Tiffany Rowe, a 46-year-old life coach in the San Francisco Bay area, still remembers how it felt as a teenager to be hoisted onstage to dance with Michael Jackson during his Bad concert tour.

She was 15 and recovering from an excruciating round of treatment for severe idiopathic aplastic anemia — basically total bone marrow failure.

She had met Jackson in his greenroom before the concert, but she had been told that dancing with him — her real wish — wouldn’t be possible.

Until it was.

“I was in front of all of those people, and I could hear the roar, and I was calm,” she recalls. “I was doing what I wished to do. I felt exactly the way I needed to feel, at home and confident in my body. There had been part of me that felt pretty betrayed by my body, and I felt very at peace in my own skin again.”

The moment was transformative for Rowe, who credits the experience with aiding her recovery. A study published in the journal Pediatric Research suggests her experience may not be unique.

Researchers looked back at the cases of nearly 1,000 children with serious illnesses who were treated at Nationwide Children’s Hospital in Columbus, Ohio. Half the children had received wishes and the other half hadn’t.

The children granted wishes were substantially less likely to visit the emergency department or to have an unplanned hospital admission within two years as compared with children who hadn’t received wishes. (Researchers matched the children’s personal and disease characteristics in the study.)

“My hypothesis is that these kids, when they come back, are more engaged with their families and medical providers, and perhaps they’re more adherent to their treatment plan,” says the study’s lead author Dr. Anup D. Patel, section chief of neurology at Nationwide Children’s Hospital and an associate professor of pediatrics at Ohio State University College of Medicine in Columbus.

“What’s harder to quantify is this feeling of hope and having a break from your illness,” Patel says. “It gives them an ability to fight harder, and that’s harder to measure.”

That ineffable feeling is what mattered for Rowe. Her illness had been caught late. She likely wouldn’t have lived another month without treatment, she says. Even with treatment, her prognosis was three to six months.

She lacked a perfect match for a bone marrow transplant, and she was so sick that her doctors didn’t want to risk a potentially fatal transplant rejection. So she received a then-experimental therapy called antithymocyte globulin, today a common treatment for aplastic anemia.

“I remember my mom saying, ‘We don’t know how this ends, but we have to try,’ ” Rowe says. She received her first treatment in the fall of 1984 and entered remission, but she relapsed in the fall of 1987.

“For me, relapse had a deeper emotional toll. I understood what I was headed back into, the pain and uncertainty and fear,” Rowe says. “I felt a bit demoralized, like I had failed. I didn’t want to be sick anymore. I didn’t want to have to survive anything.”

It was around then that a volunteer who had read about Rowe in the local paper visited her and offered a wish. Rowe didn’t hesitate.

“When everyone else wanted to be an astronaut, I wanted to be a dancer and dance with Michael Jackson,” Rowe says. “When he moved, it just stopped time for me. As somebody who felt so passionately about dance myself and so elementally at home in my body while dancing, I just saw that in him and felt a kinship.”

Joining him onstage gave Rowe back ownership over her body — and her future.

“There was a sense that I was fighting for something, not just against something, and that was incredibly motivating,” she says. “I was surviving to go back and live a full and extraordinary life — not that I knew that would happen, but I could give myself permission to believe it was possible.”

To qualify for a wish, a child must have a life-threatening, but not necessarily terminal, condition, says Jamie Sandys, a spokesperson at Make-A-Wish Foundation. The foundation has more than 60 U.S.-based chapters and has granted more than 300,000 wishes since 1980.

The organization granted approximately 15,400 wishes last year, Sandys says. Still, an estimated 27,000 children are diagnosed annually with an illness that qualifies them, which concerns Sandys. “There’s a huge gap that we’re trying to fill,” Sandys says.

Many past wish recipients have said the wish was an important part of their healing process. “These wishes can really be a springboard to help these children in overcoming their illnesses and producing better health outcomes for them,” Sandys says.

But verifying and quantifying those outcomes is difficult.

“It’s wonderful to have randomized controlled trials and measurable outcomes, but when you’re looking at mind-body-spirit connection in medicine, we’re not going to have the luxury of those outcomes,” says Dr. James Fahner, a division chief for pediatric oncology at the Helen DeVos Children’s Hospital in Grand Rapids, Mich. Though not involved in the study, Fahner is the immediate past chair of the Make-A-Wish America Medical Advisory Council.

“I’m fundamentally a scientist, and I expect reasonable, reproducible metrics when I’m deciding on the validity of a particular cancer therapy, yet when I walk down the hall in that same clinic and see a child who has just returned from a wish, I see positive impacts like stronger adherence to therapy, family resiliency and hopefulness in the child,” Fahner says. “The connection of mind-body-spirit can be hugely important, especially in a child going through such a rigorous and long therapy.”

