A friend of the Huntington’s community receives award for HD article in influential Brazilian magazine

Brazilian journalist Mônica Manir, holder of a doctorate in bioethics and a long-time friend of the Huntington’s disease community, received the Prêmio Synapsis (Synapsis Prize) for her in-depth December 2017 article on the disorder in the prestigious Brazilian magazine Piauí.

Titled “Dançando no escuro” (“Dancing in the Dark”), the article provides a detailed portrait of HD, focusing on families in Brazil and other countries affected by the condition, which causes involuntary movements, cognitive decline, and psychiatric problems. Piauí is on the level of The New Yorker magazine.

The Prêmio Synapsis is sponsored by the Brazilian Federation of Hospitals and awarded annually for the best journalistic reports on health issues in the categories of print publications, TV, online, and radio.

For her article, Manir did almost five months of reporting, traveling to the interior to visit a town with a large nucleus of affected families and also to the Vatican in May 2017 to witness Pope Francis’ special audience with the global HD community.

Upon receiving the Prêmio Synapsis in Brasília on November 27, Manir recalled the pope’s declaration that HD should be “hidden no more!”

Mônica Manir receiving the Prêmio Synapsis (photo by Federação Brasileira de Hospitais)

Manir received her degree in journalism at the Universidade de São Paulo (USP), one of Brazil’s leading universities, in 1990. She worked as both a reporter and editor for the Sunday news and cultural section of the newspaper O Estado de S. Paulo.

In 2013, she reported for the paper on the sixth World Congress on Huntington’s Disease, held in Rio de Janeiro. She also set up a talk by me on HD and bioethics in São Paulo at the Centro Universitário São Camilo’s graduate program in bioethics, where she received both her Master’s and Ph.D.

She is also doing a post-doctoral study at the USP’s Instituto Oscar Freire on the dilemmas of predictive testing for people at risk for HD.

On December 5, Manir granted the following interview via e-mail.

GV: What led you to study journalism?

MM: I was always a very curious person. I wanted to understand the “why” of everything. I always pestered my parents with questions. I also loved reading. When I was 14, my sister started studying literature at the Universidade Estadual de Campinas [in São Paulo state] and became a member of the Círculo do Livro [a bi-weekly book club]. I couldn’t wait to “inherit” from her all of those books that arrived at our house. I also loved writing and was praised for my school reports. In middle school, I discovered that the history taught in the schools had a political bias. I felt the wool had been pulled over our eyes with all of the language that permeated the school texts and that often hid the facts. I decided that, by becoming a journalist, I could try to get as close as I could to the truth to help people become more critical and aware. I wanted to be where things were happening and consider all the angles. To do that, I needed to do deeper reporting. That’s why I always preferred working for media that allowed me to do in-depth reporting.

GV: What inspired you to write an article for Piauí about Huntington’s?

MM: Although I already knew about the disease because of the article I did for O Estado de S. Paulo in 2013, I was inspired to do the piece for Piauí by the audience with the pope at the Vatican. I thought it was a theme appropriate for returning to the subject, now in a more profound way, because I would come into contact with the affected, the families, and the health professionals from different parts of the world.

GV: What did it mean for you to receive the Prêmio Synapsis for your article “Dancing in the Dark”? Why is the prize called “Synapsis”?

MM: It meant for me a big investment in an in-depth article. Just to report it took almost five months, including my trip to the Vatican and to Ervália, a small town with a large enclave of people with the disease in the state of Minas Gerais, and also the reading of articles and books, and long interviews with the affected, family members, specialists, artists. Then came the writing up of all that enormous amount of information, the organization of the text, and the fact-checking, and then the final version, which took up seven pages in the magazine. According to the sponsors, the name of the prize is intended to recognize the brilliant ideas regarding the improvement of Brazil’s health system. The term “synapsis” has to do with “link,” “connection.”

GV: What did you say as you accepted the prize?

MM: I thanked the sponsors for their initiative in stimulating discussion about the Brazilian health system, which is essential in a country with such social inequality in all areas. I also thanked Piauí magazine for having invested in a theme still little known, and for having sent me to the Vatican and Ervália to cover different angles of the subject. But I especially thanked the HD-affected, their relatives, and the health professionals, all of whom deal with prejudice, the difficulties of being diagnosed, and the hitches that have occurred in the search for treatments, all of this unfortunately also very common in other rare diseases. Lastly, I remembered the theme of the audience with Pope Francis: “Hidden no more!”

