“Ella empezó a combinar comidas que no van juntas, una hamburguesa con pescado en una olla. Mamá nunca cocinaba así”, dijo.

Madre e hija viven juntas en Yeadon, Pensilvania, en las afueras de Filadelfia.

Pérez es literalmente el corazón de su familia. Pasa la mayor parte de su día acurrucada debajo de una manta en un sillón reclinable en el centro de la sala de estar. La mujer de 87 años no parece darse cuenta de que su hija y nietos, ya adultos, van y vienen. Sin embargo, ellos mantienen una constante conversación unilateral con ella.

“Si la beso, tal vez se inclina hacia mí, y a veces asienta con su cabeza”, dijo Bobo. “A veces puede sonreír y decir sílabas como, ‘eh eh'”.

Pérez no puede levantar sus brazos ni mover sus piernas.

Un equipo rotativo formado por miembros de la familia se turna para cuidarla. Son experimentados y tienen rutinas y horarios, pero hace unos meses, la presión causada por estar acostada en un solo lugar creó una pequeña ampolla en la cadera de Pérez. La ampolla reventó y se convirtió en una escara que no terminaba de sanar.

“No podía curarla”, dijo Bobo. “Ya no sabíamos qué hacer porque no le encontrábamos la solución de ninguna forma”.

Alrededor de 44 millones de estadounidenses son cuidadores familiares que no reciben remuneración, como Bobo. A veces es un niño con necesidades especiales, aunque generalmente es una persona mayor, según un estimado del 2015 de la National Alliance for Caregiving (Alianza Nacional para el Cuidado). A menudo son mujeres que también tienen un trabajo de tiempo completo e hijos, aunque ahora el 40% de los cuidadores son hombres y los jóvenes millenials están cada vez más involucrados en la atención de un familiar en el hogar, dijo John Schall, CEO de Caregiver Action Network.

“En muchos casos, la gente aprende lo que tiene que hacer por sí mismos y eso es muy peligroso”, expresó Schall.

Y ocurre porque muchas personas no tienen los conocimientos necesarios. Treinta y tres estados han adoptado legislaciones que exigen que los centros médicos brinden entrenamiento básico o instrucciones a los cuidadores cuando un paciente regresa a su hogar después de haber estado internado, aunque la forma en que esto se lleva a cabo depende en gran parte del hospital.

Ken Everhart, un técnico jubilado de Carolina del Norte, se convirtió en el cuidador de su esposa, Genie, por unos meses, 10 años atrás, cuando los dos estaban en sus cincuenta.

“Lo que necesitábamos era que alguien me sentara en una clase y me dijera: ‘Así es cómo cambias las sábanas mientras ella aún está en la cama. Así es como tomas su presión arterial. Así es como controlas su respiración'”, dijo Everhart.

A Everhart le preocupaba que su esposa se le cayera mientras trataba de llevarla al baño. No estaba seguro de cuándo llamar al 911. Esa incertidumbre pesaba sobre Ken, especialmente luego de que Genie fue llevada de urgencia al hospital tres veces.

“Le di un sorbete para que bebiera mientras me fui a hacer una llamada telefónica. Estuve ausente sólo cinco minutos y al volver se estaba ahogando”, dijo. “Debería haberla sentado y no dejarle beber nada mientras no estuviera presente para vigilarla. Pero yo no lo sabía”.

Muchas familias no pueden permitirse el lujo de tener cuidadores entrenados. Contratar un cuidador profesional a domicilio por sólo unas horas semanales puede costar entre $10.000 y $ 15.000 por año.

“Cuando a los pacientes se les da el alta del hospital, generalmente salen rápido y enfermos”, dijo Susan McAllister, directora médica de calidad en la División de Medicina Hospitalaria de Cooper University Health Care en Camden, Nueva Jersey. Su equipo incluye trabajadores sociales, enfermeras domiciliarias y otras personas que ayudan a planificar el alta del paciente desde el hospital.

McAllister dijo que hoy en día es común llegar con un ataque al corazón, obtener medicamentos para abrir una arteria bloqueada y ser dado de alta sólo 48 horas después. La corta estadía en el hospital no es un problema, dijo, pero la transición al hogar debe hacerse adecuadamente.

En octubre, Minnesota se convirtió en el más reciente estado en aprobar una ley para preparar a cuidadores que potencialmente deberían atender a una persona enferma. California, Nueva Jersey, Oklahoma y Nueva York también tienen versiones de un programa para los que cuidan, el Caregiver Advise, Record, Enable (CARE) Act. A través de todo el país, AARP (organización sin fines de lucro, no partidaria, que ayuda a las personas mayores de 50 años) ha presionado fuertemente por estas propuestas.

