Tuesday, December 28, 2021

Tutu: a man of empathy, moral ardor, and some silly jokes

By CHRISTOPHER TORCHIA

Anglican Archbishop Emeritus Desmond Tutu. When Tutu died Sunday, Dec. 26, 2021 at age 90, he was remembered as a Nobel laureate, a spiritual compass, a champion of the anti-apartheid struggle who turned to other global causes after Nelson Mandela, another moral heavyweight, became South Africa's first Black president. (AP Photo/Themba Hadebe, File)

One Christmas Day in the 1980s, Desmond Tutu led a packed church service in Soweto, the Black Johannesburg township and fulcrum of protest against white racist rule in South Africa. An American family — mine — found standing room at the back.

We were among the few white people in the congregation and, as we shook hands with Tutu on the steps upon leaving, he made a joke. Something like: “So, it really is a white Christmas.”

Evoking the Irving Berlin song ’’White Christmas,” famously crooned by Bing Crosby, in tense, dusty Soweto was quintessential Tutu. He couldn’t resist a pun about race in an inflamed country suffering the agonies of apartheid, the system of white minority domination that was extinguished in 1994.

(Actually, every once in a very long while, it has snowed in Johannesburg, but certainly not at Christmas time, which falls in the Southern Hemisphere’s summer).

When Tutu died Sunday at age 90, he was remembered as a Nobel laureate, a spiritual compass, a champion of the anti-apartheid struggle who turned to other global causes after Nelson Mandela, another moral heavyweight, became South Africa’s first Black president. Barack Obama praised Tutu for fighting injustice wherever he saw it.

But the former U.S. president also recalled the activist’s ″impish sense of humor.″ And it is that Desmond Tutu — the funny, kind, gracious man behind the icon — whom I and so many others recall.

To see Tutu up close was to bask in his rollercoaster laughter, to revel as his eyes would widen theatrically, to luxuriate in his pristinely enunciated remarks, and to come away infused with the man’s joy and warmth. If he had a chance to dance, usually in church, he was on his feet — with the help of a cane in later years, as he grew more frail.

He seemed to embody the best of what it is to be human, at a granular level. The small generosities, the willingness to listen, the empathy, lightening the mood with … let’s face it, some pretty silly jokes.

He kept that up through grim times in South Africa, showing anger and frustration too at dehumanizing state policies, the violence of white-controlled security forces and the killing within Black communities as apartheid, a scourge that he described as ’’evil,” played out bitterly.

Not everyone was a fan. His moral ardor ran up against realpolitik. His notion of the ″rainbow nation,″ an idealized vision of racial tolerance, is at odds with the social and economic imbalances of South Africa today.

But he always reached out, always looked for and found the humanity in people. In advance of a small service at St. George’s Cathedral in 2015, participants were asked to send photos of themselves; I watched as Tutu went around the congregation, asking each person to say a little about themselves.

I was a boy on that Christmas Day when Tutu riffed on Bing Crosby, and my father was reporting for The Associated Press in South Africa. In 1989, my parents moved to Stockholm. A few months before they departed, a postcard arrived with Tutu’s scrawl on the back.

’’Go well. Thanks for your splendid service,” he wrote. “Will miss you. Will certainly try to see you in Sweden. God bless you.”

In time, I became a journalist and also worked for the AP in South Africa, sometimes covering Tutu’s post-apartheid commentary on corruption and other challenges, as well as his hospitalizations for the prostate cancer that afflicted him for nearly a quarter century.

I would recall the one time he visited our Johannesburg home for dinner. He didn’t stay long. He was charming, easygoing.

Afterwards, he sent us another postcard. On the front was an elephant; on the back was something that could be taken both as a bread-and-butter note and as an unintended valedictory from a remarkable man who, even at age 90, left the world too soon.

“Just an inadequate note to thank you very much for your kind hospitality,” he wrote. “I enjoyed myself and was sorry to have to leave early. God bless you.”

It was signed, simply, “Desmond.”

Torchia reported from South Africa for the AP from 2013 to 2019. He is currently based in Mexico City.

Young South Africans learn of Tutu’s activism for equality

By MOGOMOTSI MAGOME and ANDREW MELDRUM

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A woman is comforted outside the historical home of Anglican Archbishop Desmond Tutu, in Soweto, Johannesburg, South Africa, Monday, Dec. 27, 2021. South Africa's president says Tutu, South Africa's Nobel Peace Prize-winning activist for racial justice and LGBT rights and the retired Anglican Archbishop of Cape Town, died Sunday at the age of 90. (AP Photo/Shiraaz Mohamed)

JOHANNESBURG (AP) — Archbishop Desmond Tutu’s legacy is reverberating among young South Africans, many of whom were not born when the clergyman battled apartheid and sought full rights for the nation’s Black majority.

Tutu, who died Sunday at the age of 90, was awarded the Nobel Peace Prize in 1984 for those efforts.

Even though they did not know much about him, some young South Africans told The Associated Press on Monday that they understood his role as one of the most prominent figures to help their country become a democracy.

Zinhle Gamede, 16, said she found out about Tutu’s passing on social media and has learned more about him over the past day.

“At first I only knew that he was an archbishop. I really did not know much else,” Gamede said.

She said Tutu’s death had inspired her to learn more about South Africa’s history, especially the struggle against white minority rule.

“I think that people who fought for our freedom are great people. We are in a better place because of them. Today I am living my life freely, unlike in the olden days where there was no freedom,” she said.

Following the end of apartheid in 1994, when South Africa became a democracy, Tutu chaired the Truth and Reconciliation Commission that documented atrocities during apartheid and sought to promote national reconciliation. Tutu also became one of the world’s most prominent religious leaders to champion LGBTQ rights.

“As a gay person, it is rare to hear people from the church speaking openly about gay issues, but I found out about him through gay activists who sometimes use his quotes during campaigns,” said Lesley Morake, 25. “That is how I knew about him, and that is what I will remember about him.”

Tshepo Nkatlo, 32, said he is focusing on the positive things he hears about Tutu, instead of some negative sentiments he saw on social media.

“One of the things I picked up on Facebook and Twitter was that some people were criticizing him for the TRC (Truth and Reconciliation Commission) because there are still many issues regarding the TRC,” Nkatlo said, referring to some who say Tutu should have been tougher on whites who perpetrated abuses under apartheid and should have ordered that they be prosecuted.

South Africa is holding a week of mourning for Tutu. Bells rang at midday Monday from St. George’s Anglican Cathedral in Cape Town to honor him. The bells at “the people’s cathedral,” where Tutu worked to unite South Africans of all races against apartheid, will toll for 10 minutes at noon for five days to mark Tutu’s life.

“We ask all who hear the bells to pause their busy schedules for a moment in tribute” to Tutu, the current archbishop of Cape Town, Thabo Makgoba, said. Anglican churches across South Africa will also ring their bells at noon this week, and the Angelus prayer will be recited.

Several services in South Africa were being planned to honor Tutu’s life, as tributes came in from around the world.

Tutu’s coffin will be displayed Friday at the cathedral in Cape Town to allow the public to file past the casket, “which will reflect the simplicity with which he asked to be buried,” Makgoba said in a statement. On Friday night Tutu’s body will “lie alone in the cathedral which he loved.”

A requiem Mass will be held Saturday and, according to Tutu’s wishes, he will be cremated and his ashes placed in the cathedral’s mausoleum, church officials said Monday.

In addition, an ecumenical and interfaith service will be held for Tutu on Thursday in South Africa’s capital, Pretoria.

South Africans are laying flowers at the cathedral, in front of Tutu’s home in Cape Town’s Milnerton area, and in front of his former home in Soweto.

