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Andrea Constand’s impact statement: Bill Cosby "robbed me" of my health, vitality and trust

The following victim impact statement was submitted in writing by Andrea Constand, the former Temple University employee whom Bill Cosby was convicted of drugging and sexually assaulting in 2004, and released by prosecutors at Cosby’s sentencing Tuesday in Norristown, Pennsylvania. Cosby was sentenced to three to 10 years in state prison.

To truly understand the impact that sexual assault has had on my life, you have to understand the person that I was before it happened.

At the time of the assault, I was 30 years old, and a fit, confident athlete. I was strong, and skilled, with great reflexes, agility and speed. When I graduated from high school in Toronto, I was one of the top three female high school basketball players in Canada. Dozens of American colleges lined up to offer me basketball scholarships, and I chose the University of Arizona.

For four years, I was a shooting guard on the women’s basketball team, scoring up to 30 points a game. It was an amazing time in my life, and I learned a lot, developed a circle of really good friends, many of them teammates, and travelled around the U.S. to compete.

The only downside was that I missed my family and developed severe homesickness. When it started to affect my studies and my training, my Dad came up with the idea to move his own father and mother to Tucson.

My grandparents were in their late 60s when they gamely agreed to move more than 2,000 miles to help me adjust to life away from home. They were retired after selling their Toronto restaurant business, and figured the warm, dry climate would suit them anyway. I had always enjoyed a special relationship with my grandparents. Not only had I grown up in their home, but I spoke Greek before I spoke English. They got an apartment close to mine, and I was there most days, talking and laughing over my favourite home-cooked meals. The homesickness quickly evaporated.

After I graduated from the University of Arizona with a degree in Communications, I signed a two-year contract to play professional basketball for Italy. Going pro took my athletic training to a whole new level. Once again, I thrived in the team atmosphere, and enjoyed travelling Europe although we rarely saw more than the basketball venues and the hotel rooms where we slept.

When my contract ended, my former coach from the University of Arizona encouraged me to apply for a job as Director of Operations for the women’s basketball team at Temple University in Philadelphia. It was a busy, challenging position that required me to manage a lot of logistical details so that others could focus on training the team for competition. I also made all the travel arrangements and went to tournaments with the team and support staff.

It was a great job but after a few years, I knew I wanted to pursue a career in the healing arts, my other passion. I also wanted to work closer to home, where I would be reunited with my large, extended family, and many friends.

I knew who I was and I liked who I was. I was at the top of my game, certain that the groundwork provided by my education and athletic training would stand me in good stead whatever challenges lay ahead.

How wrong I was. In fact, nothing could have prepared me for an evening of January 2004, when life as I knew it came to an abrupt halt.

I had just given my two-month notice at Temple when the man I had come to know as a mentor and friend drugged and sexually assaulted me. Instead of being able to run, jump and pretty much do anything I wanted physically, during the assault I was paralyzed and completely helpless. I could not move my arms or legs. I couldn’t speak or even remain conscious. I was completely vulnerable, and powerless to protect myself.

After the assault, I wasn’t sure what had actually happened but the pain spoke volumes. The shame was overwhelming. Self-doubt and confusion kept me from turning to my family or friends as I normally did. I felt completely alone, unable to trust anyone, including myself.

I made it through the next few weeks by focusing on work. The women’s basketball team was in the middle of the Atlantic 10 tournament and was travelling a lot. It was an extremely busy time for me, and the distraction helped take my mind off what had happened.

When the team wasn’t on the road, however, I was in the basketball office at Temple, and was required to interact with Mr. Cosby, who was on the Board of Trustees. The sound of his voice over the phone felt like a knife going through my guts. The sight of the man who drugged and sexually assaulted me coming into the basketball office filled me with dread. I did everything my job required of me but kept my head down, counting the days until I could return to Canada. I trusted that once I left, things would get back to normal.

Instead, the pain and anguish came with me. At my parent’s house, where I was staying until I got settled, I couldn’t talk, eat, sleep or socialize. Instead of feeling less alone because I was back home with my family, I felt more isolated than ever. Instead of my legendary big appetite and “hollow leg” – a running joke in my family – I picked at my food, looking more like a scarecrow with each passing week. I was always a sound sleeper but now I couldn’t sleep for more than two or three hours. I felt exhausted all the time.

I used the demands of my new courses to opt out of family gatherings and events, and to avoid going out with friends. As far as anyone could tell, I was pre-occupied with my studies. But the terrible truth about what had happened to me – at the hands of a man my family and friends admired and respected – was swirling around inside me.

Then the nightmares started. I dreamed that another woman was being assaulted right in front of me and it was all my fault. In the dream, I was consumed with guilt, and pretty soon, that agonizing feeling spilled over into my waking hours too. I became more and more anxious that what had happened to me was going to happen to someone else. I grew terrified that it might already be too late, that the sexual assaults were continuing because I didn’t speak out.

Then one morning I called my mother on the telephone to tell her what had happened to me. She had heard me cry out in my sleep. She wouldn’t let me put her off, and insisted that I tell her what was wrong. She wouldn’t settle for anything less than a complete and truthful explanation.


Reporting the assault to the Durham Regional police in Toronto only intensified the fear and pain, making me feel more vulnerable and ashamed than ever. When the Montgomery County District Attorney outside Philadelphia decided not to prosecute for lack of evidence, we were left with no sense of validation or justice. After we launched civil claims, the response from Mr. Cosby’s legal team was swift and furious. It was meant to frighten and intimidate and it worked.

The psychological, emotional and financial bullying included a slander campaign in the media that left my entire family reeling in shock and disbelief. Instead of being praised as a straight-shooter, I was called a gold-digger, a con artist, and a pathological liar. My hard-working middle-class parents were accused of trying to get money from a rich and famous man.

At the deposition during the civil trial, I had to relive every moment of the sexual assault in horrifying detail in front of Mr. Cosby and his lawyers. I felt traumatized all over again and was often in tears. I had to watch Cosby make jokes and attempt to degrade and diminish me, while his lawyers belittled and sneered at me. It deepened my sense of shame and helplessness, and at the end of each day, I left emotionally drained and exhausted.

When the case closed with a settlement, sealed testimony and a nondisclosure agreement, I thought that finally – finally – I could get on with my life, that this awful chapter in my life was over at last. These exact same feelings followed me throughout both criminal trials. The attacks on my character continued, spilling over outside the courtroom steps attempting to discredit me, and cast me in false light. These character assassinations have caused me to suffer insurmountable stress and anxiety, which I still experience today.

I still didn’t know that my sexual assault was just the tip of the iceberg.

