On June 3, 2021, a roughly 60-year-old man in the riverside city of Magdeburg, Germany, received his first COVID vaccine. He opted for Johnson & Johnson’s shot, popular at that point because unlike Pfizer’s and Moderna’s vaccines, it was one-and-done. But that, evidently, was not what he had in mind. The following month, he got the AstraZeneca vaccine. The month after that, he doubled up on AstraZeneca and added a Pfizer for good measure. Things only accelerated from there: In January 2022, he received at least 49 COVID shots.
A few months later, employees at a local vaccination center thought to themselves, Huh, wasn’t that guy in here yesterday? and alerted the police. By that point, the German Press Agency reported, the man had been vaccinated as many as 90 times. And still he was not done. As of November, he said he’d received 217 COVID shots—217!
That’s according to a new paper published in The Lancet. After German researchers learned of the man from newspaper articles, they managed to contact him via the public prosecutor investigating the case. He was “very interested” in participating in a study Kilian Schober, an immunologist at Uniklinikum Erlangen and a co-author on the paper said in a statement. They pieced together his vaccination timeline through interviews and medical records, and collected blood and saliva samples to examine the immunological effects of “hypervaccination.”
The man’s identity hasn’t been revealed, and in the paper he’s referred to only as “HIM” (seemingly an acronym, though what it stands for is not specified). He is hardly the world’s only hypervaccinated person. A retired postman in India had reportedly received 12 shots by January 2022 and told The New York Times, “I still want more.” A New Zealand man, meanwhile, allegedly racked up 10 in a single day. But pause for a moment and consider the sheer logistics of HIM’s feat. In all, he received his 217 vaccinations over the course of just under two and a half years, which comes out to an average of seven and a half shots a month, although the distribution was far from even. For several weeks in early 2022, he received two shots nearly every day. He seems to have had a strong preference for the Pfizer and Moderna vaccines, but he also got at least one shot of AstraZeneca and Sanofi-GSK and, of course, Johnson & Johnson.
Why? you might wonder. The paper itself elides this question, saying only that he did so “deliberately and for private reasons.” Perhaps the most obvious explanation would be extreme, probably pathological COVID anxiety. News reports from April 2022 offer another possible explanation: that he did so to sell the vaccination cards. But German prosecutors did not bring charges once HIM’s scheme was uncovered, and he continued getting unnecessary shots.
Getting 217 COVID shots is very much not the public-health guidance in Germany or anywhere else. Yet the strategy seemingly panned out: HIM has never contracted COVID, researchers concluded based on antigen tests, PCR tests, and bloodwork. “If you ask immunologists, we might have predicted that it would be not beneficial to do this,” Cindy Leifer, an immunologist at Cornell University who wasn’t involved with the Lancet study, told me. They might have expected the constant action to exhaust the immune system, leaving it vulnerable to actual viral threats. But such worries came to nothing.
Still, immunologists cautioned against inferring any strong causal connection. He avoided the virus; he got vaccinated 217 times. He did not necessarily avoid the virus because he got vaccinated 217 times. In fact, the authors wrote, although hypervaccination seems to have increased the quantity of antibodies and T cells that HIM’s body produced to fend off the virus—even after 216 shots, the 217th still produced a modest increase—it had no real effect on the quality of the immune response. “He would have been just as well protected if he had gotten a normal number of three to four vaccinations,” Schober told me.
Nor did hypervaccination lead to any adverse effects. By shot 217, one might have expected to see some of the rare side effects associated with the vaccines, such as myocarditis, pericarditis, or Guillain-Barré Syndrome, but as far as researchers could tell, HIM was completely fine. Remarkably, he didn’t even report feeling minor side effects from any of his 217 shots. On some level, this makes total sense: As Schober reasonably pointed out, HIM probably would not have gotten all those shots if each one had knocked him out for a day. Fair, but still: 217 shots and no side effects? How?
If nothing else, HIM is one hell of an advertisement for the vaccines. Worried about side effects from your third booster? Well, this guy’s gotten more than 200, and he’s a-okay. Travis Kelce has been called Mr. Pfizer, but he’s got nothing on HIM. Scientifically, things are somewhat murkier. The results of the HIM study were largely unsurprising, researchers told me, but the mysteries at the margins—such as the absence of any side effects—are a good reminder that four years after the pandemic began, immunology is still, as my former colleague Ed Yong wrote, “where intuition goes to die.”
At the end of the paper, the authors are very clear: “We do not endorse hypervaccination as a strategy to enhance adaptive immunity.” The takeaway, Leifer said, should not be the more shots, the better. Schober told me he even tried to personally convey this message to HIM after his 216th shot. “From the bottom of my heart as a medical doctor, I really told him that he shouldn’t get vaccinated again,” Schober said.
HIM seemed to take this advice seriously. Then he went and got shot No. 217 anyway.
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On a Thursday morning in April, I met with Vice President Kamala Harris at Number One Observatory Circle, the Victorian mansion that, for the past two and a half years, she and the second gentleman, Doug Emhoff, have called home. She can be a striking presence when she walks into a room, with a long stride and an implacable posture that make her seem taller than she is (about 5 foot 2). By the time I saw Harris at the residence, I had already traveled with her to Atlanta, New York, Los Angeles, and Reno, Nevada, as well as to Africa, trips on which she had carried herself with ease and confidence.
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Ease and confidence have not been the prevailing themes of Harris’s vice presidency. Her first year on the job was defined by rhetorical blunders, staff turnover, political missteps, and a poor sense among even her allies of what, exactly, constituted her portfolio. Within months of taking office, President Joe Biden was forced to confront a public perception that Harris didn’t measure up; ultimately, the White House issued a statement insisting that Biden did, in fact, rely on his vice president as a governing partner. But Harris’s reputation has never quite recovered.
Harris is intensely private, so I was somewhat surprised to be invited to her home. The residence had been redecorated, and in keeping with past practice the work was done without fanfare. There have been no photo spreads, and the designer, Sheila Bridges, signed a nondisclosure agreement. But Harris seemed to enjoy showing me around. In the turret room, she pointed to the banquette seating built along the curve. (“I just love circles,” she said.) She gestured at some of the art she’d brought in, on loan from various galleries and collections, describing each piece in terms of the artist’s background rather than its aesthetic qualities—Indian American woman, African American gay man, Japanese American. “So you get the idea,” she said. We moved into the library, with its collection of books devoted to the vice presidency. (Who knew there were so many?) The green-striped wallpaper pattern that the Bidens had favored when they lived here was gone. Now there was bright, punch-colored wallpaper—chosen, Harris explained, in order to “redefine what power looks like.”
She said this with a laugh, but it was a studied phrase. Redefining what power looks like has been the theme of every chapter of Kamala Harris’s political career. She is the U.S.-born daughter of immigrants—her mother a cancer researcher from India, her father an economist from Jamaica. As Biden’s running mate, she became the first woman, first Black American, and first South Asian American to be elected vice president. Before that, she was the first South Asian American and only the second Black woman to serve in the U.S. Senate. Before that, she was the first woman, Black American, and South Asian American to serve as attorney general of her native California. Before that, she was the first Black woman in California to be elected as a district attorney.
When Biden underwent a colonoscopy in November 2021, Harris served as acting president, becoming the first woman (and first South Asian American) to officially wield presidential authority. If vice presidents have historically been tormented by the question of legacy—compelled to wonder not how they will be remembered but whether they will be remembered at all—Harris was assured of a mandatory nod in the history books the moment she was sworn in.
The hazy nature of Harris’s responsibilities has made for easy satire—“White House Urges Kamala Harris to Sit at Computer All Day in Case Emails Come Through,” read an early Onion headline. Clips of Harris sound bites gone wrong have ricocheted across social media, and not just right-wing sites. A Daily Show feature in October 2022 paired clips from various Harris speeches (“When we talk about the children of the community, they are a children of the community …”) with clips from the fictional vice president Selina Meyer, played by Julia Louis-Dreyfus, on Veep (“Well, we are the United States of America because we are united … and we are states”).
In June 2023, an NBC News poll put Harris’s approval rating at 32 percent. While Biden’s own approval numbers, in the low 40s, are hardly inspiring, the percentage of those who disapprove of Harris’s performance is higher than for any other vice president in the history of the poll.
Ordinarily, as people around Harris like to remind reporters, a vice president’s approval rating does not warrant notice. But if Biden—already the country’s oldest president—wins reelection, he would begin a second term at age 82. And although Democrats recoil at any mention of Biden’s mortality, it’s hardly a coincidence that, as the 2024 campaign gathers pace, people have begun to contemplate the possibility that Harris could become president. In the campaign’s announcement video and at events across the country for the past few months, Harris has been enlisted more prominently as a spokesperson for the administration’s accomplishments—more visible, often, than the president himself. But unlike Biden, Harris does not simply need Americans to agree that she deserves four more years in her current job. She needs them to trust that she is ready, should the moment require it, to step into his.
Republicans may offer a mandatory “God forbid” when raising the prospect of some presidential health crisis, but they are already pushing the idea that “a vote for President Biden is a vote for President Harris.” They are doing so in large part because they see her as a more inviting target than the president himself: a woman of color whose word-salad locutions turn themselves into campaign ads, and whose outspoken advocacy on social issues makes her easier to paint as an ideologue lying in wait.
Harris and I talked at the residence for an hour. Toward the end of the conversation, she patted the cushion between us. “No reporter has sat here ever,” she said. It was a small moment, but it seemed to represent a recognition that something had to change—if not about the way Harris actually does her job, then about the way she presents herself, and her role, in public.
Even today, people who have worked for Harris make a point of telling you where they were during the Lester Holt interview. Usually, it is because they want to make clear that they were not involved.
In June 2021, at the end of a two-day trip to Guatemala, the vice president sat down with the NBC anchor to discuss Biden’s immigration agenda. Harris had recently become the administration’s lead on the so-called root-causes element of border policy, working with Central American countries to alleviate the violent and impoverished conditions that lead many migrants to flee north to the U.S. in the first place. The questions should have been easily anticipated—such as whether Harris had any plans to visit the border itself, where crossings had surged. Yet when Holt did ask that question, Harris threw up her hands in evident frustration. “At some point, you know, I—we are going to the border. We’ve been to the border. So this whole, this whole—this whole thing about the border. We’ve been to the border. We’ve been to the border.” Holt corrected her: “You haven’t been to the border.” Harris became defensive. “And I haven’t been to Europe,” she snapped. “I don’t understand the point you’re making.”
The exchange became the subject of headlines and late-night monologues. (“Well, that escalated quickly,” Jimmy Fallon said on his show the same night.) Afterward, Harris shied away from the camera for months.
For many Americans, the Holt interview was the first real exposure to Harris as vice president. She had spent the better part of her career as a “smart on crime” prosecutor who won her first election—district attorney of San Francisco, in 2003—by positioning herself as a pragmatic reformer. As California’s attorney general, she targeted transnational gangs and cartels and won billions in extra relief from big banks at the center of the foreclosure crisis. She had been the state’s junior senator for just over two years when she launched a bid for the presidency, in 2019, buoyed by the brief but bright flashes of stardom she’d earned from her tough, courtroom-style questioning of Trump-administration officials, including Attorney General Jeff Sessions (“I’m not able to be rushed this fast; it makes me nervous,” Sessions complained to her at one point), and of the Supreme Court nominee Brett Kavanaugh. And although she was an early favorite for the 2020 Democratic presidential nomination, raising millions in donations as she promised to “prosecute the case against Donald Trump,” her campaign fell apart before the Iowa caucus, beset by uneven messaging, disorganization, and low morale.
Throughout her time in national politics, Harris has repeated some advice imparted to her by her mother: “You don’t let people tell you who you are. You tell them who you are.” Yet a consistent theme of Harris’s career has been her struggle to tell her own story—to define herself and her political vision for voters in clear, memorable terms. The result, in Harris’s first months as vice president, was that high-profile mistakes assumed the devastating weight of first impressions. Verbal fumbles (“It is time for us to do what we have been doing. And that time is every day”) became memes and were anthologized online. Shortly after the Holt interview, White House aides began leaking to variousnewsoutlets about top-to-bottom dysfunction in Harris’s office and Biden’s apparent concern about her performance. In her first year and a half as vice president, Harris saw the departure of her chief of staff, communications director, domestic-policy adviser, national security adviser, and other aides. Her current chief of staff, Lorraine Voles—formerly Al Gore’s communications director, who has expertise in crisis management—was brought on initially to help with, as Voles put it, “organizational” issues with the team still in place.
Ron Klain, Biden’s first chief of staff, told me that after her initial missteps, Harris became highly risk-averse: “She’s always nervous that if she does something that doesn’t go well, she’s setting us back.” David Axelrod, a former senior strategist for President Barack Obama, noticed the same trait. “I think it’s one of the things that plagued her in the presidential race,” he told me. “It looked as if she didn’t know where to plant her feet. That she wasn’t sort of grounded, that she didn’t know exactly who she was.” He went on: “People can read that. When you’re playing at that level, people can read that.”
Those closest to Harris have tried to make sense of why the vice president’s positive qualities—her intelligence, her diligence, her integrity—have failed to register with Americans. It is impossible, of course, to talk about perceptions of Harris without laying some of the blame on racism and sexism. The briefest glance at the toxic comments about Harris on social media reveals the bigotry that motivates some of her most fervent detractors. But the vice president’s allies also acknowledge that she has struggled to make an affirmative case for herself. Judging from what has gone viral online, she is better known for her passion for Venn diagrams than for any nugget of biography; right-wing personalities enjoy mocking this predilection almost as much as they enjoy mocking the way she laughs.
Harris may understand intellectually the imperative to seem “relatable” to a broad audience—to condense her background to a set of compelling SparkNotes to be recited on cue—but she hasn’t made a habit of doing so. In smaller settings, she can be funny at her own expense. When I asked her what advice she would give to a successor, she referred back to some of those social-media reviews: “Don’t read the comments.” In our conversation at the residence, she touched briefly on how her “first woman” status shapes even the most workaday elements of the job: “I’m not going to tell you who said to me—it’s a previous president of the United States. He said, ‘Wow, women—I get up, I go work out, I jump in the shower, and I’m out the door. You guys …’ ” (I suspect she was quoting Obama, a friend of hers who has spoken about his efficient morning routine.) Harris told me that she has to let the Secret Service know a day in advance if she is going to be wearing a dress instead of a pantsuit, because agents have to pick her up in a different kind of car.
