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And abundant of the money is advancing beeline from the federal government.
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1000 Pushing Away Quotes on Pinterest | All I Want, Push Me Away ... | quotes about being pushed awayThe pill, alleged Nuedexta, is accustomed to amusement a ataxia apparent by abrupt and uncontrollable bedlam or arrant -- accepted as pseudobulbar affect, or PBA. This activity afflicts beneath than 1% of all Americans, based on a abacus application the drugmaker's own figures, and it is best frequently associated with bodies who accept assorted sclerosis (MS) or ALS, additionally accepted as Lou Gehrig's disease.
Nuedexta's banking success, however, is actuality propelled by a sales force focused on accretion the drug's use amid aged patients adversity from dementia and Alzheimer's disease, and high-volume prescribing and advancement efforts by doctors accepting payments from the company, CNN found.
Since 2012, added than bisected of all Nuedexta pills accept gone to abiding affliction facilities. The cardinal of pills rose to about 14 amateur in 2016, a jump of about 400% in aloof four years, according to abstracts acquired from QuintilesIMS, which advance biologic sales. Absolute sales of Nuedexta accomplished about $300 amateur that year.
Nuedexta is accustomed by the Aliment and Biologic Administration (FDA) to amusement anyone with PBA, including those with a array of acoustic altitude such as dementia. But aged physicians, dementia advisers and added medical experts told CNN that PBA is acutely attenuate in dementia patients; several said it affects 5% or less. And accompaniment regulators accept begin doctors afield diagnosing nursing home association with PBA to absolve application Nuedexta to amusement patients whose confusion, agitation and assertive behavior accomplish them difficult to manage.
"There has to be a assay for every biologic prescribed, and that assay has to be absolute ... it cannot be artlessly fabricated up by a doctor," said Kathryn Locatell, a aged physician who helps the California Department of Justice investigate cases of ancient corruption in nursing homes. "There is little to no medical abstract to abutment the drug's use in nursing home association (with dementia) -- the citizenry allegedly actuality targeted."
CNN articular dozens of cases above the country back 2013 in which accompaniment nursing home inspectors questioned the use of Nuedexta.
In a Los Angeles nursing home aftermost year, regulators begin that added than a division of its association -- 46 of 162 -- had been placed on Nuedexta, acquainted that a ability analyst had accustomed a allocution about the biologic to employees. This analyst was a paid apostle for Avanir.
At accession ability in 2015, additionally in Southern California, an agent accepted to inspectors that a citizen had been accustomed a assay of PBA to "somehow absolve the use" of Nuedexta, alike admitting its advised purpose was to ascendancy the resident's "mood disturbances" and babble out.
And an Ohio doctor paid by Avanir has appear beneath government assay for allegedly accepting kickbacks for prescribing the biologic and fraudulently diagnosing patients with PBA in adjustment to defended Medicare advantage -- admitting the doctor has denied any wrongdoing.
Based in Aliso Viejo, California, the maker of Nuedexta, Avanir Pharmaceuticals, has been cashing in on nursing homes.
The federal government foots the bill for a big allocation of the money actuality spent on Nuedexta in the anatomy of Medicare Part D decree biologic funding, for bodies 65 and over and the disabled. In 2015, the best contempo year for which abstracts is available, this Medicare affairs spent $138 amateur on Nuedexta -- up added than 400% from aloof three years earlier.
Medicare is declared to pay for biologic uses that accept been authentic safe and able for the citizenry they are advised to amusement or that accept been contrarily authentic by a specific accumulating of medical research. Nuedexta is currently alone accustomed by the FDA for patients who accept PBA. So experts say that Medicare advantage of the drug, which has been acute to its banking success, relies on the assay of this distinct condition. Alleged "off-label" prescribing, in which doctors use the biologic to amusement patients who accept not been diagnosed with PBA, would about not be covered.
The Centers for Medicare & Medicaid Casework (CMS) beneath to animadversion on the growing use of Nuedexta in nursing homes.
Thousands of the doctors prescribing Nuedexta accept accustomed money, or at atomic a meal, from its maker -- a accustomed but arguable convenance in the industry. Amid 2013 and 2016, Avanir and its ancestor company, Otsuka, paid doctors about $14 amateur for Nuedexta-related consulting, promotional speaking and added services, according to government data. The companies additionally spent $4.6 amateur on biking and dining costs, both for speakers and for doctors actuality targeted by salespeople.
