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  • The Most Dangerous Democrat in Iowa

    The Most Dangerous Democrat in Iowa

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    The third graders were not interested in meeting the state auditor.

    It was career day at Samuelson Elementary School in Des Moines, and Rob Sand had assembled a table in the gymnasium alongside a dozen other grown-ups with jobs. All the other adults had brought props: the man from the bathroom-remodeling company handed out yellow rubber ducks, a local doctor let the kids poke and prod a model heart, and an engineer showed off a long, silly-looking tube that had something to do with the mass production of hot dogs.

    Sand had packed only a stack of fliers, and for an hour, the rail-thin auditor stood alone while most of the children gave him a wide berth. At one point, a little girl with braids approached him cautiously: “What’s auditing?” she asked. Sand was excited. “Auditing, well, it’s about finding the truth,” he told her, crouching down. “And it usually has to do with where money’s going or whether people are following the rules.” But the little girl wasn’t listening anymore. She was staring at the hot-dog tube.

    Sand has spent the past two months practically begging people to care about his job. Iowa Republicans passed a bill in March limiting the auditor’s access to information, against the Democrat’s loud objections, and the governor is expected to sign it soon. People on both sides of the political aisle told me that the bill is a blatantly partisan move meant to defang the last remaining Democrat in a statewide elected position. Republicans in Iowa are so determined to crush their opponents, in other words, that they’re going after a man whose office most of their constituents don’t even know exists.

    But as the lone Democrat in state office, Sand is a glimmer of hope for his party in Iowa, where the past several years have brought only defeat after miserable defeat. “They’re trying to clip his wings, but they paid him a compliment,” David Yepsen, a former chief political reporter at the Des Moines Register, told me, referring to Sand’s Republican adversaries. “He’s [got] an early leg up to be the Democratic nominee” for governor.

    Sand’s office in the Capitol building occupies a stately chain of rooms decorated with the heads of dead animals. I gasped when I walked in, suddenly face-to-face with an enormous bison. “North Star Preserve, Montour, Iowa,” Sand said. He pointed at the other trophies mounted on the walls and recited where in Iowa he’d shot them with his compound bow. “Madison County. Madison County. Des Moines city limits.”

    Sand is a Democrat, but he is a Democrat who hunts. Bowhunting may be a genuine passion, but it’s also part of the myth he’s built up around himself: a duty-bound centrist, who will hold everyone in government to account, no matter their party. He wears camo and seed-company hats. He goes to church every Sunday. He went out of his way to appoint a Republican, a Democrat, and an independent to serve on his leadership team in the auditor’s office.

    Sand often says that he hates political parties, and he constantly paraphrases John Adams: “My greatest fear is two great parties united only in their hatred of each other.” Sand registered as a Democrat in 2004 because of his Christian faith’s social gospel, he said; they do “a better job of looking out for those that are on the bottom rungs of society.”

    The auditor is 40 but looks 20. He’s lanky, with eyes that crinkle at the corners and a big forehead. Good-looking in an impish way, and a little preachy aside from the occasional expletive, Sand is part Pete Buttigieg, part youth pastor. Like Buttigieg, he was a young achiever. He grew up in Decorah, Iowa, then moved East to major in political science at Brown University. Somewhat incongruously, given his down-to-earth image today, Sand did some fashion modeling in college, appearing in runway shows in Paris and Milan. Today, he likes to say that he chose the University of Iowa over Harvard Law for his law degree. He worked for seven years under Democratic Attorney General Tom Miller, for whose office Sand successfully prosecuted, in his 30s, the Hot Lotto scandal, in which a man had rigged lottery tickets in five states.

    Sand can sometimes sound self-righteous—his wife’s brothers refer to him as “Baby Jesus.” But the job of auditor requires being a Goody Two-Shoes about the rules—and having a solid backbone. Sand seems to fit that bill. He didn’t drink until he was 22, and he stopped again for more than a decade as part of a commitment to a friend who was struggling with alcoholism. “He’s kind of a square, and he can come across as a little bit arrogant,” a personal friend of Sand’s, who asked for anonymity to speak more candidly, told me. “But he’s a hugely decent person.”