President Cyril Ramaphosa visited Tutu’s home Monday in Cape Town where he paid his respects to Tutu’s widow, Leah.

“He knew in his soul that good would triumph over evil, that justice would prevail over iniquity, and that reconciliation would prevail over revenge and recrimination. He knew that apartheid would end, that democracy would come,” Ramaphosa said Sunday night in a nationally broadcast address.

“He knew that our people would be free. By the same measure, he was convinced, even to the end of his life, that poverty, hunger and misery can be defeated; that all people can live together in peace, security and comfort,” said Ramaphosa who added that South Africa’s flags will be flown at half-staff this week.

“May we follow in his footsteps,” Ramaphosa said. “May we, too, be worthy inheritors of the mantle of service, of selflessness, of courage, and of principled solidarity with the poor and marginalized.”

Our Cabinet League Table: Johnson
falls to his lowest ever negative
rating.

https://www.conservativehome.com/

Perhaps the only good news for Boris Johnson is that his score, woeful as it is, is nowhere near as dire as that of Theresa May in the spring of 2019 – when she broke the survey’s unpopularity record, coming in at a catastophic -75 points.
Nonetheless, this is the Prime Minister’s second consecutive month in negative ratings, his third altogether, and his lowest total of the lot. The explanation? Parties, competence, Covid restrictions, Paterson, taxes and Net Zero, not necessarily in that order.
Nadine Dorries is down from fourth (plus 61) to mid-table sixteenth (plus 25), Michael Gove from twelfth to sixth from bottom (plus 43 to plus 16) , and Sajid Javid from eighth to twelfth (plus 54 to plus 29). All are associated with support for Covid restrictions.
Mark Spencer stays in the red and Priti Patel inches into it: in her case, the explanation is “small boats”. Liz Truss is top again, Ben Wallace is up from second to fifth, and Anne-Marie Trevelyan and Nadhim Zahawi are scoring well. Generally, there’s a drift down.

State Papers
1995: Irish Government was advised that then-journalist Boris Johnson’s views on Northern Ireland were ‘naive’

Boris Johnson at The Spectator

Ralph Riegel
December 28 2021

British Prime Minister Boris Johnson’s views on Northern Ireland were described as “naive” by an Irish embassy official who had gone for lunch with the then-journalist in 1995.

Details of the lunch were revealed in confidential Department of Foreign Affairs files released as part of the State Archives.

Mr Johnson – a well-known journalist in the 1990s who had worked in both Brussels and London – was described by the Irish Embassy official as being ‘Eurosceptic’, a prescient summary of the future politician who would become a standard-bearer for Brexit and getting the UK out of the EU.

Colin Wrafter was press officer at the Irish Embassy in London and had gone for lunch with Mr Johnson on April 24, 1995. Details of the journalist’s views on major Anglo-Irish and European issues were then forwarded to the Department of Foreign Affairs in Dublin on April 27.

No details of the venue for the lunch or its cost were included in the memo.

At the time of the lunch, the then 31-year-old Mr Johnson was editor of The Spectator magazine and was also working as a Daily Telegraph columnist.

“Johnson was previously Brussels Correspondent for The Daily Telegraph and was recalled to London to succeed Simon Heffer at The Spectator when the latter was made Deputy Editor at The Daily Telegraph,” Mr Wrafter wrote.

“His own politics would be Thatcherite and Eurosceptic but he has, he told me, incurred the wrath of the editor of The Daily Telegraph, Charles More, for a piece in The Spectator in February which argued that the (Northern Ireland) framework documents were deliberately pitched by the British in the nationalist direction so as to ensure that a final settlement would be much more sensitive to unionist concerns.

“He has written approvingly – if naively – of the Northern Ireland Tories in his weekly column in The Daily Telegraph. Our lunch took place before the announcement by the British government that it would commence ministerial talks with Sinn Féin.

“It says something for the standing of The Daily Telegraph that he knew what the British government would announce that afternoon and that his (press) lobby colleague, Phil Johnson, had time to travel to Belfast for Minister Ancram’s briefing at 5pm.”

Mr Wrafter advised Seán Ó hUigínn at the Department of Foreign Affairs there was one element of the luncheon that should be noted.

“Boris made one remark of which you may wish to be aware – the prime minister is determined to proceed with the peace process at a pace just a little on the right side of ‘stalling’,” Mr Wrafter wrote.

“In this he was reflecting a view widely held by political journalists in Westminster.

“While the prime minister wants history to acknowledge his role in helping to bring about peace in the North, he is determined to move cautiously in order to avoid the risk of exposing himself to Tory backbench unrest...”

How the West hung Ukraine out to dry

False friendship and empty promises have set the stage for Russian invasion

Illustrated | Getty Images, iStock, Library of Congress

RYAN COOPER
DECEMBER 28, 2021

We might soon witness an honest-to-God war of conquest in Europe. Russia's Vladimir Putin already chomped Crimea off Ukraine in 2014, and now it appears he's hungry for the rest of the country.

If Putin does attack, a major reason will be the bungling diplomatic incompetence of the United States and its principal allies in Western Europe. Western nations have repeatedly raised Putin's ire using Ukraine as a proxy but have refused to dedicate the money or military might to actually defend it.

Western states' behavior isn't the sole factor here, of course. There's the fact that Putin is basically a dictator and has a habit of using wars of aggression against weaker neighbors to boost his public profile (a short, successful war is a classic political sugar high). And there's is the fact that Russia today is smaller than it was from the mid-17th century through 1991, and that much of Ukraine was included in both the old Russian Empire and the Soviet Union, leading to an apparently widely-shared belief among Russian nationalists that Ukraine is a rightful Russian possession.

Moreover, as my colleague Damon Linker points out, Europe badly needs Russian gas to deal with an unusually cold winter and a global shortage of energy. The United States is distracted by internal turmoil, the COVID-19 pandemic, and the risk of collapse of our own democratic institutions. Putin probably won't have a better opportunity in his lifetime.

But that isn't the whole story. Since the fall of the USSR, the West has treated Ukraine either with appalling neglect or as an imperialist toy. It was Western economists and governments in thrall to neoliberal dogma who pushed through the crash privatization of Ukrainian assets in the immediate post-Soviet years. That created an economic catastrophe and a veritable plague of corruption from which the country has yet to recover.

When Western financial deregulation led to the global economic crisis in 2008, it hit Ukraine particularly hard, because the country had large debts denominated in foreign currency. With implicit U.S. backing, the European Union offered a pitifully inadequate loan of 610 million euros, along with requirements for brutal austerity. As historian Adam Tooze writes in his book Crashed, "There were Ukrainian oligarchs with personal fortunes larger than this."

Putin counter-offered with a loan of $15 billion, an attempt to draw Ukraine away from the West. Liberal and pro-EU Ukrainian groups, fearing Russian imperialism and backed by Western powers, launched a revolution that turfed out the former president and signed the EU deal. In response, Putin seized Crimea and started a brushfire conflict in eastern Ukraine that continues to this day. (Recall that it was shipments of anti-tank missiles that former President Donald Trump tried to use to bully the Ukrainian president into making up dirt about his then-rival, Joe Biden.)

In short, Western powers have repeatedly used Ukraine to give Putin a bloody nose, but they have neither given it the resources that would be necessary to make an alliance with the West a good deal nor made enough of a military commitment to deter Russia.

NATO extends this combination of arrogance and incompetence toward Russia and Ukraine. The declared purpose of the treaty organization was to counter the Soviet Union and contain the spread of international communism. Neither of those have existed for 30 years, yet NATO continued mindlessly expanding throughout the 1990s and 2000s. Nobody seemed to consider whether Russia might get the idea that NATO was still an anti-Russian alliance, nor that Moscow might have understandable reasons to worry about a Western military presence in Ukraine.