Estas leyes generalmente requieren que los hospitales y las instalaciones de rehabilitación registren el nombre del cuidador en la ficha médica del paciente. Los centros médicos y de rehabilitación deben ofrecer a los cuidadores capacitación básica o instrucciones, y se supone que el cuidador debe ser notificado si un paciente es dado de alta y puesto al cuidado de otro miembro de la familia, o si regresó a su hogar.

McAllister dijo que el centro Cooper se dio cuenta de que se necesitaba hacer mucho más para asegurarse de que las personas pudieran sanar adecuadamente en casa. Desde el primer día, los cuidadores son parte del plan de alta del paciente, contó. El segundo día, una trabajadora social puede asistir a la familia en la búsqueda de la ayuda que necesitará en casa.

“Al tercer día, podemos comenzar a enseñarles dentro del hospital”, dijo McAllister.

Los hospitales no reciben pagos extras por estos pasos adicionales. Pero ahora, Medicare penaliza a los centros médicos con una sanción financiera si demasiados pacientes regresan al hospital y tienen que ser readmitidos. El Programa de Reducción de Readmisiones de Hospitales del gobierno federal fue creado bajo la Ley de Cuidado de Salud Asequible.

Muchos cuidadores domiciliarios dicen que la responsabilidad pesa mucho.

“Te asusta”, dijo Angela Bobo. “Cuando tengo dolor, puedo decirlo. Ella no puede decirme cuando está dolorida”. Así que cuando la escara de su madre no sanaba después de tantos días, “entonces es cuando me dije: ‘tengo que llevarla al médico, porque yo no sé qué está pasando'”.

Bobo llevó a su madre al médico. El doctor le escribió una receta diciendo que su mamá necesitaba más ayuda. De esa manera, Medicare pagó por la atención de un enfermero especializado en el hogar, y Angela Bobo tomó clases de limpieza y de vendaje para la herida de su madre. Ahora sabe qué hacer.

“Le dije que iba a empeorar antes de mejorar”, dijo David Wilson, el enfermero registrado de Crozer-Keystone Home Health Services que fue a la casa de Bobo. Es un especialista en cuidado de heridas, y su trabajo es visitar a domicilio.

“Para hacer que una herida se mejore, tienes que quitar el tejido muerto y empezar desde cero”, dijo Wilson.

Algunas enfermeras van a domicilio, hacen su trabajo y se van, pero Wilson dijo que enseñar es parte de su trabajo. Muchas veces él es quien anima a los cuidadores familiares reticentes que se preocupan pensando que lo harán mal.

“En el cuidado en el hogar, el desafío más grande es el miedo”, dijo Wilson.

Wilson recomendó un nuevo régimen de cuidados para la escara de Ruth Pérez, y la mujer recibió un colchón de aire que alivió la presión sobre su piel. Medicare también pagó por eso. El enfermero regresó varias veces para verificar cómo estaba la familia, y Bobo dijo que eso le dió más seguridad de que estaba haciendo las cosas correctamente al cuidar a su madre.

Este artículo es parte de una asociación que incluye el programa de salud de WHYY, The Pulse, NPR y Kaiser Health News.

Ìý

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“She would put food together that didn’t belong together — hamburger and fish in a pot. Mom never cooked like that,” she said.

The mother and daughter live together in Yeadon, Pa., just outside of Philadelphia.

“In too many cases, people just learn this stuff by themselves and that’s really kind of dangerous,” Schall said.

That’s because many people don’t have the necessary skills. Thirty-three states have adopted legislation requiring medical centers to give caregivers basic training or instructions when a patient heads home from the hospital, though how this is carried out is largely up to the hospital.

Ken Everhart, a retired tech guy from North Carolina, became a caregiver for his wife, Genie, for just a few months 10 years ago, when the two were in their mid-50s.

“What we needed was for someone to sit me down in a class and say, ‘Here’s how you change the sheets while she’s still in the bed. Here’s how you take her blood pressure. Here’s how you monitor her breathing,'” Everhart said.

He worried he’d drop her as they struggled to get to the bathroom. He wasn’t sure when to call 911. That uncertainty weighed on Ken — especially when Genie was rushed back to the hospital three times.

“I had given her a straw to drink out of, and a sippy cup, and I went to make a phone call. I wasn’t gone five minutes and I came back in and she was choking,” he said. “I should have sat her up, and I should not have allowed her to have anything to drink while I wasn’t in there to watch. But I didn’t know that.”

Many families can’t afford to use trained caregivers. Hiring help at home for just a few hours a week can cost $10,000 to $15,000 a year.

“When patients leave the hospital, they generally leave quick and sick,” said Susan McAllister, medical director of quality in the Division of Hospital Medicine at Cooper University Health Care in Camden, N.J. Her team includes the social workers, home health nurses and others who help plan a patient’s discharge from the hospital.

McAllister said these days it’s common to come in with a heart attack, get medicine to open a blocked artery, and leave just 48 hours later. The short hospital stay isn’t a problem, she said, but the transition home has to be done right.

