NHS patients dying in hospital corridors, A&E doctors tell Theresa May

Doctors running 68 A&E departments tell PM patients are dying prematurely because staff are too busy to treat them

Patients are dying in hospital corridors during the ongoing winter crisis because the NHS is so underfunded and short-staffed that it cannot cope, senior doctors have warned Theresa May.

A&E units are under such intense strain that patients are at intolerable risk of being harmed by receiving poor care, specialists in emergency medicine from 68 hospitals have told the prime minister in a letter of unprecedented alarm.

In recent weeks some hospitals have become so overloaded that they have been looking after as many as 120 patients a day in corridors, with some dying prematurely as a result, the letter says.

The doctors, consultants who work in or run A&E units in England and Wales, have written to May to highlight the very serious concerns we have for the safety of our patients. This current level of safety compromise is at times intolerable, despite the best efforts of staff.

Conditions in many A&E units are so appalling that they could kill patients, claim the signatories, who work at both major teaching hospitals and smaller district general hospitals. They include Frimley health trust in Surrey, which May visited last week in an attempt to reassure the public that the NHS was coping well this winter.

As you will know a number of scientific publications have shown that crowded emergency departments are dangerous for patients. The longer that the patients stay in [the] emergency department after their treatment has been completed, the greater is their morbidity and associated morbidity, they write.

Their intervention came as new NHS figures showed that the percentage of patients being treated within four hours at hospital-based A&E units in England fell last month to its lowest-ever level 77.3%. The performance of all types of settings offering A&E-type care taken together, including walk-in centres and urgent care centres, was better but still the joint worst ever at 85.1% far below the politically important target of 95%.

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Only three of the NHSs 137 acute trusts hit the 95% target, while 32 were at or below 70%. Blackpool teaching hospitals trust had by far the lowest performance, at 40.1%. The figures reinforced the warning to ministers on Thursday from NHS Providers that it would be impossible to deliver on their pledge that all hospitals would be achieving 95% by March.

Our emergency departments are not just under pressure, but in a state of emergency, said Dr Taj Hassan, the president of the Royal College of Emergency Medicine, which represents A&E doctors.

The NHS undertook unprecedented planning to help services cope with the annual spike in demand in December and January. Despite that, hospitals had a record number of emergency admissions last month 520,163, a 4.5% rise on the numbers admitted in December 2016.

A drive to free up 2,000-3,000 beds by 1 September, to avoid hospitals becoming dangerously full, appears to have failed. Separate NHS figures for last week show that 19 trusts were on 99% or 100% bed occupancy between 1 and 7 January. Three were completely full.

Average bed occupancy shot up last week to 95%, far higher than the 85% that experts say, and the NHS accepts, hospitals need to maintain in order to stop patients getting hospital-acquired infections such as MRSA or Clostridium difficile, or experiencing poor care.

Bed occupancy as high as 95% is a danger to patient safety, with around 7,000 fewer beds open than in the same period last year, said Hassan.

Drawing on their own experiences in recent weeks ,the doctors who signed the letter painted a stark picture of conditions inside A&E units. Common situations include over 50 patients at a time waiting beds in the emergency department [and] patients sleeping in clinics as makeshift wards.

A Department of Health and Social Care spokeswoman said in response to the letter: There has been a 68.7% increase in the number of A&E consultants since 2010, and the NHS was given top priority in the recent budget with an extra 2.8bn allocated over the next two years.

But we know there is a great deal of pressure in A&E departments, and we are grateful to all NHS staff for their incredible work in challenging circumstances. Thats why we recently announced the largest single increase in doctor training places in the history of the NHS a 25% expansion.

May stressed on Thursday that flu was a key factor in the intense strain that NHS services were facing. We have seen the extra pressures that the NHS has come under this year. One of the issues that determines the extent of that pressure is flu and we have seen in recent days an increase in the number of people presenting at A&E from flu, she said.

Q&A

Why is the NHS winter crisis so bad in 2017-18?

A combination of factors are at play. Hospitals have fewer beds than last year, so they are less able to deal with the recent, ongoing surge in illness. Last week, for example, the bed occupancy rate at 17 of Englands 153 acute hospital trusts was 98% or more, with the fullest Walsall healthcare trust 99.9% occupied.

NHS England admits that the service has been under sustained pressure [recently because of] high levels of respiratory illness, bed occupancy levels giving limited capacity to deal with demand surges, early indications of increasing flu prevalence and some reports suggesting a rise in the severity of illness among patients arriving at A&Es.

Many NHS bosses and senior doctors say that the pressure the NHS is under now is the heaviest it has ever been. We are seeing conditions that people have not experienced in their working lives, says Dr Taj Hassan, the president of the Royal College of Emergency Medicine.

The unprecedented nature of the measures that NHS bosses have told hospitals to take including cancelling tens of thousands of operations and outpatient appointments until at least the end of January underlines the seriousness of the situation facing NHS services, including ambulance crews and GP surgeries.

Read a full Q&A on the NHS winter crisis

Hours after she spoke, new figures from Public Health England confirmed that flu was putting a sharply increased burden on GP surgeries as well as hospitals.

Last week 758 peple around the UK were hospialised because of flu, up from 421 the week before. Of those, 240 were so sick they had to be admitted to an intensive care or a high dependency unit, up from 114. The number of people consulting a GP with flu-like symptoms almost doubled.

A further 27 people died of flu-related symptoms last week, three more than the week before, taking the toll of deaths this winter to 85.

Read more: https://www.theguardian.com/society/2018/jan/11/nhs-patients-dying-in-hospital-corridors-doctors-tell-theresa-may

Dont listen to Gwyneth Paltrow: keep your coffee well away from your rectum | Jen Gunter

The colonic irrigation and coffee enemas promoted on Paltrows website Goop are not merely unnecessary, they are potentially dangerous, writes obstetrician and gynaecologist Dr Jen Gunter

It seems January is Gwyneth Paltrows go-to month for promoting potentially dangerous things that should not go in or near an orifice. January 2015 brought us vagina steaming, January 2017 was jade eggs, and here we are in the early days of January 2018 and Goop.com is hawking coffee enemas and promoting colonic irrigation.

I suspect that GP and her pals at Goop.com believe people are especially vulnerable to buying quasi-medical items in the New Year as they have just released their latest detox and wellness guide complete with a multitude of products to help get you nowhere.

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Ha ha, go deep. Nice play on words for a dangerous yet ineffective therapy. An advertisement on Goop.com.

One offers to help if youre looking to go deep on many levels. Ha ha, go deep. Nice play on words for a dangerous yet ineffective therapy. Goop.com is not selling a coffee machine, it is selling a coffee enema-making machine. That, my friends, is a messed-up way to make money. I know the people at Goop will either ignore the inquiries from reporters or release a statement saying the article is a conversation not a promotion and that they included the advice of a board-certified doctor, Dr Alejandro Junger, but any time you lend someone else your platform their ideas are now your ideas. That is why I never let anyone write guest posts for my blog. And lets be real, if you are selling the hardware to shoot coffee up your ass then you are promoting it as a therapy especially as Goop actually called the $135 coffee enema-making machine Dr Jungers pick. I mean come on.

The interview with Junger is filled with information that is unsupported both by the medical literature and by human anatomy and physiology. There is no data to suggest that a colonic helps with the elimination of the waste that is transiting the colon on its way out. That is what bowel movements do. There are no toxins to be cleansed or irrigated. That is fake medicine. A 2011 review on colonics concluded that doctors should advise patients that colon cleansing has no proven benefits and many adverse effects.

The idea that colonics are used in conjunction with a cleanse is beyond ridiculous. Junger tells us via Goop that a cleanse creates some kind of extra sticky mucus that blocks elimination of what needs to be disposed of (I will admit that hurt my brain more than a little). Dr Junger says this cleanse residue is a mucoid plaque, basically some kind of adherent, cleanse-induced super-glue that needs a colonic for removal. He supports this assertion not with published research, but by telling Goops readers to Google mucoid plaque.

No really. That is what he said. Google it. So I did. This is what came up first:

Mucoid plaque (or mucoid cap or rope) is a pseudoscientific term used by some alternative medicine advocates to describe what is claimed to be a combination of allegedly harmful mucus-like material and food residue that they say coats the gastrointestinal tract of most people.

Apparently, the term mucoid plaque was coined by Richard Anderson, who is a naturopath, not a gastroenterologist, so not a doctor who actually looks inside the colon. I looked mucoid plaques up in PubMed. Guess what? Nothing colon-related. There is not one study or even case-report describing this phenomenon. Apparently only doctors who sell cleanses and colonics can see them. I am fairly confident that if some gastroenterologist (actual colon doctor) found some crazy mucus that looked like drool from the alien queen that she or he would have taken pictures and written about it or discussed it at a conference.

If we needed cleanses to live and thus colonics to manage this alien-like mucous residue created by cleanses, how did we ever evolve? Wouldnt we have died out from these mysterious toxins? Wouldnt our rectums be different? Wouldnt we have invented irrigation tubing before the wheel? So many questions.

There is only a side mention in the Goop post of two of the many complications seen with colonics: colon perforation and damage to gastrointestinal bacteria. And as for coffee enemas? While Dr Kelly Brogan, Paltrows Aids-denialist doctor gal pal who is speaking at In Goop Health later this month, is also a huge fan, there is no data to suggest that coffee offers any benefit via the rectal route but there are plenty of reports of coffee enema-induced rectal burns.

So here are the facts. No one needs a cleanse. Ever. There are no waste products left behind in the colon that need removing just because or after a cleanse. If a cleanse did leave gross, adherent hunks of weird mucus then that would be a sign that the cleanse was damaging the colon. You know what creates excess, weird mucous? Irritation and inflammation.

