Better sleep for kids starts with better sleep for parents – especially after holiday disruptions to routines

Everyone knows that sleep is critical for growing children and their mental and physical health. Regular, high-quality sleep habits help children consolidate memory and learn better. A lack of sleep contributes to childhood depression, anxiety and even risk of suicide, along with physical health problems, including risk of injury. The challenge is making sure kids log those valuable zzz’s.

There are three main components of high-quality sleep for children. First, they need enough total hours – sleep duration. Sleep quality is important, too – sleeping soundly during the night with few disruptions or awakenings. And, finally, there’s sleep timing – essentially, a consistent schedule, with bedtime and risetime about the same across the whole week.

Even when you know how important good sleep is, it’s easy for sleep duration, quality and timing to get knocked off track. It can happen for infrequent reasons, such as the pleasant chaos of a holiday, or the disturbances that accompany pandemic life. Healthy sleep habits are hard to maintain for everyday mundane reasons, too, such as parent-child disagreement, busy schedules and older children’s leisurely weekend behavior. But there are ways for families to get sleep back on course.

As a child development researcher and family therapist, I study parenting and family behaviors that create healthy environments for children’s sleep patterns. In particular, I help parents to develop consistent and nurturing routines. Sleep patterns are set early, and parents play an important role in nurturing children’s perspectives and attitudes. Here’s the overarching advice I share with families, no matter the age of their kids.

yawning woman holding a glowing phone

Grown-ups can’t ignore their own sleep hygiene while expecting kids to stick with the rules.
Boy_Anupong/Moment via Getty Images

1. Set and model family values about sleep

Children are observant learners. They pay very careful attention to both the spoken and unspoken rules of their clan.

To get everyone in the household sleeping well, sleep can’t be something that only children must care about, while adults who have freedom and power joke about their own unhealthy habits. If sleep seems like punishment, rather than the gift for health that it is, children will be likely to resist it.

Adults need to talk the talk and walk the walk that sleep is a priority for everyone in the family. Be a role model. If you’ve fallen into a habit of binge-watching TV into the wee hours, for instance, work on reining that in. Use positive language about your own sleep. Pay attention to what you say, and what you communicate through your own habits, reinforcing that it’s important to the whole family to get sleep and have energy for the next day. Don’t make the mistake of discussing bedtime as a chance for adults to get distance from the kids.

2. Know your child

Remember, every kid is unique, so don’t expect one-size-fits-all sleep advice to work universally. A child’s temperament plays a significant role in the duration, quality and timing of their sleep. For instance, a feistier child may not adapt as quickly to a sleep schedule over the first year. And temperament is a pretty stable part of who your child is and will continue to be.

A parent’s job is to keep encouraging routines and setting limits – but with ongoing warmth and sensitivity about the characteristics of the one-of-a-kind child you have.

When you’re exhausted and struggling with a child’s behavior, it can be hard to stay positive. My recommendation is to use the daytime hours wisely as investment in your relationship. Be proactive about noticing the good in your kid. Remind yourself that your child is their own person, learning in lots of ways throughout the day, and that child development is a marathon, not a sprint, for positive change. Sleep regressions or other sleep difficulties, like night awakening or changes in sleep habits, are opportunities for growth, not punishment.

By laying this groundwork, it becomes easier to tap into a positive and respectful attitude during times of stress. Remind yourself that change over time is more important than control over a given moment. After all, strained parent-child relationships can actually lead to continuing sleep and behavioral problems in young children.

boy leaning into man who's kissing his head

Strengthening your relationship during the day supports healthy sleep at night.
Hill Street Studios/DigitalVision via Getty Images

3. Aim for consistency, with some flexibility

In my practice, I see two common – but opposite – mistakes that parents make around sleep.

First, many parents let go of rules and boundaries altogether. Often this happens as a result of what children bring to the equation: personal temperament or age-related phenomena. For instance, the peak in behavioral aggression that can come in toddlerhood or the shift in sleep timing that comes in adolescence can cause some parents to just throw in the towel and give up.

Alternatively, other parents become rigid. They see conflict around sleep as a struggle for power that the adult must win.

I argue that balance is key. Parents should adopt a consistent approach that fits with the sleep values they’ve been clear about all along. But they must also remain flexible to help children adapt routines to their own unique needs.

For example, all children at all ages should have a regular bedtime and risetime. However, parents may be open to a collaborative plan with older children about what those times should be, or attending to patterns and cues from younger children, working on a reasonable compromise that takes into account the needs of the individual child. Parents’ message about the importance of sleep should never waiver.

4. Manage household issues that influence sleep

child lying in bed holding up tablet

Blue light before bed prevents a young body from winding down.
Dejan_Dundjerski/iStock via Getty Images Plus

Research shows that certain problems outside the bedroom create immediate and long-term risk for children’s sleep quality. These include exposure to second-hand smoke, excessive or evening-timed blue light exposure from screens and conflict in the home. Dealing with these factors will likely pay dividends when it comes to your kids getting a good night’s sleep.

Good sleep hygiene is a family affair. It’s never too late to nudge habits in a good direction and recommit to everyone getting the rest they need. Your child’s sleep habits can be a critical building block of lifelong wellness.


This course teaches students how to connect with older adults to forge intergenerational bonds and help alleviate loneliness and isolation

Text saying: Uncommon Courses, from The Conversation

Uncommon Courses is an occasional series from The Conversation U.S. highlighting unconventional approaches to teaching.

Title of course

“Legacy Building with Older Adults – Students Re-Humanizing Health Care”

What prompted the idea for the course?

In March 2020 – as the COVID-19 pandemic was causing widespread lockdowns across the U.S. – I heard from a chaplain friend about older adults who were dying in assisted living facilities and skilled nursing homes indirectly because of social isolation and loneliness.

I was finishing my dissertation, focused on developing a curriculum to assist underrepresented and underserved university students. But after hearing about the needs of older adults, I was moved to do something to help them.

So I shifted my focus and geared my curriculum toward bridging the needs of older adults, who are also often underserved, with young people who are learning the principles of health care.

I developed the concept and then piloted it at my alma mater, the University of Toledo, with counseling and pre-med students. I then further developed it to be suitable for a course aimed at connecting university students in health-care-related fields with older adults who may feel isolated and alone.

