A dozen doughnut holes. Growing up, that was a typical breakfast for Tassiana Willis, a 24-year-old African-American poet. In her family, moments of joy centered around sweets. Her grandfather, a man of few words, showed affection through weekend trips to McDonald’s.

Willis, who grew up in San Francisco, has harnessed the power of poetry to raise awareness about Type 2 diabetes, a preventable disease caused largely by poor dietary habits and lack of exercise. It once affected mostly adults but now is , especially ethnic minorities and youth from low-income households.

“Raise your voice and change the conversation,” urges the tagline on four new videos produced for an arts and public health campaign called . The videos, including one by Willis called “The Longest Mile,” show young poets telling deeply personal stories about the life circumstances that promote diabetes.

The videos challenge viewers to look at “the bigger picture” behind the startling rise of diabetes. Instead of highlighting poor individual choices, they expose the social and economic factors — everything from food pricing and marketing to unequal access to parks and playgrounds — that conspire to push young people of color into an unhealthy lifestyle.

“The way these stories are told … really calls for social change,” said Natasha Huey, who managed the campaign for Youth Speaks, one of four youth development organizations across California that partnered with the University of California-San Francisco’s Center for Vulnerable Populations to produce the poetry videos.

The Bigger Picture, which launched in 2011, has produced more than two dozen videos about diabetes, which together have been viewed more than 1.5 million times on YouTube. They have also been presented at school assemblies for thousands of Bay Area students.

The rise in Type 2 diabetes among youth goes hand in hand with .

Willis said she is obese now because of the way her financially strapped family ate when she was young. “There are powerful emotions behind why we eat what we eat,” she said in an interview.

In “The Longest Mile,” Willis recalls the humiliation of being unable to run a mile during PE class in middle school. “I wasn’t slow / I was just fat.” Obesity is fueling the spread of Type 2 diabetes, and Willis knows she’s at high risk for the disease.

Unlike , which is related to lifestyle choices and obesity, typically develops in early childhood and is believed to be the result of genetic factors and environmental triggers, including viruses.

Over the past decade, rates of Type 2 diabetes have tripled among Native Americans, doubled among African-Americans and increased by as much as 50 percent in the Asian, Pacific Islander and Hispanic populations,

“We’re at the tipping point in this disease,” said Dr. Dean Schillinger, a professor of medicine at UCSF and director of health communications at Zuckerberg San Francisco General Hospital and Trauma Center, who co-created the Bigger Picture campaign. “The trajectory is very scary and the rate of increase, is exponential.”

In a recent featuring the new videos, he stressed the importance of shifting the way diabetes is characterized in public health education.

“The overarching objective is to change the conversation about diabetes away from it being an individual ‘shame and blame’ message to approaching it as a societal problem,” Schillinger said.

In another video, “Empty Plate,” Anthony “Joker” Orosco, a 20-year old Chicano poet, depicts his farmworker relatives who can’t afford to buy the produce they pick.

Orosco, who grew up in Stockton, a city in California’s agricultural San Joaquin Valley, said he was inspired to honor the hard work of immigrants who sacrificed for his generation.

Low-income people often struggle to buy fresh vegetables, whole grains and other nutritious foods, because those choices are more expensive than the sugary, fat-laden processed foods widely available in many poor neighborhoods. In a , researchers at Harvard and Brown universities found that a healthful diet costs about $550 a year more per person than an unhealthy one.

Schillinger said that, based on his earlier experience with the AIDS epidemic and anti-tobacco campaigns, he believes there needs to be a “groundswell of grass-roots activism” if the course of Type 2 diabetes is to be reversed.

“A young person getting diabetes is an injustice, and so the campaign features young people who are targets of diabetes risk but are now becoming agents of change,” he said.

In “Monster,” Rose Bergmann, 17, and Liliana Perez, 16, talk about fathers who relied on sugar-packed energy drinks to work double shifts to support their families.

The industry that makes sweetened drinks has taken notice. “We do agree that people need to manage their sugar intake,” said Lauren Kane, senior director of communications for the American Beverage Association in Washington, D.C. She said beverage makers are “aggressively working to innovate to offer more products with less sugar … and to create interest in access to those beverages.”

McDonald’s has also recently announced to reduce the number of calories in its Happy Meals, which are marketed to children.

Los Angeles poet Edgar Tumbokon, 19, said nutritious food did not play a big role in his childhood. “I grew up in a food desert surrounded by a culture and kids who loved to eat junk food,” he said. “Eating healthy was considered ‘a white thing.’”

Tumbokon, who weighed 13 pounds at birth, said his poem, “Big Boy,” was inspired by his immigrant Filipino mother, who developed gestational diabetes, which now afflicts 1 in 11 pregnant women. He grew up watching her test her blood sugar and inject herself with insulin.

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La madre soltera con cinco hijos había estado luchando para poder pagar las cuentas. “Escuché que el alquiler era mucho más barato aquí, así que me mudé”, contó.

Pero cuando tuvo problemas de salud –comenzó a perder el equilibrio y a caerse-, Castaneda encontró menos opciones médicas en su nueva área. Incapaz de encontrar atención especializada local, viajó casi 65 millas a un hospital público en Los Ángeles, donde los médicos descubrieron un tumor en su columna vertebral.

La cirugía para extirparlo fue a 75 millas de su casa, en el centro oncológico City of Hope en Duarte, California. El procedimiento la dejó parcialmente paralizada. “Entré al hospital y nunca volví a caminar”.

