Maryna Lialko had raised the girls alone after their father left the family, their grandmother, Nina Lialko, said.

“She was devoted to these two girls,” she said.

Kateryna was discharged this fall from Ohmadyt hospital, where she received psychiatric and physical therapy, and the girls are now in Kyiv living with their grandmother and aunt.

The aunt, Olha Lialko, said she has seen a shift in their personalities. Kateryna is increasingly turning inward; she speaks very little and struggles to maintain eye contact. Yuliia still can’t fully comprehend the loss.

“Katya is very closed; she keeps it all to herself,” Olha Lialko said. “Yuliia is missing mom a lot. She needs attention, she likes to cuddle.”

The family is trying to help the girls process their loss. And occasionally they see glimpses of the girls they knew before the war.

They dye their hair wild colors and play with makeup. They fight as only sisters can, and cling closely to each other for company.

But no one knows what will come next for them. Their life is on hold. They attend school online and have few friends in the new city. The family is unable to return home to Donetsk but unwilling to commit to staying in Kyiv.

“It will be very difficult for them to live without her,” their grandmother said. “This life has no sense at all.”

Oleksandra Mykolyshyn contributed reporting

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How Ukraine’s Surrogate Mothers Have Survived the War

KYIV, Ukraine — After months huddled in a basement to escape shelling, a surrogate mother named Viktoria was able to get her family, and the unborn child she carried for foreign clients, away from the fighting in northeastern Ukraine.

She could do so, she said, because her employer, a surrogacy agency, had offered financial aid and an apartment in the capital, Kyiv, to ensure her safety and the baby’s. And although she had initially been reluctant to leave her home, Kharkiv, even under artillery attacks, she is now glad to live in relative security.

“I would not have left if the clinic had not persuaded me,” she said.

Viktoria is one of hundreds of surrogate mothers who have brought pregnancies to term over seven harrowing months, running for safety as air-raid sirens sounded, surviving in bomb shelters, then fleeing from ruined towns to deliver children for parents abroad.

Before Russia invaded in February, Ukraine was a major provider of surrogacy, one of the few countries that allows it for foreign clients. After a pause in the spring, surrogacy agencies are resuming their work, reviving an industry that many childless people rely on but that critics have called exploitative and that, in peacetime, was already ethically and logistically complex.

the business would unravel — especially as Russia tried and failed to seize Kyiv in the war’s early weeks — have proved overblown. Life in western and central Ukraine has largely stabilized despite fighting in southern and eastern regions and the continued risks of long-range missile strikes.

“We did not lose a single one,” said Ihor Pechenoha, the medical director at BioTexCom, Ukraine’s largest surrogacy agency and clinic. “We managed to bring all our surrogate mothers out from under occupation and shelling.”

marooned in a basement nursery in Kyiv. For weeks and months, it was difficult or impossible for biological parents to reach their children in Ukraine, but by August, all of the babies had gone home.

The war has not diminished the appeal of surrogacy for couples desperate to have children, said Albert Tochylovsky, the director of BioTexCom. “They are in a hurry,” he said. “To explain, ‘We have a war going on,’ doesn’t work.”

Before Russia launched its full-scale invasion, BioTexCom was impregnating about 50 women per month. Since the beginning of June, the company has begun at least 15 new pregnancies.

With the money that the business brings in, Mr. Tochylovsky said, surrogate mothers have been moved from frontline towns and Russia-occupied regions to safer places, like Kyiv.

criticism that it leaves poor women vulnerable to exploitation by clients and agencies. Advocates of gestational surrogacy, in which surrogate mothers undergo in vitro fertilization to deliver the babies of clients who cannot have children on their own, say the practice is invaluable to such couples and offers a potentially life-changing sum for surrogates.

“I do it for money, but why not?” said Olha, 28, who started a new surrogate pregnancy this summer. “I have good health and can help people who have money” and want children, she added.

Before the war, the business thrived in Ukraine, where surrogate mothers typically earn about $20,000 per child they deliver. The war has made financial security even more urgent.

One 30-year-old surrogate mother, who spoke on the condition of anonymity because she had evacuated from Melitopol in Russia-occupied southern Ukraine and feared she could be targeted for reprisal, said she credited the job with getting her family out. “With the help of surrogacy,” she said, “I saved my family.”

many new quandaries for the women, clients and medical personnel. Viktoria and her family face one such dilemma: Her payment will help them survive, but it is far from clear where they should go after her recovery from a C-section. The family has remained in the apartment rented by the clinic in Kyiv; her hometown, Kharkiv, is still hit by regular shelling.

For many surrogate mothers, the question was about where to deliver. Threats included not just fighting, but how the authorities established by the Russian occupation government would handle a surrogate birth.

A surrogate named Nadia lived in a village in Russia-occupied territory that was not at risk of artillery shelling. But she decided to evacuate to Ukrainian-controlled territory to deliver the baby, lest the biological parents be deprived of custody, and she lose the fee.

She spent two days with her husband and 11-year-old daughter sleeping in a car on a roadside that is sometimes shelled, waiting to cross the front line.

Ms. Burkovska, the small-agency owner, went into the war with two stranded surrogate babies in her care. In contrast to most surrogacy agencies, she cares for newborns in her own home before biological parents pick them up. For a time, she had to shelter in a basement with the newborns, her partner and her own children.

As more babies arrived in the first months of war, she wound up with seven newborns whose biological parents could not immediately retrieve them, as travel to wartime Ukraine became difficult and as some remaining coronavirus restrictions, like China’s, caused delays.

Ms. Burkovska’s own children helped care for the infants until their parents could get them. By August, most of the parents had arrived to pick up their children.

