When you’re making an aging-in-place plan, personal safety should be a top priority. According to the Centers for Disease Control and Prevention, more than one out of four people 65 and older fall each year. The US Fire Administration (an entity of FEMA) says that the same age group is 2.6 times more likely to die in a fire than the population as a whole. Smart safety devices can keep tabs on potential dangers and connect you with emergency services if needed. And if you’re a caregiver, you can keep an eye out for some of those worries and possibly save your loved one’s life, notifying both emergency services and contacts whether they’re on the other side of town or the other side of the country.

Smart emergency-contact systems

Michael Hession/NYT Wirecutter

Typical emergency-contact systems consist of wearable electronic devices that provide on-call monitoring and may include fall alerts; some charge a monthly fee. Having a way to contact emergency services is an absolute must. “A device that can be worn on the wrist allows for 24/7 monitoring and can help identify against the biggest and most common concern, which is a fall,” said David Siegel, CEO of Nationwide Medical. “A wrist-worn device can also provide important data, detect falls, determine location, and even serve as a telephonic or text communication device.”

For this guide, we considered nontraditional smart options, which don’t require a contract, can be used every day, and incorporate a variety of convenience features.

Compatible with: Apple Home

How it helps: An emergency-contact system works only if you actually wear the device. Our experts noted that they’ve frequently heard of resistance to wearing devices such as clunky bracelets and necklaces with built-in emergency buttons. “[Many people] don’t want to wear them because of the stigma,” said Andy Miller, senior vice president of innovation and product development at AARP. “It makes them feel old.” The Apple Watch SE is more discreet than any other emergency-contact system out there—probably because it wasn’t designed as an emergency-contact system. It’s a smartwatch that can make and take calls, stream music, control smart-home devices via Siri voice commands, and more.

Why it’s a pick: The Apple Watch SE has built-in fall detection and crash detection, as well as a side button that can call emergency contacts. This version of the Apple Watch can also share with emergency responders important medical information, such as blood type and medications, and physical activity including ECG stats. It even works with apps like FallCall, which can trigger a central monitoring station (versus 911) via Siri voice commands or an icon on the watch. If you want more advanced sensors to monitor additional heart info and blood-oxygen levels, we recommend the Apple Watch Series 9.

One important note: To contact emergency services, the base-model Apple Watch must be paired with an iPhone that’s within Bluetooth range or connected to a known Wi-Fi network (with Wi-Fi calling enabled). If that’s a concern inside or outside the home, opt for a pricier model with a cellular plan (which costs extra). We also recommend pairing the Apple Watch with a bedside wireless charger, which increases the cost but also improves the functionality.

Compatible with: Amazon Alexa

How it helps: If you don’t like the idea of a wearable but want the assurance of easy access to assistance, consider Alexa Emergency Assist, a paid service ($6 per month or $59 per year) that connects you to live responders who can request emergency services and relay critical medical information. It works with all Amazon Echo smart speakers and screens, but we like the Amazon Echo Dot because it’s the smallest, least expensive Echo smart speaker, and it responds well to voice commands to deliver entertainment and news, as well as to put you in near-instant touch with emergency contacts such as family, friends, and caregivers through Alexa Calling.

Why it’s a pick: Alexa Emergency Assist had the fastest response time of any medical alert system we tested. In addition to connections with live emergency services and notifications when a smoke or carbon monoxide alarm has been detected, the service can notify up to 25 of your emergency contacts. If you aren’t familiar with smart speakers, it may impose a bit of a learning curve, but once you get used to it, Alexa Emergency Assist offers several potentially useful features, including the ability to act as an intercom, allowing family, friends, and caregivers with Echo devices to “drop in” for an instant two-way conversation.

Anne Madison told us that the service works well and she’s “now a firm believer in it” after a fall in the bedroom left her unable to get up. “I said something along the lines of ‘Alexa, call for help,’ and an actual human operator answered, listened to my problem, and indicated that they would call 911,” she said. Paramedics arrived within a few minutes and suggested that she call a relative. In the chaos, Anne misplaced her phone, but a quick “Alexa, call my phone” helped her locate it just as swiftly.

Smart displays and voice-communication devices

Amazon

Smart screens make keeping in touch easier and more personal than a simple phone call. These devices connect to your home’s Wi-Fi network, allowing for video and voice calls to family, friends, telemedicine appointments, emergency services, and more. They also offer voice control, which allows you to call up news, weather, and trivia, as well as to control and view smart-home devices such as light bulbs, security cameras, and smart plugs.

Compatible with: Amazon Alexa

How it helps: Smart speakers with a built-in screen let you stay on top of the news and weather, and stay in touch with the important people in your life. “Voice-enabled technologies also provide a little bit of information and social interaction for people who live alone primarily,” said Laurie Orlov, founder and principal analyst at Aging and Health Technology Watch. “A smart speaker is so nice because they can ask a question and hear a voice.”

Why it’s a pick: The Amazon Echo Show 8 (3rd Gen) has excellent sound and a 13-megapixel face-tracking camera, both of which are great for making video calls. Alexa-based smart displays also have a “drop in” feature, which enables a two-way video chat with another Echo Show, just like on a two-way intercom. (If only one party has an Alexa device, that’s okay: Video chats also work with the Alexa app on any smartphone.)

People who are more tech-savvy can also use Alexa on the Echo Show to schedule Reminders about appointments and medication doses, watch videos about cooking, or view video with closed captioning (when available). In addition, the 8-inch touchscreen can call up the Show and Tell feature, in which blind and low-vision people can identify grocery items simply by holding them up to the Echo Show’s camera and asking “Alexa, what am I holding?”

If you have speech limitations, you may have problems using Alexa successfully.

Compatible with: Apple Home

How it helps: Several experts we spoke to highly recommended a tablet, especially the Apple iPad due to its easy-to-use touchscreen, portability, and large screen size, as well as the Siri voice-control system. Like all smart speakers and screens, the iPad can provide news, weather, and podcasts, as well as games, video-streaming services, and more. Many people find an iPad more comfortable to use than a laptop, especially as it functions more or less like a smartphone and manual controls are easier to use because the app icons are larger.

Why it’s a pick: If you’re a little tech-savvy, you can use an iPad to access the apps for all of the devices we mention elsewhere in this guide. Using both Siri and an iPad, you can combine the control of multiple smart-home devices with one voice command: For instance, you can say “Siri, turn on the living room” to power several lights—and you can combine those lights with smart plugs, cameras, and other smart devices, as long as they support the Apple Home platform. (Siri voice commands and the Home platform are not compatible with as many smart-home devices as Alexa and Google Home are.)

