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I am a family therapist. Something new is happening in the relationship.



Questions of guilt hovered over another couple I worked with. He recently cheated on his wife. In general, they deeply supported each other, but after she found out about his misdeed, she was terribly upset and also confused. Their attempts to talk about what happened were unsuccessful. The #MeToo rhetoric was woven into their discussions, functioning like a superego, shaping and suppressing what they might even think. She said she felt the lessons of the movement were telling her not to forgive, but to leave him: “Especially now, if a woman has been hurt, you leave.” It was difficult for her to understand how she really felt about this. Before, he could not separate remorse from fear. He was afraid of getting into trouble, and guilt took over. His voice was hushed as he scrutinized me, worried about how he would be perceived: “There are a lot of men in this business now who have taken positions of power and are using them to have sex with people.”

They were both white, understood their privileges and apologized for it. She often overruled her own complaints—”I’m levitating”—with the thought, “Oh, poor cis-white woman.” He was also uncomfortable. He spoke of reading the news “about the murder of another black or brown person. And I just feel a little — well, I feel guilty, to be honest, for sitting here.” The lessons of the Black Lives Matter movement can initially provoke such a paralyzing sense of guilt and shame that people become defensive and stop thinking. However, over time, I have found that ideas can inspire deep psychological work, forcing people to think about the harm done, who should be involved, and the difference between virtual cues and deeper concerns. These are tough and important lessons that can be transferred to intimate relationships. In this case, the husband described a new understanding of how he exercised power at work: “Wait. Was I an ally? Was it just optics? These insights even extended to the way he talked about his wrongdoing. He rationalized his behavior by saying that his wife was not giving him the attention he deserved. But going beyond what the couple called “optics,” he now asked himself to explain more carefully what his infidelity really was and how it affected his wife. He explained how lonely he was when she travelled; he felt abandoned and abandoned, a feeling deeply familiar to him from early childhood. It was hard for him to admit his vulnerability, but it started a series of frank conversations between them. “I myself am convinced that she does not want me,” he said. “I’m not a popular guy. I’m not a strong guy.” He attributed these feelings to the insecurities he experienced as a teenager, when he was constantly teased by kids at school for being seen as effeminate.

This new, non-defensive way of speaking made her realize how his transgression had hurt her where she felt most insecure, and he could see it, engendering remorse and forgiveness between them. She described how it became easier for both of them to “check” themselves for their influence on the other person and quickly “notice or apologize”. At one of the sessions, she said, smiling: “Yesterday you were rude to me, and then a couple of hours later you apologized. You realized that you took your frustration out on me because I was an easy target.” He realized he had stopped losing sight of how he had hurt others: “I was actually just thinking about therapy and the Black Lives Matter movement made me acutely aware of the words that had just come out of my mouth and understanding that she reacted negatively to that instead of simply saying, “We’re moving on because it’s embarrassing.” Now we need to do this.” He continued, “Did I just upset you? What have I done to upset you?”

couples work always returns to the challenge of otherness. Differences may emerge around philosophical questions, such as what is important to dedicate one’s life to or whether it is ethical to have children in the face of an impending climate crisis; or it may be closer to home, such as whether it is acceptable to have sexual fantasies about a person who is not your partner; or even something as seemingly trivial as the correct way to load a dishwasher. Whatever the issue, disagreement can be the point of crisis in a relationship. The question of who is right, who is getting their way, or who is better at dealing with reality is immediately raised, narcissistic vulnerabilities in self-esteem appear, which then trigger the impulse to devalue the other. Partners try to find a way out of such impasses by working hard to convince the other of their own position, becoming even more polarized.

