Thursday 31 May 2018

The hidden ways gender affects healthcare

Women are more likely to wait longer for a health diagnosis and to be told it’s ‘all in their heads’. That can be lethal: diagnostic errors cause 40,000-80,000 deaths in the US alone, writes Maya Dusenbery in her book 'Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick'. Here's an adapted excerpt:  

Compared to many other diseases, diagnosing a brain tumour is fairly straightforward. Promptly detecting it comes down to being concerned enough about the early symptoms – which range from fatigue to seizures to personality change – to get an image of the brain. Either the tumour is there, or it isn’t.

But in 2016, the Brain Tumour Charity released a report on the treatment of brain tumour patients in the United Kingdom. It found that almost one in three of them had visited a doctor more than five times before receiving their diagnosis. Nearly a quarter weren’t diagnosed for more than a year.

Women, as well as low-income patients, experienced longer delays. They were more likely than men to see 10 or more months pass between their first visit to a doctor and diagnosis –and to have made more than five visits to a doctor prior to diagnosis.

One 39-year-old woman quoted in the report recalled: “One of the GPs I saw actually made fun of me, saying ‘what did I think my headaches were, a brain tumour?’ I had to request a referral to neurology. I went back repeated times to be given antidepressants, sleep charts, analgesia, etc. No one took me seriously.”

To diagnose a brain tumour, a doctor simply must be concerned enough to
order imaging – but it takes doctors longer to do this for women than men
(Credit: Getty Images)
A growing body of research is exploring how “implicit” bias – unconscious biases that are usually not linked to consciously held prejudiced attitudes – contributes to disparities in medical treatment. “We want to think that physicians just view us as a patient, and they’ll treat everyone the same, but they don’t,” says Linda Blount, president of the Black Women’s Health Imperative. “Their bias absolutely makes its way into the exam room.”

One of the most pervasive implicit biases in the medical system regards gender.

Brain tumours are only one example. A 2015 study revealed a longer lag time from the onset of symptoms to diagnosis in female patients in six out of 11 types of cancer. It isn’t that women wait longer to seek medical attention – the delay occurs after they’ve first visited their GP. A 2013 study concluded that more than twice as many women as men had to make more than three visits to a primary care doctor in the UK before getting referred to a specialist for suspected bladder cancer. So did nearly twice as many with renal cancer.

More than just a frustration for patients, these delays cause unnecessary deaths. Each year, an estimated 40,000 to 80,000 people die due to diagnostic errors in the US alone.


In reporting my book Doing Harm, I heard from dozens of women with a range of conditions who, at some point during their search for a diagnosis, were told that their symptoms were due to anxiety, depression, or that all-purpose catch-all: “stress”.

Recorded cases show that in six out of 11 types of cancer, women experienced
a longer lag time from symptom onset to diagnosis (Credit: Getty Images)
Jackie’s experience is typical. She first fell ill at age 16, and for years, she suffered from chronic kidney problems, fevers, fatigue, and terrible menstrual and joint pain. She saw a primary care doctor, a urologist, and a pulmonologist. “Everybody was telling me there was nothing wrong with me,” she says.

With tests revealing nothing amiss, Jackie’s primary care doctor decided that she must be depressed and prescribed antidepressants. They didn’t help at all, but Jackie was “accepting whatever the doctors said”.

The tendency to attribute women’s physical complaints to mental illness has its roots in the history of ‘hysteria’ – that mythical female disorder that, over the centuries, was blamed on a ‘wandering womb’ or sensitive nerves and eventually, post-Freud, came to be seen as a psychological problem. The terms have changed over the last century, but the concept – that the unconscious mind can ‘produce’ physical symptoms – has remained alive and well in medicine.

There is a high risk of misdiagnosis inherent in this concept, whether it’s called hysteria, somatisation, or ‘medically unexplained symptoms’ due to stress.

Back in 1965, British psychiatrist Eliot Slater warned that too often a label of hysteria allowed doctors to believe they’d solved the mystery when, in fact, usually they hadn’t. After following up with 85 patients who’d been diagnosed with ‘hysteria’ at the National Hospital in London throughout the 1950s – including by Slater himself – he discovered that, nine years later, more than 60% had been found to have an organic neurological disease, including brain tumours and epilepsy. A dozen of them had died.

Women have long been considered the typical patients with psychogenic symptoms, so it’s no wonder that they are especially likely to find their symptoms dismissed as “all in their heads”. In a 1986 study, for example, researchers looked at a group of patients with serious organic neurological disorders who’d initially been diagnosed with hysteria. They identified the characteristics that made a patient vulnerable to such a misdiagnosis. One was having a prior diagnosis of a psychiatric disorder. Another was being a woman.

The fact that women have higher rates of mood disorders is, itself, likely one reason that it’s so common for women to get a psychogenic label. In the US, women are about twice as likely to have a diagnosis of depression or an anxiety disorder as men.

Studies suggested that as many as 30-50% of women diagnosed with depression were misdiagnosed

But while women may truly have a higher risk, the difference in prevalence rates may be at least partly a consequence of overdiagnosis in women and underdiagnosis in men. Studies in the 1990s suggested that as many as 30-50% of women diagnosed with depression were misdiagnosed. Furthermore, depression and anxiety are themselves symptoms of other diseases, which often go unrecognised in women. And, of course, the stress of suffering from an undiagnosed – and therefore untreated – disease often takes its mental toll. As one article points out, “Ironically, medical misdiagnoses of physical conditions may induce depressive reactions in female patients.”

Once listed in their chart, a psychological disorder heightens the risk that any other physical symptoms a patient has in the future will be automatically dismissed as psychogenic.

Women are especially likely to find symptoms dismissed as
‘all in their heads’ (Credit: Getty Images)
I heard from one woman, a middle-aged Italian immigrant to the US with a history of depression, whose worsening abdominal pain was dismissed as menstrual pain for three years. It wasn’t taken seriously even when she brought up the fact that she had a family history of colon cancer. And it wasn’t taken seriously even when she began having rectal bleeding. When she finally pushed for a colonoscopy, it revealed stage-three colon cancer.

Just a few months longer and it would have been at stage four and incurable.


After a few years, Jackie finally got one correct diagnosis. A friend – a well-off white woman – urged Jackie to go see her doctor in a wealthy suburb. He quickly diagnosed her with endometriosis, and surgery alleviated much of her pelvic pain.

But other problems persisted and eventually worsened. After moving to a new city for graduate school, it took another few years to find another set of doctors who would take her symptoms seriously. “I had a lot of, ‘You’re just hysterical,’ ” she remembers. “One of the more common things, especially in emergency rooms, was ‘You’re just drug seeking.’”

As a woman of colour, Jackie was facing more than gender bias. Implicit biases on the basis of race, class, weight, sexual orientation, and trans status all affect clinical care as well.

There is particularly robust evidence showing that US patients of colour, black patients especially, are undertreated for pain. A 2012 meta-analysis of 20 years of published research found that black patients were 22% less likely than whites to get any pain medication and 29% less likely to be treated with opioids.

One study found that healthcare providers believe that black patients don’t
feel as much pain as whites (Credit: Getty Images)
Experts point to a stereotype – widely held by healthcare providers yet utterly false – that black patients are more likely to abuse prescription painkillers. (In fact, white Americans have the highest rates of prescription drug abuse.) But the disparity extends to children, suggesting it’s not just about the assumption of drug seeking. A 2015 study found that white children with appendicitis were almost three times as likely as black children to receive opioids in the emergency room.

