In many ways, there has never been a better time to be alive. Violence plagues some corners of the world, and too many still live under the grip of tyrannical regimes. And although all the world’s major faiths teach love, compassion and tolerance, unthinkable violence is being perpetrated in the name of religion.
And yet, fewer among us are poor, fewer are hungry, fewer children are dying, and more men and women can read than ever before. In many countries, recognition of women’s and minority rights is now the norm. There is still much work to do, of course, but there is hope and there is progress.
How strange, then, to see such anger and great discontent in some of the world’s richest nations. In the United States, Britain and across the European Continent, people are convulsed with political frustration and anxiety about the future. Refugees and migrants clamor for the chance to live in these safe, prosperous countries, but those who already live in those promised lands report great uneasiness about their own futures that seems to border on hopelessness.
A small hint comes from interesting research about how people thrive. In one shocking experiment, researchers found that senior citizens who didn’t feel useful to others were nearly three times as likely to die prematurely as those who did feel useful. This speaks to a broader human truth: We all need to be needed.
Being “needed” does not entail selfish pride or unhealthy attachment to the worldly esteem of others. Rather, it consists of a natural human hunger to serve our fellow men and women. As the 13th-century Buddhist sages taught, “If one lights a fire for others, it will also brighten one’s own way.”
Virtually all the world’s major religions teach that diligent work in the service of others is our highest nature and thus lies at the center of a happy life. Scientific surveys and studies confirm shared tenets of our faiths. Americans who prioritize doing good for others are almost twice as likely to say they are very happy about their lives. In Germany, people who seek to serve society are five times likelier to say they are very happy than those who do not view service as important.Selflessness and joy are intertwined. The more we are one with the rest of humanity, the better we feel.
This helps explain why pain and indignation are sweeping through prosperous countries. The problem is not a lack of material riches. It is the growing number of people who feel they are no longer useful, no longer needed, no longer one with their societies.
In America today, compared with 50 years ago, three times as many working-age men are completely outside the work force. This pattern is occurring throughout the developed world — and the consequences are not merely economic. Feeling superfluous is a blow to the human spirit. It leads to social isolation and emotional pain, and creates the conditions for negative emotions to take root.
What can we do to help? The first answer is not systematic. It is personal. Everyone has something valuable to share. We should start each day by consciously asking ourselves, “What can I do today to appreciate the gifts that others offer me?” We need to make sure that global brotherhood and oneness with others are not just abstract ideas that we profess, but personal commitments that we mindfully put into practice.
Each of us has the responsibility to make this a habit. But those in positions of responsibility have a special opportunity to expand inclusion and build societies that truly need everyone.
Leaders need to recognize that a compassionate society must create a wealth of opportunities for meaningful work, so that everyone who is capable of contributing can do so. A compassionate society must provide children with education and training that enriches their lives, both with greater ethical understanding and with practical skills that can lead to economic security and inner peace. A compassionate society must protect the vulnerable while ensuring that these policies do not trap people in misery and dependence.
Building such a society is no easy task. No ideology or political party holds all the answers. Misguided thinking from all sides contributes to social exclusion, so overcoming it will take innovative solutions from all sides. Indeed, what unites the two of us in friendship and collaboration is not shared politics or the same religion. It is something simpler: a shared belief in compassion, in human dignity, in the intrinsic usefulness of every person to contribute positively for a better and more meaningful world. The problems we face cut across conventional categories; so must our dialogue, and our friendships.
Many are confused and frightened to see anger and frustration sweeping like wildfire across societies that enjoy historic safety and prosperity. But their refusal to be content with physical and material security actually reveals something beautiful: a universal human hunger to be needed. Let us work together to build a society that feeds this hunger.
SINCE 1994 Tracey Aldridge has been arrested 100 times, jailed 27 times for more than 1,000 days and spent a total of eight years in prison. Most of her arrests have been for trivia: trespassing, prostitution, drugs, disorderly conduct, petty theft or drinking in public, all typical of the mentally ill. Ms Aldridge is so impaired that one jail needed special arm coverings for her, like full-length oven gloves, to prevent her from ripping her veins out with her teeth. More recently, in prison, Ms Aldridge ate her protective gauntlets.
Thomas Dart, the sheriff of Cook County jail, knows Ms Aldridge will end up back in his cells soon because there is nowhere else for her to go. She is sentenced, like so many seriously mentally ill people in America, to rotate in and out of correctional facilities until she dies. Prisons and jails are the main mental-health facilities in the country, something Sheriff Dart describes as an “abomination”. He is also angry about how fiscally reckless it is. At only 42, Ms Aldridge has already cost taxpayers $719,436 for her arrests and incarcerations.