The challenge of difference is most easily seen when we think of racial differences. This is certainly true for James and Michelle. Michel was a calm, gentle, somewhat reserved African-American social worker, and James, then a police officer, was a thin, wiry white man whose face did not express much emotion. They came in with classic conflicts over division of labor and different parenting styles, and then the pandemic hit. While in quarantine, working remotely, and homeschooling their 3-year-old son, they started arguing about Covid protocols. Michelle knew how Covid was destroying black communities and wanted to be careful. James, along with his fellow police officers and conservative parents, believed that the concern was exaggerated. The discussion about how race influenced the experience and ideas of James and Michelle usually ended in a dead end. If Michelle tried to bring up the subject, James insisted, “I don’t see the color,” and said he didn’t understand what she was talking about. In our sessions, Michelle sounded hopeless: she wanted him to understand how traumatic Covid was for black people. But she was frustrated by his inability to recognize real difference, as if everyone were of the same race. “He thinks like this: “I don’t see color.” She went on to state his thoughts: “I don’t want to hear what you have to say, because I don’t think so.” view “Obviously angers me,” she said. James shrugged impassively. Michelle described the infuriating experience of trying to break through the barrier: her husband did not realize that whiteness was a perspective that limited his imagination or understanding.


Pandemic learning loss needs urgent attention in US, national survey finds



A little boy in math class is overwhelmed during the COVID-19 pandemic. (Getty images)

According to a recent survey of 26 million K-8 students by researchers at Stanford, Johns Hopkins, Dartmouth and Harvard, the “educational harm” caused by the coronavirus pandemic has been “devastating.” The researchers also found that the pandemic has “exacerbated economic and racial disparities in education,” as lead authors Tom Kane of Harvard and Sean Reardon of Stanford wrote in a New York Times essay accompanying the publication of their findings last week.

Standardized test scores also showed American students losing ground in math, reading, history and social studies. But the new findings, which are part of the Education Recovery Scorecard, add important — and worrisome — context, as well as a call for urgent action.

Top line

In a survey of 7,800 communities in 40 states and Washington, DC, Kane, Reardon and colleagues Found out that between 2019 and 2022, the average “US public school student in grades 3-8 lost the equivalent of half a year of math and a quarter of a year of reading.”

Long-standing educational disparities also played a role: the less wealthy and white a community was, the more likely it was to suffer losses from the pandemic. It means the so-called gap in education what politicians have been desperately trying to shut down is only getting wider.

Consequences of school closures

An empty playground at a public school in New York, November 2020. (Wang Ying/Xinhua via Getty)

By the fall of 2020, it was clear that children were not contracting serious or fatal cases of COVID-19. Schools also did not become the sites of the massive outbreaks that some feared. However, in many districts, especially those controlled by Democrats, schools remained closed to in-person instruction until 2021.

By the end of 2022, researchers found that distance learning causes marked learning loss. In a summary of their findings, the authors of the Education Recovery Scorecard reinforce the evidence for this correlation.

“Counties that spent more time on distance learning in 2020-2021 suffered big losses,” they write.

And these losses, they found, were especially noticeable in communities where parents were employed in “essential” jobs that took them away from home. the result of labor obligations.

social capital

A young girl sits at a desk and participates in a video call with her teacher through a laptop.  (Getty images)

Child on videoconference with his teacher. (Getty images)

Kane, Reardon and their colleagues do not blame distance learning for all the learning losses they noted. Taking a more subtle stance, they argue that community-level factors also played a role.

In communities with higher COVID death rates, losses in math were more noticeable. Especially in the early stages of a pandemic. deaths were concentrated in communities of color with multi-generational households and limited access to green spaces.

Not surprisingly, children fared better if they had access to broadband internet. Asian and white households are more likely to have such high-speed connections, other studies have concluded.

Similarly, communities where adults voted and households participated in the US Census tended to have lower learning losses.

In general, institutional trust also mattered. The researchers write that communities where the majority of residents trusted institutions “may have been more willing to cooperate with their local schools and reduce disruption to student learning.”

Distrust may have been fueled by a number of factors, including the spread of pandemic-related political disinformation and suspicions stemming from deep-seated biases.

Overall, the study found that communities with a certain degree of cohesion and institutional involvement tend to provide a kind of safety net for children. “Communities with greater social capital, greater civic and volunteer participation, and greater connections among residents could better maintain social connections among residents and better support schools and households,” write the authors of the Education Recovery Scorecard.