There are serious risks to colonics such as bowel perforation, damaging the intestinal bacteria, abdominal pain, vomiting, electrolyte abnormalities and renal failure. There are also reports of serious infections, air embolisms, colitis, and rectal perforation. If you go to a spa and the equipment is not sterilised, infections can be transmitted via the tubing.

Coffee enemas and colonics offer no health benefit. The biology used to support these therapies is unsound and there can be very real complications. Keep the coffee out of your rectum and in your cup. It is only meant to access your colon from the top.

Dr Jen Gunter is an obstetrician, gynaecologist and pain medicine physician. This piece originally ran on Jen Gunters blog

Read more: https://www.theguardian.com/commentisfree/2018/jan/09/gwyneth-paltrow-goop-coffee-enema-colonic-irrigation

Is everything you think you know about depression wrong?

In this extract from his new book, Johann Hari, who took antidepressants for 14 years, calls for a new approach

In the 1970s, a truth was accidentally discovered about depression one that was quickly swept aside, because its implications were too inconvenient, and too explosive. American psychiatrists had produced a book that would lay out, in detail, all the symptoms of different mental illnesses, so they could be identified and treated in the same way across the United States. It was called the Diagnostic and Statistical Manual. In the latest edition, they laid out nine symptoms that a patient has to show to be diagnosed with depression like, for example, decreased interest in pleasure or persistent low mood. For a doctor to conclude you were depressed, you had to show five of these symptoms over several weeks.

The manual was sent out to doctors across the US and they began to use it to diagnose people. However, after a while they came back to the authors and pointed out something that was bothering them. If they followed this guide, they had to diagnose every grieving person who came to them as depressed and start giving them medical treatment. If you lose someone, it turns out that these symptoms will come to you automatically. So, the doctors wanted to know, are we supposed to start drugging all the bereaved people in America?

The authors conferred, and they decided that there would be a special clause added to the list of symptoms of depression. None of this applies, they said, if you have lost somebody you love in the past year. In that situation, all these symptoms are natural, and not a disorder. It was called the grief exception, and it seemed to resolve the problem.

Then, as the years and decades passed, doctors on the frontline started to come back with another question. All over the world, they were being encouraged to tell patients that depression is, in fact, just the result of a spontaneous chemical imbalance in your brain it is produced by low serotonin, or a natural lack of some other chemical. Its not caused by your life its caused by your broken brain. Some of the doctors began to ask how this fitted with the grief exception. If you agree that the symptoms of depression are a logical and understandable response to one set of life circumstances losing a loved one might they not be an understandable response to other situations? What about if you lose your job? What if you are stuck in a job that you hate for the next 40 years? What about if you are alone and friendless?

The grief exception seemed to have blasted a hole in the claim that the causes of depression are sealed away in your skull. It suggested that there are causes out here, in the world, and they needed to be investigated and solved there. This was a debate that mainstream psychiatry (with some exceptions) did not want to have. So, they responded in a simple way by whittling away the grief exception. With each new edition of the manual they reduced the period of grief that you were allowed before being labelled mentally ill down to a few months and then, finally, to nothing at all. Now, if your baby dies at 10am, your doctor can diagnose you with a mental illness at 10.01am and start drugging you straight away.

Dr Joanne Cacciatore, of Arizona State University, became a leading expert on the grief exception after her own baby, Cheyenne, died during childbirth. She had seen many grieving people being told that they were mentally ill for showing distress. She told me this debate reveals a key problem with how we talk about depression, anxiety and other forms of suffering: we dont, she said, consider context. We act like human distress can be assessed solely on a checklist that can be separated out from our lives, and labelled as brain diseases. If we started to take peoples actual lives into account when we treat depression and anxiety, Joanne explained, it would require an entire system overhaul. She told me that when you have a person with extreme human distress, [we need to] stop treating the symptoms. The symptoms are a messenger of a deeper problem. Lets get to the deeper problem.

*****

I was a teenager when I swallowed my first antidepressant. I was standing in the weak English sunshine, outside a pharmacy in a shopping centre in London. The tablet was white and small, and as I swallowed, it felt like a chemical kiss. That morning I had gone to see my doctor and I had told him crouched, embarrassed that pain was leaking out of me uncontrollably, like a bad smell, and I had felt this way for several years. In reply, he told me a story. There is a chemical called serotonin that makes people feel good, he said, and some people are naturally lacking it in their brains. You are clearly one of those people. There are now, thankfully, new drugs that will restore your serotonin level to that of a normal person. Take them, and you will be well. At last, I understood what had been happening to me, and why.

However, a few months into my drugging, something odd happened. The pain started to seep through again. Before long, I felt as bad as I had at the start. I went back to my doctor, and he told me that I was clearly on too low a dose. And so, 20 milligrams became 30 milligrams; the white pill became blue. I felt better for several months. And then the pain came back through once more. My dose kept being jacked up, until I was on 80mg, where it stayed for many years, with only a few short breaks. And still the pain broke back through.

I started to research my book, Lost Connections: Uncovering The Real Causes of Depression and the Unexpected Solutions, because I was puzzled by two mysteries. Why was I still depressed when I was doing everything I had been told to do? I had identified the low serotonin in my brain, and I was boosting my serotonin levels yet I still felt awful. But there was a deeper mystery still. Why were so many other people across the western world feeling like me? Around one in five US adults are taking at least one drug for a psychiatric problem. In Britain, antidepressant prescriptions have doubled in a decade, to the point where now one in 11 of us drug ourselves to deal with these feelings. What has been causing depression and its twin, anxiety, to spiral in this way? I began to ask myself: could it really be that in our separate heads, all of us had brain chemistries that were spontaneously malfunctioning at the same time?

To find the answers, I ended up going on a 40,000-mile journey across the world and back. I talked to the leading social scientists investigating these questions, and to people who have been overcoming depression in unexpected ways from an Amish village in Indiana, to a Brazilian city that banned advertising and a laboratory in Baltimore conducting a startling wave of experiments. From these people, I learned the best scientific evidence about what really causes depression and anxiety. They taught me that it is not what we have been told it is up to now. I found there is evidence that seven specific factors in the way we are living today are causing depression and anxiety to rise alongside two real biological factors (such as your genes) that can combine with these forces to make it worse.

Once I learned this, I was able to see that a very different set of solutions to my depression and to our depression had been waiting for me all along.

To understand this different way of thinking, though, I had to first investigate the old story, the one that had given me so much relief at first. Professor Irving Kirsch at Harvard University is the Sherlock Holmes of chemical antidepressants the man who has scrutinised the evidence about giving drugs to depressed and anxious people most closely in the world. In the 1990s, he prescribed chemical antidepressants to his patients with confidence. He knew the published scientific evidence, and it was clear: it showed that 70% of people who took them got significantly better. He began to investigate this further, and put in a freedom of information request to get the data that the drug companies had been privately gathering into these drugs. He was confident that he would find all sorts of other positive effects but then he bumped into something peculiar.

Illustration
Illustration by Michael Driver.

We all know that when you take selfies, you take 30 pictures, throw away the 29 where you look bleary-eyed or double-chinned, and pick out the best one to be your Tinder profile picture. It turned out that the drug companies who fund almost all the research into these drugs were taking this approach to studying chemical antidepressants. They would fund huge numbers of studies, throw away all the ones that suggested the drugs had very limited effects, and then only release the ones that showed success. To give one example: in one trial, the drug was given to 245 patients, but the drug company published the results for only 27 of them. Those 27 patients happened to be the ones the drug seemed to work for. Suddenly, Professor Kirsch realised that the 70% figure couldnt be right.

It turns out that between 65 and 80% of people on antidepressants are depressed again within a year. I had thought that I was freakish for remaining depressed while on these drugs. In fact, Kirsch explained to me in Massachusetts, I was totally typical. These drugs are having a positive effect for some people but they clearly cant be the main solution for the majority of us, because were still depressed even when we take them. At the moment, we offer depressed people a menu with only one option on it. I certainly dont want to take anything off the menu but I realised, as I spent time with him, that we would have to expand the menu.

This led Professor Kirsch to ask a more basic question, one he was surprised to be asking. How do we know depression is even caused by low serotonin at all? When he began to dig, it turned out that the evidence was strikingly shaky. Professor Andrew Scull of Princeton, writing in the Lancet, explained that attributing depression to spontaneously low serotonin is deeply misleading and unscientific. Dr David Healy told me: There was never any basis for it, ever. It was just marketing copy.

I didnt want to hear this. Once you settle into a story about your pain, you are extremely reluctant to challenge it. It was like a leash I had put on my distress to keep it under some control. I feared that if I messed with the story I had lived with for so long, the pain would run wild, like an unchained animal. Yet the scientific evidence was showing me something clear, and I couldnt ignore it.

*****

So, what is really going on? When I interviewed social scientists all over the world from So Paulo to Sydney, from Los Angeles to London I started to see an unexpected picture emerge. We all know that every human being has basic physical needs: for food, for water, for shelter, for clean air. It turns out that, in the same way, all humans have certain basic psychological needs. We need to feel we belong. We need to feel valued. We need to feel were good at something. We need to feel we have a secure future. And there is growing evidence that our culture isnt meeting those psychological needs for many perhaps most people. I kept learning that, in very different ways, we have become disconnected from things we really need, and this deep disconnection is driving this epidemic of depression and anxiety all around us.

