Harvard Health Ad Watch: An upbeat ad for a psoriasis treatment

Psoriasis is a chronic disease in which skin cells rapidly divide, causing the skin to develop rough, red, scaly patches. Plaque psoriasis is the most common form: affected skin has sharply defined, inflamed patches (plaques) with silvery or white scales, often near an elbow or on the shins and trunk.

The cause of psoriasis isn’t known, but there are a number of treatment options. Possibly you’ve seen a glossy, happy ad for one of these treatments, a drug called Skyrizi. It’s been in heavy rotation and in 2020, hit number four on a top 10 list for ad spending by a drug company.

Splashing in blue water

A woman in a bathing suit sprints down a dock and jumps into the water with several friends. There’s lots of smiling and splashing. A voiceover says "I have moderate to severe plaque psoriasis. Now, there’s Skyrizi. Three out of four people achieved 90% clearer skin at four months after just two doses."

Then, the voiceover moves to warning mode: "Skyrizi may increase your risk of infections and lower your ability to fight them. Before treatment your doctor should check you for infections and tuberculosis. Tell your doctor if you have an infection or symptoms such as fever, sweats, chills, muscle aches, or cough, or if you plan to or recently received a vaccine."

As these warnings are delivered, we’re treated to uplifting pop music — "nothing is everything," a woman sings — while attractive young people flail about in the water.

"Ask your doctor about Skyrizi," a voice instructs. Did I mention a plane is skywriting the drug’s logo? I guess it’s putting the "sky" in Skyrizi.

What is Skyrizi?

Skyrizi (risankizumab) is an injectable medication that counteracts interleukin-23, a chemical messenger closely involved in the development of psoriasis. The standard dosing is two injections to start, followed a month later by two injections once a month, and then two injections once every three months.

Did you catch that "injectable" part? This is not a pill. If you missed that point while watching the commercial, it’s not your fault. The word "injection" appears once, written in faint letters at the very end of the commercial.

By the way, the FDA has only approved this drug for moderate to severe — not mild — plaque psoriasis. The studies earning approval enrolled people with psoriasis on at least 10% of their skin and two separate measures of severity.

What the ad gets right

  • The ad states that 75% of people with moderate to severe psoriasis experienced 90% clearance of their rash within four months after only two doses of Skyrizi. This reflects the findings of research studies (such as this one) that led to the drug’s approval.
  • The recommendations regarding screening for infections (including tuberculosis) and telling your doctor if you’ve gotten a recent vaccine are appropriate and should be standard practice. By lowering the ability to fight infection, this drug can make current infections worse. It may reduce the benefit of certain vaccines, or increase the risk of infection when a person gets a certain type of vaccine called a live-attenuated vaccine.

And the theme song? People with visible psoriasis often cover up their skin due to embarrassment or stigma. The rash isn’t a contagious infection or a reflection of poor health, but other people may react as if it is. So, an effective treatment could potentially allow some to forego covering up and show more skin: it means "everything" to someone suffering with psoriasis to cover "nothing." Thus, a theme song is born.

What else do you need to know?

A few things about this ad may be confusing or incomplete, including:

  • Currently, each dose of Skyrizi is actually two injections. So, a more accurate way to summarize its effectiveness would be to say that improvement occurred within four months after four injections (rather than "just two doses").
  • Like most newer injectable medications, this one is quite expensive: a year's supply could cost nearly $70,000. The drug maker offers a patient assistance program for people with low income or limited health insurance, but not everyone qualifies. Health insurance plans generally require justification from your doctor for medications like Skyrizi, and your insurer may decide not to cover it. Even if covered, this prior approval process can delay starting the medication, which may still be expensive due to copays and/or deductibles.
  • There is no mention of the many other options to treat psoriasis, some of which are far less costly. These include medications that do not have to be injected (such as oral methotrexate or apremilast), and UV light therapy (phototherapy). And there are other injectable medications. So, ask your doctor about the best options for you.

The bottom line

Some people appreciate the information provided by medication ads. Others favor a ban on such advertising, as is the case in most other countries. And recently, two advocacy groups asked the FDA not to allow drug ads to play music when the risks of drug side effects are presented, arguing that it distracts consumers from focusing on this important information.

Since these ads probably are not going away anytime soon, keep in mind that they may spin information in a positive light and leave out other important information altogether. So, be skeptical and ask questions. Get your medication information from your doctor or another unbiased, authoritative source, not a company selling a product.

Regardless of how you feel about medical advertising, it’s hard to hate the Skyrizi theme song. Feel free to sing along.

Thinking about COVID booster shots? Here’s what to know

Vaccination against the virus that causes COVID-19 is the most important lifesaving tool we have in this pandemic. Fortunately, the vaccines authorized in the US have proven remarkably safe and effective. And we’ve known from the start that the strong protection they provide would likely wane over time.

But has protection declined enough to warrant booster shots? Studies published in the last few months by researchers in the UK, Israel, and the US (reviewed here and here) raised this possibility, and Israel and the UK have already started ambitious booster programs.

First things first: Vaccinate everyone

In the US, the CDC and FDA have reviewed the necessity, safety, and effectiveness of boosters for the Pfizer/BioNTech, Moderna, and Johnson & Johnson vaccines. I’ll discuss these recommendations in a moment.

But first, it’s important not to overlook this fact: vaccinating the unvaccinated should be a much bigger priority than giving booster shots to those who’ve received vaccines. That goes for people in the US who have been unable or unwilling to get the vaccine, and people in places throughout the world with limited access to vaccines.

Broadening the pool of people with initial vaccinations would not only save more lives than promoting boosters, but would also reduce COVID-related healthcare disparities between richer and poorer countries. That’s why the World Health Organization (WHO) called for a moratorium on booster doses. Meanwhile, the Biden administration has announced a promise to donate another half billion vaccines to countries with low vaccination rates, bringing the total US commitment to donate 1.1 billion doses. The administration emphasizes that starting a booster program in the US and helping other countries get their citizens vaccinated are not mutually exclusive.

