’re going to have side effects. And then there are withdrawal symptoms, and that’s termination shock.”

Dr. Keutsch is now investigating whether calcium carbonate or diamond dust might be a better material than sulfur, and pondering issues around how a deployment might one day be governed. There are no current plans for a field experiment.

Academic energy in the field has followed Dr. Keith to the University of Chicago, which is allowing him to hire 10 full-time faculty members and build a new program focused on various types of geoengineering. The total cost could reach as much as $100 million.

The move has puzzled some. Dr. Pierrehumbert, who recently departed the University of Chicago for Oxford, said he was “flabbergasted” and contended that those research dollars could be better spent investigating ways to reduce the use of fossil fuels.

To celebrate his 60th birthday in October, Dr. Keith went hiking in the Canadian Rockies and came across a glacier that had shrunk dramatically in recent years. It was a visual reminder that global warming is upending the natural world, and it confirmed his central, controversial belief: Humans have already altered the planet, heating the climate with greenhouse gases. To repair the climate and return it to a more pristine state, we may need to take even more drastic action and engineer the stratosphere.

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“I’m more motivated even now to push on solar geo because the rationalist case for it is looking stronger,” Dr. Keith said. “While there are still lots of strong individual voices of opposition, there are a lot of people in serious policy positions that are taking it seriously, and that’s really exciting.”

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Secret shoppers find long waits and scarce openings in L.A. for psychiatric care with Medicaid

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Secret shoppers find long waits and scarce openings in L.A. for psychiatric care with Medicaid

Only 15% of phone calls seeking psychiatric appointments for Medicaid patients resulted in an appointment in Los Angeles, the lowest percentage out of four cities in a “secret shopper” audit, researchers found.

Los Angeles also had the longest wait times, with the median wait stretching 64 days — more than twice as long as in New York City or Chicago and nearly six times the median wait in Phoenix, secret shoppers found.

The findings, published Wednesday in a research letter in JAMA, underscore long-standing concerns about Medicaid recipients being unable to access psychiatric care when they need it.

Earlier research has found that psychiatrists are less likely than other physicians to accept Medicaid, a public insurance program serving people with low incomes. The headaches for would-be patients are exacerbated by what critics refer to as “ghost networks,” in which health insurers list medical providers in their directories who aren’t accepting new patients, don’t take their insurance or are otherwise inaccessible to patients.

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As a medical student at Weill Cornell Medical College trying to ensure follow-up for patients leaving the hospital, “one area in which I consistently was coming up against a wall was making outpatient mental health appointments,” said Dr. Diksha Brahmbhatt, who helped spearhead the audit and is now a resident physician at Brigham and Women’s Hospital in Boston.

For one young man on Medicaid, “it took about an hour and a half to try to get any appointment for him at all” — and it was scheduled about 40 days after his discharge, Brahmbhatt said.

Such experiences left her wondering, “What is the extent of this issue, especially in urban areas where we might expect access to actually be better for patients?”

To see what Medicaid patients might encounter when seeking psychiatric care, researchers from Weill Cornell Medical College randomly chose scores of “psychiatric prescribing clinicians” — psychiatrists, nurse practitioners and physician assistants — who were listed as accepting new patients by the biggest managed care plans for Medicaid patients in each city, then phoned to ask for the soonest available appointment.

They found that less than 18% of the listed clinicians they tried to contact were reachable, accepted Medicaid and could offer an appointment for a new patient on the insurance program. Even among those psychiatric providers able to schedule an appointment, waits could stretch up to six months.

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All in all, only 27.2% of offices they phoned had an appointment available for a Medicaid patient with either the intended provider or another one at the same practice. In L.A., that rate was only 15%, compared with 27.5% in Chicago, 30% in Phoenix and 36.3% in New York City. The typical waits were much longer in L.A. as well.

The JAMA letter did not speculate on why such appointments might be scarcer or waits longer in L.A. Brahmbhatt said that the study wasn’t designed to examine those differences and that the number of offices they called — 320 total — limited their ability to draw conclusions.

Health economist William L. Schpero, one of the researchers who performed the audit, said that “the access challenges we identified are likely the product of multiple factors,” including “inaccuracies in plan directories, clinician reluctance to participate in Medicaid, and an under-supply of psychiatric clinicians in some areas.”

“Which of those factors — among others — is primarily driving the relatively low appointment availability we found in L.A. requires additional research,” Schpero said.