What does the course explore?

This course covers issues in social and cultural determinants of health. Social determinants of health are the conditions in the environments where people live, play, work, attend community events – and where they age. These environments can influence what decisions people make, and the decisions they make can affect a wide range of health and quality-of-life results.

Students in this course connect with older adults once a week, for one hour, in person, via phone or through virtual visits. Throughout the course, students receive training materials in growth mindset, resiliency, mindfulness and goal-setting both for themselves and for the older adults. Students are also trained in reminiscence therapy, which is an approach to help students guide or support the older adult, reaffirming the value of the adults’ stories as they reminisce.

The sessions that involve discussions between students and older adults focus on building rapport and connecting. They also allow for an older adult to impart wisdom and share stories of their past with the students. At the end of the sessions, the older adult participants receive a digital or physical book – which I call a legacy book – that summarizes the stories the older adult shared with the student, to help reinforce that their story matters.

“Legacy builders” connect with older adults through phone calls or virtual visits.

Why is this course relevant now?

One of the most profound lessons from the pandemic has been that staying connected is important for one’s health.

Emerging research shows how social isolation and loneliness before and during the COVID-19 pandemic are correlated with many physical and mental health problems, including heart disease, diabetes, high blood pressure, heart failure, stroke, dementia, anxiety, depression and suicide.

Researchers estimate that health issues caused by isolation and loneliness increase the risk of early death by 26% and have been equated to smoking 15 cigarettes a day. One of the major ways to build a foundation for addressing isolation and loneliness is building connection between generations.

Many older adults said the most valuable part of the program for them was the relationship and friendship they developed with their legacy builder. One older adult reported back that it was uplifting to know that she could communicate well with the younger generation, and that she is now more confident in talking with her young adult grandchildren.

Older adults can also learn new technology skills from their legacy builder. Many have started texting for the first time and learned how to send pictures via text. Another learned from her legacy builder to create a Facebook account for herself, and she now stays connected with the student through Facebook.

What’s a critical lesson from the course?

The critical lesson that I hope students take away from the course is that every person has value, and it is worthwhile to listen to the person’s stories to understand what they value and why it matters so much.

I want students to learn how they can reinforce the strengths and self-efficacy in another individual by valuing their stories and lived experiences. I also want health care students in particular to understand that those they serve are the experts of their own lived experiences and have a story worth listening to. On top of that, each person has something to be learned from the other. Ultimately, both leave the conversation feeling edified and uplifted.

What materials does the course feature?

The content mainly focuses on communication and listening skills, with mindfulness, growth mindset and goal-setting strategies. Emphasis is placed on gaining skills in interviewing, connection and building rapport.

What will the course prepare students to do?

The course will prepare students to treat the people they serve and care for as human beings, whether or not the student enters the health care field.

We all are children of someone. We all have birthdays. I believe we all deserve to live a life with a sense of dignity, respect and honor. We all need connection, and, whether it be in health care or everyday life, this is a skill that must not be left out of the curriculum.


Celine Dion’s diagnosis of stiff-person syndrome brought a rare neurological diagnosis into the public eye – two neurologists explain the science behind it

The announcement by celebrated singer Celine Dion in early December 2022 that she has stiff-person syndrome – a rare neurological disorder – stunned the world and led to an outpouring of support for the French Canadian star.

Until Dion’s revelation, most people had probably never heard of the condition. Worldwide, stiff-person syndrome affects only about 1 in a million people, mostly between the ages of 20 and 50, with twice as many women as men having the disorder.

First reported in 1956, the classic and most common form of stiff-person syndrome is characterized by painful and fluctuating stiffness, mostly in the muscles of the trunk, including the back and abdomen and upper legs. Patients also experience painful muscle spasms, sometimes triggered by touch or noise.

The onset of the disorder is usually gradual, and those who suffer with it may experience progressive worsening of their symptoms. The experience of living with stiff-person syndrome varies from person to person, as it depends on the severity of symptoms and one’s response to treatment. Ultimately, stiff-person syndrome can affect the ability to walk, increasing the risk of falls and the need for assistance with a cane, walker or wheelchair.

We are specialized neurologists who treat patients with movement and neuroimmunological disorders. Because stiff-person syndrome is so rare, patients typically will receive extensive testing by multiple doctors before being diagnosed with the condition. In our experience, it is not uncommon for us to be the third or fourth doctor whom individuals seek out for an evaluation and diagnosis.

Many stiff-person syndrome patients can be treated effectively with medication and immunotherapy.

Biological underpinnings

Stiff-person syndrome is different from other neurological disorders like Parkinson’s disease or multiple sclerosis. Although in each of these conditions people can experience stiffness and cramps, the underlying cause of symptoms is different in all three.

Stiff-person syndrome is an autoimmune disorder – a broad term to describe when the body’s natural defense system mistakenly attacks the person’s own body.

In the late 1980s, researchers discovered what are known as “auto-antibodies” related to stiff-person syndrome. Antibodies are a critical part of the body’s defense system to help fight off infection or anything that appears to be foreign. So auto-antibodies are those that mistakenly target specific receptors, cells or organs of one’s own body. But it was the discovery of one key auto-antibody that gave physicians important insights into the disease process of stiff-person syndrome and how to manage it with various medications and immunotherapy.

The human nervous system is comprised of various pathways that prevent too much or too little muscle activation. An enzyme called glutamic acid decarboxylase, or GAD, helps convert a neurotransmitter – a chemical that nerve cells use to communicate – called glutamate to gamma-aminobutyric acid, or GABA. This process plays an important role in preventing excessive muscle activity.

Researchers have found that 60% to 80% of people with classic stiff-person syndrome have elevated levels of the auto-antibody called anti-GAD. Antibodies against GAD prevent the formation of GABA, which can then lead to excessive muscle activity such as stiffness.

While anti-GAD appears to be the most common auto-antibody in those with classic stiff-person syndrome, recent discoveries have revealed additional antibodies that can also result in the condition.

Treatment options

To date, there is no cure for stiff-person syndrome. Current treatments are aimed at improving the stiffness and spasms, and modulate the immune system.

Different types of muscle relaxants are used to treat the muscle tightness and spasms. And some anticonvulsants, used to treat epilepsy, have also been shown to reduce muscle spasms.

