from the world's big
How to Survive 20,000 Rejections
Jacob M. Appel is a bioethicist and fiction writer. He holds a B.A. and an M.A. from Brown University, an M.A. and an M.Phil. from Columbia University, an M.D. from Columbia University's College of Physicians and Surgeons, an M.F.A. in creative writing from New York University, and a J.D. from Harvard Law School. He has most recently taught at Brown University in Providence, Rhode Island, and at the Gotham Writers Workshop in New York City. He publishes in the field of bioethics and contributes to such publications as the Journal of Clinical Ethics, the Journal of Law, Medicine & Ethics, and the Bulletin of the History of Medicine. His essays have appeared in The New York Times, The New York Daily News, The Chicago Tribune, and other publications.
Appel has also published short fiction in more than one hundred literary journals. His short story, Shell Game With Organs, won the Boston Review Short Fiction Contest in 1998. His story about two census takers, "Counting," was shortlisted for the O. Henry Award in 2001. Other stories received "special mention" for the Pushcart Prize in 2006 and 2007.
He is admitted to the practice of law in New York State and Rhode Island, and is a licensed New York City sightseeing guide.
Appel contributed a Dangerous Idea to Big Think's "Month of Thinking Dangerously," advocating that we add trace amounts of lithium to our drinking water to help reduce the suicide rate.
Appel is a Big Think Delphi Fellow.
Question: How do you pursue creative writing on top of two other careers?
Jacob Appel: Well, I think part of it is the importance of viewing them as separate careers. I think there are some writers who view writing and practicing medicine are very much interrelated and they write short stories about medicine or **** by medicine, some of them are very talented. Perri Klass comes to mind, Ethan Canin comes to mind, for me they're two very separate animals. And I view my occupation as being a bioethicist. And any extra benefits or extra blessing I get from being a writer, I'm very happy to have but if it doesn't work out, I'm not devastated by it. And in some ways that makes it easy to do, I know I can step back from it and go to the hospital and do my job and I haven't abandoned something that is essential to my well being.
I don't have to earn a living as a writer, which makes being a writer both more interesting and more pleasurable. That being said, my wisdom to anybody out there who is thinking about become a writer, and I tell all my writing students, is that the vast majority of success as a writer comes just not from persistence, but relentlessness.
I have recently reached a point where I have now more than 20,000 rejection letters. I don't know if 20,000 rejection letters is a record for people submitting small journals, but it shouldn't be because anybody else out there who wants to be a successful writer should also accumulate 20,000 rejection letters. The most successful writers I know, even those who are doing well who have several good books out still submit to small journals, still submit articles and reviews, get rejected, pick themselves off of the ground and fight back again.
Question: How do you persist in spite of so much rejection?
Jacob Appel: Well it's interesting, I actually did an interview a couple of years ago where 11,000 was the number, and I have a nice little journal where I keep track of every submission I have made, and if I ever do become a more successful writer, which is not a guarantee, but if I do, some day somebody will have my journal and be able to see exactly every submission I have made. And I've gotten some horrifically discouraging rejections. I've gotten rejections that say things like, "Not only will we not accept this story, but please never submit to us again." Or, "Consider this a preemptive rejection of anything you might write in the future." And the way you deal with that, on the one hand, is to know that writing is very much a matter of taste. And once you have a certain number of acceptances, you can say to yourself, I know I've gotten 20,000 rejections, but I've gotten over 100 acceptances, so somebody must like what I'm doing. And the other half of it is to realize that the same story that may be rejected by numerous journals, or numerous periodicals can then be accepted, which shows that someone else shares your sensibility.
One example I cite frequently is, I had the honor and privilege of a story of mine called "Shell Game With Organs" receiving an award from the Boston Review about a decade ago; my first significant literary honor, actually more than a decade now. It was rejected by more than 75 journals before I finally placed it; some of them rather unceremoniously, which suggested that it wasn't the shortcoming of the story, but simply a failure of the story to match the taste of a particular writer. I also urge people submitting stories to write a cover letter that convinces whoever the intern or college student first reading your work that you are somebody important enough that they shouldn't pass up on passing this letter on to the next stage.
The story I always tell, I was once a screener, at one point, I worked for Congressman Ted Weiss down here in lower Manhattan back in 1980’s. And I screened all of his phone calls, and the poet, Allen Ginsberg called to congratulate him on a recent election and I didn't believe it was Allen Ginsberg the poet, so I told him to write a letter and hung up on him. And about 10 minutes later he called back on the Congressman's private line and I nearly lost my job. Your goal is to convince whoever has the role like mine at a literary agency that you are important enough to get through to the boss.
Question: Should writers change their work based on rejections, or have faith in it as it stands?