What’s next?

Elementary students follow their teachers down the corridor to their classroom.

Ellis Elementary School students follow their teacher Megan Westmore to her classroom on August 22, 2022 in Denver. (R.J. Sangosti/Denver Post via Getty Images)

Educators across the country have been desperate to catch up with students with intensive teaching and other forms of correction. But this may not be enough. The authors of the sobering Education Recovery Scorecard say better education is needed. And they point to an offer that may not be very popular with students: summer school.

“It seems clear that we need to approach recovery as an ongoing effort,” they write. “In order to fully recover, districts will need to continue to invest the agreed funds into student education in the coming years.”

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Rural District Choice: Use opioid funds to pay down debt or overpay them up front to curb the crisis



Over the past two years, rural Greene County in northeast Tennessee has raised more than $2.7 million from regional and national communities with opioid manufacturers and distributors. But instead of helping people suffering from addiction, county officials are finding other ways to spend them.

They have put 2.4 million dollars to pay off the county’s debt and have directed another 1 million dollars arrived for more than ten years in the capital projects fund. In March, they allocated $50,000 from that fund to buy a “garbage truck,” a pickup truck used by inmates to collect trash along the county’s roads.

“It’s amazing,” said Nancy Schneck, a retired nurse who has seen addiction creep into a society where employers avoid drug testing for fear of losing too many employees, and mental health crises and homelessness are rampant. She wants the money to go towards mental health and addiction treatment. Why can’t county leaders “see that it can be beneficial to treat some people and maybe get them out of this cycle?” She said.

In 2021, the latest year for which comparable data is available, Green County’s drug overdose death rate exceeded state and national rates.

But Mayor Kevin Morrison said the county has been taking on the costs of the opioid epidemic for years: it has funded a beleaguered sheriff’s office, improved a prison that’s filled with people who have committed addiction crimes, and supported a drug court to redirect some people into care. It has also suffered the indirect costs of the crisis: people are leaving their jobs due to addiction, schools and social services are caring for more traumatized children, and some taxpayers are leaving the county altogether. Drug addiction is not the only cause of Green County’s economic problems, but it has contributed to more than 30 million dollars debt.

Greene County, Tennessee is putting some of its opioid money into the county’s capital projects fund. In March, $50,000 of that fund was set aside for the purchase of a “garbage truck,” a pickup truck used to transport prisoners who are tasked with picking up trash on the side of the road. The new truck hasn’t been used yet, but looks exactly like this white truck, the sheriff’s office says. (Green County Sheriff’s Office)

“We’ve been facing this crisis for quite some time, but nobody wants to pay the bills when they come,” Morrison said. “So when these funds become available, we are paying bills that should have been paid for quite some time now.”

The debate in this Appalachian county is resonating across the country as state and local governments receive billions of dollars from companies that made, distributed or sold opioid painkillers, such as Johnson & Johnson, Cardinal Health and CVS. The companies have been accused of fueling the overdose epidemic, and the money is earmarked to remedy that harm. About 3 billion dollars already landed to state, county, and city coffers, with about $50 billion more expected over the next decade and beyond.

States are required to spend at least 85% of money on opioid-related programs, but KFF Health News’s ongoing investigation into how money is being used – and misused – shows that this standard is widely interpreted and there is little oversight.

This restriction did not apply to Green County money transferred to its capital projects fund.

In many rural communities that have struggled for decades to cover the costs of addiction, local authorities justify using settlement funds to recoup past costs. Most of Tennessee’s 95 counties are heavily indebted, he said, which could make it difficult to decide how to use the money. Robert Packco-director of the Addiction Science Center at East Tennessee University.

However, he and many of his supporters hope that the settlement funds will be spent on fighting the current crisis. after all, more than 200 people across the country die of overdose every day. Investments in treatment and prevention can save lives and protect future generations, they say.

“There is no good reason to sit on funds or put them in a general fund,” he said. Trisha Christensenpolitical director of the non-profit Community Education Group. Organization tracking of estimated expenses through the Appalachians, which Christensen called the epicenter of the epidemic. “These dollars should be used to support the people most affected by the overdose crisis.”

