TIME health

New Global Study Calls Violence Against Women ‘Epidemic’

A Pokot woman holds a razor blade after performing a circumcision on four girls in a village about 80 kilometres from the town of Marigat in Baringo County, Kenya, Oct. 16, 2014.
A Pokot woman holds a razor blade after performing a circumcision on four girls in a village about 80 kilometres from the town of Marigat in Baringo County, Kenya, Oct. 16, 2014. Siegfried Modola—Reuters

Governments need to step up their game to protect women, says extensive new research

When it comes to stopping violence against women, actions speak louder than words. So even though there’s increased worldwide awareness about violence against women, the problem won’t be solved unless countries make significant policy and financial changes to support victims, according to a five-part series of studies in The Lancet, one of the world’s premier medical journals.

The series, entitled “Violence Against Women and Girls,” calls the violence a “global public health and clinical problem of epidemic proportions,” and the statistics are bleak. 100-140 million women have undergone female genital mutilation worldwide, and 3 million African girls per year are at risk. 7% of women will be sexually assaulted by someone besides their partner in their lifetimes. Almost 70 million girls worldwide have been married before they turned 18. According to WHO estimates, 30% of women worldwide have experienced partner violence. The researchers said that these problems could only be solved with political action and increased funding, since the violence has continued “despite increased global attention,” implying awareness is not enough.

“No magic wand will eliminate violence against women and girls,” series co-lead Charlotte Watts, founding Director of the Gender Violence and Health Centre at the London School of Hygiene & Tropical Medicine, said in a statement. “But evidence tells us that changes in attitudes and behavior are possible, and can be achieved within less than a generation.”

One of the major problems highlighted in the Lancet series is that much of the current research on violence against women has been conducted in high-income countries, and it’s mostly been focused on response instead of prevention. The study found that the key driver of violence in most middle-and-low income countries is gender inequality, and that it would be near impossible to prevent abuse without addressing the underlying political, economic, and educational marginalization of women.

The study also found that health workers are often uniquely positioned to help victims, since they’re often the first to know about the abuse.

“Health-care providers are often the first point of contact for women and girls experiencing violence,” says another series co-lead, Dr. Claudia Garcia-Moreno, a physician at the WHO, in a statement. “The health community is missing important opportunities to integrate violence programming meaningfully into public health initiatives on HIV/AIDS, adolescent health, maternal health, and mental health.”

The series makes five concrete recommendations to curb the violence against women. The authors urge nations to allocate resources to prioritize protecting victims, change structures and policies that discriminate against women, promote support for survivors, strengthen health and education sectors to prevent and respond to violence, and invest in more research into ways to address the problem. In other words: money, education, and political action are key to protecting the world’s most vulnerable women. Hashtag activism, celebrity songs, and stern PSAs are helpful, but this problem is too complicated to be solved by awareness alone.

“We now have some promising findings to show what works to prevent violence,” said Dr. Cathy Zimmerman from the London School of Hygiene & Tropical Medicine. “We urgently need to turn this evidence into genuine action so that women and girls can live violence-free lives.”

The study comes just in time for the UN’s International Day for the Elimination of Violence Against Women, on Nov. 25.

TIME health

New Crisis Line Aims to Help Transgender People at Risk of Suicide

On 2014's annual day of remembrance for transgender victims of violence, a new hotline is ready to field calls

On Nov. 20, people are gathering at events around the nation to read names of transgender people who have died in the past year in violent crimes. The descriptions on the website for the occasion, the annual Transgender Day of Remembrance, are chilling: “massive trauma, found dead in an alley,” “murdered and burned,” “gunshot to the back.” Transgender people, particularly transgender women, are subject to high rates of violence and harassment. A 2013 report found that 72% of homicide victims in LGBT-related hate crimes were transgender women of color.

On this somber day, an organization based in the Bay Area is trying to get the word out that there’s a new resource available to fight what may be an even deadlier problem among transgender people: suicide.

According to the most definitive report on transgender issues in recent years, 41% of transgender people attempt to commit suicide, a statistic that doesn’t necessarily factor in successful attempts. That’s a number that the people behind Trans Lifeline (877-565-8860), a crisis hotline staffed entirely by transgender people, want to see decreased.

“There are a ton of suicide hotlines. There’s no shortage of them,” says Greta Martela, a software engineer and president of the organization that went live this month. “But it’s really difficult to get a person who isn’t trans to understand what it’s like to be trans.”

Empathy is a powerful emotion for people attempting to come to terms with being transgender. Many transgender people say they only had the courage to come out once they met someone else who was living a happy life as an openly transgender person, people Orange Is the New Black actress Laverne Cox calls “possibility models.”

Martela came out last year, as a 44-year-old parent. Before she did, she was plagued by anxiety and debilitating panic attacks. In the process of coming out, she called a suicide hotline. A man answered the phone, she says, and when she explained the trouble she was having, he just went quiet and told her to go to the hospital. “They had no idea how to deal with a trans woman,” she says. And when she got to the hospital seeking help, she had to explain what being transgender was to the hospital staff.

Her aim is to get people in crisis—whether that person is a suicidal, closeted teenager or the confused parent of a six-year-old—access to volunteers who can understand what they’re going through right away and direct them to more help wherever they are. “Those are the people I want to call the most,” Martela says of parents who are trying to understand what a child is going through. “Getting them good resources could spare their child a lifetime of pain.”

