TIME Viewpoint

Modi and the World

Narendra Modi addressing a rally in Vadodara
PM-designate Narendra Modi addressing a rally in Vadodara, Gujarat, after the BJP won the Lok Sabha elections on Friday, May 16, 2014. The India Today Group—India Today Group/Getty Images

A crisis could force the hand of India’s new leader as he navigates Asia’s shifting geopolitics

Often fiery and intermittently reasonable, sometimes banal but occasionally innovative, Narendra Modi’s statements on foreign policy over the past few years have been so meager and uneven that they cannot readily serve as a guide for how he will act as India’s Prime Minister. Wonks call him a realist. Political admirers and critics both say he’s hard-line. But the specifics of what he might do in office are unclear.

In the past, Modi has berated the Manmohan Singh government for being weak in its dealings with Pakistan and China, two of India’s most important neighbors. During the election campaign, however, he was careful not to paint himself into a corner. In his first major foreign policy speech, he gave pride of place to a corny slogan—“Terrorism divides, tourism unites”—but also showed a capacity for out-of-the-box thinking, saying India should convene a global summit with countries interested in developing solar power as a major source of future energy.

While there is likely to be continuity in many aspects of India’s foreign policy—its stand on major international issues, its bilateral and multilateral partnerships—Modi’s tenure will be defined by how he responds to four specific challenges.

The first is economic, where everything depends on his ability to boost growth. Besides strengthening India’s economic partnerships with the U.S., Europe and Asia, a stronger economy will give the country the heft it needs to play a larger role on the world stage.

Politically, the big challenge for Modi will be to move away from his Bharatiya Janata Party’s rhetoric of “Hindu nationalism” and find ways of forging closer ties with India’s two Islamic neighbors, Bangladesh and Pakistan. In opposition, the BJP attacked Singh for his initiatives on this front. During the campaign, Modi played on the sentiment of Hindus living near Bangladesh, describing Muslim migrants as “infiltrators” out to destroy India. The reality is more complex. While there are large numbers of Bangladeshi migrants in India, many Indians work in Bangladesh and send back nearly two-thirds of the amount of money that Bangladeshis in India transmit out of the country every year, according to the World Bank. Closer ties with Dhaka, and Islamabad, are clearly in New Delhi’s interest. Inviting neighboring leaders, including Pakistan’s Nawaz Sharif, to his inauguration is a good first step by Modi.

On the strategic front, the shifting geopolitics of the wider Asian region will present Modi with difficult choices. His instincts may lead him to seek closer ties with a more assertive Japan and a U.S. officially committed to the Asia “pivot.” But the economic pragmatist in him will be wary of fanning Chinese fears about encirclement. As chief minister of Gujarat, Modi visited China several times, and China’s President Xi Jinping is due to visit New Delhi in the fall. The Shinzo Abe government is keen for Modi to visit Tokyo before that, and the new PM will meet with President Barack Obama in New York City in September. Striking a balance between the three will require great dexterity.

When it comes to Washington, much has been made of the denial of a U.S. visa to Modi when he was chief minister. In campaign interviews, the Prime Minister–elect chose to strike a philosophical tone, saying one should look forward and not back. And although the chances that Modi and Obama will hit it off are close to zero, both leaders know the stakes are too high to let feelings come in the way.

The greatest—and most immediate—foreign policy challenge for Modi is likely to be on the crisis-management front. What happens if Lashkar-e-Taiba, al-Qaeda or other Pakistan-based terrorist outfits stage an attack against India? Modi would come under enormous pressure from his party’s rank and file to react in a muscular manner, though the country’s diplomatic and security establishment is likely to drive home the absence of any neat military options. A crisis may also come up on the Chinese side if there is a repeat of the kind of intrusions Chinese military patrols have engaged in along the yet-to-be-settled international boundary between the two countries. Vague as Modi’s positions have been thus far, he will have to get very specific, very quickly. n

Varadarajan is a senior fellow at the Center for Public Affairs and Critical Theory at New Delhi’s Shiv Nadar University

TIME Viewpoint

How To Get Paid for Planning Your Death

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PhotoAlto/Ale Ventura—Getty Images/Brand X

An Oklahoma senator wants to pass a bill that would pay you to write your end of life directive ahead of time

A couple of days before my mother jetted off on a three-week trip abroad, she sent me her usual email that detailed flight info and where she would be staying, “just in case.” But this time, she also included her preferences in case of an emergency—like what she wanted to happen to her if she couldn’t make her own medical decisions. She told me she was an organ donor and didn’t want anything too fancy when it comes to a funeral. If it’s just my sister and I, that would be just fine.