A CNN assay additionally begin that about bisected the Nuedexta claims filed with Medicare in 2015 came from doctors who had accustomed money or added allowances from the aggregation (ranging from a few dollars' account of aliment or alcohol to hundreds of bags of dollars in absolute payments).
Pharmaceutical companies are accustomed to pay a doctor to advance a biologic to colleagues and added medical professionals. It is illegal, however, for doctors to appoint the biologic in barter for kickback payments from a manufacturer.
Several of these paid advocates of Nuedexta altercate that PBA manifests abnormally depending on the person. With dementia patients, they say, the archetypal arrant or bedlam outbursts apparent in assorted sclerosis patients may be absent. Instead, affection may accommodate moaning, wailing, hitting a wheelchair over and over afresh or repeating the aforementioned phrase. And they are determined that the medication can be life-changing for patients, touting how safe and amiable it is.
"I never hear, 'hey doc, we put a accommodating on this and had absolutely bad ancillary effects,'" said Jason Kellogg, a aged analyst who sees patients at nursing homes above California. Kellogg has accustomed $612,000 in payments, commons and biking from Avanir and its ancestor aggregation amid 2013 and 2016, according to government data. He was a top Medicare prescriber for the biologic in 2015, the best contempo year for which abstracts is available.
Kellogg, who said he was complex in aboriginal aggregation testing of the biologic for PBA, said Nuedexta is "such a absolution in psychiatry."
"In our treatments, we don't accept abounding meds that are able-bodied tolerated, and I would abhorrence if accession took that abroad from me," he said.
During the FDA approval process, two key doctors on the board aloft apropos about Nuedexta actuality acclimated for PBA in Alzheimer's patients. They both acerb recommended that Nuedexta alone be accustomed for PBA in patients with MS or ALS. They argued that affirmation it would be able in added altitude was "weak," that not abundant was accepted about the assurance of the biologic in the elderly, and that it was cryptic that PBA alike existed in Alzheimer's patients. Despite these concerns, the bureau accustomed Nuedexta in 2010 for alleviative PBA in patients who accept acoustic altitude such as dementia.
Soon afterwards Nuedexta hit the bazaar in 2011, doctors, nurses and ancestors associates began filing letters of abeyant abuse -- alignment from rashes, blackout and avalanche to comas and death. Nuedexta was listed as a "suspect" medication in about 1,000 alleged adverse accident letters accustomed by the FDA account ancillary effects, biologic interactions and added issues, CNN found. While the FDA uses these autonomous letters to adviser abeyant issues with a drug, a abode does not beggarly that a doubtable medication has been disqualified the account of the harm.
The FDA beneath to animadversion on these adverse contest or the apropos aloft about Nuedexta during the approval process. But it did say that afterwards any biologic is approved, the bureau continues to assay assurance advice from a array of sources (including adverse accident data) and will booty activity as bare -- such as afterlight a medication's label, akin its use or alike demography it off the bazaar entirely.
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Sometimes we push people away. This quote is the story of my life ... | quotes about being pushed awayLon Schneider, administrator of the University of Southern California's California Alzheimer's Ache Center, advised advice from about 500 of the letters which CNN acquired through a Freedom of Advice Act request. Schneider, a physician specializing in aged and dementia care, said he was anxious about the problems stemming from abeyant interactions amid Nuedexta and added able medications advised to amusement ambiguous behaviors.
He warned that accustomed how antibacterial the aged about are, abacus aloof one added bolus -- abnormally one that hasn't been abundantly activated -- could be dangerous.
One abode filed by a assistant practitioner in 2015 abundant the accelerated abatement of an 86-year-old Alzheimer's accommodating afterwards Nuedexta was added to the consciousness-expanding medications she took including Zoloft (an antidepressant), Xanax (an antianxiety drug) and Risperidone (an antipsychotic). Nuedexta had been assigned to amusement PBA and "weeping with basal Alzheimer's dementia."
Almost immediately, the woman accomplished weakness and fatigue to the point that she was almost able to allocution and was declared as actuality "almost unresponsive." The dosage of Nuedexta was increased, and her affection worsened. The biologic was discontinued about a anniversary later, but she bootless to recover. She remained clumsy to eat or alcohol and her kidneys bootless -- ultimately arch to her death.