Now, more than 60 other women have self-identified as sexual assault victims of Bill Cosby. We may never know the full extent of his double life as a sexual predator but his decades-long reign of terror as a serial rapist is over.

I have often asked myself why the burden of being the sole witness in two criminal trials had to fall to me. The pressure was -enormous. I knew that how my testimony was perceived – that how I was perceived – would have an impact on every member of the jury and on the future mental and emotional well-being of every sexual assault victim who came before me. But I had to testify. It was the right thing to do, and I wanted to do the right thing, even if it was the most difficult thing I’ve ever done. When the first trial ended in a mistrial, I didn’t hesitate to step up again.


I know now that I am one of the lucky ones. But still, when the sexual assault happened, I was a young woman brimming with confidence and looking forward to a future bright with possibilities. Now, almost 15 years later, I’m a middle-aged woman who’s been stuck in a holding pattern for most of her adult life, unable to heal fully or to move forward.

Bill Cosby took my beautiful, healthy young spirit and crushed it. He robbed me of my health and vitality, my open nature, and my trust in myself and others.

I’ve never married and I have no partner. I live alone. My dogs are my constant companions, and the members of my immediate family are my closest friends.

My life revolves around my work as a therapeutic massage practitioner. Many of my clients need help reducing the effects of accumulated stress. But I’ve also trained in medical massage at Memorial Sloan-Kettering Cancer Center in New York, and often help cancer patients manage the side effects of chemotherapy and radiation. I help many others too – people with Parkinson’s, arthritis, diabetes, and so on. Some of my clients are in their 90s. I help them cope with the ravages of old age, reducing stiffness, aches and pains.

I like my work. I like knowing that I can help relieve pain and suffering in others. I know that it helps heal me too.

I no longer play basketball but I try to stay fit. Mostly, I practice yoga and meditation, and when the weather is warm, I like to pedal my bike up long steep hills.

It all feels like a step in the right direction: away from a very dark and lonely place, toward the person I was before all this happened.

Instead of looking back, I am looking forward to looking forward. I want to get to the place where the person I was meant to be gets a second chance.

I know that I still have room to grow.


I would like to acknowledge some of the people who have helped me get here today. I will always be grateful for their counsel, friendship and support.

First of all, my lawyers Dolores Troiani and Bebe Kivitz. These two smart, courageous women have been there for me since the beginning. Without them, I would never have been able to navigate this legal and emotional minefield.

I will also be eternally grateful to Kevin Steele, the District Attorney of Montgomery County, who had the guts to believe in me, in the truth, and for trusting that the justice system could get things right- even if the process had to be repeated.

I also want to thank Mr. Steele’s incredible team of professionals. including assistant district attorneys Kristen Feden and Stewart Ryan, detectives Richard Schaffer, Mike Shade, Harry Hall, Jim Reape, Erin Slight, Kiersten McDonald, victims services, and many others, for their passion for justice, their skill, and their hard work and perseverance despite the odds.

Thank you to the jurors for their civic duty and great sacrifices.

Thank you to all of the friends, old and new, who have stood by me. You know who you are, and each and every one of you has made a huge difference. Please know that.

Last but not least, I want to thank my incredible family: my mother, Gianna, and my father, Andrew, my sister Diana, her husband Stuart, and their beautiful daughters – my nieces Andrea and Melanie. Thank you for proving over and over again that if there’s one thing in life you can always count on, it’s family.

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Aspire Health hacked by phishing scheme, lost ‘protected health information’


Your clever password may not be as safe as you think. Buzz60′s Sean Dowling has more.

Aspire Health, a large Nashville health care company that offers in-home treatment in 25 states, was hacked earlier this month and lost at least some patient information to an unknown cyberattacker.

The hack, disclosed for the first time in federal court records filed on Tuesday, occurred after a phishing attack gained access to Aspire’s internal email system on Sept. 3. The hacker then forwarded 124 emails to an external email account, including emails that contained “confidential and proprietary information and files” and “protected health information,” according to the court records.

No other information about the contents of the hacked emails have been made public, so it is unclear how many patients have been exposed and what kind of information was leaked. Aspire has issued a statement saying it has already alerted a “small handful” of patients who “may have been impacted” by the email breach.

Other patients who are concerned about the breach have been asked to contact the company’s 24-hour help number at 615-346-8468.

Cory Brown, a chief compliance officer for Apsire, wrote in an email to The Tennessean that the company immediately locked the compromised email account after discovering the phishing attack.

Brown added that it is unknown if the stolen emails were actually opened by the hacker.

“Aspire takes the security of its data and the personal information of its patients very seriously,” Brown said in the email statement. “Aspire is now working through the legal process to determine if any Aspire information was ultimately accessed by a third-party.”

Aspire Health was founded in 2013 by former Sen. Bill Frist and current CEO Brad Smith. The company offers house-call physicians offering palliative care for advanced cancer and other serious illnesses.

Aspire trying to ID the hacker

In the court records filed on Tuesday, Aspire has said it has tried to identify the hacker but so far has been unable to do so. The phishing attack originated from a website with an IP address in Eastern Europe for which Google is the registrar. The hacked emails were also forwarded to a Google email address –

Since the phishing attack was discovered, Google has flagged the Eastern European website as “deceptive.” Anyone who now visits the site is now met with a bright red warning sign saying they may be tricked until revealing personal information.

DATA BREACH: Identities of thousands of Tennesseans with HIV made vulnerable by government error

The hacking attack was revealed Tuesday as Aspire filed a federal court motion seeking to subpoena Google for more information on the unknown hacker. Aspire attorney James Haltom said in the court motion that Google’s internal records should be able to identify the culprit – currently known only as John Doe 1.

Haltom wrote in court records that Aspire has requested the information from Google “informally,” but Google said Aspire would need to get a subpoena.

“The proposed subpoena to Google should provide information showing who has accessed and/or maintains the phishing website and the subscriber of the e-mail account that John Doe 1 used in the phishing attack,” Haltom wrote. “This information will likely allow Aspire to uncover and locate John Doe 1.”

A phishing attack, one of the most basic forms of corporate hacking, involves fraudulent email that uses false pretenses in an effort to obtain private information, including computer passwords.

Brett Kelman is the health care reporter for The Tennessean. He can be reached at 615-259-8287 or at Follow him on Twitter at @brettkelman.

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31% of Beneficiaries Face Social Isolation, More Health Risks

By Thomas Beaton

September 25, 2018 - A new survey of Humana’s commercial population has found that almost one-third of members over 65 years old experience social isolation. The survey reveals that payers could benefit by addressing social isolation among their elderly members because reducing loneliness enhances member satisfaction as well as overall health.