GV: After the ceremony at which you received your trophy, many people greeted you and said that they had not heard of HD but would now take an interest in it. What explains this reaction?

MM: I think the fact that a prestigious magazine like Piauí took interest in the subject is already a reason for reading the article. Another point is that this disease can be present in a family or friends without anybody knowing about it. Or, even if people know about it, they might lack detailed information. So, there’s curiosity about learning more about HD. One couple present at the ceremony said that they knew about the disease because a relative had symptoms. They called it “Huntington’s chorea,” as it is still sometimes known in Brazil, and praised the fact that the magazine had addressed the subject.

GV: It’s been a year since the publication of “Dancing in the Darkness.” Beyond your prize, what has been the article’s impact in Brazil?

MM: When it was published, it drew praise from various quarters, from apartment doormen to Brazilian celebrities, besides the subjects themselves.

GV: What was it like to cover the affected families in Rome in May 2017?

MM: It was a very rich experience! I understood much better the anguish of the families, the factors that accentuated or eased that anguish, and the determination to diminish the silence on the matter. Everybody was very kind to me, answering patiently my endless questions!

GV: What led you to study bioethics?

MM: I think bioethics combines perfectly with journalism in the sense that the guiding concept is “it depends.” Central questions of human existence can’t be viewed just from one angle. It’s necessary to turn the prism and observe the effects that has on the light. It’s necessary to understand the context of a matter, people’s wishes, the internal and external pressures, and, from that point, try to register things with sensitivity. Bioethics showed – and continues to show – me the profound dilemmas of life and death that are still far from being answered with a single response. 

GV: What has most impacted you regarding Huntington’s?

MM: Huntington’s is a hereditary disease that leaves families on hold. Questions hang over them: “Do I carry the gene? Does my child? And my mother? And my nephew?” Despite the existence of a predictive test, very few undergo testing to learn their status before the actual onset of symptoms – which is completely understandable, because there is still no cure. At the same time, there are cutting-edge research projects that could block the genetic trigger and, as a result, help to treat and/or cure this and other diseases.

GV: What message would you like to transmit to the Huntington’s community in Brazil? And beyond?

MM: I would like to say that I understand very well all of the suffering encompassing the disease and how, sometimes, people feel like hiding it in the closet. But I think the prize confirms the main point of the papal audience: we must speak about Huntington’s. Shedding light on things hurts. However, it helps to make people aware of alternatives and of the partners to be found on this journey. The disease does not affect my family, but my empathy – and that of so many other individuals – is not a question of blood, but of soul. I’m with you!

‘No Marine deserted on the battlefield’: two surviving spouses join forces to speed the defeat of Huntington’s disease

After the deadly, untreatable Huntington’s disease claimed their spouses, Jonathan Monkemeyer and Jane Mervar – once strangers, now close – decided to devote their lives to finding ways to speed the search for effective remedies and making the case for the importance of juvenile HD (JHD) in the process.

Without at first knowing the cause of his wife Sheryl’s strange illness, Jonathan quit his job in the early 2000s to become her full-time caregiver until she died from HD in 2009 at 46.

“It’s the thing you have to do,” Jonathan, an accomplished electrical engineer, said in a recent phone interview from his home in suburban Philadelphia. “You really don’t have a choice in our country. We did a lot of nice things, which was good. We did peaceful things like traveling to local gardens. She spent a lot of time with our son.”

Sheryl died at home. “I didn’t expect her to die,” Jonathan said. “I thought we would get the cure in time. The doctor said she had five years. But she fell and got hurt. She couldn’t sit. I had to hold her. Her weight went from 109 pounds to 89 pounds within four weeks. She died of a heart attack, which is like starving to death.”

Caring for Sheryl depleted the family’s life savings, Jonathan added. “I’m heating with wood right now,” he said. “I’m not using heating oil.”

The couple’s son Jonathan, now 14, has a 50-50 chance of having inherited the HD gene from his mother. (Usually only adults can decide whether to be tested for the gene, and most choose not to do so. Children can be tested if they already show symptoms.)

