TIME medicine

Here’s Why You May Soon Be Using Sunscreen in the Dark

The latest studies reveal some surprising things about melanin, the compound responsible for tans, and the need for sunscreen after sun exposure

The guidelines for sun exposure are pretty familiar by now—cover up exposed skin, steer clear of the peak UV streaming hours of 10 am to 2pm, and always, always wear sunscreen.

Now, in a series of experiments described in the journal Science, researchers say that may not be enough to shield against skin cancer. Working with human cells in a lab dish, as well as with mouse models, they found that melanin—which is produced in response to UV exposure to protect sensitive skin from being damaged—may have a dark side to its skin-protecting role. And, even more concerning, the harm triggered by the sun’s rays may linger long after the sun sets.

MORE: You Asked: Is Sunscreen Safe—And Do I Really Need It Daily?

Douglas Brash, professor of therapeutic radiology and dermatology at Yale University School of Medicine, and his colleagues say that activating melanin has lasting effects—some positive, but mostly negative—on the body’s chemistry for up to three hours after sun exposure. That could mean that the risk of skin cancer from agents generated by UV damage continues even in the dark, they add.

Melanin is supposed to be the body’s natural sunblock. It’s released in response to UV light and protects delicate skin from burning, as well as the DNA deeper in skin cells from being scrambled so they don’t cause cancer. But when the scientists exposed mouse cells to UV light, they found that the melanin-containing cells produced mutations, and continued to do so for three hours after the light was removed. Similar cells from albino mice, which are missing melanin, didn’t show the same effect. Human melanin-containing cells also generated these damaging changes long after exposure.

MORE: We’re One Step Closer to Better Sunscreen

The vast span of time during which damage could occur after exposure surprised the researchers. “To have the [changes] made after exposure is like having a process that should have taken a second during the time of the dinosaurs just finish up today,” says Brash. “That’s how bizarre this is.”

Once activated, he says, some of the melanin is highly energized, and in that state, starts to degrade. “When you create high-energy molecules, the energy has to go somewhere,” says Brash. In some cases, it transfers to the DNA where it continues to monkey with normal DNA codes for hours.

MORE: Obama Signs Law for Better Sunscreen

The good news is that this process can be interrupted, as long as the excess energy has an outlet. “If we can divert some of that energy to another molecule and change it into heat, it doesn’t cause problems,” says Brash. In the study, he experimented with some agents including vitamin E, which eliminated the harmful high-energy agents, and kojic acid, which reduced them by 85%.

But it’s not clear yet how these agents should be used or for how long after sun exposure. The findings do make a strong case, however, that applying sunscreen after being out in the sun might become just as important as slathering them on while outside. In the meantime, “continue doing what you’re doing and use sunscreen,” says Brash. “Sunscreens do block UV wavelengths, and will prevent some of these processes from starting. And the lower dose of exposure you have, the better off you are. We just might have to start considering continuing that protection a little longer than we thought.”

TIME medicine

What the Year’s Health Films Got Right—And Wrong

Medical experts dish on how Hollywood handles health

In 2014, health-centered films were some of the most watched and most applauded. Films like The Theory of Everything and Still Alice are nominated for Oscars, and The Fault in Our Stars made well over $124 million at the box office. But how true to health were they?

We asked medical experts, from Alzheimer’s physicians to pain specialists, to grade five of this year’s films for medical accuracy and the authenticity of patient experience. Find out which passed with flying colors—and which ones need a checkup.

  • The Theory of Everything

    THE THEORY OF EVERYTHING, Eddie Redmayne as Stephen Hawking, 2014. ph: Liam Daniel/©Focus
    Focus Features

    The film tells the story of Stephen Hawking, the brilliant physicist who lives with amyotrophic lateral sclerosis (ALS) or Lou Gehrig’s disease. It’s nominated for five Oscars: Best Picture, Best Actor, Best Actress, Best Original Score and Best Adapted Screenplay.

    Reviewer: Dr. Jeffrey D. Rothstein, director of the Brain Science Institute and the Robert Packard Center for ALS Research at Johns Hopkins University

    Grade: A

    What the film got right: In summer of 2014, the Ice Bucket Challenge forever and dramatically changed our exposure to ALS, a relatively rare and fatal neurological disease. As a physician scientist experienced in diagnosing patients with ALS, caring for them, and carrying out research on the disease, I always feel it’s important that Hollywood portray medical disorders accurately. It’s as important as getting the plot right. In my opinion, the director, writers and, most importantly, the actors did a pretty darn good job at educating viewers about this condition.

    First, the film authentically portrays the subtle and typical early-onset changes that characterize the disease, like the occasional tripping, fumbling or dropping of objects. These changes reflect early hand, foot and leg muscle weakness. The slowing of Hawking’s walk, his clumsy writing and his stumbling when he tries to walk up steps and hold chalk are all common in the early stages of the disease. The actor also so movingly and faithfully shows the terrible frustration patients feel when simple tasks like eating and picking up a spoon become so difficult. The loss of these simple actions rob an individual of their independence in daily activities. The film’s depiction of Hawking’s eventual tracheotomy—the hole in the windpipe which allows for better breathing—accurately shows the tragic loss of speech and communication, and the terrible and primitive way patients years ago had to spell out words to produce simple sentences. The film also successfully relays the emotional and physical stress ALS places on spouses and loved ones. I’ve seen it often in my own practice.

