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From banning hugs to gentle parenting, how are you supposed to raise kids, anyway?

News Feed
Wednesday, May 17, 2023

Cristina Spanò for Vox The endless cycling — and recycling — of parenting advice. Part of the issue Everything old is new again from The Highlight, Vox’s home for ambitious stories that explain our world. On a recent Monday, my son didn’t want to go to school. The straps of his bicycle helmet were too loose, or possibly too tight, and because he is 4, this was a catastrophe that simply could not be borne. He informed me, through tears, that he would not be leaving the house, and neither would I nor his baby brother, who was already strapped to my chest and ready for day care. Then he lay down on his bed with his shoes on and refused to move. As a millennial parent in 2023 with a phone and a medium Instagram addiction, I had a lot of advice at my fingertips for handling such a situation. “Authoritative” parenting, a calm but firm style characterized by clear boundary-setting, would probably dictate that I explain to my child, without raising my voice, that his behavior was not okay and we needed to go to school (I tried this). Advocates of “gentle” parenting, a more recent trend that discourages rewards and time-outs in favor of trying to understand the feelings behind a child’s behavior, might suggest I ask my son why he didn’t want to go to school (I tried this, too). Some of the homesteading, homeschooling influencers I see on my feeds might suggest that I pull the kid out of pre-k entirely and go live in the woods (I won’t say I didn’t think about it). I probably could have tried some tricks from devotees of free-range parenting, French parenting, or tiger parenting, schools of thought Jessica Grose of the New York Times mentions in a recent rundown, but I was getting pretty exhausted. The fact that none of my tactics worked and I was still fruitlessly begging, bribing, and ordering my son out of bed half an hour past school drop-off time illustrates an age-old truth about parenting: It is hard, confusing work, and we are often eager for people to tell us how in the world to do it. To parents, it can seem like a new child-rearing trend pops up every few years, complete with new buzzwords and new ways to screw up. Each parenting philosophy presents itself as the definitive way to raise happy, well-adjusted, hard-working kids. The advice we get, however, is often both more and less than we bargained for. The effect can be dizzying — are we doing gentle parenting now or what? Indeed, child-rearing advice tends to be cyclical and reactionary, with each trend reversing what came before. Making sense of the conflicting and overlapping ideologies of parenthood is, to some degree, about tuning out the noise and tuning in to your individual family; as Mia Smith-Bynum, a professor of family science at the University of Maryland College Park, put it, “listen to your child and adapt accordingly.” It’s also, on a broader level, about understanding the history of parenting advice, one that’s steeped in racism, classism, and a kind of toxic individualism that seeks to blame everything on Mom rather than finding systemic solutions for the problems that plague families. [Parenting] is hard, confusing work, and we are often eager for people to tell us how in the world to do it Pushing back on this kind of blaming and shaming requires us to understand parenting less as a series of individual success and failures, and more as something we do as part of a community. It requires us “to really value the logistical, intellectual, and emotional labor of caregiving,” said historian Jodi Vandenberg-Daves. Parents have always gotten advice from one another and from their elders. It’s “just part of the human experience,” said Vandenberg-Daves, a professor at the University of Wisconsin La Crosse and the author of Modern Motherhood: An American History. But at least in the US, larger cultural trends in advice for mothers, specifically, began to come to the fore in the 1830s and 1840s, with the rise of women’s magazines that promulgated “the idea of the moral mother, the pure and pious woman who operates from her sphere of influence, which is the domestic sphere.” This represented a shift in attention toward mothers and away from fathers, who had previously been seen as “the moral leaders of the family and especially as the disciplinarians,” Vandenberg-Daves said. The mid-19th century also brought the new idea of children as innocent and better suited to the “gentle, soft influence” that mothers could provide. The idea of the mother at home, softly tending to the children, was always “full of assumptions about race and class, as well as gender,” Vandenberg-Daves said. In the 1830s, for example, millions of Black women in America were enslaved, many of them forced to care for the children of white families rather than their own. While the norms of parenthood in general and motherhood in particular would shift in the decades that followed, the commentators dishing out parenting advice would continue, explicitly or implicitly, to hold up a white, middle- or upper-middle-class family arrangement as the ideal. Adhering to this ideal wasn’t just an individual responsibility — indeed, good parenting has long been sold as both a moral and social imperative. “Every Christian family ought to be as it were a little church, consecrated to Christ, and wholly influenced and governed by his rules,” the Puritan preacher Jonathan Edwards once said in a sermon. “And family education and order are some of the chief means of grace.” Though child-rearing ideology lost some of its explicitly religious character with time, the idea that bringing up children correctly was part of a greater or higher good continued to hold sway — and may help explain why Americans, expert or not, have long felt entitled to comment on one another’s families. After all, American babies, children, and even pregnant people are often treated as a kind of communal property, even if their well-being is not a communal responsibility. Outside commentary on families and children became more formal in the late 19th and early 20th centuries, as child-rearing advice became more professionalized, with a crop of mostly male doctors and psychiatrists putting themselves forth as experts, said Paula Fass, a professor of history emerita at UC Berkeley and the author of The End of American Childhood: A History of Parenting from Life on the Frontier to the Managed Child. Pediatrics was emerging as a medical specialty, and science was replacing religion as the main influence on parenting ideals, Vandenberg-Daves said. By the 1920s, American families got “an explosion of parenting advice,” Fass said, much of it sending the message that “mothers don’t know what they’re doing, and that they need to turn their children over to the advice of those who do.” American babies, children, and even pregnant people are often treated as a kind of communal property, even if their well-being is not a communal responsibility Such allegedly knowledgeable people included John B. Watson, father of the psychological discipline of behaviorism, which held essentially that humans were no more or less than a collection of responses to conditioning — or, as Fass put it, “you are what you are trained to do.” In 1928, Watson published Psychological Care of Infant and Child, which became the most influential parenting book of its time. Watson was “very skeptical about mothers’ and women’s roles” and wanted to replace women’s supposedly “tender emotions” with a sterner approach, Fass said — he instructed parents not to hug or kiss their children. Watson was also responsible for the notorious “Little Albert” experiment, in which he and colleague Rosalie Rayner trained a baby to fear a white rat, and later furry things in general, by playing loud noises at him. In addition to discouraging hugs, the parenting experts of the early 20th century spent a lot of time telling immigrant parents to make their children more American. Advice included “do not give them the foods of your home country,” said Bethany L. Johnson, a doctoral student in history at the University of South Carolina and co-author of the book You’re Doing it Wrong! Mothering, Media and Medical Expertise. American doctors of the period warned that a non-American diet would make children sick, and advocated bland staples like cornflakes, milk, and stewed pears. Child welfare programs of the period dispensed advice for families in poverty about how to keep their homes clean, sterilize bottles for safe infant feeding, and make sure their children got sunlight and fresh air. The organizers of these programs rarely acknowledged that poor parents might not have the money, space, or time to keep a spotless home or guarantee their children ample outdoor playtime. Instead, the idea was “if you just tried harder, you would be like these middle-class people who have clean children,” Johnson said. The tide began to shift again in 1946, with the publication of Benjamin Spock’s bestselling book Baby and Child Care. Dr. Spock, as he became known, “wanted to bring back confidence in American mothers,” Fass said. His famous maxim was, “Trust yourself. You know more than you think you do.” Spock’s advice was less judgmental than the finger-wagging of Watson and the behaviorists, but it was also “based on this idea of essential maternal instincts that all women have,” said Vandenberg-Daves. “There are a lot of gendered assumptions in Dr. Spock.” Despite (or perhaps in part because of) these assumptions, Spock reigned supreme for decades — Baby and Child Care has sold more than 50 million copies, and is now in its 10th edition. In fact, there has arguably yet to be a central figure in American parenting discourse to unseat him. But what has come to the fore since about the 1980s, scholars argue, is a more generalized movement often called intensive parenting, based on the idea that, as Vandenberg-Daves put it, “to be a really good parent you have to be extremely involved.” A constellation of factors, from an increase in women entering the workforce to a media-fueled panic over kidnappings to deepening income inequality and financial insecurity among the middle class, likely led to the rise of intensive parenting. Whatever the cause, the result was that parents, especially moms, were asked to put a new level of time and energy into child-rearing, even above the norms of the supposedly family-obsessed 1950s. Indeed, working moms in the 2010s spent as much time with their kids as stay-at-home moms in the 1970s, and across income groups, parents are spending more of their money on their kids than they did in 1980. Vandenberg-Daves has tracked the shift using Mama Bear from the Berenstain Bears books — the bonnet-headed matriarch starts out her career relaxing in the treehouse, but by the 1990s she’s chasing her cubs with sunblock at the beach, trying to get them to watch less TV, and “lying awake at night worrying about her children while Papa Bear lies there,” Vandenberg-Daves said. “She is doing intensive parenting.” But what kind of intensive parenting? Today, in 2023, there are many ways of doing the most. Attachment parenting, which rose to prominence in the 1980s, emphasizes bed-sharing, babywearing, and breastfeeding on demand as ways of establishing a secure attachment between a parent (almost always the mother) and child, which adherents say will help that child grow up into a confident and emotionally healthy adult. The philosophy has inspired a backlash, with critics arguing that its emphasis on the nursing parent’s constant physical availability to a child is emotionally taxing, guilt-inducing, and often incompatible with work and adult relationships. Still, Instagram and TikTok are full of parenting coaches and enthusiastic amateurs ready to tell you that if you don’t nurse your baby in response to every cry, you are a monster. A more recent trend is “positive” parenting, sometimes called “gentle,” “conscious,” or “respectful” parenting. Popularized by experts like Janet Lansbury and Becky Kennedy, the approach discourages time-honored tactics like the sticker chart and the time-out in favor of trying to suss out the feelings behind children’s behavior and helping them regulate those feelings. As Jessica Winter writes in the New Yorker, “Instead of issuing commands (‘Put on your shoes!’), the parent strives to understand why a child is acting out in the first place (‘What’s up, honey? You don’t want to put your shoes on?’) or, perhaps, narrates the problem (‘You’re playing with your trains because putting on shoes doesn’t feel good’).” Much like the parenting philosophies of the past, gentle parenting requires a set of resources that simply aren’t available in every home. In America today, “we do not have guaranteed paid parental leave, we do not have a universal pre-K, and then we’re in a period of inflation,” said Smith-Bynum, the family science professor. “If you take any parent, and you put that kind of constant economic pressure on that family, you’re just going to have less patience.” Also, “you’re going to have less time.” Still, as with attachment parenting, there are plenty of passionate devotees of the gentle/positive/conscious ethos out there making shouty TikToks about how raising kids any other way will doom them to a life of psychological problems. All this is extra confusing because a number of other parenting styles also have their own, opposing camps — no matter what you’re doing, you can certainly find someone to tell you you’re doing it wrong. “What we have today is a mishmash,” Fass says. “There’s just a lot of continuing and contradictory advice.” Part of cutting through those contradictions is simply understanding how little is truly new when it comes to childrearing ideology. Parenting advice tends to evolve less through innovation than through reaction, as Katie Pickert pointed out in her viral Time cover story on attachment parenting back in 2012. Spock was reacting to the harshness of Watson; positive parenting is, to an extent, reacting against a strand of baby boomer helicopter parenting that some millennials argue resulted in a generation of anxious people-pleasers. Parenting TikTok is rife with references to “cycle-breaking,” or interrupting the generational cycle of trauma by raising your children differently than you were raised. It is, of course, possible to avoid repeating a previous generation’s mistakes, and we’ve certainly learned some lessons as a culture since the days of the “Little Albert” experiment. There is now broad consensus among experts, for instance, that corporal punishment is abusive and results in worse behavior in children over time. Still, the problems of the past are all too evident in a lot of parenting advice today. Parenting advice tends to evolve less through innovation than through reaction For example, 21st-century experts do tend to acknowledge that fathers exist — revised editions of The Baby Book, the 1992 “attachment-parenting bible” written by William Sears, include sections on “attachment fathering.” But mothers still do a disproportionate amount of child care in American families; mothers were the ones most affected by the daunting new parenting challenges of the pandemic; most of the people listening to Becky Kennedy and poring over parenting books at night are moms. “Fathers are being addressed in child-rearing advice” today, Fass says. “But it’s still mothers who are being made crazy.” Mainstream parenting texts have also become somewhat more inclusive of queer families over time — the 2004 edition of Spock’s Baby and Child Care included advice for gay parents. But images and anecdotes of cisgender, heterosexual couples still dominate American parenting discourse. In the 2021 memoir The Natural Mother of the Child, Krys Malcolm Belc writes about the legal and social hoops he’s forced to jump through as a transmasculine parent who has given birth — when one of his kids “asks when we can meet other families like ours,” he writes, “I say, honestly, that I do not know.” Indeed, despite some gestures toward gender, racial, and class equity, today’s culture of parenting advice is not so different from the 19th-century tips about keeping a clean house. Then, as now, child-rearing philosophy centered on the idea that “we can fix the problems that ail children and families through maternal education,” Vandenberg-Daves said. If we just tell women the right things to do, they’ll raise healthy, well-adjusted children — no outside support required. “We have a very privatized model of parenting and the family,” Vandenberg-Daves said, “and an assumption that mothers will take so much upon themselves.” This kind of thinking can result in advice that’s at best unhelpful, and at worst stigmatizing. Recommendations to limit kids’ access to screens, for example, assume that parents have the time and resources to entertain their families in screen-free ways. “It’s all very well and good to say, when you’re in the car together, listen to stories or talk to each other,” Johnson said. “But if you don’t have access to your own car, you have to take three buses to get your kids to day care so you can go to work, there might be a reason that you’re making different choices about your parenting.” The American hyperfocus on individual maternal behavior can be actively dangerous for families — Black moms, for example, have been literally policed for their parenting choices, to the point of having their children taken away if they let them play without constant supervision. Short of that, there’s the constant fear of social media shaming, like what a mom experienced in 2016 when she was photographed looking at her phone in an airport while her baby lay on a blanket nearby. American mothers in 2023 are “being surveilled by others at all times,” said Margaret M. Quinlan, a professor of communication at the University of North Carolina Charlotte and co-author of You’re Doing It Wrong. None of this is to say that parenting advice today is entirely toxic or useless. Indeed, the basic tenets of “gentle” parenting have been practiced by many families for generations, and not only in affluent homes, Smith-Bynum said. When people say they didn’t have a lot of money growing up, but “we had a lot of love,” she explained, “that’s gentle parenting.” Taking what works from child-rearing wisdom past and present, then, is about understanding that while kids have some needs in common, every family situation is unique. “Kids need to feel loved,” Smith-Bynum said. “They need to feel valued and respected. They need clear guidance and direction. And you as the parent need to adapt to the demands on the ground.” That can mean ignoring certain maxims if they don’t work for you or your kid. “My children have different personalities,” Johnson said. Some responses “that feel really good and really respectful to my daughter,” like making eye contact during a tantrum, just make her other child upset. “If you’re trying to do something, and it’s not working in your family, go ahead and give yourself the freedom to just not do it,” she said. Parents (and non-parents) need to extend the same grace to other families, Johnson said. “If you find something that resonates with you and works on your family, go for it. But don’t assume that’s going to work for anyone else.” On a broader social level, navigating the chaos and stigma of parenting advice is also about recognizing that child-rearing shouldn’t be an individual task that moms (always: moms) succeed or fail at, but something people do in concert with others, both in their families and in the wider world. Vandenberg-Daves calls for a return to “community-building around the work of caregiving and advocacy around the work of caregiving,” which can look like parents’ groups, advocacy groups devoted to issues like gun violence or environmental justice, or using “public schools as spaces to bring families together.” Child care as a collective act is already common in many communities. “Black folks have a long tradition of caregiving that goes back many generations, particularly when caring for what we might call play kin or fictive kin,” Smith-Bynum said. “I myself have several play-nephews and nieces.” For people who don’t have support close at hand, or who may be marginalized in their geographical area, such as parents of trans kids, social media can be a powerful tool. Families “can find a space online that may help build community that they may not have in their immediate physical environment,” Vandenberg-Daves said. I wish I could say that when my son refused to go to school, I called on my neighbors or friends for help, or that I reached out to one of the many authors and journalists of my generation who are writing wisely about caregiving and who I’ve come to think of as a kind of intellectual community. The truth is that, eventually, I pulled the book Everyone Poops off the shelf and read it to my screaming kid. This allowed him to think about poop, which is all he ever wants, and it improved his mood enough that he agreed to leave the house. Parenting is difficult and confusing; it’s also ridiculous, silly, and absurd. We are all doing what we can with what we have. These truths have not changed in decades, maybe centuries. They are something to hold on to, even as everything else shifts.