Jacob Appel: I think you just have to have faith. I often make changes to the work based on acceptance. The editor who will call me and say, "We loved your story, but we had trouble with the ending." We are still thinking about publishing it, will you change the ending. Now, that's someone who is invested enough in the story, but I'm willing to say, maybe this person has a point and I'll go back and take a look at it and often, I will make changes. I think one story that comes to mind was a story of mine, "Grappling," that appeared in Stories South a couple of years ago about alligator wrestling. And the editors there, Jason Stanford particularly, were excellent advisors who said, "We loved your story, but you should really change the order of the scenes. And they were dead on. The advice I give young writers is never take advice from anyone that doesn't have a vested interest in your future. Once an editor says, we might publish the story; they have a vested interest in your future. The editor that sends you a note that says, we're not publishing your story and it's no good for the following reasons, has no vested interest in you and you take their wisdom with a grain of salt.
Recorded on March 1, 2010
Interviewed by Austin Allen
Discouraged writers, take heart! Jacob Appel has been turned down by nearly every publication in existence—and has the records to prove it. So what keeps him plugging away?
Sallie Krawcheck and Bob Kulhan will be talking money, jobs, and how the pandemic will disproportionally affect women's finances.
Vaccines find more success in development than any other kind of drug, but have been relatively neglected in recent decades.
Vaccines are more likely to get through clinical trials than any other type of drug — but have been given relatively little pharmaceutical industry support during the last two decades, according to a new study by MIT scholars.
An article in Journal of Bioethical Inquiry raises questions about the goal of these advocacy groups.
- Two-thirds of American consumer advocacy groups are funded by pharmaceutical companies.
- The authors of an article in Journal of Bioethical Inquiry say this compromises their advocacy.
- Groups like the National Alliance on Mental Illness act more like lobbyists than patient advocates.
The Corruption That Brought Prozac to Market — Robert Whitaker, Journalist<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="bea9cff2b25efc18b663a011a679ba16"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/UyaJExxFPAE?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span><p>Consumer-oriented groups gained steam over the ensuing decades. Their efforts helped inspire the 1938 Food, Drug, and Cosmetic Act after over 100 people (mostly children) died from a sanctioned drug, Sulfanilamide. If not for the hard work of these advocates, this case might have been overlooked.</p><p>Early efforts also focused on the food industry, which was increasingly using chemical preservatives. The origin of Consumer Reports can be found in the consumer advocacy movement. Both the food and drug industries were getting a free pass to experiment on citizens with few repercussions.</p><p>These movements provided a social foundation for important advocacy work in the second half of the century. Female-led groups evolved to focus on women's reproductive rights, AIDS, and mental health. As the authors write, these groups struck a balance between working <em>with</em> and <em>against</em> current trends. Sometimes you need to craft legislation with officials; at other times, you have to rage against the machine with everything you've got. </p><p>Advocacy marked an important turning point in public health (and culture in general). These groups were tired of placating to a medical model that treated the male body as the standard. This wasn't limited to anatomy. As I <a href="https://bigthink.com/coronavirus/pandemic-warnings-rp-eddy" target="_self">wrote about last week</a>, a high-profile 1970s-era conference about the role of women on Wall St featured no women on stage. You can imagine what reproductive health looked like during that time. </p><p>Advocacy groups made real impact in public health. Then the money began pouring in. </p><p style="margin-left: 20px;">"These groups were funded largely by individual donations with some foundation support, but in the late 1980s, newer women's health groups moved to professionalize, effectively splitting the women's health movement."</p><p>A number of groups resist corporate ties to this day, such as the National Women's Heath Network and Breast Cancer Action. Too often, however, groups argue that their existence depends on corporate funding. This can lead to uncomfortable compromises. </p><p>An estimated two-thirds of patient advocacy groups in America accept funds from the pharmaceutical industry. Pharma companies gave <a href="https://link.springer.com/content/pdf/10.1007/s11673-019-09956-8.pdf" target="_blank">at least $116 million</a> to such groups in 2015 alone.</p><p>For example, over a three-year period, the National Alliance on Mental Illness (NAMI), which was founded by two mothers whose sons suffered from schizophrenia, received nearly $12 million from 18 pharmaceutical companies. The largest donor was Prozac manufacturer, Eli Lilly. By 2008, three-quarters of NAMI's budget was funded by the pharmaceutical industry. It gets worse:</p><p style="margin-left: 20px;">"An Eli Lilly executive was even 'on loan' to NAMI, paid by Eli Lilly, while he worked out of the NAMI office on 'strategic planning.'"</p>
A customer waiting for his medication at the Headache Bar in a pharmacy in Sydney, Australia. Among the items on sale are 'Paigees with Chlorophyll' and Alka Seltzer on tap.