    What the film got wrong: The discussion Hawking and his doctor have about his diagnosis in a hallway is not how physicians tell a patient about such a terrible and impactful diagnosis. It lacks the privacy and respect you need when you’re meeting with a patient, and I hope Hawking had a more appropriate encounter in real life. Sometimes movies get everything wrong when it comes to diseases and treatments, but overall, I don’t think The Theory of Everything got much wrong at all.

  • Still Alice

    STILL ALICE, Julianne Moore, 2014. ©Sony Pictures Classics/courtesy Everett Collection
    Sony Pictures

    A well-respected linguistics professor at Columbia University, Dr. Alice Howland, is diagnosed with early-onset Alzheimer’s disease. The film is Oscar-nominated for Best Actress.

    Reviewer: Dr. Kristine Yaffe, professor of psychiatry, neurology and epidemiology at University of California, San Francisco and member of the Alzheimer’s Association Medical & Scientific Advisory Council

    Grade: B

    What the film got right: In Still Alice, we watch a highly accomplished woman trying to hold onto her life while future is transformed by Alzheimer’s disease. Julianne Moore, who plays Alice, is successful at capturing the initial memory and interrupted thought symptoms of the disease, followed by denial, then attempts at control, and finally solace and grace.

    Since Alzheimer’s disproportionately affects women, the focus on a woman keeps with the statistics. Women are at slightly higher risk of developing Alzheimer’s, and many more women have the disease because they live longer. It almost goes without saying that women are also much more likely to provide care to people with dementia.

    Scientifically, the first phase of Alice’s symptoms and the encounter with her consultant neurologist are very realistic and deeply moving. The movie accurately demonstrates the early word-finding challenges, occasional memory lapses and sense of becoming overwhelmed in once familiar situations.

    What the film got wrong: The course of Alice’s decline from Alzheimer’s was too fast by almost any standard. The character went from early symptoms while lecturing at a conference in Los Angeles to being almost mute, not recognizing her daughter and requiring full-time care all in about a year. While this helps the tempo of the movie, it does not match the often decade-long disease progression we see.

    The viewer may also inaccurately conclude from the movie that Alzheimer’s disease is more definitively diagnosed with neuroimaging (brain scans such as PET and MRI) than it can be, and more genetically influenced than it often is.

    Neuroimaging is among the most promising areas of research focused on early detection of Alzheimer’s, but for now, these tests are appropriately used only to clarify a difficult diagnosis when it is not clear what is causing the dementia symptoms. It’s also used for unusual cases, such as early onset of symptoms.

    Slight reference is given in the film to the young onset type of Alzheimer’s being more grounded in genetic risk. But the jump to genetic testing on the second medical visit, followed by testing Alice’s children and even possibly the pregnant daughter’s offspring was unrealistic and over-simplified. It is important to note that young onset Alzheimer’s affects perhaps only 2 or 3% of the total population of people with the disease—or about 200,000 out of the more than 5 million people living with Alzheimer’s in the U.S. today.

    It was hard for me to connect with any character other than Alice and her youngest daughter. They were the only ones in the film with real intimacy, emotion and connection. In real life, Alzheimer’s disease explodes family dynamics and pushes the diagnosed individual and their family to deal with a disease that slowly strips an individual of certain strengths.

  • Obvious Child

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    A24

    A young woman has a one-night stand, an unplanned pregnancy and an abortion.

    Reviewer: Dr. Mary Jane Minkin, professor of obstetrics, gynecology and reproductive sciences at Yale School of Medicine

    Grade: B

    What the film got right: In Obvious Child, Donna, a 28-year-old aspiring stand-up comic, breaks up with her boyfriend and meets Max, a very eligible young man who has shown up at her comedy club. They hit it off immediately; much alcohol and a wild night of sex ensue. As you correctly surmise, she conceives, and ultimately at the movie’s end she has an abortion, with Max’s emotional support.

    The film brings attention to some very important themes. One half of the pregnancies that occur in this country are unplanned. Donna is drinking way too much alcohol to conceive a healthy pregnancy. Max speaks about how much he wants to be a father, and one would certainly hope that their relationship will develop well. As an obstetrician, I’d like to see a happy ending: Donna’s stand-up career takes off, she stops drinking such a significant amount of wine, she starts taking a folic acid vitamin every day, and then she conceives. (And of course they live happily ever after!) But that’s not exactly how things play out. However, Donna’s pregnancy symptoms, sore breasts and nausea, were accurately depicted, as was her use of a home pregnancy test kit.

    What the film got wrong: One primary “obvious choice” wasn’t made in the film. After the liaison, one would expect a sophisticated New Yorker to think to herself that during a very intoxicated evening, a condom might not have been used correctly, and that she should proceed to her nearest pharmacy to purchase a morning after contraceptive. Morning after contraception is widely available over the counter to women of all ages, and is extremely effective when used right after the event, actually up to 72 hours later, and is very well tolerated. But then we would have had no movie!

    Donna, quite reasonably, goes to an office of Planned Parenthood. However—and this is what’s most problematic to me—the physician there tells Donna that she is “too early for an abortion.” Donna is about 5 weeks from her last menstrual period, or about 3 weeks pregnant. The doctor is quite correct in suggesting that a suction abortion would not be the appropriate choice at this point, since the gestational sac is so small that it might well be missed during the procedure. But the doctor does not mention any of the medicinal methods of termination, such as the RU-486 pill, which is ideal to use earlier in the gestation. Then again, if Donna takes RU 486, we have no drama. Donna won’t be waiting for two weeks, and we wouldn’t overhear the discussion Donna has with her mother about her mother’s experience having an illegal abortion in the 60s. There would be no dramatic scene in the waiting area of the clinic. Women using RU 486 miscarry at home, and not on a schedule.