At the national level, settlement dollars were largely ignored. The administration of President Joe Biden has promised to secure funds to address the addiction crisis, but has taken little action. Accountability at the state level varies.

In Tennessee, 15% of the state’s opioid settlement funds are controlled by the legislature and another 15% by local governments. These two buckets have several limitations.

The remaining 70% are controlled Opioid Council, which has more stringent standards. When the council, which must give 35% of its funds to local governments, recently over $31 million given away districts, required funds to be spent on list of approved interventionssuch as building recovery housing and expanding drug treatment for uninsured people.

“I can guarantee that we are going to chase these funds,” he said. Stephen Loyd, chairman of the board and physician recovering from opioid addiction. If the counties use them for unauthorized purposes, he said, the counties will not receive payments in the future.

Green County’s reimbursement of its capital projects fund comes from its own pocket – 15%, which is entirely controlled by the local government.

In such cases, the public can hold officials accountable, Loyd said. “If you don’t like how the money is being spent, you have the option to vote.”

According to him, local leaders, as a rule, do not show “vileness” in these decisions. They make hundreds of budget choices a month and simply don’t have the addiction experience or health care policy to guide their use of the money.

Loyd and other local experts are trying to fill this gap. He meets with county officials and encourages them to talk to local anti-drug coalitions or hold listening sessions to hear from community members. Pack from East Tennessee urges them to expand access to medicines that proven effectiveness in the treatment of opioid dependence.

Both men point counties to online ecosystem recovery indexwhere leaders can see how their area’s recovery resources compare to those of others.

For example, in Greene County, the index shows that there are no recovery homes and the number of treatment facilities and mental health care providers per 100,000 residents is below the state and national averages.

“It’s a great place to start,” Loyd said.

Some Green County residents want opioid funds to go to local initiatives that are already in place. V Green County Anti-Drug Coalition, for instance, hosts performances to educate young people and their parents on the risks of drug use. They are meeting with convenience store owners to stress the importance of banning the sale of alcohol, cigarettes or vaping devices to minors. In the future, the coalition hopes to offer classes on life skills such as budgeting and decision making under stress.

“If we can do preventive work with children, we can change the trajectory of their adult life,” he said. Wendy Peisecretary of the anti-drug coalition and executive director of the United Way of Greene County.

The coalition has requested settlement funds from the county, but has yet to receive them.

The Green County Anti-Drug Coalition holds presentations at local schools and community events to educate youth and their parents about the risks of drug use. Despite the request, as of April 2023, the coalition has not received any funds from the county to settle opioids. (Wendy Pei/Green County Narcotics Coalition)

A woman in a black and white top with dark trousers and sneakers stands on the branches of a tree.

Greene County, Tennessee resident Nancy Schneck wants opioid settlement funds used for addiction treatment and mental health. She says it’s “amazing” that most of the money so far has gone to pay off the county’s debt. (Paul Ferrari)

Nearby in Carter County, a new inpatient treatment facility. takes shape on the site of the former prison. At least seven counties, cities, and towns in the region have committed a total of $10 million in opioid settlement funds to support it. stacy street, the criminal judge who came up with the idea. Green County is one of the few local governments that has not contributed.

It will become part of a regional drug enforcement system that sends drug addicts who commit crimes to resuscitation rather than prison.

There are currently no long-term homes for such patients in the area, Street said. Too often, people in his yard heal during the day and return home at night, “to the same sandbox, playing with the same sandboxes,” which increases the risk of relapse.

Street said the new facility would not offer drugs to treat opioid addiction – the gold standard of medical care – due to safety concerns. But some patients may be transported off-campus for appointments.

Morrison, the mayor of Green County, said he was worried about the contribution to the facility because it’s a recurring expense and funds for the settlement will stop coming in 2038.

“There is a lot of pressure on local organizations like Greene County to try to solve this problem with this limited amount of funding,” he said, when “the federal government, which has the ability to print money to solve these problems, is not in a position to this business.”