A parallel story

Halfway across the country in the village of L’Anse in the Upper Peninsula of Michigan, Jane faced her own difficult odyssey to decipher the disease afflicting her family. She lost not only her 49-year-old husband Karl, but also her 13-year-old daughter Karli Mukka to HD, both in early 2010. (Jane gave her daughters her maiden name.)

“Karl was a wonderful, ambitious, intelligent man,” Jane said at the start of an exhausting and emotional four-hour interview. “He had very strong family values. He could always make me laugh.”

However, she recounted, gradually “he started to change. Nobody could explain to me what was going on.”

Karl Mervar and daughter Karli Mukka, both victims of HD (family photo)

Like many HD patients, Karl became angry and aggressive, threatening his family with violence.

“Karl held us hostage with his guns,” Jane said, recalling the dangers she, Karli, and her three other daughters faced as Karl’s behavior became increasingly irrational. “There were a lot of scary, scary times. We had a safe room in the house. We’d go in the room and push the bed up against the door. The girls knew this routine. Then I would try to play with him or try to distract him.

“The darn thing is, I knew we were everything left in the world that meant anything to him.”

JHD ravaged Karli’s body, displacing the organs in her chest cavity and forcing her spine to the far side. Because of the disease’s uncontrollable movements, Karli had chewed off half of her tongue by the time she died, Jane said.

A nurse suggested that Jane give Karli morphine and “let her go.” She declined the advice.

“It was a hard spot to be in,” Jane said. “I talked to Karli and asked her if she was ready to go on baby Jesus’s lap. She said no. She died of natural causes.”

Today Jane just gets by financially, thanks to Social Security benefits, as she cares full-time for her two other daughters with Karl, 22-year-old Erica Mukka and 20-year-old Jacey Mukka. Like Karli, both have JHD. Karisa Mukka, a 26-year-old daughter from a previous relationship, lives nearby.

Partners in love and advocacy

In June 2010, still in mourning for their lost loved ones, Facebook friends Jonathan and Jane struck up a lively conversation while sitting next to each other at the 25^th convention of the Huntington’s Disease Society of America (HDSA) in Raleigh, NC. After the convention, they spoke daily for at least a couple of hours. Jonathan visited L’Anse, and shortly thereafter Jane and Jacey stayed nine days with the Monkemeyers.

Their friendship led Jonathan and Jane into a romantic, long-distance relationship.

“They’re an incredible family,” Jonathan said of Jane and her daughters. “Their value system is not about themselves.”

“I was in a pretty low place,” Jane recalled. “I had lots of grief after Karli and Karl died. I wanted a reprieve from caregiving – just wanted to be dead. I’d be laughing after I finished talking to Jonathan. I think he saved me.”

Their relationship and support for each other’s families also became a partnership in advocacy for HD patients.

Bridging the gaps

To achieve their goals, Jonathan and Jane are politely but firmly challenging bureaucratic inertia.

Supporting himself and his son with his son’s Social Security survivor benefits, Jonathan dedicates himself full-time to HD advocacy. He has developed a deep understanding of HD science. By his account, he has so far skimmed through more than 10,000 scientific articles related to the disease.

Applying an engineering approach to the problem of developing treatments, Jonathan developed a website, HDCircle.org, currently offline, on which he has posted information about HD researchers from around the world, links to HD organizations, and reviews of potential HD treatments. He plans to reactivate the site soon.

He also created a Facebook discussion page, Hereditary Disease Circle, with the goal of finding connections between HD and other neurological conditions such as Parkinson’s disease, multiple sclerosis, posttraumatic stress disorder, and amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease.

In addition, he attends relevant meetings and conferences in order to network with people from other disease communities. He seeks to bring their best results and ideas to bear on HD research.

As Jonathan explained, he aims to create “synergies” and “bridge the gaps” among HD researchers and the various key organizations such as HDSA, the Hereditary Disease Foundation (HDF), the CHDI FoundationInc., the multi-million-dollar, non-profit virtual biotech formed solely to seek HD treatments, and the National Institutes of Health (NIH).

As one example, Jonathan said he has spoken personally with NIH Director Dr. Francis Collins, one of the pioneers in the search for the HD gene in the 1980s and 1990s, more than a dozen times, including last week in Washington, D.C.

NIH Director Francis Collins (left) and Jonathan Monkemeyer (personal photo)

“Essentially, engineers design things hierarchically,” Jonathan explained. “I created a website, which is a blueprint for how the system works.