Right now, the corporation—which has applied for status as a non-profit—is a shoestring operation, fueled by open source software that allows Trans Lifeline to funnel calls to on-duty volunteers wherever they are. They’re raising funds for advertising to get their number out there, to people like Martela who couldn’t find anything like the hotline when she needed it. “There’s a body count associated with people not accepting trans people,” Martela told TIME in a previous interview for a cover story on transgender issues. “It’s costing lives.”

TIME Obesity

You Exercise Less When You Think Life Isn’t Fair

The 'why try' effect gets in the way of weight loss

People who have been the target of weight discrimination—and who believe the practice is widespread—are more likely to give up on exercise than to try to lose weight, according to a new study published in Health Psychology.

The online study of more than 800 Americans specifically looked at whether participants believed in “a just world,” or in this case, the belief that their positive actions will lead to good results. People who experienced weight bias in the past and didn’t believe in a just world were more likely to say they didn’t plan to exercise than those who did believe the world is just. In a separate part of the study, participants primed with anecdotes designed to suggest that the world is unjust were more likely to say they didn’t plan to exercise.

Experiencing discrimination leads some people to adopt a pessimistic view of the world, and they accept negative stereotypes about themselves, including the belief that they’re lazy, said study author Rebecca Pearl. “When someone feels bad about themselves and is applying negative stereotypes to themselves, they give up on their goals,” said Pearl, a researcher at Yale University, referring to a phenomenon known as the “why try” effect.

It’s an area of conflicting research. Some previous studies found that weight discrimination leads to weight loss, while others concluded that weight discrimination discourages exercise. Belief in a just world may be the factor that distinguishes between the two, Pearl said. People who think their exercise will pay off are more likely to try.

Because believing in a just world is key to losing weight, Pearl said that legislation and other public policy efforts could act as a “buffer against loss of sense of fairness.”

“It’s important for doctors to be aware of what people are experiencing, to know that these experiences might have real effects on people’s confidence,” Pearl said.

TIME

Your Pharmacist Called. You Owe $1.3 trillion

A new report predicts that drug spending will shoot up 30% by 2018

Here’s a shocker: global spending on drugs is going up. Way up.

A new report from IMS Institute for Healthcare Informatics projects the world will shell out $1.3 trillion for medications in 2018, a 30% increase over the figure in 2013.

The proliferation of new, pricey specialty medications like Sovaldi, Gilead’s $84,000 Hepatitis C wonder drug, has something to do with this spending increase, particularly in developed markets, but so does an aging population and increased accessibility of healthcare around the globe.

Take the U.S., the world’s largest drug market, where spending is forecast to rise 11.7% in 2014. New innovative treatments— particularly for cancer, diabetes, and autoimmune disorders—are one bigger driver for this, but so is Obamacare, which has expanded the number of individuals receiving medical care. (The spending increase in the U.S. this year was particularly dramatic because of the small number of drugs that went off patent. Also, the $1.3 trillion figure does not reflect the impact of rebates and discounts, pricing adjustments that are increasingly common in the modern health care landscape.)

A growing middle class and the adoption of universal healthcare is fueling drug spending in other parts of the world. Generics, rather than branded drugs, dominate these markets: IMS predicts spending on pain medication, the largest category of drugs in developing marketing, will increase roughly 10% annually. (IMS pegs the compound annual growth rate at between 8% and 11%.)

The rise in drug spending isn’t inexorable. The research firm points out that France and Spain are likely to see drug spending decrease, thanks in part to cost containment efforts.

The world is in a relative sweet spot for drug innovation. Whisked along by the FDA’s new breakthrough drug designations, the number of launches of novel medications will remain high in the coming years, IMS says. That’s particularly true in oncology. Cancer drugs account for 30% of the world’s pharmaceutical pipeline, and sales are expected to top $100 billion in 2018, largely because of breakthrough immunotherapy treatments.

This article originally appeared on Fortune.com

TIME health

Smoking News to Make You Cringe

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Stephen St. John—Getty Images/National Geographic Creative

Read TIME's reports from the era when the medical community thought it was O.K. to smoke

Thursday marks the American Cancer Society’s Great American Smokeout (GASO), a nationwide event encouraging smokers to kick the habit.

We know today that cigarette smoking causes serious diseases in every organ of the body, including lung cancer, diabetes, colorectal and liver cancer, rheumatoid arthritis, erectile dysfunction, age-related macular degeneration, and more. Tobacco use rakes up more than $96 billion a year in medical costs, and it’s estimated that 42.1 million people, or 18.1% of all adults in the U.S. smoke cigarettes.

This year marked the 50th anniversary of the historic 1964 Surgeon General’s report that concluded that smoking caused lung cancer, and should be avoided. Before then, smoking messaging was depressingly inaccurate. Despite concerns — initially from a small minority of medical experts — the tobacco industry boomed in the U.S., and even doctors considered the effects of cigarettes to be benign.