Castaneda, de 58 años, recibe pagos por discapacidad del Seguro Social y es beneficiaria del Medi-Cal, el programa estatal de Medicaid para personas de bajos ingresos. “Pero aquí no hay médicos disponibles”, dijo Castaneda. “Llamé a todos los del directorio, y nadie recibe a pacientes de Medi-Cal”. Ahora, Castaneda ve a médicos a casi 50 millas de distancia, en Northridge.

Los suburbios en los Estados Unidos, a menudo percibidos como enclaves de los ricos, albergan a casi , más que en las ciudades o áreas rurales, y la creciente demanda de atención restringe la capacidad de los servicios de salud suburbanos para proporcionarlas, según reciente publicado en Health Affairs. Históricamente, las áreas suburbanas han recibido apenas una fracción del financiamiento para la salud del que tienen las ciudades, lo que las deja con una infraestructura inadecuada, y obligando a personas como Castaneda a pelear por la atención médica que necesitan.

El estudio de Health Affairs encontró que aproximadamente una quinta parte de las personas pobres que viven en los suburbios no tienen seguro, y muchos de los que sí tienen cobertura, especialmente los que reciben Medi-Cal, no pueden encontrar proveedores o deben viajar muy lejos para sus citas médicas.

La Ley de Cuidado de Salud Asequible (ACA) redujo la tasa de personas sin seguro en California del 17% en 2013 a aproximadamente debido principalmente a la expansión de Medicaid, que sumó más de 3.7 millones de adultos a las listas de Medi-Cal. Pero eso no ha asegurado el acceso a la atención médica para millones de habitantes de los suburbios, apuntó Alina Schnake-Mahl, aspirante a un doctorado en la Harvard T.H. Chan School of Public Health en Boston, y autora principal del estudio de Health Affairs.

“Eso va en contra de la idea de que todos en los suburbios están asegurados porque todos tienen un trabajo profesional o administrativo con cobertura”, dijo.

Pero la cobertura no equivale a atender siquiera a los pacientes con Medi-Cal, como puede atestiguar Castaneda. Antes de la ley de salud, tenían problemas para encontrar médicos que los vieran debido a las bajas tasas de pago de Medi-Cal. Ese problema se intensificó cuando millones más se inscribieron en el programa, lo que motivó a muchos afiliados a buscar servicios en las instalaciones de atención de la red de seguridad.

Los servicios de atención médica en los suburbios “no son lo suficientemente sólidos como para cubrir las necesidades de una creciente población de bajos ingresos”, dijo Charlie Gillig, abogado supervisor en el Centro de Servicios de Salud del Consumidor del condado de Los Ángeles, quien ha asesorado a Castaneda sobre servicios de transporte médicos bajo Medi-Cal.

La mitad de los 39 millones de residentes de California vive en los suburbios, y las tasas de pobreza oscilan entre cerca del 25% en Bakersfield, en el Valle Central, y alrededor del 8% en los suburbios fuera de San Francisco, según de Elizabeth Kneebone, directora de investigación en el Centro Terner para la Innovación de la Vivienda de la Universidad de California-Berkeley y miembro senior de Brookings Institution. El mismo análisis mostró que 2,7 millones de californianos de los suburbios vivían por debajo de la línea de pobreza en 2016, en comparación con 1,9 millones en las principales ciudades.

Castañeda, quien usa una silla de ruedas motorizada grande, dice que es difícil, “a menudo imposible”, organizar un viaje en una camioneta. Llegar al médico se ha convertido en una larga y dolorosa prueba.

Y eso es si puede programar una visita, dijo Castaneda, y agregó que también enfrenta largos tiempos de espera para ver a su médico en Northridge, un suburbio que está recibiendo cada vez más pacientes de zonas más pobres. “No se puede hacer una cita cuando estás enfermo… así que he estado esperando y esperando”, contó. “Me dijeron, ‘si te enfermas lo suficiente, solo ve a la sala de emergencias'”.

Por supuesto, también puede ser difícil conseguir una cita en la clínica o ver a un especialista en las ciudades, pero en los suburbios, dijo Gillig, “la geografía agrava un problema ya existente”.

En su sobre la cambiante geografía de la pobreza, Scott Allard, profesor de políticas públicas y gobernabilidad en la Universidad de Washington, mostró que el .

Las áreas metropolitanas de California han tenido muchas décadas para construir sistemas masivos de atención médica para atender a los pobres, incluidos los hospitales del condado, los centros de salud calificados a nivel federal y las clínicas comunitarias. Pero la escala actual de la pobreza suburbana es una tendencia reciente.

Los legisladores luchan por atender las necesidades de salud de las ciudades en el este del condado de Contra Costa, a unas 50 millas de San Francisco. En Oakley, por ejemplo, los líderes empresariales y comunitarios cabildearon fuertemente por un nuevo centro de salud, que se inauguró en 2011.

“Aquí hay una gran necesidad, especialmente para las personas indocumentadas o que no tienen seguro. No tienen otro lugar adonde ir”, dijo Leticia Cazares, gerenta regional de La Clínica, que opera el nuevo centro de salud. La clínica tiene dos doctores y una enfermera practicante para atender a 3,000 pacientes, la mayoría de los cuales tienen Medi-Cal.

Muchas de las personas que visitan clínicas comunitarias como la de Oakley no tienen seguro, ya sea porque son inmigrantes sin papeles o porque ganan demasiado dinero para calificar para Medi-Cal o para cobertura subsidiada bajo el Obamacare, y no pueden pagarla de su propio bolsillo.