A previous study tried to measure the effects of wish-granting and found less distress, fewer episodes of depression and reduced anxiety symptoms among children expecting a wish in the near future compared with those placed on a waiting list.

This new study found more concrete differences, including cost savings. The average cost of a wish is $10,682, but multiple unplanned hospitalizations cost more. The study found that twice as many wish recipients had reduced health costs compared with people who didn’t receive them.

Patel was inspired to conduct this study after seeing changes in his own patients and before he joined the organization’s medical advisory council. He had one 15-year-old boy with intractable seizures return from meeting the Los Angeles Clippers and never have a seizure again — a dramatic if rare and unlikely outcome.

But Patel is also a scientist who believes in evidence. He knew his study would be scrutinized by others who doubted “that something as wishy-washy as a wish could make a difference.” He chose to measure use of health care services because it is quantifiable in a way that “wellness” isn’t.

All the children were treated at the same hospital by the same medical teams, though it’s unclear why some received a wish and some didn’t.

The researchers used medical records to identify 496 children who received a wish and compared them with 496 others with the same approximate age, gender, disease category and disease complexity. The distribution of private insurance, no insurance or Medicaid was also similar in both groups.

Cancer was the most common illness — at 45 percent — among the children studied. After that, the most frequent conditions were blood-related/kidney (16.5 percent), neurological (14.5 percent) or genetic (14 percent). The breakdown is consistent with national figures: 45 percent of Make-A-Wish recipients have cancer and 13.5 percent have a nervous system disorder, Sandys says.

The researchers found that wish recipients were 1.9 times more likely to have fewer emergency department visits and 2.5 times more likely to have fewer unplanned hospitalizations in the two years after their wish was granted, compared with matched children.

The study is observational, so it can’t show that receiving a wish caused better outcomes since other factors may have affected the results. But many health care providers see change in their patients after wishes are granted.

“More positivity can sometimes be correlated with treatment adherence,” says Ashley Andrews, a social worker at Children’s Mercy Hospital in Kansas City, Mo. Andrews wasn’t involved in the study but has connected children diagnosed with cystic fibrosis to Make-A-Wish.

The excitement of a wish can change a family’s and child’s outlook enough that they may work harder with their medical providers, she says. “If their adherence has improved, obviously that would decrease the emergency department visits and hospitalizations.”

But it’s also possible other factors affected emergency visits and hospitalizations in nonrecipients, such as the reasons some children didn’t receive wishes. Perhaps they weren’t well enough to travel and weren’t interested in nontravel wishes. Perhaps parents turned down a wish if they felt another family deserved it more.

Andrews also cautioned against too much optimism about the findings. “These kids still have a chronic illness and have to go through a lot of obstacles that you and I don’t have to go through,” Andrews says. “That’s their reality, so I don’t want people to think that just because these kids have Make-A-Wish that everything’s fine.”

Dr. Arthur Lavin, chair of the American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health, says the findings make sense to him, too. But he also cautions that a child’s worse health outcomes aren’t a “failure” of the wish or of positive thinking.

“We like to think you can only have improved health if you have an expensive medication, and those things can be critical to help, but being kind and caring to someone has an amazing impact on [their] health and well-being,” Lavin says.

But the measurement of the effect of kindness isn’t entirely clear or predictable, he notes. Even if such effects aren’t as quantifiable as other therapies, Patel sees their value in less quantifiable terms.

“I recognize on a daily basis that I’m not going to help get seizures gone in a majority of cases with traditional interventions, so I’m always looking for ways to help families beyond treatment,” Patel says. “Even if it’s just making a kid happy for a couple of weeks, that’s sometimes better than any medicine I can give them.”

Tara Haelle is a freelance health and science writer.

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In a windowless classroom at the John J. Moran medium-security prison in Cranston, R.I., three men sit around a table to share how and when they began using opioids.

For Josh, now 39, it was when he was just 13 years old. “I got grounded for a week in my house, so I grabbed a bundle of heroin and just sat inside and sniffed it all week.”

“I started using heroin at 19,” says Ray, now 23. “I was shooting it. It was with a group of friends that I was working with, doing roof work.”

“At 26 years old, I experimented with heroin,” says Kevin, 50. “I wasn’t the person that I wanted to be. Once I put that in my system, I felt like this is what I’m supposed to do and this is what I’m supposed to feel like.”