Lets look at one of those causes, and one of the solutions we can begin to see if we understand it differently. There is strong evidence that human beings need to feel their lives are meaningful that they are doing something with purpose that makes a difference. Its a natural psychological need. But between 2011 and 2012, the polling company Gallup conducted the most detailed study ever carried out of how people feel about the thing we spend most of our waking lives doing our paid work. They found that 13% of people say they are engaged in their work they find it meaningful and look forward to it. Some 63% say they are not engaged, which is defined as sleepwalking through their workday. And 24% are actively disengaged: they hate it.

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Antidepressant prescriptions have doubled over the last decade. Photograph: Anthony Devlin/PA

Most of the depressed and anxious people I know, I realised, are in the 87% who dont like their work. I started to dig around to see if there is any evidence that this might be related to depression. It turned out that a breakthrough had been made in answering this question in the 1970s, by an Australian scientist called Michael Marmot. He wanted to investigate what causes stress in the workplace and believed hed found the perfect lab in which to discover the answer: the British civil service, based in Whitehall. This small army of bureaucrats was divided into 19 different layers, from the permanent secretary at the top, down to the typists. What he wanted to know, at first, was: whos more likely to have a stress-related heart attack the big boss at the top, or somebody below him?

Everybody told him: youre wasting your time. Obviously, the boss is going to be more stressed because hes got more responsibility. But when Marmot published his results, he revealed the truth to be the exact opposite. The lower an employee ranked in the hierarchy, the higher their stress levels and likelihood of having a heart attack. Now he wanted to know: why?

And thats when, after two more years studying civil servants, he discovered the biggest factor. It turns out if you have no control over your work, you are far more likely to become stressed and, crucially, depressed. Humans have an innate need to feel that what we are doing, day-to-day, is meaningful. When you are controlled, you cant create meaning out of your work.

Suddenly, the depression of many of my friends, even those in fancy jobs who spend most of their waking hours feeling controlled and unappreciated started to look not like a problem with their brains, but a problem with their environments. There are, I discovered, many causes of depression like this. However, my journey was not simply about finding the reasons why we feel so bad. The core was about finding out how we can feel better how we can find real and lasting antidepressants that work for most of us, beyond only the packs of pills we have been offered as often the sole item on the menu for the depressed and anxious. I kept thinking about what Dr Cacciatore had taught me we have to deal with the deeper problems that are causing all this distress.

I found the beginnings of an answer to the epidemic of meaningless work in Baltimore. Meredith Mitchell used to wake up every morning with her heart racing with anxiety. She dreaded her office job. So she took a bold step one that lots of people thought was crazy. Her husband, Josh, and their friends had worked for years in a bike store, where they were ordered around and constantly felt insecure, Most of them were depressed. One day, they decided to set up their own bike store, but they wanted to run it differently. Instead of having one guy at the top giving orders, they would run it as a democratic co-operative. This meant they would make decisions collectively, they would share out the best and worst jobs and they would all, together, be the boss. It would be like a busy democratic tribe. When I went to their store Baltimore Bicycle Works the staff explained how, in this different environment, their persistent depression and anxiety had largely lifted.

Its not that their individual tasks had changed much. They fixed bikes before; they fix bikes now. But they had dealt with the unmet psychological needs that were making them feel so bad by giving themselves autonomy and control over their work. Josh had seen for himself that depressions are very often, as he put it, rational reactions to the situation, not some kind of biological break. He told me there is no need to run businesses anywhere in the old humiliating, depressing way we could move together, as a culture, to workers controlling their own workplaces.

*****

With each of the nine causes of depression and anxiety I learned about, I kept being taught startling facts and arguments like this that forced me to think differently. Professor John Cacioppo of Chicago University taught me that being acutely lonely is as stressful as being punched in the face by a stranger and massively increases your risk of depression. Dr Vincent Felitti in San Diego showed me that surviving severe childhood trauma makes you 3,100% more likely to attempt suicide as an adult. Professor Michael Chandler in Vancouver explained to me that if a community feels it has no control over the big decisions affecting it, the suicide rate will shoot up.

This new evidence forces us to seek out a very different kind of solution to our despair crisis. One person in particular helped me to unlock how to think about this. In the early days of the 21st century, a South African psychiatrist named Derek Summerfeld went to Cambodia, at a time when antidepressants were first being introduced there. He began to explain the concept to the doctors he met. They listened patiently and then told him they didnt need these new antidepressants, because they already had anti-depressants that work. He assumed they were talking about some kind of herbal remedy.

He asked them to explain, and they told him about a rice farmer they knew whose left leg was blown off by a landmine. He was fitted with a new limb, but he felt constantly anxious about the future, and was filled with despair. The doctors sat with him, and talked through his troubles. They realised that even with his new artificial limb, his old jobworking in the rice paddieswas leaving him constantly stressed and in physical pain, and that was making him want to just stop living. So they had an idea. They believed that if he became a dairy farmer, he could live differently. So they bought him a cow. In the months and years that followed, his life changed. His depressionwhich had been profoundwent away. You see, doctor, they told him, the cow was an antidepressant.

To them, finding an antidepressant didnt mean finding a way to change your brain chemistry. It meant finding a way to solve the problem that was causing the depression in the first place. We can do the same. Some of these solutions are things we can do as individuals, in our private lives. Some require bigger social shifts, which we can only achieve together, as citizens. But all of them require us to change our understanding of what depression and anxiety really are.

This is radical, but it is not, I discovered, a maverick position. In its official statement for World Health Day in 2017, the United Nations reviewed the best evidence and concluded that the dominant biomedical narrative of depression is based on biased and selective use of research outcomes that must be abandoned. We need to move from focusing on chemical imbalances, they said, to focusing more on power imbalances.

After I learned all this, and what it means for us all, I started to long for the power to go back in time and speak to my teenage self on the day he was told a story about his depression that was going to send him off in the wrong direction for so many years. I wanted to tell him: This pain you are feeling is not a pathology. Its not crazy. It is a signal that your natural psychological needs are not being met. It is a form of grief for yourself, and for the culture you live in going so wrong. I know how much it hurts. I know how deeply it cuts you. But you need to listen to this signal. We all need to listen to the people around us sending out this signal. It is telling you what is going wrong. It is telling you that you need to be connected in so many deep and stirring ways that you arent yet but you can be, one day.

If you are depressed and anxious, you are not a machine with malfunctioning parts. You are a human being with unmet needs. The only real way out of our epidemic of despair is for all of us, together, to begin to meet those human needs for deep connection, to the things that really matter in life.

This is an edited extract from Lost Connections: Uncovering the Real Causes of Depression and the Unexpected Solutions by Johann Hari, published by Bloomsbury on 11 January (16.99). To order a copy for 14.44 go to guardianbookshop.com or call 0330 333 6846. Free UK p&p over 10, online orders only. Phone orders min p&p of 1.99. It will be available in audio at audible.co.uk

Read more: https://www.theguardian.com/society/2018/jan/07/is-everything-you-think-you-know-about-depression-wrong-johann-hari-lost-connections

Excitement as trial shows Huntington’s drug could slow progress of disease

Hailed as enormously significant, results in groundbreaking trial are first time a drug has been shown to suppress effects of Huntingtons genetic mutation

A landmark trial for Huntingtons disease has announced positive results, suggesting that an experimental drug could become the first to slow the progression of the devastating genetic illness.

The results have been hailed as enormously significant because it is the first time any drug has been shown to suppress the effects of the Huntingtons mutation that causes irreversible damage to the brain. Current treatments only help with symptoms, rather than slowing the diseases progression.

Q&A

What is Huntington’s disease?

Huntingtons disease is a congenital degenerative condition caused by a single defective gene. Most patients are diagnosed in middle age, with symptoms including mood swings, irritability and depression. As the disease progresses, more serious symptoms can include involuntary jerky movements, cognitive difficulties and issues with speech and swallowing.

Currently there is no cure for Huntington’s, although drugs exist which help manage some of the symptoms. It is thought that about 12 people in 100,000 are affected by Huntington’s, and if a parent carries the faulty gene there is a 50% chance they will pass it on to their offspring.

Prof Sarah Tabrizi, director of University College Londons Huntingtons Disease Centre who led the phase 1 trial, said the results were beyond what Id ever hoped … The results of this trial are of ground-breaking importance for Huntingtons disease patients and families, she said.

The results have also caused ripples of excitement across the scientific world because the drug, which is a synthetic strand of DNA, could potentially be adapted to target other incurable brain disorders such as Alzheimers and Parkinsons. The Swiss pharmaceutical giant Roche has paid a $45m licence fee to take the drug forward to clinical use.

Huntingtons is an incurable degenerative disease caused by a single gene defect that is passed down through families.

The first symptoms, which typically appear in middle age, include mood swings, anger and depression. Later patients develop uncontrolled jerky movements, dementia and ultimately paralysis. Some people die within a decade of diagnosis.

Most of our patients know whats in their future, said Ed Wild, a UCL scientist and consultant neurologist at the National Hospital for Neurology and Neurosurgery in London, who administered the drug in the trial.

The mutant Huntingtons gene contains instructions for cells to make a toxic protein, called huntingtin. This code is copied by a messenger molecule and dispatched to the cells protein-making machinery. The drug, called Ionis-HTTRx, works by intercepting the messenger molecule and destroying it before the harmful protein can be made, effectively silencing the effects of the mutant gene.

How the drug works to slow the progress of Huntington’s disease

To deliver the drug to the brain, it has to be injected into the fluid around the spine using a four-inch needle.

Prof John Hardy, a neuroscientist at UCL who was not involved in the trial, said: If Id have been asked five years ago if this could work, I would have absolutely said no. The fact that it does work is really remarkable.