Smart contact sensors

Sarah Kobos/NYT Wirecutter

If you’re planning to get a home security system, such as the Ring Alarm system, buy sensors that work with that specific system. Otherwise, individual smart contact sensors are very inexpensive and offer a good way to create a do-it-yourself home security system that can keep tabs on doors, windows, and drawers. Such sensors are also helpful for caregivers who need to track a loved one’s daily activities. For instance, a sensor on a door can send smartphone alerts whenever someone enters or leaves, or if the door has been left open too long. And a sensor placed on a refrigerator door lets you know that your loved one is remembering to eat.

Compatible with: Amazon Alexa, Apple Home, Google Home, IFTTT, Matter, SmartThings

How it helps: Many smart contact sensors are tied to security systems or specific platforms, such as Alexa, Apple Home, or Google Home. All of them can integrate with other smart devices so that opening a door can trigger a light, prompt a voice announcement, or even call the police.

Why it’s a pick: The Aqara Door and Window Sensor uses Zigbee wireless technology instead of Wi-Fi, so it works well in parts of a house where Wi-Fi is weak. This device requires the use of a plug-in device called an Aqara Hub, which can support up to 128 sensors and also adds smart-home support so that you can pair it with other smart devices around the house. For instance, we created automated Routines using the Alexa app that would announce “The back door is open” on an Amazon Echo Show and trigger a smart light bulb to turn on whenever someone opened the door.

Water-leak sensors

Marki Williams/NYT Wirecutter

About one in 60 US households each year file an insurance claim related to water-damage incidents, according to the Insurance Information Institute. Those often happen in hard-to-notice and even harder-to-reach areas such as the basement, by the water heater, or behind the washing machine. Smart water-leak sensors can alert you the instant they detect water, by sending an alert to your smartphone. Some also have a siren or alarm or can be configured to trigger other devices like smart lights to ensure that you catch small leaks before they become a big headache.

Compatible with: Amazon Alexa, IFTTT

How it helps: A good leak sensor ensures that you are aware of detected water, even if you aren’t home or nearby. The best models have a loud alarm and the ability to integrate with smart-home platforms so that you can receive smart alerts. We also prefer when alerts can be silenced in the app, so you don’t need to physically access the detector (or wade through water) to stop an alarm.

Why it’s a pick: The YoLink Water Leak Sensor 4 requires a YoLink hub, which you can buy separately or as part of a bundle with multiple sensors. The YoLink model is one of the few to have both top- and bottom-mounted sensor probes, which makes such designs potentially more versatile — in our tests, both sensing methods detected water within two seconds. If water is present, the hub emits an 87-decibel alarm and sends a smartphone alert.

YoLink also sends a smartphone alert when the sensor has gone offline, which we appreciate. You can set an off timer in the app to ensure that the sensor won’t keep beeping after it detects water. If you don’t want to purchase a hub or want Google Home compatibility, we recommend the Kidde Water Leak + Freeze Detector.

Smart locks

Michael Murtaugh/NYT Wirecutter

Everyone forgets their keys now and then—and sometimes people forget to lock the door, too. Smart locks let you live key-free if you like, and they also allow others to have access to your home without difficulty. Smart locks can respond to remote control as well, and you can set them to alert you when the lock is triggered (and set them to auto-lock). A smart lock can also be helpful if you’re caring for a loved one who tends to wander, or if you just want to make sure the house is locked up for the night. (Note that although many smart locks also offer a keypad option, we don’t recommend that option for anyone with memory issues.)

Compatible with: Amazon Alexa, Google Home

How it helps: From a security perspective, smart locks are especially handy because there are no keys to lose—and you can be notified whenever someone triggers the lock. You can also check the status of locks using voice or an app, and you can program them to automatically lock after a set period, when you leave or arrive home, and at a set time every night.

Why it’s a pick: The Schlage Encode Smart WiFi Deadbolt doesn’t have some of the bells and whistles of other smart locks, but this model is about as easy as it gets to set up and use. This lock is also strong and reliable, with built-in smarts that allow you to lock and unlock the door remotely, as well as to check whether the door has been left open. And if you or a loved one ever forgets or misplaces a key, you can use an app to unlock the door.

Another option to consider: The Aqara Smart Lock U100 offers more ways to get into the house, including a keypad and a fingerprint reader. And if you own an Apple Watch or iPhone, you can set up this smart lock to unlock when you simply hold up your phone, via Apple HomeKey. This lock is compatible with Amazon Alexa, Apple Home, Google Home, and Matter.

Cameras and monitoring

Michael Murtaugh/NYT Wirecutter

Smart security cameras are like a digital castle wall—they allow you to see who is outside your door without having to open it. Doorbell cameras let you screen who is visiting and allow you to decide whether to answer, and regardless they send smartphone alerts and capture video footage when someone visits. Indoor cameras are a great tool for caregivers to keep an eye on the things of a loved one, and they can send alerts when someone is moving about the house (and can serve as a way to document falls for health professionals).

All the experts we spoke with cautioned that the decision to put a camera into someone else’s home should be made in conjunction with the person who will be living with the camera. Some people find a camera to be intrusive, and it can be very scary for anyone with memory issues.

Compatible with: Amazon Alexa, Google Home

How it helps: A smart doorbell camera allows you to screen whoever comes to the door from anywhere in the world, regardless of whether the guest rings the bell. When someone rings the bell, you hear it at home but also receive a smartphone notification. From there, you can opt to answer the door remotely or just keep a record of who is coming and going—and how long they hang around. “Video doorbells are great, especially if [the person living with them is] having mobility challenges,” said William Dale, MD, PhD, professor and chair of supportive care medicine at the Center for Cancer and Aging at City of Hope. “Maybe the house is a little big for them or they have to be in a far part of the house, and getting all the way to the doors becomes a challenge.”

Why it’s a pick: The Google Nest Doorbell delivers the best performance, when it comes to speed and accuracy, for determining whether a visitor is a person, animal, car, or package delivery. It can record video to cloud-based storage for free—though it hangs on to that footage for only three hours. If you want to keep video recordings longer, a Nest Aware plan costs $8 per month or $80 per year; bumping that up to $15 per month (or $150 per year) buys you motion-event storage for up to 60 days or 10 days of 24/7 recording.

Compatible with: Amazon Alexa, Google Home, IFTTT, SmartThings

How it helps: An indoor camera provides peace of mind when you’re not home, whether you want to monitor your property or your pet. For caregivers, it allows you to remotely monitor home visits, movement, and whether someone is taking their medicine.