A Chinese client with BioTexCom, Zhang Zong, was one of those who struggled to reach Kyiv through travel delays. He said the wait had been excruciating. “I was very worried because of the war,” he said.

Meeting his 6-month-old son, he said, was both thrilling and a little strange. “I was extremely excited when they let me hug him,” Mr. Zhang said. “He has been here for a long time and everyone hugs him, everyone likes him, and I am not so special.”

But he added that was only for now. “When he grows up,” Mr. Zhang said, “I can tell him this story.”

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How a Hospital Chain Used a Poor Neighborhood to Turn Huge Profits

RICHMOND, Va. — In late July, Norman Otey was rushed by ambulance to Richmond Community Hospital. The 63-year-old was doubled over in pain and babbling incoherently. Blood tests suggested septic shock, a grave emergency that required the resources and expertise of an intensive care unit.

But Richmond Community, a struggling hospital in a predominantly Black neighborhood, had closed its I.C.U. in 2017.

It took several hours for Mr. Otey to be transported to another hospital, according to his sister, Linda Jones-Smith. He deteriorated on the way there, and later died of sepsis. Two people who cared for Mr. Otey said the delay had most likely contributed to his death.

the hospital’s financial data.

More than half of all hospitals in the United States are set up as nonprofits, a designation that allows them to make money but avoid paying taxes. Although Bon Secours has taken a financial hit this year like many other hospital systems, the chain made nearly $1 billion in profit last year at its 50 hospitals in the United States and Ireland and was sitting on more than $9 billion in cash reserves. It avoids at least $440 million in federal, state and local taxes every year that it would otherwise have to pay, according to an analysis by the Lown Institute, a nonpartisan think tank.

In exchange for the tax breaks, the Internal Revenue Service requires nonprofit hospitals to provide a benefit to their communities. But an investigation by The New York Times found that many of the country’s largest nonprofit hospital systems have drifted far from their charitable roots. The hospitals operate like for-profit companies, fixating on revenue targets and expansions into affluent suburbs.

borrowing tricks from business consultants, have trained staff to squeeze payments from poor patients who should be eligible for free care.

John M. Starcher Jr., made about $6 million in 2020, according to the most recent tax filings.

“Our mission is clear — to extend the compassionate ministry of Jesus by improving the health and well-being of our communities and bring good help to those in need, especially people who are poor, dying and underserved,” the spokeswoman, Maureen Richmond, said. Bon Secours did not comment on Mr. Otey’s case.

In interviews, doctors, nurses and former executives said the hospital had been given short shrift, and pointed to a decade-old development deal with the city of Richmond as another example.

In 2012, the city agreed to lease land to Bon Secours at far below market value on the condition that the chain expand Richmond Community’s facilities. Instead, Bon Secours focused on building a luxury apartment and office complex. The hospital system waited a decade to build the promised medical offices next to Richmond Community, breaking ground only this year.

founded in 1907 by Black doctors who were not allowed to work at the white hospitals across town. In the 1930s, Dr. Jackson’s grandfather, Dr. Isaiah Jackson, mortgaged his house to help pay for an expansion of the hospital. His father, also a doctor, would take his children to the hospital’s fund-raising telethons.

Cassandra Newby-Alexander at Norfolk State University.

got its first supermarket.

according to research done by Virginia Commonwealth University. The public bus route to St. Mary’s, a large Bon Secours facility in the northwest part of the city, takes more than an hour. There is no public transportation from the East End to Memorial Regional, nine miles away.

“It became impossible for me to send people to the advanced heart valve clinic at St. Mary’s,” said Dr. Michael Kelly, a cardiologist who worked at Richmond Community until Bon Secours scaled back the specialty service in 2019. He said he had driven some patients to the clinic in his own car.

Richmond Community has the feel of an urgent-care clinic, with a small waiting room and a tan brick facade. The contrast with Bon Secours’s nearby hospitals is striking.

At the chain’s St. Francis Medical Center, an Italianate-style compound in a suburb 18 miles from Community, golf carts shuttle patients from the lobby entrance, past a marble fountain, to their cars.

after the section of the federal law that authorized it, allows hospitals to buy drugs from manufacturers at a discount — roughly half the average sales price. The hospitals are then allowed to charge patients’ insurers a much higher price for the same drugs.

The theory behind the law was that nonprofit hospitals would invest the savings in their communities. But the 340B program came with few rules. Hospitals did not have to disclose how much money they made from sales of the discounted drugs. And they were not required to use the revenues to help the underserved patients who qualified them for the program in the first place.

In 2019, more than 2,500 nonprofit and government-owned hospitals participated in the program, or more than half of all hospitals in the country, according to the independent Medicare Payment Advisory Commission.

in wealthier neighborhoods, where patients with generous private insurance could receive expensive drugs, but on paper make the clinics extensions of poor hospitals to take advantage of 340B.

to a price list that hospitals are required to publish. That is nearly $22,000 profit on a single vial. Adults need two vials per treatment course.

work has shown that hospitals participating in the 340B program have increasingly opened clinics in wealthier areas since the mid-2000s.

were unveiling a major economic deal that would bring $40 million to Richmond, add 200 jobs and keep the Washington team — now known as the Commanders — in the state for summer training.

The deal had three main parts. Bon Secours would get naming rights and help the team build a training camp and medical offices on a lot next to Richmond’s science museum.

The city would lease Bon Secours a prime piece of real estate that the chain had long coveted for $5,000 a year. The parcel was on the city’s west side, next to St. Mary’s, where Bon Secours wanted to build medical offices and a nursing school.

