“I think a lot of times we are so focused on wanting to get good results that we just have tunnel vision,” she said.
Ms. Ng lives across from a testing center. Almost daily, she watched a constant stream of people go in for tests, a strategy that many public health experts say is a waste of resources in such a highly vaccinated country.
“Freedom Day — as our ministers have said — is not the Singapore style,” said Jeremy Lim, an associate professor at the National University of Singapore and an expert on health policy, referring to England’s reopening in the summer. But moving too cautiously over the potential disadvantages of restrictions is a “bad public health” strategy, he said.
The handwritten doctor’s order was just eight words long, but it solved a problem for Dundee Manor, a nursing home in rural South Carolina struggling to handle a new resident with severe dementia.
David Blakeney, 63, was restless and agitated. The home’s doctor wanted him on an antipsychotic medication called Haldol, a powerful sedative.
“Add Dx of schizophrenia for use of Haldol,” read the doctor’s order, using the medical shorthand for “diagnosis.”
But there was no evidence that Mr. Blakeney actually had schizophrenia.
Antipsychotic drugs — which for decades have faced criticism as “chemical straitjackets” — are dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections, falls and other ailments. But understaffed nursing homes have often used the sedatives so they don’t have to hire more staff to handle residents.
one in 150 people.
Schizophrenia, which often causes delusions, hallucinations and dampened emotions, is almost always diagnosed before the age of 40.
“People don’t just wake up with schizophrenia when they are elderly,” said Dr. Michael Wasserman, a geriatrician and former nursing home executive who has become a critic of the industry. “It’s used to skirt the rules.”
refuge of last resort for people with the disorder, after large psychiatric hospitals closed decades ago.
But unfounded diagnoses are also driving the increase. In May, a report by a federal oversight agency said nearly one-third of long-term nursing home residents with schizophrenia diagnoses in 2018 had no Medicare record of being treated for the condition.
hide serious problems — like inadequate staffing and haphazard care — from government audits and inspectors.
One result of the inaccurate diagnoses is that the government is understating how many of the country’s 1.1 million nursing home residents are on antipsychotic medications.
According to Medicare’s web page that tracks the effort to reduce the use of antipsychotics, fewer than 15 percent of nursing home residents are on such medications. But that figure excludes patients with schizophrenia diagnoses.
To determine the full number of residents being drugged nationally and at specific homes, The Times obtained unfiltered data that was posted on another, little-known Medicare web page, as well as facility-by-facility data that a patient advocacy group got from Medicare via an open records request and shared with The Times.
The figures showed that at least 21 percent of nursing home residents — about 225,000 people — are on antipsychotics.
The Centers for Medicare and Medicaid Services, which oversees nursing homes, is “concerned about this practice as a way to circumvent the protections these regulations afford,” said Catherine Howden, a spokeswoman for the agency, which is known as C.M.S.
“It is unacceptable for a facility to inappropriately classify a resident’s diagnosis to improve their performance measures,” she said. “We will continue to identify facilities which do so and hold them accountable.”
significant drop since 2012 in the share of residents on the drugs.
But when residents with diagnoses like schizophrenia are included, the decline is less than half what the government and industry claim. And when the pandemic hit in 2020, the trend reversed and antipsychotic drug use increased.
A Doubled Risk of Death
For decades, nursing homes have been using drugs to control dementia patients. For nearly as long, there have been calls for reform.
In 1987, President Ronald Reagan signed a law banning the use of drugs that serve the interest of the nursing home or its staff, not the patient.
But the practice persisted. In the early 2000s, studies found that antipsychotic drugs like Seroquel, Zyprexa and Abilify made older people drowsy and more likely to fall. The drugs were also linked to heart problems in people with dementia. More than a dozen clinical trials concluded that the drugs nearly doubled the risk of death for older dementia patients.
11 percent from less than 7 percent, records show.
The diagnoses rose even as nursing homes reported a decline in behaviors associated with the disorder. The number of residents experiencing delusions, for example, fell to 4 percent from 6 percent.