A 2016 study suggested that healthcare providers may underestimate black patients’ pain in part due to a belief that they simply don’t actually feel as much pain. When 200 white medical students and residents were quizzed on a series of claims about biological differences between the races, like “blacks’ skin is thicker than whites,” a full half thought one or more of the false statements were true. And, when they later read case studies of two patients reporting pain, those who had endorsed more false beliefs thought the black patient felt less pain, and undertreated them accordingly.


The biggest danger of having your symptoms dismissed is that once doctors believe they are ‘all in your head’, they stop searching for another explanation

Not being taken seriously enough to be treated is frustrating enough. But the biggest danger of having your symptoms dismissed is that once doctors have settled on the conclusion that they are ‘all in your head’ – or made up in order to get painkillers – they stop searching for another explanation.

Consider the experience of patients with rare diseases, who go more than seven years, on average, before being correctly diagnosed. Along the way, they visit four primary care doctors and four specialists and receive two to three misdiagnoses.

While some delay in diagnosing an uncommon disease may be inevitable, this staggering seven-year gap is not simply because it takes that long for doctors to crack a challenging case. According to a Eurordis survey of 12,000 rare disease patients in Europe, those who were initially misdiagnosed experienced longer diagnostic journeys. And, while being misdiagnosed with the wrong physical disease doubled the time it took to get to the right diagnosis, getting a psychological misdiagnosis extended it even more – by 2.5 up to 14 times, depending on the disease.

Given women’s vulnerability to a psychogenic misdiagnosis, it is perhaps not surprising that they reported significantly longer delays than men.

For example, it took an average of 12 months for men to get diagnosed with Crohn’s disease, an autoimmune disease of the gastrointestinal tract, compared to 20 months for women. Men were diagnosed with Ehlers-Danlos syndrome, a group of genetic disorders that affect the connective tissue, in four years. For women: 16 years.

It takes an average 12 months for men to receive a diagnosis of Crohn’s
disease; for women, 20 months (Credit: Getty Images)
“Being a woman should have no influence on a physician’s clinical ability to diagnose a disease,” the authors of the report wrote. “It is, therefore, difficult to accept that overall women experience much greater delays in diagnosis than men. The more rapid diagnosis of men illustrates that the capacity to do so exists.”

As for Jackie? Midway through graduate school, she finally caught a break. She had been sick for months with a fever that the doctors, despite soaking her in antibiotics, could not break. “A primary care doctor – a woman of colour – believed me, and she collected all of my medical records and literally took them home with her and started trying to piece them together like it was a puzzle.”

She suspected that Jackie might have lupus. A test confirmed it. Jackie thought her battle to be taken seriously was over. In fact, as a black woman managing a chronic disease that frequently landed her in the ER with excruciating pain, there would many more encounters with dismissive healthcare providers in her future.

But at least, after 10 years of searching, she finally had a diagnosis — and, with it, the assurance that it had never been ‘all in her head’. Something really was wrong with her. And now, it could get better.

(Source: BBC)

Children are not weightlifters nor schoolbags loaded containers: Madras High Court

The Madras High Court has directed CBSE and the Association of Management of Private Schools to use only NCERT books, not over-load children with books and other study material and assign homework in classes I and II.

“The children are neither weightlifters nor schoolbags are loaded containers. Joy, happiness, enthusiasm, trolling, rolling, kicking, running, fighting, playing with other children are natural qualities of the children. They are moulded as memory chips to store information, due to faulty pattern of educational system and to download them in the exams to prove their memory capacity which is the yardstick to assess and measure the alleged merits of children. Bundle of joy and enthusiasm, emotions, curiosity make the innocence of a child.

The said innocence is being robbed of by ‘ambitious’ parents, ‘taskmaster’ teachers and ‘result-oriented’ school managements by prescribing irrelevant books in the very young age itself. Instead of learning with joy, the children end up rote memorising, with fear and stress, which in no way could help them or the parents. Instead of making creative minds, the system only does destruction of younger minds,” Justice N Kirubakaran said.

The judge was passing orders on a writ petition from M Purushothaman, an advocate, which challenged the CBSE circular dated July 29, 2017 and further direct the Department of School Education and the Literacy, Human Resource Development Ministry, New Delhi and the NCERT, Bengaluru, to require CBSE schools to buy books published by NCERT alone and not books published by private publishers.

He contended that excess subjects, not prescribed by NCERT, are prescribed by CBSE schools to kids of classes I to V, homework, which have been prohibited to be given to students of classes I and II, is given. Excess subjects make the schoolbags heavier.

Passing final orders, the judge observed that children are distracted in many ways depriving their regular sleep nowadays. They spend more time on mobile and TV screens, endangering their health. With all these distractions and reduction in sleep time, when young children are forced to do homework, it would cause unwanted stress, anxiety and depression.

The judge also directed the Union government to formulate a policy forthwith on the lines of Children School Bags (Limitation on Weight) Bill, 2006 and to ask the State governments and the Union Territories forthwith to formulate a Children School Bag Policy’  to reduce the weight of bags.

(Source: TNIE)

UAE bans fruits from Indian state after Nipah virus outbreak

The United Arab Emirates (UAE) has banned imports of fresh vegetables and fruits from the southern Indian state of Kerala where 13 people have died due to an outbreak of the rare brain-damaging Nipah virus, the Gulf state said on Tuesday.

The UAE's Ministry of Climate Change and Environment also notified other local authorities, including the Abu Dhabi Food Control Authority and the municipalities of its emirates, to prevent the entry of any fresh produce from Kerala, it said in a statement.

The ministry suspects that fruit bats are the source of the virus. It said it was banning fresh produce, including mangoes, dates and bananas - the bats' preferred fruits.

Indian health officials have not been able to trace the origin of the Nipah outbreak and have begun a fresh round of tests on fruit bats from Perambra, the suspected epicenter of the infection.

In this file photo taken on May 21, 2018 Animal Husbandry department and Forest officials deposit a bat into a container after catching it inside a well at Changaroth in Kozhikode in the Indian state of Kerala. (AFP)
Kerala has sent 116 suspected cases for testing in recent weeks, 15 have been confirmed with the deadly disease and 13 of these people have died, with two patients still undergoing treatment.

No confirmed cases of the virus have been found outside the state.

There is no vaccine for the virus, which is spread through body fluids and can cause encephalitis, or inflammation of the brain, the World Health Organization (WHO) says.

Last week, the UAE consulate in Kerala advised travelers to take precautions and follow safety instructions issued by the Indian authorities.

The Gulf state has also banned imports of live animals from South Africa, based on a notification from the World Organization for Animal Health (OIE) of the registration of Rift Valley Fever disease, the ministry said.

(Source: The Peninsula)

Nipah outbreak: Death toll rises in India as brain-damaging disease spreads

As the rare virus claims more lives in the Indian state of Kerala, concerns have been raised about the potential of Nipah to become a global health emergency, writes Dominique Mosbergen in HuffPo. Read on:

As health workers in India scramble to contain an ongoing outbreak of Nipah, a rare and deadly virus with no known cure, concerns have been raised about the disease’s potential to become the next global health emergency.