"The accommodating seemed to be accomplishing fine," the assistant practitioner reported, "until she was placed on Nuedexta."
Advancing sales force
The aggregate of two all-encompassing drugs that makes up Nuedexta -- a ahem suppressant and affection medication -- was already accessible from specialty pharmacists accommodating to amalgamate the capacity for beneath than $1 a pill, according to a US Senate abode on ascent decree biologic prices.
Now the FDA-approved medication costs as abundant as $12.60 a pill, broad appraisement abstracts from Aboriginal Databank shows. That can add up to added than $9,000 a year, admitting the bulk a accommodating absolutely pays depends on factors including alone allowance coverage. Medicare Part D spending on the biologic averaged $3,400 per accommodating in 2015.
It is Avanir's capital artefact and bigger moneymaker. It has acquired absorption with the accessible through its television bartering featuring amateur Danny Glover seesawing amid amusement and tears. And it was this drug's banking abeyant that admiring Japanese biologic behemothic Otsuka to the bazaar California firm, purchasing Avanir for $3.5 billion several years ago. Otsuka beneath to animadversion for this story.
Avanir broker abstracts accept declared that alone a baby atom -- 100,000 of the 1.8 amateur patients adversity from abstinent to astringent PBA -- alive in abiding affliction facilities. Yet the aggregation has declared nursing homes as key to its growth.
On a 2013 balance call, Rohan Palekar, a top controlling who eventually became CEO but is no best with the company, said Avanir had "just aching the apparent of its abounding potential" in nursing homes, according to an online transcript. He said the aggregation aimed to get Nuedexta assigned in far added facilities. Palekar did not acknowledge to requests for comment.
To arbor up these prescriptions, salespeople articular doctors, nurses and pharmacists who could serve as advocates for the drug, according to interviews with above Avanir advisers and centralized abstracts and emails advised by CNN. Salespeople again formed carefully with these advocates to analyze abeyant patients. In one case, a agent formed with a doctor's appointment administrator to cull patients' charts, analyze those who should be alive for PBA and accomplish abiding that Nuedexta brochures were amid in their files. The sales force additionally accomplished doctors and ability advisers on how to action for Medicare advantage of the biologic if it was initially refused.
Federal laws bind the approach biologic sales assembly can use to advertise a medication. They can't accord favor or payments in barter for a doctor prescribing the drug. They can't accept any acquaintance with clandestine accommodating records, afterwards the patient's consent. And they can't advance use of a biologic off-label, in a way that hasn't been accustomed by the FDA.
Internal aggregation emails acquired by CNN appearance a ability abounding with acute burden to get the biologic awash and how Avanir sales assembly were encouraged to anon ambition dementia and Alzheimer's patients -- a convenance which is accustomed as continued as these patients additionally had PBA.
In an email from several years ago, one of the company's bounded managers, Kevin Tiffany, bluntly apprenticed his salespeople to absorb "99.9 percent" of their time focused on such patients.
Devoting time to added altitude added frequently associated with PBA amounted to "diluting your chances," wrote Tiffany, a chief sales administrator in California.
"Give yourself the best adventitious to win," Tiffany added.
Tiffany, who no best works for Avanir, beneath to animadversion through an attorney.
Other emails from managers appearance how the government's crackdown on alarming antipsychotic drugs -- which were already broadly acclimated to ascendancy assertive and aberrant behavior in nursing home patients -- created an befalling for Avanir.
After accepting the FDA's best astringent "black box" admonishing for an added accident of afterlife in aged dementia patients, antipsychotics are now carefully monitored by government regulators, who amerce and lower the ratings of accessories that overuse them. Centralized aggregation communications appearance Avanir salespeople were directed to accurately ambition accessories that historically acclimated aerial levels of antipsychotic medications -- accessories that would see Nuedexta as an adorable alternative.
Some of these approach alive by Avanir salespeople cantankerous into ethical gray areas, said medical ethicists and added experts who were apprehend the emails and sales training abstracts or provided with capacity from them.
"It absolutely feels like it is too abundant in the business of prescribing and not in the business of carrying information," said Michael Santoro, a Santa Clara University assistant and an able in biologic industry ethics."It feels like (the salespeople) are absolutely accommodating in the prescribing decision."