Row of parents holding babies with speech bubbles above their heads. They are all offering the same advice to new parents.
Cristina Spanò for Vox

The endless cycling — and recycling — of parenting advice.

Part of the issue Everything old is new again from The Highlight, Vox’s home for ambitious stories that explain our world.

On a recent Monday, my son didn’t want to go to school.

The straps of his bicycle helmet were too loose, or possibly too tight, and because he is 4, this was a catastrophe that simply could not be borne. He informed me, through tears, that he would not be leaving the house, and neither would I nor his baby brother, who was already strapped to my chest and ready for day care. Then he lay down on his bed with his shoes on and refused to move.

As a millennial parent in 2023 with a phone and a medium Instagram addiction, I had a lot of advice at my fingertips for handling such a situation. “Authoritative” parenting, a calm but firm style characterized by clear boundary-setting, would probably dictate that I explain to my child, without raising my voice, that his behavior was not okay and we needed to go to school (I tried this). Advocates of “gentle” parenting, a more recent trend that discourages rewards and time-outs in favor of trying to understand the feelings behind a child’s behavior, might suggest I ask my son why he didn’t want to go to school (I tried this, too). Some of the homesteading, homeschooling influencers I see on my feeds might suggest that I pull the kid out of pre-k entirely and go live in the woods (I won’t say I didn’t think about it). I probably could have tried some tricks from devotees of free-range parenting, French parenting, or tiger parenting, schools of thought Jessica Grose of the New York Times mentions in a recent rundown, but I was getting pretty exhausted.

The fact that none of my tactics worked and I was still fruitlessly begging, bribing, and ordering my son out of bed half an hour past school drop-off time illustrates an age-old truth about parenting: It is hard, confusing work, and we are often eager for people to tell us how in the world to do it.

To parents, it can seem like a new child-rearing trend pops up every few years, complete with new buzzwords and new ways to screw up. Each parenting philosophy presents itself as the definitive way to raise happy, well-adjusted, hard-working kids. The advice we get, however, is often both more and less than we bargained for. The effect can be dizzying — are we doing gentle parenting now or what? Indeed, child-rearing advice tends to be cyclical and reactionary, with each trend reversing what came before.

Making sense of the conflicting and overlapping ideologies of parenthood is, to some degree, about tuning out the noise and tuning in to your individual family; as Mia Smith-Bynum, a professor of family science at the University of Maryland College Park, put it, “listen to your child and adapt accordingly.” It’s also, on a broader level, about understanding the history of parenting advice, one that’s steeped in racism, classism, and a kind of toxic individualism that seeks to blame everything on Mom rather than finding systemic solutions for the problems that plague families.

Pushing back on this kind of blaming and shaming requires us to understand parenting less as a series of individual success and failures, and more as something we do as part of a community. It requires us “to really value the logistical, intellectual, and emotional labor of caregiving,” said historian Jodi Vandenberg-Daves.

Parents have always gotten advice from one another and from their elders. It’s “just part of the human experience,” said Vandenberg-Daves, a professor at the University of Wisconsin La Crosse and the author of Modern Motherhood: An American History. But at least in the US, larger cultural trends in advice for mothers, specifically, began to come to the fore in the 1830s and 1840s, with the rise of women’s magazines that promulgated “the idea of the moral mother, the pure and pious woman who operates from her sphere of influence, which is the domestic sphere.”

This represented a shift in attention toward mothers and away from fathers, who had previously been seen as “the moral leaders of the family and especially as the disciplinarians,” Vandenberg-Daves said. The mid-19th century also brought the new idea of children as innocent and better suited to the “gentle, soft influence” that mothers could provide.

The idea of the mother at home, softly tending to the children, was always “full of assumptions about race and class, as well as gender,” Vandenberg-Daves said. In the 1830s, for example, millions of Black women in America were enslaved, many of them forced to care for the children of white families rather than their own. While the norms of parenthood in general and motherhood in particular would shift in the decades that followed, the commentators dishing out parenting advice would continue, explicitly or implicitly, to hold up a white, middle- or upper-middle-class family arrangement as the ideal.

Adhering to this ideal wasn’t just an individual responsibility — indeed, good parenting has long been sold as both a moral and social imperative. “Every Christian family ought to be as it were a little church, consecrated to Christ, and wholly influenced and governed by his rules,” the Puritan preacher Jonathan Edwards once said in a sermon. “And family education and order are some of the chief means of grace.” Though child-rearing ideology lost some of its explicitly religious character with time, the idea that bringing up children correctly was part of a greater or higher good continued to hold sway — and may help explain why Americans, expert or not, have long felt entitled to comment on one another’s families. After all, American babies, children, and even pregnant people are often treated as a kind of communal property, even if their well-being is not a communal responsibility.

Outside commentary on families and children became more formal in the late 19th and early 20th centuries, as child-rearing advice became more professionalized, with a crop of mostly male doctors and psychiatrists putting themselves forth as experts, said Paula Fass, a professor of history emerita at UC Berkeley and the author of The End of American Childhood: A History of Parenting from Life on the Frontier to the Managed Child. Pediatrics was emerging as a medical specialty, and science was replacing religion as the main influence on parenting ideals, Vandenberg-Daves said. By the 1920s, American families got “an explosion of parenting advice,” Fass said, much of it sending the message that “mothers don’t know what they’re doing, and that they need to turn their children over to the advice of those who do.”

Such allegedly knowledgeable people included John B. Watson, father of the psychological discipline of behaviorism, which held essentially that humans were no more or less than a collection of responses to conditioning — or, as Fass put it, “you are what you are trained to do.” In 1928, Watson published Psychological Care of Infant and Child, which became the most influential parenting book of its time. Watson was “very skeptical about mothers’ and women’s roles” and wanted to replace women’s supposedly “tender emotions” with a sterner approach, Fass said — he instructed parents not to hug or kiss their children. Watson was also responsible for the notorious “Little Albert” experiment, in which he and colleague Rosalie Rayner trained a baby to fear a white rat, and later furry things in general, by playing loud noises at him.