Doctors may also use treatments that target the immune system. Evidence is accumulating that one treatment, known as intravenous immunoglobulins, may be effective. Immunoglobulins, or antibodies, collected from thousands of healthy donors are given intravenously at regular intervals to patients with stiff-person syndrome to help improve their symptoms.

Alternate treatments for those who do not respond to these approaches may include antibody therapy with the drug rituximab, or a procedure called plasma exchange in which the auto-antibodies are filtered out. However, evidence for the effectiveness of these therapies is lacking.

Living with the diagnosis

Doctors like us still have a lot to learn about stiff-person syndrome, but increasing awareness of this condition may lead to a more timely diagnosis and help accelerate research. And as more people learn about it, they may be more likely to recognize the symptoms and seek treatment earlier.

Patients with milder disease or those who respond well to treatment may continue functioning independently while they continue medical therapy. For others, symptoms may not be completely controlled and could lead to disability.

We recognize that the journey to a diagnosis of stiff-person syndrome can be challenging and receiving the diagnosis can be life-altering. But through capable teams of doctors and other support systems for people who are diagnosed with stiff-person syndrome, researchers like us hope to help patients continue living life to the fullest.


What is voluntary sterilization? A health communication expert unpacks how a legacy of forced sterilization shapes doctor-patient conversations today

Sterilization is a safe and effective form of permanent birth control used by more than 220 million couples around the world. Despite its prevalence, however, patients seeking sterilization from their doctors often face a surprising number of challenges.

In men, the sterilization process is known as a vasectomy, which involves severing the tubes that carry the supply of sperm to the semen. In women, sterilization involves a procedure called tubal ligation. In this form of permanent birth control, the fallopian tubes are severed – or ligated – preventing eggs produced by the ovaries from traveling through the fallopian tubes to fertilize an egg. Vasectomies and tubal ligations can be reversed in some cases, although success rates vary widely.

A 2018 study found that female sterilization is the No. 1 form of contraception in the U.S., used by nearly 1 in 5 women ages 15 to 49. And a partner’s vasectomy is the fifth leading contraceptive, relied on by 5.6% of women in that age group, after birth control pills, male condoms and intrauterine devices, or IUDs.

I’m a scholar of health communication with expertise in women’s health issues and interactions between patients and doctors. My work explores how patients manage the stigma associated with seeking sterilization and communicate with others about their reproductive decisions. My research also illuminates why patients find talking about sterilization with their doctors so challenging.

Illustrated anatomical examples of vasectomy on the left and tubal ligation on the right.

The two common forms of sterilization, or permanent birth control, are vasectomy for men and tubal ligation for women.
elenabs/iStock via Getty Images Plus

Access to sterilization

Ethical guidelines from the American College of Obstetricians and Gynecologists recommend that doctors should respect a female patient’s wishes as a matter of “reproductive justice” when deciding whether to approve their request for voluntary sterilization. The American Urological Association, on the other hand, does not appear to offer ethical guidelines concerning the provision of vasectomy services for male patients.

Yet research has documented that patients seeking sterilization procedures, especially women, are sometimes told that their doctors will not perform the procedure because of the person’s age, number of children or potential risk of regret, among other factors. Providers may also refuse to perform sterilization procedures for other reasons, including fear of legal culpability, backlash from the medical community or conscientious refusal. The latter means that a doctor cannot be compelled to provide a medical service that goes against their best judgment or personal convictions.

This hesitancy to approve sterilization requests reflects the tension over forced sterilization in the past.

How history has shaped views on sterilization

Perceptions of sterilization in the U.S. have been marred by a dark history of eugenics, in which racist ideas about who ought to have children have shaped reproductive policies and doctors’ reproductive counseling. And these views have given rise to the term “voluntary” sterilization, meant to contrast with the “involuntary” – or forced – sterilization of earlier decades.

From the late 1800s until the late 1940s, eugenicist movements sought to preserve racial purity by limiting the breeding of people who were considered “unfit” and promoting the proliferation of those who were white and of European descent, from middle or upper classes and considered able-bodied and of sound mind. Widespread federally funded involuntary sterilizations continued in the U.S. until 1979.

In contrast, women who were poor, disabled, immigrant, Black, Hispanic or Indigenous who sought to have children often faced coercive or forced sterilization, sometimes without their consent or knowledge.

Women of color were frequent targets of forced sterilization campaigns during the eugenics movement of the early 1900s in the U.S.

When women who were considered “desirable” sought to limit their family size or forgo having children altogether through voluntary sterilization, they were sometimes denied the procedure. That trend continues today despite ethical guidelines recommending otherwise, since doctors cannot be compelled to perform medical procedures they find objectionable. Furthermore, sterilization services, like other reproductive health services, are often not offered at religiously affiliated hospitals.

Disparities in sterilization access

These cultural views contribute to disparities in access to sterilization that persist today.

In 1979, federal legislation went into effect to halt Medicaid-funded involuntary sterilizations and to limit Medicaid-funded sterilization services to any person of sound mind over the age of 21. But ironically, this legislation – which was designed to prohibit involuntary sterilization – now restricts some patients who are seeking sterilization.

Laws vary widely from state to state, meaning that where you live dictates how accessible voluntary sterilization is to you. For example, in Kansas, the most legally restrictive U.S. state, individual doctors are not held accountable for refusing to perform sterilizations, even if they are medically necessary. In addition, medical facilities and individual doctors can also legally refuse to provide information or refer patients elsewhere to procure the procedure.

In contrast, in California – a state that has progressive reproductive health care rights – a right to voluntary sterilization is enshrined in law. This means that patients cannot be discriminated against because of factors like age or the number of children they have. Yet forced sterilization is still legal in California for patients with developmental disabilities who are under conservatorship.

This patchwork of policies across U.S. states creates room for bias in the patient counseling process. Today, when Black and Native American women seek sterilization voluntarily, they are still more than twice as likely as non-Hispanic white women to be approved for the procedure by their doctors. In my view, this shows that decisions about who can be sterilized are still inherently attached to racial bias as well as gender and class bias.