The trial involved 46 men and women with early stage Huntingtons disease in the UK, Germany and Canada. The patients were given four spinal injections one month apart and the drug dose was increased at each session; roughly a quarter of participants had a placebo injection.

After being given the drug, the concentration of harmful protein in the spinal cord fluid dropped significantly and in proportion with the strength of the dose. This kind of closely matched relationship normally indicates a drug is having a powerful effect.

For the first time a drug has lowered the level of the toxic disease-causing protein in the nervous system, and the drug was safe and well-tolerated, said Tabrizi. This is probably the most significant moment in the history of Huntingtons since the gene [was isolated].

The trial was too small, and not long enough, to show whether patients clinical symptoms improved, but Roche is now expected to launch a major trial aimed at testing this.

If the future trial is successful, Tabrizi believes the drug could ultimately be used in people with the Huntingtons gene before they become ill, possibly stopping symptoms ever occurring. They may just need a pulse every three to four months, she said. One day we want to prevent the disease.

The drug, developed by the California biotech firm Ionis Pharmaceuticals, is a synthetic single strand of DNA customised to latch onto the huntingtin messenger molecule.

The unexpected success raises the tantalising possibility that a similar approach might work for other degenerative brain disorders. The drugs like Lego, said Wild. You can target [any protein].

For instance, a similar synthetic strand of DNA could be made to target the messenger that produces misshapen amyloid or tau proteins in Alzheimers.

Huntingtons alone is exciting enough, said Hardy, who first proposed that amyloid proteins play a central role in Alzheimers. I dont want to overstate this too much, but if it works for one, why cant it work for a lot of them? I am very, very excited.

Prof Giovanna Mallucci, associate director of UK Dementia Research Institute at the University of Cambridge, described the work as a tremendous step forward for individuals with Huntingtons disease and their families.

Clearly, there will be much interest into whether it can be applied to the treatment of other neurodegenerative diseases, like Alzheimers, she added. However, she said that in the case of most other disorders the genetic causes are complex and less well understood, making them potentially harder to target.

About 10,000 people in the UK have the condition and about 25,000 are at risk. Most people with Huntingtons inherited the gene from a parent, but about one in five patients have no known family history of the disease.

The full results of the trial are expected to be published in a scientific journal next year.

Read more: https://www.theguardian.com/science/2017/dec/11/excitement-as-huntingtons-drug-shown-to-slow-progress-of-devastating-disease

Why the UN is investigating extreme poverty in America, the world’s richest nation

At the heart of Philip Alstons special mission will be one question: can Americans enjoy fundamental human rights if theyre unable to meet basic living standards?

The United Nations monitor on extreme poverty and human rights has embarked on a coast-to-coast tour of the US to hold the worlds richest nation and its president to account for the hardships endured by Americas most vulnerable citizens.

The tour, which kicked off on Friday morning, will make stops in four states as well as Washington DC and the US territory of Puerto Rico. It will focus on several of the social and economic barriers that render the American dream merely a pipe dream to millions from homelessness in California to racial discrimination in the Deep South, cumulative neglect in Puerto Rico and the decline of industrial jobs in West Virginia.

With 41 million Americans officially in poverty according to the US Census Bureau (other estimates put that figure much higher), one aim of the UN mission will be to demonstrate that no country, however wealthy, is immune from human suffering induced by growing inequality. Nor is any nation, however powerful, beyond the reach of human rights law a message that the US government and Donald Trump might find hard to stomach given their tendency to regard internal affairs as sacrosanct.

The UN special rapporteur on extreme poverty and human rights, Philip Alston, is a feisty Australian and New York University law professor who has a fearsome track record of holding power to account. He tore a strip off the Saudi Arabian regime for its treatment of women months before the kingdom legalized their right to drive, denounced the Brazilian government for attacking the poor through austerity, and even excoriated the UN itself for importing cholera to Haiti.

The US is no stranger to Alstons withering tongue, having come under heavy criticism from him for its program of drone strikes on terrorist targets abroad. In his previous role as UN special rapporteur on extrajudicial executions, Alston blamed the Obama administration and the CIA for killing many innocent civilians in attacks he said were of dubious international legality.

United
United Nations Special Rapporteur on extreme poverty and human rights, Philip Alston. Photograph: Ng Han Guan/AP

Now Alston has set off on his sixth, and arguably most sensitive, visit as UN monitor on extreme poverty since he took up the position in June 2014. At the heart of his fact-finding tour will be a question that is causing increasing anxiety at a troubled time: is it possible, in one of the worlds leading democracies, to enjoy fundamental human rights such as political participation or voting rights if you are unable to meet basic living standards, let alone engage, as Thomas Jefferson put it, in the pursuit of happiness?

Despite great wealth in the US, there also exists great poverty and inequality, Alston said in remarks released before the start of the visit. The rapporteur said he intended to focus on the detrimental effects of poverty on the civil and political rights of Americans, given the United States consistent emphasis on the importance it attaches to these rights in its foreign policy, and given that it has ratified the International Covenant on Civil and Political Rights.

Poverty experts are watching the UN tour closely in the hope that it might draw public attention to a largely neglected but critical aspect of US society.

David Grusky, director of the Center on Poverty and Inequality at Stanford, said the visit had the potential to hold a mirror up to the country at a moment when globalization combined with a host of domestic policies have generated a vast gulf between rich and poor.

The US has an extraordinary ability to naturalize and accept the extreme poverty that exists even in the context of such extreme wealth, he said.

Grusky added that the US reaction to Alstons visit could go either way. It has the potential to open our eyes to what an outlier the US has become compared with the rest of the world, or it could precipitate an adverse reaction towards an outsider who has no legitimacy telling us what to do about internal US affairs.

Alstons findings will be announced in preliminary form in Washington on 15 December, and then presented as a full report to the UN human rights council in Geneva next June. An especially unpredictable element of the fallout will be how Trump himself receives the final report, given the presidents habit of lashing out at anyone perceived to criticize him or his administration.

Trump has also shown open disdain towards the world body. In the course of the 2016 presidential campaign he griped that we get nothing out of the United Nations other than good real-estate prices.

On the other hand, observers have been surprised that the White House has honored the invitation to host Alston after the initial offer was extended by Barack Obama. US diplomats on more than one occasion since Trumps inauguration have said they welcomed the UN party.

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Ruby Dee Rudolph in her home in Lowndes County. A recent study suggests that nearly one one in three people in Lowndes County have hookworm, a parasite normally found in poor, developing countries. Photograph: Bob Miller for The Guardian

Alston himself is reserving his comments until the end of the tour. But his published work suggests that he is likely to be a formidable critic of the new president. In a lecture he gave last year on the challenges posed by Trump and other modern populist leaders, he warned that their agenda was avowedly nationalistic, xenophobic, misogynistic, and explicitly antagonistic to all or much of the human rights agenda.

Alston concluded the speech by saying: These are extraordinarily dangerous times, unprecedentedly so in my lifetime. The response is really up to us.

The UN poverty tour falls at a singularly tense moment for the US. In its 2016 state of the nation review, the Stanford Center on Poverty and Inequality placed the US rank at the bottom of the league table of 10 well-off countries, in terms of the extent of its income and wealth inequality.

It also found that the US hit rock bottom in terms of the safety net it offers struggling families, and is one of the worst offenders in terms of the ability of low-income families to lift themselves out of poverty a stark contrast to the much-vaunted myth of the American dream.

To some extent, Trumps focus on making America great again a political jingo that in itself contains an element of criticism of the state of the nation chimes with the UNs concern about extreme poverty. His call for greater prosperity for white working Americans in declining manufacturing areas that proved so vital to his election victory will be echoed in Alstons visit to the depressed coal-producing state of West Virginia, which backed Trump in 2016 by a resounding 69%.

In many other ways, though, the Trump administration in its first year has taken a radically hostile approach towards communities in need. He has tried, so far unsuccessfully, to abolish Obamacare in a move that would deprive millions of low-income families of healthcare insurance, was widely criticized for his lackluster response to the hurricane disaster in Puerto Rico that has left thousands homeless and without power, and is currently pushing a tax reform that would benefit one group above all others: the super rich.

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A man who lost his home during Hurricane Maria in September sits on a cot at a school turned shelter in Canovanas. Photograph: Alvin Baez/Reuters

The US poses an especially challenging subject for the UN special rapporteur because unlike all other industrialized nations, it fails to recognize fundamental social and economic rights such as the right to healthcare, a roof over your head or food to keep hunger at bay. The federal government has consistently refused to sign up to the international covenant on economic, social and cultural rights arguing that these matters are best left to individual states.

Such an emphasis on states rights has spawned a patchwork of provision for low-income families across the country. Republican-controlled states in the Deep South provide relatively little help to those struggling from unemployment and lack of ready cash, while more assistance is likely to be forthcoming in bigger coastal cities.

By contrast, raging house prices and gentrification is fueling a homelessness crisis in liberal cities such as Los Angeles and San Francisco the first stop next week of the UN tour.

Martha Davis, a law professor specializing in US human rights at Northeastern University, said that such vast regional variations present the UN monitor with a huge opportunity. Unlike other international officials, he has the ability to move freely at both federal and state levels and be equally critical of both.

Theres a lot that Philip Alston can say about basic inequality that goes to the heart of the rights that he is reviewing, Davis said.

Read more: https://www.theguardian.com/world/2017/dec/01/un-extreme-poverty-america-special-rapporteur

A journey through a land of extreme poverty: welcome to America

The UNs Philip Alston is an expert on deprivation and he wants to know why 41m Americans are living in poverty. The Guardian joined him on a special two-week mission into the dark heart of the worlds richest nation

Los Angeles, California, 5 December

You got a choice to make, man. You could go straight on to heaven. Or you could turn right, into that.