All the experts we spoke with were adamant that for caregivers, installing indoor security cameras needs to be a decision made between you and your loved one. “Transparency should be obvious. Nobody likes to be monitored without knowing,” said City of Hope’s William Dale. “These kinds of things have to be really carefully thought about rather than just assumed that it’s okay.” Talk about why it’s important to the person living with the camera, how it works, and how you can use it to communicate, since most cameras come equipped with a speaker and microphone.

Why it’s a pick: The TP-Link Tapo C120 can distinguish between people, pets, vehicles, and general motion, but it’s also inexpensive to run. You can opt to use a microSD card and record 24/7 footage or just motion-activated events. It also supports cloud storage, so you never have to worry about accessing content if someone pulls the card or a power outage occurs; a Tapo Care plan starts at $3.50 per month for one camera and increases to $7 for two, $10.50 for three, and $12 for up to 10. For multiple cameras, this model is more expensive than some of our other picks, but we think the price is still reasonable.

Another option to consider: The Tapo C120 supports Alexa and Google Home but not Apple Home. If Apple Home is your preferred ecosystem, or if you want to use Apple HomeKit Secure Video (a free video-storage service that comes with paid iCloud plans starting at $1 per camera), we recommend the Eufy Indoor Cam C120. The Eufy camera has some of the same features as the Tapo model but is a bit more expensive.

Overview

On his first day in office as the 47th president of the United States, President Trump signed a slew of executive orders (EOs) that impact the LGBTQ+ community, as well as many others. It is important to note that executive actions do NOT have the authority to override the United States Constitution, federal statutes, or established legal precedent. Many of these directives do just that or are regarding matters over which the president does not have control. Given that, many of these orders will be difficult, if not impossible, to implement, and efforts to do so will be challenged through litigation.

Currently, much is unknown about whether or how the administration or other actors will comply with these directives, and in most instances rules will need to be promulgated or significant administrative guidance will need to be issued in order for implementation to occur. These are processes that take time and require detailed additional plans to be developed.

Newly Issued Executive Orders

A number of executive actions yesterday will impact the LGBTQ+ community. However, the below addresses only those executive orders that directly name or are targeted at LGBTQ+ people specifically:

The Anti-Transgender Executive Order (titled “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government”) attempts to end legal recognition of transgender and nonbinary people under federal law and greenlight discrimination against the full LGBTQ+ community in the workplace, education, housing, healthcare, and more. This EO is built on the lies of those like the authors of Project 2025, referring to transgender people as an “ideology,” rather than reality – and the consensus of the medical community, including every major medical association, such as the American Medical Association, American Psychological Association, the American Academy of Pediatrics, and others. Enforcing this definition of sex defies decades of federal statute and legal precedent, violating the U.S. Constitution. It targets transgender people and includes significant negative impacts on LGBQ people as well.

This EO would make it the policy of the administration to recognize two sexes, male and female (as defined below), and refuse to accept that people can transition from one sex to another or recognize nonbinary people.

Definition of Sex : The EO directs federal agencies that, for purposes of sex nondiscrimination laws, “‘Sex’ shall refer to an individual’s immutable biological classification as either male or female. ‘Sex’ is not a synonym for and does not include the concept of ‘gender identity.’” HHS is directed to provide guidance expanding on these definitions in the next 30 days.

: The EO directs federal agencies that, for purposes of sex nondiscrimination laws, “‘Sex’ shall refer to an individual’s immutable biological classification as either male or female. ‘Sex’ is not a synonym for and does not include the concept of ‘gender identity.’” HHS is directed to provide guidance expanding on these definitions in the next 30 days. Direction to Defy Bostock : The EO directs the Attorney General to immediately issue guidance to agencies to “correct the misapplication of the Supreme Court’s decision in Bostock v. Clayton County ” (2020) to sex-based distinctions in agency activities. Bostock held that discrimination on the basis of sexual orientation and gender identity constitutes illegal sex discrimination. If implemented, this directive could allow federal agencies to refuse to acknowledge discrimination against the full LGBTQ+ community in the workplace, education, housing, health care, and more.

The EO directs the Attorney General to immediately issue guidance to agencies to “correct the misapplication of the Supreme Court’s decision in ” (2020) to sex-based distinctions in agency activities. held that discrimination on the basis of sexual orientation and gender identity constitutes illegal sex discrimination. If implemented, this directive could allow federal agencies to refuse to acknowledge discrimination against the full LGBTQ+ community in the workplace, education, housing, health care, and more. Refusal to Respect Transition – Including in Use of Pronouns and Bathrooms for Title VII regulated employers. The order directs the Attorney General to issue guidance allowing people to refuse to use a transgender or nonbinary person’s correct pronouns, and to claim a right to use single-sex bathrooms and other spaces based on sex assigned at birth at any workplace covered by the Civil Rights Act of 1964 and federally funded spaces. If implemented by the Attorney General, this could open a transgender or nonbinary person up to misgendering, harassment, and humiliation at work – simply for being themselves. Note: the EEOC is the primary agency in charge of enforcing Title VII, and it is a quasi-independent agency that is not legally required to take direction from the President via an executive order. Legal precedent surrounding the use of bathrooms at work and respectful use of pronouns already exist, and would be in conflict with implementation of this directive.

The order directs the Attorney General to issue guidance allowing people to refuse to use a transgender or nonbinary person’s correct pronouns, and to claim a right to use single-sex bathrooms and other spaces based on sex assigned at birth at any workplace covered by the Civil Rights Act of 1964 and federally funded spaces. Bathroom Bans on Federal Property: Directs agencies to limit access to restrooms and other single-sex facilities based on the adopted definition of sex/sex assigned at birth. This may impact federal property that is owned, leased, or controlled by federal agencies. If implemented, this could mean restricting access to restrooms for transgender and nonbinary people in federal offices, on military bases, and at national parks.

Directs agencies to limit access to restrooms and other single-sex facilities based on the adopted definition of sex/sex assigned at birth. This may impact federal property that is owned, leased, or controlled by federal agencies. Implications for Federal Identity Documents: The EO directs the Secretaries of State and Homeland Security to cease issuing federal identity documents (namely, passports, visas, and Global Entry cards) that conflict with the new definition of sex. This means that transgender and non-binary people will no longer be able to access new or renewed passports that reflect their gender identity. Regulatory safeguards protect validly issued passports from rescission . In response to a request from NOTUS, White House Press Secretary Karoline Leavitt confirmed that the executive order will not be retroactive and thus will not rescind valid passports.

