The Environmental Protection Agency rule would many products that contain perfluoroalkyl and polyfluoroalkyl substances. They’re a family of chemicals that don’t degrade in nature and have been linked to cancer, birth defects, and hormone irregularities.

Companies would have to disclose any PFAS that have been manufactured or imported between 2011 and when the rule takes effect, with no exemptions for small businesses or for impurities or byproducts cross-contaminating goods with PFAS. Those disclosures would be available to the public, barring any trade secrets linked to the data. The EPA will finalize the rule in the coming months, agency spokesperson Catherine Milbourn said, then require companies to report back within 12 months.

The effort excludes pesticides, foods and food additives, drugs, cosmetics, and medical devices regulated under the Federal Food, Drug, and Cosmetic Act, Milbourn said. It also is essentially a one-time reporting and record-keeping requirement — and companies wouldn’t need to provide updates.

Still, the chemical and semiconductor industries are grumbling about what the EPA estimated is a to comply with the rule. The U.S. chemical industry says it generates .

On the other side, environmental health activists say the data collection exercise would be flawed, as it accounts for only a tenth of PFAS chemicals, which are used in everything from nonstick cookware to kids’ school uniforms. Moreover, they say, it wouldn’t stop PFAS from making their way into the air, waste, or consumer products, nor would it clean up existing contamination.

Congress gave the EPA the power to track PFAS chemicals in 2016, when it revised the Toxic Substances Control Act. Then a , which President Donald Trump signed into law, called for the EPA to inventory PFAS. However, health activists warn that unless Congress overhauls U.S. chemical laws to give the EPA and other agencies more power, PFAS will continue to threaten humans and the environment.

These so-called forever chemicals went from marvel to bête noire in just 50 years. When PFAS debuted, they were revered for making Teflon pans nonstick and Gore-Tex jackets waterproof. They are effective at repelling water and oil yet so durable they don’t break down in the natural environment. That strength has become their downfall, as the chemicals accumulate in landfills, soil, drinking water supplies, and, ultimately, human bodies. As scientists learn more about PFAS’ toxic nature, governments around the world have set limits or imposed outright bans.

Because PFAS are found in thousands of products — , cosmetics, , paper plates, clothing, and dental floss, to name just a few — regulators are scrambling to gather data on the scope of the PFAS threat. The EPA data collection proposal is a move in that direction.

Milbourn told Â鶹ŮÓÅ Health News that 1,364 types of PFAS may be covered by the rule, and EPA officials are reviewing public comments they received to determine whether they should modify its scope to capture additional substances.

By contrast, the European Union is discussing banning or limiting , according to Hanna-Kaisa Torkkeli, a spokesperson for the European Chemicals Agency.

“In the U.S., chemicals are innocent until proven guilty,” said , director of science policy at Public Employees for Environmental Responsibility, a nonprofit based outside Washington, D.C. “In the EU and Japan, chemicals are guilty until proven safe — and that’s why they have fewer PFAS.”

That lack of regulation in the U.S. is driving states to take matters into their own hands, pursuing PFAS bans as gridlock and in Washington thwart tougher federal laws. Minnesota’s limits the chemicals in menstrual products, cleaning ingredients, cookware, and dental floss. Maine’s law will . and ban PFAS in food packaging.

“The states are acting because our federal system doesn’t currently allow the government to say ‘no more use of PFAS,’” said , director of the federal policy program at Toxic-Free Future, a national advocacy group. “And even if it did, that wouldn’t clean up the mess already made.”

U.S. courts are also weighing in on PFAS contamination. On June 22, 3M up to $12.5 billion to settle lawsuits by communities around the country that argued their drinking water was contaminated by the company’s PFAS-containing products.

Additionally, the U.S. military is , after said more than 600,000 troops were in drinking water contaminated largely by PFAS-laden .

Just cleaning up PFAS waste could cost at least $10 billion. Removing it from U.S. drinking water supplies more than $3.2 billion annually to the bill, according to a report commissioned by the American Water Works Association.

“The CDC estimates that 99% of Americans have PFAS in their blood,” said , vice president of government affairs for the Environmental Working Group, a nonprofit that researches the ingredients in household and consumer products. “We estimate that 200 million Americans are exposed to PFAS in their drinking water right now.”

Officials with the U.S. Geological Survey released a similar finding that the agency’s researchers estimate more than 45% of U.S. tap water is contaminated with at least one PFAS chemical after they conducted a nationwide study of water samples.

As ubiquitous as PFAS are, the reason they haven’t generated more outrage among the public may be that the damage from PFAS chemicals isn’t immediate. They affect health over time, with repeated exposure.

“People aren’t getting headaches or coughing from exposure to PFAS,” Bennett said. “But they are getting cancer a few years down the line — and they don’t understand why.”

Some environmental health advocates, such as Arthur Bowman III, policy director at the , say the EPA’s data collection project could help. “It will be fairly straightforward for the EPA to gather PFAS information on cleaning products and other wet chemicals that contain PFAS,” Bowman said. “And this will lead to phaseouts of PFAS.”

Some retailers, such as and , have recently announced plans to remove the chemicals from many of their products.

But Bowman said it will be more difficult for manufacturers to remove PFAS used in the production of semiconductor chips and printed circuit boards, since alternative products are still in the research phase.

The Semiconductor Industry Association to the proposed reporting requirements because, it maintains, semiconductor manufacturing is so complex that it would be “impossible, even with an unlimited amount of time and resources, to discern the presence (if any) of PFAS in such articles.” Other industries have also asked for waivers.

The American Chemistry Council, which represents large PFAS manufacturers such as 3M, disagrees with those calling for the entire class of PFAS chemicals to be banned. “Individual chemistries have their own unique properties and uses, as well as environmental and health profiles,” said Tom Flanagin, a spokesperson for the trade group.