But she prefers a discreet distance from topics like these. A friend of Harris’s advised me before our first interview to avoid “small talk” or “diving immediately into personal matters.” The friend explained: “She appreciates the respect in that way.” Minyon Moore, a Democratic strategist with long-standing ties to Harris, made a related point: “She’s not a person—which I kind of like, but it doesn’t do her any good—she’s not a person that’s going to brag on herself. In fact, she’s very uncomfortable, say, beating her own chest. She just wasn’t raised that way.” Lateefah Simon, a former MacArthur fellow and now a candidate for Congress, was in her mid-20s when Harris hired her to run a program for young people convicted of nonviolent felonies, mostly involving drugs. Simon remembers Harris telling her she could either stand outside with a bullhorn or come push for change from the inside. “If you know Kamala Harris, she’s stern—she was a stern 38-year-old,” Simon recalled. But she could also be more than that: Harris gave Simon her first suit after she showed up on day one in Puma sweats.
Harris in 1997, when she was a deputy district attorney of Alameda County, California (Mary F. Calvert / MediaNews Group / The Mercury News / Getty)
Nearly three years after Harris’s swearing-in, her current and former staff still seem to be unearthing pertinent elements of her life story. Twice while I was reporting this article, aides highlighted an experience in Harris’s adolescence—one that had informed her decision to become a prosecutor—that they’d learned about only after joining her team. In high school, a friend confided in Harris that she was being molested by a family member, so Harris insisted that the friend move in with her own family (and she did). The outrage Harris felt in that moment would help define her path to the Alameda County district attorney’s office, where much of her work as a deputy involved prosecuting sex crimes against children.
I understood why her aides wanted me to hear that story, which is not widely known. I wondered why—when I’d asked about her decision to become a prosecutor—Harris hadn’t mentioned it herself. When we spoke at the residence, she did acknowledge the “request, sometimes the demand,” for personal revelation. “I guess it’s a bit outside of my comfort level,” Harris said, “because for me, it really is about the work. You know, I am who I am. I am who I am. And I think I’m a pretty open book, but I am who I am.” She went on a little longer, making clear that she understands that people want to know more. And then, in a softer tone, she said: “And I just, you know, yeah. I don’t know what to say about that.”
But what is “the work”? For the first time in her career, Harris holds a job devoid of any clear benchmarks of success. She was a transformational figure by the mere fact of her election, but the office to which she was elected doesn’t lend itself to transformational leadership.
After settling into Observatory Circle, Harris made a point of gathering historians for dinners—to discuss not just American democracy but also the history of the vice presidency itself. “You’re not supposed to be visible,” Heather Cox Richardson, who attended one dinner, told me, referring to the nature of the vice president’s job. “So there’s that really fine tightrope you walk, between how do you make people understand that you’re qualified without looking like you’re unqualified because you don’t understand your role.”
Neither Biden nor Harris arrived in Washington with a particular vision for Harris’s vice presidency. Harris had issues in which she was interested—racial justice, climate change, gun violence, maternal mortality—and as vice president she has explored these and others. But America imposed its own urgent agenda: Getting the pandemic under control absorbed much of everyone’s attention. With a 50–50 partisan split in the Senate, Harris was also compelled to spend much of her time in her old place of work, exercising the vice president’s constitutional duty to cast the deciding vote in the case of a tie. “We couldn’t make plans for me to be outside of D.C. for at least four days of the workweek,” she recalled.
More fundamentally, Biden and Harris came into office with few instructive models for their partnership, despite Biden having once held the job himself. For nearly half a century, with occasional exceptions, the vice president has been a creature of the capital. The president, in contrast, has been a relative outsider. Walter Mondale, the archetype of the modern American vice president, had 12 years in the Senate under his belt when he was sworn in. He became Jimmy Carter’s anchor to Washington. George H. W. Bush did the same for Ronald Reagan, as did Al Gore for Bill Clinton, Dick Cheney for George W. Bush, Joe Biden for Barack Obama, and Mike Pence for Donald Trump. But Harris and Biden flipped the script: a comparative newcomer serving as vice president to a man who’d launched his Senate career before she reached her tenth birthday.
In our interviews, Harris spoke of her relationship with Biden largely in generalities. When I asked how she and the president complement each other, she said, “Well, first of all, let me just tell you, we really like each other,” and then went on to talk about shared values and principles. When I asked Harris what aspects of her skill set Biden depends on, she was more direct: “You’ll have to ask him.” (When I did, a spokesperson for Biden sent this statement: “Kamala Harris is an outstanding vice president because she’s an outstanding partner. She asks the hard questions, thinks creatively, stays laser-focused on what we’re fighting for, and works her heart out for the American people. She inspires Americans and people around the world who see her doing her job with skill and passion and dream bigger for themselves about what’s possible. I trust her, depend on her, admire her. And I’m proud and grateful to have her by my side.”)
Current and former aides to both say Harris and Biden have a good friendship. The president made the relationship a priority early on, setting up weekly lunches with Harris, like the ones he himself had valued with Obama. She still has lunch with him, she says, “when he’s not traveling, when I’m not traveling.” Given that Harris loves to cook—and regularly has friends and family over for meals—I asked whether she and her husband had hosted the Bidens for dinner. She said that they hadn’t, and seemed momentarily stuck in a feedback loop: “We have a plan to do it, but we have to get a date. But he and I have a plan, we have a plan to do it. And yeah, no, we actually have a plan to do it.”
As vice president, Harris has been unfailingly loyal to Biden. For West Wing staff, especially at the beginning, this was no small thing. During Harris’s vetting for the job, some of those close to Biden—reportedly including his wife, Jill—struggled with the memory of her sharp attacks on him during the presidential primary. In a televised debate, Harris had brought up the subject of Biden’s past opposition to busing, leading to one of the most withering exchanges of the race. “There was a little girl in California who was part of the second class to integrate her public schools, and she was bused to school every day,” Harris told Biden. “And that little girl was me.”
Perhaps in recognition of this history, Harris has been an unswerving advocate of Biden and his policy priorities. Ultimately, she told me, that is what she sees as the core of her mandate as vice president. Building out the rest of the mandate has proved more complicated.
The path to the Lester Holt interview began with tension over Harris’s policy portfolio. During one of the administration’s early multiagency meetings about the surge of unlawful crossings at the Mexican border, Biden was impressed as Harris outlined ideas for engaging the Central American countries that many of the migrants were coming from. According to Ron Klain, the president turned to Harris and said, “Well, why don’t you do that?”—meaning, become the point person on the morass of root-cause elements. Harris approached the chief of staff after the meeting. “And she said,” as Klain recalled, “ ‘Well, I wasn’t really looking for that assignment—my idea was, this is what we should do, and someone else should do it.’ ” Klain told Harris he understood but, as vice president, Biden had worked on this aspect of immigration policy for Obama, and they needed her to take it on as well.
It wasn’t that Harris lacked relevant experience; as attorney general of California, she had worked extensively with law enforcement in Mexico on drug and human trafficking. But the politics of the issue were radioactive. Harris knew this, and so did Klain. “It was obviously a controversial assignment,” he acknowledged to me. “It wasn’t necessarily anyone’s idea of a glory assignment.” (Asked about this, the vice president’s office responded that Harris had “plunged into the issue with vigor.”) Harris broke the news of the task to her staff on a mordant note, opening a meeting with the announcement that she was “going to oversee the Israeli-Palestinian conflict,” according to a person who was in the room, then dialing back to the slightly less grim reality.
As Klain saw it, Biden intended the appointment—to the same role he had once held—as a show of respect. But it also suggested obliviousness to Harris’s need, early in her term, for a measure of stability and success. Of course, as the Holt interview showed, Harris could make the task harder all on her own. Republican lawmakers and Fox News personalities relished the prospect of pinning the border crisis on Harris. She may have been responsible for just one sliver of U.S. policy, but they used her proximity to border issues to fuel the image of Harris as Biden’s “border czar.”
In the first year of his presidency, Biden did little to present Harris as essential to the administration; neither did the Democratic Party more broadly. Indeed, there was a sense that Harris might be a liability more than anything else. Less than two weeks into office, Harris appeared on a West Virginia news station to pitch the Biden administration’s coronavirus stimulus package—which Joe Manchin, the state’s conservative Democratic senator, was not yet sold on. In an interview on the same station the next day, Manchin said he was shocked that Harris had given him no notice of the appearance. “I couldn’t believe it,” he said. “That’s not a way of working together.” Later that year, as my colleague Franklin Foer has reported, Biden invited Manchin to the Oval Office to discuss the stimulus package; Harris was there initially, but after pleasantries was sent on her way. Biden had once said that Harris’s would be “the last voice in the room” during important conversations. Not this time.
Harris and her husband, Doug Emhoff, as they arrived in Accra, Ghana, in March 2023 (Ernest Ankomah / Getty)
In June 2021, Biden asked Harris to take the lead on voting rights for the administration. The House had recently passed the For the People Act—a massive overhaul of election law that addressed voter access, gerrymandering, campaign finance, and other matters—and Democratic leaders were eager to see movement in the Senate. That was unlikely. Mitch McConnell, the Senate GOP leader, promised that no Republican would support the bill; not all Democrats were on board either. The legislation would likely die by filibuster—a procedure that Biden, despite calls from many in his party, was almost certainly not going to try to undermine.
Harris’s allies would later characterize voting rights as one of those impossible issues—intractable is the word they often use—that the president had saddled her with. Yet it was Harris herself who had lobbied for the assignment. Her personal background made her a natural spokesperson, and as attorney general of California, she had signed on to an amicus brief urging the Supreme Court to uphold the protections against discrimination in the Voting Rights Act—the protections eventually struck down in Shelby County v. Holder. But the bill’s death by filibuster was virtually inevitable. And Harris didn’t do much to stave it off.
Harris’s aides once described her to reporters as potentially a key emissary for the administration in Congress—helping corral votes by way of “quiet Hill diplomacy.” But she lacked the deep relationships needed to exert real influence. Congressional officials told me that Harris rarely engaged the more persuadable holdouts on either side of the aisle. At a key moment in the negotiations, Biden went to talk with the two resistant Democrats, Joe Manchin and Arizona’s Kyrsten Sinema. Harris did not go with him. A White House official declined to get into details and said only that Harris was “interested and engaged” in conversations with Democratic lawmakers during this period. Harris shifted the terms of the discussion when I asked how her Senate background had proved useful in the administration’s push for legislation: “I mean, I think the work we have to do is really more in getting folks to speak loudly with their feet through the election cycle”—an unusual image, though the point was clear enough: Electing more Democrats might be more effective than trying to twist more arms.
For now, Senate Democrats are not fighting for time with Harris when she’s on the Hill. “You’d be hard-pressed to find a Democratic office that actually engages with her or her team on a regular basis,” one Democratic senator’s chief of staff told me. Traditionally, this person said, officials from the executive branch who visit the Capitol are cornered by lawmakers hoping to get their priorities before the president. But few people are “scrambling to make alliances” with Harris—not because of any dislike, as this person and other congressional officials told me, but simply because of uncertainty about the nature of her role. “In her case,” the chief of staff said, “it’s kind of like, ‘Hey, good to see you.’ And that’s kind of the end of it.”
This past spring, I traveled with Harris to Los Angeles, where she was scheduled to appear on Jennifer Hudson’s daytime talk show. When Hudson asked Harris what she missed most about her old life, before the White House, the vice president replied, “Have you watched The Godfather ?” I was in the greenroom with her staff as they looked apprehensively at the screen, wondering where their boss was going with this. Harris went on to describe the scene in which Michael Corleone is out for a quiet walk in Sicily with his fiancée, “and then the shot pans out, and the whole village is on the walk with them.”
There’s no escaping the reality that her every move is probed and dissected. During our conversation at the residence, Harris pointed to the veranda. “Sometimes in the summer, I’ll come and sit out with my binders and a cup of tea, and it’s just really nice and quiet,” she said. It wasn’t until later, when I listened again to the tape of the conversation, that I remembered what she’d said next: “You almost forget that there are 5,000 people around here.”
Having worked in politics and government for the better part of her life, Harris is accustomed to a certain amount of scrutiny. But in her past jobs—as a prosecutor, as attorney general—people were looking at her actual accomplishments. That was how it seemed to her, at least. A friend of Harris’s told me that her professional yardstick was “outcome driven.” Campaigning for district attorney of San Francisco, Harris criticized the incumbent’s low conviction rate for felonies; running later for reelection, she talked about how she had improved it by 15 percentage points. Communication wasn’t a matter of rhetoric. It was just laying out the facts.
This is still, in some ways, how Harris tends to perceive her job. She is always asking aides to get to the point: Show me the data; show me the metrics. And for some things, this works. But success in national politics involves gauzier, more emotional elements. It’s not an accident that the single utterance by Harris that most people can call to mind—“That little girl was me”—drew on searing personal experience.
Go to enough of Harris’s events and you’ll notice a pattern. Many of them—conversations with community leaders at, say, a college campus or a civic center—begin shakily. The moderator opens by asking Harris a sweeping question about the state of the country, or the administration’s approach to some major issue—the sort of question that a seasoned politician should be able to spin her way through on autopilot. And yet Harris often sounds like she’s hearing the question for the first time.
During a discussion at Georgia Tech focused on climate change, I listened as Harris was asked to speak about the administration’s progress over the past two years in addressing the crisis. Her baroque response began: “The way I think about this moment is that I do believe it to be a transformational moment. But in order for us to truly achieve that capacity, it’s going to require all to be involved … and I will say, on behalf of the administration, a whole-of-government approach to understanding the excitement that we should all feel about the opportunity of this moment, and then also thinking of it in a way that we understand the intersection between so many movements that have been about a fight for justice and how we should see that intersection, then, in the context of this moment … And so I’m very excited about this moment.”
This is not Churchill. It’s not even Al Gore. Only when Harris assumed the role of interrogator herself did she seem to find her rhythm, pressing the moderators on the stage—two scientists—to discuss their personal journey toward an interest in climate issues. She then leveraged one moderator’s story to explain the administration’s plan to replace lead pipes across the country—using $15 billion from the bipartisan infrastructure deal, one of the Biden administration’s marquee victories. The communities that have been suffering from contamination “have been fighting for years and years and years,” Harris noted. “It didn’t take a science degree for them to know what was happening to their children.” The audience responded as if at a church service, with murmurs of affirmation.
Hillary Clinton told me that she has met with Harris at the White House and the vice president’s residence, and has talked with her numerous times by phone. “I’ve tried to be as helpful and available to her as possible,” Clinton said, adding, “It’s a tough role.” She noted that Harris isn’t a “performance” politician, a comment she intended not as a criticism but as an acknowledgment that Harris’s skills mainly lie elsewhere. (Clinton isn’t a performance politician either.) Harris doesn’t dispute the point: “My career was not measured by giving lovely speeches,” she told me.