The implications of the fall of Roe

In the aftermath of the fall of Roe v. Wade, which overturned nearly 50 years of abortion rights, people living in at least 13 U.S. states may now be in a double bind: unable to find a doctor who will grant them the permanent sterilization they desire to prevent an unwanted pregnancy, and also unable to access an abortion should a pregnancy occur.

With abortion access reduced in many states after the Supreme Court’s ruling overturning Roe v. Wade, it’s more important than ever for patients to be able to discuss voluntary sterilization freely with their medical providers.


China wants more people to eat potatoes – how changing national diets could help fix our global food crisis. Podcast

How do you get a country to change its national diet? That’s what China has been trying by introducing potato as a staple as part of an effort to improve food security. In this episode of The Conversation Weekly, we talk to three experts about why countries need to shift what their citizens eat, and what the optimum diet for our planet might be.

Chinese farmers plant the largest amount of potatoes in the world, and the country produces about 20% of the global potato output. But while fresh potatoes are a traditional part of the Chinese national diet, they’re viewed as a vegetable rather than as a staple, and China’s per capita consumption of potato is below the global average.

In 2015, the Chinese government decided to try and change that. It introduced a policy to promote the potato as the country’s fourth staple alongside rice, wheat and maize. As Xiaobo Xue Romeiko, a professor at the University at Albany, State University of New York in the US explains, behind the strategy lay concerns over food security and the availability of arable land. “Potato is more versatile and it can be grown in marginal land which is not suitable as our arable land,” she says.

Potatoes are also less energy intensive to grow and, according to her research, have the potential to reduce greenhouse gas emissions from food production in China, particularly if it introduces varieties with higher yields.

Other countries may need to follow China’s lead. As pressures mount on the global food system thanks to climate change, the COVID-19 pandemic and Russia’s invasion of Ukraine, food security has become a central issue for many more governments. “At the moment the food system really is under the highest stress,” says Paul Behrens, associate professor in environmental change at Leiden University in the Netherlands. In 2022, the UN’s food price index, which measures monthly changes in international prices of a basket of food commodities, has hit record highs.

Behrens says that many of the responses from governments so far have been short-sighted. “I don’t see an awful lot of governments considering the fundamental system transitions that are needed to really secure food systems and make them more resilient to future climatic change.” He argues that countries need to radically change their nations’ diets, specifically in high-income nations where the over-consumption of meat is driving much of the interlocking crisis.

So what would an optimum diet that is nutritious and sticks within planetary boundaries actually look like? A group of researchers put their heads together to find out and came up with the EAT-Lancet diet, also known as the planetary health diet.

One of them was Marco Springman, a professor of climate change food systems and health at the London School of Hygiene and Tropical Medicine in the UK, and also a senior researcher at the University of Oxford. “You shouldn’t have more than one serving of red meat per week. Not more than two servings of poultry per week, not more than two servings of fish per week. And if you have dairy, not more than one serving per day,” he says. Counting that up, that means being vegetarian or vegan on two days a week.

To find out more about where responsibility lies to shift national diets, listen to the full episode on The Conversation Weekly podcast.

This episode was produced by Mend Mariwany and Katie Flood, with sound design by Eloise Stevens. It was written by Mend Mariwany. Gemma Ware is the show’s executive producer. Our theme music is by Neeta Sarl.

You can find us on Twitter @TC_Audio, on Instagram at theconversationdotcom or via email. You can also sign up to The Conversation’s free daily email here. A transcript of this episode will be available soon.

Listen to The Conversation Weekly via any of the apps listed above, download it directly via our RSS feed, or find out how else to listen here.


Pharma’s expensive gaming of the drug patent system is successfully countered by the Medicines Patent Pool, which increases global access and rewards innovation

Biomedical innovation reached a new era during the COVID-19 pandemic as drug development went into overdrive. But the ways that brand companies license their patented drugs grant them market monopoly, preventing other entities from making generics so they can exclusively profit. This significantly limits the reach of lifesaving drugs, especially to low- and middle-income countries, or LMICs.

I am an economist who studies innovation and digitization in health care markets. Growing up in a developing region in China with limited access to medications inspired my interest in institutional innovations that can facilitate drug access. One such innovation is a patent pool, or a “one-stop shop” where entities can pay one low price for permission to make and distribute all the treatments covered by the pool. My recent research found that a patent pool geared toward public health can spur not only generic drug access in LMICs but also innovation for pharmaceutical companies.

Patent pools can help increase access to expensive drugs.

Drug patents in the global landscape

Patents are designed to provide incentives for innovation by granting monopoly power to patent holders for a period of time, typically 20 years from the application filing date.

However, this intention is complicated by strategic patenting. For example, companies can delay the creation of generic versions of a drug by obtaining additional patents based on slight changes to its formulation or method of use, among other tactics. This “evergreens” the company’s patent portfolio without requiring substantial new investments in research and development.

Furthermore, because patents are jurisdiction-specific, patent rights granted in the U.S. do not automatically apply to other countries. Firms often obtain multiple patents covering the same drug in different countries, adapting claims based on what is patentable in each jurisdiction.

To incentivize technology transfer to low- and middle-income countries, member nations of the World Trade Organization signed the 1995 Agreement on Trade-Related Aspects of Intellectual Property Rights, or TRIPS, which set the minimum standards for intellectual property regulation. Under TRIPS, governments and generic drug manufacturers in low- and middle-income countries may infringe on or invalidate patents to bring down patented drug prices under certain conditions. Patents in LMICs were also strengthened to incentivize firms from high-income countries to invest and trade with LMICs.

Determining what is patentable can be complicated.

The 2001 Doha Declaration clarified the scope of TRIPS, emphasizing that patent regulations should not prevent drug access during public health crises. It also allowed compulsory licensing, or the production of patented products or processes without the consent of the patent owner.

One notable example of national patent law in practice after TRIPS is Novartis’ anticancer drug imatinib (Glivec or Gleevec). In 2013, India’s Supreme Court denied Novartis’s patent application for Glivec for obviousness, meaning both experts or the general public could arrive at the invention themselves without requiring much skill or thought. The issue centered on whether new forms of known substances, in this case a crystalline form of imatinib, were too obvious to be patentable. At the time, Glivec had already been patented in 40 other countries. As a result of India’s landmark ruling, the price of Glivec dropped from 150,000 INR (about US$2,200) to 6,000 INR ($88) for one month of treatment.