Is there a difference between a booster dose and a third shot?

It’s not trick wording: not all extra vaccine doses are boosters. In August 2021, the FDA approved a third dose of the Pfizer or Moderna vaccine for people who are immunocompromised. This includes people who have HIV and those receiving treatment for cancer that suppresses the immune system. For them, the extra dose is not a booster; it’s considered part of their initial immunization series.

Getting the timing and dose right on vaccine boosters

Ideally, vaccine boosters are given no sooner than necessary, but well before widespread protective immunity declines. The risks of waiting too long are obvious: as immunity wanes, the rates of infection, serious illness, and death may begin to rise.

But there are downsides to providing boosters too early:

  • Side effects might be more common. While studies published to date suggest that boosters are safe, we don’t yet have long-term data.
  • The benefit may be small. It may be better to wait on boosters if most people are still well-protected by their initial vaccinations.
  • Current boosters may not cover future variants. If new variants of concern emerge in the coming months, boosters may be modified to cover them.
  • Waiting longer before a booster might lead to a stronger immune response. As noted by Dr. Anthony Fauci recently: “If you allow the immune response to mature over a period of a few months, you get much more of a bang out of the shot.”

The recommended dose for the Pfizer/BioNTech booster and Johnson & Johnson booster is the same as the initial dose. For the Moderna booster it’s a half-dose, which may reduce the risk of side effects and increase the number of doses available to others.

Recommendations for vaccine boosters

In the US, adults 18 or older who have had a COVID vaccine are eligible for a booster shot.

  • If you had the Pfizer/BioNTech or Moderna vaccine The FDA and CDC have authorized Pfizer/BioNTech and Moderna boosters for all adults 18 or older at least 6 months after the initial series. According to the CDC, people 50 or older, or adults 18 or older who live in long-term care facilities should get boosters. Other adults 18 or older may decide whether to have a booster.   
  • If you had the Johnson & Johnson vaccine A booster dose of the Johnson & Johnson vaccine has also been authorized for all adults 18 or older two or more months after the first dose.

Mixing or matching booster shots

The FDA and the CDC have concluded that mixing or matching vaccines when getting a booster dose is safe and effective. Regardless of the initial vaccine you received, any of the three available vaccines may be given as a booster.

Plenty of unknowns

The release of these new recommendations for vaccine boosters raises a number of questions:

  • How convincing is the safety data? Reports to date suggest boosters are safe, but we need more research and real-world data.
  • Will the boosters be modified to protect against emerging variants of concern?
  • Will additional boosters be needed in the future? If so, how often?

There are important gaps in our knowledge of how well vaccine boosters work. We need larger and longer-term studies involving a broad range of participants representing all races and ethnicities and people with compromised immune systems. Look for further information in coming months.

What’s next?

You can expect the FDA and CDC to continue to expand recommendations for boosters based on review and analysis of ongoing research. Guidelines for teens and kids under age 18 will be particularly important. In the meantime, we should redouble our efforts to vaccinate people who haven’t yet received vaccines. Boosters can play an important role in protecting individuals. But, as CDC director Dr. Rochelle Wallensky notes, “we will not boost our way out of this pandemic.”

Can vaping help you quit smoking?

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Lately it seems like everywhere I look, someone is vaping as they walk by, stand outside a store, or roll up in the car next to me at a stoplight. It’s not surprising: e-cigarette use, or vaping, has become remarkably popular in recent years. About 6% of adults in the US now report vaping. That’s about 15 million people, double the number from just three years ago. Of course, regular cigarettes are known to cause cancer and a host of other health problems.

While considered less harmful than smoking tobacco, vaping isn’t risk-free. We know some, but not all, of its risks. We also know vaping is increasingly popular among teens and young adults, and this makes the recent FDA announcement authorizing sales of three additional vaping products surprising.

A surprise announcement from the FDA

In its announcement, the FDA authorized the R. J. Reynolds Vapor Company to market and sell its Vuse Solo device with tobacco-flavored vaping liquid to adults.

The FDA denied marketing authorization for 10 flavored products made by the same company. It also reports having denied more than a million flavored vaping products from other companies.

By the way, the agency emphasizes it is not actually approving these vaping products, or declaring them safe. The announcement states that marketing authorization will be reversed if

  • the company directs advertising to younger audiences
  • there is evidence of “significant” new use by teens or by people who did not previously smoke cigarettes
  • R. J. Reynolds does not comply with extensive monitoring requirements.

Why did the FDA take this action?

The decision was reportedly based on data from the company — unfortunately not provided in the press release — demonstrating these products would benefit individuals and public health. How? By helping smokers quit.

Some studies have suggested that e-cigarette use can be modestly helpful for smokers trying to quit. For example, an analysis of 61 studies found that e-cigarette use was more effective than other approaches to quitting smoking. The study authors estimated that out of every 100 people who tried to quit smoking by vaping, nine to 14 might be successful. When only using other methods, such as nicotine patches or behavioral counselling, only four to seven smokers out of 100 might quit. A separate study suggests vaping may help smokers who aren’t able to quit reduce the number of cigarettes smoked per day — at least for six months, the duration of the study.

Does vaping harm health less than smoking cigarettes?

Despite claims that vaping is less harmful than smoking cigarettes and that it might help smokers quit, concern about its risks is well deserved.

