A newly published cost-minimization analysis from Argentina offers one of the clearest economic assessments to date on how immunization budgets should be evaluated [1]. The study, conducted by the CINVE research group, compares two hypothetical hexavalent vaccination strategies, one containing whole-cell pertussis (wP) antigens, the other acellular pertussis (aP) antigens, and reaches a seemingly counterintuitive conclusion: the vaccine with the higher purchase price can result in lower total costs to the health system. These wP vaccines are known to have higher rates of side effects (adverse events), placing a significant additional burden on the healthcare system and society [2].

The findings of the study add to a growing body of evidence from previously published cost-minimization studies and go further than most, modelling wP and aP hexavalent strategies and highlighting the monetary benefits of lower reactogenicity.

A long-held assumption is now being challenged

Where the effectiveness of two strategies (or options) aiming to protect against the same pathogen is assumed to be similar, immunization budget holders will typically focus on acquisition cost alone. But a vaccination program’s costs extend well beyond the product: logistics, cold chain, additional appointments, staff time, adverse event management, and the productivity lost when parents take time off work or travel for care.

The evidence from Argentina suggests that this approach risks overlooking where the greatest costs actually occur: in adverse events and their subsequent consequences.

A global randomized controlled trial by Decker et al. assessed the risk of adverse events between wP and aP [3]. Many adverse events, such as pain, redness, and fever, are far more common among those who receive wP vaccines. Fever rates were between two and nearly five times higher among wP recipients [4]. Primary-series recipients are infants, many of these adverse events lead to primary care visits, generating direct costs to the system and households, along with distress that other studies link to reduced willingness among families to accept vaccination more broadly [2]. The impacts of these adverse events are often overlooked and not factored into budget considerations.

The long-held assumption that whole-cell vaccines are the economical choice is becoming increasingly difficult to defend. Assessed against total health care and societal costs rather than acquisition price alone, acellular hexavalent vaccination increasingly presents as the more favorable option.

The current vaccination situation in Argentina

Argentina’s public schedule currently uses three doses, and a single booster dose of a pentavalent wP-containing vaccine (combined with diphtheria, tetanus, Hib (Haemophilus influenzae type B), and hepatitis B antigens), alongside three IPV (Inactivated Poliovirus Vaccine) doses. This option is available through the public healthcare system; however, Argentina’s immunization program already recognizes the more favorable tolerability profile of acellular (aP) hexavalent vaccines by providing them to certain premature infants through Pan American Health Organization (PAHO) supported programs [5].

Those with the means to purchase the acellular vaccine, with its more favorable tolerability profile, can opt for it through the private market [5]. For most Argentinian infants, however, the wP vaccine remains the default option, as it is offered in the National Immunization Program. Families with private insurance have access to the better-tolerated aP formulation as a matter of course. The burden of adverse events and their associated costs falls disproportionately on the public system and the households it serves.

Can the ‘more expensive’ vaccine be the cheaper option?

The answer, according to the analysis of Argentina, is an unambiguous yes. The upfront acquisition cost of an aP hexavalent vaccine is substantially higher than its wP equivalent. In Argentina’s public sector, the PAHO Revolving Fund price is $21.54 per dose for the aP formulation, versus $4.90 per dose for the wP formulation. On a per-vial basis, the case for wP looks straightforward [1].

But the Argentina study exposes the flaw in this reasoning. The vaccine acquisition cost is only one line item in the budget. Modelling Argentina’s annual birth cohort of roughly 495,000 infants across the public sector (representing 94% of the birth cohort), the wP program’s total societal cost was $70 million: $7 million in acquisition costs, $5 million in programmatic costs, and $58 million in adverse event management. The aP program’s acquisition cost was higher at $32 million, with similar programmatic costs ($5 million), but adverse event management fell to $24 million — enough to bring total societal cost down to $61 million [1].

Total public sector costs fell by $9.1 million (~13.0%) under the aP scheme, driven by a $33.6 million reduction in adverse event management costs. In practical terms, this translated to 533,110 fewer primary care visits, 308,687 fewer emergency department visits, 2,868 fewer hospitalizations, and 1,654,129 fewer missed working days for parents [1].

The cost of adverse events is higher than many assume

The study’s most important methodological contribution may be its rigorous quantification of the costs of adverse events. The paper effectively demonstrates that adverse events are not simply clinical inconveniences. They consume healthcare resources at a scale that is seriously underestimated.

Adverse events management costs accounted for 64% of total costs under the wP hexavalent scheme [1]. It reflects the real-world consequences of administering a more reactogenic vaccine to hundreds of thousands of infants. Pain, redness, fever, prolonged crying, and, in rare but serious cases, seizures and hypotonic-hyporesponsive episodes each generate healthcare resource use: medications, outpatient visits, emergency visits, hospitalizations, and the parental time and travel that accompany them.

Notably, the economic model used adverse event data from Decker et al. 1995 [3]. The estimates from this study report smaller differences between wP and aP vaccines compared with more recent analyses, such as Zhang et al. 2014 [2] and Patterson et al. 2018 [6], which suggest a higher risk in the adverse event profiles of wP vaccination. Consequently, the estimates of savings related to adverse events presented for aP vaccination may be rather conservative.

Argentina is unlikely to be an exception

Comparable findings are emerging across different health systems, procurement models, and income settings. A previous whitepaper from Algeria, discussed in Medika Life [7], demonstrated that acellular hexavalent vaccination has improved vaccination coverage and simplified the vaccination schedule by reducing the number of appointments from 10 to 6. Overall, the higher upfront cost of adopting the new vaccine was offset by around 73% through savings generated by managing adverse events, improved logistics and transportation, and increased parental productivity.

Peru and South Africa saw similar patterns after adopting hexavalent vaccines: higher initial costs were substantially offset by reduced adverse events, lower programmatic expenses, and logistical efficiencies. Peru reported a reduction in logistical costs of nearly 60%, with roughly 44% of the initial cost increase recovered [8]. South Africa achieved overall savings of about $10 per child [9]. Projections from Paraguay and Uruguay estimate overall system savings of $2 million and $16.1 million, respectively, when comparing wP vs aP hexavalent vaccination [10,11].

A potential, and very rare, “double-win” for the health system

Evidence indicates that vaccination should be viewed as an investment, rather than an upfront cost, yielding up to 54 times the initial investment according to the WHO [12]. Much of this return on investment is calculated over a very long period, taking into account costs incurred by the medical system after vaccination, not just acquisition costs. The figure demonstrates the power of vaccines, leading to better health outcomes throughout childhood, fewer missed school days, and, in turn, better prospects later in life.

For a policymaker, on the other hand, the initial cost of a new vaccination program must be justified against a host of other healthcare interventions competing for health system resources. Long-term benefits calculated over many years are often insufficient to justify the expenditure. Because most of the savings in this case come from reducing the direct impacts of adverse events, they are realized in the short term. In addition, the societal costs of adverse events are reduced, with fewer children hospitalized and fewer parents taking time off work to care for sick children.

Healthcare decision-makers are often asked to choose between better outcomes and lower costs. The emerging evidence surrounding acellular hexavalent vaccination increasingly suggests that this may be one of the very rare situations in which both objectives can be achieved simultaneously.

[This consensus paper is based on the findings of a white paper discussing the findings of a group of vaccination experts focusing on pediatric immunization, supported by Sanofi. Intended for professional use.]