She is not alone. Depending on how you measure it, Sheriff Dart’s jail is either the largest, or second-largest, mental-health institution in America. On any given day in Cook County jail one building is home to between 2,000 and 2,500 people with diagnosed mental illnesses. Each night’s stay costs at least $190. Costs escalate when medical care is included. The Lamp Community, a non-profit working for the mentally ill in Los Angeles, says the desperate cycle of emergency-room visits and stints in jail can exceed $100,000 a year for each homeless person. Permanent supportive housing costs only $16,000.
The history of this quiet disaster can be traced back to the 1960s, when John Kennedy decided to treat more of the mentally ill in the community and a new drug called thorazine promised to help. Over the next decade, however, new centres did not arrive and thorazine was not as good as everyone hoped. Moreover, there was a rise in legal actions against state facilities.
Pete Earley, a journalist and author of a book on the American mental-health system, says that in one year in California 19,000 beds were cut. “There was no place for anyone to go, they were literally thrown on to the street,” he says. Matters deteriorated in the 1980s, when large cuts were made to housing programmes. Funds for the mentally ill remain a soft target.
Indeed, these days it is very rare for people to be put in a mental-health institution unless they are a danger to themselves or others. Even when they are held in a hospital, they are unlikely to stay long enough for any course of drugs to stabilise them. If someone decides he wants to walk around naked, or cannot give his name to a police officer, the likelihood is that he will end up in jail. Sheriff Dart, whose job is only to keep people safe while they await trial, says they should be treated better. People should not be pushed out on the street on their release day with “a baggie of drugs”. Instead, he is discharging them with videos to help them adjust and counselling about the different services they may be able to use.
He is most excited, though, about a small pot of funding he has found which might divert a few of the mentally ill away from his jail. New arrivals now have an interview, and evidence of any brain disorder is passed to the public defender (a lawyer for those who cannot afford one), who is then able to plead for an alternative to jail. With some philanthropic help from a local businessman, Sheriff Dart has managed to get about a dozen people into a secure former nursing home where he monitors them with an ankle bracelet.
Carla Clark thinks this works well. She is the mother of a young woman, Melissa, who had a psychotic breakdown and who looked certain to be heading into the criminal-justice system. Melissa’s problems started when it appeared she was taking something without paying at Wholefoods Market; but when two security guards came after her and she thought they were attacking her, she fought back. This led to a felony charge for robbery.
Her mother believes Melissa needs to be somewhere secure, so much so that she refused to bail out her daughter from jail because she was not taking her tablets. But now Sheriff Dart has found the girl a place in a home, things are much better. Melissa is taking her pills, and there is even a bit of group therapy. “Asylum”, says Mrs Clark, “means safe place. What is so bad with that?”
Mindprep believes that the mentally ill should receive more attention and focus should be reformatative rather than putative. Our GP students learn about these concepts and are able to discuss. Are You?
Here’s something I never thought I’d say: I just went back to work after a nine-month maternity leave.
This state of affairs is unexpected in part because I’m an American, and maternity leave for many women in America is six to 12 weeks — and much of that requires stockpiling and then cashing in your vacation. Let’s take a moment and all laugh out loud at the idea that newborn care has anything to do with vacation.
This year-long leave is possible because I now live in Canada, where I moved nearly four years ago to be closer to my Toronto-based boyfriend (now my husband). In Canada I can take up to a year of maternity leave and still return to my job. The government provides Employment Insurance — it’s not a salary replacement but it helps cover some costs while I’m off.
But my lengthy leave is even more surprising because I love what I do. I’m one of the few people I know who went to school and studied what would eventually be my career. I have worn a bunch of different hats and had many different roles, but all in the same industry. And almost all focused on emerging companies and/or nascent tech. I still wake up excited to work in tech most days.
I couldn’t imagine wanting to take a full year away from work. I initially told my office to expect me back after six months. But midway through my leave, I realized I wanted — I needed — more time. Lucky for me, I live in a place where that’s an option.
In Canada, taking a full year of maternity leave is the norm
I am fortunate to live in a country with such progressive family leave policies. When I told people that I thought I might go back before the year mark, I was suddenly well outside the norm for Canadian mamas.
“What do you mean you don’t think you’ll take the full year?”
“You know you’ll never get this time back again. They’re only babies once.”
“I can’t imagine not having had the full year with my kids.”
“Work will be there when you get back. Your team will be fine without you. They’ll figure it out.”
I knew this last piece of advice was true. I hand-picked my maternity leave contractor. I knew my team would be fine without me. They would learn new things from a seasoned leader whom I trusted to run the show in my absence.