Here are some examples of tobacco-related beliefs that appeared through the years in TIME Magazine:

1923: In an article about a recent compilation of smoking-related data, TIME was mostly concerned with whether smoking made people more or less brainy: “The outstanding fact of this survey is that every man in the literary group smokes, and the majority of the literary women. Moreover, most of them consider its effects beneficial, and claim that their literary and imaginative powers are stimulated by it.” And later: “From the laboratory data, the author concludes that it is impossible to say that tobacco smoking will retard the intellectual processes of any one person, but in a large group it may be predicted that the majority will be slightly retarded.”

1928: Some experts tried early on to warn about the effect of nicotine, but were met with resistance. In an article about a researcher presenting data on nicotine and the brain, TIME writes: “Many U. S. doctors have contended and often hoped to prove that smoking does no harm. In Newark, N. J., five children of the Fillimon family have been smoking full-sized cigars since the age of two. The oldest, Frank, 11, now averages five cigars a day. All of these children appear healthy, go to school regularly, get good grades.”

1935: Questions began to be raised about the effects on infants, though uptake was limited: “Physiologists agree that smoking does no more harm to a woman than to a man, if harm there be. According to many investigators, the only circumstances under which a woman should not smoke are while she has anesthetic gas in her lungs (she might explode), and while she produces milk for her baby. Milk drains from the blood of a smoking mother those smoke ingredients which please her, but may not agree with her nursling.”

1938 Even if there might be adverse health events for some smokers, not all physicians agreed it was a universal risk: “In step with a recent upsurge of articles on smoking, in the current issue of Scribner’s, Mr. Furnas offers several anti-smoking aids for what they are worth. Samples: 1) wash out the mouth with a weak solution of silver nitrate which ‘makes a smoke taste as if it had been cured in sour milk’; 2) chew candied ginger, gentian, or camomile; 3) to occupy the hands smoke a prop cigaret. For many a smoker, however, this facetious advice may be unnecessary, since many a doctor has come to the conclusion that, no matter what else it may do to you, smoking does not injure the heart of a healthy person.”

1949: By the late 1940s, smoking had become a contentious debate in the medical community: “Smoking? Possibly a minor cause of cancer of the mouth, said Dr. MacDonald. But smoking, argued New Orleans’ Dr. Alton Ochsner, can be blamed for the increase of cancer of the lung. Surgeon Ochsner, a nonsmoker, was positive. Dr. Charles S. Cameron, A.C.S. medical and scientific director, who does smoke, was not so sure. For every expert who blames tobacco for the increase of cancer of the lung, he said, there is another who says tobacco is not the cause.”

1962 More evidence was linking tobacco to cancer, and some groups were trying to get pregnant women to quit out of potential risks to the child, but still: “Some doctors, though, see no direct connection between smoking and prematurity; they argue that the problem is a matter of temperament, that high-strung women who smoke would have a high proportion of “preemies” anyway.”

1964 In a historic move, the 1964 Surgeon General’s report officially stated that cigarette smoking causes cancer, giving authority to anti-smoking campaigns. TIME wrote:

The conclusion was just about what everybody had expected. “On the basis of prolonged study and evaluation,” the 150,000-word report declared, “the committee makes the following judgment: Cigarette smoking is a health hazard of sufficient importance in the U.S. to warrant appropriate remedial action.” More significant than the words was their source: it was the unanimous report of an impartial committee of top experts in several health fields, backed by the full authority of the U.S. Government.

Read TIME’s full 1964 coverage of the Surgeon General’s report, here in the TIME Vault: The Government Report

TIME

America’s AIDS Miracle

How the U.S. fought the disease by thinking big and staying smart

At my home in Washington, D.C., placed so that I see it every morning, is a photograph of Princess Adeyeo, a young Liberian woman I met in 2012. Princess had been a refugee during Liberia’s civil war; when she returned there, she found that she was HIV-positive. But in Monrovia’s John F. Kennedy Hospital she was put on a course of antiretroviral drugs (ARVs), which prevent mother-to-child transmission of the virus, and a few months before our visit she gave birth to a beautiful baby boy. He was HIV-negative, healthy.

Right now, of course, people associate Liberia with Ebola. It’s right that we get mad about Ebola–mad that the world waited so long to tackle the outbreak; mad that poor, vulnerable societies don’t have the resources needed to tackle infectious diseases. But we should remember too that in the past few years, Liberia–in fact, every country, rich or poor–has seen small miracles like the story of Princess and her son, and sees more of them each year.

In 2003, across all of sub-Saharan Africa, just 50,000 people were on ARVs; now more than 9 million are. There is no reason, in the next few years, that we cannot virtually end mother-to-child transmission of HIV in even the most challenging environments. Unheralded, we just passed a tipping point: in 2013, more people were added to the rolls of those on lifesaving treatment for HIV/AIDS than the number who were newly infected. That crossover of trend lines should mark the beginning of the end of AIDS.

Say those last seven words out loud and wonder at them. How did we get to a position that, had it been suggested not long ago, would have been thought impossible? Because of brave, stubborn activists; brilliant scientists and their generous funders; dedicated doctors and nurses; patients who fought for a chance to live; and officials and politicians of all political stripes and none who devised programs that gave those patients hope. And just to be clear, those countless heroes and heroines came from all over the world.

But when, at the National Institutes of Health in 2011, Hillary Clinton, then U.S. Secretary of State, said, “In the story of this fight, America’s name comes up time and time again … No institution in the world has done more than the United States government,” she was speaking not hyperbole but truth.