References

1. Ignacio Olivera, Eduardo Lopez, Carlos Grau Pérez et al. A cost-minimisation analysis: comparison of acellular versus whole-cell hexavalent paediatric vaccination strategies in Argentina, 16 September 2026, PREPRINT (Version 1) available at Research Square [https://doi.org/10.21203/rs.3.rs-11039921/v1]
2. Zhang L, Prietsch SOM, Axelsson I, Halperin SA. Acellular vaccines for preventing whooping cough in children. Cochrane Database of Systematic Reviews 2014, Issue 9. Art. No.: CD001478. DOI: 10.1002/14651858.CD001478.pub6.
3. Decker MD, Edwards KM, Steinhoff MC, Rennels MB, Pichichero ME, Englund JA, Anderson EL, Deloria MA, Reed GF. Comparison of 13 acellular pertussis vaccines: adverse reactions. Pediatrics. 1995 Sep;96(3 Pt 2):557-66. PMID: 7659476.
4. Casabona, G., Shah, N., Choudhury, J., & Shah, U. (2026). Whole cell and acellular pertussis vaccines – rethinking the evidence. Expert Review of Vaccines, 25(1). https://doi.org/10.1080/14760584.2026.2689606
5. Olivera, I., Pérez, C.G., Lazarov, L. et al. Cost minimization analysis of a hexavalent vaccine in Argentina. BMC Health Serv Res 23, 1067 (2023). https://doi.org/10.1186/s12913-023-10038-0
6. Patterson, J., Kagina, B. M., Gold, M., Hussey, G. D., & Muloiwa, R. (2018). Comparison of adverse events following immunisation with acellular and whole-cell pertussis vaccines: A systematic review. Vaccine, 36(40), 6007-6016. https://doi.org/10.1016/j.vaccine.2018.08.022
7. Medika Life, An Expert Perspective from Algeria on Hexavalent Vaccine Adoption. https://medika.life/an-expert-perspective-from-algeria-on-hexavalent-vaccine-adoption/
8. Seinfeld J, Rosales ML, Sobrevilla A, López Yescas JG. Economic assessment of incorporating the hexavalent vaccine as part of the National Immunization Program of Peru. BMC Health Serv Res. 2022 May 16;22(1):651. doi: 10.1186/s12913-022-08006-1. PMID: 35570278; PMCID: PMC9109284.
9. Batson A, Glassman A, Federgruen A, et al. The world needs to prepare now to prevent polio resurgence post eradication. BMJ Global Health. 2022;7(12):e011485. doi: https://doi.org/10.1136/bmjgh-2022-011485
10. ID-308 – COST MINIMIZATION ANALYSIS OF THE HEXAVALENT VACCINE WITH ACELLULAR PERTUSSIS COMPONENT (HEXA PAC) VERSUS HEXAVALENT VACCINE WITH THE WHOLE CELL PERTUSSIS COMPONENT (HEXA PC). PARAGUAY 2025.Olivera Ignacio (1); Martínez Celia (2); Grau Carlos (1); Lazarov Luis (1); Dibarboure Hugo(1). Center for Economic Research, CINVE-Health, Montevideo, Uruguay; (2). Hospital de Clínicas, Asunción, Paraguay.
11. ID-307 – COST-MINIMIZATION ANALYSIS OF THE HEXAVALENT ACELLULAR PERTUSSIS COMPONENT VACCINE (HEXA PAC) VERSUS HEXAVALENT WHOLE-CELL PERTUSSIS COMPONENT (HEXA PC). URUGUAY 2025.Olivera Ignacio (1); Grau Carlos (1); Lazarov Luis (1); Dibarboure Hugo (1). Center for Economic Research, CINVE-Health, Montevideo, Uruguay.
12. WHO, Fully-funded Gavi, the Vaccine Alliance, is a lifeline for child survival, says WHO. https://www.who.int/news/item/28-03-2025-fully-funded-gavi–the-vaccine-alliance–is-a-lifeline-for-child-survival–says-who

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KYLE, Texas — Kenney Blewett was diagnosed with lung disease more than a decade ago but started experiencing flare-ups this year that made him feel like he couldn’t breathe.

Blewett described those flare-ups as “the scariest thing in the world,” said his wife, Cindy, adding that while the episodes typically lasted no more than a few minutes, they had become more frequent.

On top of that, simple tasks, like taking out the trash, left Blewett winded. He rarely left the house and had recently lost 45 pounds. “That sounds like cancer,” Cindy remembered one of his doctors said. It was clear, she said, that her husband’s poor health, tied to decades of smoking, was getting worse.

That’s why, on June 2, Blewett’s pulmonologist wrote him a prescription for a new medication to improve the terrifying breathing issues caused by chronic obstructive pulmonary disease, or COPD. But the prescription wasn’t immediately filled. Two days after that doctor appointment, Blewett received an email from Walgreens explaining that, “due to an insurance issue that we’re working to resolve,” the medication was delayed.

“He was hopeful that it would work,” Cindy said of the drug, two months after her husband’s death. “I wish we had the chance to find out.”

Insurance delays and denials have become an infamous feature of the American healthcare system, with nearly 7 in 10 adults calling them “a major problem,” in a January KFF Health Tracking Poll.

In June 2025, six months after UnitedHealthcare’s CEO was shot in New York, the Trump administration announced a highly publicized industry pledge, signed by dozens of major health insurers, to remove some of the barriers that block or delay patients from accessing doctor-recommended care. And yet that pledge was voluntary, and it carries no penalties if companies fail to comply. Indeed, a report published by KFF Health News in July found that some insurers that signed the pledge would not implement all the promised initiatives as originally outlined.

Insurers Hedge on Trump-Backed Pledge To Improve Denials Process

Last year, the Trump administration announced a voluntary pledge by dozens of insurers to improve prior authorization, which often requires patients to seek approval before treatments. But prior authorization remains commonplace, and there’s no evidence the government is trying to hold insurers to account.

In recent years, lawmakers in most states, including Texas, have attempted to address delays and denials by regulating the insurance industry in the absence of substantial federal reform. But most health insurance plans, including traditional Medicare policies and employer-sponsored offerings, which together cover more than half of all Americans, typically aren’t under state jurisdiction.

Even some medical office staff and pharmacy employees find the patchwork of state and federal insurance rules and regulations confusing, a problem that is poised to become more complicated as artificial intelligence plays a larger role in approving and processing claims.

“It’s just gotten completely out of hand,” said Matt Toresco, CEO of Archō, a patient advocacy and consulting company. He argued that patients need more assistance facing insurance hurdles.

The Blewetts’ story illustrates how navigating these complexities remains a herculean task for patients and their caregivers.

Cindy has sought answers from Medicare; Kenney’s private Part D drug plan; his pulmonologist’s office; and Walgreens. She still has questions about who was responsible for the medication delay and how the holdup could have been prevented.

If the COPD flare-up Blewett experienced on the afternoon of Sunday, June 7, could have been avoided, she wondered, would he still have chosen to die by suicide that night?

‘Complex and Convoluted’

During that first week of June, Cindy said her husband repeatedly asked if his prescription — a liquid medication meant to be inhaled through the nebulizer machine Kenney owned — was ready to be picked up from Walgreens.

Cindy said she wasn’t initially surprised or worried by the delay. Since its acquisition by a private equity firm last year, Walgreens has cut thousands of jobs across the country, according to the Private Equity Stakeholder Project. Cindy said in August that their Walgreens pharmacy in Kyle seemed to her to have been understaffed for months, and that prescriptions were being filled more slowly.

When Cindy called the pharmacy a few days after Kenney’s appointment to find out more about the insurance delay, she said, a Walgreens employee told her the prescription required prior authorization. Also called preapproval or precertification, prior authorization is a practice widely used by health insurers that requires medical providers to seek permission before their patients may receive covered treatment.

But Cindy didn’t know which of Kenney’s insurers required prior authorization for this medication.

For years, she had helped manage multiple policies on behalf of her husband. Kenney was insured by Medicare parts A and B, the federal health insurance program for people 65 and older or with disabilities. But he also had a private Part D plan to cover drug costs through Wellcare Value Script, as well as a Medicare supplement plan through Blue Cross and Blue Shield of Texas — also called a “Medigap” plan — that paid for other out-of-pocket costs.

Initially, Cindy assumed that Kenney’s Part D plan had invoked prior authorization for his new medication. But because it was a liquid that is inhaled through a nebulizer machine, this drug was one of relatively few covered by Medicare Part B’s durable medical equipment benefit, not Part D.

The federal government had no record showing that this prescription had been billed to Kenney’s Part B policy, the Medicare agency told Cindy over the phone, she said.

Sarah Tanner and Myriea Amaya, spokespeople for Centene, Wellcare Value Script’s parent company, would not answer questions for this article.

After Kenney’s death, when Blewett sought clarification at the Walgreens pharmacy, she said the employee “kept saying different things.” She recalled his explaining that the prescription was submitted to Medicare Part B but without a necessary diagnostic code that the doctor should have included.

Carmen Lopez, a spokesperson for Walgreens, told KFF Health News in late September that the company “cannot comment on matters involving specific individuals.”