Patent challenges and pools

Although TRIPS seeks to balance incentives for innovation with access to patented technologies, issues with patents still remain. Drug cocktails, for example, can contain multiple patented compounds, each of which can be owned by different companies. Overlapping patent rights can create a “patent thicket” that blocks commercialization. Treatments for chronic conditions that require a stable and inexpensive supply of generics also pose a challenge, as the cost burden of long-term use of patented drugs is often unaffordable for patients in low- and middle-income countries.

One solution to these drug access issues is patent pools. In contrast to the currently decentralized licensing market, where each technology owner negotiates separately with each potential licensee, a patent pool provides a “one-stop shop” where licensees can get the rights for multiple patents at the same time. This can reduce transaction costs, royalty stacking and hold-up problems in drug commercialization.

Diagram of licensing markets with and without a patent pool

Patent pools create a one-stop shop for multiple patients, allowing multiple licensees to enter the market.
Lucy Xiaolu Wang, CC BY-NC-ND

Patent pools were first used in 1856 for sewing machines and were once ubiquitous across multiple industries. Patent pools gradually disappeared after a 1945 U.S. Supreme Court decision that increased regulatory scrutiny, hindering the formation of new pools. Patent pools were later revived in the 1990s in response to licensing challenges in the information and communication technology sector.

The Medicines Patent Pool

Despite many challenges, the first patent pool created for the purpose of promoting public health formed in 2010 with support from the United Nations and Unitaid. The Medicines Patent Pool, or MPP, aims to spur generic licensing for patented drugs that treat diseases disproportionately affecting low- and middle-income countries. Initially covering only HIV drugs, the MPP later expanded to include hepatitis C and tuberculosis drugs, many medications on the World Health Organization’s essential medicines list and, most recently, COVID-19 treatments and technologies.

But how much has the MPP improved drug access?

I sought to answer this question by examining how the Medicines Patent Pool has affected generic drug distribution in low- and middle-income countries and biomedical research and development in the U.S. To analyze the MPP’s influence on expanding access to generic drugs, I collected data on drug licensing contracts, procurement, public and private patents and other economic variables from over 100 low- and middle-income countries. To analyze the MPP’s influence on pharmaceutical innovation, I examined data on new clinical trials and new drug approvals over this period. This data spanned from 2000 to 2017.

Diagram of the Medicines Patent Pool licensing structure

The Medicines Patent Pool works as an intermediary between branded drug companies and generic licensees, increasing access to drugs.
Lucy Xiaolu Wang, CC BY-NC-ND

I found that the MPP led to a 7% increase in the share of generic drugs supplied to LMICs. Increases were greater in countries where drugs are patented and in countries outside of sub-Saharan Africa, where baseline generic shares are lower and can benefit more from market-based licensing.

I also found that the MPP generated positive spillover effects for innovation. Firms outside the pool increased the number of trials they conducted on drug cocktails that included MPP compounds, while branded drug firms participating in the pool shifted their focus to developing new compounds. This suggests that the MPP allowed firms outside the pool to explore new and better ways to use MPP drugs, such as in new study populations or different treatment combinations, while brand name firms participating in the pool could spend more resources to develop new drugs.

The MPP was also able to lessen the burden of post-market surveillance for branded firms, allowing them to push new drugs through clinical trials while generic and other independent firms could monitor the safety and efficacy of approved drugs more cheaply.

Overall, my analysis shows the MPP effectively expanded generic access to HIV drugs in developing countries without diminishing innovation incentives. In fact, it even spurred companies to make better use of existing drugs.

Technology licensing for COVID-19 and beyond

Since May 2020, the Medicines Patent Pool has become a key partner of the World Health Organization COVID-19 Technology Access Pool, which works to spur equitable and affordable access to COVID-19 health products globally. The MPP has not only made licensing for COVID-19 health products more accessible to low- and middle-income countries, but also helped establish an mRNA vaccine technology transfer hub in South Africa to provide the technological training needed to develop and sell products treating COVID-19 and beyond.

Licensing COVID-19-related technologies can be complicated by the large amount of trade secrets involved in producing drugs derived from biological sources. These often require additional technology transfer beyond patents, such as manufacturing details. The MPP has also worked to communicate with brand firms, generic manufacturers and public health agencies in low- and middle-income countries to close the licensing knowledge gap.

Questions remain on how to best use licensing institutions like the MPP to increase generic drug access without hampering the incentive to innovate. But the MPP is proving that it is possible to align the interests of Big Pharma and generic manufacturers to save more lives in developing countries. In October 2022, the MPP signed a licensing agreement with Novartis for the leukemia drug nilotinib – the first time a cancer drug has come under a public health-oriented licensing agreement.


More than 4 in 5 pregnancy-related deaths are preventable in the US, and mental health is the leading cause

Preventable failures in U.S. maternal health care result in far too many pregnancy-related deaths. Each year, approximately 700 parents die from pregnancy and childbirth complications. As such, the U.S. maternal mortality rate is more than double that of most other developed countries.

The Department of Health and Human Services declared maternal deaths a public health crisis in December 2020. Such calls to action by the U.S. Surgeon General are reserved for only the most serious of public health crises.

In October 2022, the Centers for Disease Control and Prevention released new data gathered between 2017 and 2019 that further paints an alarming picture of maternal health in the U.S. The report concluded that a staggering 84% of pregnancy-related deaths are preventable.

However, these numbers don’t even reflect how widespread this problem could be. At present, only 39 states have dedicated committees in place to review maternal deaths and determine whether they were preventable; of those, 36 states were included in the latest CDC data.

I am a therapist and scholar specializing in mental health during the perinatal period, the time during pregnancy and postpartum. Research has long demonstrated significant mental health risks associated with pregnancy, childbirth and the year following childbirth. The CDC’s report now makes it clear that mental health conditions are an important factor in many of these preventable deaths.

A closer look at the numbers

The staggering number of preventable maternal deaths – 84% – from the CDC’s most recent report represents a 27% increase from the agency’s previous report, from 2008 to 2017. Of these pregnancy-related deaths, 22% occur during pregnancy, 13% during childbirth and 65% during the year following childbirth.

This raises the obvious question: Why are so many preventable pregnancy-related deaths occurring in the U.S., and why is the number rising?