At first, I was dumbstruck. My mother is healthy, she isn’t particularly morbid and she was traveling to the stable country of France. But the more I thought about it I realized that getting answers to those difficult, devastating questions while she’s well (as opposed to in a hospital bed) was far better for both of us. It turns out my mom is in the minority. Only about 30% of Americans have so-called “advance directives”—legal documents that lay out exactly what they want when it comes to resuscitation, power of attorney, and overall preferences for treatment, like whether a person prefers to die at home. That’s something Republican Oklahoma Senator Tom Coburn is hoping to change. His strategy? Pay people $75 to write one.

He recently introduced the Medicare Choices Empowerment and Protection Act, which would give seniors cash for putting in writing what they want to happen if they can’t speak for themselves in a medical situation. The bill is co-sponsored by Democratic Senator Chris Coons of Delaware and the Act would allow people on Medicare to get a payment of $75 from the Centers for Medicare and Medicaid Services for completing an online directive, and $50 for manually creating one, Reuters reports. Dying is expensive, and planning ahead may be one way to cut costs since end of life spending is in the billions of dollars in the United States. According to The Medicare NewsGroup, in 2011, Medicare spending reached about $554 billion, and of that $554 billion, Medicare spent about $170 billion on patients’ last six months of life.

A 2011 study of 3302 Medicare beneficiaries found that advance directives were associated with less Medicare spending, a lower risk of dying in a hospital, and higher use of hospice care in areas of the U.S. characterized by higher spending in end of life care. Advance directives also make it easier for doctors and family members to make decisions with confidence, and are meant to protect—and carry out—patients’ choices.

“Many people want to complete advance directives, but procrastinate doing so because it requires the unpleasant task of thinking about your own mortality. As a result, new approaches to helping people overcome their inertia might improve the proportions of patients who receive the type of care that they want,” says Dr. Scott Halpern, director of the Fostering Improvement in End-of-Life Decision Science (FIELDS) program at the University of Pennsylvania.

Some cities and states have made advance directives a priority. For instance, 96% of people who die in La Crosse, Wisconsin, have some kind of document about their end-of-life health care wishes, NPR reports. And La Crosse spends less on patients at the end of life than any other place in the country, according to the Dartmouth Health Atlas. Nurses and health professionals in La Crosse have been trained to start talking to patients about advance directives earlier, so that discussions are easier and there’s less confusion.

Some critics of the proposal say that the sheer volume of paperwork that would be required presents a logistical nightmare. Others contend that people won’t take the time to think about their decisions as they click through boxes, and not having thoughtful conversations with family members. Some remember back to 2009, when Sen. Johnny Isakson sponsored an end of life planning bill that would require Medicare to cover voluntary end-of-life counseling sessions between doctors and their patients. Former Governor of Alaska Sarah Palin called them “death panels,” and the unfortunate nickname stuck—the bill died.

But advocates say that since advance directives are a hassle to figure out, incentivizing them to be done in advance is helpful. “Generally the hospice community is in favor of anything that incentivizes the conversation,” says Angie Truesdale, vice president of public policy National Hospice and Palliative Care Organization. “[The proposal] takes a very patient-centered approach. The only way it could be stronger is if they would incentize patients to revisit it every year.” Although that would be more expensive, Truesdale says patients should have conversations with their family and doctors and update it according to their health and wishes.

Coburn told Reuters he wrote his own advance directive 20 years ago. He will be stepping down from his post in January, due to health issues. The bill has been referred to the Finance Committee which will decide whether to send the bill to the Senate.

Next time I visit my parents, my mom says she plans to sit us all down to complete, or at least consider completing, our own documents. “It will be good for you to have them done,” she sent me in a text message. And my mother is always right.

You won’t get paid for it—yet—but you can start making your own big decisions here.