Harris communicates most effectively when she can shift the focus away from herself. The first two conversations I had with the vice president, both while traveling with her, felt stilted and strained, as if I were tiptoeing around glass. But at the residence, alone, Harris was warm, inviting, at times even maternal. “You’re newly married,” she said. (“Yes,” I responded, though it wasn’t a question.) “Pay attention to your marriage,” she counseled. “Friendships, marriage require that you pay attention. Because life has a way of sweeping you up.”
Harris has configured many of her public events to resemble a back-and-forth conversation rather than a standard Q&A: She likes talking with people. The grassroots settings that Harris enjoys represent a mode of retail politics that rarely grabs national attention. But such events have given her a good read on what voters care about. They have also allowed her to inhabit her own space. As Klain observed, in Washington, you’re “just the vice president.” In the rest of the country, you’re “the vice president.”
In the aftermath of the Supreme Court’s 2022 decision in Dobbs v. Jackson Women’s Health Organization, which overturned the abortion protections embodied in Roe v. Wade, Harris had a strong sense of American public opinion on the issue. Amid a crush of headlines predicting a so-called red wave in the upcoming midterm elections—with the economy as the central issue—Harris was steadfast in her view that abortion rights would shape the contest. She spent much of 2022 on the road, hosting conversations on reproductive rights in red and blue states alike. Women, she told me, “won’t necessarily talk loudly” about an issue like abortion. “But they will vote on it.” In this respect, Harris understood the mood of the country, and the potential impact at the ballot box, better than most people in Washington. In the midterms, the Democrats did far better than expected, even winning a majority in the Senate; there was no red wave. Harris has continued to travel and talk about abortion rights ever since. It is a central issue for the Democratic base and one that Biden—a devout Catholic who, in his own words, isn’t “big on” abortion—has been reluctant to press himself.
Harris marking the 50th anniversary of Roe v. Wade at an event in Tallahassee, Florida, in January 2023 (Aileen Perilla / Redux)
Fighting Dobbs will be a long battle. But it’s the kind Harris may be suited for. In one of our conversations, she spoke about “the significance of the passage of time”—a line that featured in one of her more unwieldy speeches as vice president. I remember steadying myself when the phrase surfaced. But what followed was a revealing commentary about the diligence and patience that are required to produce real change. Harris told me about a commencement speech she had given at the law school of UC Berkeley. She spoke to the new graduates about Brown v. Board of Education—about how, after the ruling, integration largely took place on a creeping, county-by-county basis, and only in response to continual pressure. Exerting that pressure meant building a legal foundation, erecting a structure brick by brick, and laboring over the details, all in return for progress that was often measured in inches. This is a truth, Harris noted, that Thurgood Marshall and Charles Hamilton Houston and Constance Baker Motley all knew. “And I just got up there and I was like, ‘You want to be a lawyer?’ ” she recalled. If you do, she told them, then you must learn to “embrace the mundane.”
She laughed at the memory of that line. “And the parents are like, Ooh, this is good,” she recalled. “And the kids are like, Oh, fuck.”
Harris’s engagement with abortion rights has broken through to voters more than anything else in her vice presidency, according to the Democratic pollster Celinda Lake. But Harris has been effective in another arena—diplomacy—that to the public is hardly visible at all.
During his two terms as vice president, Joe Biden traveled to 57 countries—and before that, as a senator, he had decades to acquire experience abroad. In the past two years, Harris has traveled to 19 countries, including France, Germany, Poland, Guatemala, Mexico, Thailand, Singapore, Vietnam, the Philippines, Ghana, Tanzania, Zambia, and Indonesia. She has met with 100 or so foreign leaders. They have tended to appreciate, as more than one White House official told me, how fact-based and direct she is. She has “very little patience,” one of them said, for the euphemisms and platitudes of routine diplomacy. Harris’s risk aversion appears to stop at the water’s edge.
Her first major diplomatic test came during a five-day trip to France in November 2021. For some time, Harris had been considering an invitation to attend the Paris Peace Forum, whose purpose was to discuss global inequalities exacerbated by the pandemic. But in the weeks before the event, relations between Washington and Paris had been pitched into tumult after the announcement of a lucrative joint U.S.-British submarine deal with Australia that nullified France’s own submarine deal with Australia. French President Emmanuel Macron was furious, recalling his ambassador from Washington; Biden soon admitted that his handling had been “clumsy.” For Harris, the trip to Paris went from optional to crucial.
In front of the cameras, Harris and Macron both said what they were expected to say about a positive long-term bilateral future. The atmosphere was one of chilly civility. But behind the scenes, Harris was helping lay the groundwork for cooperation on the looming crisis in Ukraine. She used her nearly two-hour meeting with Macron at the Élysée Palace to present an array of U.S. intelligence. Harris urged the French president to take seriously the threat of a Russian invasion of Ukraine.
Three months later, Biden asked Harris to represent the administration at the high-visibility Munich Security Conference. It was a sign of Biden’s confidence—on a personal level (Biden had attended the conference many times) and also because of the timing. The U.S. now knew that a Russian invasion of Ukraine was imminent, and Harris was tasked with helping press allies and partners to develop a coordinated response. Five days before the invasion, Harris met with Ukrainian President Volodymyr Zelensky to share U.S. intelligence and plans for military support. Publicly, Zelensky still seemed uncertain about Russia’s intentions and the scale of the threat. “The vice president directly and very clearly conveyed to Zelensky and his team that this was going to happen,” an official on the trip told me, “and they should really be planning on that basis and not waste any time.”
Harris returned to the Munich Security Conference this past February. Speaking for the administration, she formally declared the U.S. view that Russia had committed “crimes against humanity” in Ukraine.
A month later, I joined Harris on a multicountry tour of Africa. China’s deepening presence on the continent provided the geopolitical backdrop. But Harris was bringing with her more than $7 billion in commitments, largely from the private sector, to promote climate-resilience initiatives, money she had raised herself through months of tree-shaking phone calls to companies and individuals. The trip was a seven-day sprint, and logistically taxing. On one occasion, the American advance team had to upgrade an entire road from dirt to gravel; the vice president’s Secret Service code name may be “Pioneer,” but there are limits to what her motorcade can handle.
In Cape Coast, Ghana, Harris walked through the Door of No Return, where enslaved people had taken their final steps in Africa before being forced onto ships. She discarded her prepared remarks—something she had almost never done before—and spoke powerfully about the legacy of the diaspora in the Americas. In Lusaka, Zambia, she was driven to the rural outskirts of the capital to visit Panuka Farm, powered entirely by renewable energy. The vice president had spent time on a farm as a child; wearing jeans and Timberlands, she seemed at home inside the netted enclosures of sweet peppers and iceberg lettuce. Washington felt very far away.
Harris’s allies touted the Africa trip as a historic effort to deepen ties with the fast-growing continent. But it hardly registered back home. Terrance Woodbury is a Democratic pollster who focuses on young and minority voters; he saw the Africa trip as a “pivot” in terms of Harris’s self-presentation. Yet when I asked whether the trip had made any difference politically, he said, simply, “No.”
The trip also offered a reminder of Harris’s ongoing struggle when it comes to telling her own story—and of the Veep comparison. The vice president’s visit to Zambia had been billed as a kind of homecoming. As a young girl, Harris spent time in Lusaka with her maternal grandfather, P. V. Gopalan, who had been dispatched there in the 1960s from India to advise Zambia’s first independent government on refugee resettlement. Now, decades later, she was returning to Zambia as one of the most prominent public figures in the world. Harris’s scheduled stop at her grandfather’s old home in the capital, where she was expected to speak about his work and how his career as a civil servant had shaped her own ambitions, promised to be a special moment.
Instead, dozens of reporters and others looked on as Harris laughed somewhat awkwardly in front of a concrete-and-stucco office building. Greeting her near the doorway was a U.S.-embassy official, who explained that, after a year of combing through public records, researchers had managed to locate the plot of land on which Gopalan’s house had stood. The house itself, however, had been replaced by the headquarters of a Zambian financial-services group. Seeming not to know what else to do, Harris accepted an offer to tour the building. Reporters and cameramen, who had been anticipating a press conference at the end of the event, were ushered away. When I asked why the press conference had been scrapped, an aide said, “She needed a private moment.” Life has a way of sweeping you up.
My conversation with Harris at the residence came three weeks after our return from Africa. She took me through her herb garden, just off the driveway, crouching to examine the state of her oregano, dill, rosemary, thyme, and sage. Washington’s springtime pollen was at its worst, and my eyes were red-rimmed and watery as we made our way inside. After finding a box of tissues, Harris sympathized, referring to D.C. as “a toxic swamp of pollen.” People from outside the area, she went on, “are not acclimated to this mix.” It was a botanical comment, but it reminded me of something one of Harris’s old friends had told me about the vice president’s seeming discomfort in the capital, and how much happier she appeared when traveling to other parts of the country.
Perceptions of Harris appear to be frozen in 2021. A recent op‑ed in The Hill, largely sympathetic to the vice president, urged the Biden campaign to get her “off the sidelines”—this during a week when she traveled to Indianapolis; Jacksonville, Florida; and Chicago. (Many weeks, she is on the road at least three days out of seven.) At one point during my conversation with David Axelrod, he wondered why Harris hadn’t become more of a champion for the administration’s most significant achievements, such as the infrastructure package. But much of her cross-country travel is focused exactly on that.
Of course, Harris is not alone in having trouble breaking through. “I mean, why do only a third of voters know what the president has done?” Celinda Lake, the pollster, asked when we spoke. “My God, they spent millions of dollars on it. They’ve got ads up now.” If voters don’t know what the president has done, Lake said, “they sure as heck aren’t going to know what the vice president has done.”
This summer, I asked Jeff Zients, the current White House chief of staff, if he could recall a moment when Biden had noticeably leaned on Harris for guidance, or when her input had meaningfully changed the administration’s approach to an issue. He had mentioned earlier in our interview that Harris had been instrumental in putting “equity” at the forefront of the administration’s COVID response—ensuring that public-health efforts reach the underserved. Other examples? “Let me think of a specific anecdote, and I’ll have somebody follow up,” he said. His spokesperson texted after the call to confirm that the office would get back to me. Despite my follow-ups, that was the last I heard.
Vice presidents are chosen mainly for political reasons—as Harris was—and not actuarial ones. In most of the presidential elections during the past half century, the possibility that the candidate at the top of the ticket might die in office was not a significant issue. (It was an issue for John McCain, in 2008, with his history of multiple melanomas, which was one more reason McCain’s selection of the erratic Sarah Palin as his running mate had such negative resonance.) This time around, given Biden’s age, the words heartbeat away connote a real possibility.
When I asked Zients what he’s observed in Harris that makes him confident about her abilities as a potential chief executive, he at first started chuckling in what seemed to be discomfort at the subtext of the question. (“Well, I want to, you know, make sure we’re not talking about anything—but, you know, she’s prepared.”) But after that he went on thoughtfully: “You know, the first thing I go to is when you’re president, there are so many issues, and understanding what’s most important to the American people, what’s most important to America’s position in the world—it takes experience, which she has, and it takes a certain intuition as to what matters most, and she’s very good at quickly boiling it down to what matters most, and focusing on those issues, and then within those issues or opportunities, understanding what’s most important, and holding the team accountable.”
That’s a sharp assessment of what a vice president can bring to the table, and not a bad way to make important observations about Harris that seem matter-of-fact and not tied to the prospect of a sudden transition.
So I was surprised when another White House official, who knows both Harris and Biden well, treated the topic of readiness as if it were somehow illegitimate—a ploy by desperate Republican candidates. “People who are polling near the bottom do things and say things to try and be relevant and get oxygen.” Was it ridiculous to ask about Harris’s constitutional closeness to the presidency? “She is the closest to the presidency, as all of her predecessors have been.”
Nikki Haley, Tim Scott, Chris Christie, and Ron DeSantis, all of them presidential candidates, have explicitly raised the specter of a “President Harris.” So have other Republicans. The probable GOP nominee, Donald Trump, who habitually belittles women, will likely do so too. He has referred to Harris as “this monster” and has questioned her citizenship. On one occasion, he made fun of her name—“Kamala, Kamala, Kamala,” repeating it slowly with various pronunciations. Harris called him childish for that, but has largely declined to take the bait. Perhaps not surprisingly for a former prosecutor, she has become more publicly outspoken than anyone else in the White House about the indictments that Trump faces and the need to hold lawbreakers accountable.
The Biden administration has every incentive to embrace Harris. Why does addressing preparedness seem so difficult? Harris has affirmed that she is ready, if need be, but there’s a limit to what she herself can say. It’s not unusual for a president, any president, to take pains to demonstrate his vice president’s readiness for the top job, if only by regularly referencing their closeness—the notion that the person is briefed on everything and has an opportunity to weigh in on major decisions, even if the fingerprints aren’t always visible. And no president comes to the Oval Office with every necessary skill. Harris is an uncomfortable fit in the vice president’s role, whatever that is, and she cannot speak or act independently; the job makes every occupant a cipher. But she has been a successful public servant for more than three decades. She ran the second-largest justice system in America, in a state that is the world’s fifth-largest economy. By virtue of her position, she is among those who represent the future of her party, and she represents its mainstream, not its fringe. Of course Kamala Harris is ready for the presidency, to the extent that anyone can be ready. This should not be hard for her own colleagues to talk about. Not talking about it leaves the subject open for political exploitation—by opponents whose own likely candidate makes the idea of readiness absurd.
And yet the topic is treated as a trip wire. In a brief conversation after an abortion-rights rally in Charlotte, North Carolina, on the first anniversary of the Dobbs decision, I asked Harris herself: Had she and Biden discussed how to address questions about her readiness to step in as president, should circumstances ever require it? “No,” she said. And that was the end of the conversation.
This article appears in the November 2023 print edition with the headline “Her?” When you buy a book using a link on this page, we receive a commission. Thank you for supporting The Atlantic.
Since the pandemic’s earliest days, epidemiologists have been waiting for the coronavirus to finally snap out of its pan-season spree. No more spring waves like the first to hit the United States in 2020, no more mid-year surges like the one that turned Hot Vax Summer on its head. Eventually, or so the hope went, SARS-CoV-2 would adhere to the same calendar that many other airway pathogens stick to, at least in temperate parts of the globe: a heavy winter peak, then a summer on sabbatical.