This group therapy session is part of a $2 million program the Rhode Island Department of Corrections launched in 2016. These men are all serving prison sentences for crimes driven by their drug addiction — including robbery, shoplifting and possession of controlled substances. NPR agreed to only use their first names so they could speak frankly about illegal behavior.

They are among the approximately 275 inmates and pretrial detainees getting medication-assisted treatment behind bars.

The program is central to Rhode Island Gov. Gina Raimondo’s strategy to reduce opioid overdose deaths in the state. Today, Rhode Island remains the only state to screen every individual who comes into the correctional system for opioid use disorder, and to offer, along with drug counseling, all three types of drugs approved by the Food and Drug Administration to treat addiction — methadone, buprenorphine and naltrexone.

While prisons have long offered medication-assisted treatment to small subsets of inmates, such as pregnant women, many prisons in the U.S. do not offer it at all, despite the fact that it’s considered by physicians to be the most effective treatment for opioid addiction.

The criminal justice reform bill currently before Congress would require the Federal Bureau of Prisons to assess its capacity to provide medication-assisted treatment to inmates who are dependent on opioids, and to draw up plans to expand access to medically aided treatment “where appropriate.” But the bill leaves open who would determine when and where the medication is appropriate.

“It’s just ludicrous that we have a whole population of people who are by and large incarcerated because of their disease, and we have an effective medication treatment for the disease and we don’t give it to them,” says Dr. Josiah Rich, director of the Center for Prisoner Health and Human Rights at the Miriam Hospital in Providence.

Rich was one of the experts tapped by Raimondo to identify where best to direct resources to bring down the state’s overdose deaths. He made the case for a prison program, given the high death rate among people recently incarcerated.

“This is a population of the most severely impacted, the most advanced stages of opioid use disorder — the people who have taken the greatest risks and gotten caught up in the system,” Rich says. While in prison, the inmates’ opioid use usually ends, and so does their ability to tolerate high doses of the drugs without overdosing.

“Then you get released into a very stressful situation with a lot of triggers, and you typically relapse,” Rich says. “And if you relapse back to the same level you were using, you’re set up for overdose and death.”

This is what drove the Rhode Island Department of Corrections to offer medication-assisted treatment not just to people coming into prison, but also to those who began serving their sentences before the program existed. Eight to 12 weeks before their release, inmates with histories of addiction are offered methadone, buprenorphine or naltrexone to ease their transition back to society, beginning with very low doses.

“Even if somebody has not used in many years, they may still have changes in their brain,” says Dr. Jennifer Clarke, the Department of Corrections medical programs director. “The cravings are always going to be there. So, if somebody’s going back to the same old neighborhood, chances are they’re going to be exposed to the same people as when they were using drugs.

“So, providing the medication before someone gets out really helps to prevent a relapse,” Clarke says.

The possibility of relapse is top of mind for the men in group therapy. They have friends who have overdosed and died after serving time.

Kevin has just a few weeks left in his sentence, one of many that he’s served in his adult life. “It feels good, but I’m nervous. I always get nervous,” he says. “As soon as I walk out the gates — my feet, when they hit the pavement outside of here, I have to get busy immediately.”

“You worry about the drug aspect once you hit the street,” says Josh who has also served multiple sentences for drug-related crimes. “Many times, I’ve gone out of here and overdosed repeatedly. Not on purpose, just accidentally, trying to hide from the pain, hide from myself.”

This time, Josh says, the treatment program has given him a way to focus on a different way out.

“I still have to fight the other drugs,” he says. “But at least I have something to help with one of the ones that’s brought me closer to death than anything else.”

The program inside the prison is run by CODAC, a behavioral healthcare organization that also runs substance abuse treatment programs outside the prison, with locations across Rhode Island. Prisoners who enter the program remain clients when they exit prison, with treatment outside typically paid for by Medicaid. Discharge planners from CODAC help the inmates get organized for that transition.

“I already have counseling appointments lined up, doctors appointments lined up,” says Ray, who is scheduled to be released in December. In prison, he’s been taking buprenorphine, which he’ll continue the day he gets out. “I really don’t want to use heroin again.”

Early reports from the program are promising. In a study published in JAMA Psychiatry last spring, researchers found that overdose deaths among people who had recently been imprisoned dropped sharply in the first six months of 2017 as compared to the same period the year before — nine deaths, compared to 26.

Researchers continue to track outcomes and are interviewing inmates and correctional staff to learn more about how well the program is functioning.

There have been hurdles to overcome, says Lauranne Howard, substance abuse coordinator for the Department of Corrections, starting with resistance from security staff about the use of buprenorphine in the program. Buprenorphine itself is an opioid, though less potent than street drugs in many of its effects, and sometimes ends up sold or given to people outside its intended use.