The EO directs the Secretaries of State and Homeland Security to cease issuing federal identity documents (namely, passports, visas, and Global Entry cards) that conflict with the new definition of sex. . In response to a request from NOTUS, White House Press Secretary Karoline Leavitt confirmed that the executive order will not be retroactive and thus will not rescind valid passports. Other Implications for Sex Discrimination Employment Law (Including Federal & Title VII Employers). This directive would be in direct conflict with much of the opinion in Bostock v. Clayton County , binding precedent from the United States Supreme Court interpreting Title VII’s prohibition of discrimination on the basis of sex in the workplace. That precedent regulates both the federal government’s employment practices as well as private employers covered by Title VII. Potentially broad implications for discrimination on the basis of sex in Title VII, including protections against sex stereotyping and sexual harassment. Decades of case law, in the federal courts including the United States Supreme Court, have interpreted discrimination on the basis of sex to include any number of important protections that many Americans now take for granted – including that a non-transgender woman in the workplace who is perceived to be violating gender norms in terms of her dress, decision to work outside the home, affect or other presentation is protected from discrimination under Title VII. These long standing protections are known as “sex stereotyping” and are a critical component of enforcing Title VII. Protections from sexual harassment also spring from Title VII’s prohibitions from discrimination on the basis of sex. Interpretation and enforcement of these other critical facets of Title VII could also be impacted by the adoption of this definition. Attempts to Add Bathroom Exemption Into Title VII: Directs the Attorney General, Secretary of Labor, and the EEOC (an independent agency that does not answer directly to the President) to enforce Title VII so as to allow/enforce access to restrooms only consistent with this policy. If they were to do so, these agencies would penalize any private employers subject to Title VII for allowing transgender people to access restrooms consistent with their gender identity in the workplace. They would also enforce the same rules in the federal workforce.

This directive would be in direct conflict with much of the opinion in , binding precedent from the United States Supreme Court interpreting Title VII’s prohibition of discrimination on the basis of sex in the workplace. That precedent regulates both the federal government’s employment practices as well as private employers covered by Title VII. Halt Federal Funding – including Grants and Contracts – Promoting “Gender Ideology” or Collecting Data on Gender Identity: Agencies can no longer fund, via contracts or grants, any content that is deemed to be promoting “gender ideology”. Additionally, the EO directs agencies to rescind various guidance, toolkits, and memoranda from DOJ, Ed, the AG and the EEOC related to LGBTQ+ issues.

Agencies can no longer fund, via contracts or grants, any content that is deemed to be promoting “gender ideology”. Additionally, the EO directs agencies to rescind various guidance, toolkits, and memoranda from DOJ, Ed, the AG and the EEOC related to LGBTQ+ issues. Reverse “Equal Access Rule” Protections for LGBTQ+ People in Housing and for Transgender Women in Shelters: Directs HUD to repeal the Equal Access Rule (which protects LGBTQ+ people from discrimination in housing and has been in place since before the first Trump Administration), and to promulgate a rule that prevents transgender women from being able to access domestic violence shelters. This would conflict with not only Bostock but also other federal laws , and could create requirements for determining a person’s sex for admission into emergency shelters that would directly impact individuals who do not conform with sex stereotypes – even if they are not transgender.

Directs HUD to repeal the Equal Access Rule (which protects LGBTQ+ people from discrimination in housing and has been in place since before the first Trump Administration), and to promulgate a rule that prevents transgender women from being able to access domestic violence shelters. , and could create requirements for determining a person’s sex for admission into emergency shelters that would directly impact individuals who do not conform with sex stereotypes – even if they are not transgender. Incarceration: Directs agencies to issue regulations to force transgender women to be housed with men in prisons or detention centers, and directs Bureau of Prisons to cease providing gender-affirming care of any kind. Actions that place transgender women into unsafe incarceration placements are in conflict with the Prison Rape Elimination Act (PREA).

Directs agencies to issue regulations to force transgender women to be housed with men in prisons or detention centers, and directs Bureau of Prisons to cease providing gender-affirming care of any kind. Actions that place transgender women into unsafe incarceration placements are in conflict with the Prison Rape Elimination Act (PREA). Implementation Reporting Within 120 Days: Within 120 days each agency shall submit an update on implementation to OMB that includes changes to documents, changes in relationship to federally funded entities (including grantees and contractors). Additionally directs the drafting of a bill to codify this definition of sex into law.

Ending DEI in the Federal Workplace. This directive instructs the Office of Management and Budget (OMB), with assistance from the Attorney General and the Office of Personnel Management, to end DEI/DEIA “mandates, policies, programs, preferences, and activities” throughout the federal government, including instructing OMB to terminate all equity-related grants and contracts. Incredibly, “DEI” is not defined, and confusion and differing understandings of what DEI entails are likely to extend the regulatory process and may, in the meantime, have a chilling effect on any efforts that could potentially be considered “DEI.” Each agency is directed to assess the costs of DEI under the last administration, and inform the President of the prevalence and economic costs of DEI in the federal government. The preamble to the order includes a mention of the Project 2025 trope “gender ideology.”

Rescission of Existing EOs

Of the dozens of Executive Orders that were rescinded collectively yesterday, several touched specifically on LGBTQ+ Issues. Among the most important of these was the repeal of President Biden’s directive to agencies to implement the Supreme Court ruling in Bostock v. Clayton County, which found that Title VII’s prohibition of discrimination on the basis of sex includes prohibitions of discrimination on the basis of sexual orientation and gender identity. While this clearly signals that the Trump administration is not planning to fully enforce Title VII’s protections from employment discrimination on behalf of LGBTQ+ people, Bostock v. Clayton County remains binding Supreme Court precedent that the administration is not free to ignore.

One problem with traditional amputations is that they leave agonists and antagonists without that bone connection. What was in essence the muscles’ means of communication or coördination is gone. But Carty and Herr, in close collaboration with Shriya Srinivasan and Tyler Clites, who were then graduate students in Herr’s lab, started to envision ways of functionally reconnecting those agonist and antagonist muscles.

After a traditional amputation, the neural signals from severed muscles are only about three per cent of what they once were—insufficient for effective communication with a neurally controllable prosthesis. If the connections between agonist and antagonist muscles could be restored, however, the neural signals might be strengthened and clarified. The limb could then keep the brain informed about where it is and what it’s doing; the brain in turn might become better at controlling the muscles in a natural way. In other words, a person’s prosthetic limb could potentially be brought into close alignment with their phantom limb.

Many years of research went into this new approach to amputation. At one point, Clites spent about a year developing a way of stitching together agonist and antagonist muscles with tendons, which could slide back and forth along a bone-mounted titanium pulley. Clites told me that he had “all the ‘i’s dotted and all the ‘t’s crossed, and then that didn’t work at all.” In an experimental animal surgery, the muscles scarred down and became immobilized. “We had to ask ourselves, first, is the concept even good?” Clites told me. The titanium, which was not native to the body, seemed a likely culprit for the failure.

