ReportWire

Tag: entire country

  • It’s Not the Economy. It’s the Pandemic.

    It’s Not the Economy. It’s the Pandemic.

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    America is in a funk, and no one seems to know why. Unemployment rates are lower than they’ve been in half a century and the stock market is sky-high, but poll after poll shows that voters are disgruntled. President Joe Biden’s approval rating has been hovering in the high 30s. Americans’ satisfaction with their personal lives—a measure that usually dips in times of economic uncertainty—is at a near-record low, according to Gallup polling. And nearly half of Americans surveyed in January said they were worse off than three years prior.

    Experts have struggled to find a convincing explanation for this era of bad feelings. Maybe it’s the spate of inflation over the past couple of years, the immigration crisis at the border, or the brutal wars in Ukraine and Gaza. But even the people who claim to make sense of the political world acknowledge that these rational factors can’t fully account for America’s national malaise. We believe that’s because they’re overlooking a crucial factor.

    Four years ago, the country was brought to its knees by a world-historic disaster. COVID-19 hospitalized nearly 7 million Americans and killed more than a million; it’s still killing hundreds each week. It shut down schools and forced people into social isolation. Almost overnight, most of the country was thrown into a state of high anxiety—then, soon enough, grief and mourning. But the country has not come together to sufficiently acknowledge the tragedy it endured. As clinical psychiatrists, we see the effects of such emotional turmoil every day, and we know that when it’s not properly processed, it can result in a general sense of unhappiness and anger—exactly the negative emotional state that might lead a nation to misperceive its fortunes.

    The pressure to simply move on from the horrors of 2020 is strong. Who wouldn’t love to awaken from that nightmare and pretend it never happened? Besides, humans have a knack for sanitizing our most painful memories. In a 2009 study, participants did a remarkably poor job of remembering how they felt in the days after the 9/11 attacks, likely because those memories were filtered through their current emotional state. Likewise, a study published in Nature last year found that people’s recall of the severity of the 2020 COVID threat was biased by their attitudes toward vaccines months or years later.

    [From the May 2021 issue: You won’t remember the pandemic the way you think you will]

    When faced with an overwhelming and painful reality like COVID, forgetting can be useful—even, to a degree, healthy. It allows people to temporarily put aside their fear and distress, and focus on the pleasures and demands of everyday life, which restores a sense of control. That way, their losses do not define them, but instead become manageable.

    But consigning painful memories to the River Lethe also has clear drawbacks, especially as the months and years go by. Ignoring such experiences robs one of the opportunity to learn from them. In addition, negating painful memories and trying to proceed as if everything is normal contorts one’s emotional life and results in untoward effects. Researchers and clinicians working with combat veterans have shown how avoiding thinking or talking about an overwhelming and painful event can lead to free-floating sadness and anger, all of which can become attached to present circumstances. For example, if you met your old friend, a war veteran, at a café and accidentally knocked his coffee over, then he turned red and screamed at you, you’d understand that the mishap alone couldn’t be the reason for his outburst. No one could be that upset about spilled coffee—the real root of such rage must lie elsewhere. In this case, it might be untreated PTSD, which is characterized by a strong startle response and heightened emotional reactivity.

    We are not suggesting that the entire country has PTSD from COVID. In fact, the majority of people who are exposed to trauma do not go on to exhibit the symptoms of PTSD. But that doesn’t mean they aren’t deeply affected. In our lifetime, COVID posed an unprecedented threat in both its overwhelming scope and severity; it left most Americans unable to protect themselves and, at times, at a loss to comprehend what was happening. That meets the clinical definition of trauma: an overwhelming experience in which you are threatened with serious physical or psychological harm.

    [Read: Why are people nostalgic for early-pandemic life?]

    Traumatic memories are notable for how they alter the ways people recall the past and consider the future. A recent brain-imaging study showed that when people with a history of trauma were prompted to return to those horrific events, a part of the brain was activated that is normally employed when one thinks about oneself in the present. In other words, the study suggests that the traumatic memory, when retrieved, came forth as if it were being relived during the study. Traumatic memory doesn’t feel like a historical event, but returns in an eternal present, disconnected from its origin, leaving its bearer searching for an explanation. And right on cue, everyday life offers plenty of unpleasant things to blame for those feelings—errant friends, the price of groceries, or the leadership of the country.

    To come to terms with a traumatic experience, as clinicians know, you need to do more than ignore or simply recall it. Rather, you must rework the disconnected memory into a context, and thereby move it firmly into the past. It helps to have a narrative that makes sense of when, how, and why something transpired. For example, if you were mugged on a dark street and became fearful of the night, your therapist might suggest that you connect your general dread with the specifics of your assault. Then your terror would make sense and be restricted to that limited situation. Afterward, the more you ventured out in the dark, perhaps avoiding the dangerous block where you were jumped, the more you would form new, safe memories that would then serve to mitigate your anxiety.