While the council’s member companies “support strong, science-based regulations of PFAS chemistries that are protective of human health and the environment,” Flanagin said, the rules shouldn’t harm economic growth “or hamper businesses and consumers from accessing the products they need.”

For their part, some environmental advocates welcome the reporting proposal, expecting it to reveal new and surprising uses of PFAS. “However, it’s going to be a snapshot,” said , the senior toxics policy adviser for the Sierra Club.

Lunder said even if PFAS were found in, for example, brands of baby bibs, pesticide containers, or pet food bags, it isn’t clear which federal agency would regulate the products. She said Americans should demand that Congress add PFAS and other harmful chemicals to all major environmental statutes for water, air, food, and consumer products.

And another worry: If the data does make it into the mainstream, will consumers simply tune it out — just as many do with ? Lunder doesn’t think so, since “the audience is scientists, regulators, and — for better or for worse — tort attorneys.”

Benesh, of the Environmental Working Group, said the disclosures could reach further and “embolden consumers to demand even more market change.”

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Â鶹ŮÓÅ Health News Florida correspondent Daniel Chang discussed the draw and dangers of Brazilian butt lifts in Miami on Al Jazeera’s “Fault Lines” on June 7.

• Read Chang’s “Shaved Costs, High Risk, Maximum Profits: Regulators Worry About Florida’s Butt Lift Boom”

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Sadé Lewis of Queens, New York, has suffered migraines since she was a kid, and as she started college, they got worse. A recent change in her insurance left the 27-year-old looking for a new neurologist. That’s when she found in New York.

MedicalArts recommended that she get an electroencephalogram (EEG) and an MRI to make sure her brain was functioning properly.

An EEG is a test to measure the electrical activity of the brain. It can find changes in brain activity that can help in diagnosing conditions including epilepsy, sleep disorders, and brain tumors. During the procedure, electrodes consisting of small metal discs with attached wires are pasted onto the scalp using adhesive, or attached to an electrode cap that you wear on your head.

A little over a week before her EEG, Lewis was given instructions that she didn’t remember getting before a previous EEG appointment.

To Lewis’ surprise, patients were told to remove all hair extensions, braids, cornrows, wigs, etc. Also, she was to wash her hair with a mild shampoo the night before the appointment and not use any conditioners, hair creams, sprays, oils, or styling gels.

“The first thing I literally did was text it to my best friend, and I was, like, this is kind of anti-Black,” Lewis said. “I just feel like it creates a bunch of confusion, and it alienates patients who obviously need these procedures done.”

The restrictions could discourage people with thick, curly, and textured hair from going forward with their care. People with more permanent styles like locs — a hairstyle in which hair strands are coiled, braided, twisted, or palm-rolled to create a rope-like appearance — might be barred from getting the test done.

Kinky or curly hair textures are and susceptible to damage. As a result, people with curlier hair textures often wear protective hairstyles, such as weaves, braids, and twists, which help maintain hair length and health by keeping the ends of the hair tucked away and minimizing manipulation.

After receiving the instructions, Lewis scoured the internet and social media channels to see if she could find more information on best practices. But she noticed that for people with thick and textured hair, there were few tips on best hairstyles for an EEG.

Lewis has thick, curly hair and believed that explicitly following the instructions on the preparation worksheet would make it harder, not easier, for the technician to reach her scalp. Lewis decided that her mini-twists — a protective style in which the hair is parted into small sections and twisted — would be the best way for her to show up to the appointment with clean and product-free hair that still allowed for easy access to her scalp.

Lewis felt comfortable with her plan and did not think about it again until she received a reminder email the day before her EEG and MRI appointment that restated the restrictive instructions and added a warning: Failure to comply would result in the appointment being rescheduled and a $50 same-day cancellation fee.

To avoid the penalty, Lewis emailed the facility with her concerns and attached photos.

“I got kind of worried, and I sent them pictures of my hair thinking that it would go well, and they would be, like, ‘Oh yeah, that’s fine. We see what you see,’” said Lewis.

Soon after, she received a call from the facility and was told she would not be able to get the procedure done with her hair in the twists. After the call, Lewis posted a detailing the conversation. She expressed her frustration and felt that the person on the phone was “close-minded.”

“As a Black woman, that is so exclusionary for coarse and thick hair. To literally have no product in your hair and show up with it loose, you’re not even reaching my scalp with that,” Lewis said in her video.

The comments section on Lewis’ TikTok video is full of people sharing in her frustration and confusion or recounting similar experiences with EEG scheduling.

West 14 Street MedicalArts declined to comment for this article.

The New York medical center is not the only facility with similar EEG prep instructions. , which has several locations in the Washington, D.C., area, provides EEG for patients reading, “Please remove any hair extensions or additions. Do not use hair treatment products such as hair spray, conditioners, or hair dressing, nor should you fix your hair in tight braids or corn rows.”

Marc Hanna, the neurophysiology supervisor at the center’s White Oak location in Silver Spring, Maryland, has more than 30 years of experience performing EEGs. He oversees 10-12 EEG technicians at the facility.

Hanna said the hair rules are meant to help a technician get an accurate reading from the test. “The electrodes need to sit flat on the scalp, and they need to be in precise spots on the scalp that are equally apart from each other,” Hanna said.

For people with thick and curly hair, this can be a challenge.

A from Science News detailed a study that measured how much coarse, curly hair could interfere with measuring brain signals. A good EEG signal is considered to have less than 50 kilo-Ohms of impedance, but the researchers found unbraided, curly hair with standard electrodes yielded 615 kilo-Ohms.

Researchers are working to better capture brain waves of people with naturally thick and curly hair. , a biomedical engineering major at the University of Miami, developed a clip-like device that can help electrodes better adhere to the scalp.

Experimentation with different braiding patterns and flexible electrode clips shaped like dragonfly wings, designed to push under the braids, has had promising results. A study, published by bioRxiv, found this method resulted in a reading well measurement.

But more research has to be done before products like these are widely used by medical facilities.

