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Interview Series: Terri Peters

Interview Series: Terri Peters

Terri Peters is an architect and researcher whose interdisciplinary work maps new trajectories of ecological design through contemporary practice, academic research and pop culture. She is an expert in sustainable housing and her research focuses on the architectural and social implications of the built environment, with a focus on more holistic qualitative parameters and wellbeing. She has published more than 20 peer reviewed journal and conference papers on sustainable housing and the impact and evaluation of daylight in homes. She is the editor of “Design for Health: Sustainable Approaches to Therapeutic Architecture” Architectural Design, 2017 and author of “Computing the Environment: Digital Design Tools for the Simulation and Visualisation of Sustainable Architecture” John Wiley and Sons 2018 which looks at how environmental data can be feedback into design process. She has a global perspective, having lived and worked in Vancouver, Tokyo, Paris, and London, and Copenhagen which was her adopted home for seven years. After 12 years abroad she is currently back in her native Canada, as an Assistant Professor at Ryerson University investigating the intersections of building science, environmental design, and wellbeing.

1.What prompted you to focus on healthcare architecture/design?

During my PhD work, which was focused on social housing I realized that the aspect of ‘people’ in that housing was missing, specifically the social impact of buildings. We know the buildings we spend time in, and our surroundings, greatly impact our wellbeing, but how does this become part of how we work? We need to be able to back up our observations and claims as designers and I think the new-ish movement towards evidence-based design, where design decisions are based on more than a designer’s intuition and experience, but also on results and interpretations of scientific evidence, can help improve design.

On a personal note, growing up in Canada and then living in bigger cities like London, where I did my professional degrees, and then in Copenhagen where I did my PhD, these places can be seen as quite dark, dreary places but I loved them. I always say maybe this is why I study daylight, because I appreciate every drop of it! In Copenhagen our apartments had lots of natural light and natural ventilation, it really shaped my thinking of how positive and life affirming a home can be. There’s this concept in Danish of hygge, or contentment, a cosy feeling. Another concept in Swedish is lagom which means something like “just enough is enough.” these are important concept in life to me and I lived and experienced them in my time in Denmark and they continue with me now.

So with all of that together, I realized that if we designed spaces in hospitals and other settings to be intentionally mood enhancing, that could make us all feel better.

2.Why is design important to our well-being?

When we design a building, we know that the decisions we make, however small, impact the moods, ideas and wellbeing of people using the spaces. Prioritizing daylight, fresh air, variety of spaces and environments with views to nature are some of the ways we address this depending on numerous other variables like site and program. We know that these decisions about building form, materials, adjacencies and sequence of spaces, and other variables change our perceptions of spaces and places and help shape our interactions with others.

Design, simply put, impacts how we feel, and not just in health care environments, but in our day to day experience in our homes and where we work. According to the World Health Organization, depression is the greatest cause of disability worldwide, and architects have a role to play in making spaces that do more than satisfy program, budget and site, but that make us feel better. In architecture schools, students learn about building performance and aspects of sustainable design, but rarely are methods, metrics or examples of health promotion or spaces that encourage positive social interactions explored in any depth. There is a wealth of knowledge in allied fields such as environmental psychology, and published studies in areas such as public health and sociology that can be tapped into to enrich the architecture curriculum. The increased focus in schools on environmental performance of buildings must be paired with understanding trade-offs and co-benefits for human performance and wellbeing – after all, buildings are for people.

3.You had an interesting personal brush with the healthcare system in two different countries. What was that like?

I had my two children in Copenhagen at Rigshospitalet, the Royal Hospital. It was built in the 1970s, but had windows that open, large rooms, and lots of daylight that enters into the lobby and patient rooms. I am really sensitive to my environment and I found that the quality of that room impacted my mood and experience.

And it was a major contrast with being in a Canadian hospital which wasn’t designed with these well-being components in mind. I broke my elbow last winter and was forced to wait in a place that had a low ceiling, was crowded, no fresh air. I actually felt sicker! And to top it off it was hard to find where I needed to go – I spent a lot of unnecessary time just navigating: it wasn’t designed with ease. In Denmark, the culture is built around design. The way people speak about it and appreciate it is really unique.

4.How did this experience impact your work as an architect and architecture professor now?

I have the challenge of teaching 1st year students what sustainability is, when often the work-life balance of many architecture students is poor. We hear that many of them are very stressed and finding it hard to thrive. We often discuss the power of building design as health promotion tools.

Architecture is unique in that you experience it whether you want to or not: the impact the buildings have on us is so extreme. When it comes to environmental psychology, which links to designing for health, we know that people have a natural inclination towards nature, whether it’s the savannah or long views. The biophilia hypothesis (biophilic design) specifically describes this affinity to nature, daylight, natural materials.

Salutogenic design is another school of thought, which keeps stress reduction at the core. Earlier this year I became “WELL® Certified,” which is a new modality that evaluates qualitative and quantitative biophilia as it relates to health promotion. They measure things that are really exciting, because it’s centered around how people respond to being in a building. There’s a huge emphasis on daylight and nutrition, fitness, and well-being. For instance, they measure daylight differently. Traditionally in architecture we usually measure how much of the building’s floorplate is well lit without needing to turn on the light, its called spatial daylight autonomy and it means that area doesn’t need artificial light 50% of the time. The idea is related to productivity. The Well® Standard measures “equivalent melanopic lux,” which is a fancy way of describing the impact of light on the physiology of body, so for instance the impact on alertness, and sleep.

In my courses I describe a concept I coined called “superarchitecture,” which means buildings that do more than minimize the impact on the environment but that exploit and maximize the synergies and benefits to people: everything from building strategies like green roofs, daylight, fresh air and natural ventilation, shading where appropriate, outdoor spaces all these strategies that we know improve the environmental performance but that really also benefit our quality of life in tangible ways.

5.What does thriving mean to you?

Thriving is having time and energy to purposefully devote yourself to what you want to do. Technology can play a role in that, not only in making us feel more connected to each other, but by helping us make better decisions about what we want to do. It also involves how our environments help bolster our ‘emergency reserves’ to handle the unexpected, a protective buffer in other words. Last, when I think of thriving I think of resilience. There’s an emerging interest in architectural research and practice around building resilience and passive survivability. Much of how we think of the resilience of buildings may be applied to people as well. Daylight and views to the outside are big ones – we need these to feel at ease and to have the capacity to deal with disturbance and change. The current thinking around building resilience in building science and architecture is too focused on how buildings would survive in extreme weather or in an earthquake – what about us? How can our buildings help us survive and bounce back?