La familia de Alex G. se adapta a ambos escenarios. Su esposo, Edward, y su hijo de 8 años, quien también se llama Alex, son ciudadanos estadounidenses, pero ella es indocumentada. La familia vive en Brentwood, una ciudad de aproximadamente 60,000 habitantes en el este del condado de Contra Costa.

Estudiante universitaria de 32 años, quien se negó a dar su apellido por temor a la deportación, Alex ha solicitado la residencia permanente, un proceso largo con un resultado incierto.

Su esposo tiene “un buen trabajo” como programador de máquinas industriales. Él tiene seguro por su empleador, pero para que Alex y su hijo tengan seguro, tendrían que pagar $1,200 por mes. Dado el alto costo de vida de California, “simplemente no podemos darnos el lujo de pagar eso”, dijo Alex. El salario de su esposo, de $70,000, es demasiado alto para los subsidios de Medi-Cal u Obamacare.

Alex sufrió recientemente fuertes dolores de estómago y tuvo que esperar varios días por una clínica móvil que estaciona frente a un centro comunitario cercano una vez a la semana.

Cada vez que su hijo tiene una infección en el oído o fiebre, Alex lo lleva a la clínica móvil gratuita. “Al no tener seguro, me preocupa mucho cada vez que se enferma”, dijo.

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The single mom with five kids had been struggling to pay the bills. “I kept hearing that the rent was a lot cheaper out here, so I moved,” she said.

But when she developed health problems — losing her balance and falling — Castaneda found fewer care options in her new town. Unable to find local specialty care, she traveled nearly 65 miles to a public hospital in Los Angeles, where doctors discovered a tumor on her spine.

Then she had to drive nearly 75 miles to the City of Hope cancer center in Duarte, Calif., for an operation to remove the growth. The procedure left her partially paralyzed. “I walked into the hospital and I never really walked again.”

Castaneda, 58, receives Social Security disability payments and is enrolled in Medi-Cal, the state’s Medicaid program for low-income people. “There are no doctors available here,” said Castaneda. “I called every single one of them in the book, and nobody takes Medi-Cal out here.” Instead, Castaneda now sees doctors nearly 50 miles away in Northridge.

Suburbs in the United States, often perceived as enclaves of the affluent, are home to  — more than in cities or rural areas — and growing demand for care strains the capacity of suburban health services to provide for them, according to a recent  in Health Affairs. Suburban areas have historically received a fraction of health funding that cities have, leaving them with inadequate infrastructure and forcing people like Castaneda to scramble for the medical attention they need.

The Health Affairs study found that about a fifth of the suburban poor are uninsured, and many who do have health insurance — especially people on Medi-Cal — either can’t find providers or must travel far for appointments.

The Affordable Care Act cut California’s uninsured rate from 17 percent in 2013 to about due largely to the Medicaid expansion, which added more than 3.7 million adults to the state’s Medi-Cal rolls. But that has not ensured access to health care for millions of suburbanites, said Alina Schnake-Mahl, a doctoral candidate at the Harvard T.H. Chan School of Public Health in Boston, who was lead author of the Health Affairs study.

“That really goes against the idea that everyone in the suburbs is insured because everyone has a white-collar job with coverage,” she said.

Coverage doesn’t equate to care even for patients with Medi-Cal, as Castaneda can attest. Before the health law, they had trouble finding doctors who would see them because of Medi-Cal’s low payment rates. That problem intensified as millions more signed up for Medi-Cal, driving many enrollees to seek services at safety-net care facilities.

Health care services in the suburbs “are not robust enough to fill the needs” of a growing low-income population, said Charlie Gillig, supervising attorney at the Health Consumer Center of Neighborhood Legal Services of Los Angeles County, which has advised Castaneda about medical transportation services under Medi-Cal.

One-half of California’s 39 million residents live in suburbs, and rates of poverty among them range from nearly 25 percent around Bakersfield, in the Central Valley, to about 8 percent in the suburbs outside San Francisco, according to an  by Elizabeth Kneebone, research director at University of California-Berkeley’s Terner Center for Housing Innovation and a senior fellow at the Brookings Institution. The same analysis showed that 2.7 million suburban Californians lived below the poverty line in 2016, compared with 1.9 million in major cities.

Castaneda, who uses an oversized power wheelchair, says it’s difficult — “often impossible” — to arrange for a ride in a van. Getting to the doctor has become a long, painful ordeal.

And that’s if she can even schedule a visit, said Castaneda, noting that she also faces long wait times for her doctor in Northridge, a suburb that has seen an influx of patients from poorer areas. “You can’t get an appointment when you’re sick … so I’ve just been waiting and waiting,” she said. “They told me, ‘If you get sick enough, just go to the emergency room.’”

Of course, it can also be tough to get a clinic appointment or see a specialist in cities, but in the suburbs, Gillig said, “geography exacerbates an already existing problem.”

±õ²ÔÌý on the changing geography of poverty, Scott Allard, a professor of public policy and governance at the University of Washington,  was as much as eight times higher in urban areas than in the suburbs.

California’s metropolitan areas have had many decades to build up massive health care systems to serve the poor, including county hospitals, federally qualified health centers and community clinics. But the current scale of suburban poverty is a recent development.

Policymakers struggle to serve the health needs of cities in eastern Contra Costa County, about 50 miles from San Francisco. In Oakley, for example, business and community leaders lobbied hard for a new health center, which opened in 2011.