In its statement, Avanir said that the aggregation was committed to "an ethical culture," uses methods "that are constant with the law" and that its ambition is "to accord doctors truthful, authentic and counterbalanced advice so they can adjudge on the able assay for their patients."
Avanir admiral accept continued accustomed affairs for accepting FDA approval for Nuedexta's use to amusement dementia patients who don't accept PBA -- ambience their architect on the added boundless activity of agitation in dementia and Alzheimer's patients, characterized by affecting and concrete outbursts and alive behaviors. The aggregation appear analytic trials for testing a adaptation of the medication for this use in 2015, but those accept not yet been completed. Afterwards added FDA approval for the drug's use in those conditions, salespeople cannot advance Nuedexta for that purpose. They can alone bazaar its use for dementia patients who additionally accept PBA.
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Heartfelt Quotes: I'll never stop caring. But if you decide to ... | quotes about being pushed awayThose who affliction for the aged abide acquisitive for accoutrement to administrate these behaviors, however. Some caregivers say investments in added staffing can abate the charge for medications. But such measures are big-ticket and don't consistently work, so some accessories opt for biologic solutions that can advice accomplish their abounding patients easier to treat."Rather than demography accession off an antipsychotic" and opting to amusement the accommodating in bureau that don't crave medication, "providers chase for a altered 'magic bullet,'" said Helen Kales, a aged analyst and University of Michigan professor.
In one case, the controlling administrator of a California assisted alive ability approved to advance Nuedexta on a dementia accommodating to abode her "aggressive" behavior, according to emails advised by CNN. The administrator at the facility, Oakmont of Mariner Point in Alameda, California, told the patient's son, Jason Laveglia, that the medication wasn't an antipsychotic and threatened to adios his mother if she wasn't put on the medication.
"(I)f her behavior cannot be aerial through decree means, I would accept no best but to accompany carrying a 30-day boot notice," Joan Riordan wrote to Laveglia aftermost year.
Laveglia angry to the accompaniment for help, and by the time admiral advised weeks later, Riordan no best formed at the facility. Social account admiral ultimately begin that her boot attack had abandoned accompaniment law. A agent for the ability would not animadversion on the state's findings, but said it "does not endorse or acclaim Nuedexta nor any added medication" and that agents should not be complex in medical decisions.
In an account with CNN, Riordan accustomed the abstraction that her emails served as an official boot notice. Riordan, who is not a doctor, said that she had recommended Nuedexta afterwards acquirements about the medication from a bounded analyst and had apparent it advice a cardinal of added advancing dementia patients afterwards the dangers and allaying furnishings of an antipsychotic.
"I've apparent it aloof assignment wonders with people," she said. "It was the alone action I could appear up with. We bare to do article not alone for her own benefit, but additionally for the bodies about her."
When asked whether her association had PBA, Riordan told CNN she had never heard of the activity and had no ability of whether they had accustomed such a diagnosis.
Red flags and ambiguous use
Across the country, the use of Nuedexta in nursing homes has prompted apropos amid accompaniment regulators whose job is to ensure adherence to federal guidelines and assure association from actuality accustomed accidental drugs -- abnormally those acclimated as actinic restraints. But to date, the red flags aloft by these regulators accept been abundantly larboard alive in nursing home assay letters and accept fatigued little accessible attention.
CNN articular added than 80 cases in 19 states back 2013 area inspectors cited nursing homes for inappropriate ecology and use of Nuedexta -- generally because association hadn't apparent any affection of PBA. Abounding of the cases -- about 40% -- were amassed in Southern California, area Avanir is based and area above advisers said there has been advancing marketing.
At the Montrose Healthcare Center abreast Los Angeles, three nursing home association were accustomed Nuedexta afterwards a doctor's decree or approval, according to one assay report. All were cognitively impaired. One was accepted to alarm out for help, while accession would cry back their ancestors larboard the facility. But advisers accustomed that they had never apparent the association beam or cry involuntarily -- the authentication indicators of PBA.
Regulators abstruse of these prescriptions in 2015, afterwards a ancestors affiliate apparent that her about was accepting Nuedexta afterwards her consent. While researching the medication, she abstruse it could be alarming for her ancestors affiliate because of added medications she took for a austere affection condition.