But three and a half years into the outbreak, the coronavirus is still stubbornly refusing to take the warmest months off. Somepublic-health experts are now worried that, after a relatively quiet stretch, the virus is kick-starting yet another summer wave. In the southern and northeastern United States, concentrations of the coronavirus in wastewater have been slowly ticking up for several weeks, with the Midwest and West now following suit; test-positivity rates, emergency-department diagnoses of COVID-19, and COVID hospitalizations are also on the rise. The absolute numbers are still small, and they may stay that way. But these are the clear and early signs of a brewing mid-year wave, says Caitlin Rivers, an epidemiologist at Johns Hopkins University—which would make this the fourth summer in a row with a distinct coronavirus bump.
Even this far into the pandemic, though, no one can say for certain whether summer waves are a permanent COVID fixture—or if the virus exhibits a predictable seasonal pattern at all. No law of nature dictates that winters must come with respiratory illness, or that summers will not. “We just don’t know very much about what drives the cyclical patterns of respiratory infections,” says Sam Scarpino, an infectious-disease modeler at Northeastern University. Which means there’s still no part of the year when this virus is guaranteed to cut us any slack.
That many pathogens do wax and wane with the seasons is indisputable. In temperate parts of the world, airborne bugs get a boost in winter, only to be stifled in the heat; polio and other feces-borne pathogens, meanwhile, often rise in summer, along with gonorrhea and some other STIs. But noticing these trends is one thing; truly understanding the triggers is another.
Some diseases lend themselves a bit more easily to explanation: Near the equator, waves of mosquito-borne illness, such as Zika and Chikungunya, tend to be tied to the weather-dependent life cycles of the insects that carry them; in temperate parts of the world, rates of Lyme disease track with the summertime activity of ticks. Flu, too, has pretty strong data to back its preference for wintry months. The virus—which is sheathed in a fragile, fatty layer called an envelope and travels airborne via moist drops—spreads best when it’s cool and dry, conditions that may help keep infectious particles intact and spittle aloft.
The coronavirus has enough similarities to flu that most experts expect that it will continue to spread in winter too. Both viruses are housed in a sensitive skin; both prefer to move by aerosol. Both are also relatively speedy evolvers that don’t tend to generate long-lasting immunity against infection—factors conducive to repeat waves that hit populations at a fairly stable clip. For those reasons, Anice Lowen, a virologist at Emory University, anticipates that SARS-CoV-2 will continue to show “a clear wintertime seasonality in temperate regions of the world.” Winter is also a time when our bodies can be more susceptible to respiratory bugs: Cold, dry air can interfere with the movement of mucus that shuttles microbes out of the nose and throat; aridity can also make the cells that line those passageways shrivel and die; certain immune defenses might get a bit sleepier, with vitamin D in shorter supply.
None of that precludes SARS-CoV-2 spread in the heat, even if experts aren’t sure why the virus so easily drives summer waves. Plenty of other microbes manage it: enteroviruses, polio, and more. Even rhinoviruses and adenoviruses, two of the most frequent causes of colds, tend to spread year-round, sometimes showing up in force during the year’s hottest months. (Many scientists presume that has something to do with these viruses’ relatively hardy outer layer, but the reason is undoubtedly more complex than that.) An oft-touted explanation for COVID’s summer waves is that people in certain parts of the country retreat indoors to beat the heat. But that argument alone “is weak,” Lowen told me. In industrialized nations, people spend more than 90 percent of their time indoors.
That said, an accumulation of many small influences can together create a seasonal tipping point. Summer is a particularly popular time for travel, often to big gatherings. Many months out from winter and its numerous infections and vaccinations, population immunity might also be at a relative low at this time of year, Rivers said. Plus, for all its similarities to the flu, SARS-CoV-2 is its own beast: It has so far affected people more chronically and more severely, and has generated population-sweeping variants at a far faster pace. Those dynamics can all affect when waves manifest.
And although certain bodily defenses do dip in the cold, data don’t support the idea that immunity is unilaterally stronger in the summer. Micaela Martinez, the director of environmental health at WE ACT for Environmental Justice, in New York, told me the situation is far more complicated than that. For years, she and other researchers have been gatheringevidence that suggests that our bodies have distinctly seasonal immunological profiles—with some defensive molecules spiking in the summer and another set in winter. The consequences of those shifts aren’t yet apparent. But some of them could help explain when the coronavirus spreads. By the same token, winter is not a time of disease-ridden doom. Xaquin Castro Dopico, an immunologist at the Karolinska Institute, in Sweden, has found that immune systems in the Northern Hemisphere might be more inflammation-prone in the winter—which, yes, could make certain bouts of illness more severe but could also improve responses to certain vaccinations.
All of those explanations could apply to COVID’s summer swings—or perhaps none does. “Everybody always wants to have a very simple seasonal answer,” Martinez told me. But one may simply not exist. Even the reasons for the seasonality of polio, a staunch summertime disease prior to its elimination in the U.S., have been “an open question” for many decades, Martinez told me.
Rivers is hopeful that the coronavirus’s permanent patterns may already be starting to peek through: a wintry heyday, and a smaller maybe-summer hump. “We’re in year four, and we’re seeing the same thing year over year,” she told me. But some experts worry that discussions of COVID-19 seasonality are premature. SARS-CoV-2 is still so fresh to the human population that its patterns could be far from their final form. At an extreme, the patterns researchers observed during the first few years of the pandemic may not prelude the future much at all, because they encapsulate so much change: the initial lack and rapid acquisition of immunity, the virus’s evolution, the ebb and flow of masks, and more. Amid that mishmash of countervailing influences, says Brandon Ogbunu, an infectious-disease modeler at Yale, “you’re going to get some counterintuitive dynamics” that won’t necessarily last long term.
With so much of the world now infected, vaccinated, or both, and COVID mitigations almost entirely gone, the global situation is less in flux now. The virus itself, although still clearly changing at a blistering pace, has not pulled off an Omicron-caliber jump in evolution for more than a year and a half. But no one can yet promise predictability. The cadence of vaccination isn’t yet settled; Scarpino, of Northeastern University, also isn’t ready to dismiss the idea of a viral evolution surprise. Maybe summer waves, to the extent that they’re happening, are a sign that SARS-CoV-2 will remain a microbe for all seasons. Or maybe they’re part of the pandemic’s death rattle—noise in a system that hasn’t yet quieted down.
The lab-leak theory of COVID’s origin has always been a little squirrelly. If SARS-CoV-2 really did begin infecting humans in a research setting, the evidence that got left behind is mostly of the cloak-and-dagger type: confirmations from anonymous government officials about vague conclusions drawn in classified documents, for example; or leaked materials that lay out hypothetical research projects; or information gleaned from who-knows-where that certain people came down with who-knows-what disease at some crucial moment. In short, it’s all been messy human stuff, the bits and bobs of intelligence analysis. Simple-seeming facts emerge from a dark matter of sources and methods.
So it goes again. The latest major revelation in this line emerged this week. Taken at face value, it’s extraordinary: Ben Hu, a high-level researcher at the Wuhan Institute of Virology, and two colleagues, Yu Ping and Yan Zhu, could have been the first people on the planet to be infected with SARS-CoV-2, according to anonymous sources cited first in the newsletter Public and then in The Wall Street Journal. These proposed patient SARS-CoV-zeroes aren’t merely employees of the virology institute; they’re central figures in the very sort of research that lab-leak investigators have been scrutinizing since the start of the pandemic. Their names appear on crucial papers related to the discovery of new, SARS-related coronaviruses in bats, and subsequent experimentation on those viruses. (The Journal reached out to the three researchers, but they did not respond.)
Is this the “smoking gun,” at last, as manynowinsist? Has the Case of the Missing COVID Origin finally been solved? If it’s true these were the very first infected people, then their professional activities mean they almost certainly caught the virus in the lab, not a market stall full of marmots and raccoon dogs. The origins debate has from the start revolved around a pair of dueling “coincidences.” The fact that the pandemic just happened to take off at a wet market suggests that the virus spilled over into humans from animals for sale there. But the fact that it also just happened to take off not too far away from one of the world’s leading bat-coronavirus labs suggests the opposite. This week’s information seems to tip the balance very heavily toward the latter interpretation.
The only problem is, we don’t know whether the latest revelations can be trusted, or to what extent. The newly reported facts appear to stem from a single item of intelligence, furnished by a foreign source, that has bounced around inside the U.S. government since sometime in 2020. Over the past two and a half years, the full description of the sickened workers in Wuhan has been revealed with excruciating slowness, in sedimenting clauses, through well-timed leaks. This glacial striptease has finally reached its end, but is the underlying information even true? Until that question can be answered (which could be never), the origins debate will be stuck exactly where it’s been for many months: always moving forward, never quite arriving.
The story of these sickened workers has been in the public domain, one way or another, since the start of 2021. Officials in the Trump administration’s State Department, reportedly determined to go public with their findings, put out a fact sheet about various events and circumstances at the Wuhan Institute of Virology around the beginning of the pandemic. Included was a quick description of alleged illnesses among the staff. The fact sheet didn’t name the sickened scientists or what they did inside the lab, or when exactly their illnesses occurred. It didn’t specify their symptoms, nor did it say how many scientists had gotten sick. If you boiled it down, the fact sheet’s revelations could be paraphrased like this:
Several researchers at WIV became ill with respiratory symptoms in autumn 2019.
That vague stub did little to budge consensus views. The lab-leak theory had been preemptively “debunked” in early 2020, and broad disregard of the idea—contempt of it, really—hadn’t yet abated. The day before the State Department fact sheet was released, a team of 17 international experts dispatched by the World Health Organization arrived in Wuhan to conduct (with the help of Chinese scientists) a comprehensive study of the pandemic’s origins. By the time of their return in February 2021, they’d come out with their conclusions: The lab-leak theory was “extremely unlikely” to be true, they said.
The next month, while the WHO team was preparing to release its final report, further details of the sick-researchers story began to trickle out. In a panel discussion of COVID origins and then in an interview with the Daily Mail, David Asher, a former State Department investigator who’s now a senior fellow at a conservative think tank, filled in a few more specifics, including that the researchers had been working in a coronavirus laboratory and that the wife of one of them later died. The intel had arrived from a foreign government, he said. Now the facts that were revealed could be summarized like so:
Three coronavirus researchers at WIV became severely ill with respiratory symptoms in the second week of November 2019.
Pressure for a more serious appraisal of the lab-leak theory grew throughout that spring. In May 2021, more than a dozen prominent virologists and biosafety experts published a letter in the journal Science calling for “a proper investigation” of the matter. A week later, The Wall Street Journalpublished a leak from anonymous current and former U.S. officials: According to a “previously undisclosed US intelligence report,” the paper said, the sickened researchers had been treated for their sickness at a hospital. In other words, they probably weren’t suffering from common colds. This new aspect of the narrative was making headlines now, like this:
Three coronavirus researchers at WIV became severely ill with respiratory symptoms in the second week of November 2019 and sought hospital care.
After all of this publicity, President Joe Biden ordered the intelligence community to redouble efforts to analyze the evidence. While that work was going on, the leaks kept coming. In a 12,000-word story for Vanity Fair, the investigative journalist Katherine Eban gave some backstory on the sick-research intelligence, claiming that it had been gathered in 2020 and then inexplicably file-drawered until State Department investigators rediscovered it. (One former senior official described this as a “holy shit” moment in an interview with Eban.) Her article contained another seemingly important detail, too: The sickened researchers were doing not simply coronavirus research, her sources told her, but the very sort of research that could produce amped-up versions of a pathogen—an approach known as “gain of function.” Later in the summer, Josh Rogin, a Washington Post columnist, added that, according to his unnamed sources, the sickened researchers had lost their sense of smell and developed ground-glass opacities in their lungs. By this point, in the middle of 2021, the expanded piece of intel amounted to the following:
Three gain-of-function coronavirus researchers at WIV became severely ill withCOVID-like symptomsin the second week of November 2019 and sought hospital care.
The latest revelations are coming at just the moment when Republicans are lambasting the Biden administration for failing to declassify COVID-origins intelligence in accordance with a law that the president signed. The Sunday Times quoted an anonymous former State Department investigator who said they were “rock-solid confident” that the three sick researchers had been sick with COVID, because people as young as the researchers would rarely be hit so hard by a mere seasonal illness. A few days later, someone spilled the researchers’ names to Public. On Tuesday, The Wall Street Journal matched the scoop, and it seemed that every detail of the once-secret information was now exposed:
Ben Hu, Yu Ping, and Yan Zhu, three gain-of-functioncoronavirus researchers at WIV, became severely ill with COVID-like symptoms in the second week of November 2019 and sought hospital care.
However vivid this may sound, its credibility remains unknown. Did Hu, Ping, and Zhu really get sick, as the intel claims? If so, was it really COVID? Two years ago, the Journal cited two anonymous sources on this question: One, the Journal wrote, called the intelligence “potentially significant but still in need of further investigation and corroboration”; the other said it was “of exquisite quality” and “very precise.” Just this week, anonymous officials in the Biden administration told The New York Times that intelligence analysts had already “dismissed the evidence,” by August 2022, about the sickened workers at WIV for lack of relevance. Which secret source should be trusted to explain the significance of this secret intelligence? Readers are left to sort that out themselves.
In the meantime, over the past two years, even as the sickened-worker intel was revealed, a very different sort of evidence was mounting, too. A new research paper, published just days after Eban’s feature in Vanity Fair, revealed that live wild animals, including raccoon dogs, had been for sale at the Huanan market in Wuhan shortly before the pandemic started. In early 2022, scientists put out two detailed analyses of early case patterns and viral genome data, which argued in favor of the animal-spillover theory. Another study involving many of the same researchers came out this past spring, noting the presence of genetic material from raccoon dogs in early samples from the market; its authors described their findings as providing strong evidence for an animal origin. But other scientists were quick to challenge the study’s importance. A further study of the same data by Chinese scientists made a point of not ruling out the hypothesis that the pandemic had started with a case of tainted frozen seafood; yet another study, released in May, argued that the original work provided no useful information whatsoever on the question of COVID’s origins.
So it goes with the animal-spillover theory. The evidence in favor has always been highly esoteric, knotted with data and interpretation. Scientific points are made—a particular run of viral nucleotides is a “smoking gun” for genetic engineering, one famous scholar said in 2021—and then they are re-argued and occasionally walked back. Long-hidden sample data from the market suddenly appear, and their meaning is subjected to vituperative, technical debate. If the evidence for a lab leak tends to come from messy human stuff, the evidence for animal spillover emerges from messy data. Simple-seeming claims are draped across a sprawl of numbers.