Seniors recognize the importance of creating strong social bonds, but often struggle to find opportunities to develop friendships and spend time in social settings.

Eighty-five percent of survey respondents said it is important to establish friendships and 61 percent said establishing companionships was also important. In addition, 22 percent of respondents said that building romantic relationships with others was important as well.

Humana suggested that combining physical activity with opportunities for social engagement could improve both physical and emotional health.

“Healthy aging is a group activity,” said Dr. Meredith Williams, Lead Medical Director at Humana. “Social isolation and loneliness can often impact health as much as physical attributes, which is why we want to inspire seniors to focus on whole-person health. Going to the gym is great but going with a friend can have even larger health benefits, given the social impact.”

Twenty-two percent of survey respondents currently go to the gym for physical activity, the survey found. Only 13 percent of senior members going to the gym use their time as an opportunity to meet new people, but 54 percent of single beneficiaries expressed interest in building social connections at the gym.  

The interest among senior citizens in expanding their social relationships reiterates the importance of social engagement as a means to improve health.

Humana’s previous research in the Bold Goal Progress Report found that Humana Medicare members living in social isolation had a 22 percent higher chance of dying prematurely than members who had adequate social support. Additionally, socially isolated Medicare beneficiaries have a two times greater risk of developing Alzheimer’s disease than members with healthy social relationships.

Humana announced plans to launch public events for their senior beneficiaries and partnered with SilverSneakers, a wellness vendor, in order to address social isolation and beneficiary well-being.

The events include outdoor social events, fitness classes, cooking classes, and other lifestyle improvement activities. Humana will offer these events to beneficiaries across the US during Active Aging Week, a week-long campaign that promotes an active lifestyle.

“Social isolation has a measurable impact on physical and mental health, and older adults are often uniquely affected due to the loss of a spouse, adult children moving away, lack of transportation and a host of other reasons,” said Steve Janicak, Chief Growth Officer at Tivity Health.

“Our SilverSneakers members thrive on the social connections they make through the program. We’re excited to partner with Humana during Active Aging Week to promote the social and physical benefits of exercise to more seniors.”

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Elanco Animal Health Makes Stellar Debut

(AP Photo/Darron Cummings, File)

On September 20, 2018, shares of Elanco Animal Health Incorporated (NYSE: ELAN; $34.10; Market Capitalization: $12.5 billion) began trading on NYSE. ELAN’s shares opened at $32.25, about 34% higher than the IPO price of $24.00. The shares went on to add marginal gains and close for the day at $36.00. ELAN’s listing performance has partially alleviated investor concern over the company’s ability to mimic the success story that its closest peer, Zoetis Inc. (NYSE: ZTS) has demonstrated since its listing in 2013.

After the listing performance, we expect ELAN to garner valuation similar to that of ZTS. We believe that ELAN’s current valuation captures all potential upside from growth due to revenues from new product launches and long-run margin improvements. The IPO is an opportunity for ELAN to showcase its pure-play abilities in an industry that trades at a sizeable premium to the pharmaceuticals sector and win higher valuation. Future valuation re-rating will largely be decided by how ELAN tackles some immediate challenges, such as successful cost rationalization to sustain and grow its profitability and development of its feedstock portfolio to make its products more suitable for the clean food drive. Tackling these issues will enable ELAN to guard its economic moat against ZTS. With this view, we downgrade our rating on ELAN to ‘Hold’.

Eli Lilly CoSpin-Off Research

Elanco Animal HealthSpin-Off Research

A stronger than expected investor appetite enabled ELAN, the animal health business of Eli Lilly Co. (NYSE: LLY; $106.33; Market Capitalization: $114.2 billion) to price its shares offered in the IPO at $24.00, a notch above the previously announced price range. ELAN offered 62.9 million shares at $24.00 apiece to the public. The offer period is expected to expire on September 24, 2018.

Price PerformanceSpin-Off Research

Carve-Out DetailsSpin-Off Research

Valuation and Recommendation

Based on peer group median multiple of 17.8x EV/FY19e EBITDA, ELAN’s market capitalization is expected at $12.2 billion or $33.00 per share. We are downgrading our rating on ELAN to ‘Hold’.

Using sum of the parts valuation, LLY’s market capitalization is expected at $114.7 billion or $107.00 per share. We are reiterating ‘Hold’ rating on LLY.

Eli Lilly Market Cap Split At Listing $116.7 billionSpin-Off Research

Deal Rationale

LLY’s animal health business has grown not just in size but in identity and operations, making it distinct from the human health business. While LLY maintains itself to be a human healthcare focused innovator, ELAN has matured to be a market leader in animal health through its diversified business, strategy for targeted growth categories, strength of its brand and proven track record of innovation with profitable product launches.

ELAN, currently fourth largest animal health company, is set to be the second largest pure play animal health company in the market, positioned well to capture intended market share and target markets. Its focus on product innovation and adoption of disruptive technology shows a targeted strategy to capture large parts of the animal care market particularly in food animal nutrition and companion animal disease prevention.

Key DataSpin-Off Research

Top 5 ShareholdersSpin-Off Research

Globally, ELAN is first in medicinal feed additives, second in poultry and third in cattle, per 2017 revenue. ELAN boasts a broad portfolio, leading in the market across animal type, product type and geography. However, it is still behind ZTS and Boehringer’s annual sales, which are going to be battling for the top spot over the coming years, with ELAN confident that its product pipeline can propel future organic growth. With the Novartis Animal Health acquisition and the purchase of pet vaccine assets from Boehringer Ingelheim, ELAN has created a platform for much stronger growth in the companion animal arena. ELAN’s companion animal business is already outperforming its food animal unit in recent quarters and this should continue into 2019.

Elanco Animal Health Revenue trendSpin-Off Reserach

ELAN accounts for around 16% of LLY’s overall annual revenues, while Merck Animal Health represents 9% of its parent company and Bayer Animal Health is at approximately 3%. Merial was 8% of Sanofi’s annual revenues before the asset swap. The growing share in LLY business makes the need for a dedicated ELAN management necessary and beneficial.

ELAN’s MA activity involved large deals with the acquisitions of Novartis Animal Health, Lohmann Animal health and Boehringer Ingram’s vaccine portfolio being the highlights. These steps have made the business more streamlined and finesse the business prior to the spin. While these deals have expanded the capabilities of the company and induced a significant sales growth, organic growth of the company is still a challenging pursuit in the wake of the one-off sales surge normalizing.