The doctors for all three association denied anytime prescribing Nuedexta. Accompaniment board afterwards apparent nursing agents had acquired the prescriptions afterwards a doctor's approval, which they are not accustomed to do. They additionally begin that at atomic two nurses at the ability had abounding a sales academy about Nuedexta, area they were accustomed a doctor's sample decree for the medication. The ability said in a account that it had addressed the apropos aloft by the accompaniment assay abode and adapted that alfresco burden had been at play.
"Our Center does not disregard the pressuring of nurses by biologic reps and physicians to favor assertive medications," the ability said. "Should they feel pressured to administrate medications they do not feel are appropriate, our nurses can and should accompany it to our actual absorption so we may abetment them in advocating for their patients."
In New Jersey, St. Vincent's Healthcare and Rehab Center was cited by regulators aftermost year because six association were assigned Nuedexta alike admitting no affection of PBA had been documented. A adumbrative of the ability told CNN it takes a "close attending at all medications assigned to ensure adapted use."
One citizen in the abode told the facility's analyst there was a accepted acumen for their sadness: "All I absolutely appetite is a companion. I am lonely." In the case of accession citizen accustomed the medication, a assistant said the resident's arrant was an announcement of frustration, and that this had bigger with a change in routine.
Two added association at the ability were originally assigned Nuedexta for "Dementia with Behaviors."
Those diagnoses were again above out or rewritten -- replaced with "PBA."
The bolus pushers
At first, Alex Carington couldn't bulk out why her 85-year-old mother, Lenore Greenfield, was on Nuedexta, a bolus Carington had never heard of. A analyst had assigned the medication afterwards visiting the aged woman in her Los Angeles nursing home while she was sleeping, Carington said. Alike back the biologic appeared to do annihilation to affluence her mother's sadness, abashing or affecting outbursts as she battled dementia, she said the doctor kept her on it.
Alex Carington's mother, now 88, is no best on Nuedexta and lives at a new nursing home. But Carington still questions why she was assigned the bolus in the aboriginal place.
"Something about this accomplished affair fabricated me anticipate money was abaft it," Carington, who lived abreast her mother's ability and visited her often, wrote at the time in an online animadversion on the blog of a analyst who had questioned Nuedexta's advancing advertising.
As she began to attending into her mother's doctor, she apparent he had accustomed added than $100,000 from Avanir in aloof over a year.
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Best 25 Pushing away quotes ideas on Pinterest | Pushing people ... | quotes about being pushed awayOutraged, she assuredly got her mother taken off Nuedexta for good. Now, about two years later, she is in a new nursing home and Carington believes she is accomplishing abundant better.
Her mother's doctor was Romeo Isidro, a apostle for Avanir and one of the physicians paid the best by the drugmaker. Amid 2013 and 2016, Isidro accustomed added than $500,000 in payments, biking and commons from Avanir and its ancestor company. According to centralized aggregation documents, he was an apostle for Nuedexta as aboriginal as 2012, the year afterwards it hit the market.
He had added than 100 patients in 11 accessories on the biologic that year.
In Avanir training documents, a California agent explained how he formed to get Isidro to appoint Nuedexta. Now a chief sales administrator at the company, Chris Burch wrote in 2012 that he and his aide saw or batten to Isidro about alert a anniversary -- consistently calling and texting him, and visiting him at both his appointment and nursing homes. Burch wrote that Isidro was at aboriginal agnostic about the activity of PBA, but afterwards he auspiciously acclimated Nuedexta to amusement accessible affection of it in one patient, he became added adequate prescribing the medication. Burch again explained how he had anon targeted accessories area Isidro worked, award advisers who could serve as "advocate(s)" to advice analyze abeyant Nuedexta candidates for Isidro.
"He is now a apostle and I ask him to apostle in his facilities, accumulated facilities, and (to) added psychiatrists, internists and pharmacies," Burch, who did not acknowledge to requests for comment, wrote in a anatomy acclimated by the aggregation to clue assertive prescribers.
CNN attempted to acquaintance Isidro by buzz and by visiting his office, area two endless of PBA and Nuedexta pamphlets sat on a table in the cat-and-mouse room. He beneath to be interviewed but ultimately provided a accounting account adage that he had "never assigned medication for banking incentives" and that he prescribes Nuedexta to patients who he has appropriately diagnosed with PBA.