In addition to discouraging hugs, the parenting experts of the early 20th century spent a lot of time telling immigrant parents to make their children more American. Advice included “do not give them the foods of your home country,” said Bethany L. Johnson, a doctoral student in history at the University of South Carolina and co-author of the book You’re Doing it Wrong! Mothering, Media and Medical Expertise. American doctors of the period warned that a non-American diet would make children sick, and advocated bland staples like cornflakes, milk, and stewed pears.

Child welfare programs of the period dispensed advice for families in poverty about how to keep their homes clean, sterilize bottles for safe infant feeding, and make sure their children got sunlight and fresh air. The organizers of these programs rarely acknowledged that poor parents might not have the money, space, or time to keep a spotless home or guarantee their children ample outdoor playtime. Instead, the idea was “if you just tried harder, you would be like these middle-class people who have clean children,” Johnson said.

The tide began to shift again in 1946, with the publication of Benjamin Spock’s bestselling book Baby and Child Care. Dr. Spock, as he became known, “wanted to bring back confidence in American mothers,” Fass said. His famous maxim was, “Trust yourself. You know more than you think you do.”

Spock’s advice was less judgmental than the finger-wagging of Watson and the behaviorists, but it was also “based on this idea of essential maternal instincts that all women have,” said Vandenberg-Daves. “There are a lot of gendered assumptions in Dr. Spock.”

Despite (or perhaps in part because of) these assumptions, Spock reigned supreme for decades — Baby and Child Care has sold more than 50 million copies, and is now in its 10th edition. In fact, there has arguably yet to be a central figure in American parenting discourse to unseat him. But what has come to the fore since about the 1980s, scholars argue, is a more generalized movement often called intensive parenting, based on the idea that, as Vandenberg-Daves put it, “to be a really good parent you have to be extremely involved.”

A constellation of factors, from an increase in women entering the workforce to a media-fueled panic over kidnappings to deepening income inequality and financial insecurity among the middle class, likely led to the rise of intensive parenting. Whatever the cause, the result was that parents, especially moms, were asked to put a new level of time and energy into child-rearing, even above the norms of the supposedly family-obsessed 1950s. Indeed, working moms in the 2010s spent as much time with their kids as stay-at-home moms in the 1970s, and across income groups, parents are spending more of their money on their kids than they did in 1980.

Vandenberg-Daves has tracked the shift using Mama Bear from the Berenstain Bears books — the bonnet-headed matriarch starts out her career relaxing in the treehouse, but by the 1990s she’s chasing her cubs with sunblock at the beach, trying to get them to watch less TV, and “lying awake at night worrying about her children while Papa Bear lies there,” Vandenberg-Daves said. “She is doing intensive parenting.”

But what kind of intensive parenting? Today, in 2023, there are many ways of doing the most. Attachment parenting, which rose to prominence in the 1980s, emphasizes bed-sharing, babywearing, and breastfeeding on demand as ways of establishing a secure attachment between a parent (almost always the mother) and child, which adherents say will help that child grow up into a confident and emotionally healthy adult. The philosophy has inspired a backlash, with critics arguing that its emphasis on the nursing parent’s constant physical availability to a child is emotionally taxing, guilt-inducing, and often incompatible with work and adult relationships. Still, Instagram and TikTok are full of parenting coaches and enthusiastic amateurs ready to tell you that if you don’t nurse your baby in response to every cry, you are a monster.

A more recent trend is “positive” parenting, sometimes called “gentle,” “conscious,” or “respectful” parenting. Popularized by experts like Janet Lansbury and Becky Kennedy, the approach discourages time-honored tactics like the sticker chart and the time-out in favor of trying to suss out the feelings behind children’s behavior and helping them regulate those feelings. As Jessica Winter writes in the New Yorker, “Instead of issuing commands (‘Put on your shoes!’), the parent strives to understand why a child is acting out in the first place (‘What’s up, honey? You don’t want to put your shoes on?’) or, perhaps, narrates the problem (‘You’re playing with your trains because putting on shoes doesn’t feel good’).”

Much like the parenting philosophies of the past, gentle parenting requires a set of resources that simply aren’t available in every home. In America today, “we do not have guaranteed paid parental leave, we do not have a universal pre-K, and then we’re in a period of inflation,” said Smith-Bynum, the family science professor. “If you take any parent, and you put that kind of constant economic pressure on that family, you’re just going to have less patience.” Also, “you’re going to have less time.”

Still, as with attachment parenting, there are plenty of passionate devotees of the gentle/positive/conscious ethos out there making shouty TikToks about how raising kids any other way will doom them to a life of psychological problems. All this is extra confusing because a number of other parenting styles also have their own, opposing camps — no matter what you’re doing, you can certainly find someone to tell you you’re doing it wrong.

“What we have today is a mishmash,” Fass says. “There’s just a lot of continuing and contradictory advice.”

Part of cutting through those contradictions is simply understanding how little is truly new when it comes to childrearing ideology. Parenting advice tends to evolve less through innovation than through reaction, as Katie Pickert pointed out in her viral Time cover story on attachment parenting back in 2012. Spock was reacting to the harshness of Watson; positive parenting is, to an extent, reacting against a strand of baby boomer helicopter parenting that some millennials argue resulted in a generation of anxious people-pleasers. Parenting TikTok is rife with references to “cycle-breaking,” or interrupting the generational cycle of trauma by raising your children differently than you were raised.

It is, of course, possible to avoid repeating a previous generation’s mistakes, and we’ve certainly learned some lessons as a culture since the days of the “Little Albert” experiment. There is now broad consensus among experts, for instance, that corporal punishment is abusive and results in worse behavior in children over time. Still, the problems of the past are all too evident in a lot of parenting advice today.

For example, 21st-century experts do tend to acknowledge that fathers exist — revised editions of The Baby Book, the 1992 “attachment-parenting bible” written by William Sears, include sections on “attachment fathering.” But mothers still do a disproportionate amount of child care in American families; mothers were the ones most affected by the daunting new parenting challenges of the pandemic; most of the people listening to Becky Kennedy and poring over parenting books at night are moms. “Fathers are being addressed in child-rearing advice” today, Fass says. “But it’s still mothers who are being made crazy.”

Mainstream parenting texts have also become somewhat more inclusive of queer families over time — the 2004 edition of Spock’s Baby and Child Care included advice for gay parents. But images and anecdotes of cisgender, heterosexual couples still dominate American parenting discourse. In the 2021 memoir The Natural Mother of the Child, Krys Malcolm Belc writes about the legal and social hoops he’s forced to jump through as a transmasculine parent who has given birth — when one of his kids “asks when we can meet other families like ours,” he writes, “I say, honestly, that I do not know.”

Indeed, despite some gestures toward gender, racial, and class equity, today’s culture of parenting advice is not so different from the 19th-century tips about keeping a clean house. Then, as now, child-rearing philosophy centered on the idea that “we can fix the problems that ail children and families through maternal education,” Vandenberg-Daves said. If we just tell women the right things to do, they’ll raise healthy, well-adjusted children — no outside support required. “We have a very privatized model of parenting and the family,” Vandenberg-Daves said, “and an assumption that mothers will take so much upon themselves.”

This kind of thinking can result in advice that’s at best unhelpful, and at worst stigmatizing. Recommendations to limit kids’ access to screens, for example, assume that parents have the time and resources to entertain their families in screen-free ways. “It’s all very well and good to say, when you’re in the car together, listen to stories or talk to each other,” Johnson said. “But if you don’t have access to your own car, you have to take three buses to get your kids to day care so you can go to work, there might be a reason that you’re making different choices about your parenting.”

The American hyperfocus on individual maternal behavior can be actively dangerous for families — Black moms, for example, have been literally policed for their parenting choices, to the point of having their children taken away if they let them play without constant supervision. Short of that, there’s the constant fear of social media shaming, like what a mom experienced in 2016 when she was photographed looking at her phone in an airport while her baby lay on a blanket nearby. American mothers in 2023 are “being surveilled by others at all times,” said Margaret M. Quinlan, a professor of communication at the University of North Carolina Charlotte and co-author of You’re Doing It Wrong.

None of this is to say that parenting advice today is entirely toxic or useless. Indeed, the basic tenets of “gentle” parenting have been practiced by many families for generations, and not only in affluent homes, Smith-Bynum said. When people say they didn’t have a lot of money growing up, but “we had a lot of love,” she explained, “that’s gentle parenting.”

Taking what works from child-rearing wisdom past and present, then, is about understanding that while kids have some needs in common, every family situation is unique. “Kids need to feel loved,” Smith-Bynum said. “They need to feel valued and respected. They need clear guidance and direction. And you as the parent need to adapt to the demands on the ground.”

That can mean ignoring certain maxims if they don’t work for you or your kid. “My children have different personalities,” Johnson said. Some responses “that feel really good and really respectful to my daughter,” like making eye contact during a tantrum, just make her other child upset. “If you’re trying to do something, and it’s not working in your family, go ahead and give yourself the freedom to just not do it,” she said.

Parents (and non-parents) need to extend the same grace to other families, Johnson said. “If you find something that resonates with you and works on your family, go for it. But don’t assume that’s going to work for anyone else.”

On a broader social level, navigating the chaos and stigma of parenting advice is also about recognizing that child-rearing shouldn’t be an individual task that moms (always: moms) succeed or fail at, but something people do in concert with others, both in their families and in the wider world. Vandenberg-Daves calls for a return to “community-building around the work of caregiving and advocacy around the work of caregiving,” which can look like parents’ groups, advocacy groups devoted to issues like gun violence or environmental justice, or using “public schools as spaces to bring families together.” Child care as a collective act is already common in many communities. “Black folks have a long tradition of caregiving that goes back many generations, particularly when caring for what we might call play kin or fictive kin,” Smith-Bynum said. “I myself have several play-nephews and nieces.”

For people who don’t have support close at hand, or who may be marginalized in their geographical area, such as parents of trans kids, social media can be a powerful tool. Families “can find a space online that may help build community that they may not have in their immediate physical environment,” Vandenberg-Daves said.

I wish I could say that when my son refused to go to school, I called on my neighbors or friends for help, or that I reached out to one of the many authors and journalists of my generation who are writing wisely about caregiving and who I’ve come to think of as a kind of intellectual community. The truth is that, eventually, I pulled the book Everyone Poops off the shelf and read it to my screaming kid. This allowed him to think about poop, which is all he ever wants, and it improved his mood enough that he agreed to leave the house.

Parenting is difficult and confusing; it’s also ridiculous, silly, and absurd. We are all doing what we can with what we have. These truths have not changed in decades, maybe centuries. They are something to hold on to, even as everything else shifts.

Read the full story here.
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Scientists Have Identified the Best Region To Spot UFOs

Most observations of Unidentified Anomalous Phenomena typically happen in the American West, where the closeness to public lands, dark skies, and military bases provides increased...