  • The Fault in Our Stars

    MCDFAIN FE003
    20th Century Fox

    A love story about teenage cancer patients who meet in a support group.

    Reviewer: Steven Gonzalez, teenage leukemia survivor and member of MD Anderson Children’s Cancer Hospital’s teen advisory council

    Grade: A

    What the film got right: At age 12, I was diagnosed with AML leukemia and was given a 2% survival chance. That year entailed a lot of chemotherapy, a bone marrow transplant and about 130 days of isolation in the hospital and at home. Though I try not to, I tend to view any cancer-related literature with a pretty critical eye. There’s simply too many little details, emotions and events that are left out. The Fault in Our Stars was different, however, and captured a lot of those little details that are so rarely shown.

    For starters, the nonchalant way that the characters addressed cancer was spot-on. I’ve found that the ability to joke about cancer is pretty common among survivors and a lot of patients. For us, it’s a topic that we have lived with and have become more or less comfortable with. I’ve found that cancer survivors make some of the best cancer-related jokes. I also have to applaud the characters’ emotional breakdowns. For example, when one of the main characters, Augustus, breaks down by a gas station, he wasn’t crying for sympathy or attention. He was just too medicated or had too many emotions with no way of controlling them. Those scenes gave me flashbacks.

    Another accurate moment was when Hazel’s mom tells her, “It’s okay to let go.” That foggy, in-and-out, dream-like state is exactly what I remember experiencing as a doctor told me, “You’re gonna be alright, bud,” right before my treatment took effect. The movie also gets points for not portraying the whole bald-but-somehow-still-has-eyebrows look that some television shows and movies seem to like.

    While I understood why everyone else in the theater was crying at the end, I had a different reaction. I thought the ending was happy. I felt the movie captured the tiny details and I felt like my story was finally being told right. The movie reminds us that even though Augustus and Hazel had little time together, they made the most of it and enjoyed every moment. That is the ultimate end goal in life.

    What the film got wrong: The film has a few flaws. The biggest problem I had was that while it made an effort to include details of life with cancer that aren’t usually depicted, it still showed a very Hollywood approach. At first I couldn’t put my finger on it, but after rewatching the movie, I think it boils down to the fact that cancer just isn’t that neat and clean. Literally. It involves a lot of emotions, bodily changes and a lot of bodily fluids coming out in many different ways. I’m not trying to say that cancer is all sadness and pain all day every day—some of my fondest memories, in fact, came from that year I had cancer—but it still feels like an overly polished view. Cancer can be one of the messiest-sterile environments, and The Fault in Our Stars doesn’t quite capture that concept.

  • Cake

    Cinelou Releasing

    A drama about a grieving woman suffering from chronic pain and painkiller addiction, Cake was nominated for a Screen Actors Guild Award and Golden Globe Award.

    Reviewer: Dr. Charles Kim, a pain specialist at Rusk Rehabilitation at NYU Langone Medical Center

    Grade: B+

    What the film got right: Cake embarks on a very difficult task of exploring the complicated condition of chronic pain in a way that people can hopefully appreciate and sympathize with. The movie cogently touches on many things I have seen in some of my patients, such as isolation, depression, addiction and self-realization. Also quite accurate in some patients are the pill-hoarding behaviors, sleeplessness and painful sex depicted in the film. Chronic pain can be described as a nebulous and complex medical condition, at best. It is poorly understood in the medical world and traditionally thought of as a symptom and not a disease condition. But it afflicts about one in five Americans—about 60 million people, more than diabetes, heart disease and cancer combined.

    It was quite apparent to me as a clinician that Claire, played by Jennifer Aniston, was not only inappropriately overusing the pain medications OxyContin and Percocet for her physical pain, but was also self-treating underlying depression from her unresolved grief over the tragic loss of her son. It becomes a vicious cycle. She needs higher and higher doses of these pills, likely due to her built-up tolerance. This under-recognized vulnerability is often experienced with chronic use of painkillers, but often goes untreated until it is too late. Chronic pain is associated with suicide, a point Cake doesn’t hesitate to make known. In fact, chronic pain sufferers are up to three times more likely to commit suicide than those in the general population, presumably due to insufficient control of pain and under-recognition of coexisting depression.

    From a clinical perspective, Cake is a well-executed and contemplative peek into the dark world of uncontrolled chronic pain, depression, and addiction. The film can be thoroughly appreciated by those who have chronic pain, or those close to them, and appreciated by those who have seen the gratifying life outcomes that occur when the condition is well-controlled and managed.

    What the film got wrong: Some parts of the film are exaggerated and amplified for theatrical effect, such as the fuzziness separating the boundaries of hallucination and reality, or the desperate trip to Tijuana for more medication. Very rarely are chronic pain patients in the extremes of hallucination-driven, desperate addictive behaviors. Overall, I give Cake a B+: a “B” for the respectable attempt to tackle the 800-pound gorilla of chronic pain, despite some of the glorified theatrics and excesses, and a “+” for Jennifer Aniston’s laudable portrayal of a chronic pain sufferer in our society.