  • Nicotine addiction. Whether in cigarettes or vapes, nicotine is highly addictive. And the amount of nicotine in many vaping products is much higher than in regular cigarettes. Side effects include reduced appetite, increased heart rate and blood pressure, nausea, and diarrhea.
  • Harm to lungs and heart. Vapors from e-cigarettes may contain cancer-causing toxins, metals, and lung irritants. Vaping raises risk for lung diseases, such as emphysema, asthma, chronic bronchitis, and chronic obstructive pulmonary disease. It’s also linked to an increased risk of heart attacks. Even secondhand exposure to e-cigarette vapors may trigger asthma.
  • Severe, potentially fatal lung injury. In 2019, doctors began seeing people who had recently vaped and developed shortness of breath, cough, fever, and extensive lung damage. Dubbed EVALI (e-cigarette or vaping product use-associated lung injury), more than 2,800 cases and 68 deaths were reported. The condition has been linked to vapors containing THC and a form of vitamin E (called vitamin E acetate) used as a thickening agent when vaping THC. Cases have fallen markedly since 2020. Possibly because of falling case numbers, the FDA announcement of new vaping products didn’t even mention EVALI, which seems odd. If you do vape, see these recommendations to reduce the risk of EVALI.
  • Health risks during pregnancy. Nicotine can damage a baby’s developing brain and lungs; some flavorings may be harmful as well. As a result, experts recommend that people who are pregnant not vape.

For teens and children, vaping has additional risks

An alarming number of middle-school and high-school age kids report vaping, despite the nationwide prohibition against selling e-cigarette products to anyone under age 18 (21 in some states). Its popularity is partly related to the marketing of flavors known to appeal to minors, such as bubblegum and berry-flavored products. According to one national survey, approximately 85% of teen vaping involved non-tobacco flavored products.

It’s important to know that

  • nicotine negatively affects the developing brain
  • the high exposure to nicotine and other toxic chemicals through vaping may be particularly harmful to kids because of their smaller body size
  • the addictive potential of nicotine may mean that kids who vape are more likely to become cigarette smokers.

The bottom line

For nonsmokers and teens, there is no controversy: don’t start smoking and don’t vape.

If you’re an adult smoker trying to quit, be aware that the balance of risks and benefits and the long-term health consequences of vaping are uncertain. We need more solid research to help people make decisions. Meanwhile, the FDA has come down on the side of a limited authorization to help adult smokers quit. We’ll know only in retrospect if that was the right move.

How to get your child to put away toys

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If you frequently find yourself stepping on a building block, tripping over a doll, or stumbling over a race car, then you know the challenges of getting younger children to put away their toys. Below are a few strategies to encourage children to clean up after themselves and keep the house tidy.

Make specific and focused requests

Asking your child to put many different things away all at the same time can leave room for children unintentionally to forget at least one of your requests — or intentionally skip a few. Make one specific request at a time, such as "Please put your blocks back in the bin on the shelf." After your child has finished one task, then you can request that your child puts a different toy away.

Make requests in the form of a command, not framed as a question like "Will you please clean up your blocks?" Asking a question leaves room for the child to reply, "No." Also, unless you want this to be a group activity, frame the request for just your child: "Please put your blocks back in the bin on the shelf" instead of "Let’s clean up the blocks."

Give your child time to comply, and repeat yourself only once

Children, especially young children, take more time than adults to process information. Count to five in your head after you make an initial request, to give a child time to process what you said and to comply.

If you don’t see the required action after five seconds, repeat your request in a neutral tone followed by a potential logical consequence. For example, "If you do not put your blocks away in the bin on the shelf, then you will not get to play with the blocks for the rest of the day. You can play with them tomorrow."

Count to five in your head again. If your child still does not do what you asked, say the following in a neutral tone: "Okay, you did not put the blocks away in the bin on the shelf, so you do not get to play with them for the rest of the day. You can play with them tomorrow." You can then put the blocks away and out of reach from the child so that the toys are not in use for the remainder of the day.

Stay calm and choose logical consequences

Two key elements of this approach are to remain as calm as possible and create a logical consequence.

  • Staying calm helps. Understandably, you may be very frustrated. However, it’s best to give as little attention to noncompliance as possible. Attention, even in the form of a negative tone, can make the behavior happen more often.
  • Logical consequences matter. Creating consequences that are for extensive periods of time and do not make sense to the child may spark more frustration and refusals. For example, it would not be logical for the child to lose TV time for a week if the child did not put their blocks away. Instead, limiting access to the toy is a logical consequence.

Praise behaviors you want to see

Shine attention on behaviors you’d like to see more often. Any time your child does put toys away, praise them specifically. "Good job" can confuse: the child will not know exactly what was good — sitting quietly, putting toys away, or something else. Instead, say, "Great job putting the blocks in the bin on the shelf!"

Praise with enthusiasm, and use touch, such as a pat on the back, to strengthen a behavior. If you have a child who has sensory processing difficulties, especially with tactile stimuli like a pat on the back, you can reinforce the behavior with a nonverbal gesture, such as a thumbs up.

Your days of repeating commands until you’re blue in the face and cleaning up after your children do not have to continue. The steps above can give you a breather and help your children learn to pick up after themselves.

Careful! Health news headlines can be deceiving

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Ever read a headline that catches your eye but then found the story itself disappointing? Or worse, did you feel that the dramatic headline was utterly misleading? Yeah, me too.

The impact of a well-crafted headline can be big. We often skim the headlines, then decide whether or not to read on.

Previously, I’ve written about how media coverage of drug research can mislead or confuse. Here I’m zooming in on health headlines, which can be equally deceptive. Watch for these pitfalls.