I had dropped my office hero complex years ago. I already knew that startups were dynamic, living, breathing things. They grow, they break, they bleed, they stitch back together in different configurations, they heal.
It wasn’t that I needed my work to need me. I needed it.
Conventional wisdom says babies get easier after three months. For me, conventional wisdom was wrong.
Most people find that if they can survive the first three months of a newborn, things start to get easier from there. That wasn’t my experience. The weird thing about babies is that we automatically assume two unrelated 3-month-olds have anything in common.
If you walked into a room of 100 50-year-olds from around the world and were asked what those people all had in common, you’d look for the super broad generalizations. They were all born. They all breathe air. They will all die. And that might be the end of your guesses.
At no point would you make assertions about their temperament, sleep patterns, education, brain development, or food preferences. Because that’s an insane thing to do for humans who are all special little snowflakes.
That we do it for babies as a cohort is bizarre. That we do it for babies by gender (oh that’s just how little boys *are*) is also weird.
Anyway, three months was not our turning point of awesome. That turning point was still several months away. So while my mama friends and the people in my baby groups were getting high off of procreation and delighting in their bundles of joy, I was, well, I was really tired.
“Isn’t motherhood just the most amazing/magical thing ever?”
“Don’t you just love her so much?”
“Don’t you just want to stare at her while she sleeps?”
“Do you ever just check on her to make sure she’s still breathing?”
Imposter syndrome isn’t just for work — I felt it on maternity leave, too
Canadians have an expression that I didn’t know until I got here. They talk about “making space.” And it took me a while to get the hang of it, but it’s basically leaving conversational room for the other person to express their ideas, to dissent, to disagree. As far as I know, Americans don’t have an equivalent cultural concept. As a group, we are quick to dissent, vocal when we disagree, and not shy about expressing ourselves.
After months of hearing about everyone else’s unadulterated mama bliss, I suddenly found I needed a lot of space. There was no room to say I was tired. There didn’t seem to be space for anything that wasn’t a Stepford-like enthusiasm for the aforementioned miracle of creating a small human. I felt the walls closing in on me.
Staring down an entire year of silently suffering through baby groups where they changed the lyrics to “Humpty Dumpty” so it would have a happy ending and skipped verses of “You Are My Sunshine” because they were sad began to feel insufferable.
I missed work. More than that, I missed who I was at work. I missed feeling smart and competent and on top of things.
This was the first time in my life I felt like I was failing in every direction and couldn’t just outwit the problem. And it was compounded by the sense that there was no appropriate outlet for my maternity-leave imposter syndrome.
“Isn’t motherhood just the most amazing/magical thing ever?”
It’s great. I’m not sure why my teeth are gritted like Thurston Howell the Third right now, but it’s great. Really. Really. Great. Swearsies.
“Don’t you just love her so much?”
Sometimes. Is sometimes an okay answer?
“Don’t you just want to stare at her while she sleeps?”
Honestly, if she’s sleeping, I want to be sleeping. Or showering. Staring also starts with an s and ends with -ing but no, that is not what I want to be doing.
“Do you ever just check on her to make sure she’s still breathing?”
It hadn’t even occurred to me that that was a possibility.
When my daughter was born, I’d already been step-parenting my big kid for four years. Though I was a first time bio parent, it wasn’t my first at bat for caring, feeding, nurturing, and loving a small human. I suspect this colored my experience of first-time motherhood in that it was both a new and not entirely new experience all at the same time. This also put me a bit outside the baby group discussions around how to co-parent with your partner for the first time, how to leave the kid with a babysitter, and why dirt and germs are an important part of your kid’s diet, etc.
So much of what was hard about those early months was feeling alone, like I was the only mom who missed work. Or, worse, that something was wrong with me because I didn’t have the insta-bliss my friends reported.
At about five months, we found our turning point. It wasn’t overnight but I can look back and say that while we still had ups and downs, the overall trend line started to improve.
With more sleep, I could see that I was in the wrong baby groups. I quit the ones that changed lyrics to provide universally happy outcomes. Bit by bit, I found my mama tribe. We’d go on long walks. We’d drink strong coffee. We’d talk about the good, the bad, and the ugly parts of caring for a baby. We’d say out loud that we were lonely. Or bored. Or tired. Or that we couldn’t remember the last time we’d brushed our teeth. Or hair. Or worn an actual bra.
What it was like to tell my office I wanted to take a longer maternity leave
I had told work I to expect me back after six months. That was already double the amount of time off I could expect if I’d been in the US. Before my daughter was born, it was hard to imagine being off for longer than that.
I need to know this baby. I need to feel like I got to enjoy our time together, and for the first four months, we could barely leave the house. I need more time. I want the summer. People in Toronto are at the cottage in August. The office will be quiet. I’ll go back when the weather turns.