A study has analyzed UAP sightings across the U.S., revealing that environmental factors and proximity to air traffic and military installations significantly influence sighting reports. This research aids in distinguishing between identifiable objects and true anomalies, emphasizing the importance of contextual understanding in addressing national security concerns and public curiosity about UAPs.Most observations of Unidentified Anomalous Phenomena typically happen in the American West, where the closeness to public lands, dark skies, and military bases provides increased chances of witnessing unusual objects in the sky.“This [Tic Tac-shaped object that] had just traveled 60 miles in…less than a minute, was far superior in performance to my brand-new F/A-18F and did not operate with any of the known aerodynamic principles that we expect for objects that fly in our atmosphere.”In July of 2023, a retired commander in the U.S. Navy David Fravor testified to the House Oversight Committee about a mysterious, Tic Tac-shaped object that he and three others observed over the Pacific Ocean in 2004. The congressional hearings riveted the world by bringing Unidentified Anomalous Phenomena (UAP) out of the “alien truther” realm and into the mainstream. As sensor technology has advanced and personal aircraft-use has skyrocketed, our ability to explain strange events has become harder to resolve. The U.S. Department of Defense has increasingly taken UAP, formerly known as Unidentified Flying Objects (UFOs), as a serious threat to national security.A new study led by University of Utah geographers attempts to understand if local environmental factors increase or decrease the number of sighting reports. The authors used data from the National UFO Research Center, and included approximately 98,000 total sighting reports over a 20-year period, from 2001 to 2020. For each county in the contiguous U.S., the researchers analyzed two conditions: Sky view potential, which refers to the area’s light pollution, cloud cover, and tree canopy cover; and the potential for objects to be present in the sky, meaning the proximity to airports and military installations.VIDEOIn July of 2023, retired commander in the U.S. Navy David Fravor testified to the House Oversight Committee about a mysterious, Tic Tac-shaped object that he and three others observed over the Pacific Ocean in 2004, off the coast of San Diego. According to his testimony, the object traveled 60 miles per hour in less than a minute and “did not operate with any of the known aerodynamic principles that we expect for objects that fly in our atmosphere.” His crew captured the Tic Tac-shaped Unidentified Anomalous Phenomena (UAP) on video. This is one of three videos that the U.S. military declassified and approved for public release in April of 2020. It’s the only official footage captured by a U.S. Navy F/A-18 Super Hornet that was present at the “2004 Nimitz Incident,” named for the USS Nimitz aircraft carriers on which Fravor’s U.S. Navy fighter jet was based. Credit: United States NavyThe majority of sightings were in western parts of the U.S. due to the region’s physical geography—lots of wide-open spaces and dark skies. UAP-reporting hotspots had credible relationships with air traffic and military activity, suggesting that people are spotting real objects, but not recognizing what they are.“The idea is that if you have a chance to see something, then it’s more likely that you’re going to see unexplained phenomena in the sky,” said Richard Medina, associate professor of geography at the University of Utah and lead author of the study. “There’s more technology in the sky than ever before so the question is: What are people actually seeing? It’s a tough question to answer, and it is an important one because any uncertainty can be a potential threat to national security.”Understanding the environmental context of these sightings will make it easier to find explanations for their occurrence and help identify truly anomalous objects that are a legitimate threat.The paper was recently published in the journal Scientific Reports.Hot spots and cold spotsThe authors looked at the number of sightings per 10,000 people per county and identified significant clusters of low numbers of reports (cold spots) and high numbers of reports (hot spots). There were far more sightings reported in the West and in the very Northeast, along some isolated areas. The cold spots were in the central plains and the Southeast. All results except for cloud cover supported the general hypothesis that people will see things when there’s an opportunity.“The West has a historical relationship to UAP—Area 51 in Nevada, Roswell in New Mexico, and here in Utah we have Skinwalker Ranch in the Uinta Basin and military activity in the U.S. Army Dugway Proving Ground,” said Medina. “Plus, there’s a robust outdoor community that recreates in public lands year-round. People are out and looking skyward.”Hotspot analysis of reported sightings from 2001 to 2020. Credit: Medina, Brewer & Kirkpatrick. Sci Rep (2023)Traditional academia has mostly avoided UAP research because of the stigma of flying saucers and space invaders. Yet people around the world continue to spot unexplainable objects in the sky. What little research exists tends to rely on firsthand accounts or look for cultural and psychological explanations, which limits the ability to analyze patterns over a large area.Additionally, legitimate data sources and questionable accounts have limited rigorous study. The authors note that the National UFO Research Center’s data is a public, self-reporting system with no real way to verify hoaxes. However, the authors assert that if the data were entirely invalid due to some psychological and sociological cause, then there would be no spatial pattern. But there is.“There are many factors that can contribute to the report of anomalous objects,” said Simon Brewer, associate professor of geography at the U and co-author of the study. “By examining the spatial distribution of reports and how they relate to the local environment, we hope to provide some geographical context that may help resolve or understand reports by both the public and in military settings.”Timeline of the National UFO Research Center reported sightings from 2001 to 2020. Credit: Medina, Brewer & Kirkpatrick. Sci Rep (2023)Roswell, X-Files, and StarlinkIn July of 2022 the U.S. Deputy Secretary of Defense, in coordination with the Director of National Intelligence, directed the establishment of the All-domain Anomaly Resolution Office (AARO) as the single authoritative UAP office to lead and synchronize a whole government approach to the issue. Earlier UAP tracking efforts include Project BLUE BOOK, a U.S. Air Force-led project that investigated UFO sightings between 1947 and 1969. Project BLUE BOOK’s most famous report is the Roswell, New Mexico, incident alleging that a flying saucer crashed in the desert town on July 8, 1947, and its alien occupants were recovered by government officials. Many Roswell residents witnessed the unexplainable event, which may have led to the flurry of flying-saucer-sightings that swept the nation. Silence from government officials led to wild speculation of otherworldly visitors and subsequent coverups. Later, the U.S. Air Force disclosed that the incident was caused by a classified, multi-balloon project to detect Soviet nuclear tests.Many UAP sightings have a natural explanation—the planet Venus is a regular culprit, for example. The last few years have seen a boost in UAP reports, likely related to the exponential growth in spacecraft launches and orbiters, such as the Starlink satellite-train blazing across the night sky and the ubiquity of personal drones. The challenge is to parse which reports signal a real threat.The authors are exploring whether there are temporal considerations for fluctuations in sightings, based on socio-cultural triggers. For example, were there more reports after the congressional hearings in July of 2023 or after a Space X launch? They’re also investigating whether sociocultural factors influence UAP sightings—is there a spike in reports after a show like “X-Files” gets popular? Are some cultures more likely to see UAPs because of their beliefs?“The U.S. government—the military, intelligence, and civil agencies—needs to understand what is in the operating domains to ensure the safety and security of the nation and its people,” said Sean Kirkpatrick, first director of the AARO, adjunct assistant professor of physics at the University of Georgia and co-author of the study. “Unknowns are unacceptable in this age of ubiquitous sensors and data availability. The scientific community has a responsibility to investigate and educate.”Reference: “An environmental analysis of public UAP sightings and sky view potential” by R. M. Medina, S. C. Brewer and S. M. Kirkpatrick, 14 December 2023, Scientific Reports.DOI: 10.1038/s41598-023-49527-x

When treating transgender youth, how informed is informed consent?

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In the debate over transgender medicine for youths, two radically opposing views take up most of the airtime. People who support the currently dominant gender-affirming model of care for children see kind practitioners trying to do their best for vulnerable patients who often have severe mental health issues due to living in a transphobic society.Those who oppose this model see overconfident practitioners experimenting on these same vulnerable patients, many of whom might not be capable of giving truly informed consent for treatments such as puberty blockers, cross-sex hormones and surgeries, which can have lifelong consequences.Both views will find vindication in a new report from the think tank Environmental Progress, which contains a leaked cache of internal discussions from within WPATH, the World Professional Association for Transgender Health, a group that brings together clinicians from various specialties involved in treating gender-dysphoric patients. These discussions reveal both caring people trying hard to do things right and a medical culture that appears to be operating without adequate guardrails against things going wrong.One exchange is at once the most reassuring and the most worrying for those who are trying to sort out the competing narratives: In a workshop discussing transition and the challenge of obtaining minors’ informed consent for gender-affirming procedures, participants come across as deeply thoughtful folks doing their best to grapple with complexities. But some also seem to acknowledge that their patients cannot actually give fully informed consent. Many haven’t completed puberty — or high school biology. And even the brightest 16-year-old cannot yet understand the full implications of treatments that can mean, in some cases, a lifetime of infertility and medical maintenance.This is not a novel problem in medicine. As therapist Dianne Berg points out in that discussion, if children have diabetes, they are given insulin even if they haven’t learned how the pancreas works. If they have depression, they might be given drugs that could increase their risk of suicide or permanently alter their developing brains to help them toward happier futures. And if a kid has a pediatric cancer, doctors don’t wait for her to be old enough to give fully informed consent to amputation or infertility — because without treatment, she might never reach that age.Youth gender medicine is increasingly treating puberty as though it were a life-threatening condition like cancer or diabetes, and natal sex organs as though they were potentially dangerous growths. This is, of course, entirely appropriate if they are threatening, and letting nature take its course will end in suicide or a lifetime of emotional agony. Of course, with that kind of diagnosis you want to be very sure — and unlike doctors treating cancer or diabetes, who can rely on blood tests and imaging, gender-medicine doctors ultimately have only the patient’s feelings to go by.In the popular discourse, and apparently at some gender clinics, it’s often taken for granted that that’s enough — that we know transgender medical interventions are saving lives, because trans people are at higher risk for suicide. And for adults, who are entitled to decide what to do with their bodies, it is. Yet for children, it’s more complicated, because this risk, while real, does not approach the magnitude of cancer or diabetes, and might persist even after treatment. In a large-scale Dutch study, trans patients were found to have almost four times the suicide risk of the general population. The researchers saw 49 suicides among more than 8,000 patients, many of which occurred during or after transition. A nationwide study of suicide rates among trans people in Denmark similarly found 12 suicides in a population of 3,759.It would be ideal if doctors could drive that rate to zero — perhaps by identifying future trans adults, blocking their puberty and eventually treating them with hormones and possibly surgery so that their adult appearance would more closely resemble their gender identity. Unfortunately, though, we don’t yet know to what extent these treatments actually improve mental health or prevent suicide. The data on their long-term efficacy is more limited than it should be, even for adults. The evidence regarding youth interventions is even less clear.Several European health authorities have reviewed the available studies and rated the evidence for using puberty blockers and cross-sex hormones in dysphoric youth as “very low certainty,” “deficient” and “limited by methodological weaknesses.” A recent systematic evidence review by German researchers concludes that the current body of evidence is “based on very few studies with small samples and problematic methodology and quality. Adequate and meaningful long-term studies are equally lacking.”In other words, though WPATH says these interventions are “not experimental,” youth gender medicine is still, well, effectively experimental. Now, this is true, as well, of many pediatric oncology treatments, because when a child’s life is in danger, doctors pull out all the stops. About 60 percent of juvenile cancer patients are enrolled in a clinical trial, according to CureSearch, a funder of children’s cancer research. But gender medicine does not yet approach the same level of rigor as an FDA-supervised clinical trial.This puts clinicians in a difficult position, and this is what we see in the WPATH files: well-intentioned doctors and therapists groping through the considerable gaps in current medical knowledge. Yet one can also see this work being made more difficult because, as an editorial in the journal Acta Paediatrica recently put it: “The discourse surrounding the use of puberty blockers in gender dysphoria is often framed as a political human rights issue rather than as a medical issue.”In a discussion of detransitioning, one writer calls the whole idea “problematic” because “it frames being cisgender as the default, and reinforces transness as a pathology.” (As though it were inherently bigoted for someone to prefer, where possible, the option that doesn’t require drugs or surgery.) Others rather blithely suggest we should reframe detransition as “learning” or part of a “gender journey” rather than a “mistake.”Many other conversations in the WPATH files, of course, portray sensitive, intelligent caregivers doing their best — beset by many uncertainties, yet ultimately in little doubt that they’re doing the right thing for most of their patients. I’m glad such people are trying to help some of our vulnerable people alleviate terrible distress. But I also came away wishing they seemed willing to entertain a few more doubts.

