You learn a lot when you move from investigator to subject. I just heard about Drive-by Tylenol for day-care and school age kids. This is the practice of stuffing a couple of Tylenol down the little tyke's throat to bring down a fever just before entering the daycare center. The objective is to get 4 or 5 hours of work in before being called to school because your child has a fever. The underground lore about it includes not using any flavored Tylenol preps with red dye in them so that when the child urps up everthing after lunch there will be no tell-tale pink color savvy teachers will recognize. The teachers have no such problem. Many of them are also coming to the classroom sick. We don't pay teachers well and many have no benefits. They can't afford to miss work any more than their parents can miss work when their kids are sick. According to the Center for Economic and Policy Research, the US is alone among 22 wealthy nations not having a mandatory sick leave policy:
"Working Americans can't afford to stay home when they're sick because they don't have paid sick days," said Dr. Jody Heymann, Director of the Institute for Health and Social Policy and Professor of Epidemiology at McGill University and lead author of the report. "The lack of paid sick days puts Americans at substantially greater risk of contagious diseases - from the flu, which kills thousands annually, to diarrheal disease, respiratory infections, and the threat of new diseases like the H1N1 flu virus."
To compare the various national policies, the authors calculated employer- or government- provided financial support available to workers facing a bout of flu requiring that they miss five days of work or a cancer treatment requiring that they miss fifty days of work.
The authors show that the United States is the only country in the study that does not provide paid sick leave for a worker undergoing a fifty-day cancer treatment and that only three countries - the United States, Canada and Japan - have no national policy requiring employers to recover from the flu. (Center for Economic and Policy Research [CEPR])
This is argued as an economic policy, but it has real and tangible public health implications, as in the practice of Drive-by Tylenoling or working sick "presenteeism." In an economic downturn, relying on employers to subsidize public health with a sensible sick leave policy is unrealistic and in fact is a clear failure. The result is billions of dollars of loss to communities in infected kids, co-workers and customers, not to mention the pain, misery and potentially fatal consequences.
In May, Rep. Rosa DeLauro (D-Conn.) sought to remedy this disgraceful record by introducing a bill mandating up to 7 paid sick days a year:
DeLauro's bill would allow workers to earn one hour of paid sick leave for every 30 hours worked.* She stressed that it provides protections for businesses -- companies with fewer than 15 employees will be exempt, and companies that already provide leave won't have to change their policies.
DeLauro said that the bill will bring government policy in line, not just with other countries, but with the modern American lifestyle, in which it's less and less common for a household to have a stay-at-home parent to care for sick children, so a parent loses out on wages or a sick kid infects his classmates at school.
"Our public policy has not caught up with the way today people are living their lives." (HuffPo)
This isn't a giveaway. You'd have to work more than 4 years to get the maximum sick leave, but it's at least a move in the right direction (forward). And we're currently standing still -- or worse.
I am seeing up close what these kind of sick leave non-policies produce in the context of a flu outbreak: Drive-by Tylenol.
Assuming an 8 hour working day, you'd earn an hour of sick leave every 3.75 working days, so every 30 working days you'd earn one working day off with the lurgey. So very roughly, if you're not sick in the first year, you'd pro-rata up to the max 7 days.
Unless I've totally misunderstood or my maths is up the spout...?
But dude, we're all about personal responsibility in the US! Not like those shitty socialists in Europe. Let those lazy shiftless sick fuckers take personal responsibility for getting sick.
Why should *I* pay for someone else to stay home and watch teevee because they're "sick". The free market will weed out these sickness prone weaklings so that strong hearty hale people can fulfill their evolutionary mandate.
"We don't pay teachers well and many have no benefits."
Maybe they don't have benefits in privately run day-care, but public school teachers are typically township employees with excellent healthcare plans. At least they are here in New Jersey
I do agree with the first part of that sentence and with the article overall. The company I work for put out an internal memo at the start of the swine flu scare telling everyone that they should consider carefully before coming to work if they felt sick.
The rest of the memo (90% of it) was to remind people how little sick time they actually had.