In October, Minnesota became the latest state to pass laws to prepare potential caregivers to know what the sick person may need. California, New Jersey, Oklahoma and New York also have versions of a Caregiver Advise, Record, Enable (CARE) Act. Across the country, has lobbied strongly for the proposals.

These laws generally require hospitals and rehabilitation facilities to record the name of the caregiver in the patient’s medical chart. Medical centers and rehab centers must offer caregivers basic training or instructions, and the caregiver is supposed to be notified if a patient is discharged to another family member or back home.

McAllister said years ago, Cooper realized it needed to do a lot more to make sure people were healing safely at home. From day one, caregivers are part of discharge planning, she said. On day two, a social worker might help the family shop for help at home.

“On day three, we may start teaching inside the hospital,” McAllister said.

Hospitals don’t get paid more for those extra steps. But now Medicare hitsÌýmedical centers with a financial penalty if too many patients bounce back to the hospital and have to be readmitted. The federal government’s was created under the Affordable Care Act.

Many at-home caregivers say the responsibility weighs heavily.

“It scares you,” said Angela Bobo. “When I’m in pain, I can tell you. She can’t tell me that’s she’s in pain.” So when her mother’s bedsore wouldn’t heal after so many days, Bobo said, “That’s when I said: ‘I’m going to take her to the doctor’s, because I don’t know what’s going on with this.’ ”

Bobo took her mother to the doctor, and he basically wrote a prescription saying her mom needed more help. That way, Medicare paid for skilled nursing care at home, and Angela Bobo got lessons in cleaning and dressing her mother’s wound. Now she knows what to expect.

“I told her it’s going to get worse before it gets better,” said David Wilson, a registered nurse from who went to Bobo’s house. He’s a wound-care specialist whose job is house calls.

“To get a wound better, you have to remove the dead tissue and start from the ground up,” Wilson said.

Some nurses come to the house, do their job and leave, but Wilson said teaching is part of his work. Lots of times he’s the one nudging reluctant family caregivers who worry they’re going to do the wrong thing.

“I will tell you in home care, the biggest thing is fear,” Wilson said.

Wilson made several visits. He recommended a new wound-care regimen for Ruth Perez’ bedsore, and Perez got an airflow mattress that relieved the pressure on her skin. Medicare paid for that, too. The nurse returned several times to check on the family, and Bobo said that gave her more confidence that she was doing the right things to care for her mother.

This story is part of a partnership that includes WHYY’s health show , and Kaiser Health News.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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“Anything to avoid antibiotics or being out of commission,” the 37-year-old said.

After getting a 100-milliliter drip of a liquid the clinic calls Ìýpumped directly into her bloodstream via a needle in her arm, Shapiro said she feels like “a new person.” The infusion, which costs $179, takes less than a half-hour. While she waits, she can recline in one of the cushy seats, watch the 64-inch, flat-screen TV or dim the lights in the room.

“I take this time as ‘me time’ — to relax and kick back and close my eyes for a couple of minutes,” she said.

But if you mostly eat your kale and quinoa, why would you need a boost of vitamins delivered straight to the vein? Skeptical physicians say you probably don’t need it. A healthy gut absorbs all the nutrients we need from food. And anyone well enough to drink fluid, they say, can get all the rehydration they need by mouth.

Still, clinics that market treatments of intravenous fluid to the stressed out and worried well can now be found nationwide.

Newer firms offer a menu of drips that claim to help , balance hormones, improve chronic medical conditions or simply give the skin a healthier glow.

Osteopathic medicine physician Jason Hartman, who launched RestoreIV with a partner out of his Philadelphia , saidÌýpeople want the experience he offers. Hartman’s specialty is using touch to diagnose and treat patients.

He sometimes helps people remedy a hangover, he said, but his business also includes people with more serious illnesses, including chronic fatigue and migraines. For those patients, he says, IV treatment supports healing. Other clients are generally healthy and want to stay that way.

The basic IV therapy cocktail includes vitamin C, zinc and B vitamins. If you have a headache, the doctor might add a little magnesium.

“These are your natural pharmacy,” Hartman said, “and in chronic diseases these things can be depleted [by] just a stressful lifestyle. And if they become deficient enough, it alters your internal pharmacology enough to possibly manifest as a symptom or disease.”

The promised benefits of this sort of intravenous treatment vary from company to company.

At the bottom of the website for , you’ll find this warning:

“These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease. This service is intended only for healthy adults.”

Hartman saidÌýany intravenous infusion comes with a small risk of infection — or pain, bruising or bleeding if the needle misses the vein. Moreof an IV treatment can include a blood clot, or inflammation of the vein.

And people with certain medical conditions — some metabolic diseases, for example, or congestive heart failure — shouldn’t get these treatments, Hartman cautions. That’s why, he said, his clinic questions every client about their medical history before a treatment begins.