I had already made my decision.
I called my head of HR.
There was no guilt. There was no stress. There was no shame. My head of HR did not hesitate. She was supportive and understanding. She let me set my terms and do what made sense for me and my family.
In my faraway gaze, when the baby is happily banging the potato masher (currently her favorite toy) on the top of her exersaucer, I think about how that conversation would have gone if I were still living in the US. I remind myself that parental leave varies by company and empathy varies by HR person.
But when I’m honest with myself, I let my brain acknowledge what my heart already knows. I’m lucky to be a mom in Canada.
Over the past few months, I have frequently looked at my partner and said, “It’s just the most magical thing that we made a human. Isn’t she amazing?!”
I stare at her while she sleeps and I check to see if she’s breathing (all via baby monitor so as not to wake her — I’m not a total chump).
And when our girls are laughing together, a big knot wells up in the middle of my chest and I am physically overwhelmed by how much I love them.
Motherhood isn’t just one thing. There isn’t just one way to do it. To assume so is as ridiculous as walking into that room full of 50-year-olds and expecting them to have anything in common. Once I was able to cut out the noise of other people’s expectations, it was easy to make the decisions that were right for me and my family.
Regardless of where they live, one of the most powerful ways moms can support other moms is to make space for the full spectrum of motherhood experiences, especially when those experiences are different from their own.
Melissa Nightingale is an aspiring Canadian, a startup exec at Wattpad, and a proud bonus and bio mama to two amazing girls.
At MindPrep, we believe in maternity leave! Also Students need to read more about other countries for their GP!
In the history of the United Nations, the General Assembly has only held high-level meetings on health issues three times: for HIV, Ebola, and chronic diseases like diabetes and obesity.
On Wednesday, September 21, world leaders will be holding one of these rare meetings on health: This time, it’s about the “nightmare” and “catastrophic threat” of antimicrobial resistance.
There are billions of bacteria that live in and around us, most of which help us survive and thrive. But some bacteria can make us sick, and antibiotics can kill off these harmful microbes. In addition to curing us when we’re ill, these wonder drugs revolutionized medicine and vastly expanded the scale of food production.
Antibiotics have a major downside, though: The more we use them, the more quickly bacteria outsmart them, and the faster the drugs stop working.
Since Alexander Fleming discovered penicillin in 1928, he and many other scientists, public health officials, and doctors have been sounding alarm bells over antibiotic resistance. Yet we continue to abuse these drugs in medicine, inject them into our food supply, and use them liberally in everything from yoga mats to sanitation products.
Nearly 90 years after Fleming’s warnings, antibiotic-resistant bacteria have become a massive health problem worldwide, sickening and killing tens of thousands of people every year.
Over the past decade, entire countries, individual hospitals, and even food companies have made efforts to address the issue. (Many attribute all the recent attention to the work of the UK government, and in particular to the leadership of England’s chief medical officer, Dame Sally Davies.)
But even if some countries or major players take action, they won’t be able to fix the problem alone. To truly address superbugs, we need a global plan. (Remember: Microbes travel as easily as people can hop on planes.)
So far, we have done terrifyingly little to curb the resistance crisis at the global level, and the problem has been deemed “a classic ‘tragedy of the commons'” on par with climate change.
That’s where this UN meeting comes in. Health experts are calling it a major turning point and a potential start for globally coordinated action. “Politically, I think people have woken up,” said Marc Mendelson, an antibiotic resistance expert and professor of infectious diseases at the University of Cape Town.
“The last time the UN was poised to take major action on antimicrobial resistance was September 11, 2001,” said Boston University’s Kevin Outterson, “[and] the release of the WHO Global Strategy in New York was lost after the terror attacks that day. It has taken 15 years to get back on the global agenda.”
Here’s why the meeting is happening, what experts think should come out of it, and what’s actually likely to change after Wednesday.
Why the UN is tackling this problem: Our antibiotic use is out of control
Though antibiotics still save millions of lives a year, more often than not, we use them incorrectly and unnecessarily.
The best estimates suggest that fully half of antibiotic prescriptions may actually be unnecessary. And specifically regarding emergency rooms and doctors’ offices in the US, a recent study in JAMA estimated that 30 percent of antibiotics doled out were unnecessary, amounting to 47 million prescriptions every year. There’s also been a dramatic increase in the number of last-resort antibiotics being used in US hospitals.
Another study in JAMA found that doctors treat 71 percent of bronchitis cases, which are usually caused by viruses, with antibiotics. Doctors may know they will be ineffective, yet they prescribe antibioticsbecause patients demand them. Or sometimes they’re unsure of their diagnosis and want to be on the safe side.