Hanna said the facility where he works does not automatically ask patients to remove their protective styles because sometimes the technician can complete the test without them doing so.

“Each one of those cases are an individual case,” Hanna said. “So, at our facility, we don’t ask the patient to take all their braids out. We just ask them to come in. Sometimes, if one of the technicians are available when the patient is scheduling, they’ll just look at the hair and say, ‘OK, we can do it’ or ‘We don’t think we can do it.’ And we even might say, ‘We don’t think we can do it but come in and we’ll try.’”

In practice, Hanna said, it’s not common for hair to be an issue. But for patients whose hairstyle might make the test inaccurate, he said, it becomes a conversation between the doctor and the patient.

When Lewis arrived the following day for her MRI and EEG appointment, she was told her EEG had been canceled.

“It was just kind of baffling a little bit because, literally, as soon as I walk in, I saw about four different Black women who all had either twists, locs, braids, or something,” she said. “And on the call, the woman was saying if you come in and my hair is not loose, we’re going to charge you. And she did recommend to cancel my appointment. But I never approved that.”

After Lewis explained what happened during the phone call, she said, the receptionist was very apologetic and said the information Lewis was given was not true. Lewis said she spoke with one of the EEG technicians at the facility to confirm that her mini-twists would work for the test — and felt a sigh of relief when she saw the technician was also a Black woman.

“The technician, I think overall, they just made me feel safe,” Lewis said. “Because I felt like they could identify with me just from a cultural standpoint, a racial standpoint. So, it did make me feel a little bit more valid in my feelings.”

Lewis later returned to the facility to get the procedure done while still wearing mini-twists. This time, the process was seamless.

Her advice for other patients? “When you feel something, definitely speak out, ask questions.”

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El consultorio de Miami donde programó lo que se conoce como levantamiento (lifting) de glúteos brasileño había cerrado y transferido sus registros a un centro diferente, explicó. El precio que le ofrecieron, y que pagó por adelantado, aumentó el día de la intervención, y no conoció a su cirujano hasta poco antes de recibir anestesia general.

“Estaba lista para irme”, afirmó Ruston, de 44 años, de Lake Alfred, en Florida Central. “Pero ya había pagado todo”.

Pocos días después de la intervención, que fue en julio, Ruston fue hospitalizada por una infección, pérdida de sangre y náuseas, según consta en su historial médico.

“Busqué lo más barato, eso es lo que hice”, recordó Ruston recientemente. “Busqué el precio más bajo y lo encontré en Instagram”.

A personas como Ruston se las atrae para que vayan a centros de cirugía en consultorios del sur de Florida. Ocurre a través de marketing en redes sociales que muestran al levantamiento de glúteos brasileño, y a otras cirugías cosméticas, como engañosamente indoloras, seguras y asequibles, según investigadores, defensores de pacientes y asociaciones de cirujanos.

A diferencia de los centros de cirugía ambulatoria y de los hospitales, en donde un paciente puede pasar la noche en observación después del tratamiento, los centros de cirugía en consultorios ofrecen procedimientos que no suelen requerir hospitalización, y están regulados como una extensión de la consulta privada de un médico.

Pero estos centros suelen ser propiedad de corporaciones que ofrecen precios reducidos contratando a cirujanos a los que se incentiva para que atiendan al mayor número posible de pacientes al día, en el menor tiempo posible, según reguladores estatales y médicos que son críticos de estos centros.

Ruston dijo que ahora vive con un dolor constante, pero a otras pacientes un levantamiento de glúteos brasileño les ha costado la vida. Después de una serie de muertes, y a falta de normas nacionales, los reguladores de Florida fueron los primeros en promulgar destinadas a hacer que los procedimientos sean más seguros. Más de tres años después, los datos muestran que .

Los defensores de los pacientes y algunos cirujanos —incluidos los que realizan el procedimiento ellos mismos— anticipan que el problema empeorará. Las impuestas por la junta médica del estado en junio expiraron en septiembre, y el modelo de negocio popularizado en Miami se ha extendido a otras ciudades.

“Estamos viendo entidades con una fuerte huella en la cirugía estética de alto volumen y bajo costo, con sede en el sur de Florida, que han aparecido en otras partes del país”, señaló el , vicepresidente de la Sociedad Americana de Cirujanos Plásticos y médico en Houston, Texas.

Durante un levantamiento de glúteos brasileño, se extrae grasa mediante liposucción de otras zonas del cuerpo, como el torso, la espalda o los muslos, y se inyecta en los glúteos. En 2021 se realizaron en todo el país más de 61,000 procedimientos de aumento de glúteos, tanto levantamientos como implantes, lo que supone un alza del 37% respecto al año anterior, según , un grupo de cirujanos plásticos.

Como ocurre con toda cirugía, pueden surgir complicaciones. El forense del condado de Miami-Dade ha documentado casi tres docenas de muertes de pacientes de cirugía estética desde 2009, de los cuales 26 fueron consecuencia de un levantamiento de glúteos brasileño. En cada caso, el paciente murió de una embolia pulmonar grasa, es decir, la obstrucción de vasos sanguíneos por grasa que entró a través de las venas en los músculos de los glúteos e impidió que la sangre fluyera a los pulmones.

Ningún sistema nacional de informes o códigos de aseguradoras hacen un seguimiento de los resultados y los datos demográficos de los pacientes que se realizan un levantamiento de glúteos brasileño.

A nivel mundial, a cerca de un 3% de los cirujanos se les ha muerto un paciente como resultado del procedimiento, según un de un grupo de trabajo de la Fundación para la Educación e Investigación de la Cirugía Estética.

Expertos médicos dijeron que el problema surge, en parte, al tener a asistentes médicos y a enfermeras realizando partes clave del levantamiento de glúteos en lugar de a médicos. También es la consecuencia de un modelo de negocio motivado por los beneficios, no por la seguridad, que incentiva a los cirujanos a superar el número de operaciones estipulado en sus contratos.