At RestoreIV, the treatments cost from $150 to $200, and there’s an initial $35 fee to consult with the doctor. The business doesn’t accept health insurance; patients pay Hartman’s office directly.

So, with the out-of-pocket expense, and only anecdotal evidence of benefit, why do people sign up for these sessions?

, a doctor of naturopathic medicine and health researcher at the Yale School of Medicine, saidÌýthat if an IV infusion of this type makes people feel better, it’s probably because of the placebo effect. And the placebo effect can be powerful.

Several years ago, Ali and his colleagues tested a popular IV treatment called theÌý on a small group of people with fibromyalgia, a syndrome of muscle pain and fatigue that can be hard to ease. Half the 34 participants in his got Myers’ intravenous cocktail of vitamins and minerals in weekly treatments for eight weeks, and the other half got without vitamins.

“The interesting finding,” Ali said, “was that everyone got better.” People in both groups reported less pain, and said they were better able to do the things they need to do every day.

The placebo phenomenon is more complicated than many people understand, Ali explains. Research has shown, for example, that injections, or other invasive procedures, can generate a than dummy pills do.

If, as in the case of his study, people feel a fairly innocuous treatment is helping them, and they haven’t been able to get relief in other ways, that may be a reason to use it, Ali saidÌý— even if the “fix” is 100 percent placebo effect.

“When your child falls down and scrapes their knee, you give them a kiss,” he said. “There’s value in that, whether or not there’s clinical trial data showing that giving a kiss is better than doing nothing.”

Still, Ali saidÌýhe can’t ethically recommend the intravenous vitamin treatments for healthy patients.

“If people are just using it to feel good or for an energy boost,” he said, “I would just say go exercise for 30 minutes and you’ll get more out of that.”

This story is part of a partnership that includes , and Kaiser Health News.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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“It’s because somebody pointed a gun at him and pulled that trigger. It’s not because of cancer; it’s not because of car accidents; it’s not because of house fires. It’s because somebody pointed a trigger,” he says.

Charles is at Temple University Hospital. The medical center now offers bystander first-aid training, called Fighting Chance, to give friends and family something to do in the minutes before help arrives.

At 6 o’clock one evening, kids run around while their parents and neighbors gather in an elementary school cafeteria. There are training stations set up, and at the back a nurse is showing people how stop blood flow from a gunshot wound.

“The pressure point is located on the inside of the arm,” he explains. “And basically, you’re going to take your hand and get up underneath the inside of the arm and clamp it down.”

At the end of the evening, the trainers stage a minidrama to test the group.

Bryan sets the chaotic scene and calls out directions. One person is the victim. There’s a pretend shooter.

“Remember, you can ask somebody: ‘Help me control the scene.’ That’s good,” he calls out.

Charles helped develop the first-aid education program after a local resident came to him to complain that he was sick and tired of hearing about young men who died before getting to the ER.

“As we wait for laws to be changed, many people are going to find themselves on the wrong end of a gun,” Charles says. “While those things are certainly important, we have to put the power in people’s hands to address this issue.”

The goal is to saturate one neighborhood with people who have basic lifesaving skills. About 250 people have been trained so far.

This story is part of a reporting partnership with NPR, WHYY’s health show and .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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Lore has it that 35-year-old Paris physician was caring for a young woman who was apparently plump, with a bad heart and large breasts.Ìý, an obstetrician at East Tennessee State University who collects vintage stethoscopes, said the young Dr. Laennec didn’t feel comfortable pressing his ear to the woman’s bosom.

“So he took 24 sheets of paper and rolled them into a long tube and put that up against her chest, listened to the other end and found that not only could he hear the heart sounds very, very well, but it was actually better than what he could hear with his ear,” Davis said.

Or, maybe it wasÌýpoor 19th century hygiene — lice and the smell of an unwashed body — that kept Laennec from getting too close to his patient.

Either way, he went home and crafted a wooden cylinder with a hole down the middle and that became the first stethoscope.

It took a while for the art of listening to the body through a tube to catch on. But the new tool fit into an evolving idea that doctors needed a more focused approach to diagnosis, “that you should distinguish tuberculosis from a lung abscess — and not just call it all consumption,” saidÌý, a professor at Drexel University College of Medicine.

“You don’t realize until you are wearing it and trying to use it, how pokey it is in your ears,” she said. “I’m almost embarrassed to wear it because it implies I have knowledge I don’t have yet.”

Medical schools teach the art of listening.

“I am astounded at the things I’ll find with my stethoscope,” saidÌý, a third-year student at the Perelman School of Medicine. “I had a patient whoÌýhad pneumonia, and it was really wonderful to be able to listen to her and say, ‘This is what I think it is.’ And then, later, see on the chest X-ray that, that was exactly what it was.”

But some argue that the stethoscope is becoming less useful in this digital age.Ìý, an emergency medicine physician at Mt. Sinai Hospital in New York, said clinicians now get a lot more information from newer technology.