And that’s just medicine.
Most of our antibiotics are actually used in agriculture, in animals like chickens, cattle, pigs, and fish. In the US, for example, more than 70 percent of the antibiotics that are medically important for humans are sold for use in animals.
Farmers have typically used the drugs in three ways: to treat sick animals, to prevent infections, and to fatten up animals. The first use is uncontroversial, but public health experts have criticized the latter two uses. They argue that many livestock producers needlessly overuse antibiotics to prevent infections and promote growth — essentially relying on them as an alternative to hygiene and good nutrition. These are considered “nontherapeutic” uses.
The main concern with antibiotic use on farms is that it will lead to resistant bacteria that will make humans sick. Both the Food and Drug Administration and the Centers for Disease Control and Prevention have told Congress there’s a link between the routine nontherapeutic use of antibiotics on farms and the superbug crisis in general.
“Poultry, cattle, and swine raised with antibiotics harbor significant populations of antibiotic-resistant bacteria, which are transmitted to humans through direct contact with the animals and through their meat, eggs, and milk,” according to this Center for Disease Dynamics, Economics, and Policy (CDDEP) report on global antibiotic use.
The rise of superbugs is threatening modern medicine
In recent years, antibiotic misuse has sped up the natural process of resistance, rendering some antibiotics useless and causing experts to warn that we are at the “dawn of a post-antibiotic era” that amounts to a health threat on par with terrorism.
In the US alone, antibiotic-resistant infections are associated with 23,000 deaths and 2 million illnesses every year. We’ve already seen a number of bacterial infections —gonorrhea, carbapenem-resistant enterobacteriaceae (CREs), strains of tuberculosis — that no longer respond to any of the drugs we have.
Overusing antibiotics also kills off the good bacteria in people’s bodies, potentially wreaking havoc on our microbiomes and weakening our immune systems. This means more people get sick, stay sick for longer, and die from resistant infections that we have no cure for — while the costs of treatment of antibiotic resistance go up.
A recent report commissioned by the UK government contains an alarming prediction: By 2050, antimicrobial-resistant infections will kill 10 million people across the world — more than the current toll from cancer.
It’s not an overstatement to say that most of modern medicine hinges on the effectiveness of antibiotics. Whenever you go to the hospital for an operation — a hip replacement, an ACL repair, heart surgery — almost without exception, doctors will give you a dose of antibiotics to prevent infection. Antibiotics also make the cesarean section, one of the single most life-saving procedures on the planet, possible.
Without antibiotics that work, common medical procedures like hip operations, C-sections, or chemotherapy will become more dangerous, and some medical interventions — organ transplants, chemotherapy — will be impossible to survive.
“It’s almost unimaginable how going back to a pre-antibiotic era would affect US health care,” said Outterson.
Jirka Taylor, an analyst at the RAND Corporation, put it in these terms: “If you had a 5 percent chance of contracting an infection that had a 40 percent case fatality rate, would you still be interested in submitting to a relatively mundane procedure such as hip replacement, when your survival did not depend on it?”
What the best minds think we should do to solve the problem
A few key concepts are raised again and again and again when it comes to the problem of antibiotic resistance. “We may quibble over the details, but there is solid agreement on the science and basic policy directions,” said Outterson.
You can organize these ideas under three broad categories: conservation, innovation, and access.
1) Conserving antibiotics by removing financial incentives for overuse, phasing them out of food production, and improving public awareness
We want to make sure the drugs we have continue to be effective, so we want to try to reduce the overuse and abuse of antibiotics. There are a number of interesting proposals to achieve this, as I’ve written before with Steven Hoffman.
a) The first is to remove the financial incentives that lead to irrational use. One way to do this is by “delinking” the pharmaceutical business model. The idea here is that traditional research and development models link the volume of patent-protected sales to the return on investment for companies. While drug companies still have their patent, they must sell as many drugs as they can — even if it’s potentially dangerous for public health.
Through delinking, companies would instead be compensated for their antibiotic development on some other basis, such as grants or innovation prizes, instead of volume of sales.
b) The second key idea for conserving antibi
otics is to phase antibiotics out of livestockwhen they’re used for prevention and growth promotion. Some countries are further along on this than others. Researchers and lawmakers who worry about the growing problem of drug resistance have been trying to get countries to go the way of Europe, where farmers now only use the drugs to treat sick animals.
The US is part of the way there. In 2014, the FDA set rules that asked livestock producers to phase out the use of antibiotics to boost animal growth (a practice that has been dwindling anyway). But the FDA ruling is voluntary, and didn’t place any restrictions on using antibiotics for disease prevention.
c) Doctors also need to get better at curbing their overprescribing habits, and patients need to get better at not demanding the drugs when they’re not necessary. One way to do that is through betterpublic education. There are huge gaps in knowledge when it comes to antibiotics.