After many discussions, Herr, Carty, Srinivasan, and Clites went with a design that fashioned a pulley from a part of the ankle joint which in traditional amputations is basically tossed out. The idea looked good in theory, and the team presented it at a plastic-surgery conference. “The predominant feedback from surgeons was ‘That’s a really cool idea, but it will scar down and it will not move,’ ” Clites recalled.

The team tried out the surgery on human cadavers and animal models and thought that it might be working. “But you can’t get a rat to tell you what they are feeling,” Carty said. Did movement feel natural? How much could the animal sense its phantom limb or prosthesis? Did the prosthesis move in accordance with its thoughts? To answer these questions, the researchers needed a human—someone who was healthy but needed an amputation, and who was willing to receive a novel procedure. As Carty put it, they were looking for a “first astronaut.”

In the years after Herr’s accident, he had done numerous climbs with Ewing, his roommate. In the Stat documentary, Ewing recalled that, when they were about twenty, Ewing had “Life sucks” written on his left shoe; on the right, he had “And then you die.” On one climb, part of the way up the rock face, Herr asked him, “Does life really suck, Jim?” Ewing eventually married, had a child, and became a mechanical engineer, but he kept mountaineering. One day, in 2014, he was scaling a limestone cliff in the Cayman Islands with his daughter. He slipped, fell, stopped a couple of times, and then fell again—this time all the way down, about fifty feet. Somehow, he survived.

Ewing’s left foot was so badly injured that putting any pressure on it caused excruciating pain, even a year later. “As an engineer, I was researching all kinds of different things to rebuild my ankle,” he said. But he couldn’t find anything that would let him climb again. Even walking was very difficult. “I was super depressed,” he said. He knew that Herr was leading a biomechatronics lab, so he got back in touch to inquire about anything new and experimental—and, alternatively, to hear what life with an amputation might be like. He remembers Herr saying, “Well, funny that you ask—we’ve just developed this new amputation protocol.” Herr directed him to Carty, and a couple of months later Ewing decided on amputation. He would be the first person with an “agonist-antagonist myoneural interface”—AMI for short.

Precisely when people began to make and use prostheses is unknown. A prosthetic leg, fashioned from poplar and tipped with a horse’s hoof, was found in a two-millennia-old grave in present-day China, along the Silk Road. A Roman general is said to have received an iron replacement for his right hand, to allow him to hold a shield. Ambroise Paré, a sixteenth-century French military barber-surgeon, devised a mostly metal leg with a knee joint, which could bend when a person was walking and lock when he was standing. Paré also worked on innovative surgical approaches to amputation, such as saving skin and muscle.

Throughout the years, prostheses have been reimagined in creative ways. Still, for a long time, the main difficulty for soldiers who needed amputations was surviving long after the operation. During the American Civil War, when infections killed more soldiers than artillery did, it was said that a soldier was lucky to have a limb shot off rather than cut off by a battlefield surgeon; field surgeons were unlikely to be working with a clean blade. (Advertisements from the time offered a type of ankle prosthesis that contained no metal and had a socket made from polished ivory and vulcanized rubber. It was touted as “EXTREMELY LIGHT; MUCH LIGHTER THAN ANY OTHER.”) For people who needed amputations, the greatest advance in care arguably was not superior prostheses but more modern surgical practices.

In the century that followed, amputation remained a neglected area of medicine. “When I was a medical student, amputations were sometimes given to the most junior member of a surgical team, and it was a contest to see how fast you could get the limb off,” David Crandell, a physiatrist in the Department of Physical Medicine and Rehabilitation at Harvard Medical School, told me. To this day, surgeons performing amputations too often have little sense of what happens to a patient in the years after recovery.

“Part of the problem was that amputation was thought of as a failure,” Carty told me. “The thinking was, Either you salvage the limb or you fail to salvage the limb.” He brought up Ewing’s case to demonstrate how that approach can be misguided. “He had this preserved foot, but it’s painful all the time,” Carty said. “He stops climbing—he stops doing all these things that matter most to him.” For Ewing, an amputation and a fitting with a prosthesis could be more restorative than keeping the foot.

Carty and his colleagues were confident that the AMI amputation would be safe, and that Ewing would be able to use a conventional prosthesis without trouble. “Still, when you’re doing something for the first time, you’re freaking out the whole time, because you’re wondering what you’ll find,” Carty said. They were not sure that the surgery would allow the muscles to move more freely, which was essential for a strong neural connection to a prosthesis.

According to a description of what would become known as the Ewing amputation, the surgeon makes a “stairstep incision” over the shin using a scalpel. The relevant part of the limb is “exsanguinated.” A flap of skin is peeled back to expose the leg muscles. Care is to be taken, the account notes, to isolate the saphenous vein and a nearby nerve. This is only the beginning of what is simultaneously a delicate, gruesome, and revolutionary surgical procedure; one of the required tools is a bone saw.

On July 19, 2016, Ewing spent more than five hours in the operating room. “Things went pretty well for me,” he recalled. Two weeks after the surgery, even before he had healed enough to have a prosthesis fitted, he went to a local climbing gym. “I remember feeling very liberated,” he said. “I was using just one leg, but I felt free from pain. I could propel myself up that wall dynamically.”

A few weeks later, Ewing went to the lab at M.I.T. The first thing the team wanted to know was whether the connected agonist and antagonist muscles in the amputated limb could move. An ultrasound probe showed that they could. “For a scientist, that’s Christmas morning,” Clites, who is now an assistant professor at the U.C.L.A. School of Engineering, said. “That was the big wow.” The research team then worked on picking up electrical signals from the muscle, measuring the strength of those signals, and using them to guide the movement of a prosthetic leg.

Ewing amputations are now the standard of care at Brigham and Women’s, and are performed at many hospitals. Carty frequently teaches the method to other surgeons, sometimes even by Zoom. Footage from the documentary shows one of Ewing’s later visits to the lab, the first time that the research team connected the prosthesis directly to his leg. “It’s really cool to feel it through my knee,” he says in the video. “Feels like there’s a foot there.” At first, he moves the prosthesis slowly. Later, he observes, “Literally within minutes of having it all connected, it starts becoming part of me.” We see him sitting cross-legged, with the prosthesis on top, fidgeting the foot by flexing and pointing it repeatedly—a moment Carty remembers as astonishing. “I said, ‘Jim, do you know you’re doing that?’ ” Carty recalled. Ewing replied, “No, I was just hanging out.”