Finally, the nonprofit’s executives promised city leaders that they would build a 25,000-square-foot medical office building next to Richmond Community Hospital. Bon Secours also said it would hire 75 local workers and build a fitness center.

“It’s going to be a quick timetable, but I think we can accomplish it,” the mayor at the time, Dwight C. Jones, said at the news conference.

Today, physical therapy and doctors’ offices overlook the football field at the training center.

On the west side of Richmond, Bon Secours dropped its plans to build a nursing school. Instead, it worked with a real estate developer to build luxury apartments on the site, and delayed its plans to build medical offices. Residents at The Crest at Westhampton Commons, part of the $73 million project, can swim in a saltwater pool and work out on communal Peloton bicycles. On the ground floor, an upscale Mexican restaurant serves cucumber jalapeño margaritas and a Drybar offers salon blowouts.

have said they plan to house mental health, hospice and other services there.

a cardiologist and an expert on racial disparities in amputation, said many people in poor, nonwhite communities faced similar delays in getting the procedure. “I am not surprised by what’s transpired with this patient at all,” he said.

Because Ms. Scarborough does not drive, her nephew must take time off work every time she visits the vascular surgeon, whose office is 10 miles from her home. Richmond Community would have been a five-minute walk. Bon Secours did not comment on her case.

“They have good doctors over there,” Ms. Scarborough said of the neighborhood hospital. “But there does need to be more facilities and services over there for our community, for us.”

Susan C. Beachy contributed research.

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They Were Entitled to Free Care. Hospitals Hounded Them to Pay.

In 2018, senior executives at one of the country’s largest nonprofit hospital chains, Providence, were frustrated. They were spending hundreds of millions of dollars providing free health care to patients. It was eating into their bottom line.

The executives, led by Providence’s chief financial officer at the time, devised a solution: a program called Rev-Up.

Rev-Up provided Providence’s employees with a detailed playbook for wringing money out of patients — even those who were supposed to receive free care because of their low incomes, a New York Times investigation found.

nonprofits like Providence. They enjoy lucrative tax exemptions; Providence avoids more than $1 billion a year in taxes. In exchange, the Internal Revenue Service requires them to provide services, such as free care for the poor, that benefit the communities in which they operate.

But in recent decades, many of the hospitals have become virtually indistinguishable from for-profit companies, adopting an unrelenting focus on the bottom line and straying from their traditional charitable missions.

focused on investments in rich communities at the expense of poorer ones.

And, as Providence illustrates, some hospital systems have not only reduced their emphasis on providing free care to the poor but also developed elaborate systems to convert needy patients into sources of revenue. The result, in the case of Providence, is that thousands of poor patients were saddled with debts that they never should have owed, The Times found.

provide. That was below the average of 2 percent for nonprofit hospitals nationwide, according to an analysis of hospital financial records by Ge Bai, a professor at the Johns Hopkins Bloomberg School of Public Health.

Ten states, however, have adopted their own laws that specify which patients, based on their income and family size, qualify for free or discounted care. Among them is Washington, where Providence is based. All hospitals in the state must provide free care for anyone who makes under 300 percent of the federal poverty level. For a family of four, that threshold is $83,250 a year.

In February, Bob Ferguson, the state’s attorney general, accused Providence of violating state law, in part by using debt collectors to pursue more than 55,000 patient accounts. The suit alleged that Providence wrongly claimed those patients owed a total of more than $73 million.

Providence, which is fighting the lawsuit, has said it will stop using debt collectors to pursue money from low-income patients who should qualify for free care in Washington.

But The Times found that the problems extend beyond Washington. In interviews, patients in California and Oregon who qualified for free care said they had been charged thousands of dollars and then harassed by collection agents. Many saw their credit scores ruined. Others had to cut back on groceries to pay what Providence claimed they owed. In both states, nonprofit hospitals are required by law to provide low-income patients with free or discounted care.

“I felt a little betrayed,” said Bev Kolpin, 57, who had worked as a sonogram technician at a Providence hospital in Oregon. Then she went on unpaid leave to have surgery to remove a cyst. The hospital billed her $8,000 even though she was eligible for discounted care, she said. “I had worked for them and given them so much, and they didn’t give me anything.” (The hospital forgave her debt only after a lawyer contacted Providence on Ms. Kolpin’s behalf.)

was a single room with four beds. The hospital charged patients $1 a day, not including extras like whiskey.

Patients rarely paid in cash, sometimes offering chickens, ducks and blankets in exchange for care.

At the time, hospitals in the United States were set up to do what Providence did — provide inexpensive care to the poor. Wealthier people usually hired doctors to treat them at home.

wrote to the Senate in 2005.

Some hospital executives have embraced the comparison to for-profit companies. Dr. Rod Hochman, Providence’s chief executive, told an industry publication in 2021 that “‘nonprofit health care’ is a misnomer.”

“It is tax-exempt health care,” he said. “It still makes profits.”

Those profits, he added, support the hospital’s mission. “Every dollar we make is going to go right back into Seattle, Portland, Los Angeles, Alaska and Montana.”

Since Dr. Hochman took over in 2013, Providence has become a financial powerhouse. Last year, it earned $1.2 billion in profits through investments. (So far this year, Providence has lost money.)

Providence also owes some of its wealth to its nonprofit status. In 2019, the latest year available, Providence received roughly $1.2 billion in federal, state and local tax breaks, according to the Lown Institute, a think tank that studies health care.

a speech by the Rev. Dr. Martin Luther King Jr.: “If it falls your lot to be a street sweeper, sweep streets like Michelangelo painted pictures.”