In a World Health Organization survey on global antibiotic use across 12 countries, most people did not understand the basics of drug resistance, and how and when antibiotics should be used. That’s why health experts have called for mass public education campaigns.
2) Innovation of new antibiotics and better diagnostics
One of the scariest features of the antibiotic resistance crisis is that pharmaceutical companies aren’t developing new drugs quickly enough: The drug pipeline is essentially dry.
Only a handful of new antibiotics have come on the market in the past decade, and health organizations such as the Infectious Diseases Society of America worry that progress on other drugs is “alarmingly elusive.”
Drugmakers have been reluctant to invest in antibiotics because they don’t offer great financial returns. Unlike treatments for chronic diseases, people only use antibiotics for short periods of time. And the calls to use them even more judiciously are not exactly an appealing business proposition for large pharmaceutical companies.
Though many of the best thinkers on antibiotics will argue that the conservation piece is as important as — or even more important than — the innovation piece, there’s no denying that we need more antibiotics in the pipeline. To encourage research and development, expertshave been calling for a global innovation fund to fill in the gaps left by industry and support research on antibiotic resistance and its solutions.
Innovation on antibiotic resistance doesn’t just mean just developing new drugs. It also means investing in drug alternatives and better diagnostics to rapidly assess infections and avoid unnecessary prescribing. That’s why governments have been coming out with hugecash prizesfor innovators who invent things like cheap, easy, and accurate point of care tests to diagnose bacterial infections.
3) Improved access to antibiotics, sanitation, and vaccines
The United States still leads the world in per capita antibiotics consumption. In 2010, there were 22 doses of antibiotics given to each person, compared with 11 in India and seven in China.
But while wealthy countries overall maintained or decreased their antibiotic consumption between 2000 to 2010, the BRICS countries had the biggest rise in antibiotic use: 68 percent in Brazil, 19 percent in Russia, 66 percent in India, 37 percent in China, and 219 percent in South Africa, according to CDDEP. “About three-quarters of the total increase in global consumption occurred in these nations; however, they accounted for only one-third of the world’s increase in population from 2000 to 2010,” CDDEP reported.
In low- and middle-income countries, the major driver of infections — and the need for antibiotics — is still poor sanitation. Many people still live in areas that have been contaminated by human and animal waste, which is why ensuring clean water and sanitation for all are key to preventing the need for antibiotics.
Even though antibiotic overuse is a problem in many parts of the world, many people still don’t have access to these lifesaving drugs when they need them. This lack of access, or delayed access, to antibiotics actually kills more people globally than superbugs. For example, in a Lancetstudy, researchers estimated that improved access to antibiotics could mean preventing three-quarters of the deaths of children under 5 caused by pneumonia alone. (That’s about half a million deaths annually.) So improving access to affordable antibiotics would make a big dent in poorer countries’ antibiotic resistance problems.
Related to that, the researchers on the Lancet paper — and manyother experts — haveargued that expanding vaccine coverage would avert infections and reduce antibiotic use.
What might come out of the UN meeting
On Wednesday, heads of state and leaders of delegations are expected to discuss the problem of antimicrobial resistance and agree on solutions, which should come out in the form of a UN General Assembly declaration.
But don’t expect that to turn into global law. “The declaration will be as binding as any other UN General Assembly resolution,” Outterson said, “but don’t give it short shrift. This is historic global political engagement, and really good news.”
Indeed, as global health researcher (and Vox contributor) Steven Hoffman explained, “The most impactful outcome of this meeting would be if it starts a longer-term process for countries to engage in a serious way on this issue.”
Realistically, that means we’re probably not going to see any major new initiative or agency or structure that’s created at this meeting. But we might see targets with time horizons attached to them for things like reducing the use of antibiotics for growth promotion and disease prevention in agriculture, improved superbug surveillance, and pledges for dollars to support antibiotic innovation.
The biggest and more tangible immediate outcome will be political. “It should sufficiently capture the attention of enough world leaders to realize this is one of the most fundamental issues of our time,” Hoffman added. Considering the long history of the problem, and our failure to work together to tackle it, this attention alone is a pretty big deal.
Groups protesting earlier EpiPen price increases.CreditErik McGregor/Pacific Press, via Lightrocket, via Getty Images
WASHINGTON — Against a growing outcry over the surging price of EpiPens, a chorus of prominent voices has emerged with a smart-sounding solution: Add the EpiPen, the lifesaving allergy treatment, to a federal list of preventive medical services, a move that would eliminate the out-of-pocket costs of the product for millions of families — and mute the protests.