One of the many eerie elegances of our bodies is that we manage to walk without thinking much about it. We never have to study a user’s guide to our legs in order to coördinate the contraction of one muscle and the relaxation of another. Almost all of that labor is done unconsciously. I sometimes think of the conscious mind as a clueless factory boss who spends her time daydreaming while the workers on the floor operate all the necessary machinery. Every so often, the self-important boss is startled into action and sends down a message like “Step around that puddle!” or “Run faster!” But only the workers know all the detailed adjustments required to carry out the order. “Even now, we don’t fully understand walking—which surprises people,” Herr told me. His lab has spent thousands of hours filming, assessing, scanning, and mathematically modelling people as they walk.

Even the most sophisticated robotic leg prostheses are engaged in merely a rough approximation of human locomotion; they “know” only what the current science knows about how we walk or run or jump, which leaves out a considerable amount. They have microprocessors that make thousands of calculations a second, and they can convey a burst of energy that, even in the absence of a calf muscle, enables a person to lift their prosthetic heel with the appropriate amount of energy. But on uneven ground, for example, they don’t allow a person to move in a truly biomimetic way. This means that an almost incomprehensibly complex technology effectively knows less than a child.

When Clites was a Ph.D. student in Herr’s lab, he worked closely with Ewing to “tune” the prosthesis to Ewing’s perception of movement. The sensors for electromyography (EMG), which is like an EKG for muscles outside the heart, were taped to his residual limb and detected the electrical activity in his leg muscles. (The team is also researching an approach to detecting muscle movements that involves small implanted metal spheres.) If Ewing was asked to lightly flex his foot but the prosthetic foot flexed intensely, the system could be adjusted. “Maybe one philosophical concept here is that, if the amputation is done well and the interface is done well, then the best possible prosthetic device is a really stupid one,” Clites told me. “It is one that doesn’t have to think very much at all . . . because the person’s brain and spinal cord are doing all the thinking.” Herr described this in a clarifying way: “There’s no real algorithm on the robot. It’s all from biological computation. That’s cool, because the person is in control.”

Diabetes used to be a death sentence, but that changed in 1922 when a teenager’s miraculous recovery brought hope to millions. The discovery of insulin and subsequent breakthroughs by Nobel Prize laureates led to advancements in how we treat the chronic disease. Now, efforts are focused on tackling the unfolding diabetes “epidemic” and finding a cure that could relegate the disease to history.

In January 1922, a 14-year-old boy called Leonard Thompson became the first person to receive an insulin injection as a treatment for diabetes. For the first time in history, diabetes was no longer a death sentence.

Born in 1908, Leonard grew up in a working-class street in Toronto, Canada with his parents, one brother and two sisters. He was described as a happy child who loved football and other sports. However, at the age of eleven, Leonard was diagnosed with diabetes, a then incurable condition. He was put on a strict diet, which at the time was only capable of managing his symptoms.

Leonard Thompson first received insulin in Jan. 1922. He lived for 13 years on insulin and died April 20, 1935 at the age of 27. Credit: Thomas Fisher Rare Book Library, University of Toronto

By the time he was 14 years old, Leonard was much smaller and weaker than a boy of his age should be. He weighed just 65lbs and ended up in hospital, drifting in and out of consciousness. Desperate to save their son’s life, Leonard’s parents Harry and Florence agreed for him to test a new treatment.

On January 11, 1922, Leonard received his first insulin injection. While the first attempt didn’t work, later injections showed great improvement. “The boy became brighter, more active, looked better and said he felt stronger,” according to his medical records. A few months later, Leonard had recovered enough to return home.

“It was a miracle.” Professor Juleen Zierath, Member of the Nobel Assembly at Karolinska Institutet Watch the video ’Insulin’s impact: The story behind the 1923 Nobel Prize in Physiology or Medicine’

While Leonard was the first person with Type 1 diabetes to benefit, within just a year insulin was saving the lives of others thanks to the rapid work of researchers at the University of Toronto who managed to isolate the hormone.

More than 100 years after its discovery, insulin continues to be used to help some of the over 400 million people around the world with diabetes.

A death-defying discovery

Diabetes is a chronic disease that occurs when a person’s blood sugar is too high. Long before the discovery of insulin, doctors suspected that the pancreas secreted a substance that controlled carbohydrate metabolism. During the beginning of the 20th century, several attempts were made at preparing pancreatic extracts that could lower blood glucose. However, due to an inability to remove impurities, toxic reactions prevented its use in humans.

In the early 1920s, a young surgeon called Frederick Banting came up with an idea to solve the diabetes enigma. Reportedly waking up in the middle of the night, he scribbled down his hypothesis on a piece of paper.

For Banting the key was isolating a pure version of pancreatic extract that could be used to treat diabetes. His breakthrough was hypothesising that another substance produced in the pancreas, trypsin, was breaking down insulin before it could be extracted. He set about trying to overcome this problem.

Banting reached out to John Macleod, professor of physiology and department head at the University of Toronto. In John Macleod’s laboratory in 1921, Frederick Banting and his research assistant Charles Best treated dogs so that they no longer produced trypsin. Insulin could then be extracted and used to treat diabetes. When they managed to isolate insulin from dogs, colleagues remarked that it looked like “thick brown muck”. Biochemist James Collip joined the group to work on purifying insulin so it would be safe enough to be tested in humans, and together they refined the substance so that it could give hope to Leonard Thompson and countless others with diabetes.

Swipe left and right to see more photos 1 (of 3) Copy of black and white photograph showing Banting and Best with a dog on the roof of the Medical Building, University of Toronto. This well-known photo was taken by Henry Mahon in August 1921. The dog, although frequently identified as Marjorie (Dog 33) is actually Dog 408. Credit: Henry Mahon/Thomas Fisher Rare Book Library, University of Toronto Swipe left and right to see more photos 2 (of 3) This note is Frederick Banting’s original idea for diabetes research. Note dated Oct 31/20 from loose leaf notebook 1920/21. Credit: Thomas Fisher Rare Book Library, University of Toronto Swipe left and right to see more photos 3 (of 3) Photograph of Frederick Banting, assisted by Sadie Gairns, performing surgery on a dog. Credit: Thomas Fisher Rare Book Library, University of Toronto See all photos

Banting, Collip and Best were awarded US patents on insulin and the method used to make it, but sold them to the University of Toronto for $1 each.

“Insulin does not belong to me, it belongs to the world.” Frederick Banting

Demand for insulin surged as news of Leonard’s remarkable recovery spread.

“One by one the implacable enemies of man, the diseases which seek his destruction, are overcome by science. Diabetes, one of the most dreaded, is the latest to succumb,” said an article in The New York Times.

