Dalai Lama: Behind Our Anxiety, the Fear of Being Unneeded

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.

Why?

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.

Economics of Mentally Ill Criminalisation

Justice

Locked in

The costly criminalisation of the mentally ill

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?”

How living in Canada made me see the cruelty of the American maternity leave system

How living in Canada made me see the cruelty of the American maternity leave system

Antibiotic-resistant superbugs are a catastrophic threat

The UN is finally treating antibiotic-resistant superbugs like a catastrophic threat

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 better public 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

Approvals for new antibiotics have declined since the 1980s.
CDDEP

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.

Several countries, including the United States and China, have already started developing such funds, and in February 2016 the US government launched the BARDA Biopharmaceutical Accelerator to fund antibiotic research through partnerships with industry and nonprofit organizations.

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 prizes for 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

Percentage of Staphylococcus aureus isolates that are methicillin-resistant (MRSA) in selected countries, 1999-2014.
CDDEP

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 Lancet study, 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 many other 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.

EpiPen Maker Lobbies to Shift High Costs to Others

EpiPen Maker Lobbies to Shift High Costs to Others

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.

Dr. Leonard Fromer, an assistant clinical professor of family medicine at the University of California, Los Angeles, just promoted the idea in the prestigious American Journal of Medicine. A handful of groups are preparing a formal request to the government. And Tonya Winders, who runs a patient advocacy nonprofit organization, reached out late last monthto crucial lawmakers on Capitol Hill.

“We can save lives by ensuring access to these medications,” said Ms. Winders, chief executive of the Allergy and Asthma Network.

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.

Photo

Heather Bresch, chief executive of Mylan, called working with legislators part of “our unconventional approach to growing this franchise” in remarks to Wall Street analysts last year. CreditMichael Nagle/Bloomberg

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.

For the preventive drug push, Ms. Winders has been joined by representatives from other allergy organizations, all with somewhat similar financial ties to Mylan. They include the American Latex Allergy Association, the Food Allergy & Anaphylaxis Connection Team and theAsthma and Allergy Foundation of America.

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.)

As of last week, he decided to no longer accept donations from pharmaceutical companies that make products that serve his members.

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.