“There’s a huge need out here, especially for people who are undocumented or uninsured. They don’t have anywhere else to go,” said Leticia Cazares, regional manager for La Clinica, which operates the new health center. The clinic has two doctors and a nurse practitioner to serve 3,000 patients, most of whom are on Medi-Cal.

Many of the people who visit community clinics like the one in Oakley lack insurance, either because they are undocumented immigrants or because they make too much money to qualify for Medi-Cal — or subsidized coverage under Obamacare — and can’t afford it on their own.

Alex G.’s family fits both scenarios. Her husband, Edward, and 8-year-old son — also named Alex — are U.S. citizens, but she is an undocumented immigrant. The family lives in Brentwood, a town of about 60,000 in eastern Contra Costa County.

A 32-year-old community college student who declined to give her last name for fear of deportation, Alex has applied for permanent residency — a long process with an uncertain outcome.

Her husband has “a good job” as a programmer of industrial machines. He has employer-based insurance, but it covers only him. For Alex and her son to be covered, the family would have to pay $1,200 a month. Given California’s high cost of living, “we just can’t afford to pay that,” Alex said. Her husband’s salary of $70,000 is too high for Medi-Cal or Obamacare subsidies.

Alex recently experienced sharp stomach pains and had to wait several days for a mobile clinic that parks in front of a nearby community center once a week.

Whenever her son has an ear infection or a fever, Alex takes him to the free mobile clinic. “Not having insurance, I worry all the time about him getting sick,” she said.

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Supervisor Malia Cohen, sponsor of the proposed ordinance, joined Tuesday with public health experts and community advocates to announce the measure, which she said goes beyond more narrow laws on flavored tobacco in cities such as Chicago, Berkeley and New York.

“The legislation I’ve authored is a full restriction on the sale of all flavored tobacco products, and that does include menthol. There are no exemptions,” Cohen said. This includes cigarettes, cigars, smokeless tobacco and e-cigarettes.

The proposed ordinance is designed to address two major groups, youth and minorities, who have been targeted in successful, well-financed advertising campaigns that promote menthol cigarettes and flavored non-cigarette tobacco products. The products often attract African-Americans, Asian-Americans and Latinos, as well as teenagers.

San Francisco Mayor Ed Lee endorsed the proposal. “We know from research and studies that tobacco-related diseases continue to be the No. 1 cause of preventable deaths, especially among low-income and minority communities,” he said.

A similar measure is being considered in Oakland.

Cohen, who represents the predominantly African-American Bayview-Hunters Point district of San Francisco, said the ordinance grew out of her personal experience with family members who smoked menthol cigarettes and died of cancer, and her desire to spare San Franciscans a similar fate. “This is an evidence-based tobacco prevention strategy that will save lives and cut costs for taxpayers who are collectively shouldering the health care costs of tobacco-related illnesses,” she said.

Nearly 9 in 10 prefer menthol cigarettes, according to the federal Centers for Disease Control and Prevention. Menthol is believed to make the harmful chemicals contained in cigarettes more easily absorbed by the body, and some research shows that menthol cigarettes are more addictive than regular ones, according to the CDC.

“African-Americans don’t have a genetic disposition that makes them smoke menthol cigarettes,” said Dr. Valerie Yerger, an associate professor of health policy at the University of California-San Francisco. “It’s the result of a very conscious advertising campaign by the tobacco industry.” Menthol cigarettes are also preferred by a majority of Latinos and Asian-Americans who smoke, according to Randy Uang, director of tobacco prevention and control services at Breathe California, a Golden Gate Public Health Partnership.

Public health experts say restricting menthol and other flavored tobacco would improve health outcomes not only for the minority populations but also for teens. “Because flavors play such a key role in youth starting to smoke, restricting access to these products means that fewer youth will start smoking,” said Uang.

Flavors are popular with inexperienced smokers, he said, because they mask the taste of tobacco and decrease the irritating effects of nicotine.

E-cigarettes are now the tobacco-related product most by young people in the U.S., according to the CDC. It found that more than 8 in 10 youths ages 12-17 who vape said they use flavored e-cigarettes that taste like mint, candy or other sweets.

The San Francisco ordinance, if approved, would fill a gap in federal legislation that authorized the U.S. Food and Drug Administration to regulate tobacco. In 2009, the FDA banned “characterizing flavors,” such as candy, fruit and chocolate, in cigarettes. But, faced with tobacco industry lobbying, it stopped short of prohibiting menthol in cigarettes or flavorings in other tobacco-related products such as e-cigarettes, little cigars and smokeless tobacco.

Tobacco-control advocates, such as Yerger, have been pushing the FDA to ban menthol and other flavorings for years. “This ordinance didn’t happen overnight,” she said. “It’s been a very long process and part of that has been gathering evidence about the role of menthol in hooking kids at a very early age and the tobacco industry knowing that it has the ability to do that by manipulating the levels of menthol in their products.”

Cohen noted the tobacco lobby is strong in Sacramento and she’s expecting pushback from the industry. “I would imagine they will be fighting this legislation every step of the way,” she said.

If enacted, the tobacco ordinance would become effective Jan. 1. Enforcement would be the job of the Department of Public Health, which also would be responsible for educating retailers about the new restrictions.

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Trump’s spending plan — running into opposition from Republicans and Democrats alike — would cut about 20 percent of the roughly $30 billion budget of the nation’s medical research agency that supports research on cancer, Alzheimer’s disease, Zika and other conditions.

Research institutions nationwide decried the cuts as potentially devastating to their work.

Among those who stand to lose the most are the University of California, San Francisco, which for the past three years has received more in NIH biomedical grants than any other public university in the country.