The county is still deciding how to spend nearly $334,000 of the settlement funds it recently received from the State Opioid Board. Morrison said they are considering using it for anti-drug coalition and district drug court outreach activities. Given the recommendations of the emission control board, these funds cannot be used to pay off old debts.

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Masking confers small reduction in COVID risk, review concludes



The use of masks in both community settings and health care settings may slightly reduce the risk of contracting COVID-19, but the evidence base leaves much to be desired, the final setting is alive, a quick review of the few studies found.

“The reliability of the evidence for a reduced risk of SARS-CoV-2 infection with surgical masks compared with no masks remained low based on two previous randomized controlled trials (adjusted prevalence rate 0.89, 95% CI 0.78–0.997 and OR 0. 82, 95% CI 0.52-1.23) and two observational studies, and this is not enough for N95 respirators versus no mask, or cloth mask versus no mask,” wrote Roger Chow, MD, and Tracey Dana , MLS, both from the Oregon Health and Science University in Portland, in Annals of Internal Medicine.

“There were no new studies and insufficient evidence to support surgical and cloth masks and N95 versus surgical masks,” they added.

“While the focus is on higher quality research, the evidence base still has important limitations,” Chow and Dana said. “Randomized controlled trials (RCTs) were few and had some inaccuracies and methodological flaws. In addition, RCTs have evaluated interventions to encourage or encourage mask use and have been designed pragmatically, improving applicability but potentially dampening the intended effects due to suboptimal compliance and overlap.”

Ninth in the series

This article was the ninth in a series of reviews; the first eight looked at a total of two RCTs and 10 observational studies, Chou and Dana explained. “While preparing Update 8, we were aware of the completed RCT of N95 versus surgical masks and were planning for a final update once it was published. The goal of this update is to include this RCT and other new research.”

A total of three RCTs and 21 observational studies were included.

The authors sought answers to two questions: What is the effectiveness and comparative effectiveness of respirators (N95 or equivalent), face masks (surgical), and cloth masks in addition to standard community and healthcare precautions (high versus low risk) settings to prevent SARS-CoV infection -2? And what is the evidence for prolonged or repeated use of N95 respirators to prevent SARS-CoV-2 infection?

To get an answer, they searched PubMed, MEDLINE, and Elsevier EMBASE for relevant studies; they also searched medRxiv and reviewed lists of links to relevant articles. The search for the latest update was conducted from June 2022 to January 2023.

Although they found no new studies on mask use versus no use, one good quality Danish RCT (n = 6024) found that recommending mask use was associated with a small but not statistically significant reduction in COVID risk based on antibody testing. , polymerase chain reaction (PCR) testing, or hospital diagnosis at 1 month (1.8% vs 2.1%; OR 0.82, 95% CI 0.54–1.23).

Chow and Dana reported that there were no differences in mask effects based on age (≤48 vs >48 years), gender, or daily time away from home (≤4.5 vs >4.5 hours). “Furthermore, mask compliance was suboptimal (46% as recommended, 47% predominantly as recommended) and widespread use of other infection control measures may have offset the benefits.”

Benefits of disguise

In studies related to community settings, “observational studies of masks versus no masks consistently found masks to be associated with a reduced risk of SARS-CoV-2 infection, but had methodological limitations and some inaccuracy,” the authors write. “Evidence regarding surgical and cloth masks or more masks versus less consistent mask use is still insufficient.”

In healthcare settings, “a new RCT showed that the effect of instructions for the use of surgical masks is not inferior to instructions for the use of N95 respirators for routine patient care,” they added. “However, non-inferiority was defined as less than a doubling of risk, with a CI corresponding to a risk increase of up to 70%. Due to the imprecision of a single study, the strength of the evidence was low. In addition, RCTs may have reported diminished benefits of N95 respirators in healthcare settings due to infections acquired in the community or at home.”