“The reaction was, why are you going to bring in a medication that we’re working real hard to keep out? And that’s a legitimate concern,” Howard says.

In response, the program has made some changes. CODAC’s Leslie Barber, who directs the prison program and runs the group therapy sessions, says they launched the program using buprenorphine pills, which take awhile to dissolve.

“We compromised by switching to the films which, although more expensive, dissolve quicker,” she says. CODAC says the buprenorphine pills cost approximately $4 each, while the films cost approximately $8 each.

A number of other states have taken notice and sent corrections officials to Rhode Island to learn from their experiences. Clarke points out that Rhode Island has the advantage of being a small state with a combined jail and prison system, so that everyone who is incarcerated comes to the same campus.

“Places like Rikers Island [in New York City] have all three types of medication for opiate use disorder, but they can’t start people who might have a prison sentence, because they’re going to be sent to a different facility, and they don’t have the same opportunities to continue treatment that we have,” Clarke says.

Patricia Coyne-Fague, acting director of corrections for Rhode Island, recognizes that even with this program, people will stumble and make mistakes — even end up reincarcerated. Still, she defends the $2 million annual expenditure with the argument that the program saves lives.

“Sometimes there can be a negative attitude about whose lives we are saving,” she says. “But everybody belongs to somebody. And so, while they may have committed a crime and deserve to be incarcerated, they’re still human beings. And if we can keep people from dying, that’s a good thing.”

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The Food and Drug Administration announced Thursday that it will seek a ban on the sale of menthol-flavored cigarettes.

The announcement came as the agency officially released a detailed plan to also restrict the sale of flavored electronic cigarettes. It also wants to ban flavored cigars.

In a statement, FDA Commissioner Scott Gottlieb says the moves are aimed at fighting smoking among young people. Flavored e-cigarettes, menthol-flavored tobacco cigarettes and flavored cigars are all popular among teenagers.

“Today, I’m pursuing actions aimed at addressing the disturbing trend of youth nicotine use and continuing to advance the historic declines we’ve achieved in recent years in the rates of combustible cigarette use among kids,” Gottlieb says.

While cigarette smoking has hit a record low in the United States, vaping has been skyrocketing. That trend has raised concerns that a new generation of young people will become addicted to nicotine.

Gottlieb says the moves were prompted by new data showing a 78 percent increase in e-cigarette use among high school students and a 48 percent increase among middle school students, from 2017 to 2018.

“These data shock my conscience,” Gottlieb says.

The ban on menthol, in particular, has been long sought by public health authorities and antismoking advocates. The concern is that the flavoring masks the harshness of tobacco smoke, making it easier for people to start smoking.

“I believe these menthol-flavored products represent one of the most common and pernicious routes by which kids initiate on combustible cigarettes,” Gottlieb says.

Menthol cigarettes are especially popular among African-Americans, leading some to charge that tobacco companies have been using the flavoring to target minorities.

Several groups, including the NAACP, endorsed the FDA’s plan even before it was officially announced. “For decades, data have shown that the tobacco industry has successfully and intentionally marketed mentholated cigarettes to African Americans and particularly African American women as ‘replacement smokers,’ ” the NAACP said in a statement.

Several cigarette companies that market menthol cigarettes didn’t immediately respond to requests for comment. In the past, they have vigorously opposed any effort to ban menthol cigarettes.

“We continue to believe that a total ban on menthol cigarettes or flavored cigars would be an extreme measure not supported by the science and evidence,” said a statement from Altria Group Inc., maker of Marlboro Menthol.

The proposed ban will require a lengthy rule-making process by the FDA before it can go into effect.

Antismoking groups hailed the announcement.

“FDA’s decision to move forward with a ban on menthol cigarettes is one of the most significant public health actions that the FDA has taken in years and will have a greater impact on the death and disease caused by tobacco in the United States than almost any other single action,” says Matthew Myers, president of the Campaign for Tobacco-Free Kids.

“Menthol cigarettes are the single most important pathway to get kids to start smoking in the United States. It makes sense because what it does is coat your throat. It makes it much easier to get used to the harshness of tobacco smoke,” Myers says.

Some opponents of a menthol ban have argued that it could create an underground market for menthol cigarettes. But Myers and others dismiss that concern.

While Myers praised the FDA’s new restrictions on e-cigarette flavorings, he called for the agency to go further and completely ban the flavorings. According to the plan released Thursday, the FDA would continue to allow adults to buy flavored e-cigarettes.

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