En mayo, después de que muriera el quinto paciente en varios meses por complicaciones en el condado de Miami-Dade, el doctor Kevin Cairns propuso una norma estatal de emergencia para limitar el número de operaciones de levantamiento de glúteos que un cirujano pudiera realizar al día.

“Estaba harto de leer sobre mujeres que morían y de ver casos que llegaban a la junta”, explicó Cairns, médico y ex miembro de la Junta de Medicina de Florida.

Algunos médicos realizaban hasta siete cirugías, según expedientes disciplinarios contra cirujanos abiertos por el Departamento de Salud de Florida. La norma de emergencia las limitaba a no más de tres, y exigía el uso de una ecografía para ayudar a los cirujanos a reducir el riesgo de coágulo de grasa pulmonar.

Pero un grupo de médicos que realizan operaciones de levantamiento de glúteos brasileño en el sur de Florida, respondió formando la organización . Argumentaron que los nuevos requisitos empeorarían la situación. Los médicos calificados tendrían que hacer menos procedimientos, dijeron, lo que llevaría a los pacientes a acudir a profesionales médicos peligrosos que no siguen las reglas.

Desde entonces, el grupo ha donado más de $350,000 al Partido Republicano del estado, a candidatos republicanos y a comités de acción política republicanos, según datos de contribuciones a campañas del Departamento de Estado de Florida.

Surgeons for Safety declinó las repetidas solicitudes de entrevista de KHN. Aunque el presidente del grupo, , escribió , en agosto, que estaba de acuerdo en que no todos han seguido los estándares de cuidado, calificó de “arbitrarios” los límites impuestos a los cirujanos. La norma sienta “un precedente histórico de controlar a los cirujanos”, declaró durante una reunión con la junta médica de Florida.

En enero, la senadora republicana por Florida, Ileana García, presentó ante la legislatura estatal que propone que no haya límite en la cantidad de levantamiento de glúteos brasileños que un cirujano pueda realizar en un día. En cambio, requiere que los centros de cirugía en consultorios, en donde se realizan los procedimientos, cuenten con un médico por paciente, y prohíbe que los cirujanos trabajen en más de una persona a la vez.

El proyecto de ley también permitiría a los cirujanos delegar algunas partes del procedimiento a otros médicos bajo su supervisión directa, y el cirujano debe usar un ultrasonido.

La legislatura de Florida se vuelve a reunir el 7 de marzo.

Se pide precaución a los consumidores que estén pensando en someterse a procedimientos estéticos. Al igual que Ruston, muchas personas basan sus expectativas en las fotos del antes y el después, y en los videos de marketing publicados en plataformas de redes sociales como Facebook, Snapchat e Instagram.

“Eso es muy peligroso”, afirmó Basu, de la Sociedad Americana de Cirujanos Plásticos. “Se entusiasman con un precio bajo y se olvidan de hacer los deberes”, añadió.

El precio promedio de un levantamiento de glúteos en 2021 fue de $4,000, según datos de la Aesthetic Society. Pero eso es solo por los honorarios del médico y no cubre la anestesia, los costos de la sala de operaciones, las recetas y otros gastos. Un levantamiento de glúteos brasileño “seguro”, realizado en un centro acreditado y con los cuidados postoperatorios adecuados, cuesta entre $12,000 y $18,000, según en el sitio web de la Sociedad Americana de Cirujanos Plásticos.

Aunque Florida requiere una licencia médica para realizar una liposucción en pacientes que están bajo anestesia general, es común que profesionales médicos de nivel medio, como los asistentes médicos y las enfermeras, realicen el procedimiento en un consultorio, según el , coautor del estudio, de 2017, del grupo de trabajo de la Fundación para la Educación e Investigación de la Cirugía Estética.

Al depender de personal que no tiene la misma capacitación especializada y recibe menos paga, los cirujanos que trabajan en consultorios pueden completar más levantamientos de glúteos por día y cobrar un precio más bajo.

“Los hacen todos a la vez, en tres o cuatro salas distintas, y los atiende un solo cirujano”, explicó Mofid, cirujano plástico en San Diego, quien agregó que él no realiza más de un levantamiento de glúteos brasileño al día. “El cirujano no es quien está sobre el caso real, son sus asistentes”.

Basu dijo que los pacientes deben preguntar si su médico puede realizar el mismo procedimiento en un hospital o un centro de cirugía ambulatoria, donde hay reglas más estrictas que en los consultorios, en términos de quién puede realizar levantamiento de glúteos y cómo deben hacerse.

Se les recuerda a las personas en busca de gangas que la cirugía estética puede tener otros más allá de los mortales coágulos de grasa, como infecciones y perforación de órganos, además de problemas en los riñones, el corazón y los pulmones.

A la cirugía de Ruston la realizó un cirujano plástico certificado que dijo haber encontrado en Instagram. En un principio se le presupuestó $4,995, que dijo haber pagado en su totalidad antes de la cirugía. Pero cuando llegó a Miami, contó que la clínica agregó cargos por liposucción, y por prendas y dispositivos posquirúrgicos.

“Terminé pagando unos $8,000 “, dijo Ruston. Pocos días después de regresar a Lake Alfred, Ruston empezó a sentirse mareada y débil, y llamó al 911.

Los paramédicos la llevaron a la sala de emergencias, donde le diagnosticaron anemia por pérdida de sangre e infecciones sanguíneas y abdominales, según su historia clínica.

“Si pudiera volver atrás en el tiempo”, concluyó, “no me lo habría hecho”.

Chaseedaw Giles, de KHN, colaboró con este informe.

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The office in Miami where she scheduled what’s known as a Brazilian butt lift had closed and transferred her records to a different facility, she said. The price she was quoted — and paid upfront — increased the day of the procedure, and she said she did not meet her surgeon until she was about to be placed under general anesthesia.

“I was ready to walk out,” said Ruston, 44, of Lake Alfred in Central Florida. “But I had paid everything.”