Subsequently, Cindy said, a district pharmacy supervisor for Walgreens reached out by phone, and told her the pharmacy tried to process the prescription through Part B on June 2, the same day as the pulmonologist appointment, but that the prescription was missing a diagnostic code from the physician. The supervisor said Walgreens sent a request for that code to the pulmonologist’s office later that day, Cindy recalled.

Kenney’s pulmonologist — Rajesh Shetty of LungDocs — did not respond to phone or email messages from KFF Health News. But Cindy said an employee at the practice told her they did not see a fax from Walgreens asking for a diagnostic code for the prescription.

Meanwhile, it couldn’t have been an issue with Kenney’s Medigap plan, since those policies don’t require prior authorization.

“Short of getting attorneys involved,” Cindy said, “I’m not sure how to find out what really happened.”

More Red Tape Ahead

Confusion surrounding these Part B and Part D distinctions is common, said Mike Hess, senior director of advocacy and regulatory affairs at the nonprofit COPD Foundation. “Medicare has gotten to be so complex and convoluted over the years,” he said, that even medical office staff and pharmacy employees often misunderstand the nuances.

And with the introduction of AI to the preapproval process, navigating insurance hurdles will likely get more complex for Medicare beneficiaries, doctors say.

Historically, traditional Medicare, unlike Medicare Advantage, used prior authorization sparingly. But in January, Medicare launched a pilot program in six states — Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington — testing the use of AI to preapprove some healthcare services.

It is intended to “root out waste in Original Medicare,” CMS Administrator Mehmet Oz has said, but physicians and patients say the program is creating more red tape for Medicare beneficiaries and leading to inappropriate denials. The pilot program does not currently impose prior authorization requirements on COPD medications, but industry experts expect the scope of the initiative will grow to include more services and states.

On the night of June 7, hours after her husband’s last COPD flare-up, Cindy Blewett was sitting on their back porch when she heard a loud noise. She assumed a picture had fallen off the wall in the living room. In fact, it was a gunshot. She discovered Kenney’s body in their bedroom.

“I can’t tell you how horrible it was,” Cindy said.

She said her husband had struggled with his mental health for a long time and had attempted suicide once before, years ago. His deteriorating health only made things worse, she said.

Kenney confirmed that much in a note he left. He told Cindy that she was a wonderful wife, mother, and grandmother but that his health was too poor to continue living.

A second COPD medication, which his pulmonologist ordered directly from the drug manufacturer during the June 2 appointment, arrived several weeks after Kenney’s suicide, she said.

“Perhaps, just perhaps,” Cindy said, “if he had received both medications in a timely manner, he would be here today, and we would have had many more years together.”

Do you have an experience with prior authorization you’d like to share? Click here to tell KFF Health News your story.

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That question makes AI in Health: A Guide to Winning in the New Age of Intelligent Health more than a book about technology. It is a leadership guide designed to make people think long and hard about using AI in ways that improve care, support caregivers and remain accountable to the people health systems exist to serve. Lawry understands the technology, yet throughout the book he brings readers back to something more consequential: what these increasingly powerful tools mean for people.

A former Microsoft leader in health and life sciences, health-system executive, founder of health technology companies and now principal consulting firm Second Century Tech, Tom Lawry helped chart this field before health AI became a fixture of every conference agenda. That experience gives this second edition unusual authority. He understands how quickly the technology is changing while keeping his attention on the people who must live with its consequences.

Lawry Combines Leadership with Caring

In an endorsement appearing on the book’s back cover, I wrote: “Tom Lawry understands that AI has no purpose apart from humanity, making this book an indispensable roadmap for leaders who want innovation to amplify compassion, judgment and the human experience of care.” Having reviewed this new edition, I continue to believe that assessment is essential and belongs on the desk of anyone involved in health AI or seeking a state-of-the-art perspective.

Lawry is, without doubt, a fan of AI applications.  He recognizes the risks and responsibilities.  He also reflects on the struggle of the nation’s sick care system and sees that “AI has the ability to save health care from itself.”

Early in AI in Health, Lawry asks readers to consider two photographs of the same New York intersection, twenty years apart. In 1905, horses filled the streets around the Flatiron Building. By 1925, automobiles had replaced them. The buildings remain; the world around them has changed.

Lawry’s point is not simply that technology advances. Transformative technologies change how people prioritize workflow, how organizations operate and what society comes to expect, often before those living through the change fully recognize what is happening. Health care, he suggests, is standing at this intersection now.

That makes leadership the book’s essential subject. AI is no longer something health leaders can simply observe or delegate to the technology team. Lawry asks them to decide what problems it should solve, what values should guide its use, how the workforce should be engaged and who remains accountable when intelligent systems influence care.

From a Promising Pilot to Better Care

One of the edition’s strongest chapters concerns responsible AI. Lawry presents a hospital scenario in which an adverse-event prediction model yields an impressive overall improvement. However, a closer look reveals it performs far better for one patient population than another. The average result looks successful. Beneath it lies a more consequential question: Who benefits, who may be left behind and who is accountable for the difference? That is the kind of question every health leader should be prepared to ask before celebrating a successful pilot.

Lawry carries the point into governance: What is a tool designed to do, and for whom? What evidence supports its effectiveness? How does it perform across populations? What happens when it is wrong? Who owns the strategy, risk, monitoring and response? These are operational decisions with moral weight. A model can meet a technical target and still fail the people who need it most.

Separately, Hal Wolf, President and CEO of HIMSS, the world’s largest health technology professional society and a center for global conversation on technology and health, has repeatedly emphasized that realizing AI’s promise requires leadership and governance. It is fitting that Lawry’s book will once again find itself on the shelves of the HIMSS Global Health Conference bookstore.

The book also earns its place as a working guide. Lawry moves from the principles of leadership and governance to practical exercises for building an AI leadership charter, setting a vision, engaging the workforce, selecting use cases and assessing vendors. These sections give teams a way to turn an ambitious conversation into decisions they can revisit and measure. The chapter on why promising AI projects fail to scale is especially useful for organizations surrounded by pilots but unsure which efforts deserve lasting support.

Readers who already know the technical vocabulary may find the AI primer familiar. They should keep reading. Its value lies in connecting that vocabulary to leadership choices, including when to automate a task, when to support professional judgment and when to leave a decision firmly with a person. Those distinctions matter greatly in health, where a confident answer can be mistaken for a correct one and a convenient workflow can conceal an inequitable result.

Kathleen McGrow, DNP, MS, RN, PMP, FHIMSS, FAAN, Global Chief Nursing Innovation Officer at Microsoft Health & Life Sciences, calls this edition “…both a strategic guide and a leadership manifesto for a healthcare system at a critical inflection point.” Her back cover assessment fits a book that treats workforce experience as central to AI strategy. Lawry asks leaders to involve the people delivering care in deciding where intelligent tools can genuinely help.

From Applications to Expectations

Lawry’s scope is broad, reaching from consumer expectations and clinical applications to workforce development and the future of medicine. The breadth makes the book relevant beyond hospital leadership. Developers, researchers, payers, communicators and policymakers all shape the conditions under which AI reaches people. Each has reason to ask whether a claimed improvement is visible in a patient’s life or a caregiver’s day.

AI technologies will continue to change at extraordinary speed. Lawry wisely builds this edition around leadership questions that should outlast any individual tool or product announcement. What problem are we solving? What evidence will tell us whether people benefit? Whose experience is missing from the design? How will we respond when the evidence changes? A leader who can answer those questions is better equipped for both the next generation of tools and the current one.

That is why this second edition belongs on the desk of anyone helping shape health AI. Lawry writes as a pathfinder who understands the technology while never losing sight of the people expected to benefit from it. His perspective draws not only from his years inside health systems and technology but also from his continuing work as a global advisor and, perhaps most importantly, as a constant observer.

He listens, questions and learns from the people confronting these changes in real time, bringing to AI in Health a perspective shaped by experience, curiosity and an enduring desire to understand what comes next. At a moment when intelligent tools can move faster than health systems can absorb them, AI in Health makes the essential case that greater intelligence becomes better care only when people are prepared to lead.

Available Now on Amazon

AI in Health is now available for pre-order on Amazon.

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She asked: “If they got all the cancer out, why do I still need radiation?” It should have been easy to explain. Instead, I found myself saying things like “to be safe” and “to reduce recurrence risk” without actually telling her what her risk was without treatment, how much radiation might reduce it, or what that difference meant for her. I was describing what we did, not why it mattered for the person in the room. That question has stayed with me. It is the question that changed how I practice.