An ultrasound, for example, turns sound waves into moving images of blood pumping and heart valves clicking open and shut; those visual cues are easier to interpret than muffled murmurs and may produce a more accurate diagnosis, Nelson said.

He admits the stethoscope is an icon, but doesn’t buy the argument that if you lose the stethoscope, you lose the tradition of “healing touch.”

“Pulling an ultrasound machine out of my pocket, or wheeling the cart over next to the patient [and] talking through with them exactly what I’m looking for and how I’m looking for it — the fact that they can see the same image on the screen that I’m seeing, strengthens that bond more than anything in the last 50 years,” Nelson said.

Nelson is 42 years old and graduated from medical school 16 years ago. He teaches medical students and said it’s helpful to show new learners what “lies beneath.” At Mt. Sinai, when medical students are taught to examine a heart, they learn how to use the stethoscope and an ultrasound machine on the same day.

“They know how to feel it, they know how to listen to it, and they know how to look at it,” Nelson said.

Still, obstetrician George Davis wants to keep the stethoscope around for a while. High-tech machines and imaging scans are great backup resources, he said, but his stethoscope helps him figure out which patients actually need additional testing.

“How much do those ultrasound machines cost?” Davis asked. “I can get a good stethoscope for less than $20. We are not going to sit there and do an echocardiogram on every patient who walks through the door.”

Davis worries that a whole generation of doctors is learning to rely too much on technology; he wants to hold on to first-line tools that are safe, effective and cheaper.

“Shouldn’t we be using what is low-tech and practical?” he asked.

Nelson counters that point-of-care imaging is becoming less expensive every day. Twenty years ago, he says, an ultrasound machine was as big as a refrigerator and cost $400,000. Today, a handheld, portable device plugs into a computer tablet, and costs less than $10,000.

Many care providers in the community may even have an ultrasound in their pocket one day soon, he says, combined in a single device with, “a slide rule, a calculator, a flashlight, a phone, a computer terminal and 36 video games.” In other words: on their smartphone.

This story is part of a reporting partnership with WHYY’s health showÌý, and Kaiser Health News.

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There’s a basketball court like one you’d see at any high school, except there’s a corrections officer on guard near the three-point line.

Sixteen stationary bikes are set up in a half circle in the corner. On bike number two, Lakiesha Montgomery, 32, from Philadelphia, is pedalingÌýfast and singing along to the Nicki Minaj’s song “Fly.”

“I didn’t think I’d be able to keep up, I’m not the skinniest thing in the bunch,” she says.

But she is keeping up.

“Over and over I had conversations with women who were saying, ‘While I was incarcerated, I put on 60 pounds, I put on 70 pounds,’ ” she says. Then she would ask them how long they were in prison and she says they’d typically respond, “six months.”

At Riverside, Montgomery spends time in the prison yard most days but doesn’t get much exercise there.

“The outside is not a real outside, it’s like a mini garage. They have a basketball court there, but I don’t play basketball. It’s a lot of people that come out so you don’t have room to really jog or walk. It’s like you sit out to just get some air,” she says.

She has arm tattoos and a sprinkle of freckles across her nose. Her hair is braided back into cornrows. She also has high cholesterol.

Montgomery was charged with assault this year, among other charges, and has been in county jail for about six months.

“First time, last time,” she says. In the meantime, spin class is something to do.

“Keep away frustration being locked up, it helps you get through,” Montgomery says.

The Department of Justice surveyed the health of state and federal inmates in 2012 and found that women are more likely than men to be obese.

A study of prison health in Kentucky found greater weight gain for women compared to men. Women on average gained nearly 11 pounds, men only gained 2.5 pounds.

Gearing Up is working with researchers at Temple University to track the weight and body image of the women who spin at Riverside Correctional. The study was just eight weeks long and small, but they’ve already found small improvements in resting and recovery heart rate—two preliminary measures of heart health.

Gavin says often the women come to class initially to stop gaining weight then later find other reasons to keep coming back.

“I can speak to myself, if I weren’t given the opportunity to be physically active, I’d probably go a little crazy. I probably wouldn’t be able to manage my emotions, my temper, my anger. I think anger management is a huge issue for a lot of women who are in prison; they are victims of trauma and abuse,” Gavin says.

And, of course some of the women have hurt other people.

Exercise can be a way to release all sorts of emotions.

Erica Tibbetts from Gearing Up often leads the spin class.

Tibbetts is in bike shorts. Everyone else has on prison blues: long navy pants and a white t-shirt.

“The worst seems to be women don’t have good sports bras in here,” she says.

No one has a water bottle and exercise shorts aren’t allowed. Tibbetts says the women come to class anyway and work with what they have.

Climb on a bike and there’s a sense of freedom, even if you’re not going anywhere.

At the beginning of class, one by one, the women call out their intention for the ride. The ritual is called “clearing.”

Christina wants to leave behind shakedowns. Jean wants to forget “cough and squat.”