The researchers refined their production techniques so the wonder-treatment could be produced in larger quantities, and in October 1923 the first commercial supply of insulin was shipped.

In the same month, Banting and Macleod were awarded the Nobel Prize in Physiology or Medicine 1923. However, they were unhappy that the important contributions of their collaborators had not been recognised, so the laureates shared the prize money with Best and Collip.

”Work on diabetes shows progress against disease”, article in Toronto star weekly, Jan 14, 1922. This article is one of the first of press coverage of the discovery of insulin. Credit: Thomas Fisher Rare Book Library, University of Toronto

A new dawn for diabetes

“Since then, the understanding of how insulin works has exploded,” says Anna Krook, Professor at the Karolinska Institutet. Its discovery kickstarted a flurry of research that led to even more scientists receiving Nobel Prizes.

Frederick Sanger was one of them, awarded the Nobel Prize in Chemistry 1958 “for his work on the structure of proteins, especially that of insulin.” He began studying the composition of the insulin molecule in the 1940s, using acids to break the molecule into smaller parts, which were separated from one another with the help of electrophoresis and chromatography. Further analyses determined the amino acid sequences in the molecule’s two chains, and in 1955 Sanger identified how the chains of 51 amino acids are linked together.

This was a huge achievement and the first time that the structure of a protein had been determined.

Another method – X-ray crystallography – enabled 1964 chemistry laureate Dorothy Hodgkin to “see” the structure of insulin molecules for the first time. She began investigating the 3D structure of insulin at the age of 24, pausing her work to take on penicillin, which was a more urgent task in the World War II era. After 34 years of research, Dorothy Hodgkin was able to map the structure of insulin, shedding more light on the intriguing hormone.

Sanger’s work, followed by Hodgkin’s 1969 discovery of the 3D shape of insulin, paved the way for scientists to be able to produce man-made insulin in the lab, which millions of people with diabetes use today.

Ten years before Hodgkin mapped insulin, another laureate made a breakthrough that would also revolutionise the treatment of diabetes. Together with her research partner Solomon Berson, 1977 medicine laureate Rosalyn Yalow made a transformative contribution to medical research: radioimmunoassay (RIA), a method for measuring concentrations of substances in the blood.

The pair first attempted to use radioisotopes to more accurately estimate blood volume and soon applied their methods to insulin, in part because Yalow’s husband was diabetic.

Yalow and Berson attached radioactive iodine to molecules of insulin and injected minute amounts of the radioactive-tagged insulin into volunteers, including themselves. Blood samples taken over several hours showed how quickly the insulin was being metabolised. Using this technique, they found that people with Type 2 diabetes were unable to process insulin not because they lacked the hormone, but because their bodies produced an antibody that rejected it. This was a big discovery for the treatment of diabetes.

As a result of Yalow’s work, many diseases and conditions including diabetes can be diagnosed, treated, or tested. RIA is so sensitive that it can detect a teaspoonful of sugar in a body of water 62 miles long. Tens if not hundreds of millions of radioimmunoassays are made annually in hospitals to measure hormones such as insulin with just a drop of blood, enabling people with diabetes to receive treatment as quickly as possible.

Fighting an unfolding “epidemic”

Today, quicker diagnosis is important, as more people than ever are being diagnosed with diabetes. Insulin continues to be the treatment of choice and is available in many forms, from a synthetic hormone identical to the one produced in the pancreas, to ultra-rapid and ultra-long-acting insulins, enabling people with access to insulin who have Type 1 diabetes, to have a life expectancy approaching that of non-diabetics.

Photo: MarsBars via Getty Images

But there’s a growing challenge, spurring the need for new treatments. Today, more than 95 percent of people with diabetes have Type 2 diabetes. Related to obesity, which is due to changes in diet and lifestyle, it is still on the rise, posing a major threat to human lifespan and health span.

Some experts have warned it is an “epidemic” and it’s driving the need for more research. Weight loss plans and beta cell transplants using lab-grown cells are being explored to try and help people with Type 2 diabetes regain normal blood glucose levels. One hope is that drugs or gene deliveries could one day “tweak muscle” to respond better to insulin if people are not getting enough exercise, Professor Anna Krook of the Karolinska Institutet explains.

New treatments for Type 1 diabetes may also be on the horizon. Researchers are developing and testing immunotherapies that target the immune system to stop it from destroying beta cells in the pancreas that produce insulin. If they succeed, immunotherapies could one day prevent people from developing Type 1 diabetes at all.

The revolutionary discovery by Frederick Banting and his co-workers have paved the way for the next generation of research into diabetes. According to Professor Juleen Zierath of the Karolinska Institutet, a definite solution to end the diabetes epidemic is possible: “I’m really hopeful that researchers will come closer to finding a cure for diabetes and I believe that we have great tools in our hands.”

This article was published on 13 November 2024.

Key facts Decent work is good for mental health.

Poor working environments – including discrimination and inequality, excessive workloads, low job control and job insecurity – pose a risk to mental health.

15% of working-age adults were estimated to have a mental disorder in 2019.

Globally, an estimated 12 billion working days are lost every year to depression and anxiety at a cost of US$ 1 trillion per year in lost productivity.

There are effective actions to prevent mental health risks at work, protect and promote mental health at work, and support workers with mental health conditions.

Overview

Almost 60% of the world population is in work (1). All workers have the right to a safe and healthy environment at work. Work can protect mental health. Decent work supports good mental health by providing:

a livelihood;

a sense of confidence, purpose and achievement;

an opportunity for positive relationships and inclusion in a community; and

a platform for structured routines, among many other benefits.

For people with mental health conditions, decent work can contribute to recovery and inclusion, improve confidence and social functioning.

Safe and healthy working environments are not only a fundamental right but are also more likely to minimize tension and conflicts at work and improve staff retention, work performance and productivity. Conversely, a lack of effective structures and support at work, especially for those living with mental health conditions, can affect a person’s ability to enjoy their work and do their job well; it can undermine people’s attendance at work and even stop people getting a job in the first place.

Risks to mental health at work

At work, risks to mental health, also called psychosocial risks, may be related to job content or work schedule, specific characteristics of the workplace or opportunities for career development among other things.

Risks to mental health at work can include:

under-use of skills or being under-skilled for work;

excessive workloads or work pace, understaffing;

long, unsocial or inflexible hours;

lack of control over job design or workload;

unsafe or poor physical working conditions;

organizational culture that enables negative behaviours;

limited support from colleagues or authoritarian supervision;

violence, harassment or bullying;

discrimination and exclusion;

unclear job role;

under- or over-promotion;

job insecurity, inadequate pay, or poor investment in career development; and

conflicting home/work demands.