A point not mentioned by these advocates is that a big potential beneficiary of the campaign is Mylan, the pharmaceutical giant behind EpiPens. The company would be able to continue charging high prices for the product without patients complaining about the cost.
An examination of the campaign by The New York Times, including a review of documents and interviews with more than a dozen people, shows that Mylan is well aware of that benefit and, in fact, has been helping orchestrate and pay for the effort.
The journal article says it was “drafted and revised” by a medical writing consulting firm paid by Mylan, in consultation with Dr. Fromer. And Dr. Fromer himself has served in the last year as a paid Mylan consultant — which he discloses as part of the journal article. The company has also contributed money to many other groups behind the effort, and it has met with them — and Ms. Winders’s organization in particular — to coordinate its strategy, the participants said.
The effort has accelerated in recent weeks, just as Mylan has faced a flood of criticism about its pricing of EpiPens. The retail price for the standard two-pack has jumped nearly fivefold since 2010, hitting $608 this year. Multiple lawmakers and regulators have opened investigations into the pricing of the product, which has virtually no market competition.
The idea being advanced is simple: If the EpiPen makes the federal preventive list, most Americans would have no insurance co-pay when getting the product. That means they could obtain the medication with no direct cost, regardless of its retail price. Mylan could keep the EpiPen at the current price, or perhaps raise it more, while keeping patient anger at a minimum.
Instead, the federal government, health insurers and employers would pay the bill. Those costs, in turn, could be passed on to consumers in other ways, as in higher premiums or higher co-pays on other drugs.
“In a way, it is brilliant,” said Rachel E. Sachs, a law professor who specializes in public health policy at Washington University in St. Louis. “We are all seeing them for what they are — the poster child for high drug prices right now, but they don’t want to be. And this tactic is nothing but a self-serving move, not a public-regarding one.”
Mylan, in a statement, acknowledged financing “research, resource development and travel” by the nonprofit coalition Ms. Winders formed in collaboration with the company to help push for the change. But, the company said, “we were clear in our corporate sponsorship agreements that the coalition would maintain control.”
The company also pointed to steps it had taken to lower the price of the EpiPen. Mylan has announced more rebates for some patients and it is preparing to release a less expensive generic version.
The decision about whether to label EpiPens a preventive drug will fall to the United States Preventive Services Task Force, a federally appointed group of physicians and public health experts. The group reviews disease screenings, counseling and other treatments to determine if they are sufficiently effective to make the list. Under the Affordable Care Act, certain recommendations from the task force must be adopted by almost all insurers.
The EpiPen is an epinephrine auto-injector, meaning it contains a portable supply of epinephrine that can be quickly administered to a person suffering from an allergic reaction. Proponents of adding EpiPen to the federal list argue that it can prevent a fatal allergic reaction, by stopping anaphylactic shock from progressing, if taken immediately.
Getting the designation could be difficult, since there are no prescription medications for diagnosed illnesses on the preventive list. The task force has recommended at least one over-the-counter medication: aspirin. But generally it lists treatments for a patient only if there are “no signs or symptoms of the specific disease or condition,” the agency said — like a cancer screening. The task force chairwoman, in a statement, appeared to all but rule out adding EpiPens to its list of recommendations.
But a review of Mylan’s lobbying history makes clear that the company has an exceptional track record at influencing government policies, both in Washington and in state capitals. Heather Bresch, Mylan’s chief executive, called the effort “our unconventional approach to growing this franchise” in remarks to Wall Street analysts last year.
Mylan was actively involved in pushing a 2013 federal law encouraging schools nationwide to stock EpiPens. And the company takes credit for legislation in at least 10 states that require the product in hotels, restaurants and other places, and additional school-related legislation in nearly every state. It is also helping push legislation pending in Congressthat would require epinephrine auto-injectors on all commercial airline flights.
The company and its employees are major contributors to lawmakers, both Democrats and Republicans, on Capitol Hill. Ms. Bresch is the daughter of Senator Joe Manchin, Democrat of West Virginia.
Effectively pushing such arguments through various public awareness campaigns has helped expand the epinephrine auto-injector market. The product now accounts for 99 percent of the market’s $1 billion in sales in the first six months of this year, the research firm IMS Health estimates.
EpiPen’s market dominance is partly the result of the recall last year of a main competitor, Auvi-Q, after its manufacturer discovered problems with the dosage.
The drive to get EpiPens added to the preventive services list appears to have started in earnest late last year, just as the public and politicians started to focus on drug pricing.