Organization StructureSpin-Off Research


Eli Lilly: We believe that LLY’s stronghold lies in its diabetes franchise and that primary drugs Trulicity and Humalog will continue to drive value for LLY. Our thesis is supported by the robust trend observed in penetration rates of GLP-1 category. Trulicity’s easy application and favorable dosing plays to its advantage against competition, particularly against NOV’s Ozempic. Moreover, the fact that Ozempic has been gaining ground at the expense of Victoza implies that Trulicity will not face any serious threat to gain share in the market and is expected to extend its share gains at least until 2022. However, topline readouts from the ongoing REWARD study conducted by LLY is a significant near-term catalyst that can alter Trulicity’s growth trajectory. REWARD is being conducted to assess the drug’s effect on the patient’s cardiovascular system. Possible outcomes from the study, which is expected in October or November 2018, include no cardiovascular effect or effects that beat or lag what Ozempic (SUSTAIN-6) and Victoza (LEADER) revealed. Our FY19 estimate of $4,037 million assumes that REWIND outcome indicates Trulicity’s superiority in lowering cardiovascular risks and that its effects are similar to what LEADER exhibited.

LLY’s core diabetes portfolio (consisting of Trulicity, Humalog, Basaglar, and Jardiance) contributed 29% to LLY stub’s total revenues. Humalog is the oldest drug in the portfolio and we expect its revenues to decline through 2022 as Trulicity and Jardiance gain traction. We expect this core group to account for 37% and 44% of LLY stub’s total revenues in FY18 and FY19, respectively.

The growth story expected from LLY’s non-diabetic portfolio, particularly oncology, is pivotal to our thesis. Alimta and Verzenio are the drugs that will determine LLY’s success in oncology. Although results from Keynote-042 were not so encouraging, Keynote-189 results showed that Alimta has brighter chances of being adopted along with Keytruda, developed by Merck Co., Inc. (NYSE: MRK), by patients with non-squamous, non–small cell lung cancer (NSCLC). Better than expected penetration rates by CDK-4/6 also indicate a favorable growth potential for Verzenio. We believe that this twice-aweek drug from LLY is a particularly attractive alternative to patients who were unsatisfied with other CDK-4/6 treatments such as Ibrance and Kisqali. We expect LLY’s oncology portfolio to contribute about 19% to LLY stub’s FY19 revenues.

Eli Lilly Consolidated Guidance and Model Inputs for FY18Spin-Off Research

The peer group we compiled for valuing LLY consists of big human pharmaceutical players that trade at median 13.8x FY19e EBITDA. We expect LLY’s valuation to be primarily driven by successful positioning of the non diabetes portfolio, continued engagement with other pharma majors to enhance the adoption and viability of LLY’s drugs in long-term and REWARD topline readout in short-term.

Elanco Animal Health: We believe that ZTS, the sole listed peer of ELAN, is an appropriate comparable for valuing ELAN. The series of acquisitions and partnerships undertaken by ELAN over the past five years and the organic growth it has witnessed make it comparable to ZTS. If the market is convinced that the spin-off will follow the course of ZTS, the separation should unlock great value for the shareholders.

ZTS generates about twice as much revenues as ELAN does and is more profitable on reported-GAAP basis. ELAN’s margins have hovered around sub-20% with an aggressive strategy in place to drive them to 30%. To tackle macro factors such as heightened competition and flat prices, margins have been improved by driving efficiencies and synergies in manufacturing at the existing and newly acquired facilities. Several productivity work streams are now in place to improve both manufacturing and sales efficiency.

ELAN has been losing a bigger chunk to non-operational expenses such as asset impairment, restructuring and other special charges and amortization of intangible assets, which amounted to about 20.6%, 16.4%, and 14.7% of total revenues during FY17, FY16, and FY15, respectively. ZTS incurred relatively lesser non-operational expenses during the same periods. However, the cash expense incurred by ELAN on such non-core activities can be expected to decline as ELAN completes its cost-reduction initiatives. During 1H18, ELAN incurred $12.7 million in non-core cash expense, 91% lower from the prior year period.

Eli Lilly market capitalization includes estimated market value of 80.2% stake in ELANSpin-Off Research

After the listing performance, we expect ELAN to garner valuation at par with ZTS’. The fact that ELAN’s profitability lags that of ZTS on an adjusted EBITDA basis (adjusted EBITDA margin for ELAN and ZTS stood at 17.3% and 33.1%) is a risk to sustaining that valuation.

Based on peer group median multiple of 17.8x EV/FY19e EBITDA, ELAN’s market capitalization is expected at $12.2 billion or $33.00 per share. We are downgrading our rating on ELAN to ‘Hold’.

Using sum of the parts valuation, LLY’s market capitalization is expected at $114.7 billion or $107.00 per share. We are reiterating ‘Hold’ rating on LLY.

Implied Stub Value and Embedded ValueSpin-Off Research

LLY retains 80.2% stake estimated to be about $10.0 billion. Each share of LLY corresponds to 0.27 shares of ELAN embedded, implying an embedded value of $9.31 and a stub value of $97.02.

Company Description

Eli Lilly Co. (Parent)

Eli Lilly Co. (LLY) was incorporated in 1901 in Indiana to succeed the drug manufacturing business founded in Indianapolis, Indiana, in 1876 by Colonel Eli Lilly. LLY discovers, develops, manufactures, and markets products in one business segments: human pharmaceutical products. The mission of human pharmaceutical business is to make medicines that help people live longer, healthier, more active lives. LLY’s product portfolio consists of endocrinology products, neuroscience products, oncology medicines, immunology products and cardiovascular products.

Elanco Animal Health Incorporated (Carve-Out)

Elanco Animal Health Incorporated (ELAN) is a premier animal health company that develops, manufactures and markets products for companion and food animals. Founded in 1954 as part of LLY, ELAN is Headquartered in Greenfield, Indiana. ELAN is the fourth largest animal health company in the world, with revenue of $2.9 billion for FY17. Globally, ELAN is a market leader in medicinal feed additives measured by FY17 revenue. ELAN has one of the broadest portfolios of pet parasiticides in the companion animal sector. ELAN offers a diverse portfolio of more than 125 brands, catering to veterinarians and food animal producers in over 90 countries.

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Exploring links between senses and cognitive health

“As we live longer, we know that sensory and cognitive impairments will become more prevalent,” said Heather Whitson, MD, MHS, Associate Professor of Medicine Ophthalmology at Duke University Medical Center and one of the lead researchers for the AGS-NIA conference convened in 2017. “While we know a great deal about these impairments individually, we know less about how they are related — which is surprising, since impaired hearing and vision often go hand-in-hand and are associated with an increased risk for cognitive trouble.”