6.What are you most looking forward to with health design in general?

Looking forward to more interdisciplinary studies – for instance working with more healthcare professionals and building partnerships. I’ve been collaborating with psychologists regarding concepts of resilience in architecture and environmental psychology, which is undergoing a resurgence right now. I’m also excited about how we apply data, specifically how we can visualize the results of simulations, and how people can interact with visualizations and change our behavior to do more of what we want to.

I go to lots of industry meetings and workshops to understand what the potentials are with data and how they can benefit people.

How Sound Baths Ended Up Everywhere

How Sound Baths Ended Up Everywhere

“Bring yourself back to your awareness,” said Sara Auster, a self-proclaimed sound healer, after 45 minutes in a ballroom at a hotel in Chicago where she created vibrations using crystal bowls and tuning forks as well as a traditional Indian accordion, known as a shruti box. Seventy-five people got up like a gaggle of toddlers being shaken from a nap.

The session, which cost $30, and was like many popping up in churches, community centers and even some prisons and hospitals. The goal, practitioners say, is to use sound to tackle individual and collective anxiety, depression, insomnia and more.

Recently, musicians like Erykah Badu and the Icelandic band Sigur Ros have also dipped into sound healing.

Over in the tech world, mindfulness is deeply in vogue. Jack Dorsey, the chief executive of Twitter, swears by meditation. Since 2016, Ms. Auster, 40, has been invited as well to perform for various Google company initiatives. This past April, Adrian DiMatteo, a musician in Brooklyn who has a degree in jazz performance, led a sound bath in the neighborhood of Greenpoint for leaders at Instagram. (“They approached us to do a corporate bonding event, as they’re moving towards doing more events without alcohol,” Mr. DiMatteo said. “They had lots of questions about the instruments and the bowls.”)

Some health facilities have taken note as well. Ms. Auster has performed for Harlem House Clubhouse, an outpatient psychiatric rehabilitation program at Harlem Hospital in New York. Darren Austin Hall, a ceremonial musician and sound healer in Toronto, has performed in the atrium of Toronto General Hospital with a Canadian organization called Music Can Heal.

The Children’s Hospital of Philadelphia has also discussed incorporating sound baths. Mr. DiMatteo has offered them in the waiting area at NYU Langone through a program called Music That Heals, as well as at Coney Island Hospital and “about a dozen others,” he said.

Diane Mandle, who has offered sound healing in Encinitas, Calif., for 19 years, said: “It’s not curing, it’s healing.” She has also provided sound sessions in an oncology unit at Sharp Memorial Hospital in San Diego, as well as at a workshop for inmates at the Vista Detention Center.

“Healing is an ongoing process that contributes to a better sense of well-being,” Ms. Mandle said.

What are sound baths?

Sound baths are an experience in which a group of people gather, often while lying on a mat, to listen to sounds produced through various instruments. There is no licensing procedure for leading sound baths, and though Ms. Auster wouldn’t say where she received her training, her music background and meditation training are strong influences.

For centuries, various cultures, including my own, South Asian, have used sound as a part of religious ceremonies and prayer, with one goal being to promote and facilitate meditation. In that sense, it’s not terribly different from singing hymns in a church. Most religions and cultures use music and sound for spiritual reasons.

But what about the promise of healing? After all, the use of sound is advertised as an activity that can do many things, including “realigning your chakras” and “mind expansion.”

“Personally I have an issue with the word ‘healer,’ which is why I turn down a lot of wellness events,” Ms. Auster said. “There are all sorts of expectations with that label, and I don’t want to be seen as some magical guru person or for people to assume they could not possibly have an understanding of the experience.”

Like other forms of music, sound baths bring people together, but with an added meditative element. Anaïs Maviel, a musician in New York, said that she is often asked to perform for grass-roots organizations as part of “community-building” efforts.

Does sound have an effect on our health?

One way sound is related to health is through noise pollution: traffic noise, planes flying overhead, loud concerts. The World Health Organization lists noise pollution as an increasing threat to human health, and recently set limits on environmental noise.

This may also explain the boom in A.S.M.R. — soothing sounds that, like sound baths, aim to address stress and anxiety. A.S.M.R. has become an internet phenomenon, particularly on platforms like YouTube.

Sound, in the form of music, has been used for various conditions, including dementia. As Oliver Sacks wrote in his book “Musicophilia,” a variety of neurological conditions including symptoms of dementia and psychiatric conditions like depression and schizophrenia may also benefit from music.

But where is the evidence for sound baths? It’s unclear when “sound healing” was first used. However, medicine has used the concept for years specifically for acoustic therapy for tinnitus, a condition that involves hearing unwanted noise without a clear stimulus.

With tinnitus, essentially, the brain perceives sound as entering the ear, even though there is no sound. It is similar to phantom pain in that regard: a situation in which there is a misperception that can cause immense grief.

Often described as “acoustic therapy,” sound healing was listed as an appropriate treatment in clinical practice guidelines. But this therapy involves neither bowls nor chimes. It is typically a form of low-frequency white noise played through a hearing aid or through an app.

A 2013 study of tinnitus, led by David Baguley, a professor of hearing sciences at the University of Nottingham, listed acoustic therapy as one of several interventions. However, in December 2018 a review of existing studies found no evidence of using sound versus placebo for tinnitus.

“Well, the absence of evidence doesn’t mean absence of benefit,” Dr. Baguley said. He also noted that some patients choose calming nature or ocean sounds as opposed to white noise, which could overlap with the suggested benefits of sound baths.

“It’s more than just a distracting noise,” Dr. Baguley said. “We know that sound has a massive influence on how the brain is organized.”

So, do sound baths actually heal?

A 2014 study found that for patients being weaned off mechanical ventilation, providing them with sounds of nature significantly reduced agitation and anxiety, as measured through heart rate, expressions of pain and blood pressure, when compared with patients who did not listen to these sounds.

More recently, a research psychologist reported that singing bowl sound meditation was helpful in reducing tension, depression symptoms, fatigue and anger in a group of 62 adults.

So far, the evidence for sound healing is limited, and is aligned with what we know about the effects of calming music and the benefits of meditation.

Ms. Auster also believes that one of the biggest benefits of sound baths is that they facilitate community.

“It’s people coming together to release and let go, but in the company of others around them,” she said. “If meditation is taking the stairs, a sound bath is taking the elevator.”

**Originally published in the New York Times**

For the sake of doctors and patients, we must fix hospital culture

For the sake of doctors and patients, we must fix hospital culture

When hospitals fail to create a culture where doctors and nurses can speak up patients pay the price
By: Blair Bigham and Amitha Kalaichandran.