Grants to UCSF’s four schools that tailor to health professions reached nearly $634 million in fiscal year 2016, according to the UC Office of the President.

“It’s tremendously shocking,” said Keith Yamamoto, UCSF’s vice chancellor for science policy and strategy.

“The hope was that biomedical research would fare well,” even in the face of the administration’s stated desire to control spending, said Yamamoto, a top researcher in cellular and molecular pharmacology.

Total NIH funding for the University of California system in the 2016 fiscal year reached nearly $2 billion.

At Johns Hopkins University, the institution receiving the most in NIH grants last year, an official described the potential budget cuts as “extraordinarily threatening.” Johns Hopkins received about $651 million in NIH grants.

Officials at Harvard University, Fred Hutchinson Cancer Research Center in Seattle and the University of Alabama at Birmingham voiced similar concerns, noting that the cuts could set back basic scientific research .

Based in Bethesda, Md., the NIH spends most of its annual budget — about 85 percent — on grants to thousands of researchers and medical institutions across the country.

Traditionally, biomedical research has enjoyed strong bipartisan support, surviving ideologically driven cutbacks from one administration to the next. Grant increases to major NIH recipients had been averaging about 3 percent per year during the Obama administration.

NIH officials declined to comment on Trump’s budget blueprint, but its parent agency, the U.S. Department of Health and Human Services, released a  saying the agency is “dedicated to fulfilling our department’s mission to improve the health and well-being of the American people.”

The officials said the budget supports that mission and will help ensure delivery of critical services “in the most efficient and effective manner possible.”

Congressional Democrats are already pushing back hard against Trump’s fiscal plan, as are some Republicans. Political observers caution that presidents’ budget proposals, while signaling administration priorities, rarely are approved by Congress without major changes.

Still, UCSF’s Yamamoto said, “research laboratories run like small businesses that operate on a very tight margin. There’s no slack in any element of it.”

The results of double-digit funding cuts, he said, “would be dramatic and immediate and disastrous.”

UCSF Chancellor Sam Hawgood slammed the cuts as “deeply disturbing,” calling the NIH and the research it supports “the envy of the world.” As a public institution, UCSF has honored “a pact with taxpayers by conducting research that has improved the health of all Americans,” Hawgood said.

Federal money for research, in addition to finding cures for disease, also stimulates job creation, with grant dollars being paid back many times over, Hawgood said.

“Nearly 200 startup companies have been launched based on UCSF research,” Hawgood said. “Those companies now offer good jobs and generate tax revenues that bolster the American economy.”

The entire UC system benefits from NIH support, with UC, San Diego, winning more than $414 million in competitive grants last year — placing it squarely among the agency’s top 10 recipients. UC President Janet Napolitano issued a statement decrying the proposed budget cuts, saying they would “stifle crucial advancements toward solving our nation’s most pressing needs and challenges.”

Last year, Stanford University r grant recipients, receiving 944 grants for a total of more than $427 million, .

University officials noted that it is still “very early in the budget process,” but said in a statement it was clear that the proposed cuts would harm research in medicine and health, technology, the environment, the humanities, social sciences and many other fields.

In a press briefing Thursday, Mick Mulvaney, the director of the Office of Management and Budget, supported a major reorganization of NIH, calling for a consolidation of the agency’s 27 different institutes and centers with a “focus on efficiencies.” According to Mulvaney, the agency had been subject to “mission creep,” expanding “beyond their core functions.”

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That’s the number of new HIV infections California officials are aiming for under a  released this fall.

The “Getting to Zero” plan, intended to guide the state’s AIDS policy from 2017 to 2021, is designed to boost surveillance, increase access to care and eliminate disparities in treatment.

“Thanks to better treatment and prevention options, new testing technology and better access to health care, California has reached a point where we can envision the possibility of zero new HIV infections,” said Dr. Karen Smith, director of the California Department of Public Health.

In the near term, however, the plan seeks to cut the number of new diagnoses in half, to fewer than 2,500 per year. It’s an ambitious goal in itself, but state health officials claim it is attainable.

“We know how to do it from a clinical and from a public health perspective,” said Dr. Gilberto Chavez, deputy director for infectious disease programs at the public health department. “We have the tools to make it happen.”

Expanded testing is the cornerstone of California’s HIV response, Chavez said. “For folks with HIV infection, the sooner that they know about it the better, from both an individual and community perspective.”

Goals Versus Reality

Some say the goals in the plan may be easier stated than done.

“Getting to zero is aspirational,” said Dr. Hyman Scott, a researcher and clinician with Bridge HIV at the San Francisco Department of Public Health. “If we don’t address racial, ethnic and age disparities in HIV treatment we won’t get there.”

Dr. Paul Volberding, who codirects the AIDS Research Institute at the University of California San Francisco and has been involved in fighting the epidemic from its earliest days, also sees challenges ahead.

“We can’t just coast along and in five years get to zero,” he said. “Stigma is the biggest issue, because that’s what keeps people out of the system.”

Although enormous inroads have been made against HIV, and prominent researchers such as Volberding are talking about a cure as a possibility, the public health department’s Office of AIDS estimates that 139,000 people in the state were living with the virus in 2014, the latest year for which statistics were available. And nearly 10 percent of them were undiagnosed.

African-Americans, Latinos and immigrants have seen a disproportionate rise in infections and have the lowest rates for testing, according to Scott.

“We want people to be aware of their HIV status so they can access care and treatments that are really life-saving,” he said. The state’s plan encourages targeted testing in these communities, not only to link patients with treatment, but also to prevent new infections.