Photo by Dennis Rowe/BIPs/Getty Images<p>This influx of cash skews public understanding of drugs. It also influences advocates to overlook real problems caused by pharmaceutical interventions, especially when it comes to mental health.<br></p><p>For a real-world example, consider how Xanax came to market. As journalist Robert Whitaker <a href="https://www.youtube.com/watch?v=2e829xdb4AA" target="_blank">explains</a>, an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463502/?page=1" target="_blank">initial study</a> was conducted to determine efficacy in treating panic attacks. After four weeks, Xanax was outperforming placebo, which is common with benzodiazepines over short-term usage. But it wasn't a four-week study; it was a 14-week study.</p><p>At the end of eight weeks, there was no difference in efficacy between Xanax and placebo.</p><p>At the conclusion of the study after 14 weeks, the placebo outperformed Xanax. By a lot.</p><p>Why is Xanax still prescribed for panic attacks? Because the pharmaceutical company, Upjohn, only published the four-week data. The 14-week data was not in its favor. Nearly forty years later, over <a href="https://www.statista.com/statistics/781816/alprazolam-sodium-prescriptions-number-in-the-us/" target="_blank">25 million</a> Americans receive a prescription despite its <a href="https://drugabuse.com/xanax/effects-use/" target="_blank">long list</a> of side effects and addictive profile. </p><p>As the authors note, many consumers are not aware of how advocacy groups are funded.</p><p style="margin-left: 20px;">"An international study of groups in the United States, United Kingdom, Australia, Canada, and South Africa found that the extent of relationships with industry was inadequately disclosed in websites that addressed ten health conditions: cancer, heart disease, diabetes, asthma, cystic fibrosis, epilepsy, depression, Parkinson's disease, osteoporosis, and rheumatoid arthritis."</p><p>That's a tangled web of relationships. Pharmaceutical industry funding negatively impacts the work advocacy groups should be focused on: protecting us. NAMI, for example, claims that as a "natural ally" to the pharmaceutical industry, it helps consumers access "all scientifically proven treatments." When the industry ignores evidence of long-term damage caused by its treatments, you have to wonder what's being advocated. </p><p>Although, as the authors conclude, that question is easy to answer. </p><p style="margin-left: 20px;">"Instead of drawing insights from patient experience to set organizational agendas and challenge industry agendas, today's groups are silent on high prices and drug harms, oppose efforts to regulate these basic rights, and demand access to drugs that challenge the safety and effectiveness."</p><p><span></span>--</p><p><em>Stay in touch with Derek on <a href="http://www.twitter.com/derekberes" target="_blank">Twitter</a>, <a href="https://www.facebook.com/DerekBeresdotcom" target="_blank">Facebook</a> and <a href="https://derekberes.substack.com/" target="_blank">Substack</a>. His next book is</em> "<em>Hero's Dose: The Case For Psychedelics in Ritual and Therapy."</em></p>
Health officials in China reported that a man was infected with bubonic plague, the infectious disease that caused the Black Death.
- The case was reported in the city of Bayannur, which has issued a level-three plague prevention warning.
- Modern antibiotics can effectively treat bubonic plague, which spreads mainly by fleas.
- Chinese health officials are also monitoring a newly discovered type of swine flu that has the potential to develop into a pandemic virus.
Bacteria under microscope
needpix.com<p>Today, bubonic plague can be treated effectively with antibiotics.</p><p style="margin-left: 20px;">"Unlike in the 14th century, we now have an understanding of how this disease is transmitted," Dr. Shanthi Kappagoda, an infectious disease physician at Stanford Health Care, told <a href="https://www.healthline.com/health-news/seriously-dont-worry-about-the-plague#Heres-how-the-plague-spreads" target="_blank">Healthline</a>. "We know how to prevent it — avoid handling sick or dead animals in areas where there is transmission. We are also able to treat patients who are infected with effective antibiotics, and can give antibiotics to people who may have been exposed to the bacteria [and] prevent them [from] getting sick."</p>
This plague patient is displaying a swollen, ruptured inguinal lymph node, or buboe.
Centers for Disease Control and Prevention<p>Still, hundreds of people develop bubonic plague every year. In the U.S., a handful of cases occur annually, particularly in New Mexico, Arizona and Colorado, <a href="https://www.cdc.gov/plague/faq/index.html" target="_blank">where habitats allow the bacteria to spread more easily among wild rodent populations</a>. But these cases are very rare, mainly because you need to be in close contact with rodents in order to get infected. And though plague can spread from human to human, this <a href="https://www.healthline.com/health-news/seriously-dont-worry-about-the-plague#Heres-how-the-plague-spreads" target="_blank">only occurs with pneumonic plague</a>, and transmission is also rare.</p>
A new swine flu in China<p>Last week, researchers in China also reported another public health concern: a new virus that has "all the essential hallmarks" of a pandemic virus.<br></p><p>In a paper published in the <a href="https://www.pnas.org/content/early/2020/06/23/1921186117" target="_blank">Proceedings of the National Academy of Sciences</a>, researchers say the virus was discovered in pigs in China, and it descended from the H1N1 virus, commonly called "swine flu." That virus was able to transmit from human to human, and it killed an estimated 151,700 to 575,400 people worldwide from 2009 to 2010, according to the Centers for Disease Control and Prevention.</p>There's no evidence showing that the new virus can spread from person to person. But the researchers did find that 10 percent of swine workers had been infected by the virus, called G4 reassortant EA H1N1. This level of infectivity raises concerns, because it "greatly enhances the opportunity for virus adaptation in humans and raises concerns for the possible generation of pandemic viruses," the researchers wrote.
Want help raising your kids? Spend more time at church, says new study.
- Religious people tend to have more children than secular people, but why remains unknown.
- A new study suggests that the social circles provided by regular church going make raising kids easier.
- Conversely, having a large secular social group made women less likely to have children.