A Substitute for Staff
Caring for dementia patients is time- and labor-intensive. Workers need to be trained to handle challenging behaviors like wandering and aggression. But many nursing homes are chronically understaffed and do not pay enough to retain employees, especially the nursing assistants who provide the bulk of residents’ daily care.
Studies have found that the worse a home’s staffing situation, the greater its use of antipsychotic drugs. That suggests that some homes are using the powerful drugs to subdue patients and avoid having to hire extra staff. (Homes with staffing shortages are also the most likely to understate the number of residents on antipsychotics, according to the Times’s analysis of Medicare data.)
more than 200,000 since early last year and is at its lowest level since 1994.
As staffing dropped, the use of antipsychotics rose.
Even some of the country’s leading experts on elder care have been taken aback by the frequency of false diagnoses and the overuse of antipsychotics.
Barbara Coulter Edwards, a senior Medicaid official in the Obama administration, said she had discovered that her father was given an incorrect diagnosis of psychosis in the nursing home where he lived even though he had dementia.
“I just was shocked,” Ms. Edwards said. “And the first thing that flashed through my head was this covers a lot of ills for this nursing home if they want to give him drugs.”
Homes that violate the rules face few consequences.
In 2019 and 2021, Medicare said it planned to conduct targeted inspections to examine the issue of false schizophrenia diagnoses, but those plans were repeatedly put on hold because of the pandemic.
In an analysis of government inspection reports, The Times found about 5,600 instances of inspectors citing nursing homes for misusing antipsychotic medications. Nursing home officials told inspectors that they were dispensing the powerful drugs to frail patients for reasons that ranged from “health maintenance” to efforts to deal with residents who were “whining” or “asking for help.”
a state inspector cited Hialeah Shores for giving a false schizophrenia diagnosis to a woman. She was so heavily dosed with antipsychotics that the inspector was unable to rouse her on three consecutive days.
There was no evidence that the woman had been experiencing the delusions common in people with schizophrenia, the inspector found. Instead, staff at the nursing home said she had been “resistive and noncooperative with care.”
Dr. Jonathan Evans, a medical director for nursing homes in Virginia who reviewed the inspector’s findings for The Times, described the woman’s fear and resistance as “classic dementia behavior.”
“This wasn’t five-star care,” said Dr. Evans, who previously was president of a group that represents medical staff in nursing homes. He said he was alarmed that the inspector had decided the violation caused only “minimal harm or potential for harm” to the patient, despite her heavy sedation. As a result, he said, “there’s nothing about this that would deter this facility from doing this again.”
Representatives of Hialeah Shores declined to comment.
Seven of the 52 homes on the inspector general’s list were owned by a large Texas company, Daybreak Venture. At four of those homes, the official rate of antipsychotic drug use for long-term residents was zero, while the actual rate was much higher, according to the Times analysis comparing official C.M.S. figures with unpublished data obtained by the California advocacy group.
make people drowsy and increases the risk of falls. Peer-reviewed studies have shown that it does not help with dementia, and the government has not approved it for that use.
But prescriptions of Depakote and similar anti-seizure drugs have accelerated since the government started publicly reporting nursing homes’ use of antipsychotics.
Between 2015 and 2018, the most recent data available, the use of anti-seizure drugs rose 15 percent in nursing home residents with dementia, according to an analysis of Medicare insurance claims that researchers at the University of Michigan prepared for The Times.
in a “sprinkle” form that makes it easy to slip into food undetected.
“It’s a drug that’s tailor-made to chemically restrain residents without anybody knowing,” he said.
In the early 2000s, Depakote’s manufacturer, Abbott Laboratories, began falsely pitching the drug to nursing homes as a way to sidestep the 1987 law prohibiting facilities from using drugs as “chemical restraints,” according to a federal whistle-blower lawsuit filed by a former Abbott saleswoman.
According to the lawsuit, Abbott’s representatives told pharmacists and nurses that Depakote would “fly under the radar screen” of federal regulations.
Abbott settled the lawsuit in 2012, agreeing to pay the government $1.5 billion to resolve allegations that it had improperly marketed the drugs, including to nursing homes.