“We’re the only disease without a gene therapy. There have been 1,000 gene therapy clinical trials. But we as a community don’t seem to be organized enough. There’s something in our organizational structure. By their very nature of having a job description, when you’re within an organization, your function is to be in the organization. Everybody gets stuck in a silo of what they’re doing. With so many scientists and stakeholders in the field of HD research, moving forward gets stymied by committee and the sense of urgency gets tuned out.”

If he held a position within one of the organizations, “I’d have a boss to report to,” Jonathan continued. “As an outsider, without a job, and asking questions as an advocate, it gives you the position to help steer people in the right direction towards what needs to be done. I have the greatest freedom, not being employed in an organization. I can talk to anybody I want to.”

Sometimes Jonathan feels as if he’s “walking on egg shells, because I’m not a researcher,” he said. “You tell people very nicely and very artfully. We don’t tear down institutions. We build them up.”

He summed up his approach as “doing what needs to be done to drive innovation that will bring a therapeutic to our community.”

What might work

Significantly, Jonathan’s efforts include canvassing the research community for the latest discoveries and techniques that could translate into therapies for HD. He seeks to brainstorm about new developments, as well as previous ones, in his conversations with scientists.

Rather than simply await for the multi-million-dollar pharmaceutical efforts to bring results, advocates must actively participate in the search for treatments, perhaps even trying drugs and substances approved for other purposes in their own off-label studies, seeking advice from researchers on dosing, and having people reporting their observations via a website, Jonathan suggested.

He cited the example of Hannah’s Hope Fund (HHF), whose advocates teamed with researchers in a low-cost effort to develop gene therapy for a rare genetic condition known as giant axonal neuropathy. HHF has met with the federal Food and Drug Administration (FDA) and, if a safety study goes as planned, could start a clinical trial this year.

In the drug-discovery system in America, the profit motive “stymies innovation and responsibility” towards the patients, Jonathan observed. Rather than producing strong leaders like a Jonas Salk, who developed the vaccine for polio, the system today fosters a climate of “let’s make everybody happy.”

Jonathan also pointed to the new partnership between the NIH and the Milken Institute/Faster Cures, which seeks to increase collaboration among the government, foundations, universities, and the pharmaceutical industry in order to cure more diseases and do it faster. This initiative includes the creation of a new NIH program, the National Center for AdvancingTranslational Sciences.

Advocates for rare diseases like HD need “to get involved in every single aspect” of the search for treatments.

“AIDS advocates made the FDA bend,” he noted. “We the patients have a moral incentive. Our voice counts and makes the difference.”

An epiphany about JHD

Like other JHD advocates, Jane and Jonathan have strived to increase the attention to JHD by researchers, HD organizations, and the government.

In September 2010, Jonathan and Jane met with Dr. Steve Groft, the director of the Office of Rare Diseases Research at the NIH, to press the case for greater support for HD research.

For Jonathan and Jane, the meeting was a kind of epiphany. Pointing to the different emphases and the existence of different organizations in the field of diabetes and juvenile diabetes, Groft helped them see the key role that JHD research could play in the overall HD effort.

Dr. Steve Groft and Jane Mervar. In the middle is Max the Turtle, Karli’s stuffed animal companion that is now a mascot of the JHDKids initiative (family photo).

“The meeting was phenomenal,” Jane said. Jonathan said she came away with a greater sense of “we need to do something.”

“Everybody was so resistant to acknowledge the juvenile population,” Jane said. “It’s just like some big political game. Nobody was playing that game for our children, so we were screaming: we need a cure, we need a cure, we need a cure!”

“You need a piece of legislation to get JHD funded, and then the NIH would fund it,” Jonathan explained, pointing to one of the roadblocks facing the efforts to understand and treat JHD.

Both Jonathan and Jane observed that JHD research lags far behind other HD research, and, because of ethical concerns and the need to avoid mixing juvenile and adult research data, children aren’t included in clinical trials.

Jane tried but failed to sign up Karli for a trial for ACR-16, seen as a potentially promising HD remedy. Jane described the formal response she received as “too bad for you, you have Juvenile HD.” “I was devastated,” she said.

Karli also took the supplement creatine, currently under study for HD and taken by many in the community. “It took us almost a year to get two doctors to follow Karli when she was on creatine and to get a guideline on dosage,” Jane recalled. “There are a lot of families that are just slipping through the cracks.”