For a pregnancy-related death to be categorized as preventable, a maternal mortality review committee must conclude there was some chance the death could have been avoided by at least one reasonable change related to the patient, community, provider, facility or systems of care.

The most commonly identified factors in these preventable deaths have been those directly related to the patient or their support networks, followed next by providers and systems of care. While patient factors may be most frequently identified, they are often dependent on providers and systems of care.

Take, for instance, the example of a new mother dying by suicide from a mental health condition, such as depression. Patient factors could include her lack of awareness about the warning signs of clinical depression, which she may have mistaken for difficulties with the transition to parenthood and perceived personal failures as a new parent.

As is often the case, these factors would have directly related to the inaction of health care providers, such as a failure to screen for mental health concerns, delays in diagnosis and ineffective treatment. This type of breakdown – which is common – would have been made worse by poor coordination of care between providers across the health care system.

This example illustrates the complexities of the failures and preventable outcomes in the maternal health care system.

The U.S. has a far higher rate of pregnancy-related deaths than other developed nations.

The role of mental health

In the CDC’s latest report, mental health conditions are the overall most frequent cause of pregnancy-related death. Approximately 23% of deaths are attributed to suicide, substance use disorder or are otherwise associated with a mental health condition. The next two leading causes are hemorrhage and cardiac conditions, which combined contribute to only slightly more deaths than mental health conditions, at about 14 and 13%, respectively.

Research has long shown that 1 in 5 women suffer from mental health conditions during pregnancy and the postpartum period, and that this is also a time of increased risk for suicide. Yet, mental illness – namely, depression – is the most underdiagnosed obstetric complication in America. Despite some promising reductions in U.S. suicide rates in the general population over the last decade, maternal suicide has tripled during this same time period.

As it relates to maternal substance use, this issue is also worsening. In recent years, almost all deaths from drug overdose during pregnancy and the postpartum period involved opioids. A review from 2007 to 2016 found that pregnancy-related deaths involving opioids more than doubled.

Many of these issues stem from the fact that up to 80% of women with maternal mental health concerns are undiagnosed or untreated.

Barriers to care

In 2021, the first national data set of its kind showed that less than 20% of prenatal and postpartum patients were screened for depression. Only half of those who screened positive received follow-up care.

Research has long demonstrated widespread barriers and gaps in maternal mental health care. Many health care providers do not screen for mental health concerns because they do not know where to refer a patient or how to treat the condition. In addition, only about 40% of new mothers even attend their postpartum visit to have the opportunity for detection. Non-attendance is more common among higher-risk populations of postpartum women, such as those who are socially and economically vulnerable and whose births are covered by Medicaid.

Medicaid covers around 4 in 10 births. Through Medicaid benefits, pregnant women are covered for care related to pregnancy, birth and associated complications, but only up to 60 days postpartum. Not until 2021 did the American Rescue Plan Act begin extending Medicaid coverage up to one year postpartum.

But as of November 2022, only 27 states have adopted the Medicaid extension. In the other states, new mothers lose postpartum coverage after just 60 days. This matters a great deal because low-income mothers are at a greater risk for postpartum depression, with reported rates as high as 40% to 60%.

In addition, the recent CDC report showed that 30% of preventable pregnancy-related deaths happened between 43 and 365 days postpartum – which is also the time frame suicide most commonly occurs. Continued Medicaid expansion would reduce the number of uninsured new parents and rates of maternal mortality.

Another challenging barrier to addressing maternal mental health is the criminalization of substance use during pregnancy. If seeking care exposes a pregnant person to the possibility of criminal or civil pentalties – including incarceration, involvement with child protective services and the prospect of separation from their baby – it will naturally dissuade them from seeking treatment.

At this time, 24 states consider substance use during pregnancy to be child abuse, and 25 states require health care professionals to report suspected prenatal drug use. Likewise, there are also tremendous barriers in the postpartum period for mothers seeking substance use treatment, due in part to the lack of family-centered options.

With all these barriers, many pregnant and new mothers may make the difficult decision to not engage in treatment during a critical window for intervention.

Looking ahead

While the information described above already paints a dire picture, the CDC data was collected prior to two major events: the COVID-19 pandemic and the fall of Roe v. Wade, which overturned nearly 50 years of abortion rights. Both of these events have exacerbated existing cracks in the health care system and, subsequently, worsened the maternal health in the U.S.

In my view, without radical changes to maternal health care in the U.S., starting with how mental health is treated throughout pregnancy and postpartum, it’s likely parents will continue to die from causes that could otherwise be prevented.


Abuse in women’s professional soccer was an ‘open secret’ – the ‘bystander effect’ and structural barriers prevented more players from speaking out

An investigation has found that widespread abuse of players in U.S. women’s professional soccer existed despite some of the behavior of coaches being “an open secret.”

Based on more than 200 interviews, the report – led by former acting U.S. Attorney General Sally Yates – highlighted systemic verbal and emotional abuse against players, and sexual misconduct by coaches.

The allegations open a number of important questions regarding how such behavior was allowed to continue in a post-#MeToo society and after high-profile instances of abuse in other U.S. sports, notably women’s gymnastics.

However, as social scientists who study sexuality and violence, we have another question: What are the barriers preventing people from reporting instances of abuse?

The role of bystanders

The report into women’s soccer notes that although certain players did “doggedly” report misconduct, others were hesitant to come forward. Many players mentioned structural barriers to reporting. For example, some said that even if they had wanted to report misconduct, “they did not know how or where to make their report.” Others thought it was “futile” to report misconduct, given the failure by teams and the league to address the issue. These statements indicate serious structural issues within women’s soccer that need to be addressed by those in power.

Still, some players did not feel a sense of responsibility for taking action. These players said they thought it was “not their story to tell” or they did not want to act on “rumors.”

This reflects what the research tells us about a phenomenon known as the “bystander effect.”

Over 50 years of research has documented a bystander effect in which witnesses fail to intervene, often because they assume someone else will take action. Research applying the bystander effect specifically to sexual assault and misconduct has revealed that witnesses fail to intervene for a number of common reasons: they do not notice the misconduct; do not believe it is their responsibility to intervene; do not believe they have the skills to intervene; or are inhibited by the belief that those around them will negatively judge them for intervening.