At least 13 people in the Indian state of Kerala have died from the Nipah virus in the recent outbreak. On Monday, The Hindu newspaper reported that a patient with Nipah-like symptoms was under observation in a hospital in Goa, a state in western India. If diagnosed with the disease, the patient — reportedly a 20-year-old man who’d traveled to Goa from Kerala — could be the first case of Nipah infection outside Kerala since the recent outbreak began earlier this month.

The Nipah virus, which was first identified in 1999 after an outbreak in Malaysia and Singapore, is a disease thought to be transmitted by bats, pigs or other animals to humans. The virus, which has a mortality rate of up to 70 percent, can cause encephalitis, or inflammation of the brain, as well as severe respiratory symptoms, according to the World Health Organization. There is currently no cure or vaccine for Nipah, though research into a possible vaccine is reportedly underway.

Doctors and relatives wearing protective gear carry the body of a victim of the brain-damaging Nipah virus, during his funeral in Kozhikode, in the southern Indian state of Kerala, India, on May 24.
The current outbreak is believed to have originated with a family living in the coastal Kerala city of Kozhikode. India’s Ministry of Health and Family Welfare said last week that public health workers had found several bats in a water well that had been used by three family members who died after contracting the Nipah virus. The Times of India reported, however, that samples taken from the bats tested negative for the virus.

Health officials said this week that they would ramp up testing of other animal samples from the region in an effort to pin down the origins of the current outbreak. Officials said they were particularly keen to test samples from fruit-eating bats, which are known carriers of the disease. The Times of India said the bats in the well were insect-eating bats, which are not known carriers.

Reuters reported Monday that a 26-year-old rickshaw driver from Kozhikode was the latest Nipah virus victim.

Last week, a nurse who treated Nipah victims perished from the disease.

“I think I am almost on my way. I may not be able to see you again. Sorry,” Lini Puthusheri wrote to her husband from her hospital bed, according to the Associated Press. “Take care of our children.”

According to the Centers of Disease Control and Prevention, people can be infected with the Nipah virus after direct contact with patients of the disease. “This is most commonly seen in the family and caregivers of Nipah virus-infected patients,” the CDC said.
The Nipah virus was listed this year on the WHO’s priority list of emerging diseases that could cause a global health emergency. Ebola and Zika were also on the 2018 list, which the WHO said identifies diseases that “pose a public health risk because of their epidemic potential and for which there are no, or insufficient, countermeasures.”

Stanford epidemiologist and Nipah expert Stephen Luby said recently that Nipah could conceivably become a “global pandemic threat” if there emerged a strain of the disease that could efficiently be transmitted from person to person.

“It is conceivable that there is currently a strain of Nipah virus circulating among bats that, if it infected people, would efficiently transmit from person to person,” Luby told the Stanford Report, though noting that “so far, we have not identified such a strain.”

“Characteristics that might increase the risk of person-to-person transmission would be a virus that has a stronger tendency to move to the respiratory tract in high numbers,” he said. “It is conceivable that the virus could acquire a mutation that would enhance this capacity. One concern is that anytime a virus infects a human, it is in an environment that selects for survival in that context.”

Why women in South Africa are carrying the burden of HIV

South Africa has the biggest HIV epidemic in the world, with 7.1 million people living with the virus.

There is a huge gender disparity in infection rates, with nearly four times the number of young women infected than men their age.

Not only are women disproportionately infected, but there is another burden tying them to this life-changing illness.

Many women have been unknowingly infected with HIV, then unknowingly passed it on to their children.

Guilt, shame and responsibility are words that swirl around this heartbreaking effect of the virus, and the aftermath of such a diagnosis lasts a lifetime.

This is Sylvia, a woman that lives and breathes these statistics. And a woman fighting to make history.
‘My husband was with me when we discovered our daughter was HIV positive.
The way he reacted, that I will never forget’ Tom Ford


A person who brims with energy and love, Sylvia Mdluli’s pride in her daughter is palpable.

“Oh when Shameen was born I was the happiest mother on earth! She’s here with me now – say hello Shameen – she just turned 17.”

Fourteen years ago Shameen fell gravely ill and was referred for medical tests.

“My husband was with me when we discovered our daughter was HIV positive. The way he reacted, that I will never forget. It was like I came with HIV and gave it to our daughter knowingly.”

At the time Sylvia was pregnant antenatal care visits in South Africa did not test for HIV. This meant not only was she not diagnosed, but she knew nothing about the virus, an issue that Sylvia repeatedly stressed.

“I had so many questions in terms of what went wrong, I had no idea that I was HIV positive and didn’t know anything about it. I now think my daughter got infected through me breastfeeding her. I won’t lie, I was emotionally hurt, I couldn’t help but blame myself, I really battled with the news of knowing that I made my daughter sick.”

As well as seeking medical answers, the inevitable question of “how” plagued Sylvia.

“I was faithful to my partner and never cheated on him; however once we found out that my daughter was HIV positive my husband blamed me and said I’m the one who came with the virus.

“It was only later on that we find out that he had another girlfriend who a close friend of his told me was HIV positive. I don’t want to blame anyone, but now when I look back I can see where things might have gone wrong.”

Reeling from both the diagnosis and her husband’s reaction, Sylvia realised she needed to take back the control she had unwittingly lost.

“I read everything I could find to get as much information as possible. I just wanted to know more so that I could raise my daughter and live a long life together.

“My doctor told me to tell Shameen when she was 12, to avoid her blaming me but also to ensure that when she starts engaging in sexual activities she is fully knowledgeable.

“When I first told her about her HIV she didn’t understand, she thought she was going to die. For a young girl to be so aware of their sexuality, and have their relationship with their parent put in that situation, it is difficult for everyone.”

After an initial period of monitoring, in 2006 Sylvia’s CD4 count dropped and she began taking ARV medication.

But it wasn’t just medicine that Sylvia credits for saving her life.

She was referred to a local support group attempting to eradicate mother-to-child transmitted HIV.

Programmes like this are credited for the impressive drop in new infection rates among South African children, with the rate of transmission reaching a record low of 1.3 per cent in 2017.

Sylvia now works for the charity mothers2mothers, helping educate other mothers and children.

The hard work of groups like this are making total elimination of mother-to-child transmission less a dream and more a reality.

But there is a dangerous undercurrent stopping this goal from being achieved.

As increasing numbers of people get tested for HIV, including sex workers and other high risk groups, there are still some reluctant to come forward: victims of abuse.

Sylvia now leads household visits in Mpumalanga, where she assesses
families, caregivers and children, and then provides essential services
and advice (mothers2mothers)
Both Sylvia and a wealth of research behind the gender disparity in HIV infection rates cite violence against women as a reason mother-to-child transmission still exists.

“Most women I talk to when they are abused, they don’t come forward and talk about it. When I go into homes and ask the mother, ‘oh, what happened to your face?’, the mother will just come up with an excuse.”

This culture of silence among abused women extends to their health, meaning they are less likely to come forward and get tested.

Victims of domestic abuse may also be unable to negotiate safe sex practices with their partner, putting them at higher risk of infection.
The clear intersection between domestic abuse, rape and HIV infection rates appears to be the new battle in fighting mother-to-child transmission.

“We need to fight gender violence to improve everything else for women, so women can stand up and do positive things, because if they keep on being abused it won’t just harm women, but the whole family, so they must come forward. Women need to know their rights, because most women I visit don’t seem to, and they don’t know where to look to to use these rights.”