Sheik is leaving behind “wrongful mistakes.”

Others want to shake off the past, stress and depression.

In a 2010 survey, women at Riverside gained about 36 pounds in a year, on average. But after some changes at the facility, that weight gain dropped to 26 pounds when the medical team checked again in 2015.

Bruce Herdman, the prison’s chief of medical operations, says weight gain is a problem, but it’s not the most urgent health problem his team is managing.

“The chlamydia rate — 6.6 percent on admission. We’ll treat a thousand people for HIV. The hepatitis C rate here, largely because of intravenous drug use, is 13 percent. Then you have hypertension, diabetes, all the regular things,” he says.

The prison pays Gearing Up to hold spin class three times a week. There’s also an occasional yoga class, but the big change affecting women’s weight was the food. The meals are certified heart healthy by a nutritionist. There’s a lot of it, but portion sizes are smaller now. Last year, the prison cut calories from nearly 2,900 a day to 2,500 for men and women.

That helped, but the facility-provided meals aren’t the only food around. Inmates also make do-it-yourself meals with food from the prison commissary. A favorite is called “chi-chis.”

“It’s where you mix Ramen Noodles with cheese puffs. You put it in hot water, you put the meat inside, you can do honey mustard sauce or ranch on top, and you just put in a potato chip bag and you mix it up. It’s actually pretty good,” explains Amanda Cortes.

Cortes has been in jail for five years and eating that way for most of that time. She’s facing several charges including involuntary manslaughter and is waiting for a court date. She says lots of women use food to cope with boredom and depression.

“Some people get two or three trays, so they get fat like that. They take whole loaves of bread to their room,” Cortes says.

So Cortes cycles to keep the weight off, and on visiting day, her 10-year-old son noticed.

“When he first seen me he was like: ‘Mommy you got skinny!’ So I was excited,” she says, smiling.

During a year, going to three spin classes a week, Cortes dropped 90 pounds.

At the end of the Gearing Up class, just before the goodbyes and sweaty hugs, there’s one last ritual.

The women share what they’ve brought back from the ride.

One women says she’s “bringing sexy back.” She and everyone around the circle has a wish: “I’m Jean, and I’m bringing back my bikini. I’m Ruth, and I’m bringing back faith and confidence.”

This story is part of a reporting partnership with NPR, WHYY and Kaiser Health News.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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John Pike, age 53, is an example of a Camden resident who used to be a frequent flier at the ER.ÌýPike has a smoker’s cough, and when that cough, or pain in his bad hip flared up, he’d go to the ER — maybe eight or nine times a year. But when he did, ER staffers didn’t really remember him or his medical history.

“You get to feeling you are irritating them,” he says. “It would be a simple problem. I’m wasting their time where they could be dealing with a real emergency.”

Once, he says an ER nurse pulled him aside and said, “This is something your doctor can deal with.”

“Not much I could say, because she was telling the truth,” he says.

But Pike didn’t have a primary care doctor until a community group called theÌýÌýopened a doctor’s office right inside Pike’s apartment building.

, the director of research and evaluation for the coalition,Ìýsays the idea was to get “super users” like Pike to stop going to the hospital so frequently.

Gross says the group saw ER overuse in Camden as “a sign for us, from the data, that you don’t have a source of primary care, or you have a loose relationship with primary care or you can’t get an appointment with your primary care because of your work hours.”Ìý

Gross leads a team ofÌýÌýat the coalition. For several years they gathered hospital billing information from across Camden. Then they mapped the data block by block.

It turns out that John Pike’s building is marked as a bright-red “hot spot” on the map. John and his neighbors at the Northgate II building had been racking up more than $1 million a year in hospital admissions and trips to the emergency roomÌýfor about a decade.

These days, Pike rides an elevator to the doctor, just six floors down from his apartment. The space is bare bones, with just two exam rooms and a tiny file office, but Pike has his own doctor now. Her name is Dr. Madhumathi Gunasekaran.

“I feel comfortable with her. I can talk to her; she doesn’t shove you off like some doctors,” Pike says.

Dr. Jon Regis is a longtime member of the Camden coalition. His company, theÌýÌýoperates 21 offices across New Jersey, including the practice at Northgate II. The subsidized housing there is home to many low-income seniors and people with disabilities. Many people who live in Northgate II now see Dr. Gunasekaran for check-ups and other medical issues. But Regis says it took longer than he hoped to win over residents — almost two years.

“We thought that since they were having such a difficult time, we could just open up the door and they would come down. That wasn’t the case,” he says.

Regis says some residents told him that they didn’t want their neighbors to know they’re going to the doctor. But Regis was persistent in trying to get residents to use Dr. Gunasekaran instead of the ER.

“We had to do a number of different things, like health fairs and meet-and-greets. We had to engender a sense of trust in the residents before they would come down to see us. I think that was somewhat surprising. But we’re starting to get past that now,” he says.