    Sand’s wife, Christine, the CEO of an agri-science business, comes from a wealthy family; her relatives have provided much of the funding for his campaigns. When Sand first ran, in 2018, his bid was notable for its dad humor—and his pledge to “wake up the watchdog,” bringing more action to the auditor’s office and cracking down hard on waste, fraud, and abuse. He did that: During the coronavirus pandemic, Sand’s office discovered that the Republican governor, Kim Reynolds, had misspent federal relief money on two occasions. But he also defended the governor on other occasions: When some residents accused the Iowa Department of Public Health of fudging COVID numbers, Sand’s office reported that the state’s data were accurate.

    Last year was not a good one for Democrats in Iowa. Sand won his reelection campaign by two-tenths of a percentage point; the two other Democrats in state office—the attorney general and the treasurer, each the longest-serving in their office in Iowa history—were knocked out of their seats. Reynolds was heard on tape in the spring of 2022 saying that she wanted her “own” attorney general and “a state auditor that’s not trying to sue me every time they turn around.”

    The governor got the former. Now her party’s working to deliver the latter.

    GOP lawmakers claimed that the new auditor bill was about protecting privacy. But the final version of the legislation prevents Sand from being able to subpoena state agencies for records. Disputes over information would instead be settled by an arbitration panel comprising one representative from Sand’s office, one from the governor’s office, and one from the agency being audited—most likely someone appointed by the governor. Sand would be outnumbered every time.

    The bill was the punctuation mark at the end of the most consequential legislative session Iowans have seen since 1965, Yepsen said, in which Republican lawmakers dutifully passed almost every item on the governor’s wishlist, including bans on gender-affirming care for minors, prohibitions on sexuality and gender discussions in school, and new limits on SNAP and Medicaid eligibility. Republicans have a lock on the legislature now in Iowa, and they’re using it.

    The auditor bill stands out most, though, for its almost comically obvious targeting of Sand. It is, in the phrase of my colleague David A. Graham, another example of “total politics”—a growing phenomenon in which politicians “use every legal tool at their disposal to gain advantage” without regard for democratic norms or long-term effects. We’ve seen similar moves in Tennessee, where Republicans in the state House expelled two Democrats over their gun-violence protests, and in Montana, where GOP lawmakers are trying to rewrite election laws for a single cycle to make it easier to defeat Democratic Senator Jon Tester.

    Well-respected, nonpolitical organizations such as the American Institute of CPAs and the National State Auditors Association have spoken out against the Iowa bill affecting Sand. Even six Republicans in the Iowa statehouse voted against it: “It opens the door to corruption,” one of them, Luana Stoltenberg, who represents the Davenport district and who attended the pro-Trump Stop the Steal protest near the U.S. Capitol on January 6, 2021, told me. “It doesn’t matter who’s in [the office]—that’s wrong.”

    “If Rob Sand were a Republican, would this bill have been introduced, and would it have passed?” Mike Mahaffey, a former chair of the Iowa Republican Party who endorsed Sand in 2022, told me. “I think we all know—or we can plausibly argue—it probably wouldn’t have.” The legislation is shortsighted, he and other Republicans I talked to agreed. “Some of these Republican legislators (and it’s not just Iowa) are acting like they’ll never be in the minority again,” one Iowa GOP strategist, whom I agreed to grant anonymity so they could speak candidly, texted me.

    But for many Democrats, the Republicans’ targeting of Sand seems less about owning the libs than about neutralizing any political threat, however slight. Right now the auditor “is the entire Democratic bench. He’s their main hope,” Sand’s friend told me. “He’s their Luke Skywalker.”

    The Iowa Democrats’ Luke Skywalker drives a white Ford F-150 pickup, because of course he does. Sand picked me up in it last weekend on his way to two events in the conservative southwest corner of the state. Every year, he holds a town hall for each of Iowa’s 100 county seats; auditors don’t normally do that kind of thing. But Sand thinks it’s important for Iowans to hear what his office is up to. Or maybe he feels it’s important for people to know who he is.

    We stopped in Treynor, population 1,032, for what was billed as a bipartisan fundraising event; most attendees were Republicans, and Sand was one of three Democrats invited to speak. When he walked in, people flocked to him with questions. “Oh, Rob,” Shawnna Silvius, the mayor of nearby Red Oak, said. “You’ve really been going through it out there. You’re like a lone swan.” Sand laughed: “I haven’t gotten ‘lone swan’ before.”

    I watched as the auditor mingled for a while, looking fairly comfortable despite the fact that at least two of the lawmakers who’d voted to limit his power were sitting at a nearby table. People were finishing up their pork chops and cheesy potatoes when it was Sand’s turn to speak. He walked up to the podium, and went for it.