A few days after the July procedure, Ruston was hospitalized due to infection, blood loss, and nausea, her medical records show.

“I went cheap. That’s what I did,” Ruston recalled recently. “I looked for the lowest price, and I found him on Instagram.”

People like Ruston are commonly lured to office-based surgery centers in South Florida through social media marketing that makes Brazilian butt lifts and other cosmetic surgery look deceptively painless, safe, and affordable, say researchers, patient advocates, and surgeon groups.

Unlike ambulatory surgery centers and hospitals, where a patient might stay overnight for observation after treatment, office-based surgery centers offer procedures that don’t typically require an inpatient stay and are regulated as an extension of a doctor’s private practice.

But such surgical offices are often owned by corporations that can offer discount prices by contracting with surgeons who are incentivized to work on as many patients per day as possible, in as little time as possible, according to state regulators and physicians critical of the facilities.

Ruston said she now lives with constant pain, but for other patients a Brazilian butt lift cost them their lives. After a rash of deaths, and in the absence of national standards, Florida regulators were the first in the nation to enact meant to make the procedures safer. More than three years later, data shows .

Patient advocates and some surgeons — including those who perform the procedure themselves — anticipate the problem will only get worse. imposed by the state’s medical board in June expired in September, and the corporate business model popularized in Miami is spreading to other cities.

“We’re seeing entities that have a strong footprint in low-cost, high-volume cosmetic surgery, based in South Florida, manifesting in other parts of the country,” said , a vice president of the American Society of Plastic Surgeons and a practicing physician in Houston.

During a Brazilian butt lift, fat is taken via liposuction from other areas of the body — such as the torso, back, or thighs — and injected into the buttocks. More than 61,000 buttock augmentation procedures, both butt lifts and implants, were performed nationwide in 2021, a 37% increase from the previous year, from the Aesthetic Society, a trade group of plastic surgeons.

As with all surgery, complications can occur. Miami-Dade County’s medical examiner has documented nearly three dozen cosmetic surgery patient deaths since 2009, of which 26 resulted from a Brazilian butt lift. In each case, the person died from a pulmonary fat embolism, when fat entered the bloodstream through veins in the gluteal muscles and stopped blood from flowing to the lungs.

No national reporting system nor insurance code tracks outcomes and patient demographics for a Brazilian butt lift. About 3% of surgeons worldwide had a patient die as a result of the procedure, according to a from an Aesthetic Surgery Education and Research Foundation task force.

Medical experts said the problem is driven, in part, by having medical professionals like physician assistants and nurse practitioners perform key parts of the butt lift instead of doctors. It’s also driven by a business model that is motivated by profit, not safety, and incentivizes surgeons to exceed the number of surgeries outlined in their contracts.

In May, after a fifth patient in as many months died of complications in Miami-Dade County, Dr. Kevin Cairns proposed the state’s emergency rule to limit the number of butt lifts a surgeon could perform each day.

“I was getting sick of reading about women dying and seeing cases come before the board,” said Cairns, a physician and former member of the Florida Board of Medicine. They argued the new requirements would make the situation worse. Qualified doctors would have to do fewer procedures, they said, thus driving patients to dangerous medical professionals who don’t follow rules.

The group has since donated more than $350,000 to the state’s Republican Party, Republican candidates, and Republican political action committees, according to campaign contribution data from the Florida Department of State.

Surgeons for Safety declined KHN’s repeated interview requests. Although the group’s president, , wrote in that he agreed not all surgeons have followed the standard of care, he called the limits put on surgeons “arbitrary.” The rule sets “a historic precedent of controlling surgeons,” he said during a meeting with Florida’s medical board.

In January, Florida state Sen. Ileana Garcia, a Republican, filed a that proposes no limit on the number of Brazilian butt lifts a surgeon can perform in a day. Instead, it requires office surgery centers where the procedures are performed to staff one physician per patient and prohibits surgeons from working on more than one person at a time.

The bill would also allow surgeons to delegate some parts of the procedure to other clinicians under their direct supervision, and the surgeon must use an ultrasound.

Florida’s legislature convenes on March 7.

Consumers considering cosmetic procedures are urged to be cautious. Like Ruston, many people base their expectations on before-and-after photos and marketing videos posted on social media platforms such as Facebook, Snapchat, and Instagram. on the American Society of Plastic Surgeons’ website.

Although Florida requires a physician’s license to perform liposuction on patients who are under general anesthesia, it’s common in the medical field for midlevel medical practitioners, such as physician assistants and nurse practitioners, to do the procedure in office settings, according to , who co-authored the 2017 Aesthetic Surgery Education and Research Foundation task force study.

By relying on staffers who don’t have the same specialty training and get paid less, office-based surgeons can complete more butt lifts per day and charge a lower price.

“They’re doing all of them simultaneously in three or four different rooms, and it’s being staffed by one surgeon,” said Mofid, a plastic surgeon in San Diego, who added that he does not perform more than one Brazilian butt lift in a day. “The surgeon isn’t doing the actual case. It’s assistants.”

Basu said patients should ask whether their doctor holds privileges to perform the same procedure at a hospital or ambulatory surgery center, which have stricter rules than office surgery centers in terms of who can perform butt lifts and how they should be done.

People in search of bargains are reminded that cosmetic surgery can have other beyond the deadly fat clots, such as infection and organ puncture, plus problems with the kidneys, heart, and lungs.

Ruston’s surgery was performed by a 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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“I immediately called my mom and said, ‘Mom, is it possible that I have random siblings out there somewhere?'” said Woock, of Indianapolis. She recalled her mom responded, “No, why? That’s ridiculous.”

But the messages continued, and some of them mentioned an Indianapolis fertility practice that she knew her mom had consulted when she had trouble conceiving.

Woock researched and finally learned the truth. Dr. Donald Cline, the fertility doctor her mother saw in 1985, is her biological father.