Storyteller Ed Edmo brings Native traditions to life at Celilo Falls and other cultural sites

Edmo, Shoshone-Bannock, grew up listening to his father’s stories. “At the time, I didn’t realize it wasn’t just stories,” he says. “It was my dad giving me my culture night by night.”

This story originally appeared on Underscore.newsMany who grew up in the Pacific Northwest recognize Ed Edmo by his expressive hands and face as he tells stories, breathing life into characters like Nasho, a monster woman, and cultural tricksters like the Coyote and Spider Woman. He changes his voice, making it high for the women’s parts and low for the men’s. Sometimes he incorporates puppets or asks the audience to help him, urging them to repeat after him.Ed Edmo, Shoshone-Bannock, is a traditional storyteller, poet, playwright, published author, actor, performer, instructor and tour guide who lectures on cultural issues at cultural sites in the Pacific Northwest, such as the flooding of Celilo Falls, as well as drug and alcohol abuse and mental health for Native peoples. He has also served as a consultant to the Smithsonian Museum of the American Indian in Washington D.C.He tells a story of a monster with “long hair, claws for fingers, snaggly teeth, snot down to here, and bad breath,” asking the audience to repeat those descriptions with him every time he mentions the monster, utilizing hand motions and facial expressions to fully immerse his audience in the story. As his hands wave through the air, the light catches on his silver and turquoise rings—one on almost every finger. Edmo says this is an audience favorite.“Stories were told to teach children how to act,” shares Edmo. “…how to treat their elders, how to interact with nature and the world.”Once Edmo is on a roll, it’s hard for him to stop. He loses time, as does the audience, immersed in the moment. He tells story after story, as long as the audience is engaged. His stories explain how things work or why they are the way they are. He brings the stories and legends of his culture alive. It feels like you’re a part of the story. You can smell the wood burning, feel the bee sting, taste the salmon eyeball soup, and smell the meat cooking because of the way he tells it. He uses props like a cane and puppets of a bear, goose, coyote and eagle to help illustrate his stories.Edmo grew up listening to his father’s stories. He remembers the crackling fire and his mom, grandmother, and aunties quilting around it as they sat and listened.“At the time, I didn’t realize it wasn’t just stories,” Edmo said, stroking his salt-and-pepper braids. “It was my dad giving me my culture night by night.”‍Native resiliencyWith a birth story like Edmo’s, it’s no wonder he grew to become the traditional storyteller he is today. When Edmo was born on the Duck Valley Indian Reservation in Nevada in 1947, he was so small and weak, the delivery doctor gave him five minutes to live. Seventy-six years later, he is not only alive, but thriving. While still small in stature, Edmo’s gravitas and impact on contemporary Native culture in the Pacific Northwest is anything but.Edmo is a living testament to Native resiliency. Shortly after he was born, his family moved back to his father’s ancestral home at Celilo Village near The Dalles along the Columbia River. His paternal family’s homelands are in the Columbia Gorge. The Celilo Wy-am people are best known for what is currently known as Celilo Falls, where the river once flew down a torrential drop of over 20 feet between bluffs on the shorelines made from basalt. These were the ancestral fishing grounds for the Celilo Wy-am people, where they speared salmon while standing on rocks surrounding the falls. Later, they created platforms across the rocks from which they caught fish in nets.When Edmo was just a young boy, The Dalles Dam flooded Celilo Falls. Before the flooding, the falls provided everything that the Celilo Wy-am people needed: from salmon, sturgeon, smelt, and eel to traditional roots and berries along the riverbanks. After the falls were flooded, their land base went from over 108 acres to what is now just over seven acres.While eating lunch at one of his favorite local cafes, Ed Edmo shares a photo taken of him as a young man (center) singing in the drum circle while occupying the Portland Area Bureau of Indian Affairs office on Nov. 11, 1973. Also pictured, Al Smith (right) and Bear Cub (back right).Ed Edmo/Underscore News/Report for AmericaEd Edmo’s hands are adorned with jewelry, many are repurposed silver spoon handles that he now wears as rings.Ed Edmo/Underscore News/Report for AmericaTo keep that history alive, Edmo teaches students and community groups in the Pacific Northwest about Celilo Falls and the Celilo Wy-am people. During one of his presentations, Edmo shared slides on Celilo Falls.“I couldn’t believe how something so big and beautiful could disappear,” he said.Edmo was raised by both his parents and attended elementary school at Petersburg School in The Dalles, which was a one-room schoolhouse.“I didn’t realize it was so small,” Edmo said. “When I was so little, it seemed big!”He graduated from Wishram High School, where he first started getting involved in performance art as a drama student. In 1974, Edmo met his wife, Carol, in Portland. He said they heard about each other through various friends and relatives. They got married in 1976.Edmo is now in recovery from alcohol and lives a clean and sober life. He goes to Alcoholics Anonymous meetings to stay sober.“I’m following the path,” he shares.Grandfather StorytellerIn addition to storytelling, Edmo is a renowned poet and writer. In 1974, he received a grant from the Potlatch Fund for his poem “These Few Words of Mine.” At the time, he was attending Portland Community College.“I write about contemporary moments in time for contemporary Indians,” said Edmo. “…poems about drinking coffee and raking leaves, about my parents when I was a kid.”Poems with titles like, “Grandfather Storyteller,” and, “Burnside Cowboy.” Edmo’s most famous poem is “Indian Education Blues.” He wrote it in 1968 in Bend, Oregon. Now, it’s a part of the cultural exhibit “Poetry in Motion,” which features poetry on TriMet transit buses and light rail.He keeps a beaded pen on him, calling it his “weapon.” He explains that, as a writer, the inspiration to write can hit at any time or any place. One time, he left his journal in the car when he stopped at a Dairy Queen. There was a family in the restaurant, and he was compelled to write a story about them based on their expressions and interactions with each other and the staff, creating a whole backstory from his imagination. He wrote it on a napkin.Sharing cultureEd Edmo, Shoshone-Bannock, is a traditional storyteller, poet, playwright, published author, actor, performer, instructor and tour guide who lectures on cultural issues at cultural sites in the Pacific Northwest.Ed Edmo/Underscore News/Report for AmericaHis writing and storytelling has recently been memorialized as part of a collection of murals of Portland icons, entitled “A Place Called Home” in the Portland International Airport. The mural of Edmo depicts him dressed in a blue button-down shirt with his iconic suspenders, traditional beadwork, and his long hair in two braids. Above his dapper black hat, Edmo holds one of his favorite storytelling props: a stuffed eagle.When the mural was first unveiled, Edmo attended and sang a song for the airport employees. Edmo has spent his life sharing his culture and supporting his community – in this, and many other ways. He currently serves on the board of Red Lodge Transition Services, a program for women reentering Clackamas County after prison. He teaches cultural classes at Coffee Creek Women’s Penitentiary, and storytelling classes at Gresham High School. He says he is also looking forward to performing at the Fisher Poets Gathering in Astoria at the end of February.He finds time to dance and run sweat lodges at various men’s prisons in the Pacific Northwest where he serves as a traditional dancer. He says he doesn’t believe in competition dancing, where dancers get paid for their performances.While he admits he used to charge people coins or candy for pictures of him in his regalia when he was younger, he says he believes in the tradition of dance as ceremony and to promote healing in the community.“At Celilo, we danced for the fun of it, not for competition,” he says.— Leah Altman, Oglala Lakota, is a Native American adoptee and was raised in the Portland area. She has written for local and national publications, including Portland Monthly, Oregon Humanities, Portland State University’s Metroscape magazine, Parents.com and Indian Country Today. For over a decade, Leah has also worked for Native and BIPOC-led environmental and community organizations, including the NAYA Family Center, Verde, Native Arts & Cultures Foundation, and the Intertribal Agriculture Council.

The Farm Bill Hall of Shame

The farm bill is one of the most important but least understood pieces of US legislation, and it’s overdue for renewal. But Congress couldn’t pass a new version in the fall, reflecting partisan dysfunction and also a contentious debate about what the bill ought to be—a debate that has become ensnared in the nation’s culture […]