The question has changed

For most of my early career, breast radiation meant a fairly predictable course: five days a week, often for five or six weeks, treating the entire breast. The discussion was not nuanced. What I spend time asking now is completely different: How much treatment does this particular woman actually need?

That shift has moved through all of cancer medicine. We are getting better at identifying cancers that carry completely different risks even when they look similar under a microscope and arise in the same place. Breast cancer is not one disease. A small, estrogen-sensitive cancer in a woman in her seventies is biologically and clinically a different problem from an aggressive triple-negative cancer in a woman in her thirties. Tumor size. Lymph-node involvement. Hormone receptors. HER2 status. Age. Systemic treatment. These characteristics change not just how aggressive we need to be, but whether we need to be aggressive at all. The word breast cancer tells us where the disease started. It does not tell us the whole story. As we became better at measuring those differences, my conversations with patients changed too.

What “we got it all” actually means

When a surgeon says the cancer was completely removed, that statement has a specific meaning: the tumor came out with a rim of normal tissue around it, and a pathologist found no cancer cells at the edge. That is excellent news. But it does not mean zero percent chance that an individual cancer cell remains somewhere in the breast. No imaging can find a microscopic cluster. No surgeon can see it during an operation.

That is where radiation comes in. After breast-conserving surgery, radiation substantially reduces the chance that cancer will return in the breast. For generations of women, that combination allowed us to preserve the breast without sacrificing cancer control. But there is another part of the story: not every woman benefits by the same amount.

Some women can consider skipping radiation

This is one of the things that surprises many patients: there are women with breast cancer for whom radiation after lumpectomy may reasonably be omitted. Two landmark trials followed carefully selected older women with favorable, hormone-sensitive breast cancers after lumpectomy. Radiation substantially reduced the chance of local recurrence. Without radiation, roughly 1 in 10 women experienced a local recurrence within 10 years; with radiation, it was closer to 1 in 100. But that large reduction in local recurrence did not translate into longer survival. At 10 years, overall survival was essentially the same whether women received radiation or not.

That creates a very different conversation. Suppose one treatment reduces a woman’s chance of cancer returning in her breast but does not appear to change how long she lives. Is that treatment worth having? There isn’t one answer. One woman may say, “I want to do everything reasonable to minimize the chance this cancer ever comes back.” Another may say, “If my risk is already low, avoiding another treatment matters more to me.” Both can be rational choices. My job is not to tell someone that radiation works. My job is to help her understand how much it is likely to help her.

Less radiation does not necessarily mean worse treatment

The amount of radiation we deliver has changed too. For years, five or six weeks was standard. Then strong evidence showed that shorter courses worked just as well for many patients. Three- to four-week schedules became common. Now some appropriately selected women can complete breast radiation in five treatments. Others may not need the entire breast treated at all. Partial-breast radiation focuses treatment on the region surrounding the original tumor, where recurrence is most likely.

To someone who learned medicine under the assumption that more treatment equals better treatment, this sounds counterintuitive. It shouldn’t. The goal of cancer treatment is not to deliver the maximum amount of therapy a person can tolerate. It is to deliver enough.

A mastectomy doesn’t always eliminate the need for radiation

I hear this question regularly too: “If the whole breast is gone, why would I need radiation?” The logic makes sense. A mastectomy removes almost all breast tissue. For many women with early-stage breast cancer, no radiation is needed afterward.

But a mastectomy does not automatically make the risk of recurrence disappear. Cancer can extend beyond the breast into lymph nodes or surrounding tissues. Certain combinations of tumor size, lymph-node involvement, and other features can leave enough risk that radiation to the chest wall and regional lymph nodes meaningfully reduces the chance of recurrence. This is why two women who both undergo mastectomy may receive completely different recommendations. One may need no radiation. Another may benefit substantially from it. The operation is only part of the story.

The deeper shift

When I started in this field, I spent much of my thinking on how to deliver radiation effectively while protecting the normal tissues around the tumor. That remains enormously important. But somewhere in the middle of my career, another question became equally important to me: How much treatment does this person actually need?

I cannot point to the moment that changed. It happened gradually, through hundreds of conversations with women after treatment. I began paying more attention not only to whether treatment worked, but to what we were asking someone to endure for the benefit we expected it to provide.

And I started asking myself a harder question: Did I know that benefit existed before I recommended treatment? Or did I know it theoretically? There is a difference.

The theoretical position is: radiation prevents recurrence. The specific position is: How likely is this woman’s cancer to return without radiation? How much will treatment lower that risk? What does that difference mean to her? How does she weigh it against the inconvenience, side effects, and risks of treatment? That is a different conversation. It respects her time, her body, and her right to decide how much benefit is enough. I was not having that conversation early enough.

Sometimes the answer to “how much treatment” is more than a patient expected. A woman may undergo a mastectomy and still benefit substantially from radiation. A tiny tumor may have biological characteristics that make more treatment appropriate. But increasingly, the answer can also be less. Less surgery. Less radiation. Fewer treatments. Smaller treatment areas. For some carefully selected women, no radiation at all.

I did not learn this from being a better doctor. I learned it from listening to women describe what treatment actually costs them. That is not retreating from cancer. It is understanding what progress in cancer medicine actually looks like. When I began my career, progress often meant finding ways to treat cancer more aggressively. Thirty-six years later, I think progress sometimes means having enough evidence to know when we don’t have to.

The question I couldn’t answer well early in my career is the one I now spend the most time trying to answer: How much treatment does this particular woman actually need?

Your health deserves the same kind of individual attention. Take my free 3-minute Capacity Checkup to see where sleep, mood, focus, and physical capacity may be asking for more attention.

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But there is another form of exercise worth adding to the discussion: high-intensity interval training, or HIIT.

The concept is simple. Imagine you are riding an exercise bike in the gym. You pedal at a moderate pace for about 2 minutes, then you increase the resistance and pedal as fast and hard as you can for 30 seconds. You will likely sweat and your leg muscles will start to burn. You then revert to the slower, easier pace for 90 seconds and then repeat the high intensity/low intensity duo for a total of 8 rounds with a few minutes of cool down at the end. The total time elapsed is about 20 minutes and just 4 minutes of intense exercise.

My colleague Harry Oken, MD and I wrote about this interval exercise approach in our book BOOM — Boost Our Own Metabolism. At the time, one reason for our interest was evidence that intense exercise, especially early in the morning, could produce a substantial increase in human growth hormone and other metabolic responses. Another was that just a few minutes of high intensity achieved the same benefits of a much longer Zone 2 type of exercise. HIIT is a good way to maintain or increase your V02max, a known longevity positive.

There is a just published study in Cell Reports Medicine that looks much more deeply at what is happening in the body during HIIT. Led by Dr. Paul Cohen and colleagues at Rockefeller University, they found that the multiple organs, not just muscle, immediately produces many proteins that reach the blood stream and travel to other organs, call it organ cross talk.

The researchers compared two very different forms of exercise. One group cycled continuously at moderate intensity for 90 minutes. The other performed six 30-second all-out cycling sprints, separated by recovery periods as described above. Consider that this amounted to just three minutes of actual high-intensity exercise and a total of 11 minutes of total time plus the warm-up and cool-down periods.

The difference in what happened inside the body was remarkable.

The researchers measured nearly 2,900 proteins circulating in the blood. Immediately after the sprint exercise, 714, nearly one-quarter, had changed significantly, all but a few having increased substantially. Within a few hours, the protein levels had largely reverted to baseline. But in the group that did only moderate intensity cycling for 90 minutes, only seven protein levels had changed immediately.

The exerkines did not derive only from the exercised muscle, but multiple other organs including adipose, liver, immune, pancreas, intestine, and brain cells.

The researchers then went to large United Kingdom biobank databases and found that the sprint-altered proteins tended to be those connected to a reduced risk of cardiac and metabolic diseases/disorders including type 2 diabetes, obesity, and cardiovascular health. Interestingly, some of the proteins released by sprint exercise correlated with proteins in the Biobank that are associated with a decrease in biologic age.

Think about that. Three minutes of extremely vigorous exertion triggered an enormous molecular response throughout the body, but 90 minutes of moderate paced exercise did not. More importantly, those sprint derived exerkines were associated with markers of better health and a lower biologic age.