“I went through an identity crisis,” she said. “I couldn’t look in the mirror and think about, ‘Where did my eyes come from? Where did my hair color come from?’ I didn’t even want to think about any of that.”

Woock hadn’t known that her mom had used artificial insemination to conceive her, and neither of them knew the doctor had used his own sperm.

“We now know Cline used his own sample and squirted it into my mom,” Woock said.

In the 1970s and ’80s, Cline deceived dozens of patients and used his sperm to impregnate them. He has more than 60 biological children — and counting.

For Woock, as the story of her parentage sunk in, it was distressing for another reason: She wanted to start her own family and was having trouble conceiving. And now she needed to turn to the fertility industry that had so badly betrayed her mom.

“We were doing all of the calendaring … everything that is out there to help you get pregnant, we were doing that,” Woock recalled.

But after six months, when she still wasn’t pregnant at 32, she went to a fertility clinic for some tests.

“I had to fill out all this paperwork, and there’s a slot that says kind of like, ‘Is there anything else you’d like to share?’ ” Woock said.

Yes, there most certainly was.

The Odds Of ‘Fertility Fraud’ These Days

New allegations of doctors using their own sperm keep coming to light — because of genetic-testing services like Ancestry revealing networks of half siblings — in states like , Ohio, Colorado and Arkansas.

But those doctors performed artificial inseminations decades ago. Could what happened to Woock’s mom happen in a modern fertility clinic?

Dr. Bob Colver, a fertility specialist in Carmel, Indiana, said it’s a question many of his patients have asked. But it’s unlikely, he said. These days, there are more people involved in the process, and in vitro fertilization happens in a lab, not an exam room.

“Unless you’re in a small clinic where there’s absolutely no checks and balances, I can’t even imagine that today,” Colver said.

It’s now illegal in  for a doctor to use his sperm to impregnate his patients. But there’s no national law criminalizing what’s called “fertility fraud.”

Fertility medicine has advanced a lot since the 1980s, but women trying to get pregnant today with the help of medicine face a baffling array of treatment options that can be hard to navigate and can be hugely expensive. And some critics say the growing, multibillion-dollar fertility industry needs more regulation.

For example, sperm banks may not get accurate medical histories from their donors, who could pass along genetic diseases. And there’s no limit on how many times a donor’s sperm can be used, which some donor children worry could increase the chance of inbreeding. Sperm donation guidelines from organizations like the American Society for Reproductive Medicine are voluntary. There was a contestant on  last year who said his sperm had helped father more than 100 kids.

Unrealistic Expectations

When Woock decided to get her first fertility treatment, she set preconditions with the clinic. She insisted on having a female doctor and insisted that a doctor be in the room for all appointments and oversee everything that happened.

Her experience with her clinic was very different from her mother’s with Cline, but nonetheless there were surprises along the way.

The clinic told her that her problems conceiving could be because of husband Rob’s low sperm count and motility (meaning his sperm weren’t great swimmers). They advised a form of in vitro fertilization that involved injecting one sperm directly into one of her eggs in a petri dish.

When doctors told Woock she needed IVF, she felt pretty optimistic.

“I’m thinking going into this that our chances of success are 70, 75%,” Woock said.

Fertility treatment can be really expensive, and patients may start treatment with unrealistic expectations. That’s because success rates are complicated, and some clinics use only the best numbers in their .

For example, clinics can advertise high fertilization rates. But a 70% fertilization rate doesn’t mean 70% of eggs turn into babies — plenty can go wrong after the lab combines egg and sperm.

Success depends on your age, your clinic and the type of procedure you need. But most of the time, assisted reproduction procedures such as IVF don’t work. The Centers for Disease Control and Prevention, which  in the U.S., reports only about 24% of attempts result in a baby.

‘Add-On’ Technology — And Prices

When Woock started her first IVF cycle, she gave herself shots, a couple a day, to stimulate her ovaries to get multiple eggs ready at once. Multiple eggs means more chances for fertilization.

But the drugs have side effects. They gave her headaches and made her moody and less patient.

“I was actually allergic to one of the medications, which just means that you keep taking it and deal with the itching and rash,” Woock said.

But she hung on until it was time for a doctor to surgically retrieve her eggs, at which point patients can face even more choices. Because the couple’s fertility problem appeared to be with Rob’s sperm, the clinic offered to use a special device to help pick the best sperm for IVF.

“We were kind of like, ‘Yeah, why wouldn’t you?'” Woock said. “If it’s gonna give us a better chance, do it.”

A device like that is called an add-on. Add-ons are often new technology, described as cutting-edge, which can appeal to patients. Examples of add-ons include — which some specialists argue improves the odds of a live birth — and Ìý²¹²Ô»åÌý, both methods claiming to facilitate implantation.

Jack Wilkinson, a biostatistician at the University of Manchester in England, , which he has found can increase costs — and, he said, they may not work.

“We quite often see there’s no benefit at all,” Wilkinson said. “Or, possibly even worse, that there’s a disadvantage of using that treatment.”

Wilkinson said the device Woock’s clinic offered could work, but the evidence supporting it is thin.

Failed Fertilizations

The clinic called Woock the morning after her egg retrieval. None of Woock’s eggs fertilized. The procedure revealed that her husband’s sperm quality wasn’t the only fertility issue the couple faced.

“They immediately saw that there was something wrong with my eggs,” Woock said. “My eggs are just total crap.”

She underwent a second round of IVF with the same result — no fertilization.

“Getting that news the second time … felt even more set in stone that this was going to be a very long, challenging road,” Woock said.

Challenging and expensive. Most states, including Indiana, don’t require insurers to cover fertility treatment. Without insurance, a round of IVF can cost more than $10,000 — even more than $20,000 — with no guarantee the patient will get pregnant.

Woock was lucky that her employer-provided insurance covered a lot. But it still wasn’t cheap. She had to pay for some medications, “plus, you have to pay lab and facility fees that insurance doesn’t pay,” Woock said.