In this way, the origins question has broken down into a pair of rival theories that don’t—and can’t—ever fully interact. They’re based on different sorts of evidence, with different standards for evaluation and debate. Each story may be accruing new details—fresh intelligence about the goings-on at WIV, for example, or fresh genomic data from the market—but these are only filling out a picture that will never be complete. The two narratives have been moving forward on different tracks. Neither one is getting to its destination.
For many judicial nominees, a Senate confirmation hearing is one of life’s most grueling experiences—an hours-long job interview led by lawmakers who are trying to get them to face-plant on national television.
Not for Aileen Cannon. When the federal judge who will oversee former President Donald Trump’s criminal trial testified in 2020, the Senate Judiciary Committee didn’t go easy on her so much as they ignored her.
Cannon, then a 39-year-old prosecutor, appeared on Zoom alongside four other nominees, her face framed by a wall of diplomas on one side and an American flag on the other. Her opening statement lasted all of three minutes and sounded like an Oscar winner’s speech—lots of thank-yous and little else. She didn’t say a word about her legal philosophy or how she would approach the job of a judge. The senators didn’t seem to mind: None of them addressed a question specifically to Cannon for the rest of the hearing. The committee’s chair at the time, Senator Lindsey Graham of South Carolina, skipped the proceeding entirely, as did each of the five most senior Republicans on the panel. The hearing was over after barely an hour. Three months later, while Trump was beginning his effort to overturn his defeat in the presidential election, a bipartisan Senate majority (including a dozen Democrats) voted to confirm Cannon’s nomination as a federal judge in the Southern District of Florida.
For low-profile nominations like Cannon’s, perfunctory hearings aren’t unusual. But the scrutiny she was spared in the Senate is coming her way now. After just two and a half years as a judge, Cannon will soon preside over a trial with no precedent in American history. The defendant is the former president who appointed her, and her rulings during the investigation that led to Trump’s indictment have already prompted many legal experts to fear that she will tilt the trial in his favor.
But some of the Democratic lawyers who have appeared in Cannon’s courtroom don’t share those worries. They say that she is a smarter, more deliberate, and more even-handed judge than the early criticism of her would suggest. “I think the government should be very happy that they have Judge Cannon,” says Richard Klugh, a longtime defense attorney in Miami who has dealt with Cannon both as a judge and when she served as a federal prosecutor there. Klugh, a lifelong Democrat, told me that aside from her “narrow” rulings on Trump’s case last summer, he had heard no complaints about Cannon from either prosecutors or defense attorneys. “She’s very confident, very honest … and very thorough,” he told me. “She’s confident enough to go through things independently.”
That may be, but she’s extremely inexperienced. Since taking her seat on the bench, Cannon has worked mostly out of a courthouse in Fort Pierce, a two-hour drive from Miami and a town that one local lawyer described to me as “a backwater.” She has presided over just four trials as a judge, none of which covered crimes remotely similar to the willful retention of classified documents that the government has accused Trump of committing. (She is set to oversee a far more complex trial involving alleged Medicare fraud in the coming months.)
Cannon was born in Colombia and is the daughter of Cuban refugees. In her brief statement to the Judiciary Committee, she described how her mother, at the age of 7, “had to flee the repressive Castro regime in search of freedom and security.” Cannon graduated from Duke University, and by the time she earned her law degree from the University of Michigan, she had already joined the conservative Federalist Society. After law school, she embarked on a fairly conventional legal career: She clerked for an appellate judge, spent several years at a large law firm, and then became an assistant U.S. attorney in Miami. In written responses to the Judiciary Committee, Cannon wrote that she considered herself both an “originalist” and a “textualist”—two approaches long identified with conservative judges—but that she would follow all precedents set by the Supreme Court and other appellate rulings.
Two South Florida lawyers told me that they were struck by Cannon’s overt religiosity, which has seeped into her pronouncements in court. She routinely tells defendants “God bless you” after they enter guilty pleas, said Valentin Rodriguez, a lawyer who has appeared before Cannon. “In my entire 30-year career I’ve never had a judge mention God to a client ever,” Rodriguez told me. “She does that as a matter of course.”
Although presidents formally nominate all federal judges, they frequently appoint district-court judges at the recommendation of home-state senators. Cannon told the Judiciary Committee that she was first approached about filling a judicial vacancy by the office of Senator Marco Rubio in 2019, nearly a year before Trump sent her nomination to the Senate. Her appointment came at a moment when Trump and then–Senate Majority Leader Mitch McConnell were trying to reshape the federal courts by filling as many open judgeships as possible with young conservatives in their 30s and 40s. Three previous nominations for judgeships in Florida’s Southern District had gone to men in their 40s. “It made sense that Trump would select a woman with good credentials who also happens to be Hispanic,” a South Florida defense lawyer who knows Cannon told me. (The lawyer requested anonymity to speak candidly about a judge in their jurisdiction.)
At the time of her nomination, Cannon had virtually no public profile outside of the courtroom. On her Senate questionnaire, she said she had never given a speech, served on a panel discussion, or testified before a legislative body. She had never held public office and told the Senate she had never participated in a political campaign, although she and her husband each contributed $100 to Ron DeSantis’s bid for governor in 2018. The only interview Cannon said she had ever given for publication was for a photo feature on TheKnot.com about her wedding. Her relative anonymity has caused headaches for publications that have searched in vain for a public photo of Cannon that hasn’t already been used repeatedly; almost every story features the same Zoom screenshot from her Senate testimony in 2020.
Like most Republican-appointed judges in Florida’s Southern District, Cannon is known as a tough sentencer. But there have been notable exceptions when she has handed down a shorter prison term than she could have, Rodriguez told me. He mentioned a case in which a 21-year-old defendant, Artavis Spivey, who had been incarcerated on and off since he was 11, pleaded guilty to armed carjacking. He and another defendant committed the crime just 18 days after Spivey had been released from prison. Cannon sentenced Spivey to 15 years, but Rodriguez said she could have added many more years to his term. “She could have thrown the book at him, and I think she saw redeeming qualities in the young man,” Rodriguez said. Spivey had grown up in a troubled home without a father, “kind of given up by his parents,” Rodriguez added. “That experience tended to make me appreciate the fact that she could look beyond just the retribution and vengeance of a sentence and look at the person.”
Cannon also handed down a lighter-than-expected sentence to a 34-year-old man, Christopher Wilkins, who threw a chair at and threatened to kill a federal prosecutor after receiving a 17.5-year sentence on gun and witness-tampering charges. Cannon added six and a half years to his prison term, which was less than the sentencing guidelines called for. “I’ve heard stuff about tough sentencing. I can’t report that. I can report fair sentencing,” Wilkins’s lawyer, Jeffrey Garland, a Republican, told me.
Yet none of the decisions that Cannon has made in her young judicial career have stirred as much controversy as her rulings in the lawsuit that Trump filed after the FBI searched his Mar-a-Lago estate for unreturned classified documents last summer. Cannon initially appointed a special master to review the documents that federal investigators had collected, and barred the government from accessing some of them. The rulings were a gift to Trump at the time and delayed the FBI’s investigation. But in a sharp rebuke of Cannon, the conservative Eleventh Circuit Court of Appeals overruled her decisions and said she should not have even heard the case.
Some legal experts have cited those rulings and the fact that Trump appointed Cannon as reasons for her to recuse herself or be taken off the case. A few of the Florida defense lawyers I interviewed—who, it should be noted, routinely argue against the government’s position—characterized Cannon’s orders as understandable considering how unprecedented the case was. The defense lawyer who spoke on the condition of anonymity, however, was more critical. “That ruling was totally out of bounds,” the lawyer told me.
One of the most significant decisions Cannon now faces is whether to attempt to hold the trial in advance of the 2024 presidential election. Should Trump win the White House, he could quash the government’s prosecution of him. South Florida lawyers were dubious that Cannon could try the case before the election, noting the complexities surrounding classified documents that frequently slow down prosecutions at the federal level. Howard Srebnick, a Democratic defense lawyer on the Medicare-fraud case before Cannon, also praised her early performance on the bench. But he said that it still took 18 months for the Medicare case to get to trial even though it does not involve government secrets. “The notion that this case could go quickly? That’s absurd,” Klugh told me.
Still, Cannon has already issued her first order—one that could indicate she wants to move swiftly. On Thursday, she instructed lawyers who want to take part in the case to get security clearances by next week. That was the first of many decisions Cannon will make that, in ways big and small, will shape the first-ever federal criminal prosecution of a former president. They will change Cannon’s life, creating a reputation for favoritism or fairness where none existed. A young judge whose photograph had never appeared in a newspaper until last year is set to become a household name. As Rodriguez observed with a slightly nervous laugh: “She’s going to be famous for a long time.”
This fall, millions of Americans might be lining up for yet another kind of COVID vaccine: their first-ever dose that lacks the strain that ignited the pandemic more than three and a half years ago. Unlike the current, bivalent vaccine, which guards against two variants at once, the next one could, like the first version of the shot, have only one main ingredient—the spike protein of the XBB.1 lineage of the Omicron variant, the globe’s current dominant clade.
That plan isn’t yet set. The FDA still has to convene a panel of experts, then is expected to make a final call on autumn’s recipe next month. But several experts told me they hope the agency follows the recent recommendation of a World Health Organization advisory group and focuses the next vaccine only on the strains now circulating.
The switch in strategy—from two variants to one, from original SARS-CoV-2 plus Omicron to XBB.1 alone—would be momentous but wise, experts told me, reflecting the world’s updated understanding of the virus’s evolution and the immune system’s quirks. “It just makes a lot of sense,” said Melanie Ott, the director of the Gladstone Institute of Virology, in San Francisco. XBB.1 is the main coronavirus group circulating today; neither the original variant nor BA.5, the two coronavirus flavors in the bivalent shot, is meaningfully around anymore. And an XBB.1-focused vaccine may give the global population a particularly good shot at broadening immunity.
At the same time, COVID vaccines are still in a sort of beta-testing stage. In the past three-plus years, the virus has spawned countless iterations, many of which have been extremely good at outsmarting us; we humans, meanwhile, are only on our third-ish attempt at designing a vaccine that can keep pace with the pathogen’s evolutionary sprints. And we’re very much still learning about the coronavirus’s capacity for flexibility and change, says Rafi Ahmed, an immunologist at Emory University. By now, it’s long been clear that vaccines are essential for preventing severe disease and death, and that some cadence of boosting is probably necessary to keep the shots’ effectiveness high. But when the virus alters its evolutionary tactics, our vaccination strategy must follow—and experts are still puzzling out how to account for those changes as they select the shots for each year.
In the spring and summer of 2022, the last time the U.S. was mulling on a new vaccine formula, Omicron was still relatively new, and the coronavirus’s evolution seemed very much in flux. The pathogen had spent more than two years erratically slingshotting out Greek-letter variants without an obvious succession plan. Instead of accumulating genetic changes within a single lineage—a more iterative form of evolution, roughly akin to what flu strains do—the coronavirus produced a bunch of distantly related variants that jockeyed for control. Delta was not a direct descendant of Alpha; Omicron was not a Delta offshoot; no one could say with any certainty what would arise next, or when. “We didn’t understand the trajectory,” says Kanta Subbarao, the head of the WHO advisory group convened to make recommendations on COVID vaccines.
And so the experts played it safe. Including an Omicron variant in the shot felt essential, because of how much the virus had changed. But going all in on Omicron seemed too risky—some experts worried that “the virus would flip back,” Subbarao told me, to a variant more similar to Alpha or Delta or something else. As a compromise, several countries, including the United States, went with a combination: half original, half Omicron, in an attempt to reinvigorate OG immunity while laying down new defenses against the circulating strains du jour.
And those shots did bolster preexisting immunity, as boosters should. But they didn’t rouse a fresh set of responses against Omicron to the degree that some experts had hoped they would, Ott told me. Already trained on the ancestral version of the virus, people’s bodies seemed to have gotten a bit myopic—repeatedly reawakening defenses against past variants, at the expense of new ones that might have more potently attacked Omicron. The outcome was never thought to be damaging, Subbarao told me: The bivalent, for instance, still broadened people’s immune responses against SARS-CoV-2 compared with, say, another dose of the original-recipe shot, and was effective at tamping down hospitalization rates. But Ahmed told me that, in retrospect, he thinks an Omicron-only boost might have further revved that already powerful effect.
Going full bore on XBB.1 now could keep the world from falling into that same trap twice. People who get an updated shot with that strain alone would receive only the new, unfamiliar ingredient, allowing the immune system to focus on the fresh material and potentially break out of an ancestral-strain rut. XBB.1’s spike protein also would not be diluted with one from an older variant—a concern Ahmed has with the current bivalent shot. When researchers added Omicron to their vaccine recipes, they didn’t double the total amount of spike protein; they subbed out half of what was there before. That left vaccine recipients with just half the Omicron-focused mRNA they might have gotten had the shot been monovalent, and probably a more lackluster antibody response.
Recent work from the lab of Vineet Menachery, a virologist at the University of Texas Medical Branch, suggests another reason the Omicron half of the shot didn’t pack enough of an immunizing punch. Subvariants from this lineage, including BA.5 and XBB.1, carry at least one mutation that makes their spike protein unstable—to the point where it seems less likely than other versions of the spike protein to stick around for long enough to sufficiently school immune cells. In a bivalent vaccine, in particular, the immune response could end up biased toward non-Omicron ingredients, exacerbating the tendencies of already immunized people to focus their energy on the ancestral strain. For the same reason, a monovalent XBB.1, too, might not deliver the anticipated immunizing dose, Menachery told me. But if people take it (still a big if), and hospitalizations remain low among those up-to-date on their shots, a once-a-year total-strain switch-out might be the choice for next year’s vaccine too.
Dropping the ancestral strain from the vaccine isn’t without risk. The virus could still produce a variant totally different from XBB.1, though that does, at this point, seem unlikely. For a year and a half now, Omicron has endured, and it now has the longest tenure of a single Greek-letter variant since the pandemic’s start. Even the subvariants within the Omicron family seem to be sprouting off each other more predictably; after a long stint of inconsistency, the virus’s shape-shifting now seems “less jumpy,” says Leo Poon, a virologist at the University of Hong Kong. It may be a sign that humans and the virus have reached a détente now that the population is blanketed in a relatively stable layer of immunity. Plus, even if a stray Alpha or Delta descendant were to rise up, the world wouldn’t be caught entirely off guard: So many people have banked protection against those and other past variants that they’d probably still be well buffered against COVID’s worst acute outcomes. (That reassurance doesn’t hold, though, for people who still need primary-series shots, including the kids being born into the world every day. An XBB.1 boost might be a great option for people with preexisting immunity. But a bivalent that can offer more breadth might still be the more risk-averse choice for someone whose immunological slate is blank.)