While Putin is an aggressive, dangerous nationalist with a long record of murdering his political opponents, he is not wrong to think Western powers are working to encircle and overthrow his government. And while Russia is a pale shadow of the Soviet Union at its height of power, Putin has real power and leverage — above all thousands of nuclear weapons — that must be reckoned with. Western powers, assuming they can get whatever they want, all the time, without having to compromise, prioritize, or even commit much by way of resources, have not made that reckoning.

The result is reminiscent of what happened to the Iraqi Kurds in 1991. After Saddam Hussein's forces were routed easily in the Gulf War, then-President George H.W. Bush tried to topple him on the cheap by encouraging a military coup in several radio broadcasts. Kurdish forces (along with many other factions) took this as a promise of American aid and launched a rebellion that nearly took out Hussein's government. But Bush didn't want to risk getting bogged down in an occupation and so stood aside while government forces regrouped and massacred the rebels, causing hundreds of thousands of people to flee the country.

The problem wasn't that Bush was wary of occupying Iraq — after all, the world saw what happened when his imbecile son tried it a little over a decade later. The problem was his lying to vulnerable people (and cynically invoking a lot of pro-democracy rhetoric) as part of a foreign policy gambit. It wasn't Americans who were shot by the tens of thousands when the strategy blew up.

The same is true today. It is plainly evident that the U.S. and Western Europe aren't willing to put their own soldiers on the line to defend Ukraine. For these countries, the conflict there is a minor issue compared to the rise of China, the ongoing pandemic, climate change, and much else. Yet instead of facing that fact squarely and honestly, Western powers — and especially the U.S. — continually refuse to cut their losses, stop needling Putin, and seek some kind of detente. Ukraine will suffer the consequences.

Russia, US and Ukraine: The State of Play

George Friedman

December 28, 2021

Open as PDF

When nations negotiate, a quiet settles in before the threats begin. Such is the case now between the U.S. and Russia, which will soon hold talks over the status of Ukraine and any number of other issues. Moscow has published its list of demands – more of a wish list, really – to try to set the agenda. But in the end, agendas are set by reality. A quick recap of Russia’s year is a good place to begin establishing that reality.

Russia has been trying to reclaim the buffers it lost after the collapse of the Soviet Union. These buffers, the most important of which are in Eastern Europe, insulate Russia from potential attack. In the past, these attacks have tended to emerge unexpectedly, so Russia wants to have them before a threat emerges. It doesn’t necessarily need the buffers to be part of the Russian Federation; it just needs to make sure they are not hostile (or occupied by hostile powers).

Thus, Russian activities in the past year were predictable. When war broke out in the South Caucasus between Azerbaijan and Armenia, Russia dispatched a peacekeeping force and, with its enormous influence in the region, constructed a system of relationships dominated by Russia. In Central Asia, Moscow built a network of airfields, a process that only accelerated as the U.S. withdrew from Afghanistan. In Belarus, Russia completely dominates Alexander Lukashenko’s government.

These were important steps for Russia’s reclamation of its buffers, but none of them are as important as Ukraine. Its sheer size allows an enemy force to maneuver, and that maneuverability forces a defender to disperse forces. In war, Ukraine gives Russia time. It spent the year – and really years before it – focused on this moment.

Moscow understood from the beginning that it had to reach an accommodation with Washington. It also understood that the United States, like all countries, comes to the table only when it has to. Washington has been content with the structure of the former Soviet Union. Russia has not. So Russia had to put American interests in the region, particularly in Ukraine, at risk.

The very obvious massing of Russian forces around the Ukrainian border was the logical next step. Deployed as they were, the massed armored forces appeared to be in a position to rapidly overrun Ukraine. The problem, of course, was that though a country as large as Ukraine could be overrun, it could not be overrun rapidly.

Militarily, the United States is in a militarily difficult position. It has no significant force in Ukraine, and any infusion of forces could lead to a long and potentially indecisive war. NATO has no stomach for this kind of confrontation on its doorstep. Apart from limited militaries, the NATO model has morphed into the EU model, and the EU model has morphed into a model whose motto is peace and prosperity. A rapid deployment with few casualties is possible, but the kind of battle Russia offered is of no interest to the EU model, save for a few countries, most notably Poland. The Russian calculation was that the U.S. would not act, and if it did, it would split the Europeans. NATO would exercise and plan in Brussels, but ultra-caution would limit collective action.

From the American point of view, there is no short-term interest in intervening in Ukraine, let alone fighting another potentially losing war at long distance with questionable allies. But there is a long-term danger. The American strategy in the Cold War was to prevent Russia from imposing hegemony over Europe. Such a hegemony would wed Russian resources and manpower to European technology and manufacturing, creating a massive superpower that could challenge the U.S. in the Atlantic. This was a long-range threat, but long-range threats had to be dealt with early and cheaply. The Soviet threat was always there, but it was blocked at relatively low cost and was therefore politically acceptable in the West, especially when they were draped in anti-Soviet ideology and the principles of liberal democracy.

(click to enlarge)

The current situation in Ukraine recreates this long-range threat. The Russians view the United States as unpredictably ruthless – it never knows when the U.S. will take action, and its experience in the Cold War showed a U.S. willing to deploy massive force. Russia had to force the United States to limit its presence in Ukraine without risking a dramatic response. It had to demonstrate its power with a not fully credible force to compel a negotiation but not a massive response. And Washington could not go into talks without demonstrating a credible response to the Russian threat. It’s delicate on both sides.

Ultimately, both sides understood the weakness of the Russian strategy relative to the United States. Armored fighting vehicles such as those Russia sent to the Ukrainian border eat an enormous amount of fuel. An armored division in the U.S. military uses about 600,000 gallons of fuel per day when on the move, and Russia is deploying multiple divisions, which would have to be followed by an endless line of refueling vehicles, coming from vast fuel storages. At best, this is complicated. At worst, it’s a prime candidate for a war of attrition as the U.S., weary of Russia’s anti-aircraft capability, fires cruise missiles from afar. (Russia can, of course, shoot some down, but the losses would be huge.)

The Russian decision to carry out multidivisional armored warfare will depend on how confident it is that the U.S. would get involved, how confident Moscow is that the U.S. would choose a winning strategy, how confident it is in its own defensive systems, and how confident it is that it can politically withstand even a temporary defeat. The Russians have not engaged in multidivisional offensives since 1945. They cannot live with the loss of buffers. They cannot live with defeat.

War is filled with vulnerabilities, many of which are discovered at inconvenient times. The price Russia would pay in the event of a failed invasion is significant in terms of domestic politics and international credibility. The price the U.S. would face by a defeat would be less. Its credibility would be hurt, but a geopolitical imperative would not be lost.

The Russians know this far better than I do. So the coming negotiations will break down here and there; Russian forces will be on full alert, but Russia can’t afford a defeat and can’t be certain of victory. In the end, the thing that the Russians will have gained is that they sat down across from the Americans as equals, and the rest of the world will have seen it. There will be consequences to America for conceding the point, and the Europeans will proclaim the end of American power for the hundredth time. And history will go on.

Listing for all-black 'goth home' in Illinois goes viral

A home for sale in Lincoln, Ill., is going viral online after being dubbed the "goth home" due to its black exterior and interior walls. Photo courtesy of Seth Goodman/Zillow

Dec. 27 (UPI) -- An unusual properly listing in Illinois is going viral after the pitch black house was dubbed the "goth home" online.

The Zillow listing went viral after Twitter account Zillow Gone Wild, which curates unusual home listings, branded it the "goth home."