For here is what seems like a secret but shouldn’t be: in the past decade, Americans and their Presidents have done a great thing. From 2004 to 2013, the U.S. committed more than $50 billion to the global fight against AIDS, and last year accounted for some two-thirds of all international assistance to that effort. (About half the money to combat AIDS in the developing world now comes from the budgets of countries there.) Programs funded by American taxpayers have saved more than 7 million lives overseas.

Here’s another thing that would surprise Americans if they knew about it: in a Washington that has become a byword for dysfunction, the war on AIDS has been a model of comity. There have been political disagreements to be sure, but thanks to the work of two Administrations of different hues and countless congressional heroes from both sides of the aisle, support for the international fight against AIDS has remained solidly bipartisan.

How come? At the heart of this story are two simple and rather old-fashioned ideas. Think big, and stay with what works. For the first insight, credit the Administration of George W. Bush. The 43rd President had come into office interested in Africa’s untapped potential, and in the summer of 2001 he pledged $200 million to the new Global Fund to Fight AIDS, Tuberculosis and Malaria. A year later, he committed $500 million to fight mother-to-child transmission of HIV. The next day, he called Josh Bolten, then his deputy chief of staff, into the Oval Office and told him, “Think even bigger.”

Twelve years on, Bolten still muses on the various elements–strategic, managerial, religious–that made Bush so relentless in his determination to do something about AIDS. Bush plainly felt that the U.S., with all its blessings, had a duty to others less fortunate. Bolten remembers–as does Michael Gerson, then Bush’s chief speechwriter–the President’s frequent quotation from Luke’s Gospel that “to whom much is given, much is required.”

But for whatever reason, Bush thought big, and his team–Bolten; Gerson; Tony Fauci, the veteran AIDS researcher at the National Institutes of Health; and others–delivered. In his State of the Union message in January 2003, Bush announced a truly astonishing $15 billion commitment to tackle AIDS in Africa, in what became PEPFAR, the President’s Emergency Plan for Aids Relief, which remains the largest program devoted to combatting a single disease that any nation has ever launched.

The speech and the pledge were the drama. but it is perhaps what has happened since–the quotidian business of sticking with what works–that has been most inspiring about the U.S. effort on AIDS. On World AIDS Day in 2011, President Barack Obama paid tribute to Bush and PEPFAR and said he was “proud that we have the opportunity to carry that work forward.” That the President did–working again with a bipartisan coalition on the Hill–and then some. At a time of fiscal austerity that extended to every element of the federal budget, the amount the U.S. committed to PEPFAR and the Global Fund grew from $5.8 billion in fiscal year 2008 to $6.3 billion in 2013.

PEPFAR has evolved to follow where the science leads us. We now know, for example, that antiretroviral treatment and voluntary male circumcision can serve as prevention tools, reducing the risk of passing HIV on to others. So the program has scaled up its efforts in those areas while also targeting its resources to the regions of greatest need. But what Obama said in 2011 remains true: “The fight against this disease has united us across parties and across Presidents.”

Long may it do so. Sustained American leadership remains vital. But wherever the funding comes from, there will still be challenges. Already, the disease is concentrated among vulnerable populations, some of them hard to reach and treat for reasons of social stigma or isolation, including men who have sex with men, injection-drug users, female sex workers, adolescent girls and the disabled. Other developed nations need to step up and join the U.S. in its commitment, and national governments in the developing world need to keep their promises to spend more on health.

But given what has been done in the past few years, it would be churlish to assume the worst. In the past decade, in HIV/AIDS policy, science and treatment, the world has seen miracles: big ones, involving millions of people on lifesaving drugs, and small ones, like a mother with the disease giving birth to a healthy child.

Most miracles are a mystery. These aren’t. Thank you, America.

TO SEE MORE SOLUTIONS, GO TO time.com/solutionsforamerica

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

MONEY Health Care

You Won’t Believe Your Employer Can Ask You These Personal Health Questions

Office lamps pointed at pill bottle interrogation-style
Sarina Finkelstein (photo illustration); OsakaWayne Studios (pill bottle); David Malan/Getty Images (office lamps)

When you sign up for health coverage this year, your employer might ask you for a lot of details about your health and your habits. The goal: Cut the cost of your care.

This year, one third of employers will ask workers who enroll in the company health plan to complete a questionnaire about their health, according to the Kaiser Family Foundation. That’s up from 24% of firms last year. The questionnaires, often called a “health risk assessment,” are even more common at big companies; more than half of employers with 200-plus employees offer them.

And as more companies look to control health-care costs with programs aimed at making workers healthier, the stakes for sharing personal details about your health are getting higher.

Last year, Penn State faced a backlash for a questionnaire that, among other things, asked female employees about their pregnancy plans. Workers who refused to fill it out had to pay an extra $100 a month. Penn State later suspended the program.

If you’ve never seen one of these assessments before, here’s what to expect, what happens to the information you provide, and what your rights are.

What kinds of questions can my employer ask?

The questionnaires are crafted to identify current behaviors that may cause costly health problems in the future, says Jillian Fagan of Wellsource, a technology company that creates health risk assessments. Wellsource’s questionnaires cover a long list of topics, including weight and height, chronic illnesses, treatments you’re getting, your willingness to make lifestyle changes, tobacco use, physical activity, diet, alcohol consumption, cancer screenings, hearing and vision impairment, flu vaccinations, stress levels, and depressive symptoms.