Donor sperm and eggs aren’t generally covered, either. Those can be tens of thousands of dollars.

Woock faced a hard choice: After two failed attempts, did she want a kid enough to go through IVF again? She and her husband decided they did. So Woock did a third round of IVF. And then a fourth. When that didn’t work, she gave up on using her own eggs.

“What I expected as I was growing up and picturing my children is not what I will see,” Woock said.

Woock and her husband decided to try donor eggs. If all goes according to plan, she could still carry a child. She wants to keep trying.

“I realize that pregnancy is incredibly challenging on your body and your mental state,” she said. “If I can make it through a year of IVF, I can make it through morning sickness.”

This story is part of a partnership that includes , and Kaiser Health News. The story was adapted from Episode 6 of the podcast . You can hear more about the fallout from Dr. Donald Cline’s deception on Sick’s first season, at .

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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• The term “health care costs” means different things to different people. For most of the public, it refers to the amount they must pay out-of-pocket for premiums, deductibles and services. For policymakers, it often means the total amount the U.S. spends on the health care system. That often creates a disconnect.
• Even small changes to the way drugs are priced and ending surprise medical bills might end up satisfying many members of the public, although those adjustments might have a minimal effect on overall health spending.
• Republicans are as divided as Democrats on health care. That is the main reason Republicans did not repeal the Affordable Care Act in 2017 and why there has been no major Republican replacement proposal since then.
• Many of the Democrats running for president, meanwhile, continue to advocate for a “Medicare for All” program run by the government, although many are hedging their bets by supporting other, less sweeping proposals to expand coverage, as well.

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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Donald Rucker, who coordinates health information technology policy for the Department of Health and Human Services, said he expects that the rules, first proposed in March, will give patients new power to shop for care based on price and quality.

Consumers have long sought more knowledge about health care prices, but administration officials cautioned it could take two years or more for it to appear in a user-friendly form on a phone app. Many specifics, including how patients would make sense of complex pricing policies for purchasing health care and insurance and assessing quality via an app, remain unclear.

Rucker said in remarks prepared for a Senate Health, Education, Labor & Pensions Committee hearing Tuesday that patients “have few ways if any to anticipate or plan for costs, lower or compare costs, and, importantly, measure their quality of care or coverage relative to the price they pay.”

The Trump administration proposal comes amid growing outrage from patients hit with seemingly exorbitant “surprise” medical bills. One study found that these bills — which are for amounts far more than the patient anticipated or for care not covered by insurance — have bedeviled more than half of American adults.

The Senate committee is reviewing regulations proposed under the 21st Century Cures Act, a law passed in 2016 to promote innovation in health care.

Dr. Kate Goodrich, the chief medical officer for the federal government’s Centers for Medicare & Medicare Services, said the agency wants every American to have an electronic health record (EHR) that will follow them as they move through the health care system, “giving them the data they need to make the best decisions for themselves and their families.”

Everyone, Goodrich said in her prepared statement to the committee, “should be able, without special effort or advanced technical skills, to see, obtain, and use all electronically available information that is relevant to their health care, and choices — of plans, providers, and specific treatment options.”

Meeting these goals could prove to be a tall order. For well over a decade, federal officials have struggled to set up a digital records network capable of widespread sharing of medical data and patient records. In 2004, President George W. Bush said he hoped to have a digital record for most Americans within five years. In early 2009, the Obama administration picked up the challenge and funneled billions of dollars in economic stimulus money into a campaign to help doctors and hospitals buy the software needed to replace paper medical files.

Critics argue that poor oversight over the stimulus spending and objectives has saddled many doctors and hospitals with flawed software that typically cannot share information across health networks as promised. It has also caused new types of errors that compromise the safety of patients.

“,” a recent investigation published by Kaiser Health News and Fortune, found that the federal government has spent more than $36 billion on the EHR initiative. Thousands of reports of deaths, injuries and near misses linked to digital systems have piled up in databases over the past decade — while many patients have reported difficulties getting copies of their complete electronic files, the investigation found.

Despite the slow progress, federal officials remain optimistic that digital records will save the nation billions of dollars while reducing medical errors, unnecessary medical testing and other waste — and encouraging more Americans to take a bigger role in managing their health care by comparing prices.

But Sen. Lamar Alexander, R-Tenn., the committee’s chairman, said the results would have been better had officials not rushed out the stimulus plan. “I am especially interested in getting where we want to go with input from doctors, hospitals, vendors, and insurers, so we have less confusion, make the fewest possible mistakes, and make sure we don’t set some kind of unrealistic timeline,” he said in a statement.

Anger over the lack of easy access to health care has dominated public on the proposed regulation posted on a government website.

“The proposed policy to mandate disclosure of health care pricing by hospitals, insurance companies, etc. is one of the most important in American history. That is not hyperbolic,” one anonymous commenter wrote, adding: “The only way to save money on healthcare in America is to never receive it.”

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El análisis, presentado recientemente en Austin y en Atlanta, donde los CDC tiene su sede, abarcó 87 días del otoño pasado en Austin, cuando casi 200 personas resultaron heridas en choques con scooters. Solo uno de los ciclistas llevaba casco y para el 33% de los heridos era su primer viaje en scooter.

Los funcionarios de la ciudad de Austin pidieron ayuda a los CDC para rastrear lesiones cuando se dieron cuenta que los scooters estaban tomando el control de la ciudad. Los investigadores identificaron a 271 personas con posibles incidentes de lesiones relacionadas con estas patinetas. De ellas, 190 confirmaron haber sufrido una lesión relacionada con el uso del llamado e-scooter. La mayoría de los accidentes ocurrieron en las calles, con patinetas manejadas por hombres. Entre los heridos, el 48% sufrió una fractura, laceración o abrasión en la cabeza; 70% lesiones de las extremidades superiores; y 55% en extremidades inferiores. De los 190 analizados, el 35% sufrió algún tipo de fractura.