TIME Research

Scientists Say Aggressive New HIV Strain Discovered in Cuba

Reports of people in Cuba infected by new strain developing AIDS in less than three years

A recently-discovered form of HIV in Cuba has been found to progress into AIDS some three times faster than the most common strains of the virus, according to a recent study.

The study, conducted by researchers from the University of Leuven in Belgium, followed several reports of HIV-infected people in Cuba developing AIDS in less than three years, far faster than the usual 10 years it typically takes. All patients infected with CRF19, a recently-discovered strain of the HIV virus, had higher levels of it in their body.

They were also more likely to have developed AIDS within three years, the study published in the journal EBioMedicine found. The researchers, who looked at 95 patients at various stages of infection, concluded that the strain must be “particularly fit.”

Approximately 35 million people worldwide are living with HIV or AIDS, and nearly 40 million have died of the disease since the 1980s. Drugs exist to keep the worst effects of the disease at bay, but this new strand threatens to take a toll on patients before they realize they need treatment.

TIME Research

This Is What’s Keeping Teens From Getting Enough Sleep

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STUDIO BOX—Getty Images

The biggest factor keeping teens up at night isn't technology

Up to a third of teens in the U.S. don’t get enough sleep each night, and the loss of shut-eye negatively impacts their grades, mental well-being and physical health. Biologically, adolescents need fewer hours of slumber than kids — but there’s a bigger reason for teens’ sleep loss, according to a new study in the journal Pediatrics.

MORE: The Power of Sleep

Katherine Keyes, an assistant professor of epidemiology at Columbia University, looked at survey data from more than 270,000 eighth-, 10th- and 12th-grade students at 130 public and private schools across the country, gathered between 1991 and 2010. Each student was asked two questions about his or her sleep habits: how often they slept for at least seven hours a night, and how often they slept less than they should.

MORE: School Should Start Later So Teens Can Sleep, Urge Doctors

She found that over the 20-year study period, adolescents got less and less sleep. Part of that had to do with the fact that biologically, teens sleep less the older they get, but Keyes and her team also teased apart a period effect — meaning there were forces affecting all the students, at every age, that contributed to their sleeping fewer hours. This led to a marked drop in the average number of adolescents reporting at least seven hours of sleep nightly between 1991–1995 and 1996–2000.

That surprised Keyes, who expected to find sharper declines in sleep in more recent years with the proliferation of cell phones, tablets and social media. “I thought we would see decreases in sleep in more recent years, because so much has been written about teens being at risk with technologies that adversely affect the sleep health of this population,” she says. “But that’s not what we found.”

MORE: Here’s How Much Experts Think You Should Sleep Every Night

Instead, the rises in the mid-1990s corresponded with another widespread trend affecting most teens — the growth of childhood obesity. Obesity has been tied to health disturbances including sleep changes like sleep apnea, and “the decreases in sleep particularly in the 1990s across all ages corresponds to a time period when we also saw increases in pediatric obesity across all ages,” says Keyes. Since then, the sleep patterns haven’t worsened, but they haven’t improved either, which is concerning given the impact that long-term sleep disturbances can have on overall health.

Keyes also uncovered another worrying trend. Students in lower-income families and those belonging to racial and ethnic minorities were more likely to report getting fewer than seven hours of sleep regularly than white teens in higher-income households. But they also said they were getting enough sleep, revealing a failure of public-health messages to adequately inform all adolescent groups about how much sleep they need: about nine hours a night.

“When we first started looking at that data, I kept saying it had to be wrong,” says Keyes. “We were seeing completely opposite patterns. So our results show that health literacy around sleep are not only critical but that those messages are not adapted universally, especially not among higher-risk groups.”

TIME Healthcare

CVS Wants to Be Your Doctor’s Office

Larry Merlo says pharmacy clinics can take on more of U.S. health care

In the Fifth Season of Curb your Enthusiasm, Larry David visits a pharmacist to fill his father’s blood-thinner prescription. “You know, there’s another drug on the market that I personally like a lot better,” the pharmacist tells Larry. “But the doctor prefers this one?” Larry says. He holds up his hands like a scale and weighs his options. “Doctor,” he says, holding up one hand, then “pharmacist,” holding up the other. He decides: “I’ll go with the pharmacist.”

You may too if Larry Merlo has his way. Merlo, 59, is the CEO of drugstore giant CVS Health. Trained as a pharmacist himself, Merlo has ambitions to play a much bigger role in your health care. He’s already pretty involved. Last year at 7,800 stores, CVS, the second largest drugstore chain in the U.S., filled more than 700 million prescriptions and administered 5 million flu shots–all while selling customers everything from groceries to gift wrap.

Now Merlo says the drugstore can do more. In his vision, CVS will leverage its sizable MinuteClinic business–which already has 970 locations–to diagnose patients, decide on treatments and then sell them the pills they need to get well. In its role as the pharmacy-benefits manager for some 65 million people, CVS also negotiates the price of those pills and helps decide which ones get reimbursed under various insurance plans. Merlo would also like America to stop smoking: he roiled the tobacco industry last year by dropping the sale of cigarettes in CVS stores. And if that causes some customers to have withdrawal pains, the CVS pharmacy can fill a prescription for a drug that helps them quit.