Overstated study findings

  • Were humans studied? If a study finds that a drug is safe and effective for an important disease, that’s big news. But what if all of the study subjects were mice? Leaving out this important detail from the headline exaggerates the study’s importance.
  • Too much drama. Dramatic terms such as “breakthrough” or “groundbreaking” are common in headlines about medical research. Yet true breakthroughs are quite rare. That’s the nature of science: knowledge tends to accumulate slowly, with each finding building a bit on what came before.
  • Going too far. Headlines often make a leap of faith when summarizing a study’s findings. For example, if researchers identify a new type of cell in the blood that increases when a disease is worsening, they may speculate that treatments to reduce those cells might control the disease. “Researchers discover new approach to treatment!” blares the headline. Sure, that could happen someday (see below), but it’s an overstatement when the study wasn’t even assessing treatment.
  • Overlooking the most important outcome. Rather than examining how a treatment affects heart disease, let’s say, studies may assess how it affects a risk factor for it. A good example is cholesterol. It’s great if a drug lowers cholesterol, but much better if it lowers the rate of cardiovascular disease and deaths. Headlines rarely capture the important difference between a “proxy measure” (such as a risk factor) and the most important outcome (such as rates of death).

Faulty logic

  • A link for illness is not the same as a cause of illness. The distinction between “causation” and an “association” is important. Observational studies can determine whether there is a link (association) between two health issues, such as a link between a symptom (like a headache) and a disease (like stomach ulcers). But that doesn’t mean one actually caused the other. Imagine an observational study that compared thousands of headache sufferers with thousands of people who rarely had headaches. If more people in the frequent headache group also had more stomach ulcers, the headline might boldly declare “Headaches cause ulcers!” A more likely explanation is that people with a lot of headaches are taking aspirin, ibuprofen, and related drugs, which are known causes of ulcers.

Hazy on key details

  • Someday isn’t today. Studies of new drugs or devices may be heralded as life-changing for people or practice-changing for doctors. Yet, a closer look often reveals that the new treatment is years away from reaching the market — or it may never get approved at all.
  • A work in progress. “Preliminary” is the missing word in many headlines. Studies presented at medical conferences but not yet published in a peer-reviewed medical journal offer preliminary insights. This research, while promising at the time, may ultimately be a scientific dead end.
  • Is it a study, a press release, or an ad? It’s hard to tell with some headlines. Press releases or advertisements typically present a positive spin on new findings or treatments. We expect news stories to be more balanced.

One story, many headlines

Here’s a great example of overhyped headlines. A 2021 study presented findings about a pacemaker that treats abnormal heart rhythms for a period of time and then dissolves. Amazing, right? For people who need a pacemaker only temporarily, a dissolving pacemaker could allow them to avoid a surgical procedure to remove it once it was no longer needed.

Three headlines covering this research spun the story this way:

Coming Soon: An Implanted Pacemaker That Dissolves Away After Use

Could people one day get pacemakers that dissolve into the body?

First-ever transient pacemaker harmlessly dissolves in body

But that dissolving pacemaker had never been tried in living humans — an important fact! To test the dissolving pacemaker, the researchers had performed open-heart surgery in rats and dogs, and lab experiments on heart tissue removed from mice, rabbits, and deceased humans.

The first headline demonstrates the pitfall of overpromising on the findings of preliminary research: yes, a dissolving pacemaker might someday be routine in humans, but it’s unlikely to be “coming soon.” And when a headline says “harmlessly dissolves in body,” we might reasonably think this refers to a livinghuman body. Not so.

The bottom line

Why are we constantly bombarded with misleading headlines? A major reason is that headlines attract attention, clicks, reads, subscriptions, and influence essential to media sites. Some writers and editors lean into hype, knowing it attracts more attention. Others may not be trained to read or present medical news carefully enough.

In a world full of misleading health news headlines, here’s my advice: be skeptical. Consider the source and read past the headline before buying in. And if your go-to media often serves up misleading headlines, consider changing channels or crossing that news source off your list.

What it takes to achieve world-changing scientific breakthroughs

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In science, advances are a daily occurrence, but true breakthroughs are rare. What does it take to achieve world-changing scientific breakthroughs? Some are the result of a lucky accident, combined with curiosity: scientists traveling down one road suddenly find reason to veer onto another road, one they never planned to travel — a road that may well lead nowhere.

Other major breakthroughs stem from scientists pursuing a very specific dream. One day, usually early in their career, they get an idea that they can’t stop thinking about. It’s crazy, they say to themselves, but is it really impossible? They talk to respected colleagues who often remind them of all the reasons their idea might not work, and how damaging this could be for their career. It’s a sobering message, yet the idea won’t die. So, they scramble to find financial support and seek out colleagues willing to risk traveling that road with them — a road that may well lead nowhere. But sometimes the road leads to major breakthroughs like penicillin and mRNA vaccines.

Breakthroughs due to lucky accidents and curiosity

One day in 1928, Dr. Alexander Fleming at St. Mary’s Hospital in London was growing bacteria in a laboratory dish. Fleming was not pursuing a scientific dream. He was a microbiologist, just doing his job.

Then he noticed something odd: overnight, another kind of microbe, a fungus, had traveled through the air, landed on the laboratory dish, and started to grow and spread on the dish where the bacteria were growing. Fleming soon noticed that the growing fungus seemed to be killing the bacteria. He surmised that it was making some substance that killed the bacteria. Because the name of the fungus was Penicillium rubens, he called the substance the fungus was making “penicillin.”

When Fleming published a paper about his discovery, few were interested. It took another 10 years before other scientists tried to generate large amounts of penicillin to see if it might be able to cure bacterial infections and save lives. We all know how that worked out.

Fleming’s scientific breakthrough, like some others, occurred not because Fleming had a brilliant idea and exclaimed “Eureka!” Instead, it occurred because he noticed something and said, “That’s odd,” and then tried to figure it out.

Breakthroughs due to persistence and resilience in pursuit of a dream

The story of mRNA vaccines, like the Pfizer/BioNTech and Moderna vaccines for COVID-19, is very different from the story of penicillin. For 30 years, a small group of scientists believed that mRNA vaccines would have great advantages over traditional vaccines — if only several obstacles could be overcome. Many of these scientists gave up as they encountered those obstacles, but a few persisted and, ultimately, succeeded. (I described what mRNA vaccines are, how they work, and how obstacles were overcome in a previous blog post.)