Ms. Tizon, the spokeswoman for Providence, said the intent of Rev-Up was “not to target or pressure those in financial distress.” Instead, she said, “it aimed to provide patients with greater pricing transparency.”

“We recognize the tone of the training materials developed by McKinsey was not consistent with our values,” she said, adding that Providence modified the materials “to ensure we are communicating with each patient with compassion and respect.”

But employees who were responsible for collecting money from patients said the aggressive tactics went beyond the scripts provided by McKinsey. In some Providence collection departments, wall-mounted charts shaped like oversize thermometers tracked employees’ progress toward hitting their monthly collection goals, the current and former Providence employees said.

On Halloween at one of Providence’s hospitals, an employee dressed up as a wrestler named Rev-Up Ricky, according to the Washington lawsuit. Another costume featured a giant cardboard dollar sign with “How” printed on top of it, referring to the way the staff was supposed to ask patients how, not whether, they would pay. Ms. Tizon said such costumes were “not the culture we strive for.”

financial assistance policy, his low income qualified him for free care.

In early 2021, Mr. Aguirre said, he received a bill from Providence for $4,394.45. He told Providence that he could not afford to pay.

Providence sent his account to Harris & Harris, a debt collection company. Mr. Aguirre said that Harris & Harris employees had called him repeatedly for weeks and that the ordeal made him wary of going to Providence again.

“I try my best not to go to their emergency room even though my daughters have gotten sick, and I got sick,” Mr. Aguirre said, noting that one of his daughters needed a biopsy and that he had trouble breathing when he had Covid. “I have this big fear in me.”

That is the outcome that hospitals like Providence may be hoping for, said Dean A. Zerbe, who investigated nonprofit hospitals when he worked for the Senate Finance Committee under Senator Charles E. Grassley, Republican of Iowa.

“They just want to make sure that they never come back to that hospital and they tell all their friends never to go back to that hospital,” Mr. Zerbe said.

The Everett Daily Herald, Providence forgave her bill and refunded the payments she had made.

In June, she got another letter from Providence. This one asked her to donate money to the hospital: “No gift is too small to make a meaningful impact.”

In 2019, Vanessa Weller, a single mother who is a manager at a Wendy’s restaurant in Anchorage, went to Providence Alaska Medical Center, the state’s largest hospital.

She was 24 weeks pregnant and experiencing severe abdominal pains. “Let this just be cramps,” she recalled telling herself.

Ms. Weller was in labor. She gave birth via cesarean section to a boy who weighed barely a pound. She named him Isaiah. As she was lying in bed, pain radiating across her abdomen, she said, a hospital employee asked how she would like to pay. She replied that she had applied for Medicaid, which she hoped would cover the bill.

After five days in the hospital, Isaiah died.

Then Ms. Weller got caught up in Providence’s new, revenue-boosting policies.

The phone calls began about a month after she left the hospital. Ms. Weller remembers panicking when Providence employees told her what she owed: $125,000, or about four times her annual salary.

She said she had repeatedly told Providence that she was already stretched thin as a single mother with a toddler. Providence’s representatives asked if she could pay half the amount. On later calls, she said, she was offered a payment plan.

“It was like they were following some script,” she said. “Like robots.”

Later that year, a Providence executive questioned why Ms. Weller had a balance, given her low income, according to emails disclosed in Washington’s litigation with Providence. A colleague replied that her debts previously would have been forgiven but that Providence’s new policy meant that “balances after Medicaid are being excluded from presumptive charity process.”

Ms. Weller said she had to change her phone number to make the calls stop. Her credit score plummeted from a decent 650 to a lousy 400. She has not paid any of her bill.

Susan C. Beachy and Beena Raghavendran contributed research.

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Arizona Judge: State Can Enforce Near-Total Abortion Ban

The ruling means the state’s abortion clinics will have to shut down and anyone seeking an abortion will have to go out of state.

Arizona can enforce a near-total ban on abortions that has been blocked for nearly 50 years, a judge ruled Friday, meaning clinics statewide will have to stop providing the procedures to avoid the filing of criminal charges against doctors and other medical workers.

The judge lifted a decades-old injunction that blocked enforcement of the law on the books since before Arizona became a state. The only exemption to the ban is if the woman’s life is in jeopardy.

The ruling means the state’s abortion clinics will have to shut down and anyone seeking an abortion will have to go out of state. The ruling takes effect immediately, although an appeal is possible. Planned Parenthood and two other large providers said they were halting abortions.

Abortion providers have been on a roller coaster since the U.S. Supreme Court in June overturned the landmark 1973 Roe v. Wade decision guaranteeing women a constitutional right to an abortion. At first providers shut down operations, then re-opened, and now have to close again.

Planned Parenthood had urged the judge not to allow enforcement, and its president declared that the ruling “takes Arizonans back to living under an archaic, 150-year-old law.”

“This decision is out of step with the will of Arizonans and will cruelly force pregnant people to leave their communities to access abortion,” said Alexis McGill Johnson, Planned Parenthood Federation of America’s president and CEO, said in a statement.

Republican Attorney General Mark Brnovich, who had urged the judge to lift the injunction so the ban could be enforced, cheered.

“We applaud the court for upholding the will of the Legislature and providing clarity and uniformity on this important issue,” Brnovich said in a statement. “I have and will continue to protect the most vulnerable Arizonans.”

The ruling comes amid an election season in which Democrats have seized on abortion rights as a potent issue. Sen. Mark Kelly, under a challenge from Republican Blake Masters, said it “will have a devastating impact on the freedom Arizona women have had for decades” to choose an abortion. Democrat Katie Hobbs, who is running for governor, called it the product of a decadeslong attack on reproductive freedom by Republicans that can only be fended off by voters in November.

