Angela Lautner knew her thirst was unusual, even for someone directing airplanes, outside in the Memphis summer heat.

“We had coolers of Gatorade and water for people to always have access to,” Lautner remembers of her job as a ground services agent. “But the amount of thirst that I felt was just incredible.”

She had no appetite and she lost an unusual amount of weight. Then after a trip to the emergency room, Lautner, who was 22, was diagnosed with Type 1 diabetes. The diagnosis was life changing.

To start,it meant for the rest of her life she would require insulin injections every day to keep her alive. Unlike Type 2 diabetes, which can sometimes be controlled by diet, people with Type 1 diabetes need daily insulin injections to regulate their blood sugar.

Lautner’s diagnosis also meant she was no longer allowed to become a commercial airline pilot in the U.S. — a lifelong dream that she was training for in flight school at the time.

“I cried harder over losing my dream to fly than I did at the diagnosis of Type 1 diabetes,” Lautner says.

But after 18 years living with diabetes, Lautner now says the hardest thing about the diagnosis is accessing insulin — the expensive drug she needs to keep her alive. She’s had to borrow money from her parents to pay for insurance; she’s spent hours on the phone with drug companies; she’s switched brands of insulin to save costs; and she even moved to a new state, Kentucky, with a more generous Medicaid plan.

Last year, Lautner noticed other people with Type 1 diabetes tweeting similar stories under the hashtag #Insulin4All. She read the stories of Shane Patrick Boyle and Alec Raeshawn Smith, two men who died because they could not afford their insulin. It was an epiphany.

“I thought, ‘My goodness, there’s more people than me. I’m not the only one out here,’ ” she says.

Since then Lautner has joined a group of consumer activists, people who need insulin to live and are angry about the sky-high prices. They are putting pressure on the three main companies that make insulin: Sanofi of France, Novo Nordisk of Denmark, and Eli Lilly and Company in the U.S.

Taking on the drugmakers

The cost of insulin nearly tripled between 2002 and 2013 and has doubled again since then. The list price is over $300 for a single vial of medicine, and most people with Type 1 diabetes need multiple vials every month to live. That cost is typically lower with insurance or with discount programs. Still, for some people the price is unmanageable.

There’s been some action by lawmakers on the issue. In October Minnesota’s attorney general sued insulin manufacturers alleging price gouging, and a bipartisan caucus in the U.S. Congress issued a report in November urging action to bring insulin prices down.

But prices are still going up, so consumer activists like Lautner are taking things into their own hands.

Nonprofit group T1International, which advocates for Type 1 diabetes around the world, with a particular focus on insulin prices has started holding rallies outside the Indianapolis headquarters of pharmaceutical giant Eli Lilly and Company. (Eli Lilly and Novo Nordisk have provided financial support to NPR.)

Lautner joined more than 70 people who came together to demonstrate there in September. They were asking for three things: transparency about how much it costs to make a vial of insulin and how much profit comes from each vial, and a commitment from the company to lower the list price of insulin.

There were protesters from at least 12 states, mainly Ohio, Illinois, Indiana and Kentucky, but also from as far away as New York. Lautner, who now lives outside Cincinnati, rented a school bus with a dozen others to make the 112-mile trip.

“Insulin is kind of the face of the drug pricing crisis in America,” says Elizabeth Fiester, founder of T1International who has Type 1 diabetes herself. “We literally die without it,” she says. “We’re fighting for our lives.”

This was the third time the group had protested at Eli Lilly headquarters. Last fall, when the group held its first protest there, Fiester says, as it was “the first time where people living with Type 1 were able to physically stand and show that people are angry enough to come out.”

Eli Lilly declined NPR’s request for an interview, but in statement a spokesperson said, “we understand why people are making their voices heard.”

Protesting is one arm of their advocacy efforts; the group is also lobbying at the state and national level, and conducting online awareness-raising campaigns under the hashtag #Insulin4All.

Advocacy at the state level

Last spring, the fight got even more personal for Angela Lautner. She got a letter from her insurance company stating they were no longer going to pay for the insulin she was taking, they wanted to switch her to a different brand.

Most people with Type 1 diabetes use two types of insulin: short-acting insulin to counteract the carbohydrates consumed with meals, and long-acting insulin to keep blood sugar stable throughout the day.

Lautner has found that the long-lasting insulin brand Lantus works best with her body; it keeps her her blood sugars low, but not so low that she becomes dangerously hypoglycemic, risking death. But her insurer was dropping its coverage of Lantus in favor of a different long-lasting insulin, Basaglar.

“The problem that I immediately saw was that [Basaglar] had not worked for my body,” Lautner says. “So I go into my doctor’s office with this letter and I’m like, ‘What am I going to do?’ “

Lautner’s doctor connected her to Sanofi’s drug discount program where she was able to get a month’s supply of Lantus for a couple hundred dollars. So she decided to pay for the insulin herself.