TIME Viewpoint

Russia’s Game in Ukraine

Rising tension Pro-Russian protesters storm a regional police building in the eastern Ukrainian city of Horlivka
Rising tension Pro-Russian protesters storm a regional police building in the eastern Ukrainian city of Horlivka Alexey Kravtsov—AFP/Getty Images

Putin does not want to risk a takeover. But he does want another pliant leader in Kiev

Earlier this month, as residents of Kiev celebrated the opening of an annual festival of French culture and, days later, the start of one of the country’s largest book fairs, their compatriots in the eastern Ukrainian city of Lugansk were on edge. Armed pro-Russian separatists had seized a regional security-service building and reportedly taken more than 50 people hostage. Though the hostage situation was resolved, there were other instances of separatists causing trouble near the country’s eastern borders with Russia, as the Kremlin began to exert pressure beyond Crimea, the Black Sea peninsula it seized in March.

Moscow might deny a role in stoking the unrest, but the fear inside Ukraine was that the tensions in Lugansk and elsewhere in the east would be followed up by a wholesale influx of Russian troops, tens of thousands of whom remain massed at the border. But that did not happen—or at least, it hasn’t happened yet.

Why? Perhaps Russia was put off by the re­inforcements that appeared on the Ukrainian side—Moscow would prefer a Crimea-style takeover, instead of risking a bloody fight, even one that it would be likely to win, given its relative military strength—or maybe it was simply posturing, geared to keep Ukraine preoccupied as Kiev tries to get on with the important business of holding national elections and restructuring its struggling economy. Whatever the Kremlin and Russian President Vladimir Putin might be planning next, one thing seems clear: Moscow wants Kiev to know that an attack is possible at any moment.

We know this not only because of the troops at the border, or the separatists whipping up trouble inside Ukraine, but also because of the goings-on inside Russia, where it seems that every last nationalist is being encouraged to visit Lugansk, Donetsk and other cities in eastern Ukraine to take part in pro-Moscow demonstrations.

In mid-April, there was further unrest in Sloviansk, where a Ukrainian policeman was killed in a battle with armed separatists. Problems with pro-Russian gunmen also arose in other parts of the east, the country’s industrial heartland.

Besides fear, the developments have also sparked black humor. One story doing the rounds concerns the town of Alchevsk in the Lugansk region, where, it is said, some 150 not very sober people got together for a demonstration, proudly waving French flags instead of Russian ones—an easy mistake to make for outsiders, what with the colors being the same. But there is nothing funny about a crowd of around 2,000 people storming public buildings—which is what happened in Donetsk in early April.

In Crimea, meanwhile, a Russian sergeant shot an unarmed Ukrainian officer who was preparing to transfer to a Ukrainian base on the mainland. No charges have been filed against the sergeant.

All of the above underlines the fact that Russia is not content with annexing Crimea, nor will it simply sit back and allow ordinary Ukrainians to choose a new leader in the upcoming presidential election planned for May 25.

That does not mean Putin wants to seize the whole country. The risks of bloodshed and a more serious—and economically ruinous—confrontation with the West are too great for the Kremlin to march on Kiev. That said, the recent troubles in the east suggest that Putin is not about to let go of Ukraine and walk away either. For Moscow, the goal is another pro-Russian government in Kiev, giving it clout over a former Soviet state without the risks attached to a full-scale military invasion.

Against this backdrop, the May presidential election will be critical in determining what happens next in Ukraine. If the interim government in Kiev can hold a free and fair election, with the new government winning a mandate from the eastern regions, Putin will not be able to continue calling Viktor Yanukovych the country’s “legitimate” President. A successful vote will force Putin to reconsider his strategy. But if Russia succeeds in disrupting the polls, Ukraine would face the prospect of greater unrest.

Kurkov is a Ukrainian writer and the author of the critically acclaimed novel Death and the Penguin

TIME Addiction

Viewpoint: FDA Approval of Overdose Antidote Leaves Lives on the Table

Making the epi-pen available by prescription is just the first step. It also needs to be available over the counter.

The FDA approved on Thursday the equivalent of an “epi-pen” for overdose prevention, an antidote auto-injector that even untrained people can use to save the lives of those who have overdosed on drugs like Vicodin or heroin. Such opioid overdoses kill around 17,000 Americans each year.

While this first step is welcome, the antidote remains prescription only. But to save the most lives, it needs to be made available over-the-counter and be affordable enough to be included in every first aid kit in the country.