    The auditor bill “is a disaster in waiting for this state,” Sand told the room. Everyone was silent. He laid out the changes that the new legislation would make, and the consequences those changes would have. “The purpose of the Office of the Auditor of State is to prevent abuses of power that destroy our trust in our ability to have a system where we govern ourselves,” Sand concluded. “That was a revolutionary idea a little while back. If we want to keep it, we need to maintain those checks and balances.”

    When Sand finished, everyone clapped. A few Republicans came up to ask questions. They had no idea the bill did this, they said. How could they help? Was it too late? Sand wrote down his email and handed out business cards. He urged them all to reach out to the governor, share their concerns, and ask her not to sign the bill. “I didn’t vote for you,” one woman told Sand. “But I would have.”

    When we got back in the truck, I asked Sand what the point of all of it was. Of course Reynolds would sign. Was he possibly that naive? “Even if it’s finished, and the bill is done, this is really fucking important,” Sand said. People “need to know what is going on.” We sat while he thought out loud about whether anyone in that room would actually reach out to the governor, or email him to ask more questions—whether they’d care enough to follow through. “How else do I do this?” he asked me. “What else am I supposed to do?”

    Sand has been making many such speaking visits lately—and posting regularly on Twitter and Instagram—to broadcast his concerns to Iowans. But this moment has also provided an opportunity for Sand to broadcast himself. It’s obvious that he has bigger political ambitions. You can tell, in part, because he’s so eager to market himself. When a New York Times reporter asked him for suggestions of interesting Iowans to profile in 2020, Sand proposed that she write about him. He has taken at least two national reporters with him on hunting trips, just as he invited me along to watch as he stood up for his current cause. When I met Sand last week, he told me he was reading The Man From Ida Grove, the autobiography of Harold Hughes, a former Democratic senator and governor of the state—a little on the nose.

    Sand said he had thought about challenging Reynolds in 2022, but didn’t run because he didn’t want to miss out on time with his two young sons. Left unsaid was the political reality that last year would have been a terrible year to run. Reynolds crushed her Democratic opponent, Deidre DeJear, by nearly 20 points. Sand would probably have done better, but maybe not by much.

    He doesn’t have to decide now. Reynolds isn’t up for reelection until 2026, and by then, she may have decided not to run again—or maybe, if a Republican becomes the next president, she’ll have accepted a federal appointment. If Sand does run, he’ll have some trends in his favor: Most Iowa governors also grew up in small towns and served at least a term in public office. “In the field of Iowa Democrats, he’s the shiny light, and we don’t have a lot of light switches on right now,” Jan Norris, the chair of the Montgomery County Democrats, told me.

    But the broader political current would be pushing against him. For decades, Iowa was purple. Voters here sent Democrat Tom Harkin and Republican Chuck Grassley to the Senate, together, every chance they had. But in 2016, 31 counties that Barack Obama had won twice swung to Donald Trump—more than in any other state in the union. Six years later, Iowa elected an entirely Republican delegation to Congress for the first time in more than 60 years. Sand might have had a good shot at the governor’s mansion in that old version of Iowa. Whether he would in this one is not clear.

    “His fate is tied to the macro picture of what’s going on in the Midwest,” Yepsen, the former reporter, told me. Rural America is getting redder, and that’s a serious problem for Democrats, even one as demonstrably centrist as Sand. “Harry Truman couldn’t get elected anymore in Missouri,” Yepsen said. “George McGovern couldn’t win in South Dakota.”

    Our final stop on the truck tour of southwest Iowa was a church in Red Oak, population 5,362, where Sand gave a quick pep talk to the Montgomery County Democrats. He was casual, calm. He rolled up his sleeves and sat on the edge of a folding table to face them—youth-pastor mode. “Losing sucks—and that is what we have been doing at the top of the ticket for the last 10 years,” Sand acknowledged to the group of mostly older Iowans.

    One man asked what three issues Sand would emphasize if he were in charge of messaging for the Iowa Democratic Party. The auditor bill, Sand replied. People nodded. Plus the private-school vouchers and the way that Republicans are “criminalizing abortion.” The attendees took notes as Sand described an app they could download called MiniVAN that would help them with their door-knocking efforts.