In a life focused on her daughter and helping other women, Sylvia is determined to keep fighting this clearly gendered virus.

Along with the other women she works with in South Africa – some infected, some not – they are fighting to stop any more babies being infected with HIV.

“Over the years I’ve learnt a lot and I’m so armed with knowledge; learning about HIV, and stigma and how it affects our daily lives has given me the willpower to live. I’m not shy about my status anymore.”

After visiting countless other women, and facing her own personal battles, Sylvia’s message is clear.

“I want women to take care of themselves and to be independent. If you are a woman, you do not need to be dependent to anyone other than yourself. I think life becomes much easier when you realise that.”

(Source: Independent)

Wednesday 30 May 2018

Hurricane Maria 'killed 4,600 in Puerto Rico'

Hurricane Maria killed more than 4,600 people in Puerto Rico, 70 times the official toll, according to estimates in a Harvard University study.

A third of deaths after September's hurricane were due to interruptions in medical care caused by power cuts and broken road links, researchers say.

The Puerto Rico government said it "always expected the number to be higher than what was previously reported".

The official death toll stands at 64.

But experts say an accurate count was complicated by the widespread devastation wreaked by the storm.
The official death toll stands at 64
Carlos Mercader from Puerto Rico's Federal Affairs Administration said he welcomed the Harvard survey.

"The magnitude of this tragic disaster caused by Hurricane Maria resulted in many fatalities," he said.

He added that the island's authorities had also commissioned George Washington University to study the number of deaths and these findings would be released soon.

"Both studies will help us better prepare for future natural disasters and prevent lives from being lost," he said.

The Harvard researchers said interviews conducted in Puerto Rico suggested a 60% increase in mortality in the three months after the storm.

They contacted more than 3,000 randomly selected households between January and March this year and asked about displacement, infrastructure loss and causes of death.

Were deaths preventable?
Aleem Maqbool, BBC News, Washington

Many Puerto Ricans we spoke to felt their immense suffering after the hurricane had been trivialised and that the emergency response has been lacklustre.

A relatively small number of people may have been killed by the physical impact of the storm, but six months later we met people who had lost relatives as a result of interrupted medical care and saw others struggling to pay for expensive generators on which they were running vital life support equipment.

There was also reported to have been a spike in the number of suicides. We found many still without homes and thousands who had been living without electricity since the day Hurricane Maria struck.

Whatever the true number of those killed as a result of the storm, it is now certain to be many times the official figure. The question for US authorities about Puerto Rico, an American territory, is how many of those deaths could have been prevented with a better emergency response?

They then compared their results with the official mortality rates for the same period in 2016, more than a year before the hurricane struck the island.

The researchers said that interrupted medical care was the "primary cause of sustained high mortality rates in the months after the hurricane".

Disruption to health care was a "growing contributor to both morbidity and mortality" in natural disasters, they said, because growing numbers of patients had chronic diseases and used sophisticated equipment that relied on electricity.

On Twitter, several users noted that the death toll exceeds the nearly 3,000 Americans that were killed during the 9/11 attacks.

The mayor of San Juan, the largest city in Puerto Rico, tweeted that "the negligence that contributed to [the deaths] cannot be forgotten.

Carmen Yulin Cruz added that the death toll is "a violation of our human rights".

Hurricane Maria caused the largest blackout in US history, according to research consultancy the Rhodium Group.

There have also been repeated power cuts since then, including an island-wide one in April, nearly seven months after the hurricane.

Overall, Hurricane Maria caused losses of $90bn (£68bn), the US National Oceanic and Atmospheric Administration (Noaa) said.

The Caribbean island is home to 3.4 million US citizens.

(Source: BBC)

In the Middle East, Putin has a lot to thank Trump for right now

Once it was the State Department which called for 'restraint on all sides' – usually when the Israelis were invading or bombing Lebanon or Gaza – but now it’s the Kremlin which calls for 'restraint' between Israel and Iran. Putin is fast becoming a friend to all

Vladimir Putin will have paid very close attention to the location of the Syrian artillery battery where four Russian soldiers lost their lives at the weekend. The desert around Deir ez-Zour remains a dangerous place – politically as well as physically – in which the Americans and the Russians play an extremely risky game of war.

Putin still suspects the Americans helped the artillery guidance of a mortar battery which killed the commander of the Russian Far East 5th Army in Deir ez-Zour, Lt. Gen. Valery Asapov, less than a year ago. Was the mortar fired by pro-American Kurdish fighters? Or by Isis? The Russians say that Isis mobile attackers stormed the Syrian artillery position this weekend at night – the Islamists’ normal routine, streaming out of the desert wadis in suicide trucks and motorcycles – even though the little Syrian forts, hillocks of sand and cement strewn across the vast sand plateaus, are supposed to be invulnerable.

So now the Russians are directing artillery. First they were the air component to the Syrian army, their forward air observers on the ground with Syrian troops, directing the Sukhois onto Assad’s enemies. Then the Russians were the de-miners of Palmyra and Deir ez-Zour, Homs and Aleppo. Then the Russian military police escorted the beaten jihadists to the wastelands of Idlib province or the Turkish border. The Russians liaise between the Syrians and the pro-American Kurds on the Euphrates River.

Putin is a micromanager and an expert in making allies out of strange situations Tass/AP
Twelve months ago, Putin’s top artillery technicians were searching through the rubble of eastern Aleppo to draw up painstaking maps of the fall of shot – the exact bomb crater and blast effects of air-dropped Russian munitions. I met one of their teams. Their reports were circulated, of course, to Russian military intelligence. But they first go directly to the Kremlin.

Putin reads them. He is a micro-manager. There will be no Brezhnev-style Afghanistan disasters in Syria – or so the Russians pray – no slovenly retreats across the Amu Darya by political generals, no Kremlin lethargy. Russian officers speak good Arabic (and quite good English) – products of the Moscow School of Foreign Languages – and, like the Syrian army, their officers go to the front lines.

That’s why Asapov was killed. Putin decided to pursue his Chechen and Russian jihadi enemies all the way to Syria – and kill them all. He saved his ally, Bashar al-Assad. But at the very same time – give or take a warning or two and one downed Russian jet (courtesy of a soon-to-repent Erdogan) – he remained a trusted friend of Israel, Iran, Turkey, Egypt, Lebanon, Saudi Arabia and so on.

Refusing to join his insane counterpart in Washington in a sectarian war between Sunnis and Shias, Putin deploys the one phrase which unites every dictator, prime minister, Mafiosi autocrat, king, president, mass-murdering tyrant, public relations hack or fawning editor: the “war on terror”. I reckon Putin and Trump use this circumlocution about the same number of times. It’s a cracker for the masses, and it doesn’t matter if it’s uttered by a cynic in the Kremlin or a guy in the White House who is completely bananas. But Putin, of course, is a man for all seasons.

He accepts the praise of Bashar al-Assad for “saving” Syria. He calls Israel’s racist defence minister Avigdor Lieberman “brilliant”. Indeed, one Russian translation of a Kremlin meeting quoted Putin as claiming that Lieberman – a former nightclub bouncer from the ex-Soviet Union – was “a great Russian”. Netanyahu is always welcome at the Kremlin, even when he’s bombing the Iranians in Syria. Sultan Erdogan of Turkey, whose air force shot down one of Putin’s jets, scurried to befriend Putin when the Russians ordered their holidaymakers to dry up Turkey’s seaside tourist industry. When Putin travelled to Erdogan’s golden palace in Istanbul, he stationed a helicopter-carrier bang in the very centre of the Bosphorous, right opposite the Topkapi.