Revere, the North American phenomenon of "Drive-by Tylenol" might be adopted Down Under tomorrow -- Wednesday 10th. I've been listening to George Michael's "Older" CD and crying helplessly whilst reading words by Margaret Chan and Nick from Swine Flu in Australia Blog (see below). Life in 2010 and beyond is gonna be a nightmare:*(
Both the federal Australian health minister, Nicola Roxon, and a respected microbiologist, Professor Peter Collignon, appear to have given up on the "containment" model and are taking a bizarre laissez faire national approach to the community spread of H1N1/2009.
The most sensible and scientific course of action Oz authorities can enact is the "contain" model -- keeping the overall community numbers of H1N1/2009 infected low. Unlike the "sustain" model, this strategy assists in minimizing "evolutionary incidents" (eg. antiviral resistance mutations) and buys time for vaccine development, production and community uptake. As a secondary effect, containment also helps to minimize the random spread of the virus outwards -- via travel and commerce -- from Australia into the global community.
For the public record, I've heavily criticized Ms Roxon in comments posted on both Crof's blog and EM. There's something slightly "icky" about an educated individual downplaying the evolving science of an unstable transgenic pathogen containing genes from a variety of different species -- all efforts at hindering the community spread of this type of virus should be a priority for every Australian politician entrusted with the health and well being of their countryfolk.
Please bear with me, I've included the following blog link and excerpts to illustrate how Oz federal and state politicians -- and now, Professor Peter Collignont -- are utterly failing the interests of public health. I'm unsure if these people comprehend the evolutionary direction and global future (historical) implications of transgenic viruses like H5N1 and/or H1N1/2009 -- the Director-General of the World Health Organization sure does. Unlike Prof Collignont, she knows the current version of the H1N1/2009 virus is nothing like seasonal flu...
Excerpt from the Opening address at the Annual Session of the Executive Board of the World Food Programme, Rome, Italy (8 June 2009): WHO -- "Emergency services vital in a time of global crisis" Spoken by Dr Margaret Chan, Director-General of the World Health Organization...
"Ladies and gentlemen,
We are near the start of the first influenza pandemic of this century. Up to now, cases of the new H1N1 virus have been detected, investigated, closely tracked, and reported in well-off countries.
On present evidence, we have good reason to believe that this pandemic, at least in its early days, will be of moderate severity in countries with good health infrastructure and adequate resources.
But we are wise to anticipate a bleaker picture in the developing world. Mortality at present is low, but we are seeing some disturbing signs.
This is a contagious virus that shows a preference for younger age groups. Most cases are concentrated in people under the age of 20.
Cases of severe and fatal infection are occurring in young adults between the ages of 30 and 50, and not in the frail elderly, as is usually seen during epidemics of seasonal flu. We know, too, that the risk of severe illness is greater during pregnancy and when certain underlying chronic conditions are present..."
Swine Flu in Australia Blog -- "Alert levels may change in Australia tomorrow" By Nick (9 June 2009)
Excerpt: The Govât may change the alert levels in Australia tomorrow and take all states to the same level as Victoria. As I understand it, this would mean fewer restrictions on people returning from Vic. (Eg no more 7 day quarantines for kids returning from Vic before they can return to their schools). Thereâs an interesting quote [from ABC news here]:
"Head of microbiology at the Canberra Hospital, Professor Peter Collignon, says all states should follow Victoriaâs lead.
âThis is a virus that is less severe than what we get every season in winter... We should be adopting the approach that Canada has, most of the US has, and now Victoria, and treat this essentially as seasonal influenza, monitor what is going on and only change our practice if the virus changes.â
Jon: Containment is fruitless and stupid at this point. You probably never could contain it but you certainly can't do it now. Containment just turns flu cases into lepers.
Okay Revere, I understand your personal (familial) brush with this transgenic virus has given you fresh sociological insight into the "schoolyard cruelty" side of life.
But there are a number of points made in my posting.
Not least is the fact I was crying because I'm losing faith in the Australian "authorities" scientific understanding of H1N1/2009 -- it's not the seasonal flu is it!?! For an Oz scientist like Professor Peter Collignon to suggest that the genetics and epidemiology are... Revere, come on!