It seems too often that reporters—not doctors—sound the alarm when systemic problems plague hospitals, where whispers in the shadows indicate widespread concerns, but individuals feel unable to speak up. Recently, reports surfaced that children were dying after surgery at the University of North Carolina at higher than expected rates, despite warnings from doctors about the department’s performance. And whether in Australia, the United Kingdom, Canada, or the United States, reports show that bullying is alive and well.

This pervasive culture—where consultant doctors, residents, and other hospital staff feel that they cannot bring up critically important points of view—must change. It shouldn’t take investigative journalism to fix the culture that permits silence and bullying. But it does take all of us to rethink how physicians and leaders work together to improve hospital culture.

Investing in improving hospital culture makes a difference to patient care and the quality of the learning experience.

Recent studies on workplace culture show how important it is. In a new JAMA Surgery study, surgeons who had several reports of “unprofessional behaviour” (defined as bullying, aggression, and giving false or misleading information) had patient complication rates about 40% higher than surgeons who had none. Domains of professionalism include competence, communication, responsibility, and integrity. Last year, hospital culture was directly linked to patient outcomes in a major study led by Yale School of Public Health scientist Leslie Curry. Risk-standardized mortality rates after a heart attack were higher in hospitals that had a culture that was less collaborative and open.

Curry’s team created a programme to improve hospital culture, namely by enhancing psychological safety—a term that signifies a willingness of caregivers to speak freely about their concerns and ideas. When hospital culture changed for the better, heart attack outcomes drastically improved and death rates fell.

There are examples of good practice where psychological safety and transparency are valued, and these centres often boast better patient outcomes. A recent systematic review of sixty-two studies for instance found fewer deaths, fewer falls, and fewer hospital-acquired infections in healthcare settings that had healthier cultures.

The impact of healthcare workplace culture doesn’t just end with patient safety. Physician retention, as well as job satisfaction and teamwork, all benefit from a strong organizational culture in hospitals. This is crucial at a time where burnout in medicine is high. Hospitals can also learn from the tech industry which discovered early on that psychological safety is key to innovation. In other words, those who are afraid of failing tend not to suggest the bold ideas that lead to great progress.

So how can hospitals make improvements to their culture?

The first thing is to shine a light on the culture by measuring it. Staff surveys and on-site observations can illuminate negative workplace cultures so that boards and executives can consider culture scores in the same regard as wait-times and revenue. Regulators and accreditors could incorporate workplace culture indicators in their frameworks to increase accountability. We recently saw this in Sydney in Australia, where a third residency programme lost its accreditation due to bullying of junior doctors.

The second is to hire talented leaders not based just on their clinical competence, but also on their ability to foster inclusiveness, integrity, empathy, and the ability to inspire. By setting the “tone at the top,” leaders can influence the “mood in the middle,” and chip away at ingrained attitudes that tolerate, or even support, bullying, secrecy, and fear of speaking out.

Another solution rejects the hierarchy historically found between doctors, nurses and patients, and embraces diversity and inclusion. Effective collaboration helps shift the tribe-versus-tribe attitudes towards a team mindset. Part of this involves amplifying ideas from voices that are traditionally not heard: those of women, the disabled, and ethnic and sexual minorities. As well, leadership must change to be more diverse and inclusive, to reflect the patient population.

The field of medicine attracts motivated, intelligent, and caring people. But being a good caregiver and being a good leader are very different, and training in the latter is sadly lacking.

For every investigative report that uncovers a hospital’s culture of silence—whether it’s unacceptable bullying, unusual death rates, or pervasive secrecy—there are surely hundreds more left uncovered. The fix to this global epidemic requires deep self-reflection and a firm commitment to choose leaders who promote transparency and openness. Implicit in the physicians’ vow “to do no harm” is the vow not to stay silent as that too can be harmful. We must first and foremost create cultures that ensure we feel safe to speak up when things aren’t right. Our patients’ lives— and those of our colleagues—depend on it.

**Originally published in the BMJ**

Interview Series: Nira Kehar

Interview Series: Nira Kehar

Nira Kehar is an award-winning chef trained in French cuisine. She is also self-trained in Ayurvedic principles, which she incorporates in her cooking.  For almost six years, Kehar ran the restaurant, Chez Nini, in Delhi, India, serving clients from around the world.  Married to a musician, Kehar now spends her time between New York City and Copenhagen. Her cookbook, Ojas, was released in 2018,  just months before a chilling diagnosis of breast cancer sent her life reeling. She spoke with me in July from St. Adolphe, Quebec where we cooked a meal of kitchari, salmon, and garlic scapes.

So  what are we making today?

We are making Kitchari, which is a slow cooked dish traditionally made of rice, lentils and spices. Kitchari in modern times is often associated with a bland porridge, that Indian moms give their children when they are ill or have a bad stomach, but historically it was known as a delicacy for the royal families. It is rich in nutrition and easy for your body to break down and digestion because of the longer cooking time. Kitchari can also be made with any variety of beans or grains and I also like to top it with either vegetables, all type of proteins and different nuts and seeds. Today we are making a red lentil and quinoa kitchari topped with garlic scapes and pan seared wild-caught salmon.

What drew you towards the culinary arts?

After a debilitating spinal injury I suffered at work, I was catapulted into a life-changing existential crisis. The 8-month recovery period was filled with contemplation and an eventual re-engineering of my life, which brought to light how much I really craved a more creative path for my career. Having been raised in a house where food was the currency for love, I naturally gravitated to the idea of cooking, flavors and feeding.

But your academic  background was somewhat untraditional.

I graduated university as a computer engineer, but after my injury, I went to ITHQ in Montreal to do their French culinary program. The prospect of cooking and living a life of creative expression was the most welcome and transformative experience of my life.

What is ayurvedic cooking?

From the young age of ten, I had always been very interested in Ayurveda and it’s very well known sister science, Yoga. This interest had actually stemmed from the book “Autobiography of a yogi” which I first read in an attempt to impress my mother, but it ended up being the equivalent to my “Harry Potter” as a child. This curiosity continued throughout my life and I found myself studying and practicing Ayurveda more than ever when I was cooking professionally. Ayurvedic cooking very organically became synonymous with how I expressed the flavors and compositions in my cuisine. I used the backbone of my Ayurvedic knowledge in order to nourish people instead of just feeding them. I tweaked recipes for the everyday foods people already enjoyed, to incorporate principles of eating for your body type and using herbs and spices for balance.