About a year ago, only about 80 people got their primary care at the office. That number has grown to nearly 130 or about 19 percent of the building’s residents. It was a slow start, but Regis is pleased with the progress.

Reliance uses revenue from private pay and private insurance patients at other office locations to help finance the clinic at Northgate II. This way, he says, “We don’t have to turn anybody away, and we’ve been able to make this work.”

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Supporters say dissolvables could help smokers “step down” from their nicotine dependence on cigarettes. Opponents say it’s not clear how consumers actually use the products and who is using them. Will young people try dissolvables, develop a taste for nicotine, then graduate to smoking? Could dissolvables keep people hooked when some former smokers would have–eventually–become nicotine free?

Tobacco companies aren’t allowed to promote dissolvables as a stop-smoking aid, but there’s lots of Internet chatter from individual consumers who report that they’ve given up cigarettes or cigars with the help of dissolvables.

Rutgers University law student Gregory Conley was a smoker for eight years, but quit in August. The 24-year-old used electronic cigarettes—another smokeless product—to quit, and he says dissolvables suppress his cravings when he’s in class. He likes the tobacco-dipped toothpicks and says they give him a satisfying nicotine tingle along with a hit of mint or java flavor. Ìý “You just put it in your mouth and hold it as if you were holding a piece of straw between your teeth,” Conley said. Ìý He volunteers as a legal policy director for the and testified during the FDA’s meeting this week. Conley says electronic cigarettes, dissolvables and other smokeless alternatives are powerful tools to help smokers avoid the most toxic aspects of cigarettes. Ìý The Centers for Disease Control and Prevention one in five deaths each year to tobacco use, about 440,000 people. Cigarette smoking costs America $193 billion a year, according to government estimates for 2000 to 2004. About half of that economic cost is direct health care spending, the other half lost productivity. The FDA’s review of dissolvables was mandated by the 2009 . Matthew Myers, president of the , says the advisers will weigh the science and report on the consequences for population health, not just individual smokers. Ìý “The FDA law recognizes that even if the product is less harmful, if it’s marketed in a way that its primary appeal is to young people, the net result will be more people becoming addicted to tobacco,” Myers said. Ìý “What we’ve seen is that the colorful way that dissolvables have been promoted and the talk that they have generated has led a lot of people to believe that these products are less harmful—before there’s been an FDA review,” Myers said. Ìý Right now, FDA regulates dissolvables like other smokeless tobacco. They’re stocked behind the counter at convenience and grocery stores, not sold to minors and they have some of the same warning labels as snuff and chew: “Smokeless tobacco is addictive.” “This product is not a safe alternative to cigarettes.”

The newer products have been available in just a handful of markets so far, including Denver, Indianapolis, Portland, Ore., Columbus, Ohio, and Charlotte, N.C. The Colorado Board of Health passed a resolution asking R.J. Reynolds to remove the products from its market, but the company with the request.

A group of U.S. lawmakers wants stricter rules for dissolvables. Some public health groups say the products should be removed from store shelves until the FDA has weighed in on the science behind dissolvables. Other advocates, sometimes called “harm reductionists” say smokeless products like dissolvables can lessen the disease, death and disability caused by smoking. Ìý Jennifer Ibrahim, associate professor in the Department of Public Health at Temple University, says–done right–harm reduction is a good idea. “I think that everyone in the business of smoking cessation is realistic that people can’t quit cold turkey, but you don’t want to send the wrong message: that nicotine is safe at any level, because it’s not.” Ìý “That’s absolutely true, nothing is absolutely safe,” said Conley, but he says smokers are dying while public health officials wait for definitive proof.

Psychologist Anna Tobia, director of the smoking cessation program at Thomas Jefferson University Hospital in Philadelphia, points out that the new dissolvables are not the only nicotine products meant to be ingested.

“To be fair, they are very similar to smoking cessation products that have been on the market for a very long time–a lozenge or a gum for people who are trying to get off of tobacco,” said Tobia.

Kenneth Warner, a health economist at the University of Michigan School of Public Health, says there’s reason to be skeptical of the tobacco industry’s intention for dissolvables and concerned about what the new products will do. Ìý “The public health community got bamboozled” in the past, he said. When the tobacco makers began selling low-tar nicotine cigarettes, Warner says they were marketed as “mild, mellow,” and safer than regular cigarettes—and it turned out they weren’t. Ìý The FDA’s advisers are wading in to a long-standing debate that shows up evolving and changing ideas about what’s acceptable and what’s safe. ÌýHealth policy expert Ibrahim says electronic cigarettes and melt-in-your mouth tobacco are just the latest in a long line of novel products aimed at smokers and people trying to kick the habit. Ìý “I won’t let my kids near the e-cigarettes, because I just don’t know what’s in the vaps [water vapor] that’s coming out of them. Once upon a time people thought exposure to second-hand smoke was safe and clearly that’s not the case,” Ibrahim said. “I don’t intend to expose myself or my family to things which 10, 15 years down the road, we’ll say: ‘Oh, yeah, that’s not good for you.’” Ìý “We will take anything to get our patients better and to get them to reduce the amount of cigarettes that they are smoking,” said stop-smoking expert Anna Tobia. “If this is a good first step, and—maybe–if they can see that they can manage with less nicotine, that would be wonderful.” Many are waiting for the FDA to answer the question: Do dissolvables pose a greater or lesser risk to population health?