Nursing homes are required to report to federal regulators how many of their patients take a wide variety of psychotropic drugs — not just antipsychotics but also anti-anxiety medications, antidepressants and sleeping pills. But homes do not have to report Depakote or similar drugs to the federal government.
“It is like an arrow pointing to that class of medications, like ‘Use us, use us!’” Dr. Maust said. “No one is keeping track of this.”
published a brochure titled “Nursing Homes: Times have changed.”
“Nursing homes have replaced restraints and antipsychotic medications with robust activity programs, religious services, social workers and resident councils so that residents can be mentally, physically and socially engaged,” the colorful two-page leaflet boasted.
Last year, though, the industry teamed up with drug companies and others to push Congress and federal regulators to broaden the list of conditions under which antipsychotics don’t need to be publicly disclosed.
“There is specific and compelling evidence that psychotropics are underutilized in treating dementia and it is time for C.M.S. to re-evaluate its regulations,” wrote Jim Scott, the chairman of the Alliance for Aging Research, which is coordinating the campaign.
The lobbying was financed by drug companies including Avanir Pharmaceuticals and Acadia Pharmaceuticals. Both have tried — and so far failed — to get their drugs approved for treating patients with dementia. (In 2019, Avanir agreed to pay $108 million to settle charges that it had inappropriately marketed its drug for use in dementia patients in nursing homes.)
‘Hold His Haldol’
Ms. Blakeney said that only after hiring a lawyer to sue Dundee Manor for her husband’s death did she learn he had been on Haldol and other powerful drugs. (Dundee Manor has denied Ms. Blakeney’s claims in court filings.)
During her visits, though, Ms. Blakeney noticed that many residents were sleeping most of the time. A pair of women, in particular, always caught her attention. “There were two of them, laying in the same room, like they were dead,” she said.
In his first few months at Dundee Manor, Mr. Blakeney was in and out of the hospital, for bedsores, pneumonia and dehydration. During one hospital visit in December, a doctor noted that Mr. Blakeney was unable to communicate and could no longer walk.
“Hold the patient’s Ambien, trazodone and Zyprexa because of his mental status changes,” the doctor wrote. “Hold his Haldol.”
Mr. Blakeney continued to be prescribed the drugs after he returned to Dundee Manor. By April 2017, the bedsore on his right heel — a result, in part, of his rarely getting out of bed or his wheelchair — required the foot to be amputated.
In June, after weeks of fruitless searching for another nursing home, Ms. Blakeney found one and transferred him there. Later that month, he died.
“I tried to get him out — I tried and tried and tried,” his wife said. “But when I did get him out, it was too late.”
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GRANTHAM, England — Daniela Espirito Santo died after waiting on hold for the police to answer her call for help.
It was the seventh time in a year that she had reported her boyfriend to the police, including for death threats and for trying to strangle her. Two of those calls came in the hours before her death. The first was in the morning, after her boyfriend pinned her on the bed and pressed his forearm against her throat.
“Is this it?” Ms. Espirito Santo, 23, had gasped, according to a police report. “Are you going to kill me this time?”
The police took him into custody but quickly released him. He returned to Ms. Espirito Santo’s apartment and soon afterward she called the police to report that he had assaulted her again. The dispatcher told her that her situation wasn’t urgent, because the boyfriend had left. He directed her to a nonemergency hotline and hung up after 94 seconds.
during the first month of Britain’s lockdown — more than triple the number in that month the previous year, and the highest figure in a decade. But it also illustrates another flaw in British authorities’ efforts to address violence against women: the repeated failure of prosecutors to punish abusers.
Initially charged with manslaughter, the boyfriend, Julio Jesus, then 30, was eventually sentenced to only 10 months behind bars. The Crown Prosecution Service, the national public prosecutor, dropped its manslaughter charge because of complicating medical opinions about the condition of Ms. Espirito Santo’s heart, and convicted him on two counts of serious assault. He was released before England’s coronavirus lockdowns had ended.