Masters and Kari Lake, the Republican running against Hobbs, both back abortion restrictions. Their campaigns had no immediate comment.

Pima County Superior Court Judge Kellie Johnson ruled more than a month after hearing arguments on Brnovich’s request to lift the injunction.

The near-total abortion ban was enacted decades before Arizona secured statehood in 1912. Prosecutions were halted after the injunction was handed down following the Roe decision. Even so, the Legislature reenacted the law in 1977.

Assistant Attorney General Beau Roysden told Johnson at an Aug. 19 hearing that since Roe has been overruled, the sole reason for the injunction blocking the old law is gone and she should allow it to be enforced. Under that law, anyone convicted of performing a surgical abortion or providing drugs for a medication abortion could face two to five years in prison.

An attorney for Planned Parenthood and its Arizona affiliate argued that allowing the pre-statehood ban to be enforced would render more recent laws regulating abortion meaningless. Instead, she urged the judge to let licensed doctors perform abortions and let the old ban only apply to unlicensed practitioners.

The judge sided with Brnovich, saying that because the injunction was issued in 1973 only because of the Roe decision, it must be lifted in its entirety.

“The Court finds an attempt to reconcile fifty years of legislative activity procedurally improper in the context of the motion and record before it,” Johnson wrote. “While there may be legal questions the parties seek to resolve regarding Arizona statutes on abortion, those questions are not for this Court to decide here.”

In overturning Roe on June 24, the high court said states can regulate abortion as they wish.

A physician who runs a clinic providing abortions said she was dismayed but not surprised by the decision.

“It kind of goes with what I’ve been saying for a while now –- it is the intent of the people who run this state that abortion be illegal here,” Dr. DeShawn Taylor said. “Of course we want to hold onto hope in the back of our minds, but in the front of my mind I have been preparing the entire time for the total ban.”

Republicans control the Legislature, and GOP Gov. Doug Ducey is an abortion opponent who has signed every abortion law that reached his desk for the past eight years.

Johnson, the judge, said Planned Parenthood was free to file a new challenge. But with Arizona’s tough abortion laws and all seven Supreme Court justices appointed by Republicans, the chances of success appear slim.

What’s allowed in each state has shifted as legislatures and courts have acted since Roe was overturned. Before Friday’s ruling, bans on abortion at any point in pregnancy were in place in 12 Republican-led states.

In another state, Wisconsin, clinics have stopped providing abortions amid litigation over whether an 1849 ban is in effect. Georgia bans abortions once fetal cardiac activity can be detected. Florida and Utah have bans that kick in after 15 and 18 weeks gestation, respectively.

The ruling came a day before a new Arizona law banning abortions after 15 weeks of pregnancy takes effect. Signed by Ducey in March, the law was enacted in hopes that the Supreme Court would pare back limits on abortion regulations. Instead, it overturned Roe.

Ducey has argued that the new law he signed takes precedence over the pre-statehood law, but he did not send his attorneys to argue that before Johnson.

The old law was first enacted among a set of laws known as the “Howell Code” adopted by 1st Arizona Territorial Legislature in 1864. Arizona clinics have been performing about 13,000 abortions a year.

Additional reporting by the Associated Press.

Source: newsy.com

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Why Is There A Shortage Of Psychiatrists?

As the number of people dealing with mental health challenges increases, it’s putting a strain on psychiatrists and mental health professionals.

More American adults are seeking resources for help in getting treatment for mental health. A new CDC survey finds the trend is higher among adults 18 to 44. 

But with an increase in patients comes a new strain on mental health professionals, on psychiatrists. 

The Association of American Medical Colleges says the current shortfall is at 6%. That’s expected to be between 14,000 and 32,000 psychiatrists by 2024.  

Forensic psychiatry specialist Dr. Abdi Tinwalla, as president of the Illinois Psychiatric Society, has seen how the shortage of psychiatrists has reached a crisis point.  

“The prevalence of mental illness in the population is increasing, the American population is increasing. So year over year so far we have more doctors going into retirement than doctors coming into the workforce,” said Tinwalla. 

Another factor in the shortage, he says, is feeding the pipeline — as in residencies. These take place after medical school in a hospital or clinic and provide doctors with crucial hands-on training.

Dr. Tinwalla says there’s growing interest in the field but financial barriers are posing steep challenges. 

“This year itself there were twice the number of people wanting to go in than the seats they had available. The biggest barrier for that is funding and, you know, the government funding for these programs has not increased in the last couple of years,” said Tinwalla.   

It’s actually been decades. The Balanced Budget Act of 1997 capped the number of residents each teaching hospital is eligible to receive Medicare-funded reimbursements for. 

Individual institutions are responsible for any additional slots. Though there is a new federal push to bolster the medical workforce. The “Resident Physician Shortage Reduction Act”, which Democratic Senator Bob Menendez introduced in 2021, would expand Medicare funding for thousands of residency positions. 

But despite support from medical groups and organizations, the bill’s future is uncertain, with minimal movement since introduced. 

The demands of the job are also pushing some psychiatrists to rethink their careers.  

A 2022 meta-analysis published in the Journal of Affective Disorders found that nearly half of psychiatrists experience burnout.  

It cited lack of resources and lack of autonomy as contributors to feelings of professional exhaustion.  

“Part of us experience it in our lives, if we don’t deal with it appropriately it does lead to shortage in our careers so I definitely think burnout so if you ask me if it’s a real phenomenon? It’s a yes,” said Tinwalla. 

Despite the reasons for the shortage, Dr. Tinwalla say he sees solutions including collaborative care which involves a team approach. 