One obstacle to optimizing sensory and cognitive health is our poor understanding of the two-way street connecting both.(1) For example, we know the brain relies on sensory input to understand our environment and make decisions.(1) Researchers also know that cognitive processes — such as connections in the brain that allow us to locate visual targets — guide our visual and auditory attention.(1) Yet we have a limited understanding of how these inter-related processes are affected by age-related changes in the brain, eyes, and ears.

Is the connection between sensory impairment and cognitive decline linear, with one health concern leading to the other, or is it cyclical, reflecting a more complex connection? AGS-NIA conference attendees think answers to these questions are critical, which is why their conference report maps the state of sensory and cognitive impairment research while also outlining important priorities for future scholarship and clinical practice. These include answering questions tied to the mechanics, measurement, and management of impairments:

* Identify the Mechanisms Responsible for Sensory and Cognitive Impairments (and Their Connections)(1)

** Is there a cause-and-effect relationship between cognition, vision, and hearing?

** What biological factors or characteristics of our nervous system affect both sensory and cognitive health?

* Better Equip Clinicians and Researchers to Measure Forms of Sensory and Cognitive Impairment(1)

** What standards currently exist for measuring sensory impairment and cognitive decline? How are they used among diverse populations, particularly those who might already struggle with access to health care?

** How can we develop and validate new tools and protocols to measure cognition for people who also live with vision impairments, hearing impairments, or both? Similarly, how can we better measure hearing and vision health in older people managing cognitive health concerns?

** How can we work to ensure broad measures of cognitive and sensory impairment are included in existing research studies as a way to better adapt findings to the realities of older-adult health?

* Better Prepare Older Adults and Health Professionals to Address Sensory and Cognitive Impairments(1)

** How effective, feasible, and accessible are existing options for assisting older people living with cognitive impairments, hearing impairments, and/or vision impairments?

** What innovations will be necessary to develop new resources, tools, and protocols to improve cognitive and sensory health or to accommodate those who live with these health concerns?

“The evidence we have at present indicates that impaired vision, hearing, and cognition occur more often together than would be expected by chance alone,” summarized Frank Lin, MD, PhD, Associate Professor of Otolaryngology-Head and Neck Surgery at Johns Hopkins Medicine and another lead researcher at the AGS-NIA conference. “Figuring out why — and what can be done about a potential link — represents a critical new leap for the care we all will want and need as we age.”

This research was supported by the NIA of the National Institutes of Health (NIH) under Award U13AG054139. The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH.

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Half of 2018′s Democratic campaign ads are about health care

Money talks. Despite suggestions that health care won’t be a dominant issue in the 2018 midterm elections, a new analysis reveals Democrats are spending way more money on TV ads focused on health care than on any other issue.

The Wesleyan Media Project analyzed outside groups’ spending on campaign ads over the two weeks after Labor Day — “traditionally the start of the general election campaign,” as the Wesleyan organization put it — and found Democratic groups were spending about half of their dollars on health care ads in both House and Senate races.

They reviewed 280,000 ads over that period, an increase of 33 percent from the last midterm elections in 2014. The full report is worth reading, but on the issues, health care is far and away No. 1 for Democrats.

First, in the House campaigns, where Democrats have their best chance to retake at least one chamber of Congress:

Health care, generically, is by far the biggest issue for House Democratic campaigns, with 44 percent of ads aired focused on the issue. When you add Medicare, which comes in second at 18 percent, health care is by far the biggest issue on the airwaves for the minority.

This new ad from the Democratic Congressional Campaign Committee, airing in New York’s 19th District against Rep. John Faso (R), who voted for Obamacare repeal, is typical of the Democratic message: The Republicans voted to take away people’s health care and end Obamacare’s protections for people with preexisting conditions.

Faso’s district is a toss-up, according to the Cook Political Report. Obama won it twice, then Trump won the district by 7 points in 2016. So this is the message Democrats are deploying in races they absolutely must win.

Republicans haven’t totally given up on health care in House races — it accounts for about 34 percent of their outside ads, Wesleyan found — but, as the Daily Beast’s Gideon Resnick documented last week, Republicans in key races have actually sought to erase or soften their stances on health care on their official campaign websites.

In the battle for the Senate, spending is even more lopsided. Health care doesn’t even crack the top five issues for Republicans, but it is once again easily the top issue for outside Democratic groups.

We’ve already talked about this Sen. Heidi Heitkamp ad, but it’s worth watching again. Heitkamp, a Democrat in North Dakota, which Trump won by more than 35 points, is maybe the single most vulnerable Democrat in 2018. She’s putting her eggs in the preexisting conditions basket as a breast cancer survivor herself.

Democrats have good reason to think health care is an election winner. Polls seem to come out every week that confirm 1) health care will be an important issue for voters in 2018 and 2) voters overwhelmingly trust the Democrats more than Republicans on the issue.

Two fresh surveys confirm what we’ve seen time and again:

  • A Fox News poll released Sunday found that 49 percent of Americans believe Democrats would do a better job on health care, compared to 34 percent who said Republicans would.
  • A new CBS News/YouGov poll found that 70 percent of voters in competitive House districts said health care would be very important to their vote — higher than the Supreme Court, immigration, or guns.

It can be hard to believe (at least for me) that health care can still be so salient a year after the GOP’s Obamacare repeal dreams ended. But the ad money, and the polling, tells a clear story.

This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inbox along with more health care stats and news.

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Fox News Poll: Health care boosts Democrats in upcoming midterm elections

GOP strategist Ned Ryun weighs in on 'Fox  Friends First.'Video

Can Democrats retake the House during midterms?

GOP strategist Ned Ryun weighs in on ‘Fox Friends First.’

There is a deluge of bad news for Republicans in the latest Fox News poll.

Most voters are unhappy with the direction the country is taking.  Majorities disagree with President Trump on the border wall, and extra tax-cut cash is nowhere to be seen.  And, by a wide margin, Democrats are considered the party that would better handle health care — at a time when most prioritize health care in deciding their vote for Congress. 

With only 44 days until Election Day, maybe the thing that passes for good news for the GOP is that Democrats lead by only seven points in the generic congressional ballot among likely voters.  That suggests the battle for control of the House of Representatives could still go either way.



The poll, released Sunday, shows how much Americans have warmed to Obamacare.  Four years ago, 48 percent thought the law “went too far” (September 2014).  That’s down to 36 percent today.  And a majority believes Obamacare is “about right” (21 percent) or “didn’t go far enough” (30 percent). 

Plus, 64 percent want more people insured, even if it costs the government more money. 

Republican campaigning on the new tax law will have limited appeal, as 6 voters in 10 aren’t seeing additional money in their paycheck since Trump signed the law, and only 32 percent think the law has helped the economy. 