While it’s commonly thought that the only people who die of overdose are people with addiction, in fact, OD kills in many different scenarios. Grandma might mix up her meds and take them twice or even three times. Uncle Bob might forget that pain medication and alcohol shouldn’t mix. A toddler or a curious teenager might get into the medicine cabinet. And someone who struggled with addiction in the past might relapse: the highest risk times for overdose in addiction are initial use and then middle age, with peaks that also occur after periods of abstinence or incarceration. In many of these situations, relatives don’t realize that their loved one is at risk.

Another myth about overdose is that it typically occurs when people are alone. Research suggests that at least half of all overdoses are witnessed, but oftentimes the witnesses don’t know what they are seeing and “let them sleep it off,” which is basically the worst thing to do. Instead, if someone’s breathing is slowed or stopped, their skin is bluish, you cannot arouse them, and there’s any chance that overdose is the cause, calling 911, using naloxone, and performing rescue breathing is best.

Combined with greater awareness of these OD symptoms, the new drug delivery system could make a real difference. Called Evzio, it’s basically a sophisticated epi-pen. But instead of containing adrenaline to prevent potentially fatal allergic responses, it contains naloxone, a nontoxic FDA-approved drug that can instantly reverse potentially fatal overdoses that include opioids. (At least 2/3 of overdoses involve drug mixtures, but if one of the drugs is an opioid, Evzio will still work).

Evzio also has safety features that prevent the needle from being re-used, and recorded audio instructions that can guide people without prior training in how to save a life. There’s virtually no way to misuse it. Essentially, naloxone causes the opposite of a high and can induce distressing withdrawal symptoms in people who are addicted. Since the experience of being revived with it is unpleasant, using Evzio as “insurance” for excess that wouldn’t otherwise occur is unlikely to be a major issue. And it won’t harm even if given in error; since the only thing it does is block opioids, it doesn’t hurt in other types of OD or in other situations that cause people to lose consciousness.

Research already shows that making naloxone available to lay people in other forms is effective. A study of Massachusetts’ program published in BMJ found that not only did an intranasal version of drug revive 98% of victims to whom it was administered, it also cut the OD death rate in regions with high levels of availability by nearly 50%, compared to areas where it was less accessible.

MORE: Wider Distribution of Overdose Antidote Could Cut Death Rates By Nearly Half: Study

Since 1996, when activist Dan Bigg started the first naloxone distribution program in Chicago, around 200 such programs have sprung up in the U.S. Collectively, they’ve distributed more than 50,000 doses with at least 10,000 reported revivals. No serious side effects have come to light. The drug has been used safely in hospitals since the 1960s, and was approved for such use by the FDA way back in 1971. Last month, attorney general Eric Holder even urged that states make it available to all first responders. New York state announced Thursday a $5 million program to distribute it to police officers.

Experts agree that in an overdose situation, “time is brain.” The longer someone goes without oxygen, the worse the consequences and the more likely the overdose will be fatal. No parent I’ve spoken with has ever said that they would prefer not to have such a drug on hand if they ever came upon a blue and unconscious child.

Given this, and naloxone’s spotless safety record, there’s no reason to require prescriptions for it. And since no one can truly predict where and when an OD might occur, it should always be nearby if possible; hence first aid kits are the natural place for it. If everyone has it, no one has to feel singled out as potentially having an addicted person in the family; it’s just there for emergencies that could actually affect anyone.

Dr. Eric Edwards, the chief medical officer of Kaleo Inc., which makes Evzio, says that given naloxone’s safety profile, it’s possible that it may be made available over the counter in the future. “We think this is the first step to building the safety data needed to show that it can be used appropriately,” he says.

But people are dying every day, right now. It has taken at least 18 years from the time Bigg first distributed naloxone to get to this place, and more than four decades since the FDA originally approved naloxone for hospital use. Even the director of the National Institute on Drug Abuse, the agency charged with addiction research in the U.S., says it should be over-the-counter.

Says Bigg, “It sounds like [Evzio] is a big step forward, if it is affordable.” The price has not yet been made public.

And regardless of the price issue, is there really any reason to wait any longer to allow all types of naloxone to be sold over the counter? The FDA can choose to act on an emergency basis in terms of drug approvals if it so desires. With the availability of Evzio, there’s no justification for not doing so, other than the ongoing stigma of addiction.

MORE: Overdose Antidote Is Cost Effective at Saving Lives

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