More than half the global workforce works in the informal economy (2), where there is no regulatory protection for health and safety. These workers often operate in unsafe working environments, work long hours, have little or no access to social or financial protections and face discrimination, all of which can undermine mental health.

Although psychosocial risks can be found in all sectors, some workers are more likely to be exposed to them than others, because of what they do or where and how they work. Health, humanitarian or emergency workers often have jobs that carry an elevated risk of exposure to adverse events, which can negatively impact mental health.

Economic recessions or humanitarian and public health emergencies elicit risks such as job loss, financial instability, reduced employment opportunities or increased unemployment.

Work can be a setting which amplifies wider issues that negatively affect mental health, including discrimination and inequality based on factors such as, race, sex, gender identity, sexual orientation, disability, social origin, migrant status, religion or age.

People with severe mental health conditions are more likely to be excluded from employment, and when in employment, they are more likely to experience inequality at work. Being out of work also poses a risk to mental health. Unemployment, job and financial insecurity, and recent job loss are risk factors for suicide attempts.

Action for mental health at work

Government, employers, the organizations which represent workers and employers, and other stakeholders responsible for workers’ health and safety can help to improve mental health at work through action to:

prevent work-related mental health conditions by preventing the risks to mental health at work;

protect and promote mental health at work;

support workers with mental health conditions to participate and thrive in work; and

create an enabling environment for change.

Action to address mental health at work should be done with the meaningful involvement of workers and their representatives, and persons with lived experience of mental health conditions.

Prevent work-related mental health conditions

Preventing mental health conditions at work is about managing psychosocial risks in the workplace. WHO recommends employers do this by implementing organizational interventions that directly target working conditions and environments. Organizational interventions are those that assess, and then mitigate, modify or remove workplace risks to mental health. Organizational interventions include, for example, providing flexible working arrangements, or implementing frameworks to deal with violence and harassment at work.

Protect and promote mental health at work

Protecting and promoting mental health at work is about strengthening capacities to recognize and act on mental health conditions at work, particularly for persons responsible for the supervision of others, such as managers.

To protect mental health, WHO recommends:

manager training for mental health , which helps managers recognize and respond to supervisees experiencing emotional distress; builds interpersonal skills like open communication and active listening; and fosters better understanding of how job stressors affect mental health and can be managed;

, which helps managers recognize and respond to supervisees experiencing emotional distress; builds interpersonal skills like open communication and active listening; and fosters better understanding of how job stressors affect mental health and can be managed; training for workers in mental health literacy and awareness, to improve knowledge of mental health and reduce stigma against mental health conditions at work; and

in mental health literacy and awareness, to improve knowledge of mental health and reduce stigma against mental health conditions at work; and interventions for individuals to build skills to manage stress and reduce mental health symptoms, including psychosocial interventions and opportunities for leisure-based physical activity.

Support people with mental health conditions to participate in and thrive at work

People living with mental health conditions have a right to participate in work fully and fairly. The UN Convention on the Rights of Persons with Disabilities provides an international agreement for promoting the rights of people with disabilities (including psychosocial disabilities), including at work. WHO recommends three interventions to support people with mental health conditions gain, sustain and participate in work:

Reasonable accommodations at work adapt working environments to the capacities, needs and preferences of a worker with a mental health condition. They may include giving individual workers flexible working hours, extra time to complete tasks, modified assignments to reduce stress, time off for health appointments or regular supportive meetings with supervisors.

Return-to-work programmes combine work-directed care (like reasonable accommodations or phased re-entry to work) with ongoing clinical care to support workers in meaningfully returning to work after an absence associated with mental health conditions, while also reducing mental health symptoms.

combine work-directed care (like reasonable accommodations or phased re-entry to work) with ongoing clinical care to support workers in meaningfully returning to work after an absence associated with mental health conditions, while also reducing mental health symptoms. Supported employment initiatives help people with severe mental health conditions to get into paid work and maintain their time on work through continue to provide mental health and vocational support.

Create an enabling environment for change

Both governments and employers, in consultation with key stakeholders, can help improve mental health at work by creating an enabling environment for change. In practice this means strengthening:

Leadership and commitment to mental health at work, for example by integrating mental health at work into relevant policies.

and commitment to mental health at work, for example by integrating mental health at work into relevant policies. Investment of sufficient funds and resources, for example by establishing dedicated budgets for actions to improve mental health at work and making mental health and employment services available to lower-resourced enterprises.

of sufficient funds and resources, for example by establishing dedicated budgets for actions to improve mental health at work and making mental health and employment services available to lower-resourced enterprises. Rights to participate in work, for example by aligning employment laws and regulations with international human rights instruments and implementing non-discrimination policies at work.

to participate in work, for example by aligning employment laws and regulations with international human rights instruments and implementing non-discrimination policies at work. Integration of mental health at work across sectors, for example by embedding mental health into existing systems for occupational safety and health.

of mental health at work across sectors, for example by embedding mental health into existing systems for occupational safety and health. Participation of workers in decision-making, for example by holding meaningful and timely consultations with workers, their representatives and people with lived experience of mental health conditions.

of workers in decision-making, for example by holding meaningful and timely consultations with workers, their representatives and people with lived experience of mental health conditions. Evidence on psychosocial risks and effectiveness of interventions, for example by ensuring that all guidance and action on mental health at work is based on the latest evidence.

on psychosocial risks and effectiveness of interventions, for example by ensuring that all guidance and action on mental health at work is based on the latest evidence. Compliance with laws, regulations and recommendations, for example by integrating mental health into the responsibilities of national labour inspectorates and other compliance mechanisms.

WHO response

WHO is committed to improving mental health at work. The WHO global strategy on health, environment and climate change and WHO Comprehensive mental health action plan (2013–2030) outline relevant principles, objectives and implementation strategies to enable good mental health in the workplace. These include addressing social determinants of mental health, such as living standards and working conditions; reducing stigma and discrimination; and increasing access to evidence-based care through health service development, including access to occupational health services. In 2022, WHO’s World mental health report: transforming mental health for all, highlighted the workplace as a key example of a setting where transformative action on mental health is needed.

The WHO guidelines on mental health at work provide evidence-based recommendations to promote mental health, prevent mental health conditions, and enable people living with mental health conditions to participate and thrive in work. The recommendations cover organizational interventions, manager training and worker training, individual interventions, return to work, and gaining employment. The accompanying policy brief by WHO and the International Labour Organization, Mental health at work: policy brief provides a pragmatic framework for implementing the WHO recommendations. It specifically sets out what governments, employers, organizations representing employers and workers, and other stakeholders can do to improve mental health at work.