The farm bill is one of the most important but least understood pieces of US legislation, and it’s overdue for renewal. But Congress couldn’t pass a new version in the fall, reflecting partisan dysfunction and also a contentious debate about what the bill ought to be—a debate that has become ensnared in the nation’s culture wars. Racial equity, food sovereignty, protections for workers, and meaningful action on climate change have broadened the bill’s traditional mandate of growing food and feeding hungry people. In this special series, a partnership with the Food and Environment Reporting Network, we’ll be exploring some of the urgent issues a new farm bill must address. Read the other stories in the series here. The farm bill is among the most important pieces of legislation that Congress is more or less obliged to pass. Yet to all but a handful of people whose job it is to parse its every incremental gain or loss, it is largely inscrutable. Every five years we’re treated to bitter fights over things like the use and abuse of agricultural subsidies; attempts to defund SNAP; the notion that environmental stewardship should guide farm policy as much as increasing production; and how (and sadly whether) to build equity into an agriculture system with a racist history.  But the backstories to these fights, some ill-fated and others shameful, can provide important context and help to clarify exactly what’s at stake. Over the last 90 years there have been several key farm bill moments, the consequences of which shape the debates ongoing today. The farm bill’s original sin  The story of the farm bill is one of Black land dispossession and persistent racial inequality in American agriculture. It was baked into the first farm bill, and it has never been made right. Faced with the twin crises of the Dust Bowl and the Great Depression, the Roosevelt administration was determined to help ailing farmers. But in the rush to pass the 1933 Agricultural Adjustment Act (AAA), the era’s most dramatic piece of farm legislation, FDR sided with Southern plantation owners, who wanted to raise crop prices, and farm income, by paying farmers to plant fewer acres.  This was disastrous for Black farmers. As Jonathan Coppess writes in The Fault Lines of Farm Policy, historians argue that the AAA was “designed and used intentionally to help southern cotton planters push poor black sharecroppers off the land and consolidate their holdings.” Only landowners could sign government contracts that paid farmers to plow up their fields, and the vast majority of Black farmers were tenants or sharecroppers. White landowners were supposed to share the payments they got with their renters and sharecroppers, but few did. Others purposefully signed crop subsidy contracts only when they didn’t have tenant or sharecropper agreements, to avoid sharing the wealth. “Whether the share-cropper received any payment or any credit allowance for the cotton plowed up on his patch depended upon the tender mercies of his landlord,” wrote Webster Powell and Addison T. Cutler in Harper’s in 1934. “We encountered a number of cases where the landlord arranged with the government to plow up all of the patch operated by an individual cropper and followed this up by closing the books with the cropper and sending him ‘down the road.’” All told, the largest farms maintained or even increased their harvests while farming less land, and farmers on rented land went out of business. Between 1930 and 1935, land owned by white farmers increased by 35 million acres while land owned by all other farmers decreased by more than 2 million acres. Over the next twenty years the number of Black farmers dropped 37 percent.  The AAA was just the beginning. Decades of racist policies followed, driving further dispossession, including discriminatory USDA lending and the denial of title and other property rights. Between 1910 and 1997, Black farmers lost 90 percent of their farmland. Today, Black farmers own less than 1 percent of total US farmland. This year, a group of Senate Democrats, led by Cory Booker of New Jersey, is pushing for the Justice for Black Farmers Act, first introduced in 2020, to be included in the next farm bill. The legislation’s aim is ambitious: “[E]nd discrimination within the USDA, protect remaining Black farmers from losing their land, [and] provide land grants to create a new generation of Black farmers.”  It would be fitting if the farm bill, once used to solidify racial inequality, becomes the vehicle to right that historical wrong. Related The “Machine That Eats Up Black Farmland” The birth of huge The number of American farms has dropped from 6.8 million in 1935 to 2 million today. The remaining farms have gotten a lot bigger, with the median operation managing 445 acres and the largest 11 percent producing 82 percent of all farm goods. Large farms deal with similarly massive agribusiness companies that control seeds, fertilizer, and other things farmers need. Together, this so-called “Big Ag” system dominates our food supply, prioritizing yields and efficiency over high-quality food, a healthy environment, and rural development.   How did this happen? The conventional wisdom blames Earl Butz, Richard Nixon’s Secretary of Agriculture, who reportedly urged farmers to “get big or get out” (though there is scant evidence that he actually said it). Regardless, most farm consolidation had already happened by the time Butz took the reins at the department of agriculture in 1971.  Some of the consolidation was made possible by technological advancements that exploded yields in the post-war era, like rural electrification and better seed breeding. But the farm bill, and ag policy broadly, also favored large farms over smaller ones.  Even before the New Deal, agricultural officials envisioned a system of large, mechanized farms—the kinds of operations that needed fewer people to do the work. So when the federal money started flowing in the 1930s, most of it went to the big players who used it to invest in tractors and other technology that allowed them to get even bigger. For instance, FDR ended the 1931 “feed and seed” loans that many small farmers and tenants relied on in favor of federal lending programs with steep collateral requirements that small farmers couldn’t meet. As small cotton farmers told Harper’s in 1934, “The only thing they haven’t got a mortgage on is my wife and kids.” Even though Republicans and Democrats bemoaned the “farm problem,” or the rapid loss of farms that continued through the 1950s and into the 1970s, neither party summoned the political will to try more aggressive interventions that some states were experimenting with, like limiting corporate farmland ownership. And anti-communist Cold War sentiment shut down any consideration of collective farming or land redistribution. Late New Deal policy did aim to create a fair price floor for all farmers and discourage the overproduction that drove prices down. But policymakers never quite struck the right balance between preventing overproduction and ensuring that farms of all sizes were able to access federal support and stay afloat.  When Eisenhower and his agriculture secretary, Ezra Taft Benson, lowered New Deal price floors in 1954 and ended corn production controls in 1959, surpluses grew, prices fell, and larger farms were able to survive on those lower prices while smaller ones could not. The Kennedy administration made one last effort to support crop prices by limiting production, but wheat farmers killed it in the famous 1963 wheat referendum. The president of the American Farm Bureau Federation, the nation’s biggest agricultural lobbyist that had led the charge against the referendum, called the defeat “a major turning point in the continual battle…between those who believe in an agriculture producing for the competitive market and those who favor Government supply management.” So farm policy inched closer and closer to unfettered production for low market prices, and the “farm problem” got worse. The debate simmers on today. The clamor to do something about consolidation in the next farm bill includes a proposal for an “Office of Small Farms” that would “ensure that all USDA programs are designed to meet the needs of small farmers.”  Show me the money  The farm bill has always allowed big farms to take more than their fair share of federal subsidies and use the extra cash to outcompete smaller farms. This inequity has gotten worse since the 1970s, when the farm bill stopped trying to raise market prices as a way to help farmers and instead started making direct payments to them.  The problem is that direct payments don’t make it to the people who need them the most. Between 1995 and 2021, the top 10 percent of subsidy recipients—the largest and wealthiest farms—got more than 78 percent of commodity program payments, and the top 1 percent received a whopping 27 percent. To date, every effort to set a reasonable cap on subsidy payments for large farms has failed, stymied by the power of the ag lobby and its allies in Congress. Congress nearly passed subsidy limits in the 2014 farm bill cycle. Legislation included a $50,000 limit, stricter requirements that recipients be “actively engaged in farming” to prevent non-farmers from receiving payments, and a modest limit on crop insurance subsidies for the richest farms. Sen. Thad Cochran from Mississippi, the ranking GOP member of the Senate Agriculture Committee, who was facing a primary challenge, reportedly managed to nix the limit before the final bill was passed as part of an effort to shore up his support back home.    In May 2023, the Des Moines Register published an op-ed that called for a farm bill that ensured that subsidies go to “actual farmers instead of the current practice of sending endless subsidies to millionaires, billionaires, nonfarmers, and absentee owners who often live in big cities or even foreign countries.” It could have been written fifty years ago. Feeding the crop insurance beast In February 2023, the Government Accountability Office reiterated its longstanding plea for Congress to rein in the soaring costs of federal crop insurance, which have more than quadrupled since 2005. Since 1938 the federal government has subsidized insurance for farmers to protect against losses from things like poor harvests, a drop in market prices, and extreme weather. But until the 1990s, crop insurance subsidies were a marginal part of the farm safety net; today they’re the second most expensive program in the farm bill (after SNAP). The GAO didn’t say it, but it’s reasonable to ask: Why, as the impact of climate change is impossible to ignore, are taxpayers paying farmers billions to grow thirsty and other failure-prone crops, such as cotton and alfalfa, in the desert Southwest. And why are private insurance companies raking in taxpayer money to cover them? Here’s why. In 1996, Sen. Pat Roberts’ “Freedom to Farm” bill turned most crop subsidies into fixed payments, unrelated to market prices. It also increased federal subsidies for private crop insurance, so that if farmers wanted extra income guarantees they could pay to insure their profit margin or their crops. When crop prices collapsed one year into the Freedom to Farm plan, the new fixed payments proved paltry, driving more farmers to buy crop insurance and demand ad hoc emergency government payouts—which they got, to the tune of $30 billion between 1998 and 2002. After shelling out for emergency payments, Congress doubled down on pushing farmers to buy crop insurance and gave them even more money to cover premiums. At the end of 1994, there were 90 million acres covered by crop insurance; today nearly 500 million acres are covered. Taxpayers pay roughly 60 percent of farmers’ insurance premiums, even as plans become more expensive due to rising crop failures due to climate change. This system has one big winner: private crop insurance companies. GOP leadership—including Pat Roberts—snuck a provision into the 2014 farm bill that prevents the government from ever spending less money to subsidize crop insurance. The law effectively locks in high profits for insurers.  And how about those cotton growers in the desert? Since 2001, heat linked to climate change has driven $1.33 billion in insurance payouts to farmers across the Southwest for crops that failed amid high temperatures. And that number is only going to grow. Risky, environmentally sensitive, and less-productive farmland can get the same crop insurance subsidy as highly productive land, even though it’s more likely to underperform and require an insurance payout. With these incentives, farmers converted into crop land millions of acres of less-productive, drought-prone grasslands and sensitive wetlands that likely would not have been farmed. An analysis by the Environmental Working Group estimates that over 23 million acres of grassland, shrub land, and wetlands were turned into crop land between 2008 and 2011.  What climate crisis? Beyond the perennial call for deep cuts to SNAP, one of the biggest obstacles to a new farm bill this year is an effort by House Republicans to hijack $20 billion of funds from Biden’s big climate bill, the Inflation Reduction Act, earmarked for agriculture climate-mitigation projects and use them to fatten crop subsidies.  You may think that this is a singular bit of crazy generated by the chaos that engulfed the House GOP last fall. But in fact it is merely the latest in the ongoing degradation, via the farm bill, of farmers’ ability to mitigate the climate crisis. Farm bill conservation policy is split into “land retirement” programs, like the Conservation Reserve Program, which pay farmers to take erosion-prone or environmentally sensitive land out of production, and “working lands” programs, such as the Environmental Quality Incentives Program (EQIP) and the Conservation Stewardship Program (CSP), which pay farmers to adopt more sustainable practices.   In the run-up to the 2014 farm bill, the conservation programs came under fire as Tea Party Republicans refused to increase the debt ceiling and demanded significant spending cuts. In the face of this pressure, a small group of congressional leaders struck a deal, sometimes called the “Secret Farm Bill,” which agreed to $23 billion in farm program cuts over ten years. When the 2014 law finally emerged, conservation spending had been cut by $6 billion, or nearly 10 percent over ten years.  These changes sent US agriculture backward at a time when farms needed and wanted support to conserve biodiversity and reduce air and water pollution. An analysis by the Environmental Working Group, for instance, found that between 2017 and 2020, only 23 percent of EQIP funds supported practices deemed “climate-smart” by USDA. And even without the cuts, EQIP and CSP do not prioritize practices that reduce greenhouse gas emissions. To make matters worse, every conservation program except CRP is subject to further cuts through the annual federal budget setting process. The year after the 2014 farm bill passed Congress gave all conservation programs (other than CRP) 7 percent less money than originally stipulated. All told, the National Sustainable Agriculture Coalition estimates that these budgeting processes will have cut another $2 billion in conservation spending between 2014 and 2024. So even if Democrats manage to hang on to the billions earmarked for conservation in the Inflation Reduction Act, it will just barely make up for cuts made a decade ago. Such is the perverse reality of the farm bill. 

The hidden racial bias in U.S. lung cancer screening policy

A 2019 study found that screening eligibility rules disproportionately excluded Black smokers. Little has changed