The listing for the home at 110 Edgar St. in Lincoln features photos of the black house with an all-black shingle roof, black gutters and black vinyl siding.

Realtor Seth Goodman said he bought the octagonal house in August 2021 and decided to go for the black theme after the installation of the roof.

The listing also reveals Goodman had the interior walls painted black to match the exterior.

Goodman said he has received a lot of interest in the unusual house, but he has grown attached to the property and is considering keeping it for himself.

USA
Opioid prescriptions dispensed at retail pharmacies decline, study finds

Opioid prescriptions distributed by retail pharmacies nationally have declined over the past decade, a new study has found. Photo by jorono/Pixabay

Dec. 27 (UPI) -- The volume of prescription opioid pain medications dispensed by retail pharmacies in the United States has declined over the past decade, with larger drops seen in urban areas, a study published Monday by Annals of Internal Medicine found.

Prescription opioid painkillers distributed to consumers by retail pharmacies, including chains such as CVS and Walgreens, fell by 21% between 2008 and 2018, the most recent 10-year period with figures available, the data showed.

Metropolitan counties saw the steepest declines, at more than 22%, while those with higher rates of fatal opioid overdoses had a 35% drop in prescriptions dispensed, the researchers said.

"These results suggest the effects of clinician and policymaker efforts to reduce opioid prescribing have affected populations differently," study co-author Dr. Bradley D. Stein said in a press release.

RELATED CDC: Fentanyl-related overdose deaths rose nationally during pandemic

"Future efforts to enhance clinically appropriate opioid prescribing may need to be more clinically nuanced and targeted for specific populations," said Stein, a senior physician researcher at the RAND Corporation, a nonprofit research organization.

From May 2020 through April of this year, more than 100,000 drug overdose deaths were reported in the United States, with 64% of them involving synthetic opioids such as illicitly manufactured fentanyl, according to the Centers for Disease Control and Prevention.

Although prescription opioid pain relievers are legal, their widespread overprescribing nationally is considered a key factor in the ongoing opioid crisis across the country, which has led to widespread addiction -- with some users turning to "street" opiates, such as heroin, research suggests.

RELATED Black, Hispanic people in U.S. less likely than White people to receive opioids

In the early 2000s, opioid-based medications were the most commonly prescribed painkillers in the United States, but their use peaked in 2011, an earlier study found.

For this study, Stein and his colleagues at RAND examined differences in opioid prescriptions filled at pharmacies during the periods of 2008 through 2009 and 2017 through 2018.

The prescription information came from IQVIA Prescription data, which captures about 90% of prescriptions filled at retail pharmacies across the country, the researchers said.

RELATED Study: Addictive opioids uncalled for after knee surgery for ACL

They used days' supply and total daily opioid dose to calculate per capita morphine milligram equivalents for opioid prescriptions filled during the study periods, they said.

Morphine milligram equivalent is a commonly used measure for comparing the potencies of opioids, or the amount of drug required to create an analgesic, pain relieving effect, according to the CDC.

Because opioids are available in different forms, this measurement provides a better assessment of the total amount of opioids filled by patients as compared to just the number of pills dispensed, Stein and his colleagues said.

Over the study period, per capita morphine milligram equivalent volume declined by more than 22% in metropolitan counties across the country and by 35% in those with higher rates of fatal opioid overdoses, the data showed.

The greatest decrease in morphine milligram equivalent volume per practicing clinician was 40%, among adult primary care physicians, and 15%, in pain specialists, who had the highest volume per clinician in 2008-2009.

The greatest percentage decrease, 71%, was in prescriptions written occurred among emergency physicians, clinicians who are likely prescribing opioids predominantly to patients experiencing acute pain, according to the researchers.

"The findings do not provide concrete answers about how much of the unnecessary prescribing of opioids has been eliminated," Stein said.

"But the work demonstrates that there is a lot more nuance in the changes in opioid prescribing than we previously understood," he said.

Ketamine may quickly ease tough-to-treat depression
By Amy Norton, HealthDay News

Ketamine can help quickly in patients that have tough-to-treat depression, researchers say. File Photo by StockSnap/Pixabay

Ketamine, once most famous as a "club" drug, can rapidly improve hard-to-treat depression and curb suicidal thoughts, a new review confirms.

In recent years, ketamine has emerged as something of a wonder drug for some people who do not get better with standard antidepressants.

For those patients, who may have tried multiple conventional medications, ketamine can quickly ease depression symptoms -- even within a day. Experts say that speedy response is especially critical for people at risk of self-harm.

The new review, published recently in the British Journal of Psychiatry Open, pulls together all published research on ketamine as a treatment for psychiatric disorders.

RELATED Ketamine appears to be safe as therapy for tough-to-treat depression

And it found that for treatment-resistant depression and suicidal thoughts, the drug can have quick, "robust" effects -- albeit short-lived.

"It is important to emphasize the drug doesn't work for everyone," said senior researcher Celia Morgan, a professor at the University of Exeter in England.

Nor is ketamine simple to take. It has to be given under medical supervision, Morgan noted, so doctors can watch for "dissociative" effects -- or what lay people might call a "trip."

The drug is not a psychedelic, but typically triggers altered perceptions of reality, such as hallucinations, soon after it's given. It can also cause a short-term spike in blood pressure, Morgan said.

So before anyone tries ketamine for depression, she said, they have get a full medical and psychiatric evaluation to make sure it is appropriate for them.

Ketamine was first approved in the United States decades ago as an anesthesia drug. Because of its mind-altering effects, it also came to be abused as a party drug, known by such nicknames as "special K."

But researchers have long been aware of the drug's potential, at low doses under well-controlled conditions, to treat psychiatric symptoms.

Ketamine is not approved by the U.S. Food and Drug Administration for treating depression. But doctors can and do prescribe it "off label" for that reason.

And in 2019, the FDA approved a ketamine derivative -- called esketamine, or Spravato -- for depression that has not responded to at least two standard antidepressants.

Unlike ketamine, which is given by IV, esketamine is a nasal spray. But it still must be given under medical supervision, because it has the same side effects.

Since esketamine is FDA-approved for depression, it has become the more practical choice over ketamine, according to psychiatrists not involved in the review.

"It's much easier to get insurance coverage for esketamine," said Dr. Paul Nestadt, co-director of the Johns Hopkins Anxiety Disorders Clinic in Baltimore.

So while he has been involved in ketamine research, Nestadt said that in practice, he is prescribing esketamine.

It's not entirely clear how either drug so rapidly eases depression.

But researchers know ketamine has different brain targets than standard antidepressants, and that includes boosting activity in a chemical called glutamate, which helps brain cells communicate with each other.

Studies also suggest ketamine fosters the regrowth of synapses -- connections among brain cells that can be depleted in people with longstanding depression.

With esketamine, Nestadt said, there is a set treatment protocol: It's used in combination with a standard antidepressant, starting with two doses per week for the first month, then one weekly dose for the next month, and tapering further thereafter.

The length of that maintenance period, though, is "undefined," said Dr. Joshua Berman, an assistant professor of psychiatry at Columbia University Irving Medical Center in New York City.

In the earlier years of research, he noted, the focus was on understanding ketamine's rapid effects.

"We, collectively, had never seen anything like it," Berman said.

Now, the ongoing research question is, how long do the antidepressant effects truly last?

It's also unclear, according to the review, whether ketamine helps with other psychiatric disorders, like post-traumatic stress disorder, obsessive-compulsive disorder and drug dependence.

The researchers examined 89 published studies, some of which tested ketamine for those conditions in the short term. But while there were some "positive" effects, Morgan's team said, the results should be interpreted with caution at this point.