“Collaborative care has been popular in the last decade, its the care in which is given by the primary care physician in his office, in collaboration with a behavioral care manager and a psychiatrist is a consultant over the phone or video or whatever,” he said. 

He also says technology is opening doors for treatment with telemedicine. And he’s encouraged insurers are more likely to cover mental health appointments than in years past.  

“Well I’m hoping with the collaborative care model and hopefully with the telepsychiatry we are doing we are going to bridge some of those care gaps that we are having right now,” he said.  

Source: newsy.com

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4.4M Americans Roll Up Sleeves For Omicron-Targeted Boosters

Some Americans who got the new shots said they are excited about the idea of targeting the vaccine to the variants circulating now.

U.S. health officials say 4.4 million Americans have rolled up their sleeves for the updated COVID-19 booster shot. The Centers for Disease Control and Prevention posted the count Thursday as public health experts bemoaned President Joe Biden’s recent remark that “the pandemic is over.”

The White House said more than 5 million people received the new boosters by its own estimate that accounts for reporting lags in states.

Health experts said it is too early to predict whether demand would match up with the 171 million doses of the new boosters the U.S. ordered for the fall.

“No one would go looking at our flu shot uptake at this point and be like, ‘Oh, what a disaster,'” said Dr. David Dowdy, an infectious disease epidemiologist at Johns Hopkins Bloomberg School of Public Health. “If we start to see a large uptick in cases, I think we’re going to see a lot of people getting the (new COVID) vaccine.”

A temporary shortage of Moderna vaccine caused some pharmacies to cancel appointments while encouraging people to reschedule for a Pfizer vaccine. The issue was expected to resolve as government regulators wrapped up an inspection and cleared batches of vaccine doses for distribution.

“I do expect this to pick up in the weeks ahead,” said White House COVID-19 coordinator Dr. Ashish Jha. “We’ve been thinking and talking about this as an annual vaccine like the flu vaccine. Flu vaccine season picks up in late September and early October. We’re just getting our education campaign going. So we expect to see, despite the fact that this was a strong start, we actually expect this to ramp up stronger.”

Some Americans who plan to get the shot, designed to target the most common Omicron strains, said they are waiting because they either had COVID-19 recently or another booster. They are following public health advice to wait several months to get the full benefit of their existing virus-fighting antibodies.

Others are scheduling shots closer to holiday gatherings and winter months when respiratory viruses spread more easily.

Retired hospital chaplain Jeanie Murphy, 69, of Shawnee, Kansas, plans to get the new booster in a couple of weeks after she has some minor knee surgery. Interest is high among her neighbors from what she sees on the Nextdoor app.

“There’s quite a bit of discussion happening among people who are ready to make appointments,” Murphy said. “I found that encouraging. For every one naysayer there will be 10 or 12 people who jump in and say, ‘You’re crazy. You just need to go get the shot.'”

President Biden later acknowledged criticism of his remark about the pandemic being over and clarified the pandemic is “not where it was.” The initial comment didn’t bother Murphy. She believes the disease has entered a steady state when “we’ll get COVID shots in the fall the same as we do flu shots.”

Experts hope she’s right, but are waiting to see what levels of infection winter brings. The summer ebb in case numbers, hospitalizations and deaths may be followed by another surge, Dowdy said.

Dr. Anthony Fauci, asked Thursday by a panel of biodefense experts what still keeps him up at night, noted that half of vaccinated Americans never got an initial booster dose.

“We have a vulnerability in our population that will continue to have us in a mode of potential disruption of our social order,” Fauci said. “I think that we have to do better as a nation.”

Some Americans who got the new shots said they are excited about the idea of targeting the vaccine to the variants circulating now.

“Give me all the science you can,” said Jeff Westling, 30, an attorney in Washington, D.C., who got the new booster and a flu shot on Tuesday, one in each arm. He participates in the combat sport jujitsu, so wants to protect himself from infections that may come with close contact. “I have no issue trusting folks whose job it is to look at the evidence.”

Meanwhile, President Biden’s pronouncement in a “60 Minutes” interview broadcast Sunday echoed through social media.

“We still have a problem with COVID. We’re still doing a lot of work on it. But the pandemic is over,” President Biden said while walking through the Detroit auto show. “If you notice, no one’s wearing masks. Everybody seems to be in pretty good shape. And so I think it’s changing.”

By Wednesday on Facebook, when a Kansas health department posted where residents could find the new booster shots, the first commenter remarked snidely:

“But Biden says the pandemic is over.”

The president’s statement, despite his attempts to clarify it, adds to public confusion, said Josh Michaud, associate director of global health policy with the Kaiser Family Foundation in Washington.

“People aren’t sure when is the right time to get boosted. ‘Am I eligible?’ People are often confused about what the right choice is for them, even where to search for that information,” Michaud said.

“Any time you have mixed messages, it’s detrimental to the public health effort,” Michaud said. “Having the mixed messages from the president’s remarks, makes that job that much harder.”

University of South Florida epidemiologist Jason Salemi said he’s worried the president’s pronouncement has taken on a life of its own and may stall prevention efforts.

“That soundbite is there for a while now, and it’s going to spread like wildfire. And it’s going to give the impression that ‘Oh, there’s nothing more we need to do,'” Salemi said.

“If we’re happy with 400 or 500 people dying every single day from COVID, there’s a problem with that,” Salemi said. “We can absolutely do better because most of those deaths, if not all of them, are absolutely preventable with the tools that we have.”