“There was a litany of failures where once again a woman’s voice hasn’t been listened to,” said Jess Phillips, a Labour lawmaker who speaks for the opposition on domestic violence policy. “This case shows nothing is changing, even though victims keep being promised it is.”
fewer than 2 percent of rape cases and 8 percent of domestic abuse cases reported to the police in England and Wales are prosecuted, even as complaints are rising.
The nation was shocked earlier this year when a police officer confessed to kidnapping, raping and murdering Sarah Everard, a 33-year-old marketing executive who was abducted while walking home in South London. The crime underscored the vulnerability felt by many British women and their concern that the police and prosecutors are failing to protect them.
Parliament recently approved new legislation on domestic abuse. But changing policing and public attitudes has proved difficult for decades. Failings and missed opportunities by the police often remain hidden.
Ms. Espirito Santo’s case fit that pattern. Her death in Grantham, a market town in the largely rural English county of Lincolnshire, received little outside attention and was regarded as a tragedy, not a scandal. An inquest into her death is in limbo. Lincolnshire Police — a small force covering a wide area with a sparse but often deprived population — refused an interview, as did the Crown Prosecution Service.
But an investigation by The New York Times lays bare the escalating abuse Ms. Espirito Santo reported, gives a rare insight into police failings and raises questions about the decision by prosecutors to drop the manslaughter charge. The Times has obtained a confidential 106-page report compiled by the Independent Office for Police Conduct, an official watchdog, into the Lincolnshire force’s handling of the case.
The report documents Ms. Espirito Santo’s ever more desperate interactions with the police, revealing a haphazard response as her situation worsened. It noted that some male officers felt sympathetic toward Mr. Jesus before releasing him on bail, including one who said his “biggest concern” was the boyfriend’s mental health.
government failings on domestic abuse at the start of Britain’s lockdowns, which left victims trapped at home with abusers and isolated from family and friends. The rules were especially constricting for people with serious health conditions, like Ms. Espirito Santo, who had to pause her job at a nursing home.
“Daniela’s case is a scandalous failing by the police to recognize someone who was at an increasing risk of domestic homicide,” Ms. Wistrich said. “But it is sadly illustrative of many cases we see.”
Lincolnshire Police refused to answer even written questions, citing concerns about prejudicing a future inquest. A spokesperson for the Crown Prosecution Service said it was determined to improve the handling of crimes against women and girls and to “narrow the gap” between “reports of these terrible offenses and cases reaching court.”
Ms. Espirito Santo’s story — pieced together by The Times through the confidential report, other documents and more than a dozen interviews — is of a yearlong cry for help that went unheard.
“Everything happened because the police didn’t help Daniela when she rang,” said Isabel Espirito Santo, Ms. Espirito Santo’s mother. “If the police had helped more, I think she could still be here.”
Ms. Espirito Santo was pregnant with her second child when she first reported Mr. Jesus to the police. It was May 19, 2019, and she told officers that he had threatened to kill her, that he was violent and controlling and “excessively jealous.”
examination of domestic abuse complaints stated that it was officers’ job to “build the case for the victim, not expect the victim to build the case for the police.”
‘Is This It?’
Fifteen hours before she died, Ms. Espirito Santo made her penultimate call to the police. It was 9:48 a.m. She told the operator that Mr. Jesus had thrown her on the bed and grabbed her neck, leaving a mark. He had left, but not before pinning her with the front door and threatening to kill her. When two officers arrived, she agreed to support a prosecution.
She told the officers that she had “lost count” of how often Mr. Jesus had assaulted her, often squeezing her neck so tightly that she struggled to breathe. She said that he sometimes slammed her against furniture, that he had once broken her finger, and that she was afraid he might kill her.
Two hours later, Mr. Jesus was arrested, crying as he was taken into custody. Later that afternoon, Ms. Espirito Santo called Ms. Price-Wallace and said the police had told her that Mr. Jesus would be released pending a charging decision.
can qualify as manslaughter if it leads to a death, even if the killing was unintentional. Those found guilty can face up to life in prison.