One scientist, Dr. Katalin Karikó, joined the faculty of the University of Pennsylvania in the early 1990s with the dream of creating an mRNA vaccine. She applied for grants to support her work, but was repeatedly rejected: the reviewers stated that it was so unlikely that she or anyone could overcome the obstacles that supporting her research would be a wasted investment. Her university only agreed to continue supporting her work if she accepted a demotion and a pay cut. She accepted both, and doggedly pursued her dream.

One major obstacle to mRNA vaccines particularly fascinated her: the violent reaction of the immune system when it encounters mRNA from a virus. Ten years of dogged work helped Karikó and her colleague Drew Weissman figure out how to make a small change in mRNA that prevented that violent immune response — a major step in making all mRNA vaccines possible. Without this, the world wouldn’t have mRNA COVID vaccines today.

Two other scientists who created the Pfizer/BioNTech COVID vaccine, Uğur Şahin and Őzlem Turëci, are Turkish immigrants to Germany who met, fell in love with the idea of creating an mRNA vaccine, and then fell in love with each other. According to The Wall Street Journal, one day in 2002 they took a break for lunch, got married, and then returned in the afternoon to their laboratory to finish an experiment — just one more among many conducted over 30 years. Each experiment was one more possible step toward their ultimate dream until finally, in 2020, they achieved that dream: their mRNA vaccine for COVID-19 proved to be very safe and effective.

Holding hard to their dreams

Whichever path scientists who achieve lifesaving breakthroughs travel, they often endure disinterest, like Fleming, or repeated skepticism, ridicule, and rejection, like Karikó, Weissman, Şahin, and Turëci. Only through sheer persistence did these scientists bring their dreams to life. They have been rewarded with fame and wealth and something even more valuable: the knowledge that because of their work hundreds of millions of people around the world never got sick, and millions never died before their time.

Of course, a relentless obsession with an improbable dream fails to pay off for many scientists. Their ideas, while quite brilliant, in the end are proved wrong: nature doesn’t turn out to operate the way they predicted. In the end, their beautiful theory is murdered by a brutal gang of facts.

Still other scientific dreamers ultimately prove to have been on the right track all along and would have achieved their dream — if only they had done the experiment a little differently, if only they had persisted a little longer, or if only the support for their work had not run out. As a result, neither they nor the rest of us benefitted from what would have been — until other scientists rediscovered their work years later.

Ultimately, scientific breakthroughs are possible only if a society is willing to invest in dreamers, recognizing that not all investments will lead to major breakthroughs. However, the investments that do lead to breakthroughs bring an economic return that is far greater than the investment — as well as preventing suffering and death and changing the world.

Want to participate in COVID-19 research? Download the COVID Symptom Study app to help researchers track symptoms and hot spots across the US. Click here for information.

A conversation about reducing the harms of social media

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Editor's note: In this blog post, Dr. Sharon Levy interviews her son Isaiah Levy, a college student. We appreciate Isaiah’s insights and comments on social media's impact on teens and young adults.

It is hard to remember (or for younger people, hard to imagine) a world without social media, but indeed such a world once existed — and in fact, it is the world humans evolved in.

Humans are social animals. Friendly interactions release dopamine in our brains’ reward centers to get us to repeat the behavior. Until recently, that feedback loop suited us very well, with little opportunity to get off track. Social media changed things by providing the opportunity for nearly infinite interactions. This excess exploits our natural inclination for social contact in the same way that sweets exploit our natural drive to eat ripe fruit. Too much refined sugar can cause a cascade of medical problems; too much social media can also affect health — especially mental health.

Beyond sheer volume, social media interactions are qualitatively different from in-person meetings. For one thing, social media platforms have developed easy opportunities for viewers to react to content, resulting in objective feedback metrics for the content creator. Because the denominator is essentially infinite, no matter how many likes a post gets, the numerator may not feel like enough. Feeling insufficient, not liked enough, judged by others, or excluded from an "in group" takes a heavy toll on mental health.

For perspective from a digital native, I posed questions about social media to my son Isaiah Levy, a computer science major at New York University.

What do you see as the benefits of social media?

Theoretically, social media can connect people across the globe at scale, presenting an opportunity for users to form relationships beyond their geographic boundaries. Popular social media platforms can also provide a stage with a potential audience of one billion eyes. Social media offers tremendous potential for people who want to be noticed. However, most connections are extensions of our real-life relationships, and many users say that social media enriches friendships. For example, a Pew survey found that a majority of teenage respondents said that Instagram enhanced their connections with people they already knew (many of whom are classmates).

Why is Instagram so popular with young people?

Web developers and graphic designers created Instagram using sophisticated algorithms and attractive visual presentation, to keep users engaged and interacting with its nearly limitless content for as long as possible. According to surveys done by Facebook (owner of Instagram), youth describe Instagram as current, friendly, trendy, and creative. Many teens say that Instagram helps define who they are and makes them feel more connected to the people they know. Another significant source of Instagram's allure, particularly for younger users, are the objective feedback measures that can make users feel important or of high social status.

The flip side is that the drive for attention creates its own problems. The Pew survey linked to above found that more than one-third of teen Instagram users said they feel pressure to post content that will get a lot of likes and comments, and more than 40% feel pressure to only post content that makes them look good. According to Facebook’s own internal surveys, more than 13% of teen girls said that Instagram worsens suicidal thoughts, and 17% said their eating disorders got worse with Instagram use.

As the government considers regulating social media, what suggestions do you have in regard to protecting mental health?

