“The lines are blurred on China’s part between who constitutes a terrorist and who constitutes someone who has simply been politically active,” Mr. Small said. “Individuals who are politically and economically connected with any activities they find problematic” are likely to be targeted, he said.
The uncertain future of Uyghurs in Afghanistan has caught the attention of Abdul Aziz Naseri, a Uyghur activist who was born in Afghanistan and now lives in Turkey. Mr. Abdul Aziz said he had compiled a list of roughly 500 Afghan Uyghurs who want to leave the country.
Millions of Afghans could run out of food before the arrival of winter and one million children are at risk of starvation and death if their immediate needs are not met, top United Nations officials warned on Monday, putting the country’s plight into stark relief.
Secretary General António Guterres, speaking at a high-level U.N. conference in Geneva convened to address the crisis, said that since the Taliban takeover in Afghanistan last month, the nation’s poverty rate has soared and basic public services have neared collapse and, in the past year, hundreds of thousands of people have been made homeless after being forced to flee fighting.
“After decades of war, suffering and insecurity, they face perhaps their most perilous hour,” Mr. Guterres said, adding that one in three Afghans do not know where they will get their next meal.
The deepening humanitarian crisis tops a dizzying array of challenges confronting the new Taliban regime as it navigates governing a country propped up for decades by aid from international donors.
face potential collapse. At a local hospital in Chak-e Wardak, administrators have been unable to pay salaries or purchase new medicines with banks still closed, according to Faridullah, the facility’s resident doctor.
as drought enveloped the nation.
On Monday, in his first public remarks to Congress, Secretary of State Antony J. Blinken defended the Biden administration’s withdrawal from Afghanistan, saying there was no reason to believe the country would have stabilized had the United States remained.
“There’s no evidence that staying longer would have made the Afghan security forces or the Afghan government any more resilient or self-sustaining,” Mr. Blinken told the House Foreign Affairs Committee, in a live teleconference call. “If 20 years and hundreds of billions of dollars in support, equipment, and training did not suffice, why would another year, or five, or 10, make a difference?”
international aid workers having fled the country out of safety concerns. Those who remain are unsure if they will be able to continue their work.
During the conference on Monday, the U.N. said it needed $606 million in emergency funding to address the immediate crisis, while acknowledging that money alone will not be enough. The organization has pressed the Taliban to provide assurances that aid workers can go about their business safely. By the end of the gathering, international pledges had surpassed the amount requested.
But even as the Taliban sought to make that pledge, the U.N.’s human rights chief, Michelle Bachelet, also speaking in Geneva, said Afghanistan was in a “new and perilous phase” since the militant Islamist group seized power.
“In contradiction to assurances that the Taliban would uphold women’s rights, over the past three weeks, women have instead been progressively excluded from the public sphere,” she said, a warning that the Taliban would need to use more than words to demonstrate their commitment to aid workers’ safety.
Monday’s conference was also intended to drive home the enormousness of the crisis and offer some reassurance to Western governments hesitant to provide assistance that could legitimize the authority of a Taliban government that includes leaders identified by the U.N. as international terrorists with links to Al Qaeda.
their origin story and their record as rulers.
On Sunday, Taliban authorities sent assurances that they would facilitate humanitarian aid deliveries by road, he said.
some $12 billion in assistance to Afghanistan over four years.
While the Taliban did not have a representative in Geneva for the meeting, Zabihullah Mujahid, the Taliban’s deputy information and culture minister, said the government welcomed all humanitarian efforts by any nation, including the United States.
He also acknowledged that not even the Taliban expected to be in control of the country so quickly.
“It was a surprise for us how the former administration abandoned the government,” he said. “We were not fully prepared for that and are still trying to figure things out to manage the crisis and try to help people in any way possible.”
More than half a million Afghans were driven from their homes by fighting and insecurity this year, bringing the total number of people displaced within the country to 3.5 million, Filippo Grandi, the U.N. refugee chief said.
The danger of economic collapse raised the possibility of stoking an outflow of refugees to neighboring countries.
Said, 33, lived in Kunduz before fleeing to Kabul, where he now lives in a tent in a park. He has been there with his wife and three children for a month.