By taking on more of the role of your doctor as well as that of your druggist, CVS looks to grow beyond its already considerable size ($4.6 billion in earnings for 2014). But Merlo argues that the stakes are far higher. He thinks CVS can save lives–and hundreds of billions of dollars in unnecessary health care costs annually–by efficiently treating Americans’ routine sniffles and aches, nudging them to take better care of themselves and making sure they take their medications when they’re supposed to.

Regardless of whether getting a strep test along with a quart of milk appeals to you, many health experts say Merlo may be on to something. The Affordable Care Act–Obamacare–is driving America’s health system to widen access to care while reining in costs. That’s stoking fears that doctors will be scarce and patients will pay more out of pocket–but it’s also spurring innovation, with doctors and entrepreneurs experimenting with all kinds of new approaches, including new kinds of primary-care practices. (See “Medicine Gets Personal” in TIME’s Dec. 29, 2014–Jan. 5, 2015, issue for one example.) Against that backdrop, it isn’t much of a stretch to reimagine the corner drugstore as a health care store. And there’s no question Merlo’s plans are drawing attention: that was his mustachioed face a few seats from Michelle Obama at the State of the Union address on Jan. 20.

Merlo says America’s changing system will lead to the “retailization” of health care, a fancy way of saying that patients are becoming more like consumers and that health care is becoming more like any ordinary consumer product. But if that’s so, the consumers will need to become as savvy about shopping for a checkup as they are about the shampoo and snacks that CVS sells–and they may wonder if they want to take medical advice from a company deeply embedded in the sale of prescriptions. In other words, are they really ready to go with the pharmacist?

The List-Price Checkup

On a recent Friday at the CVS MinuteClinic in Woonsocket, R.I., the doctor isn’t in. The doctor is never in at a MinuteClinic; patients are seen by a nurse practitioner, a health care professional with a graduate degree, advanced training and the ability to prescribe medications. The nurse practitioner on duty at the moment is a young woman in a white coat named Amelia Pires. She sees patients ranging in age from 18 months–the minimum at MinuteClinic–to the elderly, and she treats dozens of conditions, from mononucleosis and shingles to ear infections, for an average price of $89. Or less if, like those of the majority of patients, the visit is covered by insurance.

Retail clinics got their start in the early 2000s as places for the uninsured to purchase basic health services, and they’ve become an easy option for a flu shot and a familiar sight everywhere from drugstores like CVS and its competitors to big-box outlets like Walmart. Now, with the ranks of the insured growing in the Obamacare era, they’re evolving to fill a different kind of need. They offer convenient after-hours visits for patients who can’t get in to see their doctors; they also serve as triage centers that can handle minor illnesses for patients who don’t have a primary-care doctor, for hundreds of dollars less than it would cost in the emergency room.

For the insured, they offer a particular type of bargain. Plans with high deductibles that require substantial initial out-of-pocket payments are becoming more popular. MinuteClinic offers routine treatments at a lower cost than the average physician. Thanks to posted prices, what you see is what you pay: $59 for a kids’-camp physical, for instance, or a maximum of $99 for flu symptoms. The underlying economics are simple to understand: according to the Bureau of Labor Statistics, the median salary for nurse practitioners and physician assistants in the U.S. is $90,000; for medical doctors in family practice, it’s more than double that.

Though they still account for a small share of patient visits–MinuteClinic expects 5 million to 6 million visits in 2015, compared with nearly 600 million outpatient visits to physicians’ offices and nearly 100 million to the ER–they are growing in popularity. And CVS is doubling down on the strategy. Its 970 clinic outlets are already more than twice the number of its closest competitor, Walgreens–and it hopes to open more than 500 new ones by the end of 2017. One sign of the growing battle: while Walgreens pushes the ad slogan “At the corner of happy and healthy,” CVS changed the name of the entire company to CVS Health. Merlo talks about the drugstore as if it’s the new doctor’s office. “If you look at the environment today, the demand for primary care is outstripping the supply of primary-care physicians,” he says. But, he adds, there’s not actually a shortage of care: “It’s the role that retail MinuteClinics are playing.”

For traditional family physicians, the idea that retail clinics should do much more than dispense flu shots is equal parts unnerving and exciting. As federal reimbursements work to shift doctors’ incentives away from ordering up zillions of tests and toward keeping patients healthy, physicians may come to rely on retail clinics for support. But the partnership between doctors and retail clinics is in its infancy, leaving gaps that raise important questions about the quality of care.

Proponents say retail clinics can be a valuable link in a chain that also includes the primary-care physician. A partnership between Cleveland Clinic and CVS, launched in 2009, suggests how this can work. Dr. Michael Rabovsky, chairman of family medicine at Cleveland Clinic, says the program grew out of doctors’ recognition that the patients in their practice liked to be able to walk into a retail clinic after hours and get treatment without an appointment. Thanks to the partnership, Rabovsky and other doctors on his team get an email that lets them know when their patient has been treated at a MinuteClinic, allowing the doctor to follow up. Cleveland Clinic doctors also oversee the MinuteClinics in the area, offering answers over the phone if a nurse practitioner has a question and reading over charts to look for ways care could improve. The relationship works well enough that Rabovsky says CVS may someday help doctors at Cleveland Clinic manage their patients’ chronic diseases. “If you asked me to predict,” he says, “I’d say there is going to be a future for it.”

Others see a trickier balance. Medical-record coordination in many places simply isn’t that advanced, says Dr. Robert Wergin, a practicing physician in Milford, Neb., and president of the American Academy of Family Physicians. That means many physicians don’t necessarily find out when their patients have received care at a retail clinic, and that can be dangerous if the patient underestimates the severity of a complaint. Says Wergin: “What you find in the practice of medicine is that every sore throat is not just a sore throat.”