I think the trouble with many ways of cooking, especially when food comes into the picture in wellness discussions are all the trends out there. There are ‘blood type’ diets which have no scientific basis for instance.  But when you describe Ayurveda using broad strokes, it makes sense. A whole-foods approach. Many  people get turned off by the term ‘Ayurveda’ because it sounds different, even though the principles have been used for centuries.

Yes I definitely agree with you. We have been eating from the time we are born and will eat pretty much till the day we die. Unlike a lot of the habits and lifestyles that we hang on to and protect whether for cultural reasons or sentimental, I have found that people tend to be surprisingly ready to just completely change what and how they eat based on diets or fads. I find this extremely unhealthy and counter intuitive. Ayurveda on the other hand is fully based on balancing your individual body in an intuitive and gradual way. It’s about building your instincts about your own body type and then slowly making adjustments to strike the balance that nature has implicitly intended for you.

What does the title of your cookbook, “Ojas,” mean?

The closest translation is similar to what is termed “Chi” in Chinese medicine. Ojas is the most subtle bi-product of your digestion. Everything you eat, experience, feel and live all result in this vital energy, which is responsible for your being alive. It is the encapsulation of the “you are what you eat” idea. Eating not being limited to only food, but everything that is taken in by your perceptions and senses.

Interesting word. There are definitely people that seem brighter and more alive, and having healthy ways to deal with stress might be part of it. Perhaps children in general have lots of it. I’ve also seen photos of people who meditate regularly who just look less tense.

Ojas is also enhanced by mediation. A person with good or high Ojas has a bright energy and a glow. Good eating habits, stress managements, the right amount of sleep, loving relationships and an understanding on how to balance your unique body are all very good ways to manage your Ojas. I am determined to be part of the community that is bringing Ayurveda to the mainstream and in turn helping people improve their Ojas.

Shifting gears: What was it like owning a restaurant in India?

Owning my own restaurant was one of the most beautiful experiences of my life. I felt so privileged every day to have each and every customer walk in and allow me to feed them. With the incredibly steep learning curve, came a deep sense of responsibility on what I served these patrons. Where I sourced the ingredients, how I stored them and cooked them was of prime importance. Even more important was the well being and growth of the people who worked with me and put their entire vitality into the everyday running of the restaurant. What they put in would be what the customer would feel. Having a restaurant is famously known to be one of the toughest businesses in the world, and I would say that if you can do it in India you can really do anything. It is not a job for the faint hearted.

Lets talk about what happened in 2018. Your book just came out and you got some unexpected news. 

I was diagnosed with breast cancer in April, a month before I was meant to start the promotional tour for my book. The cancer was discovered completely by chance and my doctor truly saved my life, because of a nagging feeling she decided not to let go of.

Five surgeries, fertility treatments, chemotherapy and radiation are all done now, and I have been cancer free for 8 months. It was an indescribably challenging time and in many ways continues to be, but I do also think in has been a surreal sort of blessing. I can never un-know the value of being present and grateful to be alive.

I’m so glad you were able to move through that period, though I know you have to continue to be monitored. It’s also interesting that your doctor had a sense that something was wrong — I’ve written about clinical intuition in that regard, and it’s fascinating. Moving to food and cancer now — there is a lot of misinformation out there around the role of nutrition when it comes to cancer. How did you approach food during all of this?

There is definitely a lack of information and guidance from most doctors on the subject. I was astonished to be told I can eat and drink whatever I wanted and even that it was ok for me to drink wine. I chose to take guidance from my Chinese medicine doctor and Ayurvedic practitioners, to integrate the allopathic treatment with a holistic diet as well as a fasting protocol during chemotherapy. I am not qualified to know what would be best for any other cancer patient to do, but I would strongly suggest making all the efforts to find the right foods and guidance for your body during this very taxing treatment. Even if your medical doctor isn’t qualified in nutrition to give you the right guidance, it is imperative to figure it out with other holistic practitioners. One important thing I made sure to do was to consult with my doctor, about any supplements I was taking because they can severely interfere with your treatments.

The role of nutrition is an interesting area of research, and admittedly I’m reexamining some of my old beliefs about the role of food as we learn more about whether there is a role for intermittent fasting in general and various new protocols for cancer treatment that look at the role of nutrition. It’s a fascinating area to keep an eye on, and like with many areas of medicine, once more data comes in we’re able to re-orient how we approach care.  Was there anything else that helped you through this devasting period?

I went to a therapist through most of my treatment and continued for some months afterwards. Your life is turned upside down and it isn’t always possible for those around you to understand what you are going through. As physical as cancer and the treatments are, I experienced a deep sense of calm and vitality by using tools like therapy and transcendental meditation.

What does well-being and ‘Thriving’ mean to you?

Eating whole foods and lots of vegetables. Finding ways that you like to eat them and not falling into the pressures of all the overwhelming information coming our way from all directions. Finding whatever way to laugh everyday and be grateful for whatever it is you have. I write a gratitude journal daily and that really shifted my daily perspective. Also re-evaluating this expectation of constant happiness and instead being content with the little things in life. The second page of my book has the quote that I like to live and cook by, which is “More and more with less and less, until you can do everything with nothing.”

What are you most looking forward to now?

I am trying not to look forward but be in the now. I work everyday on my next book as well enjoy my good health and loving friends and family.

**Originally published in ThriveGlobal**

Preventing children from dying in hot cars

One of the biggest lessons I learned a decade ago in public-health graduate school was that education was rarely enough, on its own, to fundamentally change behavior. Educating the public about health was “necessary but not sufficient,” as one of my epidemiology professors had put it. Weight loss, smoking cessation, safe sexual practices — education campaigns weren’t enough.

Decades of educating the public about the dangers of leaving children unattended in cars where the temperature can turn deadly — even on a sunny but not especially hot day — clearly have not been sufficient. The deaths of 11-month-old twins on July 26 in a hot car in the Bronx have brought a fresh sense of urgency to finding innovative technology solutions.

But even before that tragedy, bills had been introduced in Congress earlier this year to address the rising incidence of young children dying in overheated cars.

According to the No Heat Stroke organization, which tracks pediatric heatstroke deaths in vehicles, the average number of such deaths annually since 1998 is 38, with 53 deaths recorded last year — the most ever. Sadly, the nation appears certain to set a record in 2019, with 32 deaths already by the second week of August. The Kids and Cars safety group, another tracker, notes that “over 900 children have died in hot cars nationwide since 1990.”