Witnesses to sexual misconduct often fail to intervene for one or more of those reasons.

The report on women’s soccer found that players often didn’t think it was their responsibility to report, or they feared retaliation if they did – often through unfavorable trades to other teams.

What is clear from the report is that some sort of “bystander training” is needed in women’s soccer to help stop further abuse. Such training has proved to be effective with other populations, such as college students.

Bystander training programs strive to sensitize people to the warning signs of sexual assault and misconduct – like a young man leading a young woman into an isolated place – and provide them with skills so that they will know how to intervene when necessary. For example, these programs might teach participants to speak up when hearing sexist jokes or witnessing sexual harassment, walk a friend home when he or she has had too much to drink, start a conversation with a young woman who appears to be uncomfortable with her date, or call the police.

Bystander training appears to help

We were curious about the effects these bystander programs have on the behavior of witnesses to sexual misconduct. So in a 2018 study, we analyzed data from over 6,000 college students across the United States and found that programs designed to prevent sexual assault by increasing onlookers’ interventions do have a meaningful effect on bystander behavior. Compared to peers who did not participate in a bystander program, college students who did participate reported a greater ability to intervene and greater intentions to intervene, should a situation require it.

Most important, those who participated in a bystander program reported actually engaging in more bystander intervention behaviors than those who did not participate in a program. On average, these participants reported two more instances of bystander intervention in the months following the bystander program than their peers who did not attend a bystander program. Simply put, bystander programs are successful at encouraging bystanders to intervene when witnessing sexual misconduct or its warning signs.

Although we looked specifically at college students, we believe the findings apply to other populations.

The report of widespread abuse in women’s soccer reminds us that sexual misconduct is common in society and that its prevention is a communal responsibility.

As researchers who study sexuality, violence and prosocial behavior, we believe that bystanders need to keep their eyes open and speak up on behalf of potential victims. Our research demonstrates that having been educated about bystander strategies leads to greater intervention. As a society, we should strive to become better bystanders by noticing warning signs, knowing strategies to intervene and remembering that we have a collective responsibility to prevent sexual misconduct and assault.

Editor’s note: Portions of this article originally appeared in a previous article published on Oct. 5, 2018.


No, it’s not just sugary food that’s responsible for poor oral health in America’s children, especially in Appalachia

Brushing your teeth is essential for maintaining optimal oral health, but like most aspects of health, the full story is more complicated.

As directors of the Center for Oral Health Research in Appalachia, we know firsthand that inequalities exist when it comes to oral health, including in children. Some people or groups have considerably more oral health problems than others because of a combination of factors beyond personal dental hygiene.

For example, Appalachia – which stretches from the northern part of Mississippi, Alabama and Georgia up through the southern part of New York, and includes all of West Virginia – has one of the greatest burdens of oral health problems per person in the U.S.

October is National Dental Hygiene Month, which provides an opportunity to draw more attention to this chronic but often preventable problem.

Oral health defined

While the terms dental hygiene and dental health are largely focused on the teeth and gums, oral health is more comprehensive. According to the FDI World Dental Federation, oral health encompasses the proper functioning of the mouth, including one’s “ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions” without pain or discomfort. Oral health affects not only a person’s teeth but also overall well-being and quality of life.

Tooth decay affects children all across the U.S., but far too little attention is paid to how preventable and treatable it is. Cavities, or caries, are the most common chronic disease in kids – five times more common than asthma and seven times more common than environmental allergies, despite being preventable. More than 40% of children have tooth decay when they start kindergarten.

However, people who have less formal education or lower incomes, marginalized ethnic and racial groups and those living in more rural areas, such as Appalachia, tend to have more oral health problems than others, and at younger ages. The greater prevalence of childhood tooth decay in specific populations is not only an inequity but also a serious public health problem. Oral health problems early in life extend into adulthood and can be lifelong.

A map of Appalachian states indicating economic status of all counties.

County economic status in Appalachia, fiscal 2023.
Appalachian Regional Commission

Beyond personal dental hygiene

It’s a common misconception that consuming sugary foods and beverages is the only cause of tooth decay. While that is undoubtedly a problem, there’s much more to good oral health. It includes consistent brushing and flossing; eating healthy foods, like fresh fruits and vegetables; avoiding tobacco products; and wearing mouth guards while playing certain sports. Regular visits for dental care are also critical, as they provide an opportunity for cleanings and preventive care.

Oral health in kids is a reflection of their overall health and that of their families; however, in addition to behavioral and social influences, genetic and other biological factors are also at play. For example, genes influencing taste preferences – such as those for sweet foods – are associated with cavities on certain teeth and surfaces of teeth. It’s possible that our taste genes predispose some of us to prefer consuming sweet foods and drinks, which is a risk factor for developing cavities.

Bacteria and other microorganisms in the mouth, known as the oral microbiome, also play a role. Some parts of the oral microbiome are beneficial and even required for good oral health. Other bacteria are invaders that can lead to oral diseases.

Just as important are environmental factors, including air quality, access to healthy foods, the cost of dental care, access to transportation to and from the dentist, and school-based programs that encourage good oral hygiene among children. Whether one lives in a community with fluoridated water or otherwise has access to fluoride treatments is also important, as fluoride helps to prevent tooth decay. Water quality in communities is another factor. If the only available water is toxic or unappealing, people may turn to soda and other sugar-sweetened beverages.

Additionally, mothers’ perceived social support and parents’ social networks can influence their children’s oral health too. Among mothers with a high number of cavities, the availability of someone to talk to about problems has been shown to be associated with fewer cavities in their children.

Little girl and dad brushing their teeth together.
Parents can help improve their kids’ oral health by modeling good oral hygiene themselves.
Nitat Termmee/Moment via Getty Images

Role modeling good oral health

Parents’ and caregivers’ own oral health greatly influences that of their children. Kids and their parents typically drink the same water and many of the same beverages and eat a lot of the same foods. Children often follow the dental hygiene habits of their parents as well. Children typically take on their parents’ and caregivers’ feelings about dental visits too – whether it’s comfort, stress, anxiety or fear.