In Cairo, Sissi takes Putin to the opera; in the Kremlin, Putin welcomes King Abdullah of Saudi Arabia. He welcomes the Qataris. He pays court to Iran’s Rouhani. He listens – glowering, to be sure – as the Supreme Leader Khamenei explains the evils of American interference in the Middle East (this only two years ago).

Mercifully, the Iranian Sayed did not mention the Russian invasion of northern Iran in the Second World War, nor its setting up of Soviets in Azerbaijan and Mahabad in Iranian Kurdistan when the war was over. No more than Sissi recalled how Sadat threw the Russians out of Egypt in 1972. No more than Putin would have mentioned to Assad how the younger Lion of Damascus flirted with the West and attended the Bastille Day parade with Nicolas Sarkozy in 2008 – Trump was equally hooked by this military flummery last year – and declined to respond publicly to Russian requests in 2000 about Chechen rebels who had fled Russia.

But after the Libyan debacle, Putin was going to take no nonsense when his western partners tried to unseat Assad. There would be no more humiliating Russian retreats from the Mediterranean.

When the Russians later wanted to talk to the American-trained anti-Islamist Libyan military seigneur de guerre Khalifa Haftar, they simply airfreighted him onto a Russian carrier off shore. When the Americans complained that Russian airstrikes in Syria were only hitting the CIA’s favourite (and fairly mythical) “Free Syrian Army” rebels, Lavrov grimly replied that “if it looks like a terrorist, if it acts like a terrorist, if it walks like a terrorist… it’s a terrorist.”

Putin sheds as few tears over the Russian mercenaries who die in Syria fighting the Kurds as he did over the Kurds who died defending Afrin from the Turkish army and its Isis cohorts. That deal seems to have been simple. The Turks could have Afrin province – for the time being – if they let the Syrians and Russians clear the Islamists out of Idlib province in the future (note: watch out for this war).

And a bigger compromise seems to have been achieved with the Israelis. They could hit the Iranians if they wished, but no war on Syria, no Israeli (or American) no-fly zones, and – above all – no war with Iran. The Iranians don’t want a war with Israel (neither side would win, as Netanyahu knows), and in Tehran, Putin is the voice of common sense. Once it was the State Department which called for “restraint on all sides” – usually when the Israelis were invading or bombing Lebanon or Gaza – but now it’s the Kremlin which calls for “restraint” between Israel and Iran.

So to what degree has Putin’s shrewd, hard, sardonic character brought all this about – and how much did Trump’s instability and unpredictability hand Russia its political triumph in the Middle East? It’s tempting to say a bit of both. But I suspect that an Obama might have provided a regional equilibrium which Putin has now claimed for himself. When Moscow is now the “interlocuteur valable” in the Middle East, it’s difficult to take the gift of equilibrium politics away from Putin. Europe’s case is hopeless.

Europe cannot engage with a Kremlin that still occupies part of Ukraine and annexes the Crimea. It showers sanctions upon Russia. But it grovels like the Americans to an Israel which occupies the West Bank and annexes Jerusalem and Golan; and the very word “sanctions” – or disinvestment – cannot be mentioned in Europe without accusations of anti-Semitism.

Israel can fire off its missiles into Syria after claiming that Iranian missiles had fallen on Golan – actually Israeli-occupied Syrian Golan, although that got a little lost in the telling – but Putin is not going to order an end to Golan attacks. There is a strong suspicion that it was the Syrian army which fired those missiles at the Israelis – in retaliation for the constant Israeli bombing of Syrian forces (never Isis forces, of course) over the last three years. Thus the Israelis, fearful of a reopening of the “South Lebanese Front” in a future war with Hezbollah, have unthinkingly opened a “Golan Front” – along a border which has been largely silent for 45 years. It’s the kind of equation Putin can savour. Be sure, he’ll be there to intervene if anyone needs him.

And he’s insisting that it’s the Syrians who move onto the Golan plateau on their own. No Iranians. No Hezbollah. The Syrians can’t object if they’re back on their border with occupied Golan. And the Israelis can’t object if Russia keeps the Iranians and the Hezbollah out. “Deconfliction”, the Russians like to call this. Everyone backs off. No war on Golan. That’s the hope.

As for what the “experts” like to call geopolitics, Putin immediately understood the need to uphold the Iranian nuclear accord when Trump tore it up. At one stroke, he became a closer ally of Iran, he could sympathise with Europe and he was able to present himself as steadfast in a treaty he signed with China. But he is entering a potential market war with the US – a dollar war – alongside a Europe whose governments may be prepared to stand up to Washington (some of them, at least), but whose big businessmen are already showing their usual cowardice in the face of American profit and loss.

There is something scornful about all this. Putin is not going to worry about Russian mercenary deaths in Syria; their activities are intended to test American military willpower in Syria. Nor does America weep for its Kurdish mercenaries, or protect them in Afrin.

Putin is not going to scream about human rights abuses in Gaza – the shooting down of unarmed demonstrators or the Israeli destruction of clinics or hospitals – when his own jets have been destroying clinics and hospitals in Syria. He sticks to the “war on terror” – and being an ally of all. The children may rattle their toys, but the Tsar has the keys to the nursery. The crackpot in the White House neither knows nor cares nor, one suspects, understands. He long ago opened the door for Putin – and Putin walked straight through it.

(Source: Independent)

Postcards written by Soseki Natsume in the UK found after 100 years

Three postcards written by the Japanese literary legend Soseki Natsume (1867-1916) over 100 years ago during his studies in Britain have been found, the prefectural government of Fukui said Wednesday.

This photo shows one of the postcards written to a friend in Germany by Soseki Natsume during his studies in Britain. | FUKUI CHILDREN'S MUSEUM / VIA KYODO
The postcards were sent to his Japanese friends studying in Germany. In one of the postcards, written a month after Natsume arrived in London, he said he was lonely.

How Natsume spent his life in London and felt about the city are described in the postcards, which were handwritten in deliberately small letters, said Kunihiko Nakajima, honorary professor at Waseda University.

Natsume is known for novels such as “Wagahai wa Neko de Aru” (“I Am a Cat”), “Botchan” and “Kokoro.”

Two of the postcards were addressed to Teisuke Fujishiro, a scholar of German literature who served as the first dean of the literature department of Kyoto Imperial University, the predecessor of Kyoto University. The remaining one was sent to Yaichi Haga, a scholar of Japanese literature.

Natsume, Fujishiro and Haga were friends during their studies at Tokyo Imperial University, the predecessor of the University of Tokyo. They left Japan aboard the same ship in September 1900 to study abroad. Natsume spent two years in Britain.

(Source: JT)

Moscow stations get World Cup selfie spots

World Cup visitors arriving at Moscow railway stations will not have to look far for the perfect spot to take a selfie, as platforms and ticket halls will soon have special labels marking out the ideal camera angle.

Green stickers of a camera image adorned with a smiley and the words "photography allowed" will be rolled out across nine mainline railway stations, in time for this summer's football World Cup in the Russian capital, Komsomolskaya Pravda newspaper reports.