“I’m fortunate enough to have an emergency fund,” Lautner says.

But she knows others aren’t so lucky.

This year, Lautner organized her own group of diabetes activists in Kentucky, Ohio and Indiana, called KOI Insulin4All. They’ve met with legislators in all three states about establishing emergency insulin prescription refills and about making the cost of insulin more transparent.

There are similar groups starting up in Oklahoma, Pennsylvania, Minnesota and Illinois. In November, activists protested outside the Cambridge, Mass., office of Sanofi. All of them are pushing for the same thing — to make the voices of people with diabetes heard.

Bram Sable-Smith (@besables) is a health reporter based in Madison, Wis.

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Lindsay Bunker woke up from a nightmare.

The 32-year-old lives with her sixth-month-old daughter on the Lac Courte Oreilles Indian Reservation in northern Wisconsin. She’s struggled with addiction for over 10 years, mostly to heroin. Then came the nightmare: She dreamt two men were attacking her baby while she could think only about drugs.

“In my mind I was thinking, ‘If I can just get one hit, if I can get one line, I can save her,'” she recalls, pausing before continuing, “I woke up and I was panicking. How can a mother think like that?”

It was a wake-up call. Bunker says she realized in that moment that heroin was “evil” and she resolved to get into treatment. In a lot of rural America, that’s where the story could have ended.

Many rural communities lack basic resources for substance abuse. There are fewer services available than in urban areas—as many as 82 percent of rural Americans may live in counties that lack detoxification services, for example.

But Bunker was lucky. She found a community health center only about an hour from her home that recently expanded its addiction treatment services.

The clinic, NorthLakes Community Clinic,serves Medicaid and Medicare patients, and offers sliding scale payments for those with low-income. It expanded its addiction recovery program with the help of state and federal grants targeting opioid use. Though rural communities across the country struggle with addiction, community health centers like this one are modeling an approach to managing — and funding — treatment programs.

“We were seeing substance use disorders killing our community and we felt it was our job to step up,” says Reba Rice, the clinic’s CEO. “We feel that all of our patients and community members deserve a life worth living.”

Not just opioids

Rice says addiction has torn apart rural communities in Northern Wisconsin in the last five years or so, with an increase in crime, problems in schools, trauma in families.

“It was amazing how many things we were seeing changed,” she says. “The way people looked at each other, the level people were willing to trust each other, and it was all about the changes that this disease makes on its victims”

A recent poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health shows that opioid and other drug abuse is the top health concern for rural Americans.

NorthLakes has long provided primary care, dental and behavioral health services for low-income residents in Ashland, Wisconsin, and in several nearby towns. But as the opioid addiction problem worsened, Rice says she felt a responsibility as a health care provider to do something about it.

“We contributed to the problem so we needed to contribute to the solution,” she says.Rice says opioids were just part of the puzzle: meth and alcohol were huge problems too. In fact, meth use in Wisconsin it has grown by 250 percent in recent years, according to the FBI. But new funds were becoming available for opioid treatment so the clinic applied for those — and is using them to build a comprehensive addiction treatment program that addresses all the substances people there struggle with.

To fund its expanded addiction treatment services, NorthLakes applied for and won a grant from the state of Wisconsin three years ago. It also got other federal grants intended for mental health and addiction. Central to their plan was hiring a physician who could lead the new program, and could prescribe the addiction treatment buprenorphine, known by the trade-name Suboxone.

Suboxone treatment is one of the most effective ways to treat opioid addiction. But it is hard to find in rural areas, because only providers who’ve received special training are allowed to prescribe it. One 2015 study found that more than 80 percent of rural counties in the U.S. do not have a single physician able to prescribe it.

NorthLakes found a physician who could prescribe it and more than that, who had a vision for a comprehensive addiction program.

Building treatment capacity

Dr. Mark Lim says he is surprised he’s here in this 8,000 person port-town on Lake Superior. He’d dreamed of living in a big city since he moved to the U.S. from the Philippines. When he got the call about the job, he was hesitant at first. “I didn’t know where that was on a map,” he recalls.

But he saw this part of Wisconsin, where the death rate from drug and alcohol abuse is nearly twice as high as the state average, as a place where he could make a difference.

Lim’s been board certified in addiction medicine since it was officially recognized as a subspecialty in 2016, but he’s been working in the field since about 10 years ago when he started working in an addiction practice in Maine.

He took the Wisconsin job, with one stipulation: He would start a program to address addiction as a whole. His expertise would be just one part of the treatment approach.

“If I’m just going to be the Suboxone doctor I’m not doing the full practice of addiction,” Lim says.

Because while the medication can be effective for treating opioid use disorder, Lim says addiction is not just about opioids.

“Opioids are big right now,” Lim says. “But you have to work with alcohol too. You have to work with marijuana too. You have to work with methamphetamine, cocaine.”