CVS acknowledges that issue–and says it is prepared. It’s not unusual for MinuteClinic to send drop-in patients out of the store to a place that can offer a higher level of care like an urgent-care center or emergency room. “People don’t realize how sick they are,” says Pires, the nurse practitioner in Woonsocket. “MinuteClinic is probably not somewhere where you should be experiencing chest pain.”

Things are more complicated for patients who don’t have a primary-care physician (which describes half the patients who visit MinuteClinic, according to CVS). Without the high-tech record sharing that happens with CVS’s 51 health-system partners like Cleveland Clinic, nurse practitioners at a MinuteClinic may not have access to a patient’s history or the ability to update a primary-care physician if the patient does eventually get one. And though MinuteClinic nurse practitioners proactively offer to help patients find a primary-care doctor, it is ultimately up to the patient. For that reason, Wergin is disconcerted by the idea that MinuteClinic might offer services for the chronically ill. “If you are getting your blood sugar checked, you should see a doctor who knows the disease,” he says.

The Pharmacist CEO

Exam rooms and treatment plans are a long way from where CVS started. Its history traces back to 1963, when it was a health-and-beauty store in the working-class town of Lowell, Mass. Eager to take advantage of the easing of price controls for drug products by selling their merchandise at a discount, the founders–brothers Stanley and Sidney Goldstein and their partner, a salesman at Procter & Gamble–called the business Consumer Value Stores. CVS began selling pharmaceuticals in 1967 and in 1990 acquired Peoples Drug–where a young pharmacist in Washington, D.C., named Larry Merlo had become a regional vice president. After Peoples became part of CVS, he ascended the ranks until he became CEO in 2011. Merlo’s colleagues say the CEO–noticeably down to earth in person–still clears the shopping carts out of CVS parking lots out of instinct from his days as a store manager and pharmacist.

Merlo’s background as a pharmacist seems to be at the heart of a goal that’s less splashy than the MinuteClinic expansion but may play a more crucial role in the health of the average American: getting people to take their medicine. Specifically, getting them to take it on time and as instructed. Failure to take medication correctly costs the U.S. health care system up to $300 billion and results in 125,000 deaths every year, according to the Centers for Disease Control and Prevention. Estimates show that about a third of patients fail to fill their new prescriptions, for all kinds of reasons–because they are too expensive, have unpleasant side effects or seem to have no impact on their symptoms.

CVS thinks it can help with cutting-edge ideas like using data to identify high-risk patients and filling their prescriptions in prepackaged morning, noon and night doses, or alerting their physicians that they haven’t purchased a medication. As a prescription-benefit manager, CVS can also design employee prescription plans so that patients aren’t charged any co-pay for vital prescriptions that treat chronic problems like high cholesterol. Since roughly half of the U.S. population suffers from a chronic illness that requires numerous prescriptions, this kind of medication management keeps growing in importance.

What’s Really in Store?

CVS envisions savings for the U.S. health care system–and, of course, profits for its shareholders. Health care leaders say there’s logic there: in the Obamacare era, physicians may come to rely on retail clinics to outsource the little things so they can take better care of more patients.

What remains to be seen is whether there are risks that come with the potential. How will CVS’s business selling prescriptions affect the policies and decisions in its clinics? That inherent conflict of interest has long concerned medical professionals, though how it affects patients isn’t clear. Consumer advocates worry that CVS is already too powerful, thanks to its role as a pharmacy-benefit manager. The company recently made an exclusive deal to cover Gilead Sciences’ controversial drugs for hepatitis C, making them the only option for patients whose prescriptions CVS manages unless they get prior authorization from their doctor.

That arrangement reflects CVS’s ability to pit pharmaceutical companies against one another to get the lowest price. CVS says that this saves patients money and that doctors and patients can seek exceptions. “There is a process to work through the physician and the benefit-plan design to ensure that the patient is on the right therapy at the end of the day,” says Merlo. Overall, CVS says, MinuteClinic patients walk away with prescription costs on a par with or lower than those of other providers like emergency rooms.

Merlo is wasting no time in thinking up new ways to play a bigger role in customers’ health. Any day now, CVS will launch a technology-development office in Boston with 100 employees hired to devise everything from new ways for consumers to manage medications on their phones to telemedicine programs that will let MinuteClinic patients see nurse practitioners through a computer screen. And now that tobacco has been purged from the shelves, customers will soon notice a healthy food makeover too. Merlo calls CVS’s journey from beauty store to health care provider an “evolution, not a revolution.” For CVS’s 100 million customers, the impact will be huge either way.

TIME medicine

Why Doctors Should Start Prescribing Downward Dog

downward dog yoga
Getty Images

Complementary medicine is gaining traction with adults and kids alike

Americans are slowly but surely embracing complementary medicine—alternative practices to go with standard treatment—according to new data from the National Center for Health Statistics (NCHS).

Two new surveys show that while the overall use of complementary health approaches has remained relatively stable over the years at 34%, certain types are rapidly gaining popularity, especially yoga. Other common complementary practices are taking dietary supplements, doing tai chi and qi gong, meditating and getting chiropractic care.