Fifty-four percent of these victims are 1 year old or younger. In a little more than half of the deaths, children have been mistakenly left alone by their caregiver, in what is known as Forgotten Baby Syndrome. Other children die after climbing into hot cars without an adult’s knowledge, and others have been knowingly, sometimes criminally, left in hot cars.

The American Academy of Pediatrics recommends rear-facing seats for crash-safety reasons and last year removed the age recommendation, focusing instead on height and weight. But there is an immense irony in the safety policy: Rear-facing seats prevent the driver from occasionally making eye contact with the child in the rearview mirror, which would keep the child prominent in the adult’s mind. And when a rear-facing seat is often left in the car, regardless of whether a child is in it, the seat’s presence can be too easily taken for granted.

The father in the New York case said he had accidentally left the twins in rear-facing car seats. (A judge on Aug. 1 paused the pursuit of a criminal case against the twins’ father, pending the results of an investigation.)

As a pediatrics resident physician, I’ve seen hundreds of parents and caregivers of young children, and many are simply overwhelmed, sleep-deprived and vulnerable to making tragic errors. Some parents in high-stress professions may have an additional cognitive load, which can lead to distractions.

The American Academy of Pediatrics suggests several ways to help prevent these tragedies by retraining habits and breaking away from the autopilot mode that often sets in while driving and doing errands. But that’s not enough. The Post noted five years ago that automakers’ promises to use technology to prevent hot-car deaths went unrealized. Liability risks, expense and the lack of clear regulatory guidelines also discouraged innovation. Congressional attempts in recent years to legislate on this front have failed.

That all may be changing, given the rising number of child deaths. The Hot Cars Act of 2019, introduced in the House by Rep. Tim Ryan (D-Ohio), would require all new passenger cars to be “equipped with a child safety alert system.” The bill mandates a “distinct auditory and visual alert to notify individuals inside and outside the vehicle” when the engine has been turned off and motion by an occupant is detected.

The Hyundai Santa Fe and Kia Telluride already offer such technology, which is a welcome step in the right direction. But it would not identify infants who have fallen asleep and lie motionless; these detectors are not typically sensitive enough to detect the rise and fall of a child’s chest during breathing.

The Senate version of the hot cars bill proposes an alert to the driver, when the engine is turned off, if the back door had earlier been opened, offering a reminder that a child may have been placed in a car seat.

The development of sensors for autonomous-vehicle technology is promising — how much harder will it be to alert drivers to people’s presence inside the car, not outside? Other ideas to consider: A back-seat version of the passenger-seat weight sensor that cues seat-belt use, with a lower weight threshold to alert the driver (and loud enough for a passerby to hear) once the engine is shut off. Or try something that doesn’t rely on motion or weight — a carbon-dioxide detector that would sense rising levels (we exhale carbon dioxide, and this rises in a closed and confined space) after the engine is off, sounding an alarm while automatically cooling the vehicle.

No parent of a young child is immune to Forgotten Baby Syndrome — we are all capable of becoming distracted, with terrible consequences. Those who have been devastated by such a loss deserve our sympathy, not our scorn. To avoid future such tragedies, applying technical innovation to passenger vehicles is essential.

**Originally published in the Washington Post**

Climate Change is Making Us Sick

Climate Change is Making Us Sick

NO MATTER WHAT you think about the causes of climate change, we know the planet is getting warmer. What most of us don’t realize is the impact climate change has on our health, which is why it’s concerning that last week’s UN Climate Change Summit did not identify health as one of the key action areas.

While about 70 percent of Americans believe that climate change is real (and in Canada, where I live, it’s a key issue ahead of the upcoming election), the majority of Americans surveyed do not believe it will harm them personally, according to a recent Yale Climate Opinion Map of public opinion data. In an earlier survey, less than one-third could name an example of climate endangering health. It’s time for a reality-check.

A 2016 Global Change Research Program Report listed seven broad areas in which climate change can affect health: through temperature-related death and illness, air quality, extreme events (such as disasters), vector borne diseases, water-related illness, food safety and nutrition, and mental health. Particular populations – such as low-income Americans, people with chronic medical conditions, Indigenous peoples, and persons with disabilities — may be disproportionately affected, as climate change has a direct impact on worsening every social determinant of health. Hurricane Dorian, which devastated the Bahamas, is yet another reminder that often the poorest communities are hardest hit.

A warmer planet means more potential for death and illnesses related to higher temperatures. It means lower air quality, especially in densely populated areas. Mosquitoes, ticks, and other carriers of infectious diseases can cover a wider geographic range and for a longer span of the year.

Let’s take Lyme disease: due to global warming, the ticks that carry Lyme are appearing in many more states, notably in the Midwest and in much of Canada. Other vector borne diseases are also likely to increase, though, as one researcher pointed out, the exact impact is unclear without further research.

Global warming also raises the chances of suffering heat stroke and heat stress, both risk multipliers for heart attacks. Asthma sufferers experience worse symptoms from the additional carbon dioxide in the atmosphere as well as dust and other particulate matter.

Air pollution currently causes up to 7 million premature deaths, according to the World Health Organization, and millions more visits to hospitals: One study points to the increase in amounts of near surface ozone as our planet warms as the cause. This issue was highlighted by the WHO at the UN Youth Climate Summit through immersive experiences in “air pollution pods.

And those of us who enjoy seafood are at risk of neurotoxin exposure, due to increases in ocean algae blooms caused by warming temperatures. One study found that the toxic “domoic acid” increased as sea conditions became warmer.

Pregnant women are also at risk. In 2017, an extensive review of previous research on maternal health and climate change found that there are significant connections between extremes in temperatures and premature birth, low birthweight, and stillbirth.

We know that the US is one of the most sleep-deprived nations in the world, and a landmark paper has even linked warm temperatures related to climate change to insufficient sleep among those surveyed.

Lastly, we can’t forget the toll that climate change takes on mental health. The American Psychological Association summarized the effects in an extensive report, linking climate change disasters such as droughts and flooding to increased incidence of posttraumatic stress disorder and depression. And they found that worry about global warming can increase anxiety and depression, as well as substance abuse. This can be especially the case in places that have faced an environmental disaster.

Globally, no one is untouched. The WHO compiled a comprehensive set of resources that detail country-specific ways in which climate change affects human health. It estimates that between the years 2030 and 2050, 250,0000 additional deaths globally could be related to climate change, costing billions. The WHO hosted the first humanitarian conference on health and climate change in April.