But prosecutors decided to drop the charge after a cardiologist hired by Mr. Jesus’s lawyers argued that while the assault could have caused the heart failure, so could a verbal argument.
Prosecutors concluded that they could no longer meet the tests for a manslaughter conviction by proving that the heart failure was caused by an assault, a spokesperson for the Crown Prosecution Service said.
That was despite the fact Ms. Espirito Santo had reported an assault, not an argument, minutes before her death; despite Mr. Jesus’s admission that he had assaulted her that morning; and despite her history of domestic violence complaints.
The official watchdog report on Lincolnshire Police found that the “decision making of its officers may have influenced the circumstances of the events” around Ms. Espirito Santo’s death, if not caused it, and blamed officers for a “lack of detailed consideration of Mr. Jesus’s situation” on release.
Yet the report did not recommend disciplinary action and mentioned only one “potential learning recommendation” — for a formal policy around sending calls to the nonemergency number, a change that has been introduced. In a statement to The Times, the watchdog agency said it had also made “learning” recommendations for two officers on how they interacted with Mr. Jesus.
Domestic Abuse Act. It was a response to growing outrage over failures in abuse cases. For the first time, the law established that nonfatal strangulation — which Ms. Espirito Santo repeatedly reported — is a criminal offense, bringing up to five years in prison.
Since such strangulation usually does not leave marks, the police often fail to recognize it as a serious crime. Prosecutors, in turn, do not bring more serious charges. Advocates for abuse victims have welcomed the law but say it will change little unless police and public prosecutors are educated in using it, and given proper resources.
On July 5, on what would have been Ms. Espirito Santo’s 25th birthday, her mother and two dozen others scattered her ashes at her favorite spot, a lake in the Lincolnshire countryside. Her grandmother gave a reading in Portuguese by the water’s edge. Her mother wept.
“I didn’t get justice in court,” she said. “But I believe in justice of the gods.”
www.thehotline.org. In the United Kingdom, call 0808 2000 247, or visit www.nationaldahelpline.org.uk.
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Ms. Carreon-John noted that more than a third of the U.S. track and field women’s roster is made up of Nike athletes. “Individual situations of a handful of athletes are not representative of Nike’s support of women’s sport,” she said, adding, “No footwear, apparel or equipment manufacturer provides the level of support Nike provides to women’s sport, period.”
To be sure, Nike is a huge company and has supported a sprawling number of athletes for decades. “Nike has done a lot of great things, but sometimes when you’re the big brand, there are more opportunities to get things wrong at the end of the day,” said Merhawi Keflezighi, founder of HAWI Management, who represented Mr. Berian and manages Ms. Pappas. He commended the company for changing its policies for pregnant athletes and added that since 2016, the industry has become less aggressive about reduction clauses in contracts.
The new sponsorship opportunities are arising as the athletic apparel market continues to grow — a trend further fueled by the pandemic. Athleta and Lululemon were among the rare apparel brands that saw sales soar last year. In the running world, there were five to six brands that were more visible at the U.S. Olympic trials in Eugene, Ore., in June than in the past, Ms. Neuburger of Lululemon said.
“The athletic sportswear and athleisure market is transforming from growth to maturity with newer and rising entrants,” said Angeline Close Scheinbaum, associate professor of marketing at Clemson University. “So naturally, a shift in athlete endorsers from the market leader to other brands is occurring.”
Dr. Scheinbaum said that she viewed the trend as less of an exodus from established leaders and more about “athletes, especially women, joining a smaller brand that can become synonymous with these star athletes and their platforms and stories.”
Indeed, brands that are pursuing elite women athletes are keen to embrace their backgrounds and causes that matter to them. Ms. Cain said that the most famous women athletes have often become household names because they have an “and” tied to their performance — “athlete and activist” or “athlete and mental health advocate,” she said.
“Unless you have five different ways to sell yourself, you’re just not valued monetarily in the same way as the white dude next to you is,” she said. While that dynamic is unfair, she said, it has created a situation where women athletes often have bigger and more engaged followings online, and more brands are starting to take notice of that.
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