WHO's Margaret Chan is right to point out the solipsistic arrogance of our developed societies. "Containment, what a waste of time!", there's shitloads of Tamiflu and Relenza around for national cases -- and oh yes, FOXTEL tells me everybody alive on the planet lives similarly to me and has a full belly of nutrients:*)
Jon: It's not a waste of time because we have Tamiflu. It's a waste of time, energy, resources and everything else because: it's not containable; it's not contained; and containment strategies (which use Tamiflu, too) are counter productive. This is a position I have been espousing all along. It has nothing to do with the fact the family got flu. We aren't being stigmatized for it. We got the flu because it's not containable. It sounds like you are the one who is projecting your personal onto the public here. The people who suffer from misguided containment strategies are the poor and politically powerless or marginalized. And no one benefits. It's that simple.
Revere, "The people who suffer from misguided containment strategies are the poor and politically powerless or marginalized. And no one benefits. It's that simple..."
Revere, thank you for pointing out how the situation is playing out in the US -- a developed county without democratized Medicare. But, Oz life is actually the binary opposite... The middle class of Austalia are "suffering" under containment, not the poor -- the middle class darlings are cerainly not used to being TOLD to quarantine themselves (colonial inculcated creatures that they are), and naturally are rather upset:*)
But still, you have (((NOT))) responded to my enquiry, is current H1N1/2009 like Professor Peter Collignon suggests, the same as previously routine human seasonal influenza!?!
Jon: It is not seasonal flu, although clinically it is much the same. It is circulating out of season up north, few people have any immunity and it is hitting the younger age groups. Very different than seasonal flu. It is wrong for anyone to say it is. But that doesn't mean they are wrong about containment. You can't contain this any more than you can contain seasonal flu.
The highest priority should be actively looking for high risk cases before these people get critically ill.
Before this post gets further threadjacked, I wanted to say I really appreciated this post. It is funny how people make assumptions about work and sick time based on the good benefits and circumstances of the few (it is amazing how little work is done to understand what our workers get in the US). The concept of "sick time" is further eroded when you realize how many "contingent workers" there are or how managerial pressure can keep people with generous sick time at their desk.
Thank you for your reply, Revere, I'll close with an incredibly simple statement -- Margaret Chan's words moved me precisely because she understands "we" in the developed areas have an ethical responsibility to "buy time" -- and how quick it flies -- for the youth of here and now and the future...
Re: the "containment" model, this strategy assists in minimizing "evolutionary incidents" (eg. antiviral resistance mutations) and buys time for vaccine development, production and community uptake. As a secondary effect, containment also helps to minimize the random spread of the virus outwards -- via travel and commerce -- from Australia into the malnourished antiviral-less global community.
I live in France, a country with socialized medicine and sick time. It is interesting that today a report was released that showed in France 10% of Doctor prescribed sick leave was either for a period of time that was too long or was in fact not at all necessary. Also, French parents send there little ones to school sick too. They get a dose of paracetemol before going and one in the book bag for lunch. That way the parents can work all day. I don't think that any country has a monopoly on that kind of behavior.
"I live in France, a country with socialized medicine and sick time. It is interesting that today a report was released that showed in France 10% of Doctor prescribed sick leave was either for a period of time that was too long or was in fact not at all necessary."
I.e., 90% of Doctor prescribed sick leave was either for a period of time that was appropriate, or not long enough. That seems as though it might be pretty damned good, depending on the weight of the "not long enough" fraction.
Revere: I'm writing from Melbourne, so far the Swine Flu capital of Australia (due to colder climate than most other cities here). I really think Jon Singleton (above posts) needs to get a grip. There is no hysteria here. The authorities tried containment whilst it was practical, which did buy some time. However, multiple air & sea entry points ensured that the numbers quickly started growing exponentially to the point where containment is infeasible as well as futile. So they've switched to sustain & meanwhile have got the message out that this isn't ebola or the black death, it's the flu. Whilst the statement that we should "treat this as essentially seasonal flu" is not accurate, this is obviously *not* what the public health systems are doing, since they have all the worldwide data at hand and are not a bunch of morons. It was just an attempt to communicate by analogy with something the public is familiar with.
BTW, I think the idea that the contain model led to stigmatizing of patients is really a media beat-up. Australia has a long history of strict quarantine for all sorts of things, which (due to geography) has been highly effective at keeping out agricultural pests etc.
So, frankly, simple quarantine procedure does not freak Aussies out & we are not in the habit of demonizing sick people. When the pressure is on, people realize we're in it together. Doesn't stop the media from trying to create freak-out, but nobody has yet cured the media disease.
In 1918, this quarantine did keep Spanish Flu out for a long time, but with little effect overall because there was still no treatment when it finally arrived.