More and more children are also doing yoga, the survey finds, and they typically use it for ailments like back or neck pain, nerve conditions and anxiety. Interestingly, the majority of children didn’t just practice yoga for exercise, but for meditation and deep breathing. Other new research is showing that when kids practice mindfulness and meditation, they gain a range of health benefits from more self-control to higher math scores.

“The low cost and the ability to practice in one’s own home may contribute to yoga’s growing popularity,” the authors write. “Furthermore, public school systems are beginning to incorporate yoga into their fitness programs, which may accelerate use by children in the future.”

Even though many complementary practices are ancient in other countries, it’s still relatively new in the United States. Medical institutions are increasingly willing to meet patients halfway with therapies that won’t cause harm, as long as practices are safe and don’t ignore the need for conventional medicine and pharmaceuticals when necessarily. In January 2014, the Cleveland Clinic opened a Chinese herbal therapy clinic, and experts at the Mayo Clinic in Minnesota say the appetite for more integrative medicine in the hospital setting is growing. “Acupuncture is a huge practice [here],” says Dr. Brent Baur, director of the Mayo Clinic Complementary and Integrative Medicine Program. “Right now our demand for acupuncture outstrips our ability to meet that demand probably three to one. We can’t even come close to keeping up.”

“I think [interest] is being propelled by economics because our health care system is in such desperate trouble,” says Dr. Andrew Weil, founder of the Arizona Center for Integrative Medicine and a pioneer of integrative medicine in the U.S. “The great promise of integrative medicine is that it can lower costs while increasing outcomes. It does that by emphasizing lifestyle medicine and by bringing into the mainstream techniques that do not involve expensive technology.”

In a World Health Organization survey of 129 countries, 80% recognize the use of acupuncture. The U.S. may be catching up; other research shows that about four in 10 U.S. adults and one in nine kids use some form of complementary and alternative medicine.

TIME 2016 Election

Hillary Clinton Enters Vaccinations Debate to Rebuke Likely 2016 Rivals

2014 Robert F. Kennedy Ripple Of Hope Award
Taylor Hill—Getty Images Hillary Rodham Clinton speaks at the 2014 Robert F. Kennedy Ripple of Hope Gala at New York Hilton on Dec. 16, 2014, in New York City

"The science is clear," Clinton tweeted

Former U.S. Secretary of State and likely Democratic presidential candidate Hillary Clinton re-emerged on the political scene Monday evening to critique several likely rivals.

In a tweet, Clinton dismissed those who believe that vaccinations are linked to autism, hours after New Jersey Governor Chris Christie and Kentucky Senator Rand Paul suggested that parents be granted some element of control over what inoculations their children receive. Her public comments follow a period of relative quiet from Clintonland as she gears up for an all-but-certain presidential campaign in 2016.

On Monday morning, Christie said parents should have “some measure of choice” over how their children are vaccinated, when asked about an outbreak of measles in the U.S. His office later backtracked, saying the dad of four believes “with a disease like measles there is no question kids should be vaccinated. At the same time different states require different degrees of vaccination, which is why he was calling for balance in which ones government should mandate.”

In a contentious interview with CNBC on Monday afternoon, Paul said he didn’t see why his position that most vaccines should be voluntary would be controversial. “For most of our history, they have been voluntary. So I don’t think I’m arguing for anything out of the ordinary,” he said.

“I have heard of many tragic cases of walking, talking normal children who wound up with profound mental disorders after vaccines,” Paul added, repeating claims that have extremely dubious scientific grounds.

Clinton’s statement follows something of a change of heart from 2008 when she filled out a survey from a group known as the Autism Action Network, saying, “I am committed to make investments to find the causes of autism, including possible environmental causes like vaccines.”

TIME vaccines

Meet the Latest Driver of the Anti-Vaccine Clown Car (Who Thinks You’re a ‘Bad Mother’)

Not your friend: The measles virus—highly magnified—is exceedingly easy to transmit
Dr. Gopal Murti/Visuals Unlimited Not your friend: The measles virus—highly magnified—is exceedingly easy to transmit

Jeffrey Kluger is Editor at Large for TIME.

A doctor who should know better peddles dangerous rubbish

Vanity doesn’t die; misinformation doesn’t die; arrogance and narcissism and opportunism don’t die. But you know what does die? Children. That’s worth keeping in mind as the latest carnival barker from the anti-vaccine community steps up for his ignoble hour of attention.

The new medical reprobate is Dr. Jack Wolfson, an Arizona-based cardiologist and practitioner of holistic medicine. Until recently, he was a largely unknown character—which was a very, very good thing. But in the wake of the California measles outbreak that originated in Disneyland and has so far infected 93 people in eight states and Mexico, he has picked up the megaphone of social and mainstream media to inveigh against vaccines as unsafe, unnecessary, stuffed with toxins and, well, never mind. You know this drill.

The vaccines he condemns would, of course, include the measles vaccine, which was not widely available before 1980 when 2.6 million people died of the disease each year, and which, when it did become available, quickly slashed that death toll by 99.4%. Measles was declared eradicated in the U.S. in 2000—but even now, 1,000 people are being monitored in Wolfson’s own state for possible exposure to the Disneyland strain, which got a toehold in the first place only because of the nation’s falling vaccination rate.

But never mind that. Wolfson has junk science to sell, and he’s going to sell it. “We should be getting measles, mumps, rubella, chicken pox, these are the rights of our children to get it,” he told the Arizona Republic.