Voters also disagree with the president on building a U.S.-Mexico border wall (more oppose by 12 points) and increasing tariffs (more say they will hurt than help the economy by 6 points).


Currently, 55 percent of voters are unhappy with how things are going in the country.  That’s a bit of a backslide from 53 percent who felt that way at Trump’s 100-day mark (April 2017). 

And while a record number are “enthusiastic” about how the government is working — that record is a whopping 7 percent.  Another 25 percent are “satisfied.”  A majority of 62 percent is “dissatisfied” (37 percent) or “angry” (25 percent) with Washington. 


Overall, when asked who they would back if the Congressional election were today, 49 percent of likely voters say the Democratic candidate in their district and 42 percent the Republican.  Among the larger group of registered voters, the Democrat is up by 46-40 percent. 

“Usually we see Republicans do better when we go from registered voters to likely voters,” says Democratic pollster Chris Anderson, who conducts the poll with Republican Daron Shaw.  “That isn’t the case right now, Democrats actually have a larger advantage when we look just at likely voters.” 


The gender gap remains, as women are more inclined to back the Democratic candidate by a 17-point margin, while men pick the Republican candidate by 4 points.

Rural whites back the Republican by 22 points, while suburban women back the Democrat by 23.  Voters “angry” about how the government is working are four times more likely to support the Democratic candidate.

Voters who backed Hillary Clinton in the 2016 presidential election are more likely than Trump voters to be more enthusiastic about voting this year compared to past midterms (by 9 points) and more likely to be extremely interested in the election (by 11 points).

Yet that doesn’t tell the whole story.  When looking only at counties where the 2016 presidential vote was close (Clinton and Trump within 10 points), Democrats have a 17-point lead in the ballot test.  That’s almost as strong as in Clinton counties, where they are up by 19 points.

Republicans are seen as better on border security (+11 points) and the economy (+4), and hold the slightest edge on taxes (+1) and international trade (+1). 

Voters believe Democrats can better handle the issues of health care (+15 points), bringing the country together (+12), immigration (+5), and corruption (+5). 

Health care stands out, as it is the only issue that has a majority, 55 percent, saying it will be extremely important to them to vote for a congressional candidate who shares their views.  That’s followed by taxes (47 percent “extremely important”), immigration (46 percent), President Trump (46 percent), the border wall (39 percent), Brett Kavanaugh’s Supreme Court nomination (38 percent), and the Russia investigation (34 percent).

Campaign appearances from the president may not help Republicans, as 26 percent say they would be more likely to support a candidate if Trump campaigns for them, but 43 percent would be less likely to do so.  That’s a spread of negative 17 points. Vice President Mike Pence does just a bit better than his boss, at negative 13.

For former presidential candidate Vermont Sen. Bernie Sanders, the effect is neutral: 31 percent would be more likely to vote for a candidate he backs and 31 percent less likely.


Former President Barack Obama receives a positive response (+11 points):  42 percent more likely vs. 31 percent less likely. 


More broadly, 44 percent of voters approve of Trump’s performance, while 52 percent disapprove.  Last month it was 45-53 percent, and in July it was 46-51 percent. 

By 50-42 percent, voters approve of Trump’s handling of the economy.  Majorities disapprove on immigration (41-54 percent) and health care (38-52 percent). 

The poll finds only 35 percent of voters think Trump “cares about people” like them, and the same number, 35 percent, sees the disruption he’s brought to Washington as a good thing. 

Russia Investigation


Voters approve of the job Special Counsel Robert Mueller is doing (55-39 percent) and want him to take his time and do it right (52 percent).  Thirty-six percent say “wrap it up already.” 


Opposition to impeaching the president has narrowed.  Voters oppose rather than support impeachment by a 5-point margin (42 percent yes vs. 47 percent no).  In June, opposition outweighed support by 12 points. 

Among voters backing Democratic congressional candidates, 72 percent say President Trump should be impeached and removed from office.  For voters supporting the GOP candidate, an even larger 84 percent oppose impeachment.


Fifty-six percent feel like things in the country are rigged to favor the wealthy.  That’s far more than the 39 percent who think they have a fair shot at getting ahead if they work hard.  Trump voters think hard workers can get ahead, while Clinton voters say the system is rigged.

How deep is the political divide?  Just 18 percent of Republicans say Democrats love America, and only 11 percent of Democrats think Republicans do. 

On Wednesday, Trump visited areas affected by Hurricane Florence in the Carolinas.  Days earlier he denied reports about the death toll in Puerto Rico from Hurricane Maria (2017).  By a four-point margin, voters give the administration a net positive rating for its response to Florence.  The ratings it received last year for Puerto Rico were more negative than positive by 32 points. 

The Fox News poll is based on landline and cell phone interviews with 1,003 randomly chosen registered voters nationwide and was conducted under the joint direction of Anderson Robbins Research (D) and Shaw Company Research (R) from September 16-19, 2018. The full poll has a margin of sampling error of plus or minus three percentage points.  For the subgroup of 818 likely voters, the margin of sampling error is also plus or minus three points. 


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This fall, all New York students will be learning about mental health

Elementary, middle and high school students across the state of New York have a new topic on their educational agendas as they head back to class this fall: mental health.

On July 1, a new law took effect in New York, which adds a paragraph to the state’s Education Law mandating mental health as part of health education in schools. New York is the first state in the U.S. to require mental health to be taught as part of health education.

Mental health experts say it’s a big deal.

The stigma associated with mental illness and treatment for mental illness still exists, and is still a significant barrier standing in the way of more people seeking treatment for problems they face, Meredith Coles, PhD, professor of psychology at Binghamton University of the State University of New York, told NBC News BETTER. “It’s time to recognize that mental illnesses are real and treatable.”

Estimates from the National Institutes of Mental Health show that among U.S. adults 19.1 percent have had an anxiety disorder within the past year; 31.1 percent will experience an anxiety disorder at some point in their lives; and 6.7 percent are estimated to have had at least one major depressive episode.

The numbers among children are similarly if not more jarring. Data published in the Journal of the American Academy of Child and Adolescent Psychiatry from a nationally representative sample of 10,123 adolescents ages 13 to 18 found that 22.2 percent had a serious mental illness.

The intention is to give students the knowledge they need to recognize in themselves and others when they need help.

Other data estimate 50 percent of mental illness begins by age 14, and 75 percent begins by age 24.

And people aren’t getting help: The 2016 National Survey on Drug Use and Health showed that more than 11 million Americans do not receive needed mental health services.