Parents’ thoughts about dental care influence their decisions about preventive care. Dental fear and anxiety can lead to delay or avoidance of dental appointments for themselves and their children. “Oral health values” – the importance one places on maintaining natural and good-looking teeth – affect decision-making about dental hygiene and professional dental care. Depression in parents can even influence their own dental hygiene and oral health and that of their children.

Dental problems in kids can lead to missed school, pain and embarrassment about visible decay, and missing or crooked teeth. Teeth and gums are critical for speaking, eating, development and appearance. They affect social functioning and one’s enjoyment of food. Kids’ dental problems affect their parents, too, as they can result in parents’ unexpectedly missing work to bring their child to the dentist.

What can be done to improve oral health?

To a great extent, dental problems in kids can be prevented. Some preventive steps are affected by economic, educational and health care factors. One of the best things parents or caregivers can do is to establish a relationship for their child with a dental practitioner, practice, office or clinic to promote prevention but also to provide emergency care if needed. Within the oral health world, this relationship is called a “dental home.” The American Academy of Pediatric Dentistry and other professional health organizations recommend that children see an oral health care provider before age 1 or at the emergence of the first tooth. Access to dental treatment, especially preventive care, has been shown to improve oral health in families and their communities.

System-level changes are surely needed too. Since cost affects whether parents can provide their children with routine dental care, greater access to dental insurance is an important step to ensuring equal access and reducing oral health inequities. Integrating oral health practices into schools and educational programs is another system-level change that would benefit all children regardless of their family’s socioeconomic status.

Oral health is a critical factor in a person’s overall health. Teaching kids this early can help them develop a healthy smile and care for their pearly whites throughout their lives.


Hurricane Ian: Older adults have many reasons for not evacuating – here’s why it’s important to check on aging neighbors

As mandatory evacuations for Hurricane Ian began in Florida and the warnings about damaging wind and flooding intensified, I called my aging parents to check in.

Being a disaster researcher, my concern for them was already in high gear, even though they weren’t directly in an evacuation zone. My dad takes medications that require refrigeration, special needles and a sterile environment to administer. My mom is in the early stages of dementia. Both are not as spry as they used to be.

I heard the worry in their voice about their safety, about my dad’s health needs, and about what might happen to their house.

As I sat at home hundreds of miles away, I thought about all the reasons why leaving isn’t always a clear decision.

A woman sits on a porch with a dog as floodwater covers the stairs. A sign reading 'private property: no tresspassing' is on the house.
Concerns about health and home security are two reasons older adults might fear evacuating during disasters like Hurricane Harvey in 2017.
Scott Olson/Getty Images

As in other recent hurricanes, some residents will choose to ride out the storm in their homes, despite recommendations to evacuate. The risks can be high – sheltering in place during a major hurricane, with flooding rainfall, storm surge and powerful winds, can put lives at risk. The damage to neighborhoods after the storm, including loss of power can also be dangerous, and supplies can be hard to find.

It is easy to dismiss those who stay in the storm’s path as uninformed, but for older adults, evacuating can come with its own consequences. Researchers have found that older adults may not be well prepared to address the health risks that occur during disasters. Being ready to either evacuate or stay put is part of that.

Understanding and addressing the underlying reasons behind why seniors do not evacuate can help to improve disaster response for this population.

Evacuation can be expensive

For seniors who live on a fixed income, evacuation may not always be feasible for their budget. Evacuating has many associated – and hidden – costs.

Transportation, food and housing can add up quickly. Shelters may be intimidating.

A man stands in the door of a mobile home as his dog runs out to greet two police officers.
Pets are another reason some people don’t evacuate, even when officers urge them to leave.
AP Photo/Gerald Herbert

A survey we conducted in 2020 with 2,256 older adults across the U.S. found that about 1 in 4 (24%) indicated it would be difficult to afford to stay somewhere else for a week if necessary. And with so many storms happening so frequently, costs related to multiple evacuations can quickly add up.

Concerns about taking care of chronic illness

Up to 60% of older adults in America have more than one chronic health condition. Diabetes, kidney disease, and even cancer are prime examples of conditions that require daily attention in order to keep an optimum level of health.

When our research team surveyed older adults who use essential medical equipment that requires electricity, just 25% had an alternative power source for that equipment.

Further, oxygen tanks, home dialysis machines, chemotherapy and strict dietary and medication regimens can be a part of life-saving daily routines. Without this equipment, breakdowns in health can occur, which can have long-lasting effects on health.

An older man lies on a cot in an evacuation center. He has a wrist band and is clutching a bottle of water.
Shelters can be intimidating for older residents.
AP Photo/Gerald Herbert

Older adults may be hesitant to break these care routines, or worry about being away from important equipment that is not portable.

Mobility issues

Difficulty moving around, losing balance and unsteadiness are common changes that occur with aging. The risk of falling or injury while moving more than usual due to the storm preparations is a considerable challenge.

For seniors with limited mobility, the challenges of getting prepared to evacuate and then moving out of their homes and into a crowded and chaotic situation can be a serious deterrent.

Social isolation

Social isolation is also a well-documented issue among older adults. Older adults who live alone, who are caregivers for loved ones or who don’t speak English are especially at risk. These individuals may lack the awareness and resources to evacuate.

That’s why evacuation planning guidelines recommend checking in on neighbors to see if they need help. Programs, run by governments or community groups, also exist in some areas to help seniors evacuate.

Trusting in past experiences

Many seniors have chosen to stay home through decades of strong storms and hurricanes. Hurricane Ian may not seem any different – but it is.

The Gulf Coast near Tampa has not seen direct impacts of a hurricane in more than 100 years. The tendency to underestimate the severity of a disaster and its potential effects is called normalcy bias. The idea that “if it hasn’t happened before, why should it happen now?” is one that keeps many at home rather than evacuating.

Bare shelves that once held bottled water in a store with shoppers.
Store shelves in Orlando were bare of bottled water and other storms provisions a few days before Hurricane Ian’s arrival. The crowds can be difficult for some older residents to manage.
AP Photo/John Raoux

Florida Attorney General Ashley Moody told reporters, “This could be the storm that we have all feared” in the Tampa Bay area. She is right to be scared.

Hurricane Ian is expected to cause huge damages as it nears the coast of Florida, and it will almost certainly have long term effects for many of its senior residents. Building supportive communities that can help older adults prepare for – and become resilient to – disasters are needed now more than ever.