Government regulations should protect our freedom of expression while mediating risks, especially to children. The government could consider regulating some of the advanced algorithms that social media corporations use to increase user time expenditure (and thus profits). For example, "infinite swiping" is a design feature that continuously pushes forward new content after a user has exhausted content from the people they follow. These tactics pose serious threats. Just like use of alcohol, nicotine, or drugs, the act of swiping triggers neurological reward. Over time, the brain learns to seek social media instead of more natural rewards, putting users at risk of dissociation with meaningful priorities. As with drug addiction, younger users are at greatest risk. Government regulation of the most sticky algorithms would help promote a healthier balance for users. Deciding which algorithms to ban and how to implement such a ban is certainly a difficult task, and the solution will not be perfect; however, given what we know of the impact of social media on children’s mental health, it should be a federal priority.

While the government grapples with regulation, parents can step in. First, set a good example by putting your own screens down when interacting with your children. Talk to your teen about the pros and cons of social media: while it can be fun, it can also become a distraction. Set limits on your child’s social media use. Most importantly, talk to your children about their experiences, including who they are interacting with and what they are talking about. We know social media can harm mental health, so be on the lookout and intervene if you have concerns.

Preventing preeclampsia may be as simple as taking an aspirin

Preeclampsia is a common and dangerous complication of pregnancy that causes high blood pressure and excess protein in urine. Typically, it occurs during the third trimester or very soon after birth, but there may be a simple way to help prevent it.

If you’re pregnant, preeclampsia can cause kidney and liver abnormalities, blood clotting problems, headache, stroke, and even death. It makes it harder to deliver nutrients and oxygen to a growing fetus. And it’s linked to premature birth and low birthweight in babies. Yet a daily low-dose aspirin may help prevent many of these problems, according to a recent statement from the US Preventive Services Task Force (USPSTF).

Who is most likely to develop preeclampsia?

While preeclampsia can happen without any warning, certain risk factors make it more likely to occur:

  • carrying multiples, such as twins or triplets
  • having diabetes
  • being 35 or older
  • having obesity, described as a body mass index (BMI) greater than 30
  • having high blood pressure before pregnancy
  • having kidney disease or an autoimmune disorder.

Preeclampsia also occurs more often in Black people as a result of structural racism, which restricts access to care, and can also be a source of chronic stress from factors like food and housing insecurity that lead to poorer health and well-being.

Overall, preeclampsia affects about one in 25 pregnancies in the United States. It accounts for almost one out of every five medically-induced premature births. Preventing it will save lives.

What does the task force recommend to help prevent preeclampsia?

In the 2021 statement, the USPSTF recommends that doctors prescribe a daily low-dose (81 mg) aspirin for those at high risk for preeclampsia. The aspirin should be started at the end of the first trimester (12 weeks of pregnancy) and continued until the birth.

This supports a previous recommendation from the task force in 2014. And importantly, the statement reflects findings from a recent systematic review of research. The review looked at the role of aspirin in preventing preeclampsia, and whether aspirin can reduce complications among pregnant people, fetuses, and newborns. It also examined the safety of low-dose aspirin in pregnancy.

What did the review tell us?

Thirty-four randomized clinical trials comparing low-dose aspirin and placebo (a sugar pill) were included in the analysis. Most participants in the trials were young and white. Providing low-dose aspirin to those who were at high risk of preeclampsia successfully reduced risk for

  • developing preeclampsia
  • preterm birth (births before 37 weeks of pregnancy)
  • growth restriction (small babies)
  • fetal and newborn death due to preeclampsia.

The review considered whether using aspirin led to more bleeding problems. When comparing the aspirin group and the placebo group, no differences occurred in bleeding problems, such as maternal hemorrhage following a birth, fetal brain bleeding, and the placenta separating from the wall of the uterus too early.

Who should take low-dose aspirin during pregnancy?

Overall, the benefits of taking low-dose aspirin outweigh risks for some pregnant people. Your doctor may recommend it if you

  • have had preeclampsia before
  • already have high blood pressure or diabete
  • are carrying multiples, such as twins or triplets
  • have kidney or autoimmune disease.

It’s important to know that there are moderate risk factors to consider, too. When combined, they can increase the chance of preeclampsia and its complications. Your doctor may recommend low-dose aspirin if you have two or more of these factors:

  • having your first baby
  • having obesity
  • having a mother or sister who had preeclampsia
  • being 35 years old or older
  • having conceived with in-vitro fertilization (IVF)
  • having had a baby before who was small for gestational age
  • having a difficult pregnancy outcome in the past.

Unequal distribution of healthcare, and social and environmental stress, make preeclampsia and its complications more likely to occur in pregnant people who are Black and those who have lower income. Therefore, the task force recommends low-dose aspirin for these pregnant individuals even if they have only one moderate risk factor.

The bottom line

New evidence supports using low-dose aspirin to help prevent preeclampsia, a dangerous and common complication of pregnancy. If you’re pregnant or considering pregnancy, talk with your doctor or midwife about preeclampsia. It’s important to learn the warning signs of possible problems even if you’re not at high risk. Together, you can decide whether low-dose aspirin is a good choice for you.

What is neurodiversity?

Neurodiversity describes the idea that people experience and interact with the world around them in many different ways; there is no one “right” way of thinking, learning, and behaving, and differences are not viewed as deficits.

The word neurodiversity refers to the diversity of all people, but it is often used in the context of autism spectrum disorder (ASD), as well as other neurological or developmental conditions such as ADHD or learning disabilities. The neurodiversity movement emerged during the 1990s, aiming to increase acceptance and inclusion of all people while embracing neurological differences. Through online platforms, more and more autistic people were able to connect and form a self-advocacy movement. At the same time, Judy Singer, an Australian sociologist, coined the term neurodiversity to promote equality and inclusion of “neurological minorities.” While it is primarily a social justice movement, neurodiversity research and education is increasingly important in how clinicians view and address certain disabilities and neurological conditions.