If the Swine Flu looked to be a seriously vicious strain in the early days, Australia probably would have imposed strict quarantine on all air/sea movements and this could actually keep a disease out for the 3 months that a vaccine could be developed in. But the disruption would be severe & costly & did not seem warranted in this case.
I'm just giving this background to explain why there is a tendency in Australia to favour containment: because it is one of the few developed countries where this could actually work, albeit at great expense. In the present case, the strict quarantine route was not taken, so "contain" was always just the first phase.
Oz: I know Australia is big on quarantines. I think you go to excess, based on your habit regarding biological species. Flu isn't a type of insect. I think it is a losing strategy and does more harm than good. In any event, it's moot. I wish Melbourne well. Lovely city with great food (I still pine for Meyers Food Court; still there?).
One major example of where a mandatory sick leave provision would have a great impact on public health is the food service industry. A fairly large proportion of foodborne disease outbreaks can be traced back to food handlers showing up to work with obvious signs and symptoms of a gastrointestinal illness, and who proceed to infect their customers. The pressure for them to come to work comes from two sides: the direct impact that missing a day at work will have on them financially, and the pressure from their employers who will otherwise be short-staffed if they don't show up to work. Most of those outbreaks tend to be from noroviruses, and considering that people can shed the virus for several days after their symptoms resolve, they could still burn through one week of leave pretty quickly.
That said, I also remember someone my wife once worked with who remarkably and consistently developed a four hour headache every two weeks, and on precisely the same day she accrued her biweekly allotment of four hours of sick leave. So mandating sick leave isn't enough--you also need something in place to make sure it isn't abused. Requiring a note from a doctor might sound reasonable, but then people working in food service frequently aren't in a position to visit doctors either.
Revere: oddly enough, I was in the central Myer store a few days ago, but only on the ground floor, so I didn't see the food court (if it's still there). I'll have to get back to you on that!
While public school teachers usually have decent health insurance and sick leave (in my experience), daycare is an entirely different story -- poor pay and I would bet that sick leave & medical benefits are at best minimal and likely non-existent.
From a behavioral standpoint, in the USA, the rewards go to those who show up sick and the punishment goes to those who "call in sick" either for themselves or to take care of their children. And, it's NOT just those without sick leave and/ or health insurance that are choosing "presenteeism". We need comprehensive planning that reinforces the behaviors that we want to see more of. Hopefully, there will be enough data to compare the impact of public health policies / priorities ("nationalized" healthcare, liberal sick leave, etc.) between diverse countries: Mexico, USA, Canada, Australia, European countries, etc.
Personally, in the right here and right now, I think we need some public service announcements -- has anyone even seen any? I haven't seen a single one. From basic preventative hygiene to personal preparation, I think that we need to hear & see compelling (but not sensational) public health messages repetitively. We need some Public Health School House Rock in prime time, and that could be implemented immediately.
I do not know if this is a common policy or not, but in both of the major metropolitan school districts my children have attended, high school students with fewer than two absences per class, per semester, are allowed to be exempted from the final exam for that class.
Contrary to popular belief--there are a lot of ridiculously over-achieving high school students in our midst. And they seem to have no qualms about showing up to school when they are quite ill, in order to take advantage of such policies.
My seventeen year old son is one such student.
I work from home; I see my son before he leaves for school, and we have never had to factor in any inconvenience or negative impact that his being ill would cause for me or my husband. Nevertheless, I generally find out that he has not been feeling well--after the fact. He hides his illness because he worries that I will make him stay home. His high-achieving, goody-two-shoes friends (Alas! Where did I go wrong?!) tend do the same thing.
2009 swine flu had the nerve to make its debut during AP exams, SATs, and finals--our over-achieving set probably would have deceived their way through containment, despite any school policy. But if swine flu shows up again in September--I would greatly appreciate public school policies that are more in sync with public health policies.
But I do not say this from the standpoint of containment. As a mom, a daughter, a wife, friend, and neighbor, I am no longer looking at 2009 swine flu from the standpoint of containment, per se. I am now looking at it from the standpoint of containing its wrath upon my loved ones--should it strike. And I would like to see, not only public policies, but societal approval for the family leave time that a more prevalent swine flu would necessitate.