Questionnaire writers have leeway about how to pose the questions. For example, Fagan says employers usually don’t want to explicitly ask if you’re depressed. Instead, you might be asked questions like, do you have a social group? Are you married? Do you feel like you’re getting the support you need? How many alcoholic drinks do you consume every week?

You may also be asked about your outlook for the future, how much time you have to relax, your energy level, and whether you’re satisfied with your work-life balance, Fagan says. Wellsource develops its questions based on scientific research and includes links its the underlying medical literature.

Is there anything my employer can’t ask?

Inquiring about your parents’ health would probably violate the Genetic Information Nondiscrimination Act, which prohibits employers from collecting genetic information, says Maureen Maly, employee benefits and executive compensation attorney at Faegre Baker Daniels. A family history of breast cancer, say, could indicate a genetic predisposition.

“Once upon a time, it would get into some questions about family medical history,” says Maly. “Most of these questionnaires will not ask that—and they will usually have a warning saying, ‘Don’t volunteer any information.’”

Can my boss see my answers?

Generally, no. Under HIPAA, the Americans with Disabilities Act, and state privacy laws, employers are prohibited from using health risk assessments for any reason other than for wellness programs, says employee benefits attorney Todd Martin.

Keep in mind that often your employer already has information on your health. If your health plan is self-funded and self-administered—meaning your employer pays the claims directly rather than contracting with an insurer or third party—someone in your office gets your health claims. Your employer is legally bound to maintain a firewall, secure your private information, segregate it from other employment files, and limit staff access, Martin says. Health risk assessments aren’t much different.

And besides, seeing that information could expose the company to a lawsuit if you’re fired or disciplined. “Most employers don’t want to see that information as much as employees don’t want to give it to them,” says Fagan of Wellsource.

So employers usually hire a third party to administer the questionnaires. If that’s a medical provider, that firm is subject to additional privacy rules, says Martin.

That’s really personal! Why is my employer asking me all that?

The goal is to give you a picture of your health and suggest how to do better, Fagan says. “Health risk assessments show you where you’re going to be in five years,” Fagan says. “If we notice that you don’t work out, you’re eating lots of sugar, and your diet is not so great, if you continue down this road, you’re going to have tons of health problems in the years to come.”

Of course, there’s something in it for your employer too—potential cost savings if you stay healthy.

How can knowing more about my health save my boss money?

More than half of large firms surveyed say that they see wellness initiatives as one of the most effective tactics for controlling health-care costs, according to the National Business Group on Health. Such programs can include weight-loss and smoking cessation classes, nutritional counseling, gym discounts, and lifestyle coaching.

With a summary of the answers employees gave on the questionnaires in hand, a company can see, for example, that a lot of workers are struggling to quit smoking (but not who those employees are), which can help it decide whether or not to offer a smoking cessation class (a common perk). To date, however, the research on the effectiveness of wellness programs is mixed.

What’s more, Jennifer Bard, professor at the Texas Tech University School of Law, says she has serious concerns about the privacy risks associated with wellness initiatives.

“It’s not clear how those risks translate into future health,” Bard says. “There isn’t enough information to say that somebody with a particular blood pressure or cholesterol reading or weight is going to have a specific problem. It’s one thing to diagnose someone who is sick, but the science of risk is not as well-developed.”

What else can come of sharing health information?

Your employer can set health-related goals for you. For example, if you’re overweight, your employer can offer a financial incentive for you to lower your BMI. As part of the Affordable Care Act, those financial incentives can be worth 30% of the total cost of plan costs, up from 20% before health reform.

That kind of outcomes-based wellness program is subject to a strict set of rules, Martin says. If your doctor says that you are unable to achieve the goal, your employer has to offer another way for you to earn the incentive.

Outcomes-based wellness programs are growing but not yet widespread. And only 7% of employers say that employees with health risks must complete some kind of wellness program or face a penalty, according to Kaiser.

“The restrictions have made a number of employers want to stay away from outcomes-based programs and focus on the participation-based programs like the health risk assessment,” says Martin.

Can my employer force me to fill out a questionnaire?

Probably not. Only 3% of large firms that offer questionnaires require employees to fill them out, according to Kaiser.

But health assessments, medical screenings, and wellness programs are still a legal gray area.

The Department of Labor says employers can require workers complete a health risk assessment before enrolling in a company health plan, so long as the employer doesn’t deny benefits or change premiums based on the information.

But the Equal Employment Opportunity Commission recently sued three employers on the grounds that their mandatory wellness programs violated anti-discrimination statutes. The EEOC has sued Honeywell over its wellness program, even though the company says it’s voluntary. But employees and spouses who refuse to participate in health screenings face up to $4,000 in financial penalties, which, the EEOC contends, effectively makes the program mandatory.

“It’s helpful for people to know that this is unresolved,” says Bard, the Texas Tech University law professor. “These kinds of wellness programs with a bite, with a financial consequence, are relatively new. Everyone is watching the EEOC lawsuits very carefully.”

That said, if the wellness program is mandatory, you might have little choice. “In my opinion, anyone who chooses not to comply puts themselves at risk for being a test case,” Bard says.