    Sand urged the group of Democrats to have hope. He rattled off some stats: There were more split-ticket voters in Iowa than in any other competitive state in 2022, outside of Vermont. More than 48 percent of Iowans voted for three Democrats for statewide office in November. Iowa Democratic Party Chair Rita Hart lost her race in the Second Congressional District by only six votes in 2020—one of the closest House races in American history. Hearing it all, group members seemed to sit up taller in their chairs, like wilting plants getting a little water.

    “Democrats can win in the state of Iowa,” Sand said. “I’m not a unicorn.” But in Iowa, right now, he sort of is.

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    Elaine Godfrey

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  • Adult ADHD Is the Wild West of Psychiatry

    Adult ADHD Is the Wild West of Psychiatry

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    In October, when the FDA first announced a shortage of Adderall in America, the agency expected it to resolve quickly. But five months in, the effects of the shortage are still making life tough for people with attention-deficit hyperactivity disorder who rely on the drug. Stories abound of frustrated people going to dozens of pharmacies in search of medication each month, only to come up short every time. Without treatment, students have had a hard time in school, and adults have struggled to keep up at work and maintain relationships. The Adderall shortage has ended, but the widely used generic versions of the drug, known as amphetamine mixed salts, are still scarce.

    A “perfect storm” of factors—manufacturing delays, labor shortages, tight regulations—is to blame for the shortage, David Goodman, an ADHD expert and a psychiatry professor at the Johns Hopkins University School of Medicine, told me. And they have all been compounded by the fact that the pandemic produced a surge in Americans who want Adderall. The most dramatic changes occurred among adults, according to a recent CDC report on stimulant prescriptions, with increases in some age groups of more than 10 percent in just a single year, from 2020 to 2021. It’s the nature of the spike in demand for Adderall—among adults—that has some ADHD experts worried about “whether the demand is legitimate,” Goodman said. It’s possible that at least some of these new Adderall patients, he said, are getting prescriptions they do not need.

    The problem is that America has no standard clinical guidelines for how doctors should diagnose and treat adults with ADHD—a gap the CDC has called a “public health concern.” When people come in wanting help for ADHD, providers have “a lot of choices about what to use and when to use it, and those parameters have implications for good care or bad care,” Craig Surman, a psychiatry professor and an ADHD expert at Harvard and the scientific coordinator of adult-ADHD research at Massachusetts General Hospital, told me. The stimulant shortage will end, but even then, adults with ADHD may not get the care they need.

    For more than 200 years, symptoms related to ADHD—such as difficulty focusing, inability to sit still, and fidgeting—have largely been associated with children and teenagers. Doctors widely assumed that kids would grow out of it eventually. Although symptoms become “evident at a very early period of life,” one Scottish physician wrote in 1798, “what is very fortunate [is that] it is generally diminished with age.” For some people, ADHD symptoms really do get better as they enter adulthood, but for most, symptoms continue. The focus on children persists today in part because of parental pressure. Pediatricians have had to build a child-focused ADHD model, Surman said, because parents come in and say, “What are we going to do with our kid?” As a result, treating children ages 4 to 18 for ADHD is relatively straightforward: Clear-cut clinical guidelines from the American Academy of Pediatrics specify the need for rigorous psychiatric testing that rules out other causes and includes reports about the patient from parents and teachers. Treatment usually involves behavior management and, if necessary, medication.

    But there is no equivalent playbook for adults with ADHD in the U.S.—unlike in other developed nations, including the U.K. and Canada. In fact, the disorder was only recently acknowledged within the field of adult psychiatry. One reason it went overlooked for so long is because ADHD can sometimes look different in kids compared with adults: Physical hyperactivity tends to decrease with age as opposed to, say, emotional or organizational problems. “The recognition that ADHD is a life-span disorder that persists into adulthood in most people has really only happened in the last 20 years,” Margaret Sibley, a psychiatry professor at the University of Washington School of Medicine, told me. And the field of adult psychiatry has been slow to catch up. Adult ADHD was directly addressed for the first time in DSM-5—the American Psychiatric Association’s diagnostic bible—in 2013, but the criteria described there still haven’t been translated into practical instructions for clinicians.