Should my loved ones becomes ill with the swine flu, I want them to be afforded the time that their flu-ravaged bodies require for optimal recuperation. I want my loved ones, if they have to suffer, to be afforded the dignity of suffering and then recuperating at home-- not at work, not at school, not in daycare. I want my loved ones to be cared for and attended to during their illness--I do not want them to have to fend for themselves. I am looking at it from the standpoint of allowing flu-ravaged human bodies their recuperative âdue.â
Bodies that are not allowed the time, the place, and the attention they need while they are fighting the flu, recuperating from the flu, and fighting off secondary illnesses that exploit the flu, are more likely to become seriously ill - or even to die from the flu. And I think it is time to shift our focus to some of these more practical issues--such as work, school, and public health policies that constructively address the âsick timeâ that will be necessary for recuperation and caretaking, should swine flu ramp up and seriously threaten to breach the level of critical mass for our healthcare system.
Containment may be one way to keep death count down--just in terms of slowing the virus down to a speed which our infrastructure can handle. But an additional way to keep the death count down--another thing we can do--is to expect, plan for, allow, and even encourage workers and students to take the time they need for recuperation from the flu as well as the caretaking that facilitates recuperation from the flu. Any person that is able to keep another person out of the hospital during a pandemic is an invaluable economic resource to our society.
The U.S. (and every other country) has a finite number of ventilators and experienced healthcare professionals to operate them. People who become severely ill from the respiratory issues that often accompany or follow flu often require ventilators to save their lives. In a serious pandemic, there wonât be enough ventilators. Period. Even people who do not have the flu will die because of the flu--if there are no available ventilators in their local hospital.
I think people look at the odds of becoming seriously ill from the swine flu, and figure odds are on their side. But, in a serious pandemic, people will die for reasons other than flu. People will die for reasons and in ways we are not used to them dying. Medical professionals are not going to disconnect a swine flu patientâs ventilator because your mother needs life-saving heart by-pass surgery. Or because your child was in a car accident. Or because you have great health insurance, and the swine flu patient does not. Instead, the medical professional may talk to you about palliative care; about and how to provide your loved one a death that is the most pain-free.
In a pandemic, every person that does not have to be attached to a ventilator as a life-saving measure frees up a ventilator that can save another person's life. And when the woman who usually blends your Frappuccino stays home for a week to ensure that her mother gets the proper care (rest, hydration, medicine, nutrition, and love) that she needs, which, in turn, keeps her mother out of the hospital and off of a ventilator--just may be freeing up the one piece of equipment in your hospital that will be needed to save your life. Or your parent, or spouse, or childâs life.
In a pandemic--anyone who is able to take care of a friend, neighbor, or loved one, to the extent that a hospital stay is avoided is doing their civic, if not humanitarian duty. For many Americans, even seven days of sick leave won't be sufficient. And just as it is illegal to charge $500 a night for a motel on the northbound side of I-95 during a hurricane evacuation, it should be illegal for an employer to dismiss an employee for time missed while recuperating from or caretaking for the flu during a pandemic.
And those over-achieving high school students who are somehow made to feel that they canât afford to be sick (and are, quite literally rewarded for coming to school when they are sick) are simply playing out the message that, somewhere along the way, we humans stopped respecting these little beasts that are known as bacteria and viruses. Our kids are like us. And we, like no generation before us, have stopped being scared of getting sick. Because, when we get sick, thereâs always a pill or a doctor to make us better.
So as a backup plan--just in case there arenât enough pills, or good enough pills or enough doctors or good enough doctors--we need to listen to our own bodies when they start to get sick and take care of those we are responsible for taking care of if they get sick. We all need to be a bit more cautious about such things for a while--and schools and employers are just going to have to cope with that for the time being.
This is one reason telecommuting is great. When I have a mild sickness, I still end up working 4-6 hours. Better than laying around bored all day.
It doesn't matter if you have paid sick days or not. At many jobs, they get really pissed off if you take off more than a day for sick leave (like if you get a severe cold or flu) and God help you if you're not sick but your child is.
They'd rather you come in sick. They don't care about your kids.
I experienced this first hand, at more than one job. I worked in an office once where ONE PERSON got a severe cold, only stayed out the first day and infected 22 out of 24 in that office, which meant others took one day off, lost productivity, costs to those employees, etc. I was one of the two who didn't catch the cold.