More vaccination-strategy shifts will undoubtedly come. SARS-CoV-2 is still new to us; so are our shots. But the virus’s evolution, as of late, has been getting a shade more flu-like, and its transmission patterns a touch more seasonal. Regulators in the U.S. have already announced that COVID vaccines will probably be offered each year in the fall—as annual flu shots are. The viruses aren’t at all the same. But as the years progress, the comparison between COVID and flu shots could get more apt still—if, say, the coronavirus also starts to produce multiple, genetically distinct strains that simultaneously circulate. In that case, vaccinating against multiple versions of the virus at once might be the most effective defense.
Flu shots could be a useful template in another way: Although those shots have followed roughly the same guidelines for many years, with experts meeting twice a year to decide whether and how to update each autumn’s vaccine ingredients, they, too, have needed some flexibility. Until 2012, the vaccines were trivalent, containing ingredients that would immunize people against three separate strains at once; now many, including all of the U.S.’s, are quadrivalent—and soon, based on new evidence, researchers may push for those to return to a three-strain recipe. At the same time, flu and COVID vaccines share a major drawback. Our shots’ ingredients are still selected months ahead of when the injections actually reach us—leaving immune systems lagging behind a virus that has, in the interim, sprinted ahead. Until the world has something more universal, our vaccination strategies will have to be reactive, scrambling to play catch-up with these pathogens’ evolutionary whims.
In October of 1858, John Stuart Mill and his wife, Harriet, were traveling near Avignon, France. She developed a cough, which seemed like just a minor inconvenience, until it got worse. Soon Harriet was racked with pain, not able to sleep or even lie down. Mill frantically wrote to a doctor in Nice, begging him to come see her. Three days later her condition had worsened further, and Mill telegraphed his forebodings to his stepdaughter. Harriet died in their hotel room on November 3.
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Mill sat alone with her body in their room for a day. He was despondent over the loss of his marriage: “For seven and a half years that blessing was mine. For seven and a half years only!”
Later that same month, he sent a manuscript to his publisher, which opened with a lavish dedication to Harriet. He subsequently wrote that she had been more than his muse; she had been his co-author. The book was, he said, “more directly and literally our joint production than anything else which bears my name, for there was not a sentence of it that was not several times gone through by us together.” The book’s “whole mode of thinking,” he continued, “was emphatically hers.”
The book was called On Liberty. It is one of the founding documents of our liberal world order. Individuals, the Mills argued, have the right to be the architect of their own life, to choose whom to marry, where to live, what to believe, what to say. The state has no right to impinge on a citizen’s individual freedom of choice, provided that the person isn’t harming anyone else.
A society organized along these lines, the Mills hoped, would produce a rich variety of creative and daring individuals. You wouldn’t have to agree with my mode of life, and I wouldn’t have to agree with yours, but we would give each other the space to live our fullest life. Individual autonomy and freedom of choice would be the rocks upon which we built flourishing nations.
The liberalism that the Mills championed is what we enjoy today as we walk down the street and greet a great variety of social types. It’s what we enjoy when we get on the internet and throw ourselves into the messy clash of ideas. It is this liberalism that we defend when we back the Ukrainians in their fight against Russian tyranny, when we stand up to authoritarians on the right and the left, to those who would impose speech codes, ban books, and subvert elections.
After he sent in the manuscript, Mill bought a house overlooking the cemetery where Harriet was buried, filled it with furniture from the room in which she’d died, and visited every year for the rest of his life. It’s a sad scene to imagine—him gazing down at her grave from the window—but the couple left us an intellectual legacy that has guided humanity another step forward in civilization’s advance.
Many good ideas turn bad when taken to their extreme. And that’s true of liberalism. The freedom of choice that liberals celebrate can be turned into a rigid free-market ideology that enables the rich to concentrate economic power while the vulnerable are abandoned. The wild and creative modes of self-expression that liberals adore can turn into a narcissistic culture in which people worship themselves and neglect their neighbors.
These versions of liberalism provoke people to become anti-liberal, to argue that liberalism itself is spiritually empty and too individualistic. They contend that it leads to social breakdown and undermines what is sacred about life. We find ourselves surrounded by such anti-liberals today.
I’d like to walk with you through one battlefield in the current crisis of liberalism, to show you how liberalism is now threatened by an extreme version of itself, and how we might recover a better, more humane liberalism—something closer to what the Mills had in mind in the first place.
In 2016, the Canadian government legalized medical assistance in dying. The program, called MAID, was founded on good Millian grounds. The Canadian Supreme Court concluded that laws preventing assisted suicide stifled individual rights. If people have the right to be the architect of their life, shouldn’t they have the right to control their death? Shouldn’t they have the right to spare themselves needless suffering and indignity at the end of life?
As originally conceived, the MAID program was reasonably well defined. Doctors and nurses would give lethal injections or fatal medications only to patients who met certain criteria, including all of the following: the patient had a serious illness or disability; the patient was in an “advanced state” of decline that could not be reversed; the patient was experiencing unbearable physical or mental suffering; the patient was at the point where natural death had become “reasonably foreseeable.”
To critics who worried that before long, people who were depressed, stressed, or just poor and overwhelmed would also be provided assistance to die, authorities were reassuring: The new law wouldn’t endanger those who are psychologically vulnerable and not near death. Citing studies from jurisdictions elsewhere in the world with similar laws, Prime Minister Justin Trudeau declared that this “simply isn’t something that ends up happening.”
But the program has worked out rather differently. Before long, the range of who qualifies for assisted suicide was expanded. In 2021, the criterion that natural death must be “reasonably foreseeable” was lifted. A steady stream of stories began to appear in the media, describing how the state was granting access to assisted suicide to people who arguably didn’t fit the original criteria.
If you are having thoughts of suicide, please know that you are not alone. If you’re in danger of acting on suicidal thoughts, call 911. For support and resources, call the National Suicide Prevention Lifeline at 988 or text 741741 for the Crisis Text Line.
For example, the Associated Press reported on the case of Alan Nichols. Nichols had lost his hearing in childhood, and had suffered a stroke, but for the most part was able to live independently. In June 2019, at age 61, he was hospitalized out of concern that he might be suicidal. He urged his brother Gary to “bust him out” of the facility as soon as possible. But within a month, he applied for a physician-assisted death, citing hearing loss as his only medical condition. A nurse practitioner also described Nichols’s vision loss, frailty, history of seizures, and general “failure to thrive.” The hospital told the AP that his request for a lethal injection was valid, and his life was ended. “Alan was basically put to death,” his brother told the AP.
In The New Atlantis, Alexander Raikin described the case of Rosina Kamis, who had fibromyalgia and chronic leukemia, along with other mental and physical illnesses. She presented these symptoms to the MAID assessors and her death was approved. Meanwhile, she wrote in a note evidently meant for those to whom she had granted power of attorney: “Please keep all this secret while I am still alive because … the suffering I experience is mental suffering, not physical. I think if more people cared about me, I might be able to handle the suffering caused by my physical illnesses alone.” She was put to death on September 26, 2021, via a lethal injection, at the age of 41.
In The Free Press, Rupa Subramanya reported on the case of a 23-year-old man named Kiano Vafaeian, who was depressed and unemployed, and also had diabetes and had lost vision in one eye. His death was approved and scheduled for September 22, 2022. The doctor who was to perform the procedure emailed Vafaeian clear and antiseptic instructions: “Please arrive at 8:30 am. I will ask for the nurse at 8:45 am and I will start the procedure at around 9:00 am. Procedure will be completed a few minutes after it starts.” Vafaeian could bring a dog with him, as long as someone would be present to take care of it.
About two weeks before the appointment, Vafaeian’s 46-year-old mother, Margaret Marsilla, telephoned the doctor who was scheduled to kill her son. She recorded the call and shared it with The Free Press. Posing as a woman named Joann, she told the doctor that she wanted to die by Christmas. Reciting basic MAID criteria, the doctor told her that she needed to be over 18, have an insurance card, and be experiencing “suffering that cannot be remediated or treated in some way that’s acceptable to you.” The doctor said he could conduct his assessment via Zoom or WhatsApp. Marsilla posted on social media about the situation. Eventually, the doctor texted Marsilla, saying that he would not follow through with her son’s death.
Personally, I don’t have great moral qualms about assisted suicide for people who are suffering intensely in the face of imminent death. These cases are horrible for individuals and families. What’s important here is that the MAID program has spilled beyond its original bounds so quickly.
When people who were suffering applied to the MAID program and said, “I choose to die,” Canadian society apparently had no shared set of morals that would justify saying no. If individual autonomy is the highest value, then when somebody comes to you and declares, “It’s my body. I can do what I want with it,” whether they are near death or not, painfully ill or not, doesn’t really matter. Autonomy rules.
Within just a few years, the number of Canadians dying by physician-assisted suicide ballooned (the overwhelming majority of them by lethal injection). In 2021, that figure was more than 10,000, one in 30 of all Canadian deaths. The great majority of people dying this way were elderly and near death, but those who seek assisted suicide tend to get it. In 2021, only 4 percent of those who filed written applications were deemed ineligible.
If autonomy is your highest value, these trends are not tragic; they’re welcome. Death is no longer the involuntary, degrading end of life; it can be a glorious act of self-expression. In late 2022, the Canadian fashion retailer La Maison Simons released a branding video that paid tribute to the assisted suicide of a 37-year-old woman afflicted with Ehlers-Danlos syndrome, which affects the body’s connective tissue. The video, titled “All Is Beauty,” was released the day after the woman’s death. In a series of lush images of her on tourist-destination beaches and at a dinner party, the video portrayed her death as “the most beautiful exit”—a sort of rich, Instagram-ready consumer experience that you might get from a five-star resort.
Back in 2016, critics of the MAID law saw this coming. They warned that soon enough, people in anguish and near death wouldn’t be the only ones given assistance to die. That warning turned out to be understated. Within a few years, Canada went from being a country that had banned assisted suicide to being one of the loosest regimes in the world.
Some people leading pathos-filled lives have begun to see assisted suicide as a release from their misery. Michael Fraser, though not terminally ill at age 55, had become unable to walk and suffered from an array of medical problems—liver disease and incontinence, as well as mental-health issues after what he described as prolonged sexual abuse as a child. His monthly check from the Ontario Disability Support Program was barely enough to live on. “Some of the struggles he talked to me about was this feeling of not being worthy,” the doctor who gave Fraser a lethal injection on July 2, 2022, told the Toronto Star. “There’s a social aspect to poverty, a hierarchy, that affected his psyche. He told me that it did.”
Vartika Sharma
As assisted suicide has become an established part of Canadian society, the complex moral issues surrounding the end of life have drifted out of sight. Decisions tend to be made within a bureaucratic context, where utilitarian considerations can come to dominate the foreground. Or as the president of the Quebec College of Physicians, which regulates medical practice in the province, put it, assisted suicide “is not a political or moral or religious issue. It is a medical issue.” A materialist cost-benefit analysis, for some people, crowds out affirmations that life is sacred, and socioeconomic burdens weigh heavily in the balance.
Tyler Dunlop is a physically healthy 37-year-old man who suffers from schizoaffective disorder and PTSD, and has no job or home or social contact. “When I read about medically assisted dying,” he told a local news website earlier this year, “I thought, well, logistically, I really don’t have a future.” Knowing that “I’m not going anywhere,” as he put it, he has started the process for approval under MAID. The New Atlantis published slides from a Canadian Association of MAID Assessors and Providers seminar, in which a retired care coordinator noted that a couple of patients had cited poverty or housing uncertainty, rather than their medical condition, as their main reason for seeking death.
Health-care costs also sometimes come into play. According to the Associated Press, Roger Foley, a patient at a hospital in Ontario who has a degenerative brain disorder, was disturbed enough by how often the staff talked about assisted dying that he began recording their conversations. The hospital’s director of ethics informed Foley that if he were to stay in the hospital, it would cost Foley “north of $1,500 a day.” Foley replied that he felt he was being coerced into death. “Roger, this is not my show,” the ethicist replied. “I told you my piece of this was to talk to you about if you had an interest in assisted dying.” (The hospital network told The Atlantic that it could not comment on specific patients for privacy reasons and added that its health-care teams do not discuss assisted dying unless patients express interest in it.)
These trends have not shocked Canadian lawmakers into tightening the controls on who gets approved for MAID, or dramatically ramping up programs that would provide medical and community-based help for patients whose desperation might be addressed in other ways. On the contrary, eligibility may expand soon. On February 15, a parliamentary committee released a set of recommendations that would further broaden MAID eligibility, including to “mature minors” whose death is “reasonably foreseeable.” The influential activist group Dying With Dignity Canada recommends that “mature minors” be defined as “at least 12 years of age and capable of making decisions with respect to their health.” Canada is scheduled to move in 2024 to officially extend MAID eligibility to those whose only illness is a mental disorder.
The frame of debate is shifting. The core question is no longer “Should the state help those who are suffering at the end of life die?” The lines between assisted suicide for medical reasons, as defined by the original MAID criteria, and straight-up suicide are blurring. The moral quandary is essentially this: If you see someone rushing toward a bridge and planning to jump off, should you try to stop them? Or should you figure that plunging into the water is their decision to make—and give them a helpful shove?
I don’t mean to pick on Canada, the land of my birth. Lord knows that, in many ways, Canada has a much healthier social and political culture—less bitter and contentious—than the United States does. I’m using the devolution of the MAID program to illustrate a key feature of modern liberalism—namely, that it comes in different flavors. The flavor that is embedded in the MAID program, and is prevalent across Western societies, is what you might call autonomy-based liberalism.
Autonomy-based liberalism starts with one core conviction: I possess myself. I am a piece of property that I own. Because I possess property rights to myself, I can dispose of my property as I see fit. My life is a project that I am creating, and nobody else has the right to tell me how to build or dispose of my one and only life.
The purpose of my life, in this version of liberalism, is to be happy—to live a life in which my pleasures, however I define them, exceed my pains. If I determine that my suffering outweighs my joys, and that things will never get better, then my life isn’t working. I have a right to end it, and the state has no right to prevent me from doing so; indeed, it ought to enable my right to end my life with dignity. If you start with autonomy-based liberalism, MAID is where you wind up.
But there is another version of liberalism. Let’s call this gifts-based liberalism. It starts with a different core conviction: I am a receiver of gifts. I am part of a long procession of humanity. I have received many gifts from those who came before me, including the gift of life itself. The essential activity of life is not the pursuit of individual happiness. The essential activity of life is to realize the gifts I’ve been given by my ancestors, and to pass them along, suitably improved, to those who will come after.