In a 2017 article for the New England Journal of Medicine, the authors suggest a few ways in which doctors and patients can combat the effect of climate change on human health. For one, there is a unique opportunity to advocate for ‘green’ hospital design and eating less meat (which may also have health benefits, and have an impact on greenhouse gas emissions).

Earlier this summer, over 70 prominent medical organizations, including the American Academy of Pediatrics and the American Medical Association, called climate change the “greatest public health challenge of the 21st century,” and published a series of recommendations which include reducing greenhouse gases and improving access to clean water. In late August, the Doctors of British Columbia identified climate change as a major health care issue, which was followed by a similar alarm sounded by the Australian Medical Association.

Yet these calls to action can only go so far. Globally, all of us share the aspiration to obtain the highest level of health and well-being possible, however climate change has made this goal unreachable for many, and poses new challenges that even the best medicine won’t be able to fix. And as with most public health challenges, the most disadvantaged in society face the highest burden of risk. A public health approach values “upstream,” or preventative approaches to health disasters, which is why the WHO’s emphasis on the health impact of climate change matters.

While it’s unclear why it was not a core area identified in this year’s UN Climate Change Summit, weaving the health impact into the discussion will be crucial to setting much needed priorities for change before it’s too late.

**Originally published in the Boston Globe**

Use and Perceived Effectiveness of Complementary Health Approaches in Children

Use and Perceived Effectiveness of Complementary Health Approaches in Children

All residents doctors in Canada are required to work on a research project, and I was excited to apply my research/epidemiology training towards an issue that is particularly important in pediatric medicine: why parents use complementary/alternative medicine, and more importantly, perceptions on how effective various therapies and approaches might be.

My research team, led by Dr. Roger Zemek and Dr. Sunita Vohra, was excellent, and brought a variety of expertise in both emergency medicine (which was the population we surveyed) and integrative pediatrics. We worked with some excellent biostatisticians and epidemiologists as well, and were able to present at two different conferences, publish two papers, and write about our findings for the New York Times. It was a testament to the power of having a great team with skills that complement each other, with shared goals and values.

Here’s what we found:

~ About 62% of participants used complementary health approaches (CHA) for their children over the previous 12 months, with vitamins/minerals and massage being particularly common. And higher parental education was associated with a higher odds of using CHA, and most parents believed that the CHA used was effective.

~ When it came to acute conditions that required an emergency room visit, about 29% of caregivers used CHA within the previous 72hours specifically for that complaint, and use for gastrointestinal complaints was most common.

~ Open and honest discussions between parents/caregivers and their doctors about CHA are crucial, and in our NYT article myself and my research supervisors outline some of our suggestions.

Interview: Jessica Harthcock

Interview: Jessica Harthcock

This is part of a series of interviews by physician and journalist, Dr. Amitha Kalaichandran, exploring purpose, resilience, healing, and brushes with the healthcare system by trailblazers in the health and wellness community.


Jessica Harthcock is the Co-Founder and Chief Executive Officer at Utilize Health, a neuro care solution that focuses on creating a better healthcare experience for patients with neurological conditions while delivering quality-driven medical cost savings for key stakeholders.  Astounded by how much of the work her family had to do on their own; Ms. Harthcock vowed to create a service that assists patients and caregivers in locating and obtaining optimal care while minimizing expenditures for individuals, families and payers. To learn more about Utilize Health visit She spoke with me in July from Nashville Tennessee.

So what is Utilize Health, and who does it serve?

Utilize Health offers a neurological care solution to lower care costs for health plans while maximizing overall health for members. The end user of our program is the patient who has a severe neurological condition such as a stroke, spinal cord injury, brain injury, and other condition.

After my accident I spent years searching for highly specialized rehab treatments. I saw how disconnected and fragmented the healthcare system is for patients like myself and variable recovery for patients. Patients would reach out to me and ask for advice. As I saw this happen I knew there was a tremendous opportunity.

Tell me more about what happened on that fateful day while you were doing gymnastics.

It was 2004 and I was 17 practicing gymnastics in order to improve my springboard diving skills. I went to do a front double tuck with a layout twist. The last one involved going up in air; when I came down, I landed on my head. I heard a crunch and my body went numb. I had landed on my head which broke my neck as well. I was in a state of shock and couldn’t feel anything or speak. In that moment I thought about Christopher Reeves, that I would be paralyzed like him. I didn’t have sensation but I was fully conscious. Later on we found that a cyst formed around the spinal cord so it looked as though the spinal cord had herniated in the scan, which ultimately did most of the damage at T3. This accident left me to function as a T3 paraplegic.

And what was the healing process like?

It was long. I was in rehab for nearly 3 years with leg braces, electrical stimulation, at times someone  was holding on to me.  My foot first just advanced an inch. It slowly turned into an actual step. You’re shaking, your muscles are trying to function. It took me six years to walk completely unassisted. I eventually moved to having just one forearm crutch, and now I don’t need any assistance. I used gait training as well as biofeedback that was linked to the gait training. Gait training was harder to come by back then, but today it’s much more easily accessible.

What would most people be surprised to know about having that particular physical challenge? 

The biggest thing I see is how uneducated much of the public is when it comes to understanding physical differences. I always grew up conscious of people that had differences in their abilities. One of my cousins has cerebral palsy so she was in wheelchair since she was little. I never thought much of it, and my dad always talked about the ADA [American Disability Act] and how important that was, and how people with different abilities want the same things we all do.

Especially early on after my accident people would point and stare — a mother with her child in a stroller once pointed to me and said, ‘look she’s in a Stroller too.’

When I got my service dog I noticed how ignorant people were. I felt I needed to educate people about was service dogs could be used for and how mine help me. It was particularly tough when Ozzie and I would get kicked out of healthcare facilities and public spaces, even though it’s against federal law. So I to become my own advocate, and realized I needed to educate others on a larger scale so I started speaking at schools and local businesses.

There is a lot of misinformation out there around what works best for spinal cord injury. Are there any myths you would like to clear up?

The biggest misconception about spinal cord injuries and neurological conditions is that recovery is not possible. In the past 15-20 years research has advanced such that it IS possible. We now see patients make incredible strides in recovery, whether it’s regaining bowel, bladder control, whether it’s walking or sitting up and balancing again. We did believe 30 years ago that spinal cord injury meant someone would never walk again, but the fact that many patients are still told they will never recover and shouldn’t even try, and are sent home to live the rest of their life without hope doesn’t make sense to me. That’s where I get angry. I would like to see this addressed in the healthcare community. Conversations like, “this is what your prognosis is can be challenging, and this is what it can mean, but others have recovered even if we don’t fully understand why.” We still don’t know all the elements and facets and we’re at the tip of the iceberg. More research has to be done. At Utilize we’re collecting outcomes from every patient in the program, looking at countless factors: through social determinants, spiritual, and how it all plays a role in recovery. We get patients from all walks of life and we’re now looked at how we can use big data to tie it together.