For people with depression, both Berman and Nestadt emphasized the importance of a full psychiatric evaluation, along with a medical history, before starting ketamine or esketamine.

There are ketamine "clinics" popping up around the United States, but some are run by anesthesiologists, not mental health professionals.

"[Ketamine] is not a first-line therapy for depression," Nestadt stressed. "You want a good evaluation first, and you should start with treatments that have been studied for decades."

In addition, Nestadt said he keeps patients on their current treatment -- antidepressants as well as talk therapy -- during the esketamine intervention.

And while the maintenance phase of esketamine is not clearly defined, neither it nor ketamine is meant to be given "indefinitely," Nestadt said.

Berman pointed to an additional reason to be under the care of a mental health professional: If ketamine does not work, patients should have other options presented to them.

More information

Johns Hopkins has more on esketamine for depression.

Copyright © 2021 HealthDay. All rights reserved.

Heat waves may bring new health crises to the homeless, researchers say
By HealthDay News

Researchers say that heat waves could pose significant, potentially life-threatening, health risks to homeless people. File Photo by Jim Ruymen/UPI | License Photo

Add heat waves to the many health threats facing homeless people.

Last year, the United States had 580,000 homeless people -- 28% of them in California, where seven in 10 live outdoors. That's nearly nine times more than in any other state.

"The same weather that makes living unsheltered possible in California also exposes people experiencing homelessness to a higher risk of a wide range of heat-induced health conditions that can result in end-organ damage and even death," said Tarik Benmarhnia.

He is an associate professor at the University of California, San Diego, and senior author of a new study of homelessness and emergency department visits.

RELATED New approach allows for earlier prediction of weather events, researchers say

"People that experience homelessness are considered to be among the most vulnerable to extreme weather impacts, due to their exposure to the elements and high rates of preexisting health conditions such as mental illness, as well as higher rates of smoking, drug and alcohol use," Benmarhnia added in a university news release.

For the new study, his team analyzed emergency department data from two hospitals in San Diego - which has the nation's fifth-largest homeless population - along with temperature data for the city.

Of more than 242,000 emergency department visits between 2012 through 2019, nearly 25,000 were by homeless people, the findings showed.

The study focused on the warm season - May to September. During those months, homeless people visited ERs 1.29 times more during the most extreme two-day heat waves studied.

Visits increased during longer heat waves with more extreme temperatures, according to findings published this month in the American Journal of Public Health.

The researchers reported that having a mental illness tripled a homeless person's risk of heat-related illness, perhaps because these folks are less able to recognize symptoms of heat exposure, seek a cool space and rehydrate.

According to study co-author Edward Castillo, "Activating heat action plans to protect persons experiencing homelessness from heat waves is not only justified, it is necessary." Castillo is a professor of emergency medicine at UCSD.

"Adapting interventions to specific subgroups can effectively decrease the burden on both patients and health care systems from this increasingly prevalent exposure," Castillo added.

The study authors warned that climate change will increase homeless people's risk of heat illnesses.

"As the threat of increasingly frequent and intense heat waves continues to rise in the United States, particularly in California, understanding and prioritizing the needs of this rapidly growing vulnerable population will be a critical action in developing and deploying effective adaptation strategies such as heat action plans to attenuate this burden," said study first author Lara Schwarz, a doctoral student in public health.

More information

Global Citizen outlines ways to help homeless people during heat waves.

Copyright © 2021 HealthDay. All rights reserved.

Texas plant that sterilizes medical equipment spews cancer-causing pollution on schoolchildren

By Kiah Collier, The Texas Tribune and Maya Miller, ProPublica

In 2019, Yaneli Ortiz was diagnosed with acute lymphocytic leukemia, a cancer that’s been linked to ethylene oxide exposure. Her hip bone has deteriorated due to steroids that diminished the blood supply through her leg and joints, leaving her in constant pain.

Photo by Kathleen Flynn, special to ProPublica/Texas Tribune

FEATURE EXPOSE VERY LONG READ

Dec. 27 (UPI) -- Jennifer Jinot didn't expect to retire early from her role as an environmental health scientist for the federal government. She'd spent 26 years assessing the dangers of toxic chemicals for the U.S. Environmental Protection Agency. The job could be frustrating but, more than that, rewarding.

Early in her career, Jinot evaluated the health impacts of secondhand smoke exposure. It took four years -- a pace she remembers thinking was "crazy slow" -- to develop a final risk assessment, published in 1993, that determined secondhand smoke causes lung cancer in adults and impairs the respiratory systems of children. The tobacco industry sued the agency. But, in the end, her work spurred changes to the law. The victory was invigorating for Jinot, who had long dreamed of doing what she calls "socially useful" science.

In 2002, Jinot joined an EPA team that was evaluating new research to determine whether ethylene oxide, one of the world's most widely used chemicals, caused cancer. A key building block for an endless array of consumer goods and a common product used for sterilizing medical equipment, the colorless, low-odor gas wafts out of at least 160 facilities across America. Jinot's colleagues had already spent four years reading studies, scrutinizing data and consulting with experts. She was hopeful it wouldn't take much longer. The team published a draft assessment in 2006 that found the chemical was significantly more carcinogenic than the agency had previously concluded and especially damaging to children.

Jinot believed the science begged for urgent action to strengthen existing environmental regulations. But industry lobbyists and company executives attacked the draft. Audry E. Eldridge, then-president of the Missouri-based Midwest Sterilization Corporation, argued in a 2006 letter that an "extensive database of toxicological and epidemiological studies" showed the EPA's findings were flawed. Eldridge, who helped found the Ethylene Oxide Sterilization Association, a trade group that lobbies on behalf of sterilizer companies, didn't name any specific studies, but said in the letter that the cancer risk posed by the chemical was "thousands of times less than portrayed in EPA's risk estimates."

Amid pressure from industry groups, the agency agreed to another round of scrutiny from independent scientists and the public before finalizing its findings. "They don't want to put out anything that gets attacked," Jinot said of the EPA in a recent interview. The EPA defended its process for evaluating harmful environmental chemicals as "strong" in a statement to ProPublica and The Texas Tribune.

A process that, according to a director for the U.S. Government Accountability Office, should last no more than four years ended up taking another decade. In 2016, the EPA published the final version of its assessment. It concluded that ethylene oxide was 30 times more carcinogenic to people who continuously inhale it as adults and 50 times more carcinogenic to those who are exposed since birth than the agency previously thought. The chemical, which alters DNA in the human body and increases the risk of certain types of cancer such as leukemia, is particularly harmful to children because their developing bodies can't mend the genetic damage as effectively as adult bodies.

In the decade it took for the federal agency to finalize what its frustrated scientists already knew, Eldridge's sterilization company dramatically expanded its new facility in the border city of Laredo. The facility, a ProPublica analysis determined, emitted far more ethylene oxide than any other sterilizer plant in the country that reports emissions to the EPA.

Simultaneously, families along its fence line were raising a generation of children who would grow up in the plant's shadow.

Karla and Cesar Ortiz had a baby girl they named Yaneli, after a Spanish-language television character who embodied kindness and humility, traits they hoped their daughter would share. Through the years, their smiley, curly-haired little girl grew to love arts and crafts, became a fan of '80s music and K-pop and watched over her two little brothers in their home, located less than 5 miles from Midwest.

Around the same time, Nidia and Rafael Nevares were raising their two boys, Rafael Jr. and Juan Jose, or JJ, about 2 miles from the plant. The younger of the two, JJ was more outgoing and quick to make friends. Among his favorite things to do was pulling his older brother away from the computer to play hide-and-seek in the front yard.