Words matter in neurodiversity

Neurodiversity advocates encourage inclusive, nonjudgmental language. While many disability advocacy organizations prefer person-first language (“a person with autism,” “a person with Down syndrome”), some research has found that the majority of the autistic community prefers identity-first language (“an autistic person”). Therefore, rather than making assumptions, it is best to ask directly about a person’s preferred language, and how they want to be addressed. Knowledge about neurodiversity and respectful language is also important for clinicians, so they can address the mental and physical health of people with neurodevelopmental differences.

Neurodiversity and autism spectrum disorder

Autism spectrum disorder (ASD) is associated with differences in communication, learning, and behavior, though it can look different from person to person. People with ASD may have a wide range of strengths, abilities, needs, and challenges. For example, some autistic people are able to communicate verbally, have a normal or above average IQ, and live independently. Others might not be able to communicate their needs or feelings, may struggle with impairing and harmful behaviors that impact their safety and well-being, and may be dependent on support in all areas of their life. Additionally, for some people with autism, differences may not cause any suffering to the person themself. Instead, the suffering may result from the barriers imposed by societal norms, causing social exclusion and inequity.

Medical evaluation and treatment is important for individuals with ASD. For example, establishing a formal diagnosis may enable access to social and medical services if needed. A diagnostic explanation may help the individual or their family understand their differences better and enable community connections. Additionally, neurodevelopmental conditions may also be associated with other health issues that require extra monitoring or treatment. It is important that people who need and desire behavioral supports or interventions to promote communication, social, academic, and daily living skills have access to those services in order to maximize their quality of life and developmental potential. However, approaches to interventions cannot be one-size-fits-all, as all individuals will have different goals, desires, and needs.

Fostering neurodiversity in the workplace

Stigma, a lack of awareness, and lack of appropriate infrastructure (such as office setup or staffing structures) can cause exclusion of people with neurodevelopmental differences. Understanding and embracing neurodiversity in communities, schools, healthcare settings, and workplaces can improve inclusivity for all people. It is important for all of us to foster an environment that is conducive to neurodiversity, and to recognize and emphasize each person’s individual strengths and talents while also providing support for their differences and needs.

How can employers make their workplaces more neurodiversity-friendly?

  • Offer small adjustments to an employee’s workspace to accommodate any sensory needs, such as
    • Sound sensitivity: Offer a quiet break space, communicate expected loud noises (like fire drills), offer noise-cancelling headphones.
    • Tactile: Allow modifications to the usual work uniform.
    • Movements: Allow the use of fidget toys, allow extra movement breaks, offer flexible seating.
  • Use a clear communication style:
    • Avoid sarcasm, euphemisms, and implied messages.
    • Provide concise verbal and written instructions for tasks, and break tasks down into small steps.
  • Inform people about workplace/social etiquette, and don’t assume someone is deliberately breaking the rules or being rude.
  • Try to give advance notice if plans are changing, and provide a reason for the change.
  • Don’t make assumptions — ask a person’s individual preferences, needs, and goals.
  • Be kind, be patient.

Resources to learn more about neurodiversity

Neurodiversity in the Workplace

Thinking about holiday gatherings? Harvard Health experts weigh in

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Get expert advice on gathering safely from Harvard Health Publishing. Spoiler alert: vaccination is key to helping keep everyone healthy. Below, our faculty contributors share their own plans and advice for safely enjoying the holidays this year while answering three important questions.

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Roger Shapiro, MD

Associate professor of immunology and infectious diseases, Harvard T.H. Chan School of Public Health, Boston

What are your plans this year for gathering — or not gathering — with family or friends during Thanksgiving and other winter holidays, and why?

Unlike 2020, my family will be gathering for Thanksgiving in 2021. Everyone in the family is vaccinated, and most are now boosted as well. We are all comfortable with the protection that being vaccinated brings, and there is agreement that if a COVID-19 exposure were to occur, it is unlikely to cause severe illness.

What advice can you offer people planning to gather in person to reduce the chance of getting or spreading the virus that causes COVID-19?

Everyone who can get vaccinated should be vaccinated, and those who qualify for a booster should get one. Children 5 to 11 may not have their second shot by Thanksgiving but can certainly be fully vaccinated by Christmas. If there are unvaccinated members of your family, your situation is no different than in 2020: gathering is unsafe for the unvaccinated because the first exposure to this virus can be lethal without protection from a vaccine. Additionally, people who are unvaccinated are more likely to be infected before traveling, so they are more likely to bring the virus to the table, possibly causing illness (even if mild) among those who are vaccinated. For families that are all vaccinated and wishing to further reduce the possibility of transmission, taking a rapid antigen test prior to gathering can add a layer of protection.

For people planning to travel to gatherings, what would you advise?

If you are all vaccinated, enjoy the return to a normal holiday season. Vaccines are your main source of protection. If you want to add additional protection, you can consider using rapid antigen tests just before gathering to confirm that everyone is negative. If there are immunocompromised members of your family who may not be fully protected by a vaccine, you should discuss the risks case-by-case with your doctor.

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Suzanne Salamon, MD

Chief of clinical programs in gerontology, Beth Israel Deaconess Medical Center, Boston

What are your plans this year for gathering — or not gathering — with family or friends during Thanksgiving and other winter holidays, and why?

Let me start by saying my 99-year-old mother lives with us, and even though she’s had her third shot of the COVID vaccine, I’m very concerned about immune status. I also have a two-year-old granddaughter who cannot yet get the vaccine. So, everyone’s immune status is not equal. Certainly older people, even those who’ve had their third shot, may not have the same immune status as a 35-year-old.