    Addressing adult ADHD isn’t as simple as adapting children’s standards for grown-ups. A key distinction is that the disorder impairs different aspects of an adult’s life: Whereas a pediatrician would investigate ADHD’s impact at school or at home, a provider evaluating an adult might delve into its effects at work or in romantic relationships. Sources of information differ too: Parents and teachers can shed light on a child’s situation, but “you wouldn’t call the parent of a 40-year-old to get their take on whether the person has ADHD,” Sibley said. Providers usually rely instead on self-reporting—which isn’t always accurate. Complicating matters, the symptoms of ADHD tend to be masked by other cognitive issues that arise in adulthood, such as those caused by depression, drug use, thyroid problems, or hormonal shifts, Sibley said: “It’s a tough disorder to diagnose, because there’s no objective test.” The best option is to perform a lengthy psychiatric evaluation, which usually involves reviewing symptoms, performing a medical exam, taking the patient’s history, and assessing the patient using rating scales or checklists, according to the APA.

    Without clinical guidelines or an organizational body to enforce them, there is no pressure to uphold that standard. Virtual forms of ADHD care that proliferated during the pandemic, for example, were rarely conducive to lengthy evaluations. A major telehealth platform that dispensed ADHD prescriptions, Cerebral, has been investigated for sacrificing medical rigor for speedy treatment and customer satisfaction, potentially letting people without ADHD get Adderall for recreational use. In one survey, 97 percent of Cerebral users said they’d received a prescription of some kind. Initial consultations with providers lasted just half an hour, reported The Wall Street Journal; former employees feared that the company’s rampant stimulant-prescribing was fueling an addiction crisis. “It’s impossible to do a comprehensive psychiatric evaluation in 30 minutes,” Goodman said. (Cerebral previously denied wrongdoing and no longer prescribes Adderall or other stimulants.)

    The bigger problem is that too few providers are equipped to do those evaluations in the first place. Because adult ADHD was only recently recognized, most psychiatrists working today received no formal training in treating the disorder. “There’s a shortage of expertise,” Surman said. “It’s a confusing space where, at this point, consumers often are educating providers.” The dearth of trained professionals means that many adults seeking help for ADHD are seen by providers, including primary-care doctors, social workers, and nurse practitioners, who lack the experience to offer it. “It’s a systemic issue,” Sibley said, “not that they’re being negligent.”

    The lack of trained providers opens up the potential for inadequate or even dangerous care. Adderall is just one of many stimulants used to treat ADHD, and choosing the right one for a patient can be challenging—and not all people with ADHD need or want to take them. But even the most well-intentioned health-care professionals may be unprepared to evaluate patients properly. The federal government considers Adderall a highly addictive Schedule II drug, like oxycodone and fentanyl, and the risks of prescribing it unnecessarily are high: Apart from dependency, it can also cause issues such as heart problems, mood changes, anxiety, and depression. Some people with ADHD might be better off with behavioral therapy or drugs that aren’t stimulants. Unfortunately, it can be all too easy for inexperienced providers to start a patient on these drugs and continue treatment. “If I give stimulants to the average person, they’ll say their mood, their thinking, and their energy are better,” Goodman said. “It’s very important not to make a diagnosis based on the response to stimulant medication.” But the uptick in adults receiving prescriptions for those drugs since at least 2016 is a sign that this might be happening.

    The fact that adult ADHD is surging may soon lead to change. Last year, the American Professional Society of ADHD and Related Disorders began drafting the long-needed guidelines. The organization’s goal is to standardize care and treatment for adult ADHD across the country, said Goodman, who is APSARD’s treasurer. Establishing standards could have “broad, sweeping implications” beyond patient care, he added: Their existence could compel more medical schools to teach about adult ADHD, persuade insurance companies to cover treatment, and pressure lawmakers to include it in workplace policies.

    A way out of this mess, however long overdue, is only going to become even more necessary. Nearly 5 percent of adults are thought to have the disorder, but less than 20 percent of them have been diagnosed or have received treatment (compared with about 77 percent of children). “You have a much larger market of recognized and untreated adults, and that will continue to increase,” Goodman said. Women—who, like girls, are historically underdiagnosed—will likely make up a substantial share. Adults with ADHD may have suffered in silence in the past, but a growing awareness of the disorder, made possible by ongoing destigmatization, will continue to boost the ranks of people who want help. On social media, ADHD influencers abound, as do dedicated podcasts on Spotify.

    Until guidelines are published—and embedded into medical practice—the adult-ADHD landscape will remain chaotic. Some people will continue to get Adderall prescriptions they don’t need, and others may be unable to get an Adderall prescription they do need. Rules alone couldn’t have prevented the shortage, and they won’t stop it now. But in more ways than one, their absence means that many people who need help for ADHD are unable to receive it.

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    Yasmin Tayag

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