“If somebody is engaged in treatment and has a suppressed viral load, then the risk of onward transmission is negligible,” Scott said.

The state’s goal is to ensure that at least 95 percent of people with HIV get diagnosed. To get there, the blueprint encourages hospital emergency departments, primary care physicians and jail and prison health systems to offer routine testing. Such tests are free to Medi-Cal patients and Californians insured under the Affordable Care Act. Regardless of their coverage, patients are able to refuse testing.

The “Getting to Zero” plan seeks to have new patients begin antiretroviral treatment on the same day as diagnosis and to have them connected with a medical provider within 72 hours.

“In our plan, it’s not just about providing medication, but also providing a medical home and making sure that folks are getting evaluated regularly,” said Chavez.

The plan will be paid for through a mix of federal, state and local dollars. The state Department of Public Health says that it “utilizes existing state resources,” suggesting that it adds no new costs.

But California’s plan was constructed before the presidential election, which has injected uncertainty and “great fear” into the AIDS treatment community, said UCSF’s Volberding. We rely on a good deal of federal support, and if that is dramatically reversed I think we are in for some serious trouble.”

‘A Game Changer’

The best way to cure any epidemic, of course, is to prevent infections in the first place.

The state’s plan urges greatly expanded use of preexposure prophylaxis, known as PrEP.

°Õ³ó±ðÌýthe prevention therapy could reduce infections by 70 percent by 2020. It involves taking a daily dose of Truvada, an antiviral pill that contains two AIDS medications (emtricitabine and tenofovir).

When people who take PrEP are exposed regularly to HIV through sex or injection drug use, the medication can reduce their risk of infection by more than 90 percent, according to the CDC. (Still, health officials emphasize it is still important to wear condoms to protect against other STDs, pregnancy and highly-resistant strains of HIV.)

PrEP costs about $1,400 per month, but the public health department’s Chavez said it is covered by Medi-Cal and most health insurers.

“PrEP is a game-changer that can really transform our HIV prevention strategies in California and across the nation,” said Scott, who has led efforts to increase PrEP use in San Francisco. The program, established last year, has approximately 300 people on PrEP across 18 primary care clinics.

Nineteen-year-old James has been taking PrEP for nearly a year. The freshman at California State University, Chico requested that his last name not be used to protect his privacy. He has, like many of his gay peers, grown up in fear of HIV infection.

James doesn’t have a steady boyfriend and says he uses condoms “most of the time.” The student, who is majoring in animation, learned about PrEP when he was being tested for sexually transmitted diseases.

“I used to always be really worried about STDs and especially HIV, and now it’s, like, okay, that’s one great big scary thing that I don’t have to worry so much about,” he said.

James, who is insured by Kaiser Permanente, has a prescription for Truvada with no copayment. To be effective, the medication must be taken every day.

James said he takes his pill “every morning after I brush my teeth,” and has experienced no side effects. He goes to the student health center at school for regular HIV testing, which is what health officials recommend.

James is among about 9,000 Californians now taking PrEP medication, according to the . Still, officials say the treatment is indicated for up to 240,000 people in the state.

“We are just now at the beginning of our PrEP program,” Chavez said, “so there’s a long way to go.”

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A led by local and state health officials compared the new and more traditional treatment protocols in the jail system of Santa Clara County. It found a 12-week two-drug regimen is as effective as the traditional nine-month single-drug approach to treating latent infection, which is not contagious but without treatment can progress to active disease. Plus the shorter regimen significantly boosted the percentage of inmates who completed treatment.

“Essentially what we found was a huge improvement in the completion rate for latent TB infection,” said Maria Juarez-Reyes, lead author of the clinical trial and an assistant clinical professor at Stanford University and.

Santa Clara County has California’s fifth-largest jail system, with approximately 4,000 inmates, and the state as a whole has nearly double the national incidence rate of active TB, a highly contagious bacterial infection that can be fatal if not treated properly.

The Centers for Disease Control and Prevention reports that  of active TB cases are diagnosed in correctional facilities, where the population is considered at high-risk because of close living quarters, a history of inadequate medical care, underlying medical conditions such as elevated rates of HIV infection and higher levels of substance abuse.

Treating active TB is a high priority, but public health officials are also concerned about the incidence of latent TB infection, in which a patient tests positive for TB but is not yet sick. Over 6 percent of California’s population — 2.4 million people — is estimated to have latent TB, and the majority of those infected don’t know it.

Treating latent infection in jails is a cornerstone of the strategy to suppress TB, because it prevents the infection from progressing to active disease. Yet such treatment often falls short. The CDC found only about a third of inmates complete the traditional nine-month, twice-weekly treatment regimen with isoniazid, a widely used antibiotic. The completion rate was even lower — 18 percent — at the Santa Clara County Jail.

“To complete treatment is very difficult because it takes too long,” said Juarez-Reyes. “The average length of stay was three and a half months before they were transferred or released.” When they were released, inmates would receive information about county TB clinics where they could complete their treatment on the outside, but the follow-up rate was “very, very low.”

Juarez-Reyes and her fellow researchers reduced the doses of medication from 72 to 12 and shortened the duration of treatment by two-thirds.

In 2012, the jail switched from the nine-month drug protocol to a regimen of 12 weekly doses of a combination of isoniazid and a second antibiotic, rifapentine. To assess the outcome, the researchers directly observed 91 patients who received the 3-month drug cocktail and compared their results to a similar group of patients who in the past had undergone the 9-month treatment.