We are in Los Angeles, in the heart of one of Americas wealthiest cities, and General Dogon, dressed in black, is our tour guide. Alongside him strolls another tall man, grey-haired and sprucely decked out in jeans and suit jacket. Professor Philip Alston is an Australian academic with a formal title: UN special rapporteur on extreme poverty and human rights.

General Dogon, himself a veteran of these Skid Row streets, strides along, stepping over a dead rat without comment and skirting round a body wrapped in a worn orange blanket lying on the sidewalk.

The two men carry on for block after block after block of tatty tents and improvised tarpaulin shelters. Men and women are gathered outside the structures, squatting or sleeping, some in groups, most alone like extras in a low-budget dystopian movie.

We come to an intersection, which is when General Dogon stops and presents his guest with the choice. He points straight ahead to the end of the street, where the glistening skyscrapers of downtown LA rise up in a promise of divine riches.

Heaven.

Then he turns to the right, revealing the black power tattoo on his neck, and leads our gaze back into Skid Row bang in the center of LAs downtown. That way lies 50 blocks of concentrated human humiliation. A nightmare in plain view, in the city of dreams.

Alston turns right.

Philip
Philip Alston in downtown LA. Photograph: Dan Tuffs for the Guardian

So begins a two-week journey into the dark side of the American Dream. The spotlight of the UN monitor, an independent arbiter of human rights standards across the globe, has fallen on this occasion on the US, culminating on Friday with the release of his initial report in Washington.

His fact-finding mission into the richest nation the world has ever known has led him to investigate the tragedy at its core: the 41 million people who officially live in poverty.

Of those, nine million have zero cash income they do not receive a cent in sustenance.

Alstons epic journey has taken him from coast to coast, deprivation to deprivation. Starting in LA and San Francisco, sweeping through the Deep South, traveling on to the colonial stain of Puerto Rico then back to the stricken coal country of West Virginia, he has explored the collateral damage of Americas reliance on private enterprise to the exclusion of public help.

The Guardian had unprecedented access to the UN envoy, following him as he crossed the country, attending all his main stops and witnessing the extreme poverty he is investigating firsthand.

Think of it as payback time. As the UN special rapporteur himself put it: Washington is very keen for me to point out the poverty and human rights failings in other countries. This time Im in the US.

David
David Busch, who is currently homeless on Venice beach, in Los Angeles. Photograph: Dan Tuffs for the Guardian


The tour comes at a critical moment for America and the world. It began on the day that Republicans in the US Senate voted for sweeping tax cuts that will deliver a bonanza for the super wealthy while in time raising taxes on many lower-income families. The changes will exacerbate wealth inequality that is already the most extreme in any industrialized nation, with three men Bill Gates, Jeff Bezos and Warren Buffet owning as much as half of the entire American people.

A few days into the UN visit, Republican leaders took a giant leap further. They announced plans to slash key social programs in what amounts to an assault on the already threadbare welfare state.

Look up! Look at those banks, the cranes, the luxury condos going up, exclaimed General Dogon, who used to be homeless on Skid Row and now works as a local activist with Lacan. Down here, theres nothing. You see the tents back to back, theres no place for folks to go.

California made a suitable starting point for the UN visit. It epitomizes both the vast wealth generated in the tech boom for the 0.001%, and the resulting surge in housing costs that has sent homelessness soaring. Los Angeles, the city with by far the largest population of street dwellers in the country, is grappling with crisis numbers that increased 25% this past year to 55,000.

Ressy Finley, 41, was busy sterilizing the white bucket she uses to slop out in her tent in which she has lived on and off for more than a decade. She keeps her living area, a mass of worn mattresses and blankets and a few motley possessions, as clean as she can in a losing battle against rats and cockroaches. She also endures waves of bed bugs, and has large welts on her shoulder to prove it.

She receives no formal income, and what she makes on recycling bottles and cans is no way enough to afford the average rents of $1,400 a month for a tiny one-bedroom. A friend brings her food every couple of days, the rest of the time she relies on nearby missions.

She cried twice in the course of our short conversation, once when she recalled how her infant son was taken from her arms by social workers because of her drug habit (he is now 14; she has never seen him again). The second time was when she alluded to the sexual abuse that set her as a child on the path towards drugs and homelessness.

Given all that, its remarkable how positive Finley remains. What does she think of the American Dream, the idea that everyone can make it if they try hard enough? She replies instantly: I know Im going to make it.

A 41-year-old woman living on the sidewalk in Skid Row going to make it?

Sure I will, so long as I keep the faith.

What does making it mean to her?

I want to be a writer, a poet, an entrepreneur, a therapist.

Ressy
Ressy Finley, who lives in a tent on 6th Street in Downtown LA. Photograph: Dan Tuffs for the Guardian

Robert Chambers occupies the next patch of sidewalk along from Finleys. Hes created an area around his tent out of wooden pallets, what passes in Skid Row for a cottage garden.

He has a sign up saying Homeless Writers Coalition, the name of a group he runs to give homeless people dignity against what he calls the animalistic aspects of their lives. Hes referring not least to the lack of public bathrooms that forces people to relieve themselves on the streets.

LA authorities have promised to provide more access to toilets, a critical issue given the deadly outbreak of Hepatitis A that began in San Diego and is spreading on the west coast claiming 21 lives mainly through lack of sanitation in homeless encampments. At night local parks and amenities are closed specifically to keep homeless people out.

Skid Row has had the use of nine toilets at night for 1,800 street-faring people. Thats a ratio well below that mandated by the UN in its camps for Syrian refugees.

Its inhuman actually, and eventually in the end you will acquire animalistic psychology, Chambers said.

He has been living on the streets for almost a year, having violated his parole terms for drug possession and in turn being turfed out of his low-cost apartment. Theres no help for him now, he said, no question of making it.

The safety net? It has too many holes in it for me.

Of all the people who crossed paths with the UN monitor, Chambers was the most dismissive of the American Dream. People dont realize its never getting better, theres no recovery for people like us. Im 67, I have a heart condition, I shouldnt be out here. I might not be too much longer.

That was a lot of bad karma to absorb on day one, and it rattled even as seasoned a student of hardship as Alston. As UN special rapporteur, hes reported on dire poverty and its impact on human rights in Saudi Arabia and China among other places. But Skid Row?

I was feeling pretty depressed, he told the Guardian later. The endless drumbeat of horror stories. At a certain point you do wonder what can anyone do about this, let alone me.

And then he took a flight up to San Francisco, to the Tenderloin district where homeless people congregate, and walked into St Boniface church.

What he saw there was an analgesic for his soul.

San Francisco, California, 6 December

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The Gubbio project at St Boniface in San Francisco. The church opens its doors every weekday at 6am to allow homeless people to rest until 3pm. Photograph: David Levene for the Guardian


About 70 homeless people were quietly sleeping in pews at the back of the church, as they are allowed to do every weekday morning, with worshippers praying harmoniously in front of them. The church welcomes them in as part of the Catholic concept of extending the helping hand.

I found the church surprisingly uplifting, Alston said. It was such a simple scene and such an obvious idea. It struck me Christianity, what the hell is it about if its not this?

It was a rare drop of altruism on the west coast, competing against a sea of hostility. More than 500 anti-homeless laws have been passed in Californian cities in recent years. At a federal level, Ben Carson, the neurosurgeon who Donald Trump appointed US housing secretary, is decimating government spending on affordable housing.

Perhaps the most telling detail: apart from St Boniface and its sister church, no other place of worship in San Francisco welcomes homeless people. In fact, many have begun, even at this season of goodwill, to lock their doors to all comers simply so as to exclude homeless people.

As Tiny Gray-Garcia, herself on the streets, described it to Alston, there is a prevailing attitude that she and her peers have to contend with every day. She called it the violence of looking away.

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Coy Catley, 63, in her homeless box made of cardboard sheets on a sidewalk of Tenderloin, San Francisco. Photograph: Ed Pilkington for the Guardian


That cruel streak the violence of looking away has been a feature of American life since the nations founding. The casting off the yoke of overweening government (the British monarchy) came to be equated in the minds of many Americans with states rights and the individualistic idea of making it on your own a view that is fine for those fortunate enough to do so, less happy if youre born on the wrong side of the tracks.

Countering that has been the conviction that society must protect its own against the vagaries of hunger or unemployment that informed Franklin Roosevelts New Deal and the Great Society of Lyndon Johnson. But in recent times the prevailing winds have blown strongly in the youre on your own, buddy direction. Ronald Reagan set the trend with his 1980s tax cuts, followed by Bill Clinton, whose 1996 decision to scrap welfare payments for low-income families is still punishing millions of Americans.

The cumulative attack has left struggling families, including the 15 million children who are officially in poverty, with dramatically less support than in any other industrialized economy. Now they face perhaps the greatest threat of all.

As Alston himself has written in an essay on Trumps populism and the aggressive challenge it poses to human rights: These are extraordinarily dangerous times. Almost anything seems possible.

Lowndes County, Alabama, 9 December

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Aaron Thigpen discusses the poor sewage conditions in Butler County. Improper treatment has put the population at risk of diseases long believed to be extinct in the US. Photograph: Bob Miller for the Guardian


Trumps undermining of human rights, combined with the Republican threat to pare back welfare programs next year in order to pay for some of the tax cuts for the rich they are rushing through Congress, will hurt African Americans disproportionately.

Black people are 13% of the US population, but 23% of those officially in poverty and 39% of the homeless.