Your muscles are talking to the rest of you

We used to think about exercise largely in mechanical terms. The heart pumps faster. The lungs move more air. Muscles contract and burn fuel. Do that repeatedly and the heart and muscles become stronger. But as I have written previously, resistance exercise causes muscles (and other organs) to release chemicals (proteins, peptides, metabolites, and other signaling molecules) that travel to other parts of the body and generally have a positive effect on other organs’ cells. Instead of calling them the usual name of cytokines, meaning released by the cell, it has become customary to call them exerkines instead. By whatever name, they are metabolically active and impact the metabolism of other cells.

The Rockefeller study found evidence of communication involving muscle, fat, the liver, immune system, gastrointestinal tract, pituitary gland and even the brain. High-intensity exercise appears to send out a particularly powerful burst of these molecular messages.

Some of the proteins stimulated by intense exercise were associated, in large population databases, with lower risks of metabolic and cardiovascular disease. Others were associated with biological aging. The study does not prove that changing these proteins prevents disease or extends life, the investigators themselves are careful not to make that claim, but it offers an intriguing explanation for why relatively brief periods of vigorous exercise can produce substantial health benefits.

Instead of thinking about one hormone or one metabolic pathway, we can now begin to see intense exercise as producing a coordinated, body-wide response. Muscles do not simply become stronger. They communicate. Other organs listen and respond. That may help explain why exercise has effects seemingly far removed from the muscles doing the work.

HIIT and the aging body

This becomes especially important as we age. One of the most useful measurements of cardiovascular fitness is VO₂ max, essentially the maximum amount of oxygen the body can use during strenuous exercise. VO₂ max tends to decline with age, and a low level eventually has very practical consequences. Walking rapidly through an airport, climbing a flight of stairs, carrying groceries, or keeping up with grandchildren becomes increasingly difficult.

HIIT is particularly effective at improving VO₂ max. Studies of older adults have found that interval training can produce substantial improvements in cardiorespiratory fitness, in some studies greater than those achieved with continuous moderate exercise.

That reserve capacity matters. Independence in old age depends not merely on being able to perform today’s activities, but on maintaining enough physiological reserve to continue performing them years from now.

There may also be benefits for the brain. Exercise improves cerebral blood flow and stimulates biological pathways involved in neuroplasticity, the brain’s ability to adapt and maintain connections. Studies of HIIT in older adults have reported improvements in aspects of executive function, working memory, and attention, although the evidence is still developing. There is reason to believe that HIIT done regularly for many months reverses some of the losses of aging in the brain, both in the cortex and the hippocampus, slowing or even reversing some of the declines in normal cognitive aging and lowering the risk of dementia, but these are as yet unproven. We can say that maintaining cardiovascular fitness and remaining physically active are important components of maintaining brain health.

But HIIT does not mean sprinting

Here an important caution is necessary, especially for older adults.

The Rockefeller participants performing six all-out sprints were young, healthy adults. I certainly would not recommend that an 80-year-old who has been sedentary climb onto a bicycle tomorrow and attempt six or eight maximal 30-second sprints.

“High intensity” is relative. Someone who has been sedentary or who has cardiovascular, pulmonary, or significant muscle loss should discuss vigorous exercise with their physician, and if approved, begin under the guidance of a personal trainer or physical therapist. The objective is not exhaustion. It is to periodically ask the cardiovascular and metabolic systems to work substantially harder than they do during ordinary activity, followed by recovery.

Don’t give up your walk or your weights

HIIT should not replace other exercises. Continue walking. Continue cycling, swimming or whatever aerobic activity you enjoy. And especially as you grow older, include resistance exercise at least twice a week. Muscle mass and strength are essential for getting out of a chair, climbing stairs, maintaining balance, and preventing frailty. These are the essential elements of retaining independence.

Think of high-intensity intervals as an addition, a very useful addition. Once or twice a week, if your health permits and your doctor agrees, consider adding a few brief periods during your usual aerobic exercise when you substantially increase the intensity and then recover. As fitness improves, the duration or number of intervals can gradually increase.

The remarkable message from the Rockefeller study is that our bodies notice the difference.

Three minutes of intense exertion caused hundreds of proteins and metabolites to change, initiating communication among organs throughout the body. We are only beginning to understand what all those molecular conversations mean. But they reinforce something we already know. Exercise is among the most powerful medicines available to us. As we age, the goal is not to become an athlete. The goal is to preserve enough strength, cardiovascular capacity, balance, and brain function to continue doing the things that make life enjoyable. And most importantly, it is to maintain independence.

Walking matters. Strength training matters. And now we have a reason to pick up the pace.

It suggests to me, and as Dr Oken I wrote in BOOM — Boost Our Own Metabolism, a regular program of HIIT, once or twice a week for just 20 minutes, is beneficial to our health. At age 84, I plan to redouble my efforts to do it at least once a week, maybe two.

It is never too late to start and sometimes it pays to go a little faster.

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No one asked what he was taking. No one asked why he stood sideways in the bathroom mirror every morning, pulling up his shirt and frowning. And no one noticed that his heart rate was lower than it should have been for a boy his age.

Dalton is a composite, drawn from the stories of many families. But what happened to him, and what didn’t happen, is real. It’s happening in homes across the country.

It Was Never Only a Girls’ Problem

For decades, when we talked about body image, eating disorders, and the harm done by images in the media, we talked about girls. Girls were the ones being told to be thinner, and girls were the ones being admitted to hospitals. Parents, physicians, and schools learned to watch girls for trouble.

Boys were left out of that conversation, and they’re still being hurt by it.

In Ontario, Canada, researchers studied more than 11,600 hospital stays for eating disorders in children and teens between 2002 and 2019. For boys, hospital stays rose by more than 400%. For every boy sick enough to need a hospital bed, many more are struggling where no one sees it.

Part of the reason is the way we look for trouble. In 2020, researchers who reviewed what’s known about eating disorders in boys and young men found that the screening tools physicians use were mostly designed with girls in mind. They ask about wanting to be thinner, not about wanting to be bigger. A boy with a serious problem can answer every question the “right” way and never be flagged. The same review found that treatment programs were also built mostly for girls, and boys may do worse in them as a result.

That’s the main problem. Boys’ body worries usually center on muscle, not thinness. So a boy in real danger can look like a boy in great shape.

What Boys Learn, and What They Buy

Boys learn early what kind of body earns respect. They see it in superhero movies, in older boys at school, and in grown men joking about getting “shredded.” They learn that this body is what they should work toward, even if it costs them their health. And now they see that message on their phones every day.

In 2025, Common Sense Media surveyed more than 1,000 boys ages 11 to 17 across the United States. Nine out of ten said they see messages about body image online. About two out of three of the boys who saw content about how men should look and act said it showed up in their feeds without them searching for it. About 1 in 4 said social media makes them feel they should change how they look.

Boys don’t just watch. They act. A University of Minnesota study of nearly 2,800 middle and high school students found that more than 90% of the boys had exercised more in the past year to build muscle. More than one-third had used protein powders or shakes, and nearly 6% said they had used steroids. These were ordinary kids, not top athletes.

The influencers boys follow often make money from what they promote. Many earn a share of every protein powder or fat burner sold with their discount codes. Some push far more dangerous products. In 2023, the Center for Countering Digital Hate found that TikTok videos promoting steroids and similar drugs under certain hashtags had been viewed up to 587 million times in the United States over three years. The group also found 35 influencers on the app linking to websites that sold these drugs.

The harm is real. Researchers at the University of Toronto found that more than 1 in 4 boys and young men in a national Canadian sample had symptoms of muscle dysmorphia strong enough to be of real concern. Muscle dysmorphia is a condition in which a young man believes he’s small and weak, even when he isn’t. Most boys who have it have never heard its name.

The products carry their own risks. A study published in the New England Journal of Medicine estimated that supplements send about 23,000 people in the United States to the emergency room each year, with weight-loss and energy products among the most common causes.

Why Parents and Physicians Miss the Signs

When a boy is in trouble with his body, his trouble often looks like success. A boy who works out every day seems disciplined. A boy who eats “clean” seems healthy. A boy who drinks protein shakes seems like every other kid on the team. Adults praise these habits. And boys are taught not to talk about their feelings, so a boy who feels ashamed keeps it to himself.