“It’s cold here, we have no food, no shelter, and we can’t find a job in this city,” he said, adding that he had not received any aid. “We all have children and they need food and shelter, and it’s not easy to live here.”
Jim Huylebroek contributed reporting from Chak-e Wardak, Afghanistan. Sami Sahak also contributed reporting.
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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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KABUL, Afghanistan — Ten days after the chaotic evacuation of Afghanistan came to an end, a lone jetliner lifted off from Kabul’s airport on Thursday, the first international passenger flight since American forces ended their 20-year presence in the country.
The departure of the chartered Qatar Airways Boeing 777, with scores of Americans, Canadians and Britons on board, was hailed by some as a sign that Taliban-ruled Afghanistan might be poised to re-engage with the world, even as reports emerged that the group was intensifying its crackdown on dissent.
“Kabul Airport is now operational,” Mutlaq bin Majed Al-Qahtani, a special envoy from Qatar’s Ministry of Foreign Affairs, said at a news conference on the tarmac.
In recent days, Qatari and Turkish personnel worked with the Taliban to repair damage and make the airport basically functional again. But just more than a week ago, the facility was a scene of frantic desperation as people jockeyed to find seats on the last commercial and military planes out.
a suicide bombing attack at the gates of the airport killed scores of Afghans and 13 U.S. service members.
Zabihullah Mujahid, a spokesman for the Taliban who joined the Qatari envoy at the news conference, said that the resumption of international flights would be critical to ensuring that much-needed aid continued to flow into the country.
China, making cautious overtures to its unstable neighbor, has pledged to give $30 million in food and other aid to the new government. But China’s foreign minister, Wang Yi, also urged the Taliban to work to contain terrorist groups.
The United Nations warned on Thursday that the freezing of billions of dollars in Afghan assets to keep it out of Taliban hands would inevitably have devastating economic consequences.
Deborah Lyons, the U.N. special envoy on Afghanistan, told the U.N. Security Council that the international community needed to find way to make these funds available to the country, with safeguards to prevent misuse by the Taliban, “to prevent a total breakdown of the economy and social order.”
a statement. “Afghans who have taken to the streets, understandably fearful about the future, are being met with intimidation, harassment and violence — particularly directed at women.”
U.S. officials said that the Americans on board the flight from Kabul on Thursday were considered the “most interested” in getting out, but said other Americans in Afghanistan would have other opportunities to leave.
Senator Angus King of Maine, an independent who sits on the Senate Intelligence and Armed Services Committees, was cautiously optimistic on Thursday morning about Americans elsewhere in Afghanistan being able to depart from the Kabul airport, although he noted the journey could be “treacherous and difficult.” But he said it was still unclear how many who wanted to leave remained in Afghanistan, or how they would get to the capital.
“I don’t want to sound like I have a great deal of confidence in the Taliban,” Mr. King said, adding, “All I can say is that it appears that, thus far, the Taliban has honored their commitment to allow Americans to leave.”
While the flight Thursday appeared to be a step toward resolving a diplomatic impasse that has left scores of Americans and other international workers stranded in Afghanistan, it was not clear if the Taliban would allow the tens of thousands of Afghans who once helped the U.S. government and now qualify for emergency U.S. visas to leave.
Taliban and foreign officials have said that Afghans with dual citizenship would be allowed to leave, but it was unclear whether any were on the first flight.
It also remained unclear whether charter flights from the airport in the northern city of Mazar-i-Sharif, where dozens of Americans and hundreds of Afghans were waiting to leave the country, would be allowed to fly.
In recent days, Secretary of State Antony J. Blinken has said that the Taliban are to blame for the grounded flights, and that they claim some passengers on the manifesto do not have the proper documentation.
Mr. Price, the State Department spokesman, said the United States had “pulled every lever” to persuade the Taliban to allow flights to depart from Mazar-i-Sharif carrying not only American citizens and legal residents but also Afghans considered to be at high risk.
“It continues to be our contention that these individuals should be allowed to depart,” he said. “At the first possible opportunity.”
Paul Mozur and Marc Santora contributed reporting.
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