The racial element of Americas poverty crisis is seen nowhere more clearly than in the Deep South, where the open wounds of slavery continue to bleed. The UN special rapporteur chose as his next stop the Black Belt, the term that originally referred to the rich dark soil that exists in a band across Alabama but over time came to describe its majority African American population.

The link between soil type and demographics was not coincidental. Cotton was found to thrive in this fertile land, and that in turn spawned a trade in slaves to pick the crop. Their descendants still live in the Black Belt, still mired in poverty among the worst in the union.

You can trace the history of Americas shame, from slave times to the present day, in a set of simple graphs. The first shows the cotton-friendly soil of the Black Belt, then the slave population, followed by modern black residence and todays extreme poverty they all occupy the exact same half-moon across Alabama.

There are numerous ways you could parse the present parlous state of Alabamas black community. Perhaps the starkest is the fact that in the Black Belt so many families still have no access to sanitation. Thousands of people continue to live among open sewers of the sort normally associated with the developing world.

The crisis was revealed by the Guardian earlier this year to have led to an ongoing endemic of hookworm, an intestinal parasite that is transmitted through human waste. It is found in Africa and South Asia, but had been assumed eradicated in the US years ago.

Yet here the worm still is, sucking the blood of poor people, in the home state of Trumps US attorney general Jeff Sessions.

A disease of the developing world thriving in the worlds richest country.

The open sewerage problem is especially acute in Lowndes County, a majority black community that was an epicenter of the civil rights movement having been the setting of Martin Luther Kings Selma to Montgomery voting rights march in 1965.

Philp
Philp Alston talks to a resident. Many families in Butler and Lowndes counties choose to live with open sewer systems made from PVC pipe. Photograph: Bob Miller for the Guardian

Despite its proud history, Catherine Flowers estimates that 70% of households in the area either straight pipe their waste directly onto open ground, or have defective septic tanks incapable of dealing with heavy rains.

When her group, Alabama Center for Rural Enterprise (Acre), pressed local authorities to do something about it, officials invested $6m in extending waste treatment systems to primarily white-owned businesses while bypassing overwhelmingly black households.

Thats a glaring example of injustice, Flowers said. People who cannot afford their own systems are left to their own devices while businesses who do have the money are given public services.

Walter, a Lowndes County resident who asked not to give his last name for fear that his water supply would be cut off as a reprisal for speaking out, lives with the daily consequences of such public neglect. You get a good hard rain and it backs up into the house.

Thats a polite way of saying that sewage gurgles up into his kitchen sink, hand basin and bath, filling the house with a sickly-sweet stench.

Given these circumstances, what does he think of the ideology that anyone can make it if they try?

I suppose they could if they had the chance, Walter said. He paused, then added: Folks arent given the chance.

Had he been born white, would his sewerage problems have been fixed by now?

After another pause, he said: Not being racist, but yeah, they would.

Round the back of Walters house the true iniquity of the situation reveals itself. The yard is laced with small channels running from neighboring houses along which dark liquid flows. It congregates in viscous pools directly underneath the mobile home in which Walters son, daughter-in-law and 16-year-old granddaughter live.

It is the ultimate image of the lot of Alabamas impoverished rural black community. As American citizens they are as fully entitled to life, liberty and the pursuit of happiness. Its just that they are surrounded by pools of excrement.

This week, the Black Belt bit back. On Tuesday a new line was added to that simple graphic, showing exactly the same half-moon across Alabama except this time it was not black but blue.

blue belt south

It depicted the army of African American voters who turned out against the odds to send Doug Jones to the US Senate, the first Democrat from Alabama to do so in a generation. It delivered a bloody nose to his opponent, the alleged child molester Roy Moore, and his puppetmasters Steve Bannon and Donald Trump.

It was arguably the most important expression of black political muscle in the region since Kings 1965 march. If the previous entries in the graphic could be labeled soil, slavery and poverty, this one should be captioned empowerment.

Guayama, Puerto Rico, 10 December

So how does Alston view the role of UN rapporteur and his visit? His full report on the US will be released next May before being presented to the UN human rights council in Geneva.

Nobody expects much to come of that: the world body has no teeth with which to enforce good behavior on recalcitrant governments. But Alston hopes that his visit will have an impact by shaming the US into reflecting on its values.

My role is to hold governments to account, he said. If the US administration doesnt want to talk about the right to housing, healthcare or food, then there are still basic human rights standards that have to be met. Its my job to point that out.

Alstons previous investigations into extreme poverty in places like Mauritania pulled no punches. We can expect the same tough love when it comes to his analysis of Puerto Rico, the next stop on his journey into Americas dark side.

Three months after Maria, the devastation wrought by the hurricane has been well documented. It tore 70,000 homes to shreds, brought industry to a standstill and caused a total blackout of the island that continues to cause havoc.

Exclusive: footage shows young elephants being captured in Zimbabwe for Chinese zoos

Rare footage of the capture of wild young elephants in Zimbabwe shows rough treatment of the calves as they are sedated and taken away

The Guardian has been given exclusive footage which shows the capture of young, wild elephants in Zimbabwe in preparation, it is believed, for their legal sale to Chinese zoos.

In the early morning of 8 August, five elephants were caught in Hwange national park by officials at Zimbabwe Parks and Wildlife Management Authority (Zimparks).

These captures are usually kept as secret as possible. The Guardian understands that in this case the usual procedure was followed. First, a viable herd is identified. Then operatives in a helicopter pick off the younger elephants with a sedative fired from a rifle. As the elephant collapses, the pilot dive-bombs the immediate vicinity so the rest of the herd, attempting to come to the aid of the fallen animal, are kept at bay. When things quieten down, a ground-team approaches the sedated elephants on foot, bundles them up, and drags them on to trailers.

The footage, a series of isolated clips and photographs provided to the Guardian by an anonymous source associated with the operation, documents the moment that operatives are running into the bush, then shows them tying up one young elephant. The elephants are then seen herded together in a holding pen near the main tourist camp in Hwange.

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In this part of the footage, a young female elephant is seen being kicked in the head repeatedly by one of the captors. Photograph: The Guardian

Finally, in the most disturbing part of the footage, a small female elephant, likely around five years old, is seen standing in the trailer. Her body is tightly tied to the vehicle by two ropes. Only minutes after being taken from the wild, the animal, still groggy from the sedative, is unable to understand that the officials want her to back into the truck, so they smack her on her body, twist her trunk, pull her by her tail and repeatedly kick her in the head with their boots.

Altogether, 14 elephants were captured during this time period, according to the source, who asked to remain to anonymous for fear of reprisal. The intention was to take more elephants, but the helicopter crashed during one of the operations. It is estimated that 30-40 elephants were to be captured in total.

The elephants that were taken are now in holding pens at an off-limits facility within Hwange called Umtshibi, according to the source. One expert who reviewed the photographs, Joyce Poole, an expert on elephant behaviour and co-director of the Kenya-based organisation ElephantVoices, said the elephants were bunching huddling together because they are frightened.

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The young elephants in their enclosure. According to experts, they are bunching, huddling together because they are frightened. Photograph: The Guardian

Audrey Delsink, an elephant behavioural ecologist and executive director for Executive Director for Humane Society International Africa, also reviewed the photos and footage. She believed that most of the elephants were aged between two and four. Basically, these calves have just been weaned or are a year or two into the weaning process. In the wild, elephants are completely dependent on their mothers milk until they are two, and are not fully weaned until the age of five.

A number of the calves, she said, were displaying temporal streaming a stress-induced activity. Many of the gestures indicate apprehensive and displacement behaviour trunk twisting, trunk curled under, face touching, foot swinging, head-shaking, ear-cocking, displacement feeding, amongst others. Zimparks were approached but did not make a comment.

The buyer for the young elephants is a Chinese national, according to inside sources who asked not to be named. Last year he was associated with a case involving 11 wild hyenas, who were discovered in a truck at Harare international airport that had been on the road for 24 hours without food or water and were reportedly in an extremely stressed condition, dehydrated and emaciated and, in some cases, badly injured.

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One of the hyenas found in a consignment at Harare airport in Zimbabwe. Photograph: The Guardian

The legal live trade in wild animals

The capture of the baby elephants is just one of a number of operations that have taken place in Zimbabwe and across the continent over several decades. Nine elephants were reportedly exported from Namibia to Mexico in 2012, six from Namibia to Cuba in 2013, and more than 25 from Zimbabwe to China in 2015. In 2016, the US imported 17 elephants from Swaziland despite objections from the public and conservationists. From 1995-2015, more than 600 wild African elephants and 400 wild Asian elephants are reported to have been traded globally, according to a database kept by the Convention on International Trade in Endangered Species (Cites).

Under Cites, trading live elephants is legal, with a few stipulations. The destination must be appropriate and acceptable, and the sale must benefit conservation in the home country. But elephant conservationists and animal welfare advocates point out a number of flaws in the system. There are no criteria setting out what appropriate and acceptable means and what is really contributing to conservation, explained Daniela Freyer of Pro-Wildlife, a German-based organisation that seeks to improve international legislation protecting wildlife. Currently, it is entirely up to authorities in the importing countries to define and decide. There are no common rules and no monitoring of the conditions of the capture, the number of animals being traded, where they will end up or the conditions in which they will be kept at their destination. There is also no monitoring of the requirement that a sale benefit conservation.

For example, Zimbabwe and China are the biggest players in the live elephant trade, but Iris Ho, wildlife programme manager at Humane Society International (HSI), says they have found little information from the importing countries on the animals arrival. We dont know how many facilities in China have received the elephants imported from Zimbabwe during the last few years. We dont know the status of these animals.