Physicians aren’t always asking, either. In 2025, a survey of more than 800 Canadian pediatric specialists found that 17% had seen at least one young patient in the past year who needed medical care because of a performance-enhancing supplement or drug.8 Most of those patients were boys, and almost a third were only 10 to 12 years old. Yet more than half of the physicians surveyed said they never asked their young patients about these products.

The stakes are high. In the United States, men die by suicide at about four times the rate of women. Boys and men are less likely than girls and women to ask for help.

So what can we do? Parents can learn the signs. Watch for a boy who panics when he misses a workout, trains through injuries, follows strict food rules, spends long periods checking his body in the mirror, skips family meals, or has powders and pills you don’t recognize. Talk with him about health and strength, not size. Ask what he’s watching and whom he trusts online. And make a simple family rule: before he takes anything meant to change his body, he talks to you, and ideally to his physician, first.

Physicians need training to look for danger in boys, not just girls. At every checkup, they can ask boys two simple questions: “What are you doing to change your body?” and “Are you taking anything to build muscle or lose fat?” They can compare heart rate, growth, and weight with earlier visits. And they can take a parent’s worry seriously, even when the boy in the exam room looks strong.

If you’re worried about a boy and feel brushed aside, it’s okay to ask for a second opinion or a referral to a specialist in adolescent medicine or eating disorders. If a boy you love is struggling or talks about hurting himself, call or text 988 to reach the 988 Suicide and Crisis Lifeline.

Boys aren’t less at risk than girls. They’ve simply been overlooked. It’s time we changed that.

I’ve written much more about this in my new book, “Built to Be Seen: How Influencers and Supplement Sellers Endanger Boys and Young Men.” It’s a short read, a 74-page paperback to be published shortly on Amazon, written in plain language for parents, coaches, teachers, and young men themselves. It explains how social media finds boys, what’s really in the supplement aisle, the dangers of steroids and online testosterone clinics, and the warning signs to watch for.

The post Boys Are Risking Their Health to Look Like Influencers, and Almost No One Is Checking appeared first on Medika Life.

We looked around, found nothing, and shortly went back to sleep.

In the morning, my wife was opening our interior shutters, which are used to keep out sunlight, when she discovered… a bat.

What happened next seemed perfectly sensible at the time. I went to the garage, got a heavy leather glove, returned, and grabbed the bat while my wife opened the front door. We stepped outside, let it go, and it flew away. We were glad to have it out of the house and proceeded to fix breakfast.

I had just made two mistakes but did not realize it.

It was early August, and we had been staying at our vacation home in Kent County, Maryland, on the Eastern Shore. In a few days, we were back home in our retirement community just outside Baltimore. We have a lady who watches out for our vacation place when we are away. I asked her to arrange a pest control person to check out the house to see if there were other bats, perhaps in the attic. As it turned out, he arrived when we were back just before Labor Day to celebrate our 63rd anniversary.

We described what happened. He looked at me and said, “You really should go to the emergency room or see a doctor.”

My wife smiled and said, “He’s a doctor.”

“Well,” he replied, “I just want you to be safe.”

He looked around the entire house and found multiple places where a bat could slip in. He found a few bat droppings in the attic. Still, he thought this was probably a “one off.” Maybe the bat got in when the garage door was open or something like that. He said he would send us a proposal for caulking up the various holes he found. We were back home in Baltimore when we got a message from our property manager that he had sent his proposal, but he also said he really thought I should go to the emergency room. Up to now I had not paid much attention but having heard it multiple times, I decided to do some research.

What I learned

I turned to Open Evidence, an AI system that looks only at quality medical and scientific information. The answer was unambiguous. I should go to the emergency room, now.

Because the bat had actually been crawling on my head while I was asleep, and because it was no longer available for testing, I should receive rabies post-exposure prophylaxis (PEP.)

Bat bites can be so small that a person may never see or feel them. And rabies presents an unusual medical calculation: The probability that this particular bat was rabid and infected me was exceedingly small, but the consequence of being wrong was enormous. Once clinical rabies develops, it is fatal; there is no treatment. But PEP given before symptoms begin, is nearly 100% effective.

That was a clear wake up call.

The current guidance supports the central lesson. CDC says potential direct physical contact with a bat warrants assessment, and Maryland specifically advises considering treatment when bat exposure cannot reasonably be ruled out. CDC also advises not releasing a bat found in the home until public-health experts have been consulted, because testing the bat may determine whether PEP is necessary. Guidelines favor treatment whenever exposure cannot be excluded.

The last sentence is the key one.

Just to be clear, it is very uncommon for a person to develop rabies from a bat. In our area, less than 1% of bats are infected. I had no clear bite or scratch. The risk in my case was extremely small. The problem is if I do win the Lottery, that’s bad.

Bats are the source of most rabies cases, but these are rare. There were two deaths from rabies (neither person received PEP) in America last year but over 30,000 people were potentially exposed and received PEP.

The rabies virus travels from the bite site through peripheral nerves toward the spinal cord and brain. Once symptoms appear, the disease progresses to severe neurologic illness ending in coma and death. There is no reliably effective treatment once clinical rabies has developed. The opportunity to prevent the disease is therefore before symptoms begin.

What to do if you encounter a bat

I had not thought about rabies since I took the board certification exam in infectious diseases some 40 years ago. I worked with cancer patients, not the general population, so I had no experience other than book learning long ago.

It did not occur to me that the bat could have been rabid or that it might have bitten me, since I did not find evidence of a bite or scratch, nor was the bat aggressive. Not being worried about rabies, I did not think to kill the bat so it could be tested. Absent that testing, as I learned, I needed rabies post exposure prophylaxis or PEP.

I was talking with a speech therapist whose family had a cabin with “lots of bats flying around all the time.” She remembered as a kid being told that if you got bitten by a rabid bat or other animal, they would “inject you with 9-inch needles into your abdomen many, many times with lots of side effects.“ She wasn’t entirely wrong. The nine-inch needles were folklore, but the old rabies treatment really did involve numerous injections into the abdominal wall. The earliest vaccines descended from Pasteur’s 1885 work and were prepared from rabies-infected nervous tissue. They were far more cumbersome and produced substantially more adverse effects than today’s purified cell-culture vaccines.

Fortunately, that era of painful shots is long gone, but it was only in 1980 that the modern anti-rabies vaccine was licensed, so it is no surprise that the myth still abounds.

None of this means that bats are bad animals. Quite the contrary. Bats have been saddled with centuries of bad publicity, from witches to Dracula, when in reality they are among our most useful neighbors, gobbling huge quantities of insects like mosquitoes every night.

That said, the CDC reports that rabies exposures have recently increased. We just read that a rabid bat was found in a school about 20 miles from our home, and rabid bats have been reported in Los Angeles recently.

Post-exposure prophylaxis

My primary care physician called the local emergency room to determine if they had the PEP available, and learning that they did, and that they were “not too busy,” we headed off.

After signing in (“oh you’re here because of rabies”) we were ushered into the triage room where a doctor and nurse took a history. The doctor, obviously very experienced, said that there was no question that I needed PEP. He then looked at my wife and said, “You were asleep in the bed next to him, so the bat may have crawled on your head also.” “I have hair on my head,” she responded. “Yes, but he could have walked across your forehead, and you might not have been aware. You need PEP also.”

PEP for someone who has never previously been vaccinated against rabies consists of human rabies hyperimmune globulin, which supplies immediate antibodies, followed by four doses of rabies vaccine given on days 0, 3, 7, and 14 to give long lasting protection.

We went back to the waiting room and after a while we were ushered into the main area of the ER. They had to order PEP from the pharmacy, which took a while until it arrived. The hyper immune globulin dose is based on weight. For me it was 2.6ml and for my wife it was 1.7. If there had been evidence of a bite, some of the globulin would have been injected there. But for us it was divided into two shots, one into each thigh. And then the vaccine, 1ml, goes into the shoulder.

We now are back three days later for the second vaccine dose. We will still have day seven and fourteen to go.

I told this story to retired senior engineer who said she had grown up on a farm and would have done exactly the same thing with the bat. We had lunch with a family medicine physician; he also was not surprised that we just got rid of the bat. That made me feel better because, as is always easy in retrospect, it was not smart to try and catch the bat myself. But given that I did, I should have killed it so it could be checked for rabies. Chances are it would have been negative, and we would have escaped getting PEP.