    Many people don’t regularly recall the details of the early pandemic—how walking down a crowded street inspired terror, how sirens wailed like clockwork in cities, or how one had to worry about inadvertently killing grandparents when visiting them. But the feelings that that experience ignited are still very much alive. This can make it difficult to rationally assess the state of our lives and our country.

    One remedy is for leaders to encourage remembrance while providing accurate and trustworthy information about both the past and the present. In the early days of the pandemic, President Donald Trump mishandled the crisis and peddled misinformation about COVID. But with 2020 a traumatic blur, Trump seems to have become the beneficiary of our collective amnesia, and Biden the repository for lingering emotional discontent. Some of that misattribution could be addressed by returning to the shattering events of the past four years and remembering what Americans went through. This process of recall is emotionally cathartic, and if it’s done right, it can even help to replace distorted memories with more accurate ones.

    President Biden invited the nation to grieve together in 2021, when American death counts reached 500,000, and again in 2022, when they surpassed 1 million. In his 2022 State of the Union address, he rightly acknowledged that “we meet tonight in an America that has lived through two of the hardest years this nation has ever faced,” before urging Americans to “move forward safely.” But in the past two years, he, like almost everyone else, has largely tried to proceed as if everyone is back to normal. Meanwhile, American minds and hearts simply aren’t ready—whether we realize it or not.

    [Read: The Biden administration killed America’s collective pandemic approach]

    Perhaps Biden and his advisers fear that reminding voters of such a dark time would create more trouble for his presidency. And yet, our work leads us to believe that the effect would be exactly the opposite. Rituals of mourning and remembrance help people come together and share in their grief so that they can return more clear-eyed to face daily life. By prompting Americans to remember what we endured together, paradoxically, Biden could help free all of us to more fully experience the present.

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    George Makari

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  • The FDA’s New ‘Don’t Say Gay’ Policy for Blood Donation

    The FDA’s New ‘Don’t Say Gay’ Policy for Blood Donation

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    For decades now, gay men have been barred from giving blood. In 2015, what had been a lifetime ban was loosened, such that gay men could be donors if they’d abstained from sex for at least a year. This was later shortened to three months. Last week, the FDA put out a new and more inclusive plan: Sexually active gay and bisexual people would be permitted to donate so long as they have not recently engaged in anal sex with new or multiple partners. Assistant Secretary for Health Rachel Levine, the first Senate-confirmed transgender official in the U.S., issued a statement commending the proposal for “advancing equity.” It “treats everyone the same,” she said, “regardless of gender and sexual orientation.”

    As a member of the small but honorable league of gay pathologists, I’m affected by these proposed policy changes more than most Americans. I’m subject to restrictions on giving blood, and I’ve also been responsible for monitoring the complications that can arise from transfusions of infected blood. I am quite concerned about HIV, given that men who have sex with men are at much greater risk of contracting the virus than members of other groups. But it’s not the blood-borne illness that I, as a doctor, fear most. Common bacteria lead to far more transfusion-transmitted infections in the U.S. than any virus does, and most of those produce severe or fatal illness. The risk from viruses is extraordinarily low—there hasn’t been a single reported case of transfusion-associated HIV in the U.S. since 2008—because laboratories now use highly accurate tests to screen all donors and ensure the safety of our blood supply. This testing is so accurate that preventing anyone from donating based on their sexual behavior is no longer logical. Meanwhile, new dictates about anal sex, like older ones explicitly targeting men who have sex with men, still discriminate against the queer community—the FDA is simply struggling to find the most socially acceptable way to pursue a policy that it should have abandoned long ago.

    Strict precautions made more sense 30 years ago, when screening didn’t work nearly as well as it does today. Patients with hemophilia, many of whom rely on blood products to live, were prominent, early victims of our inability to keep HIV out of the blood supply. One patient who’d acquired the virus through a transfusion lamented to The New York Times in 1993 that he had already watched an uncle and a cousin die of AIDS. Those days of “shock and denial,” as the Times described it, are thankfully behind us. But for older patients, memories of the crisis in the ’80s and early ’90s linger, and cause significant anxiety. Even people unaware of this historical context may consider the receipt of someone else’s blood disturbing, threatening, or sinful.

    As a doctor, I’ve found that patients tend to be more hesitant about getting a blood transfusion than they are about taking a pill. I’ve had them ask for a detailed medical history of the donor, or say they’re willing to take blood only from a close relative. (Typically, neither of these requests can be fulfilled for reasons of privacy and practicality.) Yet the same patients may accept—without question—drugs that carry a risk of serious complication that is thousands of times higher than the risk of receiving infected blood. Even when it comes to blood-borne infections, patients seem to worry less about the greatest danger—bacterial contamination—than they do about the transfer of viruses such as HIV and hepatitis C. I can’t fault anyone for being sick and scared, but the risk of contracting HIV from a blood transfusion is not just low—it’s essentially nonexistent.