Attempts to comply with the few Cites stipulations such as appropriate and acceptable destinations are sometimes dismissed. In 2016, a Zimbabwe delegation of Zimparks and ZNSPCA inspectors travelled to China to access the facilities, where they found that most of the zoos showed signs of poor treatment of the animals. But their recommendation that a shipment of 36 elephants remain in Zimbabwe until the holding facilities in China were completed and assessed for compliance by Zimbabwe, was ignored.

On September 16 Chinese papers announced in cheery headlines that three elephants two females and a male, aged approximately four years old had arrived at the Lehe Ledu wildlife zoo. Photographs of the elephants from Chinese media were analysed by Poole, who noted that the face one of the females looked pinched and stressed. The elephant appears to have begun to wear her tusks down on the bars, rubbing back and forth in frustration. Poole added that the sunken look, dark eyes and mottled skin are common for young, captured elephants. In the wild, you only see the pinched, sunken look in sick or orphaned elephants.

The zoo has said that it is providing more than 1,000 square metres of indoor space and 3,000 sq metres outdoors. The animals have six full-time babysitters and every meal is prepared carefully, based on scientific recommendation.

A video posted on YouTube celebrating the arrival of the elephants at Lehe Ledu zoo.

Finally, questions have been asked about whether Zimbabwe is complying with the Cites stipulation that the sale of the elephants must benefit their conservation in the wild. The environment minister, Oppah Muchinguri-Kashiri, was reported in the Guardian last year as saying the sale of the elephants was necessary to raise funds to take care of national parks in Zimbabwe, which have been ravaged by drought and poaching. But in the past, there have been unconfirmed reports of Grace Mugabe, the presidents wife, using funds from the sales of elephants to pay off a military debt to the Democratic Republic of the Congo.

The international body governing the trade, Cites, is increasingly coming under fire for its role. The scientific literature states that captive facilities continue to fall far short of meeting elephants natural needs for movement, space and extended social networks, with negative effects on health, behavior and reproduction, said Anna Mul, a legal adviser on animal law at Fondation Franz Weber, an organisation that is lobbying Cites to end the trade of live elephants.

A spokesman for CITES said: The triennial CITES conference held last year (CoP17) agreed that appropriate and acceptable destinations was defined as destinations where the importing State is satisfied that the recipient of the live animals is suitably equipped to house and care for them. CoP17 also agreed on a process to assess if additional guidance on this matter is required. Further, both the importing and exporting countries are now required to be satisfied that any trade in live elephants should promote the conservation of elephants in the wild. In addition, the exporting Party must also be satisfied that animals are prepared and shipped so as to minimize the risk of injury, damage to health or cruel treatment of live elephants in trade… CITES does not address the way in which the animals are captured or stored prior to export.

But for now, China continues to import the vulnerable elephants at almost conveyor-belt speed. According to Ho, some pressure to stop the practice is beginning to be felt, but the country is influenced by the view that breeding is conservation. And then, of course, there is a willing partner in Zimbabwe and the thrill of seeing African elephants by the visitors.

Its a win-win, she said, for those who are financially profiting from the legal trade in the calves. But its a lose-lose for the animals, both imported and left behind.

Read more: https://www.theguardian.com/environment/2017/oct/03/exclusive-footage-shows-young-elephants-being-captured-in-zimbabwe-for-chinese-zoos

Facing poverty, academics turn to sex work and sleeping in cars

Adjunct professors in America face low pay and long hours without the security of full-time faculty. Some, on the brink of homelessness, take desperate measures

There is nothing she would rather do than teach. But after supplementing her career with tutoring and proofreading, the university lecturer decided to go to remarkable lengths to make her career financially viable.

She first opted for her side gig during a particularly rough patch, several years ago, when her course load was suddenly cut in half and her income plunged, putting her on the brink of eviction. In my mind I was like, Ive had one-night stands, how bad can it be? she said. And it wasnt that bad.

The wry but weary-sounding middle-aged woman, who lives in a large US city and asked to remain anonymous to protect her reputation, is an adjunct instructor, meaning she is not a full-time faculty member at any one institution and strings together a living by teaching individual courses, in her case at multiple colleges.

about

I feel committed to being the person whos there to help millennials, the next generation, go on to become critical thinkers, she said. And Im really good at it, and I really like it. And its heartbreaking to me it doesnt pay what I feel it should.

Sex work is one of the more unusual ways that adjuncts have avoided living in poverty, and perhaps even homelessness. A quarter of part-time college academics (many of whom are adjuncts, though its not uncommon for adjuncts to work 40 hours a week or more) are said to be enrolled in public assistance programs such as Medicaid.

They resort to food banks and Goodwill, and there is even an adjuncts cookbook that shows how to turn items like beef scraps, chicken bones and orange peel into meals. And then there are those who are either on the streets or teetering on the edge of losing stable housing. The Guardian has spoken to several such academics, including an adjunct living in a shack north of Miami, and another sleeping in her car in Silicon Valley.

The adjunct who turned to sex work makes several thousand dollars per course, and teaches about six per semester. She estimates that she puts in 60 hours a week. But she struggles to make ends meet after paying $1,500 in monthly rent and with student loans that, including interest, amount to a few hundred thousand dollars. Her income from teaching comes to $40,000 a year. Thats significantly more than most adjuncts: a 2014 survey found that the median income for adjuncts is only $22,041 a year, whereas for full-time faculty it is $47,500.

We take a kind of vow of poverty

Recent reports have revealed the extent of poverty among professors, but the issue is longstanding. Several years ago, it was thrust into the headlines in dramatic fashion when Mary-Faith Cerasoli, an adjunct professor of Romance languages in her 50s, revealed she was homeless and protested outside the New York state education department.

We take a kind of vow of poverty to continue practicing our profession, Debra Leigh Scott, who is working on a documentary about adjuncts, said in an email. We do it because we are dedicated to scholarship, to learning, to our students and to our disciplines.

Adjuncting has grown as funding for public universities has fallen by more than a quarterbetween 1990 and 2009. Private institutions also recognize the allure of part-time professors: generally they are cheaper than full-time staff, dont receive benefits or support for their personal research, and their hours can be carefully limited so they do not teach enough to qualify for health insurance.

This is why adjuncts have been called the fast-food workers of the academic world: among labor experts adjuncting is defined as precarious employment, a growing category that includes temping and sharing-economy gigs such as driving for Uber. An American Sociological Association taskforce focusing on precarious academic jobs, meanwhile, has suggested that faculty employment is no longer a stable middle-class career.

Adjunct
Adjunct English professor Ellen James-Penney and her husband live in a car with their two dogs. They have developed a system. Keep nothing on the dash, nothing on the floor you cant look like youre homeless, you cant dress like youre homeless. Photograph: Talia Herman for the Guardian

The struggle to stay in housing can take many forms, and a second job is one way adjuncts seek to buoy their finances. The professor who turned to sex work said it helps her keep her toehold in the rental market.

This is something I chose to do, she said, adding that for her it is preferable to, say, a six-hour shift at a bar after teaching all day. I dont want it to come across as, Oh, I had no other choice, this is how hard my life is.

Advertising online, she makes about $200 an hour for sex work. She sees clients only a handful of times during the semester, and more often during the summer, when classes end and she receives no income.

Im terrified that a student is going to come walking in, she said. And the financial concerns have not ceased. I constantly have tension in my neck from gritting my teeth all night.

To keep their homes, some adjuncts are forced to compromise on their living space.

Caprice Lawless, 65, a teacher of English composition and a campaigner for better working conditions for adjuncts, resides in an 1100 sq ft brick house near Boulder, Colorado. She bought it following a divorce two decades ago. But because her $18,000 income from teaching almost full time is so meager, she has remortgaged the property several times, and has had to rent her home to three other female housemates.

I live paycheck to paycheck and Im deeply in debt, she said, including from car repairs and a hospitalization for food poisoning.

Like every other adjunct, she says, she opted for the role thinking it would be a path to full-time work. She is so dependent on her job to maintain her living situation that when her mother died this summer, she didnt take time off in part because she has no bereavement leave. She turned up for work at 8am the next day, taught in a blur and, despite the cane she has used since a hip replacement, fell over in the parking lot.

If she were to lose her home her only hope, she says, would be government-subsidized housing.

Most of my colleagues are unjustifiably ashamed, she said. They take this personally, as if theyve failed, and Im always telling them, you havent failed, the system has failed you.

A precarious situation

Even more desperate are those adjuncts in substandard living spaces who cannot afford to fix them. Mindy Percival, 61, a lecturer with a doctorate from Columbia, teaches history at a state college in Florida and, in her words, lives in a shack which is in the woods in middle of nowhere.

Lecturer
Lecturer Mindy Percivals mobile home in Stuart, Florida. Her oven, shower and water heater dont work. Photograph: Courtesy of Mindy Percival

The mobile home she inhabits, located in the town of Stuart, north of Miami, was donated to her about eight years ago. It looks tidyon the outside, but inside there are holes in the floor and the paneling is peeling off the walls. She has no washing machine, and the oven, shower and water heater dont work. Im on the verge of homelessness, constantly on the verge, she said.

Percival once had a tenure-track job but left to care for her elderly mother, not expecting it would be impossible to find a similar position. Now, two weeks after being paid, I might have a can with $5 in change in it. Her 18-year-old car broke down after Hurricane Irma, and she is driven to school by a former student, paying $20 a day for gas.

I am trying to get out so terribly hard, she said.

Homelessness is a genuine prospect for adjuncts. When Ellen Tara James-Penney finishes work, teaching English composition and critical thinking at San Jose State University in Silicon Valley, her husband, Jim, picks her up. They have dinner and drive to a local church, where Jim pitches a tent by the car and sleeps there with one of their rescue dogs. In the car, James-Penney puts the car seats down and sleeps with another dog. She grades papers using a headlamp.