Mylan began to hear complaints, including some from the patient advocacy groups that it funds with millions of dollars in grants. Ms. Winders of the Allergy and Asthma Network said it was at a meeting with Mylan in November that the company proposed getting the epinephrine auto-injectors designated a preventive drug, and she agreed to help.
Mylan gives money to Ms. Winders’s organization to help expand treatment for severe allergies. She would not say how much the company has given, or the exact terms, citing a confidentiality agreement. But part of that money is related to this push, Ms. Winders acknowledged.
“I am being compensated to ensure access to epinephrine,” Ms. Winders said in an interview last week.
Nina Devlin, a Mylan executive, rejected a request by The Times to release these nonprofit groups from their confidentiality agreements. But she did say that the company donated a total of $1.8 million this year to nine nonprofits “in support of anaphylaxis awareness and education initiatives,” of which about $227,500 was to push for the federal listing.
Financial relationships between pharmaceutical companies and patient advocacy groups are extremely common — and often benefit the drug company’s lobbying agendas.
With company support, Ms. Winders’s organization hosts conferences every year that bring together allergists, pediatricians, school nurses and elected officials. At the conferences, held in St. Louis, Orlando and Las Vegas this year, the attendees detail plans to help win passage of legislation intended to increase the distribution of epinephrine.
Eleanor Garrow-Holding, the president of the Ohio-based Food Allergy & Anaphylaxis Connection Team, said the effort was “initiated by Mylan” and acknowledged that her group also receives annual grants from the company.
After The Times raised questions about the arrangement, she added in an email this week that Mylan was “not part of this task force moving forward. Only the patient advocacy groups are actively participating.”
In addition, Ms. Winders and Ms. Garrow-Holding both took offense to the idea that Mylan’s money had affected their organizations’ work.
“Mylan nor any other industry partner dictates our position,” Ms. Winders said. “They have no direct influence over our messaging.”
But at least two groups declined to participate in the effort, citing the appearance of a conflict of interest, their representatives said in interviews.
Dr. Bobby Quentin Lanier, executive medical director of the American College of Allergy, Asthma and Immunology, a nonprofit group of allergy doctors, said his group had spurned Mylan’s offer of payments for a series of papers focused on “the possibility of adding the epinephrine auto-injector to the national preventive drug list.”
“As we looked at it, we thought, ‘No way that we could do that,’” Dr. Lanier said.
Dr. James R. Baker Jr., chief executive and medical director of the Food Allergy Research and Education group, which has historically taken money from Mylan, said he had been offered money to lead the effort, a role Ms. Winders is now playing.
“We just didn’t feel, given the structuring, that it fully aligned with our role as a patient advocate,” Dr. Baker said. (He would not name the organization that he said had offered him the money, citing a confidentiality agreement.)
With the nonprofit groups that still take donations from Mylan, the effort to get epinephrine auto-injectors on the preventive list is moving ahead.
Ms. Winders said her group planned to send a formal submission to the United States Preventive Services Task Force in November. The patient advocates are separately planning to set up meetings with the nation’s eight largest insurers to ask them to add epinephrine auto-injectors to their own lists, even if the federal government does not make the move.
The task force could list the EpiPen in a couple of different ways: either mandating that insurers cover the auto injectors with no co-pay or putting them on a lower-priority list that many insurers still adopt, eliminating the co-pay even though the insurer is not required to do so. But Mylan, in a statement, said it was seeking the most exclusive status, on the A list. Under the Affordable Care Act, most private health insurance plans must cover certain recommended preventive service, including those on the A list, without any charge to the patient.
The article Dr. Fromer published in The American Journal of Medicine will almost certainly help the cause. It makes the exact argument that Mylan wants to push: “The recognition and classification of epinephrine as a preventive medicine by both the U.S. Preventive Services Task Force and insurers could increase patient access, improve outcomes and save lives.”
The article, published online in late August, says in an acknowledgments section that Mylan paid for medical writing consultants who “drafted and revised” the paper based on input from Dr. Fromer. But in interviews, Dr. Fromer and a Mylan spokesman said the article had not been ghostwritten and that Dr. Fromer was heavily involved in the paper. He said he intended to ask the journal to revise the language in the article to make clear that he helped write it.
“My sole purpose in writing this article was to improve access to a lifesaving medication for millions of patients,” he said. He added that while he has served as a consultant to Mylan — with payments as recently as December — he was not paid by the company to write the article.
Senator Richard Blumenthal, Democrat of Connecticut, whose office was among those contacted recently by the nonprofit groups working with Mylan, said he was disappointed with the company’s tactics: turning to patient groups and a doctor it has retained as a consultant to try to get its drug on the preventive list.
“This is the dark side of pharmaceutical practices in enlisting and paying professionals to pitch their profit-making drug,” he said.