New York City photographer Vivienne Gucwa, 44, got the new booster Monday. She’s had COVID twice, once before vaccines were available and again in May. She was vaccinated with two Moderna shots, but never got the original boosters.

“When I saw the new booster was able to tackle Omicron variant I thought, ‘I’m doing that,'” Gucwa said.

“I don’t want to deal with Omicron again. I was kind of thrilled to see the boosters were updated.”

Additional reporting by The Associated Press.

Source: newsy.com

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California Takes Steps To Further Legalize Weed

California workers won’t have to worry about being fired, or not hired, for off-the-clock marijuana use.

A new phase of California’s weed legalization begins, as the state prepares to make it illegal for a company to fire, or not hire, someone simply for their off-the-clock marijuana use. 

California is the seventh state to do it, but a potentially pivotal one for the national attitude toward weed. 

At the very least it’s an emboldening step for the millions of California adults who report using marijuana. 

At a cannabis store near San Diego, it could mean a tax boom. 

The elimination of job risk helps boost usage numbers. 

“There were a lot of myths and stigma associated with cannabis and with having a cannabis store in the community. So it’s nice to see that none of those myths came true and a lot of that stigma is starting to disappear,” said David Dallal, a California cannabis store manager. 

Cannabis industry insiders and even some law enforcement hope that destigmatizing weed will push more weed users to shop at legitimate dispensaries.

It could be a potentially life-saving choice as fentanyl-laced drugs flow over the southern border and end up on the black market. 

But the stigma around marijuana is still a challenge for people like Dr. David Berger, who’s trying to battle a new restriction in Florida that limits the amount of medical marijuana a person can get in a day. 

“Some of my patients for instance, because of their medical needs, they might need to have more milligrams than what the state is allowing for,” said Berger.  

Florida is allowing doctors to appeal the limit for those who need it. But that takes time — a potentially-serious wait for users who need the drug.

“If a person is out of their medicine they could be out of their medicine for a good week or almost two and really have no way of accessing it,” said Berger.

It’s a deep contrast to the new reality in California, where lawmakers hope making marijuana irrelevant to employability will set a new standard for the country. 

Source: newsy.com

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How Disability Misunderstandings And Stigma Impact Mental Well-Being

Disability experts say it’s common for doctors to misunderstand bodily autonomy, which can impact a person’s mental health.

CDC data shows about 26% of Americans live with a disability, whether it’s physical or mental.  

 Conditions like anxiety, spinal injury, ADHD, amputation, depression, cerebral palsy — these are just some examples.  

 Advocates say there’s a lot of misunderstanding about a person who has a disability. And that stigma not only runs deep — it can also have a huge impact on that individual’s mental health. 

Twenty-eight-year-old New Yorker Chloé Valentine Toscano knows beauty, from walking in fashion week to her Instagram reels to publishing in magazines like Allure. 

“I’m a writer. I’m someone who likes the color pink. I like butterflies. I like learning a lot about anyone and anything,” she said. “I think we all have differences, and I want to understand differences. … For me, beauty is just being open-minded,” she said.

She also has fought face-to-face with ugly mental health struggles caused by doctors who didn’t understand disability.  

“It is a journey,” Valentine Toscano said.

She lost motor function from her elbow down in 2014. She adapted and spent years living with — as she calls it — dead weight. She got into paralypmic swimming and started her career.  

Then, after years of researching and soul searching, she chose to amputate her arm. 

“I know amputation can be very traumatic because some people, a lot of people,will experience it through trauma,” she said. “But that wasn’t where I was in my case. So, it wasn’t traumatic talking about it, but it was traumatic playing a game with the yeses and the nos.”

Valentine Toscano spent three years fighting to get her procedure. She says some surgeons told her any elective amputation was too risky, even though she was healthy. Other rejections came after her surgery had been approved and scheduled. 

“The answer I got from one, he said, ‘Well, some people just need to learn to live with what they’ve got.’ That made me feel like someone else who wasn’t in my body was telling me what was better for me,” she said. “It felt very frustrating to have it and very offensive to have someone say that.”

Bodily autonomy — or the right to control what happens to your body — is a common struggle in the disability community. And disability experts say misunderstanding that is common, and can cause undue stress as well as impact a person’s mental well-being.  

In Valentine Toscano’s story, it happened a few times. 

She recounted that in one appointment: “I cried, I broke down and I felt like the minute I expressed that emotion, he sent me in for a psych evaluation, which felt like I was being punished for expressing emotion.” And then she described the examination, saying: “She was asking me, she said, ‘Do you find that you’re unattractive because of your arm and that you would be more attractive without it?’ And I was like, ‘It’s not about that at all. It’s never been about that.’ … I felt angry and belittled and just, not heard, because I was asking for one thing and being evaluated for something that wasn’t even remotely there.”

Clinical Psychologist Dr. Linda Mona has spent the past two decades working on disability and how it relates to health care.  

“If you haven’t been exposed to it personally — you have not been exposed to it through being a family friend, a lover, whoever that might be — And you’re not called to do it professionally and you don’t see it around you, you don’t think about it.”

She says, unfortunately, Valentine Toscano’s experience is all too common. Mental health experts with lived experience or expertise in disability are rare. 

“It can be quite challenging to find somebody,” Mona said. “The other thing to think about is the steps that come before that, which is that it’s very hard for people to access education if they have disability, let alone graduate school. And internship and fellowship…”

Sixty-one million U.S. adults, which is about one in 4, have some type of disability, according to the CDC.  

A 2021 anonymous survey of graduating medical students showed 7.6% identified as having a disability.  But data collected directly from medical schools show that only about 4% of medical students disclosed their disability.  

That stigma against disability —physical or mental — runs deep. 