The scientists concluded that the shorter regimen was as effective as the longer one and that the completion rate soared — from 18 percent to 85 percent.

“This is really fantastic,” said co-author Neha Shah with the Tuberculosis Control Branch of the state public health department. “The implication is we can get more people through treatment, treat them effectively before they break down and get sick and can infect other people.”

Researchers were also reassured to see the 12-dose regimen was well tolerated — even by jail inmates who have a higher rate of substance abuse, which can harm the liver. “We were worried that this regimen might lead to more liver damage, because it is once a week at a higher dose,” said Shah. But that’s not what happened.

“We found side effects to be few and mild,” she said. Only two of the participants discontinued treatment because of adverse drug reactions.

The Santa Clara trial is the latest in a series of studies that found positive results from a shortened regimen for latent TB. In December 2011, the New England Journal of Medicine of a large randomized control trial that found a 12-dose regimen of combination therapy, directly observed by health workers, was as effective as a 9-month regimen of daily self-administered isoniazid.

Two came up with a similar finding, according to the CDC.

Federal prisons have also recommended adoption of the shorter latent TB regimen. The Federal Bureau of Prisons’ October 2015 for the management of TB state that the 12-week, once-weekly two drug protocol is now the standard treatment regimen. “It should be utilized to treat [latent TB infection] unless there are contraindications for its use,” according to the guidelines.

Despite growing acceptance of the shorter treatment regimen in correctional facilities, it has not been adopted nationally in the general population. According to the CDC, the regimen for latent TB in the general population continues to be nine months of daily isoniazid.

The traditional approach is described by the agency as “very effective,” and “the preferred regimen” for HIV-infected people taking antiretrovirals, as well as for children aged 2 to 11. According to the CDC, the 12-dose regimen “does not replace” other latent TB protocols.

The shorter treatment is not appropriate for every patient. According to the state, the 12-dose regimen is not recommended for children under the age of 2, HIV-infected people taking antiretrovirals (because of potential drug interactions with rifapentine), people presumed to be infected with a drug-resistant form of TB, pregnant women or women planning to become pregnant within the treatment period.

Studies also have found that the 12-dose therapy is more expensive than the traditional approach, primarily because of the addition of a second medication, rifapentine, and the cost of direct observation by health workers. The Santa Clara study noted that cost-effectiveness may be greater in a correctional setting, since the environment is more conducive to outbreaks, which bring higher “societal costs.”

The compelling results of the Santa Clara study, led by researchers at Santa Clara Valley Health and Human Services, as well as California Department of Public Health, have led to a change in treatment guidelines in the jail system “The protocols mentioned in the study are now a standard in our jails,” said study co-author Alexander Chyorny, MD, with Adult Custody Health Services at the Santa Clara Valley Medical Center. Since the study was done, Chyorny said the therapy in the jail has been completed 65 percent to 75 percent of the time.

In California, each county jail has its own protocol for treating latent TB infection, but the state’s public health department has encouraged all correctional settings to use the three-month regimen of the two drugs, or a 4-month regimen of daily rifampin.

According to a prepared by the department, “short course regimens are preferred whenever possible,” to increase the likelihood that treatment will be completed.

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For one Oakland family, their daughter’s path was clear from the time she was 3. Her birth certificate said “male,” but the child would always say she wanted to be a girl, and that soon became, “I AM a girl,” said the mother, who asked that her family’s name not be used to protect her daughter’s privacy. She recalled a day when the girl wept in frustration trying to fashion a skirt out of some t-shirts.

“Finally I just said, ‘Honey, do you want a dress?’’ and they went to a store and bought one. “I literally thought she was going to faint or hyperventilate,” said the mother. “She couldn’t sit still, she was so excited and so happy. It was a moment of pure joy for her, and also a turning point,” she said.

She was happy growing up and attended a progressive school in the San Francisco Bay Area as a girl. But when she was approaching puberty, she became very nervous, “worried about getting facial hair or watching her shoulders get broader. It was all very painful for her,” her mother said.

“These kids are saying to the world, ‘I was born in the wrong body, and there’s something just not right about living this way,’” said Scott Leibowitz, head child and adolescent psychiatrist at the Ann & Robert H. Lurie Children’s Hospital of Chicago.

Blockers ‘Safe and Effective’

Full-blown puberty is irreversible, but for transgender children, it’s no longer inevitable. By taking a gonadotropin-releasing hormone (GnRH) agonist, secretion of the sex hormones can be stopped and the onset of puberty suppressed, so that the body does not develop secondary sex characteristics. This has been done safely for decades to suppress sex hormones in children who develop too early, a condition known as precocious puberty. Suppressors have also been used to treat endometriosis, uterine fibroids and prostate cancer.

It was only in 2008 that approved puberty suppressors as a treatment for transgender adolescents as young as 12 years old. The Society, with members in more than 100 countries, has that the intervention appears to be safe and effective.  In 2011 the (WPATH), also issued Standards of Care for the treatment of patients with gender dysphoria, which include puberty suppression.

There are few reported side effects to this off-label use of sex hormone suppressors. Despite early concerns that blocking sex hormones might harm bone development, a from the Netherlands found no evidence of long-term effects on bone mineral density. If the suppressors are halted, puberty resumes as if there had been no treatment.

Data on the use of puberty blockers is scarce, but in the past decade or so, it’s believed thousands of transgender youth and their families have chosen to suppress puberty to give adolescents a time-out while they figure out the next step in their development.