But even more importantly, it never occurred to me that the bat might have bitten or scratched me on the head since I did not see any obvious evidence. I really should have been curious and looked up the proper course of action right away. Fortunately, the pest-control man knew enough to keep pestering us. Eventually, I listened.

So here is the lesson I would pass along. If you have direct contact with a bat (or other wild animal), don’t handle it yourself. Contact animal control or your health department so that it can be safely captured and, when appropriate, tested. If the animal is gone and can’t be tested promptly, seek medical advice about whether rabies prophylaxis is needed. Rabies is exceedingly uncommon. But this is one of those unusual situations in medicine where a very small probability is paired with an almost unimaginable consequence.

And should you need the shots, don’t worry about those childhood stories of enormous needles in the belly. Modern rabies prophylaxis is nothing like that. It is still a pain in the butt — although, in our case, mostly a pain in the thigh.

The post I Woke Up with a Bat on My Head. appeared first on Medika Life.

The obvious question is whether that’s safe. But another question interests me more. I have spent 36 years taking care of people with cancer. By the time someone reaches my office, an enormous number of decisions have already happened. Someone noticed something. They decided whether it mattered. Perhaps they waited. Perhaps they searched online. Eventually, they decided to tell another human being. Medicine usually enters the story after that decision. AI is beginning to enter before it.

What happens before you arrive

When you wake up with an unfamiliar pain, the choices available to you have changed significantly. For most of human history they were limited: ignore it, ask someone you trusted, or seek medical care. Then the internet gave us another option, and millions began typing symptoms into search engines. Now AI alters that interaction in a way that matters. A search engine gives you pages to sort through. An AI system gives you a conversation. You can describe where something hurts, how long it has been happening, what makes it worse, what medications you take, what you are worried it might mean. You can ask another question, clarify an answer, ask again. It can feel remarkably close to consultation.

I don’t think the answer is to tell people to stop asking AI about their health. People have always sought medical information outside doctors’ offices, and AI can be genuinely useful for some things. It can explain an unfamiliar laboratory result in ordinary language. It can help someone understand the difference between two treatments. It can generate questions to take to an appointment or help make sense of something a physician said, something the patient only half-absorbed while frightened or tired. Medicine asks people to absorb complicated information precisely when they may be overwhelmed, and a tool that helps close that gap has real value.

But there is a threshold where explanation quietly becomes reassurance, and that’s where the problem begins. A symptom does not have to disappear for someone to delay seeking care. It only has to become sufficiently explainable. A persistent cough becomes allergies. Fatigue becomes stress. A change in bowel habits becomes diet. A new lump becomes something probably benign. And most of the time, the reassuring explanation may actually be right. Most headaches are not brain tumors. Most back pain is not metastatic cancer. Most strange sensations that appear during an ordinary week will never become dangerous. That is precisely why triage is difficult. The challenge is not simply identifying the most likely explanation. It is recognizing the uncommon situation in which the most likely explanation is wrong.

When I meet a patient, I am not simply processing the words they say. I am trying to understand the story around those words. How quickly did this change happen? Does the symptom fit the rest of their medical history? Is there something about their age, medications, previous illness, or family history that changes what an otherwise ordinary symptom means? Sometimes the most important information emerges only because I ask a question the patient did not know was relevant. But here is the vulnerability built into any conversation with an AI system: much of what it knows about you is what you decide to tell it. You may not know what matters. And a confident, coherent answer can feel more complete than the information behind it actually is.

For years, physicians worried about patients arriving with information they found on Google. I suspect we are entering a much more consequential era. Patients may increasingly arrive after having already had a long conversation about their symptoms — with possible explanations, questions they want to ask, interpretations of laboratory results, and some sense of how urgently they should seek care. Sometimes that will make the medical encounter better. The patient may be better informed, the questions sharper, medical language less intimidating. A person who might otherwise have ignored a warning sign could even be persuaded to make an appointment. But the opposite can happen too. The conversation may reassure someone enough that the medical encounter never happens. Once AI becomes the first opinion, it can influence whether there is ever a second.

I write about the signals we often miss in our health and our lives. If you’re curious about what your own body may be telling you, my free 3-minute Capacity Checkup can help you see where strain may already be showing up in sleep, mood, focus, and body.

But after 36 years in medicine, I think one of the most valuable things a good clinician does is not simply answer the question a patient brings into the room. Sometimes it is recognizing that we should have been asking a different question all along.

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This is the world that reproductive psychiatry tries to fix. It is the branch of medicine that treats mental health problems tied to pregnancy, childbirth, and the months after birth. It covers depression, severe anxiety, panic attacks, obsessive thoughts about the baby’s safety, bipolar disorder, and the rare but severe break from reality called postpartum psychosis.

Roughly one in five pregnant and postpartum women deal with some kind of mental health condition, from anxiety to depression to more severe illness. Yet only about one in four women with postpartum depression symptoms ever gets a diagnosis, and about half of those get no treatment at all.

For years, physicians and hospitals focused mostly on physical dangers like blood loss during birth. Nurses were trained to watch a mother’s blood pressure, bleeding, and vital signs, but not always her mood, sleep, or thoughts. The numbers now tell a different story, and it is not a comfortable one.

A Killer Hiding in Plain Sight

Federal health reviewers looked closely at deaths connected to pregnancy across dozens of states. Mental health conditions, including suicide and drug overdose, caused close to a quarter of those deaths. Suicide alone accounted for nearly a third of the mental health-related deaths in the most recent review.

A separate large study presented to maternal health doctors went even further. It found that homicide and suicide combined were the single leading cause of death among pregnant and postpartum women, ahead of every physical complication doctors traditionally worry about, including bleeding and high blood pressure.

The danger is not shared equally. Black mothers between the ages of eighteen and twenty-four die from violence during pregnancy and the months after birth at nearly four times the national rate. Researchers also found that states with stronger gun laws saw meaningfully fewer of these violent deaths, suggesting that policy choices outside the hospital walls still shape what happens inside it.

Most of these deaths did not have to happen. Review boards that study them in detail found that the overwhelming majority were preventable, with earlier warning, better screening, or faster access to care. That finding sits at the center of why reproductive psychiatry matters. It is not a small corner of medicine. It is a matter of life and death for young families, and it has been treated as an afterthought for far too long.

When the Warning Signs Are Missed

One of the most frightening conditions in this field is postpartum psychosis. It is rare, striking roughly one or two mothers out of every thousand births, but it can move fast and turn deadly within days. A woman can go from mild sleep trouble to hearing voices or believing things that are not true in hours.

Studies show that a meaningful share of mothers with untreated postpartum psychosis will attempt suicide, and a smaller number will harm their child. Physicians and advocates who work in this space are clear about one thing. Postpartum psychosis is a medical emergency, and with fast, proper treatment, most mothers recover fully.

This condition drew national attention when a Massachusetts nurse named Lindsay Clancy went on trial after the deaths of her three young children. Her attorneys argued that severe, untreated postpartum psychosis, not any intent to harm, drove her actions that day. The trial ended without a verdict after jurors could not agree on whether she was criminally responsible. One juror held out in the case. The defense attorney has requested an investigation into his actions.

Physicians who study the condition say cases like hers expose a hard truth. There is no standard screening test for postpartum psychosis, the way there is for postpartum depression, so doctors and family members are often left guessing until symptoms become severe.

Warning signs can include not sleeping for several nights in a row, racing or jumbled thoughts, sudden confusion about what is real, and strange new beliefs about the baby. Legal experts add that courts rarely weigh a mother’s mental state fairly. Only one state currently allows undiagnosed or untreated postpartum psychosis to count in a mother’s favor during sentencing. The gap between what medicine knows about this illness and what the legal system recognizes remains wide. How do you find someone guilty of murder when the research is so limited and faulty, and the treatment is almost pure guesswork?

Confusion at the Pharmacy Counter

Reproductive psychiatry is also fighting a newer problem, public confusion over which medications are actually safe. In September 2025, federal health officials warned that Tylenol use during pregnancy might raise a child’s risk of autism, based on studies that many scientists consider far from settled. In the months that followed, emergency rooms saw pain medication orders for pregnant patients drop by about ten percent, even as new large studies kept finding no clear link between Tylenol and autism.

Antidepressants came under a similar kind of pressure. A federal advisory panel questioned the safety of these drugs during pregnancy, and several panel members claimed, without solid evidence, that the medications cause autism or do not work at all. Leading reproductive psychiatrists pushed back hard.