From 1867 to 1974 U.S. cities had laws governing who could be in public. Codes included fining or jailing those deemed “diseased, maimed, mutilated, or anyway deformed.”

Mona says it’s federal bias favoring able-bodied people.

“You’re best at home. You’re best tucked away. Or, you’re best institutionalized out of the way of anybody else who is displeased with the way that you look,” she said.

She adds structural stigmas fueled misconceptions about disabled people’s decision-making about their own bodies. 

NEWSY’S LINDSEY THEIS: When we talk about bodily autonomy, what type of impact cannot have long term on someone’s mental well-being?  

LINDA MONA: Trying to bring that in and make your choices can have a huge effect on your mental health in the long run. … It also happens a lot with pregnancy and people with disabilities. Right? So, you know, somebody has some kind of cognitive mental difference or physical difference. There’s, you know, constant questioning about, you know, ‘you want to be pregnant? You know what that’s going to do to your body?’ … I don’t think anybody thinks those types of decisions are a simple decision. They’re complex. But you have to trust that somebody has made that made that decision with that context in mind and not assume that they’re uninformed.

In summer 2021, Valentine Toscano had her amputation surgery. She calls it a dream come true.  

“I just felt happy,” she said. “I was like, ‘Oh my gosh.’ I got this is like a huge step in my life. It just felt like one of those, like, huge dreams. I got there. I got a huge part of my personality back immediately.”

Valentine Toscano uses a prosthetic, as needed. It’s bright pink and purple with a lot of glitter.  

“If I could have decided to have been born with an arm with butterflies and sparkles on it, like right out of the womb, I would have picked that,” she said. 

 Valentine Toscano said her prosthetic cost $13,000.

“It’s something that’s very expensive,” she said. “I was fortunate to have it covered by health insurance. But that’s not something everyone has.”

Valentine Toscano continues to advocate and write, sharing her experience now from two different sides of disability. She’s also writing a book on the side.  

She says the ability to share those stories in her voice and having others listen is not only good for her well-being, it’s truly beautiful.

Source: newsy.com

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Doctors Are Still Hunting For The Cause Of Long COVID Brain Fog

Studies show 30% of COVID patients report brain fog a few months after they’re sick. It’s 65 to 85% for long-haulers sick beyond that.

COVID-related brain fog is a condition that can feel very defeating and overwhelming. 

Newsy’s Lindsey Theis has COVID-related brain fog herself. And it’s a topic she’s covered since 2020. She says each person she’s spoken with tells her it’s a dramatic change that impacts how they think and move throughout their lives. For this story, Theis met a family dealing with what she says is one of the worst cases she’s ever seen. 

On a bright, sunny day in rural Rensselaer, Indiana, 45-year-old Kari Lentino’s mind is a slow-moving storm. 

“I feel like a brain blizzard half the time,” she said. 

Lentino is immunocompromised. She’s had COVID twice. Since June 2021, it’s left her with several neurological setbacks. She says her brain fog is among the worst of it. 

“I couldn’t remember passwords to get into certain systems. I worked at the library and I would forget what I was doing while I was doing it,” Lentino said. 

Her conversations now go at a snail’s pace as she searches for words. 

The mother of four and grandmother of two had to quit work and file for disability. 

She can’t watch her grandkids. She won’t run errands or drive. Now, her time is spent mothering her brain. 

Dr. Igor Koralnik is chief of neuro-infectious diseases and co-director of the Northwestern Medicine Comprehensive COVID-19 Center, where he also runs a lab. 

He says 70% of his COVID brain fog patients are like Lentino — women in their early 40s. 

“We see that attention is their main cognitive problem,” he said. “Problem with attention, problem with memory, problem with multitasking and briefly, problems getting through their daily life and working in their current job capacity. …  We have people who have been infected back in March 2020 and still have decreased quality of life because of those symptoms and decreased cognitive function.”

Scientists think COVID cognitive dysfunction is from brain inflammation — but what causes it is still itself foggy.

One leading theory is that long COVID is an autoimmune disorder, where the immune system attacks healthy cells in the body, including the brain. 

“We find that the virus has confused the immune system, and we think that it’s driving the immune system towards autoimmunity,” Koralnik explained.

Studies show 30% of COVID patients report brain fog a few months after they’re sick. It’s 65 to 85% for long-haulers sick beyond that.  

Researchers haven’t found brain fog treatments yet, so they tackle someone’s symptoms. 

But even diagnosing brain fog is tricky. It’s invisible. There’s no set case definition but it can include trouble focusing, struggling to remember names, places, or words, reacting slowly, confused judgment, losing a train of thought often and fatigue or exhaustion from concentrating.  

Back in Rensselaer, Lentino’s husband helps her prepare her pills. She takes eight medications and two vitamins daily, plus a handful more as needed. That’s in addition to her therapies and memory aids like calendars and post it notes. Those cues share spots in the Lentino home near the signs of her former creative and vibrant self. Prescription bottles near her paintings. Reminders near her Star Wars string art. 

“It’s frustrating and depressing. It takes so long to do anything,” she said. 

In the spot where she used to stand to paint, brushes and acrylics wait patiently. 

Lentino is waiting too, like so many brain fog sufferers. It’s a long, draining wait and the ultimate test of patience.  

On a hopeful note, research shows many brain fog patients recover memory and attention near the 6-to-9-month mark. For treatment, some doctors prescribe medicine, like steroids or antihistamines, plus therapies like speech or cognitive rehabilitation therapy. If you have brain fog yourself, experts say you can try memory games and puzzles, and focus on quality sleep and healthy eating. 

Source: newsy.com

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