A St. Louis, Mo., child was classified as female at birth, one of a set of twin girls. But the parents had been discussing puberty blockers with him since he was seven years old, after he had begun dressing as a boy and showing more masculine traits.

“I remember watching a documentary where he learned what blockers were and we talked about it and he was sure that’s what he wanted when the time came,” said his mother, who also asked that the family’s names not be used to protect her child’s privacy.

“As soon as he got breast buds, it was like the panic button was hit,” the mother said. “He was quickly and very intensely uncomfortable and afraid. He would cry, knowing that this was the beginning of something that he didn’t want, that he knew wasn’t right for him,” she said.

In March, after the boy turned 11, a pediatric endocrinologist prescribed the sex hormone suppressor Eligard, an injection that he receives every four months. According to his mother, because they intervened early, the unwanted breast buds receded quickly, along with her son’s depression and anxiety. “I don’t know what we would have done if we were not able to stop puberty so he doesn’t have to feel in constant conflict with his own body,” she said.

So far, according to the mother, the biggest problem their family has faced has been trying to get insurance coverage for her son’s treatment. She said they have been lucky to obtain the injections at cost — $500 per shot — rather than the $1,500 to $2,000 per shot that the therapy typically costs. Her husband’s employer, which self-funds its medical insurance plan, chose a clause that excludes transgender care.

That kind of exclusion could change, especially since the Obama Administration recently issued that ban the denial of health care on the basis of gender identity in programs that receive federal funding. The rule could help people who feel they have been discriminated against to bring complaints or lawsuits, according to the in Oakland, Calif.

In 2014, Oregon became the first state to provide Medicaid coverage for adolescents receiving puberty blockers. Medicaid programs in other states, including New York and California, have also expanded transgender healthcare coverage, although that does not mean that puberty blockers always are covered.

How Early is Too Early?

Treatment with puberty blockers gives transgender children a breather so they can continue to mature and decide whether they will pursue treatment with cross-sex hormones or gender reassignment surgery. For many families, the question is not whether to intervene with blockers, but how early to start.

Because the onset of puberty varies so widely — as early as age 9 for some — suppression can begin at different ages. And that’s prompted some disagreement within the field — the “age versus stage” debate — about when to begin, according to Leibowitz. Most often blockers are initiated at the first visible signs of development as measured by the , a scale of sexual maturation developed by pediatrician James Tanner. The trigger for suppression is usually Tanner stage 2, when pubic hair and breast buds appear.

“If you are able to suspend puberty as soon as it happens you’re optimizing the benefits that it can bring physically,” said Leibowitz. Starting early may alleviate the need for surgical breast removal or voice modification therapy later on. It also makes it far easier for transgender teens to fit in. “That ability to blend in and be perceived as the gender that they identify with is associated with long-term psychological benefits,” said Leibowitz.

But does that mean that 9- or 10-year-old transgender kids should be started on puberty blockers? Even though the treatment is reversible and is considered safe, Leibowitz said some clinicians argue the age issue is important because less is known about very early interventions. How long can puberty be safely suppressed? And if the next step is transitioning with cross-sex hormones, at what age should that begin?

Of course, there is no treatment at all unless the parents of transgender children agree. “For most of my clients [who are minors], the issue revolves around whether they can start hormones or puberty blockers without parental consent, and the short answer is ‘No,”’ said Danielle Castro, a psychotherapist and project director at the Center of Excellence for Transgender Health at the University of California, San Francisco.

Castro said families of some transgender youth refuse the intervention because they believe their children are “just going through a phase.”  A in 2008 found that 43 percent of very young children who experienced gender dysphoria no longer felt that way after adolescence. The 27 percent who remained dysphoric were the ones who had felt that way most strongly when they were young.

Young children may indeed change their minds, but gender identity seems to be fixed by the time kids have reached puberty. The Endocrine Society finds that transgender adolescents grow up to be transgender adults “100 percent of the time.”  Dr. Stephen Rosenthal, director of the Child and Adolescent Gender Center at UCSF, : “Children who meet the mental health criteria for gender dysphoria in adolescence are likely to be transgender for life.”

In a of 70 participants  all the adolescents who had been given puberty blockers went through with sex reassignment.

The Standard of Care

Even though the Oakland family had agreed in advance that their daughter would start on blockers at the right time, “we had to reassure her constantly that we wouldn’t let it go too far,” she said.

When she turned 13, the girl started receiving monthly injections of Lupron, a widely prescribed sex hormone suppressor. “As soon as she started, you could just see the relief in her,” said the mother. “You could see it in her demeanor, in her mood; it was just a huge weight off her shoulders,” she said.

The family’s insurer, Kaiser Permanente, covered the treatment. Puberty blockers are considered “standard of care in the appropriate clinical circumstances,” said Erica Metz, medical director for Transgender Health at Kaiser Permanente Northern California. According to Metz, the treatment “gives patients and their families time to work with their mental health and medical providers to determine if it is appropriate to start transitioning.”

When the girl was 14, she started taking estrogen — the next step in her male-to-female transition. Instead of growing facial hair and a male physique, she developed breasts and some curves. Her voice didn’t deepen, and she doesn’t have an Adam’s apple.

The mother described her daughter as a social, outgoing and well-adjusted teenager. She knows the for transgender people — 41 percent have attempted suicide, nearly nine times the national average — and she doesn’t want to imagine a world where her daughter would be without puberty blockers, a medical intervention that she called a “lifesaver.”

“The thought of her having had to go through male puberty, I think it would have destroyed her mental health and well-being,” the mother said.

This story was produced by , which publishes , a service of the .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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