One new study tracked thousands of patients who had been taking antidepressants for depression or anxiety before becoming pregnant. Those who stopped their medication during pregnancy needed emergency mental health care far more often than those who stayed on it. Untreated depression on its own raises the risk of early birth and dangerous high blood pressure during pregnancy. Doctors in the field say there is no convincing evidence that antidepressants cause autism or birth defects.

This kind of public confusion often pushes women toward the riskier choice, going without needed treatment, out of fear of a smaller and far less certain risk. On top of the confusion, there simply aren’t enough specialists. It’s the same in geriatrics, where few specialists are available.

Many towns and even entire regions have no reproductive psychiatrist at all. To close that gap, hospitals and universities have started programs that let a family doctor or an obstetrician call a psychiatric expert for guidance on the spot, rather than sending every patient to a specialist who might be hours away. These access programs are growing, but they still reach only a fraction of the mothers who need them.

Reproductive psychiatry sits at a hard crossroads. The evidence is clear that mental health, not bleeding or high blood pressure, is now the greatest threat to mothers in the weeks surrounding childbirth. Yet screening tools remain incomplete, public trust has been shaken by conflicting claims from officials, and specialists are spread thin across a country where many families live far from real help.

The good news is that nearly everything described here responds to treatment. Depression and anxiety improve with therapy and medication. Even postpartum psychosis, as frightening as it is, gets better with fast psychiatric care. The real danger is rarely the illness itself. Silence, delay, and bad information often stand between a mother and the help she needs.

Family members often notice first that something is wrong. Physicians in this field give the same advice again and again. Do not wait. Do not assume the feeling will simply pass. And do not let fear over a medication rumor stand between a mother and the treatment that could save her life. A mother’s mental health is not a footnote to her physical recovery from childbirth. It is central to whether she and her baby come through this season of life safely.

The post When Having a Baby Becomes a Mental Health Emergency appeared first on Medika Life.

Household air pollution alone contributes to an estimated 2.9 million premature deaths each year. That devastating figure captures only one part of the burden. It does not account for many of the health effects associated with dampness and mold, chemical pollutants, airborne disease transmission, wildfire smoke or outdoor pollution that enters buildings.

Poor indoor air increases the risk of respiratory and cardiovascular disease, worsens asthma and allergies and contributes to the spread of airborne infections. Its effects also extend to classrooms and workplaces, where unhealthy air can undermine learning, cognitive performance, productivity, and quality of life. Children, pregnant women, older adults and people living with chronic illnesses may face greater risks because of their health, living conditions or level of exposure.

The evidence is clear. The continuing question is whether governments, institutions, businesses and communities can coordinate the policies, investments and everyday decisions needed to protect the air people breathe indoors. The International WELL Building Institute is rallying global experts to create a collaborative call to action.

A Framework for Coordinated Action

The Global Framework for Action Advancing Healthy Indoor Air Through Societal Engagement and Market Transformation offers a path forward. Developed by the Global Commission on Healthy Indoor Air, it is designed to move healthy indoor air from a growing concern to an everyday expectation across every type of building.

More than 200 Commissioners from more than 40 countries collaborated for a year to develop the framework. The Commission brought together scientists, public health leaders, technical experts, building practitioners, industry executives, advocates, policymakers and communication professionals. That breadth was essential because no profession, institution or sector can deliver healthy indoor air at scale.

“The Global Commission demonstrates what becomes possible when leaders look beyond the mission of any one organization and focus on what we can accomplish together,” shares Jason Hartke, PhD, Secretariat of the Global Commission on Healthy Indoor Air and Executive Vice President, International WELL Building Institute.  “By aligning science, policy, investment, professional practice and public engagement, this framework gives countries and communities a practical foundation for making healthy indoor air the norm rather than the exception,” he added.

Science can identify threats and evaluate solutions. Industry can develop and deploy technologies. Public health professionals can assess population-level consequences. Policymakers can establish expectations and accountability. Building professionals can translate standards into daily practice, while communication specialists can help people understand why the issue matters and what action they can take.

The framework turns that shared knowledge into a shared strategy. It establishes nine interconnected points for market transformation, 40 strategic focus areas and some 180 recommendations. Together, they connect public engagement, research, policy, education, market incentives, financing, standards, partnerships and measurement.

The Solutions Are Within Reach

Improving indoor air is not a problem waiting for invention. Effective measures are already available, including source control, moisture and mold prevention, healthier materials, ventilation, filtration, monitoring and sound building operations. These measures can reduce exposure across homes, schools, workplaces, health care settings and public spaces.

The scale of exposure gives these interventions unusual importance. The U.S. Environmental Protection Agency (EPA) reports that Americans spend about 90% of their time indoors. EPA studies also found levels of about a dozen common organic pollutants to be two to five times higher indoors than outdoors. Those findings do not mean that every indoor environment is consistently more polluted. They do show why the quality of indoor air deserves the same sustained attention given to outdoor air.

The remaining obstacle is sector-wide fragmentation. Research does not automatically translate into better building practice, and innovation does not guarantee access. A new standard does not create a workforce prepared to implement it. Public awareness does not necessarily generate investment, while policies without financing can leave communities with expectations they cannot afford to meet.

The IWBI framework addresses those gaps by showing how each lever supports the entire ecosystem of players. Research can inform codes and professional practice. Innovation can improve performance while lowering barriers to adoption. Education can prepare building professionals to apply new knowledge. Financing can help communities move from intention to implementation. Policy can create accountability, while clear performance information can help people make informed decisions about the places where they live, learn, work and receive care.

Communication Is Part of the Infrastructure

Indoor air is invisible, and its health effects may not appear immediately. People cannot ask informed questions or support better policies if they do not recognize the issue. Communication is therefore part of the public health infrastructure required to make healthier indoor environments possible.

Technical evidence must become practical knowledge. Building owners need to understand the value of better ventilation and filtration. Employers need to recognize indoor air as part of workforce health and organizational resilience. School leaders and parents need useful information about how classroom environments affect learning. Patients, clinicians and health care administrators should consider indoor air within infection prevention and healing.

Communication must also help prevent a new divide between buildings that protect health and those occupied by people with the fewest resources and choices. Healthy indoor air cannot become a premium amenity reserved for newer offices, affluent communities or prestigious institutions. The framework is grounded in the Commission’s conviction that access to healthy indoor air is a fundamental human right. Equity must therefore shape policy, financing and implementation from the beginning.

The public needs evidence presented truthfully, with uncertainty explained rather than hidden. People need useful guidance rather than fear. Understanding should lead to agency and action.

Global Direction and Local Leadership

A global framework establishes a common direction without imposing one plan on every country. Climate, governance, building stock, economic conditions and public health needs differ widely. A school system in a densely populated city faces different challenges from a rural clinic, an older apartment building, a factory or a household that relies on polluting cooking fuels.

The next stage of the Commission’s multiyear work will support national organizations and coalitions as they develop country-level Blueprints for Action. These blueprints can translate global strategy into local priorities, financing approaches, implementation pathways and stakeholder responsibilities. They also offer countries a common starting point, reducing the need to build a strategy independently and helping promising solutions move more quickly into practice.

Local adaptation should make action more practical, equitable and durable. It should never become an excuse for delay.

Healthy Buildings Support Healthy People

The COVID-19 pandemic has conditioned the world to recognize that pathogens can travel through indoor spaces. That lesson should not fade as the immediate crisis recedes. Indoor air influences heart and lung health, cognitive performance, educational opportunity, workforce productivity and community resilience.

Healthy indoor air also belongs within the larger climate conversation. Buildings must become healthier and more energy efficient. Those goals should advance together through better design, smarter operations and technologies that account for human health as well as environmental performance.

Serving as one of the Commission’s more than 200 members offered a close view of what becomes possible when scientific knowledge, industry experience, public health leadership, policy insight and communication expertise converge around a shared responsibility. The achievement belongs to the full Commission and to the many disciplines and countries represented in its work.

Its success will not be measured by the number of recommendations published. It will be visible in cleaner classrooms, safer workplaces, and healthier homes and work environments that better protect the people who occupy indoor spaces.

Everyone breathes. Healthy indoor air should be expected, measured, valued and continuously improved wherever and whenever people gather. The Global Framework for Action offers that roadmap. The opportunity is now to use it.

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