Now that we talked about myths, what are some new and surprising areas of research spinal cord injury and the role of rehabilitation (as well as other components of treatment?)

The different simulators that they can implant in your spinal cord and brain are exciting. There’s some great work out of the Fraizer Rehab Institute in Kentucky for instance, led by Dr. Susan Harkema which holds a lot of promise. It complements other research, like gait training. There are also other, more controversial, research areas such as using stem cells in spinal cord injury, which will be an area to watch over the coming years.

Was there anything else that helped you, other than surgery and rehab wise through the healing process?

I separate healing into three areas: physical, emotional and spiritual. Physical healing for me involved rehab, exercise, nutrition, and rest. Emotional healing involved handling the traumatic injury, knowing I was going to be ok in the end and the stress aspect.  Spiritually I knew something terrible had happened, but had to find a bigger purpose for it. For anyone who believes in a higher power, they have to feel something greater. I know a lot of people might not feel this way, but for me, the emotional and spiritual healing aspects were things I had to consciously focus on, to remind me that I couldn’t let this accident get the best of me. As well, I needed to surround myself with supportive people. I was lucky to have an entire army of people and support and helped me heal in really beautiful ways. My family was and still is today my rock. 

Returning back to Utilize, what has the response been?

The response has been overwhelmingly positive. We have high engagement results and our health plan partners have had fantastic results. We post great outcomes and consistently show lower costs of care. If any business can create a win-win for everyone, that’s the sweet spot.

How did that experience change who you are today, and how you see life?

I was lucky because I saw the potential of the research that was happening. Sometimes that’s all it takes, to see recovery is possible. I think that people go through adverse times and you can let it get the best of you. You can drown in it or say ‘I can conquer this.’ Having that attitude up front is key. I’m a pretty positive person anyway, but I chose things to be grateful for every day. The adversity I faced led me to the work I do today and the ability to work with amazing people. It led me to my husband who helped me to walk again (he was actually one of my trainers!). I have an incredible service dog Ozzie because of it. It’s hard to see the good in a traumatic event when you are in the thick of going through it, but I always knew there was a bigger purpose and bigger plan — I hung on to that. 

What does well-being and ‘Thriving’ mean to you?

Well-being to me encompasses six areas – physical, mental, spiritual, emotional, environmental, and intellectual. I have not achieved full balance in these areas. But I certainly try to be conscious of these areas in my life. Thriving for me means thriving in all these areas. I can be off in one and it can impact the other things.

What are you most looking forward to now? 

Serving more patients through the plans we work with through Utilize. We have an entire team that is so excited to help them, and we’re just getting started.

AI Could Predict Death. But What If the Algorithm Is Biased?

AI Could Predict Death. But What If the Algorithm Is Biased?

Researchers are studying how artificial intelligence could predict risks of premature death. But the health care industry needs to consider another risk: unconscious bias in AI.


Earlier this month the University of Nottingham published a study in PloSOne about a new artificial intelligence model that uses machine learning to predict the risk of premature death, using banked health data (on age and lifestyle factors) from Brits aged 40 to 69. This study comes months after a joint study between UC San Francisco, Stanford, and Google, which reported results of machine-learning-based data mining of electronic health records to assess the likelihood that a patient would die in hospital. One goal of both studies was to assess how this information might help clinicians decide which patients might most benefit from intervention.

The FDA is also looking at how AI will be used in health care and posted a call earlier this month for a regulatory framework for AI in medical care. As the conversation around artificial intelligence and medicine progresses, it is clear we must have specific oversight around the role of AI in determining and predicting death.

There are a few reasons for this. To start, researchers and scientists have flagged concerns about bias creeping into AI. As Eric Topol, physician and author of the book Deep Medicine: Artificial Intelligence in Healthcare, puts it, the challenge of biases in machine learning originate from the “neural inputs” embedded within the algorithm, which may include human biases. And even though researchers are talking about the problem, issues remain. Case in point: The launch of a new Stanford institute for AI a few weeks ago came under scrutiny for its lack of ethnic diversity.

Then there is the issue of unconscious, or implicit, bias in health care, which has been studied extensively, both as it relates to physicians in academic medicine and toward patients. There are differences, for instance, in how patients of different ethnic groups are treated for pain, though the effect can vary based on the doctor’s gender and cognitive load. One study found these biases may be less likely in black or female physicians. (It’s also been found that health apps in smartphones and wearables are subject to biases.)

In 2017 a study challenged the impact of these biases, finding that while physicians may implicitly prefer white patients, it may not affect their clinical decision-making. However it was an outlier in a sea of other studies finding the opposite. Even at the neighborhood level, which the Nottingham study looked at, there are biases—for instance black people may have worse outcomes of some diseases if they live in communities that have more racial bias toward them. And biases based on gender cannot be ignored: Women may be treated less aggressively post-heart attack (acute coronary syndrome), for instance.

When it comes to death and end-of-life care, these biases may be particularly concerning, as they could perpetuate existing differences. A 2014 study found that surrogate decisionmakers of nonwhite patients are more likely to withdraw ventilation compared to white patients. The SUPPORT (Study To Understand Prognoses and Preferences for Outcomes and Risks of Treatments) study examined data from more than 9,000 patients at five hospitals and found that black patients received less intervention toward end of life, and that while black patients expressed a desire to discuss cardiopulmonary resuscitation (CPR) with their doctors, they were statistically significantly less likely to have these conversations. Other studies have found similar conclusions regarding black patients reporting being less informed about end-of-life care.

Yet these trends are not consistent. One study from 2017, which analyzed survey data, found no significant difference in end-of-life care that could be related to race. And as one palliative care doctor indicated, many other studies have found that some ethnic groups prefer more aggressive care toward end of life—and that this may be related to a response to fighting against a systematically biased health care system. Even though preferences may differ between ethnic groups, bias can still result when a physician may unconsciously not provide all options or make assumptions about what options a given patient may prefer based on their ethnicity.

We know that health providers can try to train themselves out of their implicit biases. The unconscious bias training that Stanford offers is one option, and something I’ve completed myself. Other institutions have included training that focuses on introspection or mindfulness. But it’s an entirely different challenge to imagine scrubbing biases from algorithms and the datasets they’re trained on.