We have really curtailed the size of our Thanksgiving dinner to under 10 people, since the CDC recommends smaller groups. Nobody wants to see people sitting at home alone during the holidays, but we have to make it as safe as possible for those who are there.

What advice can you offer people planning to gather in person to reduce the chance of getting or spreading the virus that causes COVID-19?

COVID cases are on the rise now in many places, even though a month ago the numbers were trending down. Unfortunately, we need to be more vigilant once again.

Many people are afraid to insult family and friends by asking them about vaccine status before they come. Tell people that you really want to see them, but some family or friends may be immune-suppressed or at higher risk if they get COVID-19, and you’re trying to make the gathering safe for everyone. That’s why I’d ask people to let you know their COVID vaccine status. Even after the two-vaccine series, research is showing diminished antibodies after six months, which may put people at higher risk for getting and/or spreading the virus. I would ask people who are not vaccinated not to come.

When people gather, ventilation is really important in reducing the concentration of any virus that might be present. Have the gathering outside or on a screened porch, if at all possible. We hosted Thanksgiving last year in our garage. We left the garage doors open and set up small tables and little space heaters for warmth. People could be social yet stay separated, and ventilation was great. You can decorate small tables with colorful plastic tablecloths and candles, even put down a rug. If you’re inside, windows and doors can be kept open, which will help move the air around. Have some small space heaters and sweaters available.

Ask everyone to bring a mask, or keep a box of masks available. Wear masks while you’re all chit-chatting until you sit down to dinner. In the bathroom, have a roll of paper towels or paper guest towels rather than a cloth towel, and leave the fan on for ventilation.

For people planning to travel to gatherings, what would you advise?

Planes are thought to be very safe. In the air terminal, sit apart from people. Keep your mask on during the flight.

Traveling by car is pretty safe. If you get out to go to the bathroom or get coffee, wear a mask and wash your hands. Traveling by bus or train is tricky, because even though there is a mask requirement, people will take off their masks. Be sure to wear your own mask. I personally double-mask. Two surgical masks block out a lot and can be a bit more comfortable than the N95 masks we wear in the hospital. A plastic face shield over the mask may be a good idea for added protection.

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John J. Ross, MD

Hospitalist with specialty in infectious diseases, Brigham and Women’s Hospital, Boston

What are your plans this year for gathering — or not gathering — with family or friends during Thanksgiving and other winter holidays, and why?

We are having an unmasked, multigenerational, fully-vaccinated, traditional Thanksgiving dinner at my in-laws, just like the Before Times.

What advice can you offer people planning to gather in person to reduce the chance of getting or spreading the virus that causes COVID-19?

Everyone in attendance should have a primary COVID vaccination. Getting vaccinated against COVID reduces the risk of hospitalization or death due to COVID by more than 90%. It also reduces your risk of death from any cause. People who are eligible for booster shots should get them. That includes anyone over 65, and people over 18 with underlying medical conditions, high occupational risk, or those who live in high-risk settings such as group homes, shelters, and long-term care facilities.

Certain vaccinated people are more likely to get breakthrough COVID. This includes people of advanced age, and those with serious medical conditions or weak immune systems. These people should be extremely cautious around those who are not vaccinated or partly vaccinated. I would recommend that they mask around unvaccinated people, physically distance, and use extra ventilation (opening windows, or ideally moving the whole shebang outdoors). Rapid antigen tests may also be helpful in the setting.

For people planning to travel to gatherings, what would you advise?

For those who have long distances to travel, I would recommend flying if possible. Airplanes have excellent ventilation, and masks are mandatory. While masks are also required on trains, they are not as well ventilated as planes, and train travel has been associated with significant COVID risks.

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Amy Sherman, MD

Division of infectious diseases, associate physician, Brigham and Women’s Hospital, Boston

What are your plans this year for gathering — or not gathering — with family or friends during Thanksgiving and other winter holidays, and why?

This Thanksgiving, my fiancé and I are driving to New Jersey and New York (with our dog!) to visit our families. We will have dinner with 14 others from my close family — larger than last year’s Thanksgiving, but smaller than pre-COVID years. Everyone has been vaccinated, and most have received a third dose. We will then visit with my fiancé’s 94-year-old-grandma, choosing to see her independently instead of bringing her to a large gathering.

Although no measures can absolutely make an indoor gathering 100% safe, we will apply layers of protective measures to reduce risk, with vaccinations as the base layer. Additionally, everyone will get tested for the virus that causes COVID-19 before gathering, limit exposure risks in the week before Thanksgiving, avoid public transportation, and drive instead of flying. When we’re together, we’ll spend time outdoors as much as possible. Maybe this year will bring new traditions — an outdoor bonfire instead of nighttime movie marathons, or Friday morning jogs instead of Jazzercise with my aunt!

What advice can you offer people planning to gather in person to reduce the chance of getting or spreading the virus that causes COVID-19?

We are in a much better place this year compared to last year. Connecting with family and friends is important for our mental health and well-being. However, we still need to be cautious, especially when gatherings include people who are older, immunocompromised, or at risk of severe COVID-19. We also have seen recent outbreaks in school-age kids who are not yet vaccinated. I would encourage your family and friends to get vaccinated if they haven’t already. For those family members at higher risk, consider smaller and more intimate gatherings, or do hybrid in-person/Zoom meetings. And layer up with the other risk reducing strategies I suggested!

For people planning to travel to gatherings, what would you advise?

Avoid public transportation if possible. If this is not possible, wear a mask on the bus, train, or airplane, even if you’ve been vaccinated. Vaccinations decrease the severity of disease, but you still could become infected and transmit the virus to others.

Read more advice on gathering for winter holidays this year, such as who can and should get a COVID-19 vaccine booster, whether to take a rapid test or PCR test before spending time with family or friends, how to navigate tricky relationships, and healthy eating through the holiday season.