He additionally wrote about the aboriginal success he had apparent with the drug, and how it helped him wean an aged accommodating off of alarming consciousness-expanding medications -- acquainted that her inappropriate arrant and agreeable affection reminded him of a appointment from a Nuedexta adumbrative who had told him about PBA. He said Avanir approached him about acceptable a speaker, and that he agreed in adjustment to allotment his contiguous acquaintance with the medication -- not to advance it.
"Since acquirements about PBA, I accept become added accomplished at acquainted it in my patients, which would in about-face aftermath added numbers of patients on Nuedexta," he wrote. "I am not an apostle for a accurate biologic or biologic companies. I am an apostle for my patients and their families."
In acknowledgment to questions about Carington's mother, he said he couldn't animadversion on specific patients but that memories are not "infallible." He apprenticed CNN to actualize any claims with medical annal about her case. Carington provided her mother's annal to CNN, which accepted that Isidro had diagnosed her with PBA and assigned her Nuedexta, which she remained on for months.
Montrose Healthcare Center, a nursing ability in Montrose, California.
A altered apostle paid by Avanir, a pharmacist in arctic California, appeared to advance during a 2012 presentation that doctors could augment the use of Nuedexta back prescribing, according to an audio recording acquired by CNN. A actuality in attendance, who recorded the event, articular the pharmacist as Flora Brahmbhatt.
"I'm absolutely blame this a little bit, conceivably advised off characterization ... but maybe it's able on some of the added behaviors too that we acquisition challenging," the pharmacist said in her presentation, which was sponsored by Avanir. "There are assertive nursing home chains, accurately in Southern California, that are saying, 'Hey, if you accept somebody with dementia that has a behavior issue, try them on Nuedexta afore you put them on a consciousness-expanding (medication.)' It's a little aggressive, I'll say that. But CMS isn't authoritative it accessible for us to use antipsychotics anymore."
She went on to altercate how a PBA assay was capital for the medication to be "covered by allowance and not be off-label," as able-bodied as how PBA's analogue of inappropriate bedlam and arrant could be interpreted by physicians. At one point, she told an Avanir agent in the allowance that they could awning their ears.
"We don't accept anybody from the FDA in here. I'm cogent you ... you can extrapolate that to beggarly any affectionate of socially inappropriate behavior back you've disqualified out added causes," she said. "If they accept an anecdotal behavior and they accept an basal acoustic condition, you can appealing abundant appear up with a diagnosis."
When contacted by CNN about the accident and asked about the recorded statements, Brahmbhatt said she hadn't accustomed presentations about Nuedexta for abounding years. She said she didn't accord permission to be recorded and didn't anamnesis authoritative those statements. "I don't apperceive if I said this stuff," she said. "It was bristles years ago, at best." She was apprehend several of the quotes from the recording but beneath to accept to it. An apostle apery Brahmbhatt contacted CNN afterwards advertisement and said that Brahmbhatt denies authoritative the statements in the audio recording.
Former FDA investigator Larry Stevens, who now works for the consulting close The FDA Group, said it is a abuse of federal law for a paid apostle to advance a biologic for annihilation added than its FDA-approved use.
Yet accession paid speaker, the Ohio physician accused of accepting kickbacks in barter for prescribing Nuedexta, has been beneath government investigation. Centralized Avanir abstracts appearance Cleveland neurologist Deepak Raheja was a top prescriber of the biologic from the beginning, in 2011. Amid 2013 and 2016, he accustomed $289,000 in payments, commons and travel.
In accession to allegedly accepting kickbacks, Raheja is accused of fraudulently diagnosing patients with PBA in adjustment to defended Medicare advantage for off-label use and accretion dosages of Nuedexta above what is recommended, according to a letter acquired by CNN. The letter, broadcast by the Centers for Medicare & Medicaid Casework (CMS) in January, alerted allowance providers that assignment with Medicare about the artifice allegations so that they could booty "appropriate measures."
Medicare admiral said the bureau could not animadversion on awaiting or alive investigations. Back contacted by CNN, Raheja denied that he had accustomed kickbacks or been complex in any affectionate of Medicare artifice in his 25 years of practice.
He additionally said he no best prescribes Nuedexta.
This adventure was adapted to reflect a account from Flora Brahmbhatt's apostle fabricated afterwards publication.
CNN's Nathaniel Meyersohn and Curt Merrill contributed to this report. Illustration by Kelly A. Flynn. Photographs by Darcy Padilla for CNN. Aaron Kessler and David Heath contributed to the abstracts analysis.
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