There will be an average of 20 stickers per station, and at nine centimetres (four inches) in diameter they will be easily visible, according to the Moscow mayor's office. They will mark out prime spots in waiting rooms, business centres, on platforms, and in front of the main entrances.

'Photography encouraged'
The Moscow department of Russian Railways says the aim is to "encourage amateur photography, and allow tourists and passengers to take that first beautiful picture right after stepping off the train".

There are already some stickers on the platforms of Moscow underground stations, and the flagship Moscow Central Circle line will get 190 of the green camera labels this week, the Mayor's office said.

'Photography permitted' where the green camera smiles
"Many Moscow Central Circle stations are located in the historic city centre, and provide the perfect camera angle for memorable photos," according to the railway press office.

Moscow is expecting an influx of fans for the World Cup on 14-15 July, and railways stations are gearing up to hand out maps and guidebooks to those who choose to arrive by train - primarily at the Kazan and Leningrad terminuses.
Moscow is famous for its opulent underground stations
The official attitude to railway photography has changed dramatically since Soviet times, when stations were treated as strategic sites, and unwary snappers often ended up having uncomfortable conversations with secret policemen.

(Source: BBC)

England could have new national parks in Gove review

England could get more national parks after Environment Secretary Michael Gove announced he is launching a review into the country's natural landscapes.

Writing in the Sunday Telegraph, Mr Gove said "the time is right" for a review, nearly 70 years on from the creation of the first national areas.

It will consider whether to expand England's network of parks as well as areas of outstanding natural beauty.

England has 10 existing national parks including Dartmoor and the New Forest.

It also has 34 AONBs - including the Chilterns, the Cotswolds and the Isle of Wight.

According to Mr Gove, the UK's population growth, combined with changes in technology and a decline in some habitats, meant it was time to "look afresh at these landscapes".

Mr Gove will look at evidence from industry experts
Where are England's national parks?
He stressed that the goal of the review was not to diminish the protection of natural areas, but to "strengthen it in the face of present-day challenges".

Former government aide and journalist Julian Glover has been appointed to carry it out.

Mr Gove said: "The creation of national parks almost 70 years ago changed the way we view our precious landscapes - helping us all access and enjoy our natural world.

"We want to make sure they are not only conserved, but enhanced for the next generation.

"Are we properly supporting all those who live in, work in, or want to visit these magnificent places? Should we indeed be extending our areas of designated land?"

He added: "I want Julian explicitly to consider how we can extend and improve the protection we give to other precious landscapes."

Tony Juniper, the campaigns director for the WWF, welcomed the review, but warned that "we need to do more".

"Nature will continue to be at risk unless we have a plan for its recovery enshrined in law - through a new Environment Act that's backed by a strong watchdog with real power to enforce," he said.

England has 10 national parks - the Broads, Dartmoor, Exmoor, the Lake District, the New Forest, Northumberland, the North York Moors, the Peak District, the South Downs and the Yorkshire Dales.

The first national parks to be created were the Peak District, Lake District, Snowdonia and Dartmoor in 1951.

There are two in Scotland - Cairngorms; and Loch Lomond and the Trossachs - and three in Wales: the Brecon Beacons, Pembrokeshire Coast, and Snowdonia.

Mr Gove said that unlike other nations' national parks, "ours are working countryside" and lived in by farmers.

Dartmoor, in Devon, is one of England's 10 existing national parks
'Finest gems'
Mr Glover, who Mr Gove called a "passionate advocate for the countryside", said: "Our protected landscapes are England's finest gems and we owe a huge debt to past generations who had the wisdom to preserve them.

"The system they created has been a strength, but it faces challenges too.

"It is an honour to be asked to find ways to secure them for the future. I can't wait to get started and learn from everyone who shares an interest in making England's landscapes beautiful, diverse and successful."

Margaret Paren, chairwoman of National Parks England said the announcement was "very much welcome" and the organisation intended to "to play a full part".

She added: "And as we approach the 70th anniversary of the founding legislation we look forward to a future where their beauty is enhanced; they are loved and accessible for everyone; and they continue to support thriving communities in these working landscapes."

National parks are areas specifically protected because of their countryside, wildlife and cultural heritage and are funded by central government.

(Source: BBC)

Liam Gallagher meets daughter Molly Moorish for the first time in nearly two decades

The musician previously said 'she's best off with her mum'

Liam Gallagher has posted a photo with his estranged daughter Molly to Instagram after meeting her for the first time.

The photo featured Liam, Molly and his two sons Gene and Lennon Gallagher.

The former Oasis frontman admitted he had never met his 20-year-old daughter - who was conceived during an affair with Lisa Moorish while he was married to Patsy Kensit.

Molly also posted the photo with the caption "As you were."

"The girl’s been looked after and clothed and fed and sent to lovely schools," Gallagher said in the past of his daughter. "I bought them a house and all that tack. I just think she’s best off with her mum…They aren’t good when they are forced, these things.

"I think we leave it be. See what happens. If it happens it happens. Certainly, wouldn’t turn her away, man. Let it be."

When asked about his relationship with Lisa, the 45-year-old rocker told GQ: "She’s had her day in the sun … The kid I haven’t seen. We’ll see one day, but, no, not seen her. But if I met her, she’d be cool. She’s welcome in my world and that, you know what I mean? Without a doubt.

"But I just ain’t met her because her mam’s … Listen, we don’t work. We don’t get on."

After Liam criticised his brother Noel Gallagher for not performing at the One Manchester concert, Lisa wrote in a now deleted tweet: "Maybe he’s busy looking after his kids and the daughter you’ve never even met! AS YOU WERE x LM."

Following her tweet, she shared a photo of Molly with her Uncle Noel.

Liam also has another daughter named Gemma he's reportedly never met who was born from his affair with journalist Liza Ghorbani while he was wed to Nicole Appleton.

He has always had a relationship with his son Lennon with his mother Patsy and his son Gene with Nicole.

(Source: Independent)

Tuesday 29 May 2018

Italy crisis: Call to impeach president after candidate vetoed

Italy is mired in fresh political turmoil, with the president facing impeachment calls after he vetoed a choice for finance minister.

In a rare move, President Sergio Mattarella said he could not appoint the Eurosceptic Paolo Savona, citing concerns by investors.

The decision ended a bid by Italy's two populist parties to form a coalition.

Mr Mattarella may now appoint a stop-gap prime minster with early elections looking increasingly likely.

He has summoned Carlo Cottarelli, a former executive director of the International Monetary Fund, who could form an interim administration.

Italy, the eurozone's fourth-biggest economy, has been without a government since elections in March because no political group can form a majority.

President Sergio Mattarella said he agreed to all the nominations -
except that of finance minister
The Five Star Party had been trying to form a government with another populist party, the right-wing League.

The BBC's James Reynolds in Rome says a temporary prime minister is unlikely to last long and early elections may have to be called.

There is now a real argument between the president and the populists about Italy's position in the EU, he adds.

What caused the crisis?
A political novice, Giuseppe Conte, was proposed by the two populist parties as prime minister in an attempt to break Italy's 11-week political deadlock.

He went to meet Mr Mattarella to put forward choices for his cabinet but the president vetoed Mr Savona as finance minister, citing his fierce opposition to membership of the eurozone.

Justifying his move, he said "uncertainty about our position in the euro has alarmed Italian and foreign investors", and argued that Mr Savona's stance clashed with the two parties' own position on Europe.