My employer says it’s voluntary. Why should I fill it out?

Health risk assessments are a benefit, says Fiona Gathright, president of Wellness Corporate Solutions, a third-party vendor that administers wellness programs for employers. “We’re trying to help people manage their health, and we’re trying to help people live longer,” Gathright says. “Answer the questions as honestly as you can. If we uncover that you have a risk, we’re going to you help you a manage that risk.”

Still not convinced? More than half of large firms sweeten the deal with some kind of financial incentive, according to Kaiser; 36% of those firms offer a financial incentive worth more than $500.

I’m still uncomfortable with this. What should I do?

Carefully read the disclosures, which usually contain information about who will see your answers and in what form, says Fagan. And ask your own questions

First, who is doing the assessment? An outside vendor, especially one that’s also a medical provider, is best. How is sensitive personal information protected from data breaches?

Second, what information gets back to the employer? Only you should see your individual results. If your employer will see aggregated responses, how big is the sample size? Is there any way you could be identified—say, if you’re the only obese employee at a small firm? There may be rules against reporting results from small groups.

Finally, ask how your employer intends to use the questionnaire. Know ahead of time if you’re just getting information about your health risks—or if you’re laying the groundwork for an outcomes-based wellness program that will ask you to make big changes.

Related

TIME health

Bird Flu Returns: What Past Outbreaks Can Teach Us

BRITAIN-HEALTH-BIRD-FLU
A man wearing a face mask walks through a duck breeding farm where a case of bird flu has been identified in Nafferton, in Yorkshire, England, on Nov. 17, 2014. Oli Scarff—AFP / Getty Images

As bird flu rears its head once again, take a look at TIME's past coverage of the virus

Usually the health status of chickens in the Netherlands isn’t world news. But reports that the Dutch government had culled tens of thousands of birds at poultry farms that were potentially infected with the avian flu virus H5N8 will worry human health officials as well.

That’s because avian flus have shown the repeated ability to jump the species barrier, infecting human beings—and killing them. The most dangerous virus has been H5N1, which has infected hundreds of human beings over the past decade, mostly in Asia, killing an estimated 60% of them. Bird flu infections in human beings are still very rare, usually occurring because of close contact with a sick birds. Right now avian flus like H5N1 haven’t shown the ability to spread from person to person. But scientists fear that an avian flu virus could eventually mutate, and become more transmissible—potentially starting a new flu pandemic. And if that new flu was as transmissible as the seasonal human flu, but as deadly as H5N1 would be, the result would make Ebola look like a slight cold.

Learn about the potential dangers of avian flu with these stories from TIME’s archives:

Feb. 9, 2004: The Revenge of the Birds

An H5N1 outbreak in Asia kills thousands of chickens — and leads millions more to be slaughtered. Though the number of humans affected is low, the outbreak raises fears about what could happen if the virus mutated.

The virus probably originates in southern China, but no one knows how it has spread so widely. Transport of infected birds to chicken farms is one theory, but it’s also possible that migratory birds such as ducks and geese are spreading it through their droppings. “Did birds in Hong Kong, which nest in Siberia and North Korea, somehow spread the virus elsewhere?” asks Robert Webster, an expert in animal influenzas at St. Jude Children’s Research Hospital in Memphis, Tenn. “That’s a frightening possibility.” If H5N1 does evolve into a flu that humans can spread, a vaccine could be developed but would take months. “Once you know this virus can spread from human to human, region to region,” says Dr. Yi Guan, a SARS and avian-flu expert at the University of Hong Kong, “it’s already too late.”

Sept. 19, 2005: A Wing and a Prayer

The H5N1 virus, previously thought present in domestic animals only, appears in migratory birds, indicating that it has to potential to spread around the world.

For some time, health experts have warned of a worldwide bird-flu pandemic that could kill millions of people and wreck the global economy. “The most serious known health threat facing the world is avian flu,” said WHO director-general Lee Jong-wook earlier this year. And the threat is growing all the time, as nature keeps dropping hints that the links in a chain of events leading to a deadly pandemic continue to be forged. This summer, H5N1 spread west—perhaps in migrating birds—to new territory, including Mongolia, Tibet, Siberia and Kazakhstan. European countries are taking precautions by tightening surveillance of flocks within their borders; in the Netherlands, officials in late August ordered farmers to move the nation’s 90 million poultry indoors to prevent any contact with itinerant fowl. Meanwhile, in Southeast Asia, where at least 58 people have died and 150 million poultry have died or been culled because of avian flu since the end of 2003, the virus is still active; a Jakarta woman died of the disease on Sept. 10. The H5N1 virus has already shown it can be deadly to people who come into direct contact with infected birds or eat uncooked poultry. But bird-to-human transmission is relatively controllable because diseased flocks can be isolated or, usually, eliminated. The sum of all fears is that H5N1 could mutate into a strain with the ability to jump easily from person to person, as ordinary flu does. That could trigger a once-in-a-century catastrophe. How many would die? Nobody knows, or can know.

June 14, 2007: Living Cheek to Beak

A trip to Indonesia reveals some reasons why it’s harder than you might expect to contain the virus in birds: understanding of the potential for pandemic is low among village farmers, and the habits of daily life are harder to break. But, because of the close relationship between humans and livestock, the stakes in such a situation are particularly high.