The EPA's 2016 ethylene oxide report would not be legally enforceable until the agency incorporated it into new regulations. Even so, it inspired many states to crack down on industrial facilities that emitted the chemical - through lawsuits, stricter state regulations, air monitoring and cancer cluster studies. But Texas went in the other direction, becoming the only state to officially reject the agency's conclusions. In August 2017, the Texas Commission on Environmental Quality, the state's environmental regulatory agency, announced it would launch a review of EPA's science; it eventually ruled that the chemical was significantly less toxic than the federal agency had found. That resulted in Texas enacting a new standard that could allow plants to emit more of the chemical.

In 2018, two years after the EPA published its final report, JJ was diagnosed with acute lymphocytic leukemia, a cancer that has been linked to ethylene oxide exposure. He turned 6 years old a month later.

"Have you seen a novela mexicana?" his mother, Nidia Nevares, said. "That's what it was like, like a soap opera. Crying and crying, shock, shock, totally."

Yaneli's diagnosis came soon after. Doctors found that she had the same type of cancer as JJ in June 2019, three months before her 13th birthday.

By then, Jinot was no longer at the EPA. She had grown frustrated with industry's increased influence over the agency and with a bureaucracy that stalled critical scientific research. So when the Trump administration sought to shrink the agency's staffing in 2017 by offering employees buyouts, Jinot accepted.

"I couldn't stand the process anymore," she said. "There's no reason it should take so long."

In the dark

Communities such as Laredo, where the vast majority of the residents are Latino and more than a quarter live in poverty, have been left in the dark for years by regulators who had evidence of the dangers posed by ethylene oxide but never told the public about them.

Out of all the pollutants that the EPA regulates, ethylene oxide is the most toxic, contributing to the majority of the excess cancer risk created by industrial air pollutants in the United States, according to an unprecedented analysis of the agency's most recent modeling data by ProPublica, in collaboration with The Texas Tribune. That risk is in addition to those Americans already face from other factors like genetics or lifestyle.

The EPA says it strives to minimize the number of people exposed to emissions that create excess cancer risk worse than 1 in 1 million - meaning that if a million people were exposed to the toxic air pollutants over a lifetime of 70 years, there would likely be at least one additional case of cancer. But the agency is far more permissive about the cancer risk it considers unacceptable: greater than one additional cancer death per 10,000 people.

ProPublica's analysis of ethylene oxide assessed the impact of the chemical for an intermediate risk level, 1 in 100,000, which experts say is not sufficiently protective of public health. Using that threshold, the analysis, which examined data from 2014 to 2018, shows that more than 60% of the 6.9 million Americans who face heightened excess cancer risk from industrial air pollution are imperiled solely based on their exposure to ethylene oxide. (Though the analysis identifies elevated risk for geographical areas, it can't be used to determine the specific causes of individual cancer cases.)

The risk is particularly acute in Texas, the nation's top ethylene oxide polluter and home to 26 facilities that emit the chemical. The state stands out not just for the outsize risk its residents face but because it has emerged as a key ally for companies that emit or use ethylene oxide. Texas has fought stricter federal emissions regulations, even as many other states, including several led by Republicans, have enacted tighter controls on the chemical.

The Texas Gulf Coast is home to some of the biggest and most toxic hot spots in ProPublica's analysis, with most of the cities of Houston, Port Arthur and Beaumont exposed at a risk of often well above 1 in 100,000.

But if you look at the risk from all chemicals except ethylene oxide, these hot spots shrink dramatically, showing the outsize impact of the chemical.

Laredo, home to more than 260,000 people, is among the 20 hot spots in the country with the highest levels of excess cancer risk, according to the analysis. Midwest's Laredo plant released far more ethylene oxide on average than any other sterilizer plant in the country during the five-year period covered by the analysis, which used emissions estimates that Midwest reported to the EPA. The facility elevates the estimated lifetime cancer risk for nearly half of Laredo's residents to at least 1 in 100,000, the analysis found. More than 37,000 of those are children.

Midwest said in a statement that the cancer risk posed by its sterilization plant is overstated, asserting that the emissions it reported to the EPA are "worst case scenarios," rather than specific pollution levels. The law actually requires companies to report "reasonable" estimates of what they release into the air.

In 2019, the EPA directed its regional offices to warn more than two dozen communities facing the highest risks from ethylene oxide pollution, including those near Midwest's sterilizer plants in Laredo and Jackson, Missouri.

Armed with that information, residents across the country organized and pressured their elected officials to act. Attorneys general in Illinois and Georgia sued sterilizer plants over alleged air pollution violations, and lawmakers enacted stricter regulations of the chemical. Georgia's Republican governor, Brian Kemp, backed the effort. A bipartisan coalition of U.S. representatives from Illinois, Georgia and Pennsylvania formed to push the EPA to adopt stricter regulations on ethylene oxide that reflected the findings in the agency's final assessment.

The meetings even prompted change at Midwest's facility in Jackson, which "voluntarily installed additional controls to reduce emissions," according to Ben Washburn, a regional EPA spokesperson.

But the EPA region that oversees Texas and Louisiana trailed behind. Despite being home to the most "high-priority" ethylene oxide facilities, the region had not scheduled a single meeting on the pollutant as of March 2020. "These communities have not been given the same opportunity to interact with federal and state regulators to become informed on the issue," said an urgent alert that month from the EPA's Office of Inspector General. The region didn't hold its first community meetings anywhere in the two states until August 2021, two years after the EPA directive.

Laredo is still waiting.

More than 100 Laredo residents contacted by ProPublica and the Tribune said they hadn't heard about the cancer risk posed by the plant. Only one even knew of the facility's existence. The EPA acknowledged in a statement to ProPublica and the Tribune this month that it hadn't yet informed Laredo residents of the cancer risks tied to ethylene oxide. Madeline Beal, senior risk communication adviser for the EPA, said the agency recognizes "the critical importance of public outreach and engagement to inform impacted residents about risk and ultimately to address it."

But Beal also suggested that the federal agency is not solely responsible for informing and protecting residents. She said states are in the best position to "conduct additional, more refined investigations, as well as carry out appropriate outreach with affected communities."

Beal said, "These state-led efforts have already led to emission reductions and expected public health benefits in several areas."

Children at risk

Nidia Nevares, an accountant for a freight shipping and trucking company in northern Laredo, was working in her office earlier this year when her cellphone began ringing. Her chest tightened when she saw the caller ID: The Children's Hospital of San Antonio. She was not expecting the call.

It had been almost two years since JJ had returned home from a 10-month stay at the Ronald McDonald House in San Antonio following his first round of treatment for leukemia. The journey had been brutal, as health care workers implanted ports - attachments for tubes to access the veins near his heart - into his chest almost weekly.

Eventually, the cancer cells that had multiplied in JJ's small body were sufficiently sapped and he was allowed to return home to Laredo to finish out his treatment. JJ continued taking chemotherapy drugs and making biweekly trips to San Antonio, which many Laredo families have to travel to because their city doesn't have a children's hospital. He was doing well enough that his family started planning a trip to Orlando, Florida, where he could ride roller coasters with his older brother.

But the doctor on the other end of the phone that day delivered devastating news.

JJ's cancer was back, and it had likely spread to his spine and brain. He would have to return to San Antonio for at least a year to restart a more aggressive treatment plan.

"It's extremely hard. These are calls and moments that you don't expect to happen," Nevares said. "It's just really, really hard."

Dr. Susan Buchanan, director of the Great Lakes Center for Reproductive and Children's Environmental Health at the University of Illinois Chicago, said ethylene oxide should not be ruled out as a factor in JJ and Yaneli's diagnoses given their proximity to the Midwest facility and the amount of the chemical it releases.