“We need to change attitudes around mental health,” says Coles, whose work focuses on anxiety disorders in both children and adults. “Starting to educate children in schools makes sense.”

Decreasing stigma, changing attitudes and giving students practical knowledge they can use when it comes to mental health problems they or others face is why New York passed this legislation, New York’s State Education Commissioner, MaryEllen Elia, tells NBC News BETTER.

“When young people learn about mental health and that it is an important aspect of overall health and well-being, the likelihood increases they will be able to effectively recognize signs and symptoms in themselves and others and will know where to turn for help — and it will decrease the stigma that attaches to help-seeking,” she says in an email. “It is critical that we teach young people about mental health.”

It’s NOT about teaching psych 101. Students will learn skills they can use.

The law gives the latitude to individual districts, schools and classrooms to decide, as long as they meet some broad parameters, how to design curricula and lesson plans that cover mental health (as is the case for all subjects — including alcohol, drug and tobacco abuse and the prevention and detection of certain cancers, the only two other topics included in the education law that are required to be taught as part of health education in the state of New York).

But New York schools aren’t exactly being left on their own to figure out how to add mental health education to their teaching agendas.

After the changes to the law were passed in 2016, the New York State Education Department, along with the New York State Office of Mental Health and the Mental Health Association of New York State, Inc. (MHANYS), established the New York State Mental Health Education Advisory Council in August 2017 to provide guidance to schools on how to add mental health to the curricula.

The group published guidelines that include nine core elements they recommend be part of mental health education in all schools. Some of those core elements in the Advisory Council’s guidelines include (among others):

  • The concept that mental health is part of wellness, and we all have a personal responsibility to practice the self-care we need to maintain our mental health
  • How to identify early signs of mental health problems, as well as mental health crises
  • Negative stigma and attitudes toward mental illness can contribute to discrimination against people with such conditions and cause people to avoid getting help
  • Appropriate resources to turn to for help and support if you or someone you know is facing a mental health problem

The group has also created an online resource center — including teacher trainings, lesson plans and other tools to help schools comply with the new law — which are all available for free for all New York State schools.

The intention is to give students the knowledge they need to recognize in themselves and others when they need help, and also make sure they know where to go to get help, explains John Richter, Director of Public Policy for MHANYS and author of the white paper that outlines the guidelines.

The new requirement isn’t about teaching kids an introductory psychology course, he says. “It’s meant to be a public health approach to mental health education.”

The approach is based on principles similar to those used in mental health training programs for adults such as “Mental Health First Aid,” which are designed to increase mental health literacy by increasing knowledge in how to prevent mental health problems, recognize early signs of mental health problems, and get help (as well as where to get it). Evidence suggest this approach works, according to a systematic review and meta-analysis published in May in the journal PLoS One.

But, what does it look like when you teach it to first-graders in New York City or 10th-graders in Albany?

Elementary school students might learn about how to describe their feelings and some skills to manage their feelings, Richter says: What does it mean to be sad? What does anger look like? What does it mean to be happy? If you are angry, what are some ways you can talk about that? What can you do to feel less angry?

Older students might learn how to distinguish more specifically between times in your life when sadness is part of a healthy range of moods and emotions in everyday life (such as when you lose a family member or friend) versus when it’s a symptom or problem to be concerned about (if you’re withdrawing from your friends or losing interest in hobbies and activities you typically enjoy).

The goal is to change the way educators, students and, ultimately, everyone talks about mental health, Richter says. “We want people to get the message that your mental health is just as important as your physical health.”

Teaching mental health young has the possibility to change a lot in New York — and elsewhere.

Other mental health experts agree this approach has the capacity to do a lot of good.

“It’s really important for kids at all ages to have some understanding of what a mental health concern is so that it can be normalized,” Louis Kraus, MD, chief of child and adolescent psychology at Rush University Medical Center in Chicago, tells NBC.

Kids (and everyone, for that matter) should be able to recognize signs and symptoms of mental health problems, just like they know when someone else has asthma, allergies or another medical concern, Kraus says.

“Mental and physical health are not necessarily separate concepts and the two depend on each other for total health,” says Linda Chokroverty, MD, an attending physician and assistant clinical professor of pediatrics and psychiatry at Montefiore Health System and Albert Einstein College of Medicine in New York City.

“Knowing what traits and behaviors make young people more resilient in facing mental health challenges is important,” she tells NBC News BETTER. And teaching kids accurate and age-appropriate lessons about mental health in schools (under the guidance of knowledgeable adults) is usually a better option than allowing kids to learn about it from TV shows, movies, social media and elsewhere that may or may not provide kids with the tools they need, she says.

While New York is the first state to mandate mental health education in elementary school through high school curricula, it is certainly not the only state paying attention to the issue. Virginia passed legislation that also becomes effective this school year requiring schools to teach mental health lessons to ninth- and 10th-grade students.

Richter says other states have been in touch with MHANYS about how to implement similar legislation.

Kraus adds that many schools across the country do already teach some mental health education even though it’s not mandated to be part of the curriculum — but certainly not all schools. And similar efforts to require it should be made elsewhere, he says. “It could have a huge positive impact.”


Want more tips like these? NBC News BETTER is obsessed with finding easier, healthier and smarter ways to live. Sign up for our newsletter and follow us on Facebook, Twitter and Instagram.

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India’s Modi launches ‘world’s largest’ health insurance scheme

The Indian government has launched one of the world’s largest publicly funded health insurance scheme, set to cover some 500 million poor people.

The Ayushman Bharat programme, dubbed “Modicare” after Prime Minister Narendra Modi promised health cover worth 500,000 rupees ($6,900) to every poor family to treat serious ailments.

At the occasion of its official rollout in Ranchi, capital of the eastern state of Jharkhand, on Sunday, Modi claimed that a government scheme at “such a grand scale is not being carried out anywhere in the world”.

The prime minister said the scheme will transform India into a medical hub in the future and called it “a big step towards providing good quality and accessible healthcare to the poor of India.

“Over 100 million families will benefit,” Modi said.

The programme, which was first announced as part of the yearly budget in February, is expected to cost the central and 29 state governments $1.6bn a year in total.

Expenditures will be shared by the central and state governments at a 60 to 40 ratio in most states and funding will be increased gradually according to the demand.

On Sunday, Modi handed medical cards out at the launch in Ranchi, calling it a “historic day” for the country. 

The government is aiming is set up 50,000 wellness centres across the country over the next four years, he said. 

“The scheme will not have any distinguished plans on the basis of sect or caste. There will be no discrimination based on any race or any fraternity,” said Modi.

India spends just 1.5 percent of its gross domestic product (GDP) on healthcare compared to a global average of six percent.