Gifts-based liberals, like autonomy-based liberals, savor individual choice—but our individual choices take place within the framework of the gifts we have received, and the responsibilities to others that those gifts entail. (This understanding of choice, I should note, steers a gifts-based liberal away from both poles in the American abortion debate, endorsing neither a pure abortion-rights stance rooted in bodily autonomy, nor a blanket ban that ignores individual circumstances and pays no heed to a social consensus.) In our lives, we are citizens and family members, not just individuals and property owners. We have obligations to our neighbors as well as to those who will come after us. Many of those obligations turn out to be the sources of our greatest joy. A healthy society builds arrangements and passes laws that make it easier to fulfill the obligations that come with our gifts. A diseased society passes laws that make it easier to abandon them.
I’m going to try to convince you that gifts-based liberalism is better than autonomy-based liberalism, that it rests on a more accurate set of assumptions about what human life is actually like, and that it leads to humane modes of living and healthier societies.
Let me start with four truths that gifts-based liberalism embraces and autonomy-based liberalism subverts:
You didn’t create your life. From the moment of your birth, life was given to you, not earned. You came out bursting with the gift of being alive. As you aged, your community taught you to celebrate the prodigality of life—the birds in their thousands of varieties, the deliciousness of the different cheeses, the delightful miracle of each human face. Something within us makes us desperately yearn for longer life for our friends and loved ones, because life itself is an intrinsic good.
The celebration of life’s sacredness is so deeply woven into our minds, and so central to our civilization, that we don’t think about it much until confronted with shocking examples of when the celebration is rejected. For example, in the early 2000s, a German man named Armin Meiwes put an ad online inquiring whether anybody would like to be killed and eaten. A man came by and gave his consent. First, Meiwes cut off the man’s penis, and the two men attempted to eat it together. Then Meiwes killed and butchered him; by the time of his arrest, he had consumed more than 40 pounds of his flesh. Everything was done with the full consent of both participants, but the extreme nature of the case forced the German court system not only to sentence Meiwes to life in prison, but to face an underappreciated yet core pillar of our civilization: You don’t have the right to insult life itself. You don’t have the right to turn yourself or other people into objects to be carved up and consumed. Life is sacred. Humanity is a higher value than choice.
You didn’t create your dignity. No insignificant person has ever been born, and no insignificant day has ever been lived. Each of us has infinite dignity, merely by being alive. We can do nothing to add to that basic dignity. Getting into Harvard doesn’t make you more important than others, nor does earning billions of dollars. At the level of our intrinsic dignity, all humans are radically equal. The equal dignity of all life is, for instance, the pillar of the civil-rights movement.
Once MAID administrators began making decisions about the life or death of each applicant based on the quality of their life, they introduced a mode of thinking that suggests that some lives can be more readily extinguished than others—that some lives have more or less value than others. A human being who is enfeebled, disabled, depressed, dwindling in their capacities is not treated the same way as someone who is healthier and happier.
When such a shift occurs, human dignity is no longer regarded as an infinite gift; it is a possession that other humans can appraise, and in some cases erase. Once the equal and infinite dignity of all human life is compromised, everything is up for grabs. Suddenly debates arise over which lives are worth living. Suddenly you have a couple of doctors at the Quebec College of Physicians pushing the envelope even further, suggesting that babies with severe deformations and limited chances of survival be eligible for medically assisted death. Suddenly people who are ill or infirm are implicitly encouraged to feel guilty for wanting to live. Human dignity, once inherent in life itself, is measured by what a person can contribute, what level of happiness she is deemed capable of enjoying, how much she costs.
You don’t control your mind. “From its earliest beginning,” Francis Fukuyama writes, “modern liberalism was strongly associated with a distinctive cognitive mode, that of modern natural science.” In liberal societies, people are supposed to collect data, weigh costs and benefits, and make decisions rationally. Autonomy-based liberalism, with its glorification of individual choice, leans heavily on this conception of human nature.
Gifts-based liberals know that no purely rational thinker has ever existed. They know that no one has ever really thought for themselves. The very language you think with was handed down as a gift from those who came before. We are each nodes in a network through which information flows and is refracted. The information that is stored in our genes comes from eons ago; the information that we call religion and civilization comes from thousands of years ago; the information that we call culture comes from distant generations; the information that we call education or family background comes from decades ago. All of it flows through us in deep rivers that are partly conscious and partly unconscious, forming our assumptions and shaping our choices in ways that we, as individuals, often can’t fathom.
Gifts-based liberals understand how interdependent human thinking is. When one kid in high school dies by suicide, that sometimes sets off a contagion, and other kids in that school take their own life. Similarly, when a nation normalizes medically assisted suicide, and makes it a more acceptable option, then more people may choose suicide. A 2022 study in the Journal of Ethics in Mental Health found that in four jurisdictions—Switzerland, Luxembourg, the Netherlands, and Belgium—where assisted dying is legal, “there have been very steep rises in suicide,” including both assisted and unassisted suicide. The physician who assists one person to die may be influencing not just that suicide but the suicides of people he will never see.
Gifts-based liberals understand the limitations of individual reason, and have a deep awareness of human fallibility. Gifts-based liberals treasure having so many diverse points of view, because as individuals, we are usually wrong to some degree, and often to a very large degree. We need to think together, over time, in order to stumble toward the truth. Intellectual autonomy is a dangerous exaggeration.
Gifts-based liberals understand that at many times in life, we’re just not thinking straight—especially when we are sick, in pain, anxious, or depressed. My friend the Washington Post columnist Michael Gerson, who died of cancer last year, once said, “Depression is a malfunction of the instrument we use to determine reality.” When he was depressed, lying voices took up residence there, spewing out falsehoods he could scarcely see around: You are a burden to your friends; you have no future; no one would miss you if you died. This is not an autonomous, rational mind. This is a mind that has gone to war with its host.
In these extreme cases, human fallibility is not just foolish; it is potentially fatal. To cope with those cases, societies in a gifts-based world erect guardrails, usually instantiated in law. In effect the community is saying: No, suicide is out of bounds. It’s not for you to decide. You don’t have the freedom to end your freedom. You don’t have the right to make a choice you will never be able to revisit. Banish the question from your mind, because the answer is a simple no. Individual autonomy is not our ultimate value. Life and belonging are. We are responsible for one another.
You did not create your deepest bonds. Liberal institutions are healthiest when they are built on arrangements that precede choice. You didn’t choose the family you were born into, the ethnic heritage you were born into, the culture you were born into, the nation you were born into. As you age, you have more choices over how you engage with these things, and many people forge chosen families to supplant their biological ones. But you never fully escape the way these unchosen bonds have formed you, and you remain defined through life by the obligations they impose upon you.
Autonomy-based liberals see society as a series of social contracts—arrangements people make for their mutual benefit. But a mother’s love for her infant daughter is not a contract. Gifts-based liberals see society as resting on a bedrock of covenants. Rabbi Jonathan Sacks once captured the difference this way: “A contract is a transaction. A covenant is a relationship. Or to put it slightly differently: a contract is about interests. A covenant is about identity. It is about you and me coming together to form an ‘us.’ ”
A society constructed on gifts-based liberalism does everything it can to strengthen the bedrock layer of covenants. The MAID program, by contrast, actively subverts them. It has led a mother to plead with a doctor not to end her son’s life. It has left a man enraged, feeling that he and his other family members were shut out of the process that led to the killing of his brother. The state, seeing people only as autonomous individuals, didn’t adequately recognize family bonds.
Families have traditionally been built around mutual burdens. As children, we are burdens on our families; in adulthood, especially in hard times, we can be burdens on one another; and in old age we may be burdens once again. When these bonds have become attenuated or broken in Western cultures, many people re-create webs of obligation in chosen families. There, too, it is the burdening that makes the bonds secure.
I recently had a conversation with a Canadian friend who told me that he and his three siblings had not been particularly close as adults. Then their aging dad grew gravely ill. His care became a burden they all shared, and that shared burden brought them closer. Their father died but their closeness remains. Their father bestowed many gifts upon his children, but the final one was the gift of being a burden on his family.
Autonomy-based liberalism imposes unrealistic expectations. Each individual is supposed to define their own values, their own choices. Each individual, in the words of Supreme Court Justice Anthony Kennedy in Planned Parenthood v. Casey, is left to come up with their own “concept of existence, of meaning, of the universe, of the mystery of human life.” If your name is Aristotle, maybe you can do that; most of us can’t. Most of us are left in a moral vacuum, a world in which the meaning of life is unclear, unconnected to any moral horizon outside the self.
Autonomy-based liberalism cuts people off from all the forces that formed them, stretching back centuries, and from all the centuries stretching into the future. Autonomy-based liberalism leaves people alone. Its emphasis on individual sovereignty inevitably erodes the bonds between people. Autonomy-based liberalism induces even progressives to live out the sentence notoriously associated with Margaret Thatcher: “There is no such thing as society.” Nearly 200 years ago, Alexis de Tocqueville feared that this state of affairs not only makes
men forget their ancestors, but also clouds their view of their descendants and isolates them from their contemporaries. Each man is forever thrown back upon himself alone and there is a danger that he may be shut up in the solitude of his own heart.
As Émile Durkheim pointed out in 1897, this is pretty much a perfect recipe for suicide. We now live in societies in which more and more people are deciding that death is better than life. In short, autonomy-based liberalism produces the kind of isolated, adrift people who are prone to suicide—and then provides them with a state-assisted solution to the problem it created in the first place.
Gifts-based liberalism, by contrast, gives you membership in a procession that stretches back to your ancestors. It connects you to those who migrated to this place or that, married this person or that, raised their children in this way or that. What you are is an expression of history.
This long procession, though filled with struggles and hardship, has made life sweeter for us. Human beings once lived in societies in which slavery was a foundational fact of life, beheadings and animal torture were popular entertainments, raping and pillaging were routine. But gradually, with many setbacks, we’ve built a culture in which people are more likely to abhor cruelty, a culture that has as an ideal the notion that all people deserve fair treatment, not just our kind of people.
This is progress. Thanks to this procession, each generation doesn’t have to make the big decisions of life standing on naked ground. We have been bequeathed sets of values, institutions, cultural traditions that embody the accumulated wisdom of our kind. The purpose of life, in a gifts-based world, is to participate in this procession, to keep the march of progress going along its fitful course. We may give with our creativity, with our talents, with our care, but many of the gifts people transmit derive from deeper sources.
A few years ago, the historian Wilfred McClay wrote an essay about his mother, a mathematician, in The Hedgehog Review. One day he mentioned to her that H. L. Mencken had suffered a stroke late in life that left him unable to read or write and nearly unable to speak. His mother coolly remarked that if such a fate ever befell her, he should not prolong her life. Without a certain quality of life, she observed, there’s no point in living.
A couple of years later, she suffered a near-fatal stroke that left her unable to speak. She cried the most intense sobs of grief McClay had ever heard. It might have appeared that her life was no longer worth living. But, McClay observed, “something closer to the opposite was true. An inner development took place that made her a far deeper, warmer, more affectionate, more grateful, and more generous person than I had ever known her to be.”
Eventually McClay’s mother moved in with his family. “It wasn’t always easy, of course, and while I won’t dwell on the details, I won’t pretend that it wasn’t a strain. But there are so many memories of those years that we treasure—above all, the day-in-and-day-out experience of my mother’s unbowed spirit, which inspired and awed us all.”
She and her family devised ways to communicate, through gestures, intonations, and the few words she still possessed. She could convey her emotions by clapping and through song. “Most surprisingly, my mother proved to be a superb grandmother to my two children, whom she loved without reservation, and who loved her the same way in return.” McClay noted that her grandkids saw past her disability. They could not have known how they made life worth living for her, but being around her was a joy. After she died, McClay writes that “it took a long time to adjust to the silence in the house.” He concluded, “Aging is not a problem to be solved, my mother taught us. It is a meaning to be lived out.”
Sometimes the old and the infirm, those who have been wounded by life and whose choices have been constrained, reveal what is most important in life. Sometimes those whose choices have been limited can demonstrate that, by focusing on others and not on oneself, life is defined not by the options available to us but by the strength of our commitments.
If autonomy-based liberals believe that society works best when it opens up individual options, gifts-based liberals believe that society works best when it creates ecologies of care that help people address difficulties all along the path of life. Autonomy-based liberalism is entrenching an apparatus that ends life. Gifts-based liberalism believes in providing varieties of palliative care to those near death and buttressing doctors as they forge trusting relationships with their patients. These support structures sometimes inhibit choices by declaring certain actions beyond the pale. Doctors are there for healing, at all times and under all pressures. Patients can trust the doctor because they know the doctor serves life. Doctors can know that, exhausted and confused though they might be while attending to a patient, their default orientation will be to continue the struggle to save life and not to end life.
John Stuart and Harriet Taylor Mill believed in individual autonomy. But they also believed that a just society has a vision not only of freedom but also of goodness, of right and wrong. Humans, John Stuart Mill wrote, “are under a moral obligation to seek the improvement of our moral character.” He continued, “The test of what is right in politics is not the will of the people, but the good of the people.” He understood that the moral obligations we take on in life—to family, friends, and nation, to the past and the future—properly put a brake on individual freedom of action. And he believed that they point us toward the fulfillment of our nature.
The good of humanity is not some abstraction—it’s grounded in the succession of intimates and institutions that we inherit, and that we reform, improve, and pass on. When a fellow member of the procession is in despair, is suffering, is thinking about ending their life, we don’t provide a syringe. We say: The world has not stopped asking things of you. You still have gifts to give, merely by living among us. Your life still sends ripples outward, in ways you do and do not see. Don’t go. We know you need us. We still need you.
This article appears in the June 2023 print edition with the headline “The Canadian Way of Death.” When you buy a book using a link on this page, we receive a commission. Thank you for supporting The Atlantic.
On one level, the world’s response to the coronavirus pandemic over the past two and half years was a major triumph for modern medicine. We developed COVID vaccines faster than we’d developed any vaccine in history, and began administering them just a year after the virus first infected humans. The vaccines turned out to work better than top public-health officials had dared hope. In tandem with antiviral treatments, they’ve drastically reduced the virus’s toll of severe illness and death, and helped hundreds of millions of Americans resume something approximating pre-pandemic life.
And yet on another level, the pandemic has demonstrated the inadequacy of such pharmaceutical interventions. In the time it took vaccines to arrive, more than 300,000 people died of COVID-19 in America alone. Even since, waning immunity and the semi-regular emergence of new variants have made for an uneasy détente. Another 700,000 Americans have died over that period, vaccines and antivirals notwithstanding.