A pesar de las lesiones, el 38% dijo que volverá a usar un scooter.

“Estas lesiones podrían haberse prevenido”, concluyó el estudio. “Los estudios han demostrado que los ciclistas reducen el riesgo de lesiones en la cabeza y el cerebro al usar un casco. El uso del casco también podría reducir el riesgo de lesiones cerebrales y en la cabeza en caso de que se produzca un accidente con una patineta eléctrica”.

Con la creciente disponibilidad de scooters como alternativa en el tránsito urbano, Austin y otras ciudades del mundo están tratando de equilibrar la seguridad y las necesidades de los conductores de scooters y de los automovilistas, ciclistas y peatones que deben transitar, o caminar, alrededor de ellos en las aceras y calles.

Algunas localidades están prohibiendo totalmente los scooters, mientras que otras intentan controlar el número permitido o especificar límites de uso, o lugares para estacionarlos. Estas patinetas llegaron a Austin en abril pasado y rápidamente pasaron de cero a más de 15,000, mientras que 10 compañías obtuvieron licencias para operarlas, según el sitio web sobre estos medios de transporte de la ciudad.

Aunque no todos estos scooters están disponibles al mismo tiempo, las dos compañías con la mayor cantidad en Austin, Bird y Lime, cuentan en sus sitios web sobre la disponibilidad en más de 100 ciudades de todo el mundo. A medida que esos números continúan multiplicándose, el informe de los CDC ayudará a determinar cómo las ciudades deberían enfocar las normas de transporte, las regulaciones y la seguridad pública.

Paul Saffo, quien ha pasado más de 20 años explorando el impacto de grandes cambios a largo plazo, enseña pronósticos en la Universidad de Stanford. Dijo que las ciudades también deben considerar una pregunta fundamental sobre el uso privado de la propiedad pública.

“Los scooters están tirados en las aceras y están siendo utilizados por una empresa privada que obtiene beneficios del uso de la infraestructura pública. La pregunta es: ¿el público está siendo justamente compensado por el uso por parte de una empresa privada con fines de lucro de una infraestructura pública?”, se preguntó. “¿De quién es el derecho de paso? El peatón molesto por el scooter es probablemente un contribuyente”.

Los epidemiólogos de los CDC, colaborando con Austin Public Health y el Departamento de Transporte de la ciudad, llegaron a Austin en diciembre pasado para examinar las lesiones relacionadas con las patinetas de septiembre a noviembre, incluidas las entrevistas con los heridos y el estudio de sus registros médicos para determinar las condiciones de la carretera, el clima, el uso del casco y otros comportamientos, como el consumo de alcohol.

Laurel Harduar Morano, de los CDC, dijo: “Sabemos que nos estamos perdiendo casos de lesiones. Estas son las lesiones lo suficientemente graves como para requerir atención médica de emergencia”.

Entre los hallazgos, el 55% de los lesionados fueron identificados como hombres. La edad promedio fue de 29 años, aunque los conductores tenían entre 9 y 79 años. La mayoría de las lesiones (55%) ocurrieron en la calle, mientras que el 33% se lesionó en la acera.

El estudio también señala que los hallazgos no apoyan la percepción de que las lesiones en scooter se deben a colisiones con vehículos. Pero la velocidad es un factor, sugiere el estudio.

“Mientras que más de la mitad de los entrevistados resultaron heridos mientras conducían una patineta en la calle, solo el 10% sufrió lesiones al chocar con un vehículo”, encontró el estudio. Sin embargo, el 37% de los lesionados informaron que la velocidad excesiva del e-scooter contribuyó a su lesión. Y el 29% de los conductores de patinetas había consumido alcohol en las 12 horas anteriores.

“En general, el 63% de los lesionados habían montado un e-scooter nueve veces o menos antes de la lesión”, dijo el estudio.

“Este estudio es un primer paso crítico para que las ciudades adopten estándares claros de seguridad que todos los operadores deban cumplir”, dijo Paul Steely White, director de política de seguridad y defensa de Bird. “Aquí hay información procesable para conductores, operadores y ciudades”. Bird, con sede en Santa Mónica, California, apaga sus scooters entre la medianoche y las 5 am y limita la velocidad máxima a 15 mph.

Las lesiones, que se están registrando en hospitales y salas de emergencia en todo el país, han resultado en menos de una docena de muertes a nivel nacional, incluida una en Austin a principios de este año. Dos conductores de scooters murieron en marzo en California y otros dos fallecieron abril luego de ser atropellados por automóviles en Fort Lauderdale, Florida y Hollywood, California. También un niño de 5 años en Tulsa, Oklahoma, murió como consecuencia de un choque entre el scooter que manejaba su madre y un auto. La madre sufrió solo heridas leves.

El Senado de Texas aprobó un proyecto de ley para regular los e-scooters en todo el estado, lo que incluye prohibirlos en las aceras y a velocidades de más de 15 mph, así como establecer 16 como la edad mínima para manejarlos. La medida espera la aprobación de la Legislatura estatal.

Saffo, el pronosticador de Stanford, dijo que la discusión ahora debe ser “¿dónde encajan los scooters en opciones ecológicas de transporte cada vez más compleja?” Es mejor que las personas sepan cómo se sienten con respecto a los scooters rápidamente porque hay una gran variedad de opciones”, dijo.

La planificadora urbana Sarah Kaufman, directora asociada del Centro Rudin para el Transporte de la NYU, dijo que los scooters presentan un problema de seguridad para ciclistas y peatones, y depende de las ciudades proporcionar la infraestructura adecuada, como carriles protegidos o aceras más anchas.

“En algún momento, las ciudades tienen que cambiar las calles para alejarse de los autos como el modo principal de transporte”, dijo Kaufman. “No podemos cambiar el diseño de nuestras ciudades de la noche a la mañana, pero cuando pensamos en los planes a largo plazo, el automóvil no puede ser el medio de transporte dominante”.

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