The country’s overburdened public health system is plagued by a shortage of hospitals and doctors and most people use private clinics and hospitals if they can afford to.

But a private consultation can cost 1,000 rupees ($15), a huge sum for millions living on less than two dollars a day.

More than 60 percent of the average family’s spending goes on medicines and healthcare, the government estimates.

“There has been a lot of concern regarding the human resources, but I think within 10 to 15 years, our health sector would become a world class health sector,” Ilias Ali, a doctor based in the northeastern city of Guwahati, told Al Jazeera.

Experts have praised the latest programme but say it should have included primary day-to-day healthcare instead of just secondary and tertiary care for more serious and long-term treatment.

“Modicare does not extend to primary healthcare, which, we believe, is the weakest link in the provision of public health in India,” Rajiv Lall and Vivek Dehejia of the IDFC Institute think-tank said in a column for the Mint newspaper.

“The crucial point is that poorly delivered primary care inevitably increases the burden on health and finance at the secondary and tertiary levels down the line,” they said.

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India launches ‘Modicare,’ the world’s biggest government health …

Indian Prime Minister Narendra Modi is making a new health-care program a key plank of his platform for elections next year. (Sony Mehta/Hindustan Times/Getty Images)
Vidhi Doshi September 22 at 6:00 AM

Personalized letters from Prime Minister Narendra Modi, announcements from door-knocking health-care workers and lists pinned up at village council offices trumpet the news: India’s vast new health program has arrived.  

Starting Sunday, half a billion Indian citizens will be covered under an initiative that local media have dubbed “Modicare.” Although nobody seems to be sure whether it will work or how much it will cost, the government has touted it as the world’s biggest government-funded health scheme.

“Indian healthcare is poised for a great leap forward with Ayushman Bharat — which will insure over 50 crore [500 million] citizens,” tweeted Health Minister Jagat Prakash Nadda, referring to the program by its official name, meaning “Long Life India.”

Decades of explosive economic growth have brought new wealth to India, but the neediest of its people still lack basic services. The health-care plan, targeted at the country’s poorest 40 percent, will be a key plank of Modi’s campaign platform in national elections next year. 

Experts say the political momentum behind the program is unprecedented and promising. The British medical journal Lancet published an editorial praising its ambitious scope: “Setting up such a program has undoubtedly required heroic efforts,” it said.

There are fears, however, that new demand created by Modicare could place even greater strain on India’s already stretched health infrastructure. 

The program gives poor families insurance of up to $6,950 in hospitals, a significant sum in India. For primary care — basic services usually provided by general practitioners or nurses — the government plans to open 150,000 “health and wellness” centers, staffed by nurses, traditional medicine healers and other health workers, by 2020.

The plan leans heavily on partnerships with private hospitals and will promote traditional ideas of holistic health care, such as incorporating yoga into daily routines. 

“It’s a very, very Indian program,” said Vinod K. Paul, a pediatrician turned government official and the program’s creator. He declined to say whether any aspect of it was modeled on health-care systems elsewhere.

Paul said that most of the plan represents uncharted territory for the Indian government and that Modi had essentially signed a blank check to make it work. The final budget, he said, is difficult to pin down because nothing like this has been attempted before. The government has allocated $4.8 billion for now, but the treasury has committed to providing more on request, he said.  

Reforming health care in India is a mammoth task. According to a 2010 study, more than 63 million Indians fall under the poverty line every year because of health costs. In most states, government-funded hospitals are understaffed and ill-equipped, so many people end up paying for expensive private care. 

On a recent afternoon last month at Safdarjung Hospital, a government facility in New Delhi, dozens of people were camped outside, bedding down on mattresses and plastic sheets for days while they or family members were treated inside. 

At Safdarjung, beds are in short supply, doctors work long shifts, and patients cry as surgery dates are delayed. 

“We have been sleeping here for the past eight days,” said Mamata Devi, a young mother who had traveled more than 24 hours by train to get to the hospital after her 6-year-old daughter accidentally drank cleaning liquid. The child had been treated but needed follow-up care.

“When it rains, we sleep there,” Devi said, pointing to a small roof at a side entrance to the hospital. 

People wait for treatment for themselves or their relatives outside the government-run Safdarjung Hospital in New Delhi. (Vidhi Doshi/The Washington Post)

Mamata Devi said she traveled more than 24 hours by train to get to the hospital after her 6-year-old daughter accidentally drank cleaning liquid. (Vidhi Doshi/The Washington Post)

Devi spent about $60 on travel from her village. Food costs her an additional $3 a day. Her husband makes about $4 a day selling utensils. “We will spend the next year or two paying back the loan,” she said.

Under the new program, Devi’s daughter might have been eligible for free treatment at a private hospital closer to home. 

Moreover, government hospitals like this one stand to receive additional payments for every Modicare patient they treat, meaning that they might be able to upgrade their facilities. 

Paul, the government official, said the health plan is focused on reducing “catastrophic spending” — when families have to spend more than a quarter of their incomes on health costs. In poor families, he added, that usually happens when a patient is hospitalized.

“If a rickshaw driver’s wife gets cancer, he has no choice but to sell his rickshaw,” he said. 

Some experts say the program focuses too heavily on hospitalization and neglects primary health care — the basic general-practitioner services that many argue are the bedrock of a robust health-care system. 

Paul disputed that, saying that the government has a “profound commitment” to primary care. Nurses and practitioners of traditional Indian medicine will take “bridge courses” to enable them to provide services that include diagnosing some cancers and tuberculosis. When diagnoses are complicated, health-care workers can video-call a doctor for advice. Government-backed awareness drives and “people movements” on health issues such as nutrition will be added to existing services. 

It’s not an ideal situation, Paul conceded, but he predicted that new demand would create growth. “Everybody knows we have to build our health-care sector,” he said, adding that the need to care for India’s poor is urgent. “We can’t wait for the perfect moment.”

There are other potential hiccups. The government will pay public and private hospitals fixed rates for treating people covered under the program. So far, 15,000 hospitals — a mix of government and private — have applied for government certification, Paul said. 

But the government’s rates are much lower than the prices that private citizens pay, experts said, and there is a shortage of applications from hospitals that can provide complex surgeries.

“Private hospitals are not happy but have accepted because the government has convinced them to help them with the launch, and then revise rates next year,” said Srinath Reddy, an adjunct professor at Harvard University and president of the Public Health Foundation of India. 

Paul said this is only a first step toward extending affordable care to the country’s entire population, now estimated at more than 1.3 billion. “These are difficult things that India’s trying to do,” he said. “But we want every poor person to be able to get treated. Isn’t that your dream?”

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