I used to have to send my kids to school slightly sick. I had no choice. I was obliged to work to live, and if I could get a half day in, it went better with the bosses.
It's probable that many are in the same situation. Say what you like, but most companies do NOT want their employees taking the proper amount of time off for illness. Most employees take the first or second day off, but come back to work while pretty sick and still contagious. It happens every day.
I agree with melbren, and stillarebel: "The highest priority should be actively looking for high risk cases before these people get critically ill." I am especially concerned about pregnant women. Pregnant women seem to have an alarmingly high risk of severe illness, miscarriage and death. We don't even know how many pregnant women have died, because in so many cases we are only told that the victims had "underlying conditions" and pregnancy is always listed as an underlying condition. Even just counting the ones we know were pregnant means that the rate of death among pregnant women is VERY HIGH. Pregnant women should be warned and given top priority treatment. Pregnancy is an underlying condition that is not supposed to result in death from flu!
When I was in high school, a certain number of absences in a class would lose you credit for that year. There may or may not have been exceptions for students who were hospitalized or had serious documented illnesses; I don't know.)
I was usually pushing the limit, and every day I stayed home I was really, legitimately sick with coughs or ear infections. So if a flu like this had come along in June and I got it? I'm sure I'd have gone to school sick until I couldn't anymore, for fear of -- not being held back, because they'd have promoted me if I passed my classes -- but needing an extra year to have the credits to graduate.
And those are regular school days. During midterm and final exams, you'd have to have, as Ferris Bueller once said, hack up a lung before you could miss them. I'm not sure if you were literally required to be hospitalized, but "mere" colds (and flus?) wouldn't have excused you, even with a doctor's note. No one could be called in sick by their parents.
From an administrative/discipline standpoint, this makes sense. You don't want kids faking sick, or using minor illness to delay exams so they can study; that wouldn't be fair. Not to mention, it'd be a logistical nightmare, making teachers rewrite exams and schedule 5-6 two hour time slots for making them up for each kid.
From a public health perspective? Forcing everyone not in renal failure to attend school during a pandemic year is bound to end badly somewhere.
It's coming up on exam time.
I agree, Jane M.
The elephant in the room here is the capitalist system. It cares only about short term profits and growth and nothing for the long-term costs it dumps on workers and their families and wider society. A progressive law is not enough when it is not backed up by a truly progressive system. People with huge entitlement to paid sick leave are frightened into turning up when they really are ill and even more so in the current economic situation. All sorts of bullying tactics are in use, such as unanounced home visits by senior managers, to terrify vulnerable long-term ill workers into either resigning or turning up.
I never heard of this drive-by tylenol till your post. Then I overheard (some rather stupid loud) parents discussing drive-by Ibuprofin a couple hours ago.
I was in the hospital ER Saturday with a kidney stone & infection and vomiting/dehydration bad enough that they had a fun time getting an IV in me.
I was *at work* Monday. On pain meds. And still in pain. I have no vacation time, no sick leave, nothing left. It's all been used for doctor visits and time out sick already. I can't remember the last time I took a vacation day ...
I suspect I'll be redoing every bit of work I did this week next week.
There are a lot of responses to this blog, but I just wanted to respond to Comment #3, NoAstronomer. I believe revere was referring mainly to pre-school teachers, who, it's true, often are uninsured or underinsured. My roommate has been a preschool teachers for over 10 years (full-time, year round) and just this year got "bennies". He credits this achievement to getting a job in a well-off neighborhood, in this case Cambridge. When I expressed my concern over the swine-flu, he indicated to me that parents knowingly send their kids into school sick all the time. I agree that there are pressures on both ends (on parents not to be absent, and on teachers not to be absent) that encourage this behavior and that sick-time should be manditory.
This is why it is best for one parent to be a stay at home parent.
That is just gross that parents are doing this and infecting everyone else. This is why I am a stay at home mom.
Interesting posts, and I just saw quickly, on a Reuters blurb, that a study--by flu-test corp Quest, but nevertheless--of 75,000 test results shows the 2009h1n1 spreading out, now, "from schools into the community."
And, re no. 29 and 30 here--very nice but have you ever been a single mom, especially now we've no longer even the barebones "welfare" (AFDC) system of the 1960s-1980s; employers of single moms tend to know they're dealing with desperate workers and to restrict their benefits accordingly.