“Don’t be mad at me for speaking the truth about vaccines,” he told The Washington Post. “Be mad at yourself, because you’re, frankly, a bad mother. You didn’t ask once about those vaccines. You didn’t ask about the chemicals in them.”

CNN inexplicably afforded Wolfson the familiar split-screen, point-counterpoint platform to argue the vaccine issue with another doctor—as if there were any argument to begin with. The network touted the exchange on CNN.com as “Fiery Vaccine Debate,” which likely earned the site some clicks and gave Wolfson a patina of legitimacy in return.

The thing is though, he’s not legitimate—not as a person whose vaccine advice should be heeded at least—as the agitprop nonsense he offers on the alternative medicine site Health Impact News reveals. Concerned parents and health care providers should not be angry at him for selling his anti-vax bill of goods, he repeats. Instead, “Be angry at food companies. Sugar cereals, donuts, cookies, and cupcakes lead to millions of deaths per year. At its worst, chicken pox killed 100 people per year. If those chicken pox people didn’t eat cereal and donuts, they may still be alive.”

You should be angry at the people who make Bounce and Downy too, because, “You and your children are wearing and breathing known carcinogens” contained in the laundry sheets and fabric softener. “These products kill more people than mumps.”

But most of all, be angry at yourselves, you parents who vaccinate. Why? Because, “Let’s face it, you don’t really give a crap what your children eat. You don’t care about chemicals in their life.”

There is so very much more wrong with Wolfson and the rubbish he’s selling. There is his supposedly unanswerable riposte about the irrelevance of polio. “Where are all those 80 year olds crippled by polio?” he asks. “I can’t seem to find many.” That’s right, you can’t, because the disease has been vaccinated into extinction in all but three countries in the world. If you were looking around before 1955 you’d see plenty of them.

There is his similar dismissal of measles. “What we’re really talking about is just a fever and a rash,” he says. Yes, a fever and a rash that still kills 145,700 unvaccinated people per year. And what does 145,700 people look like? Picture four sold-out Fenway Parks. Now kill all of those people—mostly children. Every year.

Wolfson, like most anti-vaxxers, rails broadly and emptily at the “chemicals” in vaccines and argues that we shouldn’t be putting them into our children’s bodies. But arginine and alinine and octene and hexanal and 2-methyl butyraldehyde are chemicals too and they’re just five of the 73 you put in your body every time you eat a blueberry. Chemicals are not, by definition, bad things. Wolfson similarly rhapsodizes about “nature,” setting it in make-believe opposition to things that are synthetic or invented and therefore, by binary definition, are bad. But as he himself argues, viruses are part of nature, as are bacteria, and as is every other disease that could kill you or your children before your time. In some cases, the whole point of medical science, to paraphrase William Buckley, is to stand athwart nature shouting “Stop!” If you want your nature pure, you’re free to die young.

At least one Arizona pediatrician, according to The Washington Post, is already talking about reporting Wolfson to the Arizona Medical Board, and that’s not an empty threat. Simply taking a contrarian position or advocating for dubious but do-no-harm nostrums is unlikely to get you in trouble with the licensing authorities. But making an argument that is wholly, empirically, medically wrong, and doing so in a way that could actually induce real parents to refuse to vaccinate real children is something that’s demonstrably dangerous.

The state’s medical board standards for disciplining members are exceedingly broad, authorizing action against a doctor who, among other things, “may be guilty of unprofessional conduct.” It would be up to the board itself to define that, but it’s not a leap to think they would do so in a way that would apply in this case.

If there’s anything good about the rise of Wolfson, it’s that it’s a sure sign the anti-vaxxers’ bench is getting thin. He lacks the telegenic sizzle of a Jenny McCarthy. He lacks the one-time credibility of an Andrew Wakefield, whose fraudulent 1998 paper got the phony vaccines-autism link started. The paper has now been retracted and Wakefield has been stripped of his license to practice medicine.

Wolfson, like the others, will have his moment, and then, like the others, he is likely to go away. We will never know for sure how many children will be harmed by his misinformation before he’s finally gone.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME Science

You Can Sell Your Poop For $13,000 a Year

TIME.com stock photos Money Dollar Bills
Elizabeth Renstrom for TIME

Some patients need fecal transplants to aid their digestive system

Money definitely doesn’t grow on trees, but it might be growing in your bowels. If you’re really healthy, you can sell your poop to sick people who need it for as much as $13,000 a year.

People who are infected with a bacteria called C. difficile need healthy fecal matter in their gut in order to survive — otherwise they need to be on constant antibiotic treatment. Some people with Crohn’s disease also benefit from fecal transplants. So a company called Open Biome has been facilitating fecal transplants to patients in need, and paying healthy poopers a hefty sum for their services.

Fecal matter is transferred either through endoscopy or swallowed capsules, and Open Biome has already shipped about 2,000 treatments to almost 200 hospitals, according to the Washington Post. They’ll pay you $40 per sample, plus an extra $50 if you come in 5 days a week (the donations have to be made on-site.) The only thing is, you have to be super-healthy: only about 4% of prospective donors make the cut.

Open Biome gives their anonymous donors names like Vladimir Pootin, Albutt Einstein, and Dumpledore, to help make the poop-handling thing go a little more smoothly, according to a New Yorker piece on the poop-donation industry. So who knows? Maybe you could be the next Rumpoostiltskin.

[Washington Post]

Read next: What Obama’s Tax Plan Would Mean for Your Wallet

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