Acute lymphocytic leukemia, the type of cancer JJ and Yaneli have, is the most common type of cancer among children, although pediatric cases remain rare compared to adult ones. One study also found the disease to be particularly prominent among Latino youth. Studies over the past decade have found links between toxic air pollution and higher rates of blood cancers among children, including lymphoma and acute lymphocytic leukemia.

"Kids are uniquely susceptible to anything that's in the air," Buchanan said. "We should not be putting day cares and schools near the plants that are emitting ethylene oxide."

More than 40% of Laredo's nearly 70,000 schoolchildren attend campuses that are located in areas with an excess elevated risk of cancer greater than 1 in 100,000 due to ethylene oxide emissions from the Midwest plant, according to the ProPublica and Tribune analysis.

JJ attended Julia Bird Jones Muller Elementary School, a campus that, like his home, is located less than 2 miles from the Midwest plant. ProPublica's analysis shows the area the school is in faces an estimated elevated lifetime cancer risk of 1 in 3,700. That's nearly three times higher than the maximum 1 in 10,000 risk level the EPA considers acceptable, making it the most at-risk school in Laredo and one of the most at-risk in the country.

The Nevares family was shocked and angry after learning from ProPublica and the Tribune of the cancer risk posed by the facility. From the EPA to state and local governments, officials at all levels should be responsible for protecting Americans, family members said.

"You think that you can trust in the authorities, and that before they allow companies so close to residents or schools, they should regulate it, and maybe move the company somewhere further away," said JJ's aunt, Sara Montalvo Saldaña, who has been one of his primary caretakers. "Maybe, since we are on the border, there just isn't that much attention being paid."

Leaders of Laredo's United Independent School District said they "had no knowledge of the Midwest Sterilization facility or any potential risk it might pose to our students and staff" until the news organizations began asking questions. At the request of the district, TCEQ held a virtual meeting on May 14 with school leaders, telling them it had inspected the facility five times in the past four years as part of its routine checks and found no major violations.

School officials indicated that TCEQ representatives made no mention of a complaint they investigated last year that alleged Midwest's Laredo plant falsified ethylene oxide emissions readings for a decade. The complaint alleged that a device Midwest used to determine how much of the chemical is in the air had produced readings of zero from 2007 to 2017.

The TCEQ investigator assigned to the case, Sheila Serna, obtained records from Midwest that confirmed the instrument hadn't been picking up on ethylene oxide in the air. But she couldn't determine the cause because the company had recently replaced the device. Still, Serna urged her manager, Arnaldo Lanese, to refer the issue to the agency's criminal division for further investigation.

"It seems very unlikely that emissions readings before the installation of this new system were truly 0," Serna wrote in an email obtained by ProPublica and the Tribune.

Lanese replied that the investigation lacked sufficient information to merit such action, but offered to discuss the matter with Serna in person. Records indicate that the complaint wasn't referred for criminal investigation.

Midwest declined to answer specific questions about the complaint but said in a statement that the company meets or exceeds local, state and federal regulatory standards. TCEQ did not answer questions about the complaint and declined to make Serna or Lanese available for an interview.

After school leaders raised concerns, TCEQ purchased monitoring equipment that allowed it to take a single 10-minute air sample outside of the Laredo plant in June. The state agency told ProPublica and the Tribune that it found no violations of TCEQ air quality rules.

Todd Cloud, an air quality consultant who reviewed TCEQ investigative records at the request of ProPublica and the Tribune, called the agency's air monitoring "garbage."

"That is a PR stunt," said Cloud, who worked for the fossil fuel industry for more than 20 years before becoming an adviser to environmental groups. "Going out there for 10 minutes with a handheld analyzer: That's a joke."

Industry's defense: a medical benefit

Despite the health risks posed by ethylene oxide emissions, the sterilizer industry is pushing an argument that the chemical is a net win for public health.

The industry has for years fought against stricter environmental regulations by highlighting the role ethylene oxide plays in sterilizing medical equipment, which it portrays as vital to the health care system.

At a conference in Cincinnati in February 2020, a toxicologist named Lucy Fraiser presented preliminary findings of a study that sought to compare the risk of ethylene oxide pollution to the harm that banning it would cause to the medical industry. Fraiser told government and industry scientists that banning the chemical could lower exposure for a "relatively small number" of people living and working near sterilization plants. But she said that such a move would ultimately have a limited impact on overall exposure because the chemical is also present in automobile exhaust, cigarette smoke, food and consumer products.

"If EtO use in sterilizing medical equipment/devices were banned, the much more tangible risk of HAIs" - health care-associated infections - "could increase across the entire U.S.," Fraiser said, according to minutes from the conference obtained by ProPublica and the Tribune.

When Fraiser completed her presentation, an attendee asked who had sponsored her research. Fraiser responded that she was working for Midwest Sterilization Corporation, which she referred to as a small, privately owned company out of Missouri. She later told ProPublica and the Tribune that she put the study on the back burner due to a lack of data, but may eventually revisit it.

Since opening its first plant in Missouri in 1976, Midwest has become the largest privately owned contract sterilizer in the country. It now sanitizes some 40% of all medical procedure trays nationwide, according to the statement it sent to ProPublica and the Tribune.

The company has been involved in fighting stricter regulations of ethylene oxide and the sterilizer industry for decades. On several occasions, the EPA has waived requirements that would have reduced ethylene oxide pollution from sterilizer plants even as it strengthened regulations for other types of facilities that emit the chemical. Among them, the agency has halted requirements that sterilizers install a particular type of pollution control equipment to reduce emissions from a certain type of vent. It also permanently exempted the industry from a federal permitting program that would have imposed an additional level of oversight.

Beal, the EPA adviser, said in a statement that sterilizer companies are still required to abide by a federal regulation that dictates maximum pollution levels from their facilities. But in 2006, the same year Jinot and her colleagues published their draft assessment, the EPA decided against updating that rule, saying that any additional requirements would result in minimal pollution reductions at a significant cost to companies.

Texas championed the medical benefits of the sterilizer industry in the early months of the coronavirus pandemic when it finalized a new ethylene oxide standard that is far less protective than both the EPA's and the state's own previous benchmark. On May 15, 2020, the TCEQ declared that people could safely inhale 2,400 parts per trillion of ethylene oxide over their lifetimes. In contrast, the EPA's inhalation risk benchmark is a far stricter 0.1 parts per trillion. TCEQ said in a news release that the new standard "comes during a unique period of strain on the nation's medical industry."

Several scientists, including Jinot, decried the TCEQ's conclusion as flawed. They pointed out that the review, which found that ethylene oxide had "little human carcinogenic potential," wrongly excluded studies linking ethylene oxide exposure to breast cancer and drew on cherry-picked analyses of the same studies the EPA relied on.

TCEQ defended its assessment in a statement to ProPublica and the Tribune, saying it improved upon EPA's work and that its "decision to exclude breast cancer as an endpoint was supported by peer-reviewed studies."

"Using the most current science, the new limit remains protective for people living near facilities that emit ethylene oxide while providing flexibility for the medical sterilization industry to continue its own critical role in patient care in the state of Texas," TCEQ stated in its May 2020 news release.

The biggest advantage for companies of the Texas standard, critics said, is that it prevents them from having to slash existing emissions, which they would need to do if the state followed the EPA's assessment.

"It certainly stops the regulatory driver for massive statewide reductions, which we are seeing in several other states," Cloud said. "It protected the existing EtO operations."

Mustapha Beydoun, vice president and chief operating officer of the nonprofit Houston Advanced Research Center, which conducts air quality studies for local governments as well as industry, said it's concerning that the TCEQ and the EPA are so far apart on such a crucial issue.