About five years ago, Vanderbilt University epidemiologist Melinda Aldrich discovered something about the U.S. cancer care system that has eaten at her ever since. Aldrich had been studying the public health benefits of preventive lung cancer screening, widely seen as a critical first line of defense against a disease that kills more than 120,000 Americans a year — more than the combined total for breast, colon, and prostate cancers. Lung cancer is extraordinarily difficult to treat in its advanced stages, and the earlier it is detected, the better a person’s odds for survival, many experts say. But hospitals and insurers impose strict criteria for deciding who can receive preventive lung cancer screening, and when. At the time of Aldrich’s discovery, a person had to be between 55 and 80 years old and have smoked the equivalent of 30 pack-years — a pack a day for 30 years, say, or two packs a day for 15 — to be screened with the standard method for early detection, called low-dose spiral computed tomography. Aldrich’s analysis of more than 84,000 adult smokers revealed that under those criteria, Black patients at relatively high risk of lung cancer were being disproportionately excluded from the screening eligibility pool. More than two-thirds of Black smokers who were diagnosed with lung cancer did not meet the age and smoking history criteria at the time of their diagnosis. “These people are getting diagnosed with lung cancer, and yet they can't even get in the door to be screened,” Aldrich later recalled. Aldrich knew that Black Americans tended to develop lung cancer at higher rates and at younger ages than their White counterparts, despite on average smoking fewer cigarettes. And by her calculations, high-risk Black smokers were being excluded from screening at more than one and a half times the rate of White smokers. As Aldrich saw it, the screening inequity had the potential to worsen the already staggering toll that lung cancer exacts in Black communities. According to the American Lung Association, the disease claimed the lives of more than 14,000 Black Americans in 2021, the most recent year for which there was data. Black lung cancer patients were 15 percent less likely than White patients to be diagnosed early, and had the lowest five-year survival rate of any racial group. Based on their findings, Aldrich and her collaborators recommended lowering the age threshold to 50 and the smoking history requirement to 20 pack-years for Black smokers, to make rates of screening eligibility more equitable. Putting race at the center of cancer screening was in some ways a radical proposal, and Aldrich was prepared for pushback from her peers. But at the 2018 World Conference on Lung Cancer, where she first presented the findings, the response from the audience was very positive. Aldrich and her colleagues realized the work was going to be taken seriously. “These people are getting diagnosed with lung cancer, and yet they can’t even get in the door to be screened.”  Two years after the Vanderbilt study was published, the nation’s standard bearer for preventive health policy — an independent panel of experts known as the U.S. Preventive Services Task Force — revised its lung cancer screening guidelines, citing their work as a factor alongside other studies, including a large study called the Nelson trial. But rather than lower the age and pack-year requirements specifically for Black smokers, as Aldrich and her colleagues had advised, the task force loosened those criteria for all smokers, regardless of race. The new guidelines caught a larger share of Black smokers but also larger shares of White smokers and smokers of other backgrounds. As a result, it narrowed, but did not close, the racial screening gap that Aldrich and company had identified. The task force’s decision has thrust it into the center of a simmering debate about the best way to address the factors underlying racial health disparities in lung cancer and other diseases. And it has led some experts to call for a more complete overhaul of screening policy that accounts not just for race but for genetics, environment, occupation, and other risk factors in screening decisions. “Lung cancer [screening] is not going to be a one size fits all solution,” said Aldrich, who advocates for more personalized approaches to assessing risk. That those approaches have yet to gain traction in health policy circles, however, underscores a seemingly inescapable truth of the American health care system: With public health interventions like preventative screening, it’s nearly impossible to disentangle scientific findings from the politics and social forces that drive them.   Aldrich’s interest in racial disparities in lung cancer goes back two decades, to her days as a Ph.D. student at the University of California, Berkeley. There, she studied the genetic factors that influence lung cancer risk, and how those factors vary between Black American and Hispanic populations. When she arrived at Vanderbilt in 2010, she began deepening her understanding of the fraught topic, probing genetics, social determinants of health, and environmental risk factors. For the better part of Aldrich’s career, there were no official national standards for screening asymptomatic patients for lung cancer — not even for heavy smokers, who are known to be at elevated risk. In part, that was because the most common tool for examining a patient’s lungs, the chest X-ray, wasn’t very good at identifying small tumors. In 2011, however, a study known as the National Lung Screening Trial, which followed more than 53,000 people aged 55 to 74 with a history of heavy smoking, showed that low-dose spiral computed tomography, or low-dose CT, could identify early-stage tumors while they were still treatable. Study participants screened with low-dose CT had a 20 percent lower risk of lung cancer death than those screened with standard chest X-rays. Two years later, citing that study, the U.S. Preventive Services Task Force issued its first-ever lung cancer screening guidelines: Anyone 55 or older with at least a 30 pack-year smoking history should be screened annually with low-dose CT. The recommendation, like all of the task force’s guidelines, was the product of a complex calculus that weighed the benefits of early detection against potential harms like overdiagnosis, unnecessary tests, and invasive follow-up procedures. And coming from the U.S. Preventive Services Task Force, perhaps the most authoritative voice in preventive care and evidence-based medicine, the recommendation carried substantial weight. The task force’s 16 volunteer members, appointed by the secretary of the U.S. Department of Health and Human Services, draw on peer-reviewed evidence, as well as expert and public opinions to arrive at health care policy recommendations. When the task force sets screening guidelines, leading medical associations, insurance companies, and primary care physicians often adopt those guidelines as their own. After the task force released its lung cancer screening criteria, professional organizations such as the American Academy of Family Physicians and the American College of Chest Physicians soon issued guidelines that were essentially identical. But there were reasons, even then, to believe that lung cancer screening guidelines based strictly on age and smoking history might disproportionately exclude Black patients from receiving potentially life-saving care. It would not take long for that policy pitfall to come to light.   It is well documented that Black smokers tend to develop lung cancer younger and more often than White smokers, despite generally smoking less: A 2006 study published in the New England Journal of Medicine found that Black smokers with a habit of up to 20 cigarettes a day were around twice as likely as White smokers to develop lung cancer; a 2015 analysis found that Black Americans were diagnosed at younger ages for nearly every cancer type, including lung, prostate, breast, and brain cancer; and an analysis of data from the National Lung Screening Trial showed that African Americans were twice as likely as White Americans to die of lung cancer, and were generally younger at the time of diagnosis. Although the reasons for these disparities are unclear, the 2006 New England Journal of Medicine study suggested that they can’t be explained by racial differences in socioeconomic status alone. Whatever the cause of the lung cancer disparity, Black smokers’ heightened risks likely weren’t reflected in the U.S. Preventive Services Task Force’s 2013 screening recommendations. That’s because Black patients were vastly underrepresented in the National Lung Screening Trial, the study that formed the basis of the guidelines. Only 4 percent of the trial’s participants were Black, though Black people made up roughly 14 percent of the U.S. population around the time the study was conducted. If lung cancer screening guidelines were failing Black smokers, it may have been because the clinical trial system had failed them first. With public health interventions like preventative screening, it’s nearly impossible to disentangle scientific findings from the politics and social forces that drive them. Experts say this is a problem that extends beyond lung cancer. Breast cancer mortality rates, in particular, are high among Black women, who are twice as likely as White women to die of the disease before age 50. Yet for a decade, the task force recommended that women at average risk should start mammograms, the main screening tool for breast cancer, at 50, regardless of race, based largely on findings from clinical trials that lacked proportionate representation of Black women. (The task force recently updated its guidelines to recommend screening starting at 40 for women of all racial and ethnic backgrounds.) Similarly, Black men die of prostate cancer at twice the rate of White men, yet until recently, the task force advised against prostate cancer screening altogether. Overall, White people account for 60 percent of the U.S. population but more than 70 percent of clinical trial participants, according to a study published in the journal Therapeutic Innovation & Regulatory Science. This lopsidedness has dire consequences for public health, said Laurie Fenton Ambrose, president and CEO of the patient advocacy group GO2 for Lung Cancer. “We evolve clinical trials in a way that never captures real world implication.” The reasons for Black Americans’ underrepresentation in clinical trials are myriad and complicated. Experts point out that socioeconomic factors can render the basic logistics of trial participation — such as securing transportation and free time — difficult if not impossible for some people to manage. And Fenton Ambrose notes that around 80 percent of the general population is treated for diseases like cancer in hospitals in their local communities, not the major academic centers where most clinical trials for cancer are conducted. Those local facilities may not have the resources to offer clinical trial participation to patients, she says, and those patients might not even be able to access them if they knew they existed. The racial imbalances in clinical trials may be partially attributable to study design. Many trials exclude patients with high body-mass indices or chronic illnesses like high blood pressure, kidney disease, and asthma — all of which are more common among Black Americans. “There’s just so many of these barriers,” Fenton Ambrose said. "I don't think there's an intention to set parameters that exclude [people of color], it’s that the end result isn’t a sufficiently represented population.” But there’s also evidence that Black patients’ poor representation in clinical trials stems partly from racism and implicit bias. A 2020 study published in the journal Cancer found that some clinical trial recruiters withheld opportunities from racial and ethnic minorities because they viewed them as “less promising.” One asserted that African Americans have less knowledge than patients of other backgrounds, and required more time to understand the study instructions. Another said they felt African Americans were less likely to comply with the protocols and rules required by a trial. “Sometimes you'll hear researchers use the excuse that those are hard-to-reach populations,” said Carol Mangione, a primary care doctor and former chair of the U.S. Preventive Services Task Force in a 2021 interview. “I think those are hardly reached.” The gap in clinical trial participation has led to a chicken-egg problem: While there is statistical data that shows Black people get diagnosed with and tend to die at higher rates of certain cancers, there often is not sufficient clinical trial evidence to support race-specific screening recommendations. “We have to be much more purposeful about how we design studies so that it's easy for people to participate,” Mangione said. “We need the federal government to put out requests for clinical trials where you're only allowed to compete to do that research if you can guarantee that you're going to bring in a certain percentage of people of different groups.”   Five years after Melinda Aldrich arrived at Vanderbilt, she gained a collaborator who would be instrumental in helping her unearth the racial disparities stemming from the U.S. Preventive Services Task Force’s lung cancer screening guidelines. Kim Sandler joined the Vanderbilt faculty in 2016, fresh off a residency in radiology and fellowship in cardiothoracic imaging. She and Aldrich began working together, and among their first projects was to examine the relative impacts of the 2013 screening guidelines on patients of different racial backgrounds. That study called for a dataset that was much more representative of the Black population than the National Lung Screening Trial that had informed the 2013 guidelines. Aldrich and Sandler decided to use the Southern Community Cohort Study, funded by the National Cancer Institute, which follows approximately 85,000 people — mostly patients at community health centers throughout the southeast — recruited between 2002 and 2009. Of the roughly 48,000 participants in the study who reported a history of smoking, more than 32,000 were Black. Using statistical models, Aldrich and Sandler analyzed the data to see whether those patients were being screened at appropriate rates. The results were jaw-dropping. Their models suggested that only 17 percent of Black smokers met the task force’s age criteria and 30-pack-year smoking history requirement, compared with 31 percent of White smokers. Worse, during the 12-year period that they followed the cohort for the study, just 32 percent of Black smokers who were diagnosed with lung cancer met the screening eligibility at the time of their diagnosis, compared with 56 percent of White smokers. The data was compelling, but the remedy was hardly clear cut. “I actually remember having that discussion in the library of the Oxford House," Sandler recalls. "There was a group of us sitting around a table with all the data from tens of thousands of patients, but it was like, ‘how do we package this?’” she said. “It was that balance between what's best for the patients, what’s best for the population moving forward in the screening space, and what is most easily implementable.’” Ultimately, the researchers recommended lowering the smoking history criterion for African Americans to 20 pack-years, and the age requirement to 50 — steps their modeling indicated would result in more equitable screening outcomes. Aldrich and Sandler are not the only researchers to have proposed a race-conscious approach to cancer screening. A recent study published in JAMA Network Open considered racial differences in breast cancer rates and recommended that mammography screening start at age 42 for Black women, 51 for White women, 57 for American Indian or Alaska Native and Hispanic women, and 61 for Asian or Pacific Islanders. Last October in JAMA Oncology, a team led by Stanford researchers proposed that decisions to screen for lung cancer should be made using a risk-based model that takes race and ethnicity, among other factors, into account. But efforts to incorporate race into the cancer screening equation have faced pushback, in part on political and sociological grounds. Some critics worry that such medical prescriptions will only perpetuate the notion of race as biological instead of a social construct. Among them is Otis Brawley, a professor of oncology and epidemiology at Johns Hopkins University and former chief medical and scientific officer for the American Cancer Society. For more than three decades, Brawley’s stated mission has been “to close racial, economic, and social disparities in cancer prevention, detection, and treatment of cancer in the United States and worldwide.” Yet, he adamantly opposes making race a part of screening guidelines. For decades, Brawley says, medicine has attributed racial disparities in cancer outcomes to a myth that Black and White people — and the diseases that affect them — differ biologically. Quoting the Nobel Prize-winning scientist Harold Varmus, Brawley said that “if you want to divide the American population into more races than one, that’ fine, but in terms of biology, that’s like trying to slice soup.” Brawley also believes that focusing on race obscures the true driver of cancer disparities: quality of care. He notes that most Black cancer patients don’t have access to the MD Andersons and Memorial Sloan Ketterings of the world — hospitals where he says cancer outcomes are equal regardless of race. As he sees it, the examples set by those hospitals point to a very obvious solution to health disparities: “Equal treatment yields equal outcomes.” But what looks like disparity driven by biological differences is actually just a proxy for socioeconomic issues, he says, and Black patients often don’t have access to equitable treatment.   