The researchers listed several limitations in their review. In addition to not attempting a meta-analysis, “we did not formally assess publication bias due to heterogeneity and small numbers of studies for most comparisons,” Chow and Dana wrote. “We limited inclusion to articles in English and excluded environmental and mask policy studies that did not provide information on individual mask use that could provide additional information.”

“Additional studies will refine the comparative effectiveness of masks in preventing SARS-CoV-2 infection,” they added. “Future studies should have sufficient statistical power for primary as well as stratified analysis. Evaluation of masks as a source control is a challenge requiring evaluation of SARS-CoV-2 infections in masked and unmasked communities. Studies should use appropriate methods for diagnosing SARS. -CoV-2, describe the main characteristics of the mask, assess adherence, and evaluate the harm as well as the benefit.”

in on accompanying editorial, annals Editor-in-Chief Christine Lane, MD, and Associate Editor Stephanie Chang, MD, said many questions about masks remain unanswered.

“There is evidence that masks can work to prevent COVID-19, but significant gaps remain as to whether they work and under what conditions,” they wrote. “In the face of future viral outbreaks, we must act quickly to fill the gaps with timely research that avoids the limitations of research done to date. We may never reach the final truth about when the benefits of masking interventions outweigh the harms, but it is imperative that we design studies that fill in information gaps, interpret evidence accurately, and be honest about what we know and what we don’t know. with confidence in making decisions and establishing policies regarding camouflage.”

Masking in health settings is highly recommended

In the accompanying opinionTara Palmore, MD, from George Washington University in Washington, DC, and David Henderson, MD, from the National Institutes of Health, said it would be unwise to stop wearing masks in medical settings.

“Real experience shows the effectiveness of wearing masks in a clinical setting,” they noted. “Thanks in large part to the universal wearing of masks and the use of other personal protective equipment, medical personnel are at much greater risk of contracting COVID-19 from the community than from professional contacts. Transmission from patient to staff and from staff to patient when both are wearing masks does occur, but is unusual.”

They added that “presenteeism”—going to work even when sick—is a well-known problem among clinicians. In an unpublished study conducted at the National Institutes of Health that included contact tracing interviews and subsequent testing for COVID among employees who tested positive, “more than 50% subsequently admitted to having some symptoms consistent with COVID-19 at the time of testing,” written by Palmore and Henderson. . “These data highlight the problem of presenteeism and emphasize the appropriateness of masking.”

However, despite these physicians testing positive, “no transmission to patients has been identified at the facility,” requiring the wearing of masks for physicians and patients, they added.

“In our quest to return to the look and feel of normalcy, and as institutions decide which mitigation strategies to discontinue, we strongly advocate not abandoning this important lesson learned for the safety of our patients.” they concluded.

  • Joyce Frieden oversees coverage of MedPage Today in Washington, including coverage of Congress, the White House, the Supreme Court, health trade associations, and federal agencies. She has 35 years of experience in health policy. Follow

Information disclosure

Zhou reports on relationships with the Agency for Medical Research and Quality and WHO. Dana reported no conflicts of interest.

Lane and Chang reported a relationship with the American College of Physicians; they are editor-in-chief and deputy editor respectively Annals of Internal Medicine.

Palmor reported relationships with NIH, Rigel, Gilead, AbbVie, American Society for Medical Epidemiology, UpToDate and Infection control and hospital epidemiology. Henderson reports that he was the former president of the Medical Epidemiology Society of America.

main source

Annals of Internal Medicine

Link to source: Chow R, Dana T. “Major Update: Masks for SARS-CoV-2 Prevention in Healthcare and Community Settings – Live Rapid Review Definitive Update” Ann Intern Med 2023; DOI: 10.7326/M23-0570.

secondary source

Annals of Internal Medicine

Link to source: Lane S, Chang S. “Learning the Truth About the Effectiveness of Masks in Preventing COVID-19”, Ann Intern Med 2023; DOI: 10.7326/M23-1120.

Additional source

Annals of Internal Medicine

Link to source: Palmore T, Henderson D. “For the sake of patient safety, this is not the time to remove masks in healthcare facilities” Ann Intern Med 2023; DOI: 10.7326/M23-1190.

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