"TCEQ is going in the opposite direction, basically saying it's OK if you shower in this stuff," Beydoun said. "Where is the disconnect here?"

"Made it this far"

On a cool, sunny day in late September, Yaneli wailed as she stood in a royal blue ball gown at the entrance to the chapel at Iglesia Cristiana Misericordia. Whether the teenager's tears were the product of the sharp pain shooting through her legs or the raw emotions on the occasion of her landmark 15th birthday celebration was unclear even to her parents, who rarely see her cry.

The steroid pills Yaneli took for nearly two years as part of her treatment for leukemia have killed off so much of the tissue in her hip bone that it hurts to move. Karla and Cesar Ortiz worried that their daughter would need a wheelchair to make it down the long aisle of the church for the traditional quinceañera blessing that welcomes a young girl to womanhood. They didn't know if they would get to dance with her under the stars at the reception.

But Yaneli insisted on standing and, later on, dancing. Her parents walked arm-in-arm with her toward the altar that afternoon, and they held her steady as she swayed on the dance floor.

That night, Karla Ortiz recalled how she had nearly lost her daughter two years earlier.

Soon after Yaneli's cancer diagnosis, the family moved to Corpus Christi, which has a children's hospital. Yaneli developed a serious infection that her small body was having trouble fighting because the cancer had nearly depleted her healthy white blood cell count. Doctors had just finished two hourslong surgeries to rid her body of the bacteria that had proliferated.

Eventually, a surgeon arrived in the same room where Yaneli had been diagnosed with cancer weeks earlier. Through an interpreter, he told Karla and Cesar Ortiz that their daughter was not breathing on her own and offered them two options: They could keep Yaneli on life support, where she would likely stay for the remainder of her life, or remove her from the breathing machines, which he estimated would give her two or three days to live. Cesar Ortiz dropped to his knees to pray. In his hands was the Bible he always carried with him.

After four agonizing hours, the couple decided to remove the tubes that doctors said were keeping Yaneli alive. "We'll suffer if she suffers, and we can't let that happen," Karla Ortiz recalled thinking. The parents called their families and asked them to make the 2 1/2-hour drive from Laredo to Corpus Christi to say goodbye, a recommendation from the hospital's medical staff.

Karla Ortiz barely slept the night before doctors removed the tubes from Yaneli's fragile body. She felt nauseous. But when the moment came, an unconscious Yaneli suddenly started breathing on her own. Three weeks later, she woke up.

It was a blessing for the couple, and it strengthened the mother's resolve not to miss another moment with her daughter.

She quit her marketing job to take care of Yaneli full time. It would be the second job she'd left in the five months following her daughter's diagnosis. The couple needed the money, but Yaneli needed them more. They returned a car they were still paying off to the dealership, taking a hit on their credit that hampered their dream of buying a home.

Two years later, back in Laredo, they were not only commemorating their daughter's quinceañera but marking the anticipated end of her battle with cancer.

The Monday after her celebration, Yaneli was back at the children's hospital in Corpus Christi. Her legs hurt so much, it felt like they were broken.

She would need to have both of her hips replaced, but the surgeon didn't want to disrupt the final months of her treatment, which was set to end Dec. 3.

With the chemotherapy now done, Yaneli will have to return to the hospital for the hip surgeries.

"The doctors say after those she won't really be able to run again," Karla Ortiz said. "But at least we've made it this far."

"Laredo can't be a sacrifice zone"

More than 75 Laredo residents crammed into a city recreation center about 2 1/2 miles from the Midwest plant this month. Local leaders organized the meeting after reporters from ProPublica and the Tribune started asking questions about the Midwest plant. It drew so much interest that some residents listened from two nearby overflow rooms, while another 50 people tuned in via livestream.

"One of the biggest problems is we did not know," said Tricia Cortez, the executive director of the Rio Grande International Study Center, a local environmental group that focuses predominantly on water pollution. They learned about the issue in the spring, she explained, from investigative reporters. "Once we did, we were truly stunned by diving deep into EPA databases and knew that people had to know about this, and we had to address this right away."

Over the course of nearly three hours, residents expressed outrage that government officials had failed to alert them of the cancer risk posed by the Midwest plant. They listened to organizers from Illinois, who had mobilized to close an ethylene oxide plant in their community, and traded stories about loved ones who had recently been diagnosed with cancer. They also circulated a petition asking the EPA to hold a community meeting and strengthen regulations. "Let it be known that Laredo can't be a sacrifice zone to serve the rest of the country," one resident said.

A doctor with the city's health authority raised the possibility of a pilot program that would collect blood samples from 3,000 Laredo residents to test for higher concentrations of ethylene oxide. A representative from the newly established Clean Air Laredo Coalition, which formed in response to the reporting, said its members are pushing the city council to request that the Centers for Disease Control and Prevention conduct blood testing on children attending school campuses in areas facing a high excess cancer risk. And Laredo City Council members assured residents that local government officials would rely on EPA's final risk assessment, and not the more lenient view taken by TCEQ, to weigh cancer risks.

Some officials say that's just the beginning of what's needed. U.S. Rep. Henry Cuellar, D-Laredo, has been pushing the EPA's regional offices to finally hold the meeting they were asked to conduct years ago. "The worst thing they can do is hide this," Cuellar said. In November, after ProPublica published a map that showed the spread of cancer-causing chemicals from thousands of sources of hazardous air pollution across the country, including Midwest's Laredo facility, David Gray, EPA's regional director for Texas, responded to Cuellar's request. Gray said the EPA was discussing a community meeting with the local environmental group and that Cuellar could be involved in scheduling it.

Beal, of the EPA, said that the Biden administration has "reinvigorated its commitment to protect public health from toxic air emissions from industrial facilities." And she said ethylene oxide in particular is a major priority. The agency has laid out a three-year timeline for strengthening regulations for a variety of pollutants and communicating the risks to the public. That includes proposing an updated regulation for ethylene oxide sterilizers like Midwest sometime in the coming months, which may require facilities to reduce ethylene oxide emissions.

Thomas McGarity, a professor at the University of Texas School of Law who once worked in the EPA's Office of General Counsel, is skeptical that the administration will be as forceful as it is promising to be, particularly with states that are reluctant to follow its lead.

"The Biden administration has talked a big game, but let's see what they will force states to do," McGarity said. "The EPA has a lot of power, but it has always been reluctant to use it."

Five years after Jinot and her colleagues published their updated risk assessment on ethylene oxide, the agency still has not incorporated the science into the majority of the environmental regulations that govern how much of the chemical facilities can emit. The one it has updated, which would reduce ethylene oxide pollution from certain chemical plants by an estimated 1 ton overall, is facing a lawsuit from environmental groups who argue it's insufficient.

Meanwhile, the American Chemistry Council, which represents the chemical industry, formally asked the EPA to consider using Texas' standard instead of its own. The group has suggested that the EPA's assessment is outdated because it preceded the TCEQ assessment.

The EPA agreed to consider the request but hasn't yet made a decision. "I don't know what's going on now that they think they should reopen it," Jinot said. "There's nothing new here. There's just this really flawed and error-ridden alternative. It's very discouraging."

Jinot said she has tried to unplug since her retirement four years ago, but she keeps getting drawn back in to defend scientific conclusions that could have already led to stronger regulations to protect vulnerable communities.

Lylla Younes, Al Shaw, Alyssa Johnson and Ava Kofman contributed reporting

This article originally appeared in The Texas Tribune

The Texas Tribune is a nonpartisan, nonprofit media organization that informs Texans -- and engages with them -- about public policy, politics, government and statewide issues

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Tuesday, December 28, 2021

Russia, US and Ukraine: The State of Play

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