"I asked for... an authoritative person from the parliamentary majority who is consistent with the government programme... who isn't seen as a supporter of a line that could probably, or even inevitably, provoke Italy's exit from the euro," Mr Mattarella said.

He added that Mr Conte had refused to support "any other solution" and then surrendered his mandate to be PM.

How unusual is this?
Under Italian law, the president has the right to reject the appointment of a cabinet member but the power is rarely used.

According to the AFP news agency, it has happened at least three times before, including in 1994 when then-President Oscar Luigi Scalfaro blocked attempts by former Prime Minister Silvio Berlusconi to appoint his personal lawyer Cesare Previti as Minister of Justice.

The president's role is largely ceremonial but he does have some key powers, such as appointing heads of government and the ability to dissolve parliament.

With Italy seeing frequent instability - there have been dozens of governments since 1946 - the president has often stepped in during a crisis.

What was the reaction?
Five Star's leader Luigi Di Maio called for impeachment under article 90 of the constitution, which allows parliament to demand a president step down based on a simple majority vote.

If the vote is in favour, the country's constitutional court then decides whether to impeach or not.

Giuseppe Conte has handed back his mandate to form a government
"I want this institutional crisis to be taken to parliament... and the president tried," Mr Di Maio said.

"Why don't we just say that in this country it's pointless that we vote, as the ratings agencies, financial lobbies decide the governments?" he asked in a video on Facebook.

League leader Matteo Salvini called for fresh elections.

"In a democracy, if we are still in democracy, there's only one thing to do, let the Italians have their say," he told supporters in a speech in central Italy.

What happens now?
Mr Mattarella said he would wait before deciding whether to call fresh elections, and summoned Mr Cottarelli for talks on Monday.

Mr Cottarelli, 64, worked at the IMF from 2008 to 2013, gaining the nickname "Mr Scissors" for making cuts to public spending in Italy.

President Mattarella warned on Sunday that the prospect of a populist government had worsened the "spread" - the gap between Italian and German 10-year government bond yields, seen as a key measure of risk.

Paolo Savona has a reputation as a strong Eurosceptic
The spread rose to 215 basis points on Friday - the widest in four years. Ratings agency Moody's warned that it might downgrade Italy's sovereign debt rating to "Baa3" - one notch above the junk rating.

Mr Savona, who served as industry minister during the 1990s, has been an outspoken critic of the EU and an opponent of austerity programmes.

That has prompted concern over the proposed coalition's commitment to the EU and its ability to rein in the country's massive national debt - equal to 1.3 times its annual output.

(Source: BBC)

Her father loved tequila, now she runs a company that makes it

Melly Barajas Cárdenas has built a growing distillery business with a work force made up almost entirely of women, writes Valeriya Safronova in NYT. Read on: 

More than two decades ago, when Melly Barajas Cárdenas and her father were on vacation in Mazamitla, Mexico, he told her that he wanted a tequila made in his name. At the time, Ms. Barajas Cárdenas was a clothing designer in Guadalajara, where she is from.
“Once I was in the tequila industry, I loved it,” said Melly Barajas Cárdenas, who opened her
distillery, Raza Azteca, nearly two decades ago. “The smell, the taste, it was marvelous.”
CreditLindsay Lauckner Gundlock for The New York Times

“I didn’t know anything about tequila,” Ms. Barajas Cárdenas, who declined to give her age, said in a recent telephone interview conducted in Spanish. “But it was my father’s wish.” So she decided she would find a way to fulfill it. She knocked on doors, asking various tequila producers for help, and eventually found one who produced a line of bottles for her.

Ms. Barajas Cárdenas quickly realized she wanted to do more.

“At first, it was a goal I had to accomplish, more than something that I wanted to do,” she said. “My clothing business was very comfortable. I went to the office, went home, it was easy. But once I was in the tequila industry, I loved it. The smell, the taste, it was marvelous.”

“From the girls in the agave fields to those who cook the agave, process the fermentation, it’s all
women,” Ms. Barajas Cárdenas said.Lindsay Lauckner Gundlock for The New York Times
The distillery, based in Jalisco, Mexico, produces tequila for companies like La Gritona,
as well as three in-house brands.Lindsay Lauckner Gundlock for The New York Times
In 1999, she opened her own distillery, Raza Azteca, in Jalisco. At the time, according to an estimate from Mexico’s Tequila Regulatory Council, which certifies tequilas with designations of origin, eight or nine of the 79 tequila producers were women. (Today, the number is 12 of 152, or 8 percent.)

“She’s one of the few female master distillers down there,” said Andy Coronado, the owner of La Gritona, a Los Angeles company that works with Ms. Barajas Cárdenas to produce and bottle its tequila. He described Ms. Barajas Cárdenas as protective of her people, knowledgeable about her craft, tough and sometimes eccentric.

“She always has a Coca-Cola and has a steak when we go out to eat,” Mr. Coronado said. “She pushes the vegetables off her plate and says, ‘That’s the food of my food.’”

The lab and office of Vinos y Licores Azteca, Ms. Barajas Cárdenas’s company. “We are a little distillery, not a big brand on the market,” she said. “We have to make things very differently.”
CreditLindsay Lauckner Gundlock for The New York Times
Raza Azteca produces 100 percent tequila, which is not mixed with sugar or chemical flavors, for three in-house brands — El Conde Azul, Espectacular and Leyenda de México — as well as for other companies, such as La Gritona, Sino Tequila and La Quiere.

“To be a woman in this industry requires a lot of work,” Ms. Barajas Cárdenas said. “It’s a man’s world. When I started, people told me: ‘A woman in this industry? You will not make it.’ I grew off of those comments.”

And she did not focus on advancing only herself. From the early days, Ms. Barajas Cárdenas hired primarily women to work for her company, Vinos y Licores Azteca, which operates Raza Azteca.

Ms. Barajas Cárdenas with her staff on the porch of the distillery. “Most men could do this faster,” she said. “But it’s not something women can’t do. It just takes a little bit more time.”
CreditLindsay Lauckner Gundlock for The New York Times
“When I started the company, I put out job ads for women and men,” Ms. Barajas Cárdenas said. “But here in the little towns, there are more women than men because a lot of the men have left to look for job opportunities in the U.S.A.” So women filled all the openings, including those that are traditionally performed by men.

“From the girls in the agave fields to those who cook the agave, process the fermentation, it’s all women,” she said. “Some of it is really hard work, like cutting the agave. Most men could do this faster. But it’s not something women can’t do. It just takes a little bit more time.”

In creating her distillery, Ms. Barajas Cárdenas entered a market dominated by major companies like Herradura, Patrón and Sauza.

Barrels holding tequila while it ages. Raza Azteca uses methods that take longer than those at
some other distilleries.Lindsay Lauckner Gundlock for The New York Times
All of the distillery’s bottles are made in Mexico, as are the caps and labels.
Lindsay Lauckner Gundlock for The New York Times
“They’re bigger than you, and they want to eat you,” she said. She set out to make a product that would stand out by staying true to the region’s heritage. “It’s tequila like our grandparents drank,” Ms. Barajas Cárdenas said.