Given that the broader advisory council that Google just launched to oversee the ethics behind AI is now canceled, a better option would be allowing a more centralized regulatory body—such as building upon the proposal put forth by the FDA—that could serve universities, the tech industry, and hospitals.

Artificial intelligence is a promising tool that has shown its utility for diagnostic purposes, but predicting death, and possibly even determining death, is a unique and challenging area that could be fraught with the same biases that affect analog physician-patient interactions. And one day, whether we are prepared or not, we will be faced by the practical and philosophical conundrum by having a machine involved in determining human death. Let’s ensure that this technology doesn’t inherit our biases.


**Originally published in Wired**

The Power of Surfing, as Therapy

The Power of Surfing, as Therapy

Surf therapy programs often focus on children with autism or anxiety, or groups like veterans or cancer survivors.


Agatha Wallen’s son, Mason, has autism, and when he was 7, she heard about an initiative in San Diego aimed at children with special needs. It involved an unlikely tool: a surf board.

She wasn’t sure how it would work for her son, who struggled with behavioral and sensory issues. “Even getting the wet suit on was difficult for him because it was a brand-new sensory sensation,” she recalled. “From the beach I could see the surf instructors calmly speaking to him, and his whole body seemed to change and relax,” Ms. Wallen said. “He was able to stand up and catch a wave, with a big smile on his face, and ran up to shore and said ‘Mommy, I want to do it again.’”

Mason has been surfing for five years, and now his younger brother, Trevor, 9, is also an active participant in the same program, A Walk on Water. It is a California-based surf therapy nonprofit that primarily focuses on children with special needs — mostly with neurological disabilities. Ms. Wallen serves as an ambassador for the program, helping explain surf therapy to other parents.

“In the ocean there are no cars or planes or people shouting or things buzzing around,” she said.

“It might be the calmness of the waves, but it’s also being with instructors that he could trust and who were patient with him as well.”

A Walk on Water’s executive director, Sean Swentek, points to the importance of serving the whole family, including the child’s siblings, while also offering respite for parents.

“Surf therapy often provides bonding time for them, and our events are meant to be a full day of healing for the whole family,” Mr. Swentek said. The group recently released a short documentary about the role of surf therapy in the lives of three children with special needs.

“In a nutshell, surf therapy is a structured method of surfing utilizing elements of ocean and using its therapeutic benefits for those in need,” said Kris Primacio, the chief executive of the International Surf Therapy Organization, which acts as an umbrella organization to bring together surf therapy programs and researchers. “We tend to focus on underserved populations and exposing surf therapy to those who wouldn’t otherwise have access to an instructor.”

Each surf therapy organization develops its own program. In general, groups meet on the sand before a surf lesson, discuss ocean safety and often discuss mental health struggles as a form of group therapy. They then surf for a few hours and have a debriefing session.

In Britain, children with referrals for anxiety can participate in a free six-week program called The Wave Project. The program, which has received National Health Service funding in the past, gathers data before and after through questionnaires using the Stirling Children’s Well-being Scale and the Rosenberg Self-Esteem Scale.

“We focus on children who have anxiety disorders or are at risk of developing issues. Some may have autism or A.D.H.D. and are at risk of developing more series mental health problems, and most of these children feel isolated,” said Joe Taylor, the program’s chief executive. “Our approach is similar to an occupational therapy approach, and we don’t see ourselves as an alternative to support for care, but part of a package of mental health care.”

In 2014, John Newkirk started Salt Water Therapy L.A., which emphasizes mindfulness as well as surfing. As a certified drug and alcohol counselor with his own history with addiction, Mr. Newkirk wanted to share a mindfulness practice while also structuring the program with ocean safety and surf instruction.

“What happens with mental struggles, including addiction, is that there is an element of self-medicating. Surfers have called it ocean therapy for decades, because of the spiritual benefits. It’s a high with dopamine, but a safer healthier kind,” Mr. Newkirk said.

Surf therapy is not a substitute for medical care, and surfers can still struggle with mental illness. Indeed, the surf legend Sunny Garcia talked about his depression and has been hospitalized since attempting suicide this spring.

However, the evidence for surf therapy seems to validate what we know about movement and exercise, therapeutic effects of water and mindfulness. For instance, two years ago, a paper out of California State University described that just one 30-minute surf session improved mood, but the researchers didn’t distinguish the impact of surfing compared to other sports.

A qualitative study of 22 youths participating in The Wave Project, published in June in the International Journal of Environmental Research and Public Health, noted that surf therapy may work through offering a safe physical and emotional space, peer mentoring and positive reinforcement. Similarly, in 2017 a British study looked at the effectiveness of a three-month surfing program for youth and found that some elements of self-reported well-being improved. However neither study matched participants with a control group.

In June, research with 74 active duty military personnel from the Naval Health Research Center in San Diego found that depression, anxiety and PTSD symptoms decreased after surf therapy, but all participants were simultaneously receiving another form of therapy, making it hard to measure the impact of surfing alone.

Naturally, surfing is not without dangers: drowning, rip currents, sharks, just to name a few.

“The ocean is unpredictable, but leading organizations try to mitigate the risks by making sure staff are C.P.R.-certified and know how to prevent and deal with emergencies,” Mr. Swentek told me. “I think part of the reason it’s so powerful is because of those risks. It is not easy to do, so when these kids for instance are able to surf a wave and overcome their fear, there’s huge growth.”

Is the trend of surf therapy meaningfully different from exercise or mindfulness techniques? The evidence isn’t quite there. But its popularity is a sign of broader interest in a variety of tools that might improve mental fitness. Notably, a Los Angeles-based study from 2014 found that surfing may have a positive effect when delivered in combination with other forms of exercise, medication if needed, and group or individual therapy.

In Jon Kabat-Zinn’s book on mindfulness “Wherever You Go, There You Are,” he writes, “You can’t stop the waves, but you can learn to surf.” Dr. Kabat-Zinn, a physicist by training, was one of the first academics to standardize and research mindfulness approaches. In surfing, much of the challenge involves facing a real wave and pushing forward anyway, even when the easy thing to do is back away.

When I reached out to Dr. Kabat-Zinn to say that one of his best-known sayings was being taken quite literally, he replied in an email:

“The beauty of mindfulness is that you can bring it into anything, and then everything becomes your mindfulness teacher and contributes to waking you up fully. Surfing is no exception. When you are really present, the world (and the wave) can wake you up, and bring you into the timeless present moment, even in the midst of complex, unpredictable, dynamical circumstances.”

**Originally published in the New York Times**