Over the years, she said, they have developed a system. Keep nothing on the dash, nothing on the floor you cant look like youre homeless, you cant dress like youre homeless. Dont park anywhere too long so the cops dont stop you.

James-Penney, 54, has struggled with homelessness since 2007, when she began studying for her bachelors degree. Jim, 64, used to be a trucker but cannot work owing to a herniated disk. Ellen made $28,000 last year, a chunk of which goes to debt repayments. The remainder is not enough to afford Silicon Valley rent.

At night, instead of a toilet they must use cups or plastic bags and baby wipes. To get clean, they find restrooms and we have what we call the sink-shower, James-Penney said. The couple keep their belongings in the back of the car and a roof container. All the while they deal with the consequences of ageing James-Penney has osteoporosis in a space too small to even stand up.

James-Penney does not hide her situation from her class. If her students complain about the homeless people who can sometimes be seen on campus, she will say:Youre looking at someone who is homeless.

That generally stops any kind of sound in the room, she says. I tell them, your parents could very well be one paycheck away, one illness away, from homelessness, so it is not something to be ashamed of.

Ellen
Ellen James-Penney teaching an English class at San Jose State University in California. She tells her students, youre looking at someone who is homeless. Photograph: Talia Herman for the Guardian

I hung on to the dream

Many adjuncts are seeking to change their lot by unionizing, and have done so at dozens of schools in recent years. They are notching successes; some have seen annual pay increases of about 5% to almost 20%, according to Julie Schmid, executive director of the American Association of University Professors.

Schools are often opposed to such efforts and say unions will result in higher costs for students. And for certain adjuncts, any gains will come too late.

Mary-Faith Cerasoli, 56, the homeless adjunct who captured the publics attention with her protest in New York three years ago, said that in the aftermath little changed in termsof her living situation. Two generous people, a retiree and then a nurse, offered her temporary accommodation, but she subsequently ended up in a tent pitched at a campground and, after that, a broken sailboat docked in the Hudson river.

But there was, however, one shift. All the moving around made it hard for her to make teaching commitments, and in any case the pay remained terrible, so she gave it up. She currently lives in a subsidized room in a shared house in a wealthy county north of New York.

For Rebecca Snow, 51, another adjunct who quit teaching after a succession of appalling living situations, there is a sense of having been freed, even though finances continue to be stressful.

Author
Author Rebecca Snow, now retired from adjuncting, has moved to a small apartment just north of Spokane, Washington. Photograph: Rajah Bose for the Guardian

She began teaching English composition at a community college in the Denver area in 2005, but the poor conditions of the homes she could afford meant she had to move every year or two. She left one place because of bedbugs, another when raw sewage flowed into her bathtub and the landlord failed to properly fix the pipes.

Sometimes her teenage son would have to stay with her ex-husband when she couldnt provide a stable home. Snow even published a poem about adjuncts housing difficulties.

In the end she left the profession when the housing and job insecurity became too much, and her bills too daunting. Today she lives in a quiet apartment above the garage of a friends home, located 15 miles outside Spokane, Washington. She has a view of a lake and forested hills and, with one novel under her belt, is working on a second.

Teaching was the fantasy, she said, but life on the brink of homelessness was the reality.

I realized I hung on to the dream for too long.

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Read more: https://www.theguardian.com/us-news/2017/sep/28/adjunct-professors-homeless-sex-work-academia-poverty

Fran works six days a week in fast food, and yet she’s homeless: ‘It’s economic slavery’

Fran Marion and Bridget Hughes are leading voices in Stand Up Kansas City, part of the Fight for $15 movement that aims raise the minimum wage across the US

Once a customer has barked their order into the microphone at the Popeyes drive-thru on Prospect Avenue, Kansas City, the clock starts. Staff have a company-mandated 180 seconds to take the order, cook the order, bag the order and deliver it to the drive-thru window.

The restaurant is on short shift at the moment, which means it has about half the usual staff, so Fran Marion often has to do all those jobs herself. On the day we met, she estimates she processed 187 orders roughly one every two minutes. Those orders grossed about $950 for the company. Marion went home with $76.

Despite working six days a week, Marion, 37, a single mother of two, cant make ends meet on the $9.50 an hour she gets at Popeyes (no apostrophe founder Al Copeland joked he was too poor to afford one). A fast food worker for 22 years, Marion has almost always had a second job. Until recently, she had been working 9am-4pm at Popeyes, without a break, then crossing town to a janitorial job at Bartle Hall, the convention center, where she would work from 5pm- to 1.30am for $11 an hour. She didnt take breaks there either, although they were allowed.

Read more: https://www.theguardian.com/us-news/2017/aug/21/missouri-fast-food-workers-better-pay-popeyes-economics

Billionaire Bloomberg to fund $5m public health projects in 40 cities worldwide

Exclusive: Melbourne, Accra and Ulaanbaatar among cities to benefit from funding pledged by former New York mayor to tackle issues from air pollution to obesity

Michael Bloomberg, the billionaire bte noire of both the sugar industry and the tobacco industry, famously fought for a ban on the sale of large-sized colas and other sweet drinks when he was mayor of New York and lost. Although that is not how he sees it.

We actually won that battle, he says. I have always thought if we had not been stopped by the court, it would have died as an issue. Nobody would have known about it. But the fact that it kept coming back to the newspapers was a gift in disguise because people started to think, Holy God, maybe full-sugar drinks are bad for me.

So what happened was consumption of full-sugar drinks around the world has gone down dramatically. If we had won the thing, I think it would have been less.

Bloomberg did plenty more for public health while mayor of New York, including imposing one of the first bans on smoking in bars and restaurants in 2003. Since then he has widened his sphere of influence, funding successful campaigns through his philanthropic foundation for sugar taxes in Mexico and Philadelphia and for curbs on smoking all over the world.

Now, appointed last year as the World Health Organisations global ambassador for non-communicable diseases meaning anything that can harm or kill you that is not infectious the eighth richest person in the world, worth an estimated $47.5bn, is taking his philosophy and his cash to 40 cities around the globe.

His offer, taken up by about 40 cities so far and officially launched on Tuesday, is $5m in assistance from Bloomberg Philanthropies as well as technical support for cities that choose to focus on one of 10 healthy lifestyle issues, including curbing sugary drink consumption, air pollution, promoting exercise and and bans on smoking. They range from affluent Melbourne in Australia to Cali and Medellin in Colombia, Accra in Ghana, Ulaanbaatar in Mongolia, Khatmandu in Nepal and Kampala in Uganda.

National and state governments collect taxes, but it is city governments that make things happen. 50% of people currently live in cities and that is projected to rise to 70% in the next decade or so. Cities are where the rubber meets the road, Bloomberg told the Guardian. The problems are in the cities and the solutions are in the cities.

Bloomberg is upbeat, indomitable and an independent thinker. He made his money in global financial services and has been a Democrat, a Republican and an independent at various times. He says he believes the war on sugar and tobacco, of which his foundation must be seen as the main global financial backer, is being won.

In parts of the world, clearly yes, and particularly on smoking, he said. In Europe nobody would have thought people wouldnt insist on smoking in an Irish bar or pub or an Italian restaurant, but the smoking campaign has really worked, reducing consumption in all of western Europe, north and south America and even in China.

But there are places where poor people live and they are still smoking and really damaging their lungs and they are going to die young. It is up to us to keep the battle going. Sugar is a little bit less developed but still working.

His attention is on non-communicable diseases more broadly now that includes air pollution and road traffic accidents as well as cigarettes, alcohol and bad food. Cities in poor countries may argue that they have too many other problems to spend time on sugary drinks, but, says Bloomberg, poverty, ill-health and poor education are all interlinked.

It will be harder to get the public behind you because they less understand the damage being done to their own health. But thats the challenge. The cities where its easy have probably already addressed the issue, he said.

Michael
Michael Bloomberg and WHO director-general Dr Margaret Chan Photograph: Bloomberg Phlilantropies

Bloomberg would not suggest it is easy to make the sort of changes he has pushed for in all these years.

I dont remember anybody objecting to the smoking ban when we put it in, although a lot of people wanted to take my picture and a lot of people gave me one finger waves, he said. If there was an easy solution to a complex problem, we wouldnt have the problem. If you want to make things better, youre going to be doing things that are tough.

The cities that commit to the Partnership for Healthy Cities can choose between curbing sugary drink consumption, passing laws to make public places smoke-free or banning cigarette advertising, cutting salt in food, using cleaner fuels, encouraging cycling and walking, reducing speeding, increasing seatbelt and helmet use, curbing drink driving or carrying out a survey to collect data on the lifestyle risks the city population runs.

Cape Town in South Africa was one of the earliest cities to commit and will focus on reducing the intake of sugary drinks. Its mayor, Patricia de Lille, says they are facing an epidemic of type 2 diabetes, caused by obesity. Diabetes is a silent killer, she said. We dont have the luxury to work by trial and error. Unfortunately we have to get it right first time.

London has also said it wants to be involved, although which issue will be the focus has not yet been revealed. It is a city with which Bloomberg says he has a complex relationship his former wife is British and his daughters hold dual nationality. He has an honorary knighthood from the Queen. He also has an honour from the City of London that he intends one day to cash in.

I do have the right to drive sheep across London Bridge and before I die, I want to do it one day at rush hour, just to see what happens, he said.

Read more: https://www.theguardian.com/society/2017/may/16/billionaire-bloomberg-to-fund-5m-public-health-projects-in-40-cities-worldwide