Researchers have also lacked a so-called “natural history study” of JHD – a study to follow a group of patients over an extended period to better understand the condition and support the development of treatments.

Jane and Jonathan’s advocacy has included pressing the HD organizations to pay greater attention to JHD, they said. Thanks to pressure from JHD families, last year HDSA agreed to the creation of a new fundraising effort specifically for JHD, Jane explained.

“Great things can be created from hard situations,” Jane observed.

Jonathan and Jane at the White House after their meeting at the NIH Office of Rare Diseases and Research (family photo)

Raising the profile of JHD

Jane, her daughters, and other JHD families swung into action, joining other grassroots JHD initiatives in the effort to raise awareness and funds for research.

Jacey and Erica started JHDKids.com. With a computer and video equipment provided by the Make-a-Wish Foundation, Jacey has made a series of short films, including one about Karl and Karli titled The Real Huntington’s Disease, which has had more than 220,000 views on YouTube. (Watch the video below.)

The JHDKids initiative is seeking funds specifically to support the JHD research of Dr. Jane Paulsen, the co-director of the HDSA Center of Excellence at the University of Iowa, and project partner Dr. Martha Nance, the director of the HDSA Center of Excellence in Minneapolis.

Both researchers work on a volunteer basis, with all funds raised going solely to research.

In the words of the JHDKids site, JHD differs significantly from adult onset HD in several ways. “The most significant difference is that in JHD the disease occurs before the brain is fully developed,” says a statement on the site from the researchers. “This accounts for the wide variation at one age from JHD to another age. Maturation and neurodegeneration occur at the same time in JHD.”

Drs. Paulsen and Nance began following JHD patients at the annual HDSA conventions in order to carry out the natural history study.

“Now, with the awareness and fundraising getting more widespread, they’re able to bring our families into Iowa,” Jane explained. “We’re planning on going this spring. That will be the first time we’re going to Iowa.”

One big family

Jonathan and Jane have talked of bringing their families together in one place.

For now, however, they will continue their hours-long daily conversations from their respective abodes. Jonathan’s location on the East Coast facilitates his access to the corridors of scientific and medical power, while Jane wants to respect Jacey’s wish to die in the same place as her sister and father.

The distance does not diminish their commitment to each other’s families, nor to the larger cause.

Jonathan helps Jane manage her caregiving crises. “He’s always learning something new,” she said. “He’s a very faithful, spiritual person. He’s just a very good man.”

Erica and Jacey’s doctors wouldn’t predict how long they might live, although JHD patients typically die in their 20s or 30s, if not sooner, like Karli.

Jane knows that an effective, life-saving treatment might not come in time to save them. She concentrates on providing them with the healthiest, happiest life possible. Having worked as a nurse’s aide in a nursing home and seen Karl go through his final decline in such a home, she hopes to keep her girls at home as long as possible.

“Jacey has a big phobia that if she can’t see me, she’ll die,” Jane said. “We can’t calm that down. She likes to watch movies. She likes to work on the website. She likes to see all the kids with JHD. She likes to come up with new ideas for designing the website.”

At 19, Erica had married her high school sweetheart, but the marriage lasted only 11 months. She is currently dating another man. “She wants him to learn how to do her makeup and coordinate her clothing,” said Jane, who has legal guardianship over both daughters.

She obtained a court order to obtain permission for a tubal ligation for Erica.

“I cried with her,” Jane said. “It was just a real painful process to go through. She said, ‘If I had a baby and got sicker, and what if my baby’s like Karli?’”

“Fear for my son is certainly a reason,” said Jonathan of his commitment to the HD cause, noting that, so far, his son has showed no HD symptoms. “That’s a personal, selfish motivation. Why is my son’s life more important than someone else’s life? I know Jacey and Erica and everybody else that’s dying from this.”

He added, “I’m doing this full time, and as far as I’m concerned, there’s nothing more important I can do with my life. It’s knowing everybody in the community and knowing the suffering and the damage it causes to families. You don’t leave a marine in the battlefield. It’s just wrong to walk away. I can’t stop doing it. This is my life experience.”

His experiences as Sheryl’s caregiver have deepened his feelings about others facing the same plight.

“When I see HD in somebody else, the empathy is much more intense and overwhelming,” he confided. “To me, we’re all a big family. That’s why I can’t walk away.”