When the U.S. Preventive Services Task Force was reassessing its previous guidelines, it commissioned a modeling study that concluded that the suggested updates would confer more health benefits to more people compared to the existing guidelines. But that study’s modeling did not consider racial or ethnic disparities in lung cancer risk. In a statement emailed to Undark, Michael Barry, current chair of the task force, wrote that while the group always looks for evidence that would facilitate “specific recommendations for different racial and ethnic populations, especially those disproportionately burdened by a given disease or condition, that data often does not exist." Barry added that "when the Task Force considered whether it was possible to include race as a variable in the model it used for its lung cancer screening recommendation, it found that there was not sufficient underlying data. The evidence was simply not available to show how race — together with the other variables in the model — affects the way people’s health progresses over time due to both lung cancer and other medical conditions a person could develop.” For decades, Brawley says, medicine has attributed racial disparities in cancer outcomes to a myth that Black and White people — and the diseases that affect them — differ biologically. This does not mean it won’t be included in future models, as Barry acknowledged that research is constantly progressing and that new studies will be incorporated into future revisions of the screening guidelines. Barry added that, in terms of screening eligibility, dropping the pack-year threshold from 30 to 20 benefitted the Black high-risk population more than the corresponding non-Hispanic White population. Indeed, a 2022 study in JNCI Cancer Spectrum found that while the new recommendations did not eliminate the racial gap in screening eligibility, they narrowed it. According to that analysis, the new guidelines reduced a 16-percentage-point gap between the proportions of Black and White smokers with lung cancer who were eligible for screening at the time of their diagnosis to around 11 percentage points. (Under the new recommendations, Latino smokers, who had also been disproportionately excluded from lung cancer screening under the old guidelines, became the group most likely to be excluded from screening.) At the same time, some experts, like the authors of a 2023 JAMA Oncology study that found a persistent screening eligibility gap under the new guidelines, argued that new recommendations didn’t make screening access equitable. “Based on racially and ethnically diverse population-based cohort data, the 2021 USPSTF guidelines for lung cancer screening still induce racial and ethnic disparities,” the study authors wrote. In a Stanford Medicine press release, Summer Han, the study’s lead author, noted: “Our study shows that these changes to the guidelines are not sufficient to address race-based differences in lung cancer incidence and age at diagnosis.”   As some public health experts see it, stringent screening eligibility guidelines aren’t the biggest obstacle to closing lung cancer disparities. Kathy Levy, a former project manager for GO2 for Lung Cancer’s Alabama Lung Cancer Awareness, Screening, and Education project, known as ALCASE, said it matters little whether screening guidelines incorporate race because even eligible people face significant barriers to getting screened. Levy spent three years working to get more underserved people of color screened, diagnosed, and treated for lung cancer throughout Alabama’s Black Belt, a rural region home to large African American populations, and she remembers it as a slow process to get started.. There, she says, practically any cancer diagnosis comes with a social stigma. “We're rural and a cancer diagnosis is so secret,” said Levy. “They’ve just gotten to where they would start saying the word ‘cancer.’ They would call it ‘the Big C’.” Some Black people also feared getting a diagnosis because they viewed lung cancer as an automatic death sentence, she said, and didn’t want to know if they had it. “We had to do a lot of education, and a lot of hand holding, just showing the love and concern to these people that were out there in the neighborhood. You might have to talk with them six or seven times.” Nationally, just 5.8 percent of people who are eligible for lung cancer screening are actually screened; in some states, the number is only around 1 percent. According to the 2022 Lung Health Barometer from the American Lung Association, nearly 70 percent of people don’t even know that lung cancer screening exists. Black adults who are eligible for lung cancer screening are even less likely than people from other backgrounds to undergo the procedure, Levy said, due to distrust of the health care system and lack of access to care. According to Levy, the challenges don’t stop with the patients; many health care providers remain uninformed about proper lung cancer screening. She recalls sending patients for screening only to have their doctors pronounce them clear after listening to their lungs and ordering a chest X-ray, procedures that are known to be ill-equipped to detect early tumors. She later created a “Dear Doctor” letter that her patients could give to their physicians — a missive that explained the screening process and included a list of facilities that offered low-dose CT scans. The persistent frustrations notwithstanding, Levy believes her work has made a difference, particularly in her home county of Choctaw, where she is known as “the Cancer Lady” who pesters everybody about getting regular check-ups and screenings. Now, they call her asking if it’s time to get screened again, she said with a soft chuckle. Although Levy is doubtful that any screening policy change would fix the lung cancer woes that plague the Black Belt, she takes issue with the use of age restrictions on screening, a barrier that could disproportionately affect Black smokers. “I wish it was that we didn't have to worry about age on the screening because we have people that are actually younger now, [that are] getting cancer at such an early age,” she said. “Why do we have to put stipulations about an age on screening for our health?”   The debate over race-conscious screening guidelines is taking place against a backdrop of rapid changes in the treatment and scientific understanding of lung cancer. Experts acknowledge that cancer screening is imperfect , although many emphasize that they think it is worth any associated risks. For instance, early detection can skew screening statistics for topics such as five-year survival rate, even if it does nothing to extend a person’s life. One educational resource by the National Cancer Institute showed how a common metric, the five-year survival rate, can sometimes mislead: If a group of patients are diagnosed with cancer at 67 and then die of the disease at 70, they would effectively have a zero percent five-year survival rate. But if they are diagnosed early, at 60, and also die at 70, the group would have a 100 percent five-year survival rate — even though the early detection may not have helped them live any longer. The National Cancer Institute references this so-called “lead-time bias” as one of the causes of confusion and misunderstanding about screening efficacy. “Doctors frequently talk about survival rates,” says Brawley, the Johns Hopkins epidemiologist. He says he frequently tells his graduate students that if doctors are just talking about survival without talking about it in a randomized trial, "you have someone who doesn't know what the hell they're talking about.” Brawley points out that the interventions and follow-up tests that come after a positive screening result can themselves be risky. He calculated that the follow-up procedures for the group in the National Lung Screening Trial that got a low-dose CT scan killed one person for every 5.4 people the new screening method saved. Modeling work used by the U.S. Preventive Services Task Force in determining the new guidelines predicted less dire — but nonetheless significant — screening harms, including roughly one radiation-related death occurring due to annual screening for every 13 cancer deaths averted. The same model predicted around two false positives per person over a lifetime of screening, with some of those false positives resulting in follow-up biopsies. One study found that the mortality rate for patients who elect to have a surgical lung biopsy in hospitals is just under 2 percent, and almost 10 times higher than that for people who have it as a nonelective procedure. These sobering statistics reinforce the need to target screening at people at highest risk in order to reduce the number of false positives and risky follow-up procedures. The stigma of smoking leads many people to lie about or legitimately underestimate the extent of their smoking history, making it too crude an indicator of risk for some. Jennifer King, GO2’s former chief scientific officer and now the chief science officer at the International Association for the Study of Lung Cancer, would like to see clinical trials and screening recommendations consider additional risk factors, including genetic mutations known to be associated with heightened cancer risk, family history, and prior history of cancer. As she puts it, “Smoking history is not going to find everybody.” When King says “everybody,” she may be referring to people like Diane Juitt, a 59-year-old resident of Columbia, South Carolina who is among the 10 to 20 percent of American lung cancer patients who have never smoked or smoked fewer than 100 cigarettes in their lifetime. When Juitt developed an unshakeable, bone-rattling cough in the summer of 2021, she never imagined she might have lung cancer. She attributed her symptoms to the residual effects of a Covid-19 infection she’d battled earlier in the year. “It kept getting worse,” she recalls. The first time she saw a doctor, he gave her something for the cough and “it went away, but then it just came back.” Juitt, who was preparing for retirement from her job with the Army National Guard, decided to undergo a complete physical, which included a chest X-ray that revealed a spot on her lung. A follow-up low-dose CT scan led to a biopsy. By the time doctors at the Hollings Cancer Center at the Medical University of South Carolina in Charleston performed surgery, her cancer was at stage 3: The tumor had not invaded adjacent organs, but cancerous cells had spread to nearby lymph nodes in the chest. Doctors removed part of her lung and about 30 lymph nodes. Juitt is Black, but genetics may have been a more critical risk factor for her lung cancer. Subsequent tests revealed that she had a genetic mutation that increased her risk for the disease. Her two daughters were screened for the same mutation based on her experience.   The U.S. Preventive Services Task Force does not recommend lung cancer screening for people who have never smoked. It says that current evidence does not support adding other risk factors than smoking to the screening guidelines. But cases like Juitt’s exert pressure for the screening guidelines to evolve. The American Cancer Society recently updated its guidelines to eliminate the number of years since quitting smoking as an eligibility factor. Many researchers favor expanding the eligibility pool for lung cancer screening and considering a broader array of risk factors in screening decisions. Aldrich would like to see the guidelines take into account not only smoking history and race, but also other demographic factors and genetic sequencing. “Race is complicated,” she said. It’s difficult to disentangle it from social factors, diets, culture, genetic variants across populations. Fenton Ambrose, of GO2 for Lung Cancer, suggested that certain classes of workers, such as first responders and military servicemembers, should also be prioritized for screening. Lung cancer incidence and mortality rates are much higher for military personnel than the general population, due to occupational exposures to an assortment of toxins. Many researchers favor expanding the eligibility pool for lung cancer screening and considering a broader array of risk factors in screening decisions. While Barry, the U.S. Preventive Services Task Force chair, agrees that it's a good thing to look for additional risk factors and focus screening on people who would most benefit, he also warns that more complicated implementation procedures might push people away. "Our recommendation currently using just age and pack years is pretty straightforward," he said. In trying to fine tune those criteria, he added, "we want to be careful not to create an implementation barrier when we already know even with the simple criteria, that lung cancer screening is underutilized." Meanwhile, Aldrich’s collaborator, Sandler, believes that many screening eligibility guidelines are likely to change in the not-too-distant future. She points to ongoing studies that are evaluating the benefits of screening other high-risk populations. And she’s hopeful that new diagnostic tests will emerge to augment low-dose CT in the screening process. Researchers in the U.S. and Taiwan, for example, have developed a new AI tool that can detect predict future lung cancer risk within the next six years based off of a single low-dose CT scan; other tests can identify minute genetic markers circulating in the blood that signal residual or recurrent cancer. In terms of the future evolution of the task force screening guidelines, “my hope is that they will continue to address disparities in race and gender,” Sandler said, “and that we also continue to look at access.”   Melba Newsome is a freelance science, health, and environmental journalist in Charlotte, North Carolina. This reporting was supported in part by a grant from the National Institute for Health Care Management Foundation. This article was originally published on Undark. Read the original article. Read more about health inequities

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