Rice says she and Lim developed the program together with community partners including educators, law enforcement and tribal leadership. “We were successful because we had a vision for creating a program and so did he,” Rice says.

While it’s rare to have a doctor who can prescribe Suboxone in a rural area like this one, Lim says only about 40 of his more than 200 patients take it. For the rest, his program relies on a combination of counseling, group therapy for addiction and underlying mental health issues, and case management. Staff help to remove barriers to being successful in recovery, helping patients with things like, transportation to the clinic, daycare for parents during therapy, and even job placements.

This kind of recovery program that combines clinical and counseling services is exactly what rural communities need, says John Gale of the Maine Rural Health Research Center.

“That’s exactly the way it should be done. Because most people with a substance use disorder have co-occurring mental health and substance use problems,” Gale says. “If we take care of [a patient’s] heroin problems and we don’t treat the underlying mental health and substance abuse problems, they’re going to go to go to alcohol, they’re going to do something else.”

And while most of the attention and dollars are focused on opioid abuse right now, he says rural communities struggling to address addiction can use those resources to build a larger treatment capacity.

“They can use [those resources] to say, ‘Wait a minute, let’s build a treatment capacity for other people,’ ” Gale says. “And they begin to create a community where you can treat all sorts of substance use disorders.”

Lindsay Bunker gets a ride to and from the NorthLakes clinic from a medical transportation company — it’s about an hour’s drive each way from the reservation. The clinic has a baby sitter who looks after her daughter when Bunker is in appointments. She makes the trip nearly every day.

“I love being here. I feel safe. I feel strong. I feel supported,” Bunker says.

But she only sees Dr. Lim about once a week. Instead, like all of the patients here, she spends most of her time in one-on-one and group counseling sessions. There’s the early relapse prevention group (from which Bunker recently graduated), then there’s the relapse recovery group, the family group, the engaged-in-recovery group. There’ll be a trauma group soon as well.

Bunker says those group sessions are really important in helping her stay in recovery.

“I get cravings and the cravings are being taken away with that medicine [suboxone]. But being here with my peers, I love it. I really do,” Bunker says.

And she says, recovery agrees with her.

“I look good, I feel good, I’m taking care of my kid,” she says. “I’m doing very well.”

Bram Sable-Smith (@besables) is a health reporter based in Madison, Wis.

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Japanese lawmakers have passed controversial legislation expanding the number of semi-skilled foreign workers who can live and work in the notably insular nation for up to five years.

Japan has been pressed to make the change because of a critical labor shortage that results from its rapidly aging society and low birth rate.

Japan’s upper house of parliament passed the law 161 to 76 just after 4 a.m. Saturday local time, after a day when the opposition parties tried to unsuccessfully to block the measure.

The law will go into effect in April 2019.

The legislation has been viewed as a last-resort measure by Prime Minister Shinzo Abe’s ultra-conservative government to address a severe shortage of workers in 14 industries, including restaurants, nursing, construction and agriculture.

According to the Associated Press, two categories of workers will be accepted, with conditions that will discourage them from trying to immigrate permanently.

The law will apply to as many as 345,000 less-skilled workers who will be allowed to stay for up to five years, but not bring in family members. It will also permit higher-skilled workers to enter with their families for 10 years and will provide them a path to Japanese citizenship. Both categories will have requirements for Japanese language competency.

Japan’s population is expected to decline from about 127 million to about 88 million by 2065, according to the National Institute of Population and Social Security. In September, Japan’s Internal Affairs and Communications Ministry released data showing that for the first time, one in five people in the nation is older than 70.

Japan has felt the pressure of an aging population and declining birthrates for decades. The government has tried to meet labor shortages by encouraging more employment of women and older workers, and using more robots and other automation.

And it does have foreign workers. Their number has more than doubled since 2000 to nearly 1.3 million last year, out of a working-age population of 67 million, according to the AP.

“Workers from developing Asian countries used to stay mostly behind the scenes, but not anymore. Almost all convenience stores are partly staffed by Asian workers and so are many restaurant chains.”

Many foreigners are working in Japan on training visas “that don’t allow them to switch jobs even if they are abused or underpaid,” says The Wall Street Journal editorial board. Thousands of student visa holders also work in Japan, often for longer than the 28 hours a week legally allowed.

But until now the government has resisted opening the door to a legal influx of semi-skilled foreign laborers, as many Japanese, particularly Abe’s right-wing supporters, fear a loss of cultural distinctiveness and homogeneity. It’s one reason the government has been careful not to characterize the new visa program as immigration.

But, as The Washington Post reports, Abe’s government is “closely entwined with the business community, and the message it hears from every quarter — shipbuilding and construction, agriculture and fishing, elder-care establishments and convenience-store owners — is ever more insistent: We need more workers.”

A report by Tokyo Shoko Research showed the number of bankruptcies in Japan caused by staff shortages doubled between 2016 and 2017, according to The Wall Street Journal.

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