Instead of industrial machines, her distillery uses masonry ovens that are made from the soil where the blue agave is planted. This extends the cooking process from eight hours to 24 (with another 24 hours of resting). Normally, the next step, fermentation, is pushed along with additives and lasts one to two days, but Ms. Barajas Cárdenas allows the fermentation to occur naturally, which requires nearly one week. All of the packaging components, such as the labels, caps and bottles, are made in Mexico.

“We are a little distillery, not a big brand on the market,” Ms. Barajas Cárdenas said. “We have to make things very differently.”

Blue agave, grown for tequila, in Ms. Barajas Cárdenas’s fields. When she started, she said, “I had to get up early in the morning and drive from one agave field to another to search for the agave I wanted.”
CreditLindsay Lauckner Gundlock for The New York Times
Ms. Barajas Cárdenas said the most difficult challenge occurred when she first opened the distillery. She did not have her own fields of agave yet, and she wanted to use plants that were eight to 10 years old and had been grown in the highlands. (Some experts argue that terroir is as relevant to tequila as it is to wine.)

“I had to get up early in the morning and drive from one agave field to another to search for the agave I wanted,” Ms. Barajas Cárdenas said. At the time, she managed to produce 300 liters per month. Now, her distillery makes that amount daily.

In the nearly 20 years that she has been producing tequila, the amount of 100 percent tequila that Jalisco produces has more than doubled, but the industry’s male-to-female ratio hasn’t changed much.

Yet Ms. Barajas Cárdenas remains hopeful. “I tell women they can do everything they want to,” she said. “We are no better or worse than men. It’s difficult, but we can definitely do what we want. The sky’s the limit.”

FDA approves preventive migraine treatment

Migraine sufferers across the United States have their eyes on a newly approved drug that's offering hope for reducing the frequency of monthly migraine attacks.

On Thursday, the US Food and Drug Administration approved Aimovig for the preventive treatment of migraines in adults with episodic or chronic migraines. Episodic migraine is when symptoms occur zero to 14 days each month; symptoms of chronic migraine occur 15 days or more a month.

Aimovig is the first FDA-approved preventive migraine treatment in a new class of drugs that work by blocking the activity of calcitonin gene-related peptide, or CGRP, a molecule that is involved in migraine attacks. Aimovig targets that molecule's receptor in your body.

The treatment, administered through monthly self-injections, requires a prescription and could be available to patients within a week. Aimovig is expected to cost $575 monthly or $6,900 annually in the United States.

There are three other migraine treatments in this newly emerging class of drugs.
Aimovig is administered through monthly self-injections.
Those drugs target the CGRP molecule itself, instead of its receptor. They are experimental but, if approved, might be made available to patients as early as this fall for one and next year for the others, said Dr. Stewart Tepper, director of the Dartmouth Headache Center at Dartmouth-Hitchcock Medical Center in New Hampshire, who was a clinical investigator in the Aimovig trials.

"When CGRP is released, outside of the brain, it causes inflammation and blood vessel dilation -- the blood vessels get big -- and that combination of inflammation and blood vessels getting big is the pain of migraine," said Tepper, who is also a professor of neurology at the Geisel School of Medicine at Dartmouth College.

Migraine is three times more common in women than in men and affects more than 10% of people worldwide, the FDA noted. In the US, about 12% of the population gets migraine headaches.

What was found in clinical trials
The effectiveness of Aimovig was evaluated in three key clinical trials.

The first included 955 people with a history of episodic migraine. Over the course of six months, those who received the treatment experienced one or two fewer monthly migraine days, on average, compared with a placebo.

The second study included 577 patients with a history of episodic migraine. Over the course of three months, those who received Aimovig treatment experienced one fewer migraine day per month.

The third study evaluated 667 patients with a history of chronic migraine. Over the course of three months, patients treated with Aimovig experienced, on average, 2½ fewer monthly migraine days than those receiving a placebo.

"It may not get rid of all of them, but it really dramatically improves the frequency, severity and duration of the migraine attacks," Tepper said of the new treatment.

Patients "still will need to take something when they get a migraine attack, but this is the first designer medication to prevent migraine rather than treat as needed," he said.

In the clinical studies, the most common adverse side effects were pain at the injection site and constipation. The drug can be injected in the thigh, the abdomen or the outer area of the upper arm.

"The field is excited about a new drug that is specifically targeted for migraine mechanisms," said Dr. Teshamae Monteith, assistant professor of clinical neurology at the University of Miami and a member of the American Academy of Neurology, who was not involved in the development of the drug.

"Not only does the data show that it's effective for people who have what we call episodic migraine, but it's also effective for people who have chronic migraine," Monteith said.

"If you can imagine, a patient with chronic migraine has at least 15 days -- half the month -- with some type of headache, and eight days out of that month, it's what you would call a moderate to severe headache with associated symptoms, such as light sensitivity, sound sensitivity, some cognitive dysfunction, [gastrointestinal] symptoms and sometimes visual and motor symptoms," she said. "Patients can have fatigue, concentration impairment, neck stiffness and sometimes mood changes as well."

By Friday, Monteith was already receiving requests for prescriptions and questions about Aimovig from her patients, including Helene Good, who uses injections of Botox to treat her migraines.

'It's really exciting'
"I first heard about it when it showed up on my phone this morning as an article in my news, and I just happened to be on my way to see Dr. Monteith for my treatment today," Good said Friday.

"I read it to my spouse on the way over, and it's really exciting," said Good, a 63-year-old Miami resident who has had migraines since she was in her late teens.

"It's not like just having a bad headache. For me, it manifests in other ways," she said. "One side of my face droops, which sort of looks like I've had a mini stroke. I'm a pretty fast speaker, but my speech gets very slow."

When it comes to migraine treatment options, "you're always hoping and looking for hope," she said.
Treatment options for migraine sufferers typically depend on the frequency and severity of the migraine attacks. Patients who have episodic migraine usually rely on pain medications to treat the migraine pain. To avoid episodes, some patients may stay away from triggers, such as certain foods, lack of sleep or stress.

Before Aimovig, "the FDA-approved preventive medications for episodic migraine were only four. Two of them are beta blockers, anti-blood pressure medicines, and two of them are anti-epilepsy drugs," Tepper said.

"There was one FDA-approved treatment for chronic migraine, which was Botox," he said. For patients, "with our current preventive medicines, they have to take oral medicine every day, with the exception of Botox, which is given in 31 injections every 12 weeks."

Yet a problem with many of those other treatment options is that some are traditionally used for other disorders and have side effects, Monteith said.

"Not only are some of the drugs not effective for every patient, but then there's this issue with tolerability," she said. "Some of these drugs are not well-tolerated. In the right person, it's great, but certainly we need some other option."

Additionally, there are medical devices such as a FDA-approved nerve-stimulating "tiara" called Cefaly, another nerve-stimulating device called gammaCore and even an approach called transcranial magnetic stimulation. Some patients have turned to acupuncture for migraine therapy.

"As a headache specialist, there are a number of treatments that are available for our patients preventively for migraine, but many of them are associated with a lot of different side effects, and we've been waiting for the day when we can have a medication that specifically targets migraine and prevents it in this unique modality and is associated with few side effects," said Dr. Thomas Berk, headache neurologist at NYU Langone Health, who was not involved in the development of the new treatment.

"I've had a number of requests already from patients asking, is it possible to get it to them quickly? What are the ways of getting it, and the big question being, is my insurance going to cover it, which is a question that we don't really know particularly yet," he said. "Everyone's excited about it."

(Source: CNN)