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Four in five African-American women are obese or overweight, according to the U.S. Office of Minority Health, and carrying those excess pounds can spike the risk for several conditions including heart disease, Type 2 diabetes, high blood pressure and stroke.

Members of the Anderson Monarchs soccer team practice as their coach looks on. The team, which was started at Philadelphia’s Marian Anderson Recreation Center, gives game time to girls who have little chance to play another sport (Photo by Todd Vachon/WHYY).

About half of African-American women in the U.S. are obese, compared to 30 percent of white women.ÌýBlack women not only carry more weight, but they start adding extra pounds years before their white counterparts.

So when does it begin, this excess and unhealthy weight? Research suggests the problem starts early, and it may have a lot to do with when girls give up regular exercise.

Experts want kids to exercise at least 60 minutes every day, but among all children, black girls are most likely to report they got no physical activity in the past week. A lack of access to exercise opportunities may be one big reason why, says , an epidemiologist and public health professor at the University of Pennsylvania.

Research shows that opportunities for recess, sports, physical education — or just to go outside — aren’t spread evenly among children.

“If you kind of add up those situations in urban, inner-city neighborhoods — where most African-Americans live — they are not as available. That’s been documented,” says Kumanyika, who studies patterns of illness and health behavior.

But research suggests that even those girls who do engage in sports and other forms of regular physical activity tend to abandon it in their teen years — and that’s true not just for urban girls or black girls, but all girls.

A National Institutes of Health that followed girls for 10 years, beginning at age 8 or 9, found that, over time, leisure-time physical activity declined dramatically. That drop off was steepest for African-Americans girls.

“What they found was that by the age of 17 — so that’s the junior, senior year of high school — more than half of black girls, and nearly a third of white girls were reporting no leisure time physical activity at all,” says Temple University researcher .

There are lots of reasons why teen girls drop exercise from their lives, says Lenhart: “They have found changes in enjoyment of activities, in peer support or social support for physical activity. They found a lot of competing interests — be it part-time jobs or caring for younger siblings or other family members.”

Walter Stewart says he’s witnessed the phenomenon first-hand. He’s the longtime coach of the Anderson Monarchs, a soccer team of mostly African-American girls from inner-city Philadelphia.

Members of the Anderson Monarchs soccer team gather as their coach Walter Stewart talks to them. The team, which was started at Philadelphia’s Marian Anderson Recreation Center, gives game time to girls who have little chance to play another sport (Photo by Todd Vachon/WHYY).

“Eighth grade — that’s where it gets to be difficult,” he says. “They are making the transition from young kids to more teenagers, and they are more interested in boys and what boys think.”

Jennifer Johnson was determined not to let that happen to her daughter, Alexandria. Johnson discovered the Monarchs when she was looking for an affordable way to keep Alexandria active.

Alexandria is now 15 and an assistant coach with the team, but her interest in soccer dipped in middle school, around age 12, says Johnson.

“In come the friends, and in come the extracurricular activities at school, and as a parent you really have to press on. I said to her, ‘If it’s not this, you will be involved in something,'” Johnson says.

So Alexandria stuck with soccer, and so did her mother — Johnson is on the sidelines at games and during most practices.

That’s an approach that obesity researchers would approve of. Researchers say that family support — especially mom’s presence — may motivate girls to keep playing.

Researchers are beginning to count up the cost of obesity, and say women can pay a hefty price in dollars– and health.

A sedentary lifestyle and obesity may account for 25 to 30 percent of some major cancers, including colon, kidney and breast cancer in postmenopausal women, according to the National Cancer Institute. Avoiding weight gain, by contrast, can cut cancer risk.

In September 2011, researchers at Boston University reported that overweight and obesity in African-American women increases their risk of death, particularly from heart disease. The investigators reviewed body mass index–a measure of body fat–and death rates for participants in the ongoing Black Women’s Health Study. A BMI of 25 is considered overweight. The study found a significant increased death risk at a BMI of 27.5–that’s the BMI for a 5-foot-4-inch tall woman who weighs 160 pounds.

Nearly 10 percent of all health care spending in the United States, $147 billion a year, is related to the obesity epidemic. Individually, obese people cost nearly $1,500 more a year in medical expenses compared to healthy-weight people, according to estimates from researchers at George Washington University. Some of that extra expense is paid by individuals, some is passed along to their employers.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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