Schpero and Brahmbhatt found that among the psychiatric providers with whom they could not make an appointment, 15.2% had phone numbers listed that were incorrect or out of service, and 35% didn’t answer the phone after two attempts.

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This is a patient population that “already faces a lot of barriers to getting the care that they need” and may already be grappling with mental health symptoms when they seek an appointment, Brahmbhatt said.

If they hit roadblocks, they are “that much more likely to then disengage from the healthcare system.”

In California, lawmakers are weighing a bill that would mandate that health insurers keep accurate listings or face fines. The bill, AB 236, would gradually phase in requirements for increasing accuracy in provider directories, starting with at least 60% next summer and increasing to at least 95% by July 2028. Fines for faulty listings could range up to $10,000 for every 1,000 people insured by a health plan, and those penalties could be adjusted upward with time.

“When Californians can’t find a provider, it leads to delayed or more expensive care,” said Katie Van Deynze, policy and legislative advocate at the consumer advocacy group Health Access California, which sponsored the legislation. “AB 236 puts health plans on a path of improvement, so patients no longer have to call through lists of outdated providers that have moved, retired, or are not accepting new patients.”

The California Department of Managed Health Care estimated in January that implementing the bill could cost up to $12 million annually for additional staffers, but a department spokesman said it was updating its estimate based on the latest version of the bill ahead of a Monday hearing.

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The January estimate was based on “additional workload to promulgate regulations and guidance, develop methodology and review plan documents for compliance” and other needed tasks to carry out requirements under the bill, department spokesperson Kevin Durawa said in an email.

As of June, AB 236 was backed by the National Union of Healthcare Workers and the National Multiple Sclerosis Society, among others, but opposed by industry groups including the California Assn. of Health Plans and the California Medical Assn.

Mary Ellen Grant, vice president of communications for the California Assn. of Health Plans, said its members understand the frustration that arises from inaccurate listings, but “AB 236 does nothing to address the root cause of the issue” and “simply places the full responsibility of provider directory accuracy onto health plans.”

Their accuracy is “largely reliant upon providers and medical groups maintaining their own accurate records and providing that information to health plans in a timely manner,” the group said. “The bill fails to acknowledge this shared responsibility” and is “unfairly punitive against health plans.”

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As human cases of bird flu grow, feds say flu vaccine could help prevent a new pandemic

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As human cases of bird flu grow, feds say flu vaccine could help prevent a new pandemic

Although health officials say the risk of H5N1 bird flu infection is still low for the general population, they announced on Monday a $5-million plan to offer seasonal flu vaccine to livestock workers.

Nine poultry workers in Colorado are reported to have been infected; the symptoms were described as “mild,” with conjunctivitis, or pink eye, as the predominant symptom. The official case total across the U.S. since April now stands at 13.

“These cases highlight that certain groups who focus on depopulating” — like the poultry workers in charge of killing the animals — “are at heightened risk of infection,” said Nirav Shah, principal deputy director at the U.S. Centers for Disease Control and Prevention.

Officials said they are launching this program for seasonal flu vaccine to protect the health of farmworkers, and also to reduce the chance of a human flu mixing with an H5N1 virus, which could ignite a new pandemic threat.

The reassortment and recombining of flu viruses is a concerning scenario.

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The 1918 “Spanish flu,” which killed more than 50 million people worldwide, was likely the recombined product of a human and avian flu. So too was the 2009 H1N1 swine flu, which led to a pandemic estimated to have caused the death of more than 280,000 people across the globe.

“We’ve seen that livestock workers are at risk for H5 infection because of their exposure to animals,” Shah said. “They are also at risk for infection with seasonal flu. … As such, it’s possible that they could be coinfected with both seasonal influenza viruses … and with H5 virus.”

He said that although such dual infections are rare, they could “potentially result in an exchange of genetic material between the two different influenza viruses … that could lead to a new influenza virus that could pose a significant public health concern, a virus that has the transmissibility of seasonal influenza and the severity of H5N1. We want to do everything we can to reduce the risk that the virus may change because of this coinfection and reassortment.”

Shah said health officials are not considering offering a vaccine for H5N1 bird flu because so far it hasn’t been associated with severe illness or with transmission between people.

The seasonal vaccination program will be established in states that have been affected by the H5N1 in both cow and poultry populations.

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California has not had any reported infections in dairy herds; however, several poultry farms and wild birds have been struck by the virus in recent months and years.

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