    Donors’ feelings matter, too, and the FDA’s policies toward gay and bisexual men who wish to give blood have been unfair for many years. While officials speak in the supposedly objective language of risk and safety, their selective deployment of concern suggests a deeper homophobia. As one scholar put it in The American Journal of Bioethics more than a decade ago, “Discrimination resides not in the risk itself but in the FDA response to the risk.” Many demographic groups are at elevated risk of contracting HIV, yet the agency isn’t continually refining its exclusion criteria for young people or urban dwellers or Black and Hispanic people. Federal policy did prohibit Haitians from donating blood from 1983 to 1991, but activists successfully lobbied for the reversal of this ban with the powerful slogan “The H in HIV stands for human, not Haitian.” Nearly everyone today would find the idea of rejecting blood from one racial group to be morally repugnant. Under its new proposal, which purports to target anal sex instead of homosexuality itself, the FDA effectively persists in rejecting blood from sexual minorities.

    The planned update would certainly be an improvement. It comes out of years of advocacy by LGBTQ-rights organizations, and its details are apparently supported by newly conducted government research. Peter Marks, the director of the Center for Biologics Evaluation and Research at the FDA, cited an unpublished study showing that “a significant fraction” of men who have sex with men would now be able to donate. But the plan is still likely to exclude a large portion of them—even those who wear condoms or regularly test for sexually transmitted infections. An FDA spokesperson told me via email that “additional data are needed to determine what proportion of [men who have sex with men] would be able to donate under the proposed change.”

    Research done in France, Canada, and the U.K., where similar policies have since been adopted over the past two years, demonstrates the risk. A French blood-donation study, for instance, estimated that 70 percent of men who have sex with men had more than one recent partner; and when Canadian researchers surveyed queer communities in Montreal, Toronto, and Vancouver, they found that up to 63 percent would not be eligible to donate because they’d recently had anal sex with new or multiple partners. Just 1 percent of previously eligible donors would have been rejected by similar criteria. The U.K. assumed in its calculations that 35 to 50 percent of men who have sex with men would be ineligible under a policy much like the FDA’s, while only 1.4 percent of previous donors would be newly deferred. If the new rule’s net effect is that gay and bisexual men are turned away from blood centers at many times the rate of heterosexual individuals, what else can you call it but discrimination? The U.S. guidance is supposed to ban a lifestyle choice rather than an identity, but the implication is that too many queer men have chosen wrong. The FDA spokesperson told me, “Anal sex with more than one sexual partner has a significantly greater risk of HIV infection when compared to other sexual exposures, including oral sex or penile-vaginal sex.”

    If the FDA wants to pry into my sex life, it should have a good reason for doing so. The increasing granularity and intimacy of these policies—specifying numbers of partners, kinds of sex—gives the impression that the stakes are very high: If we don’t keep out the most dangerous donors, the blood supply could be ruined. But donor-screening questions are a crude tool for picking needles from a haystack. The only HIV infections that are likely to get missed by modern testing are those contracted within the previous week or two. This suggests that, at most, a couple thousand individuals—gay and straight—across the entire country are at risk of slipping past our testing defenses at any given time. Of course, very few of them will happen to donate blood right then. No voluntary questionnaire can ever totally exclude this possibility, but patients and doctors already accept other life-threatening transfusion risks that occur at much greater rates than HIV transmission ever could. When I would be on call for monitoring transfusion reactions at a single hospital, the phone would ring a few times every night. Yet blood has been given out tens of millions of times across the country since the last known instance of a transfusion resulting in a case of HIV.

    Early data suggest that the overall risk-benefit calculus of receiving blood isn’t likely to change. When eligibility criteria were first relaxed in the U.S. a few years ago, the already tiny rate of HIV-positive donations remained minuscule. Real-world results from other countries that have recently adopted sexual-orientation-neutral policies will become available in the coming years. But modeling studies already support removing any screening question that explicitly or implicitly targets queer men. A 2022 Canadian analysis suggested that removing all questions about men who have sex with men would not result in a significantly higher risk to patients. “Extra behavioral risk questions may not be necessary,” the researchers concluded. If there must be a restriction in place, then one narrowly tailored to the slim risk window of seven to 10 days before donation should be good enough. (The FDA says that its proposed policy “would be expected to reduce the likelihood of donations by individuals with new or recent HIV infection who may be in the window period.”)

    As a gay man, I realize that, brief periods of crisis during the coronavirus pandemic aside, no one needs my blood. Only 6.8 percent of men in the U.S. identify as gay or bisexual, so our potential benefit to the overall supply is inherently modest. If we went back to being banned completely, patients would not be harmed. But reversing that ban, both in letter and in spirit, would send a vital message: Our government and health-care system view sexual minorities as more than a disease vector. A policy that uses anal sex as a stand-in for men who have sex with men only further stigmatizes this population by impugning one of its main sources of sexual pleasure. There is no question that nonmonogamous queer men have a greater chance of contracting HIV. But a policy that truly treats everyone the same would accept a tiny amount of risk as the price of working with human beings.

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    Benjamin Mazer

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