Indonesia’s chickens are about meat and eggs, of course. But they are also a potentially deadly symbol of changing patterns of food production and consumption. While the H5N1 strain of avian flu has occasionally jumped from birds to people for several years now, the fear is that it will mutate and begin spreading easily from person to person, threatening the lives of millions. So a pandemic is why the world cares about dead chickens in a tiny rural village. Though the rare human bird-flu cases have gotten most of the attention, “the most effective way to prevent a pandemic is to stop the virus in animals,” says Dr. Bernard Vallat, director general of the World Organization for Animal Health (OIE). In other words: save the chickens, save the world.

May 18, 2009: How to Prepare for a Pandemic

An outbreak of swine flu (H1N1) highlights the reason why epidemiologists need to spend their time thinking about animals other than human beings. Many dangerous diseases (including Ebola) originate from animals and mutate into viruses that can be spread among humans.

Why should we spend scarce medical resources swabbing the inside of pigs’ nostrils, looking for viruses? Because new pathogens–including H5N1 bird flu, SARS, even HIV–incubated in animal populations before eventually crossing over to human beings. In the ecology of influenza, pigs are particularly key. They can be infected with avian, swine and human flu viruses, making them virological blenders. While it’s still not clear exactly where the H1N1 virus originated or when it first infected humans, if we had half as clear a picture of the flu viruses circulating in pigs and other animals as we do of human flu viruses, we might have seen H1N1 coming. (When it comes to sniffing out new pathogens, says one epidemiologist, “we’re like a drunk looking for his keys.”) Faster genetic sequencing and the Internet give us the technological means to create an early-warning system. But we need to spend more on animal health and get doctors talking to their veterinarian counterparts. “For too long, the animal side of public health has been neglected,” says Dr. William Karesh, vice president of the Wildlife Conservation Society’s global-health program.

Read more about the current outbreak of bird flu here on Time.com.

MONEY Health Care

The 7 Biggest Health Problems Americans Face—And Who is Profiting

Bottles of prescription medicine in cabinet
Kim Karpeles—Getty Images/age fotostock

Here are the most-prescribed drugs in America.

Americans include two health-related issues among the 10 most important problems facing the U.S., according to a recent Gallup survey. Healthcare in general ranked fourth on the list, with Ebola coming in at no. 8. But is Ebola really among the biggest health problems for Americans? Not when we look at the chances of actually being infected.

So, what are the actual biggest health problems that Americans face? One way to answer this question is to look at what drugs are prescribed the most. Here are the seven top health problems based on the most-prescribed drugs in the U.S., according to Medscape’s analysis of data provided by IMS Health.

1. Hypothyroidism

AbbVie’s ABBVIE INC. ABBV 3.3287% Synthroid ranks at the top of the list of most-prescribed drugs. Synthroid is used to treat hypothyroidism, a condition caused by an underactive thyroid gland.

The American Thyroid Association estimates that 2%-3% of Americans have pronounced hypothyroidism, while 10%-15% have a mild version of the disease. Hypothyroidism occurs more frequently in women, especially women over age 60. Around half of Americans with the condition don’t realize that they have hypothyroidism.

2. High cholesterol and high triglycerides

Coming in at a close second on the list is AstraZeneca’s ASTRAZENECA PLC AZN 0.4716% Crestor. The drug is used to help control high cholesterol and high triglyceride levels.

According to the American Heart Association, nearly 99 million Americans age 20 and over have high cholesterol. Elevated cholesterol levels are one of the major risk factors for heart attacks and strokes. The problem is that you won’t know if you have high cholesterol unless you get tested — and around one in three Americans haven’t had their cholesterol levels checked in the last five years.

3. Heartburn and gastroesophageal reflux disease

AstraZeneca also claims the third most prescribed drug in the nation — Nexium. The “purple pill” helps treat hearburn and gastroesophageal reflux disease, or GERD, also commonly referred to as acid reflux.

Around 20% of Americans have GERD, according to the American Society for Gastrointestinal Endoscopy. A lot of people take over-the-counter medications, but that’s not enough for many others. Medscape reported that over 18.6 million prescriptions of Nexium were filled between July 2013 and June 2014.

4. Breathing disorders

The next two highly prescribed drugs treat breathing disorders. GlaxoSmithKline’s GLAXOSMITHKLINE PLC GSK 0.0431% Ventolin HFA is used by asthma patients, while the company’s Advair Diskus treats asthma and chronic obstructive pulmonary disease, or COPD.

More than 25 million Americans have asthma. Around 7 million of these patients are children. Meanwhile, COPD, which includes chronic bronchitis and emphysema, ranks as the third-leading cause of death in the U.S.

5. High blood pressure

Novartis NOVARTIS AG NVS -0.3044% claims the next top-prescribed drug with Diovan. The drug treats high blood pressure by relaxing and widening blood vessels, thereby allowing blood to flow more readily.

Around one-third of American adults have high blood pressure. Many don’t know that they are affected, because the condition doesn’t usually manifest symptoms for a long time. However, high blood pressure can eventually lead to other serious health issues, including heart and kidney problems.

6. Diabetes

Several highly prescribed drugs combat diabetes, with Sanofi’s SANOFI S.A. SNY 1.2454% Lantus Solostar taking the top spot for the condition. Lantus Solostar is a long-acting basal insulin that is used for type 1 and type 2 diabetes mellitus.

According to the National Diabetes Statistics Report released in June 2014, 29.1 million Americans had diabetes in 2012. That’s a big jump from just two years earlier, when 25.8 million Americans had the disease. Diabetes ranks as the seventh leading cause of death in the U.S.

7. Depression and anxiety

Eli Lilly’s ELI LILLY & CO. LLY 0.8383% Cymbalta fell just below Lantus Solostar in number of prescriptions. Cymbalta is the leading treatment for depression and generalized anxiety disorder.

The Anxiety and Depression Association of America estimates that 14.8 million Americans ages 18 and older suffer from a major depressive disorder each year. Around 3.3 million have persistent depressive disorder, a form of depression that lasts for two or more years. Generalized anxiety disorder affects around 6.8 million adults in the U.S.

Common thread for common diseases

One thing that stands out about several of these common diseases affecting millions of Americans is that many people have one or more of these conditions — but don’t know it. This underscores the importance of getting a checkup on a regular basis.

Regardless of what the Gallup survey found, the odds of you getting Ebola are very low. On the other hand, the chances of you or someone in your family already having one of these seven conditions could be higher than you might think. Perhaps the truly biggest healthcare challenge facing Americans is knowing the status of their own health.

TIME health

Death is Not Only for the Dying

Dried rose
Getty Images

I would give anything to not have experienced the last week of my wife’s life

I occasionally flip my car radio to the right wing AM station to get my blood pumping and to keep up on what people with a different worldview are thinking. When I did this last week, I wasn’t too surprised to hear the topic of the afternoon call-in program was Brittany Maynard, a terminally ill California woman who moved to Oregon to take advantage of the state’s death with dignity law and end her own life.

The fact that an attractive young woman made this decision and shared it with the world had caught the media’s attention and reignited debate on the issue of physician-assisted suicide. Her story also caught my interest, having gone through the slow and painful cancer death of my own wife.

Listening to the call-in program last week, I felt empathy right away for the first caller, a widower who had recently lost his wife to heart disease. But then the caller said that Brittany’s husband should have talked her out of her decision. He was sure that her husband would regret losing her before the last possible moment. The caller said that he would give anything to have one more hour with his wife. I’m sure that is a common attitude, especially if the loved one has died suddenly, but it is not my experience. I would give anything to not have experienced the last week of my wife’s life.

As I see it, Brittany gave her husband a gift. She gave him a gift by preventing painful images from being burned into his brain. He will not have memories of his beloved gradually losing her mind and control over her bodily functions. He will not have memories of watching the person he loves most moaning in pain, and not being able to do anything about it. He will not have memories like the ones I have—of vomit and bedsores and things so horrible that I cannot bring myself to type them into this keyboard. He will not have memories of reaching the point where he started wishing that his wife, his partner of 38 years who he loved with all his heart, would die. Those memories don’t go away; they come back in dreams and nightmares.

I’m not sure that my wife would have taken advantage of a law like Oregon’s if it had existed here in California. Her method of coping with cancer was to ignore it as much as possible. She did not talk about the disease, and certainly did not make any plans related to dying. If I tried to bring it up, she would quickly cut me off with: “Are you giving up on me?” This may seem like foolish denial, but I don’t think it was. She realized that her time was short, and decided to eliminate unpleasant things from her life as much as possible. Thinking or talking about disease and death were unpleasant, so she didn’t do it.

Instead we went on camping trips to our favorite remote areas of the Sierras and the Mojave Desert. We spent time with dear friends and our first grandson. The summer before her death in October 2008, our two daughters rather hurriedly put together lovely weddings for themselves. To the very end, she stayed in our home surrounded by people who loved her. In spite of chemotherapy and intestinal obstructions, the last year of her life was a good time. The last week was not.

Nobody really tells you about death. You learn about it as you go along. The hospice nurses are wonderful. They prepare you, in a way, and are good about answering questions, but by the time you know what questions to ask, it’s too late. You also hear half-truths and little white lies, like: “We can keep her comfortable by just upping the dose of morphine.” They don’t tell you ahead of time how you are supposed to do that when she can no longer swallow, nor do they mention that the dose of morphine necessary to keep her “comfortable” is eventually the same as the dose that will stop her breathing. They don’t tell you what to do when she asks for a pill to “just get this over with.” They do reassure you that those horrible moans and gasps are worse for you than for her.

They are probably right. By then, I was sure that her essence was gone; she did not know what was happening. Still, it was horrible for me, and for what purpose?

From my wife’s death I did gain a deeper understanding of what it means to be human. One surely does not understand the full human experience without going through a great loss. I learned that grief is a physical pain that is built into our biochemistry. I learned how important good friends are when you need them. I learned that a family can come through truly bad times, that a life can be put back together after being uprooted. I would have learned all of this without that last week.

I thank Brittany Maynard for showing the world a better way. It took bravery on her part, and it was a gift to her loved ones. It will also be a gift to all of us if it gets us to think about how we want to die, and what memories we want to leave behind.

John La Grange is a retired commercial fisherman living in Solana Beach, California. He met his wife while they were students at UCSD. After 38 years of marriage, she died of ovarian cancer in 2008. He wrote this for Zocalo Public Square.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

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