For some pandemic-prevention experts, the takeaway here is that pharmaceutical interventions alone simply won’t cut it. Though shots and drugs may be essential to softening a virus’s blow once it arrives, they are by nature reactive rather than preventive. To guard against future pandemics, what we should focus on, some experts say, is attacking viruses where they’re most vulnerable, before pharmaceutical interventions are even necessary. Specifically, they argue, we should be focusing on the air we breathe. “We’ve dealt with a lot of variants, we’ve dealt with a lot of strains, we’ve dealt with other respiratory pathogens in the past,” Abraar Karan, an infectious-disease physician and global-health expert at Stanford, told me. “The one thing that’s stayed consistent is the route of transmission.” The most fearsome pandemics are airborne.
Numerous overlapping efforts are under way to stave off future outbreaks by improving air quality. Many scientists have long advocated for overhauling the way we ventilate indoor spaces, which has the potential to transform our air in much the same way that the advent of sewer systems transformed our water. Some researchers are similarly enthusiastic about the promise of germicidal lighting. Retrofitting a nation’s worth of buildings with superior ventilation systems or germicidal lighting is likely a long-term mission, though, requiring large-scale institutional buy-in and probably a considerable amount of government funding. Meanwhile, a more niche subgroup has zeroed in on what is, at least in theory, a somewhat simpler undertaking: designing the perfect mask.
Two and a half years into this pandemic, it’s hard to believe that the masks widely available to us today are pretty much the same masks that were available to us in January 2020. N95s, the gold standard as far as the average person is concerned, are quite good: They filter out at least 95 percent of .3-micron particles—hence N95—and are generally the masks of preference in hospitals. And yet, anyone who has worn one over the past two and a half years will know that, lucky as we are to have them, they are not the most comfortable. At a certain point, they start to hurt your ears or your nose or your whole face. When you finally unmask after a lengthy flight, you’re liable to look like a raccoon. Most existing N95s are not reusable, and although each individual mask is pretty cheap, the costs can add up over time. They impede communication, preventing people from seeing the wearer’s facial expressions or reading their lips. And because they require fit-testing, the efficacy for the average wearer probably falls well short of the advertised 95 percent. In 2009, the federal government published a report with 28 recommendations to improve masks for health-care workers. Few seem to have been taken.
These shortcomings are part of what has made efforts to get people to wear masks an uphill battle. What’s more,Over the course of the pandemic, several new companies have submitted new mask designs to NIOSH, the federal agency tasked with certifying and regulating masks,. Few, if any, have so far been certified. The agency appears to be overworked and underfunded. In addition, Joe and Kim Rosenberg, who in the early stages of the pandemic launched a mask company that applied unsuccessfully for NIOSH approval, told me the certification process is somewhat circular: A successful application requires huge amounts of capital, which in turn require huge amounts of investment, but investors generally like to see data showing that the masks work as advertised in, say, a hospital, and masks cannot be tested in a hospital without prior NIOSH approval. (NIOSH did not respond to a request for comment.)
New products aside, there do already exist masks that outperform standard N95s in one way or another. Elastomeric respirators are reusable masks that you outfit with replaceable filters. Depending on the filter you use, the mask can be as effective as an N95 or even more so. When equipped with HEPA-quality filters, elastomerics filter out 99.97 percent of particles. And they come in both half-facepiece versions (which cover the nose and mouth) and full-facepiece versions (which also cover the eyes). Another option are PAPRs, or powered air-purifying respirators—hooded, battery-powered masks that cover the wearer’s entire head and constantly blow HEPA-filtered air for the wearer to breathe.
Given the challenges of persuading many Americans to wear even flimsy surgical masks during the past couple of years, though, the issues with these superior masks—the current models, at least—are probably disqualifying as far as widespread adoption would go in future outbreaks. Elastomerics generally are bulky, expensive, limit range of motion, obscure the mouth, and require fit testing to ensure efficacy. PAPRs have a transparent facepiece and in many cases don’t require fit testing, but they’re also bulky, currently cost more than $1,000 each, and, because they’re battery-powered, can be quite noisy. Neither, let me assure you, is the sort of thing you’d want to wear to the movie theater.
The people who seem most fixated on improving masks are a hodgepodge of biologists, biosecurity experts, and others whose chief concern is not another COVID-like pandemic but something even more terrifying: a deliberate act of bioterrorism. In the apocalyptic scenarios that most worry them—which, to be clear, are speculative—bioterrorists release at least one highly transmissible pathogen with a lethality in the range of, say, 40 to 70 percent. (COVID’s is about 1 percent.) Because this would be a novel virus, we wouldn’t yet have vaccines or antivirals. The only way to avoid complete societal collapse would be to supply essential workers with PPE that they can be confident will provide infallible protection against infection—so-called perfect PPE. In such a scenario, N95s would be insufficient, Kevin Esvelt, an evolutionary biologist at MIT, told me: “70-percent-lethality virus, 95 percent protection—wouldn’t exactly fill me with confidence.”
Existing masks that use HEPA filters may well be sufficiently protective in this worst-case scenario, but not even that is a given, Esvelt told me. Vaishnav Sunil, who runs the PPE project at Esvelt’s lab, thinks that PAPRs show the most promise, because they do not require fit testing. At the moment, the MIT team is surveying existing products to determine how to proceed. Their goal, ultimately, is to ensure that the country can distribute completely protective masks to every essential worker, which is firstly a problem of design and secondly a problem of logistics. The mask Esvelt’s team is looking for might already be out there, just selling for too high a price, in which case they’ll concentrate on bringing that price down. Or they might need to design something from scratch, in which case, at least initially, their work will mainly consist of new research. More likely, Sunil told me, they’ll identify the best available product and make modest adjustments to improve comfort, breathability, useability, and efficacy.
Esvelt’s team is far from the only group exploring masking’s future. Last year, the federal government began soliciting submissions for a mask-design competition intended to spur technological development. The results were nothing if not creative: Among the 10 winning prototypes selected in the competition’s first phase were a semi-transparent mask, an origami mask, and a mask for babies with a pacifier on the inside.
In the end, the questions of how much we should invest in improving masks and how we should actually improve them boil down to a deeper question about which possible future pandemic concerns you most. If your answer is a bioengineered attack, then naturally you’ll commit significant resources to perfecting efficacy and improving masks more generally, given that, in such a pandemic, masks may well be the only thing that can save us. If your answer is SARS-CoV-3, then you might worry less about efficacy and spend proportionally more on vaccines and antivirals. This is not a cheery choice to make. But it is an important one as we inch our way out of our current pandemic and toward whatever waits for us down the road.
For the elderly and immunocompromised, super-effective masks could be useful even outside a worst-case scenario. But more traditional public-health experts, who don’t put as much stock in the possibility of a highly lethal, deliberate pandemic, are less concerned about perfecting efficacy for the general public. The greater gains, they say, will come not from marginally improving the efficacy of existing highly effective masks but from getting more people to wear highly effective masks in the first place. “It’s important to make masks easier for people to use, more comfortable and more effective,” Linsey Marr, an environmental engineer at Virginia Tech, told me. It wouldn’t hurt to make them a little more fashionable either, she said. Also important is reusability, Jassi Pannu, a fellow at the Johns Hopkins Center for Health Security, told me, because in a pandemic stockpiles of single-use products will almost always run out.
Stanford’s Karan envisions a world in which everyone in the country has their own elastomeric respirator—not, in most cases, for everyday use, but available when necessary. Rather than constantly replenishing your stock of reusable masks, you would simply swap out the filters in your elastomeric (or perhaps it will be a PAPR) every so often. The mask would be transparent, so that a friend could see your smile, and relatively comfortable, so that you could wear it all day without it cutting into your nose or pulling on your ears. When you came home at night, you would spend a few minutes disinfecting it.
Karan’s vision might be a distant one. America’s tensions over masking throughout the pandemic give little reason to hope for any unified or universal uptake in future catastrophes. And even if that happened, everyone I spoke with agrees that masks alone are not a solution. They’re almost certainly the smallest part of the effort to ensure that the air we breathe is clean, to change the physical world to stop viral transmission before it happens. Even so, making and distributing millions of masks is almost certainly easier than installing superior ventilation systems or germicidal lighting in buildings across the country. Masks, if nothing else, are the low-hanging fruit. “We can deal with dirty water, and we can deal with cleaning surfaces,” Karan told me. “But when it comes to cleaning the air, we’re very, very far behind.”
A few months ago, I got food poisoning. The sequence of events that led to my downfall began with a carton of discounted grocery-store sushi purchased and consumed on a Thursday, which led to me waking up a little queasy on a Friday, which devolved into a 12-hour stretch of me vomiting and holding myself in a fetal position, until my legs ached from dehydration. On Saturday the smell of my partner cooking breakfast still made me gag; I sipped water, napped fitfully, and nibbled little golf balls of white rice.
But Sunday, glorious Sunday, I awoke to a marvelous lack of pain and fatigue. The brain fog was gone. My skin felt plump with fluids. Enthralled by recovery, I found myself behaving with uncharacteristic serenity. When I dropped and broke a ceramic bowl while unloading the dishwasher, I didn’t curse and freak out. Instead, I swept up the shards with cheer. I wouldn’t sweat the small stuff. I was my normal self again, and it felt sublime.
Yet as I relished in my newfound bliss, a foreboding thought gnawed at me: I knew that as the hours passed and the specter of illness retreated, my fresh perspective, too, would fade. So much of my exuberance was defined by absence, the lifting of the burden of aches and puking. It would only be a matter of time until normal felt normal again, and I’d be back to worrying about all the petty minutiae I always worry about.
People have different baselines of health, and some might be more or less appreciative of whatever condition they’re in. Even so, humans have long lamented the ephemeral joy of relief. The feeling manifests in all kinds of circumstances: meeting a deadline, passing a test, finishing a marathon. And it can be especially acute in matters of wellness. “Health is not valued, till sickness comes,” wrote the 17th-century British scholar Thomas Fuller. Or as the 19th-century German philosopher Arthur Schopenhauer bemoaned: “Just as we do not feel the health of our entire body but only the small place where the shoe pinches, so too we do not think of the totality of our well-functioning affairs, but of some insignificant trifle that annoys us.”
So many of us, in other words, are very bad at appreciating good health when we’re fortunate enough to have it. And anyone experiencing this transcendent gratitude is unlikely to hold on to it for long. Indeed, by Monday morning, the afterglow of recovery had worn off; I was engrossed in emails and work again, unaware that just 60 hours prior I could barely sit upright in bed, let alone at my desk. This troubled me. Am I cursed to be like this forever? Or is there anything I can do to change?
To some extent, I’m sad to report, the answer might well be no. While certainly some people can have experiences of major illness or injury that change their entire outlook on life, the tendency to revert to forgetfulness seems to run pretty deep in the human psyche. We have limited attentional resources, the UC Davis psychology professor Robert Emmons told me, so in the interest of survival, our brain tends not to waste them focusing on systems that are working well. Instead, our mind evolved to identify threats and problems. Psychologists call this negativity bias: We direct our attention more to what’s wrong than what’s right. If your body’s in check, your brain seems to reason, better to stress about the project that’s overdue or the conflict with your friend than sit around feeling like everything’s fine.
A second psychological phenomenon that might work against any enduring joy in recovery from illness is hedonic adaptation, the notion that after positive or negative life events we, basically, get used to our new circumstances and return to a baseline level of subjective well-being. Hedonic adaptation has been used to explain why, in the long term, people who won the lottery were no happier than those who didn’t; and why romantic partners lose passion, excitement, and appreciation for each other over time.
Arguably, adaptation need not be seen as any great tragedy. For health, in particular, there’s an element of practicality in the human capacity to exist without fussy attentiveness. This is how we’re supposed to operate. “If our body isn’t causing us problems, it doesn’t actually pay to walk around being grateful all the time. You should be using your mental energy on other things,” Amie Gordon, an assistant professor of psychology at the University of Michigan, told me. If we had to sense our clothes on our bodies all day, for example, we’d constantly be distracted, she said. (This is actually a symptom of certain chronic disorders, like fibromyalgia—Lauren Zalewski, a writer who was diagnosed with both fibromyalgia and lupus 22 years ago, told me that it makes her skin sensitive to the touch, as if she constantly has the flu.)
All that said, there are real costs to taking health for granted. For one, it can make you less healthy, if as a result you don’t take care of yourself. For another, maintaining some level of appreciation is a good way to avoid becoming an entitled jerk. Throughout the pandemic, for instance, there has been “this language around how the ‘only’ people dying are ‘old people’ or people with pre-existing conditions,” as if these deaths were more acceptable, Emily Taylor, a vice president for the Long-COVID Alliance, a group that advocates for research into post-viral illnesses, told me. Acknowledging that our own health is tenuous—and that certainly, many of us are going to get old—could counter this kind of callousness and encourage people to treat the elderly and those with chronic conditions or disabilities with more respect and kindness, Taylor argued.
In my view, there’s something to be gained on an individual level, too. In recent years I’ve seen friends and loved ones deal with life-altering injuries and diagnoses. I know that one’s circumstances can turn on a phone call or a moment of inattention. To be healthy, to have basic needs met—to have life be so “normal” that it’s even a little boring—is a luxury. While I am living in those blessedly unremarkable times, I don’t want my fortune to escape my notice. When things are good, I want to know how good I’ve got it.
What I want, really, is to hold on to a sense of gratitude. In the field of psychology, gratitude can be something of a loaded term. Over the past decade or so, articles, podcast episodes, self-help books, research papers, celebrities, and wellness influencers alike have all extolled the benefits of being thankful. (Oprah famously kept a gratitude journal for more than a decade.) At times, gratitude’s popularity has been to its own detriment: The modern-day gratitude movement has been criticized for overstating its potential benefits and pushing a Western, wealthy, and privileged perspective that can seem to ignore the realities of extreme suffering or systemic injustices. It’s also annoying to constantly be told that you should really be more thankful for stuff.
But part of the reason gratitude has become such a popular concept is due to bountiful research that does point to genuine emotional upsides. Feeling grateful has been associated with better life satisfaction, an increased sense of well-being, and a greater ability to form and maintain relationships, among other benefits. (The research on gratitude’s effects on physical health is inconclusive.) For me, though, the pull is less scientific and more commonsense anyway: Learning to genuinely appreciate day-to-day boons like having good health, or food in the fridge, seems like being able to tap into a renewable source of contentment. It’s always so easy to find stress in life. Let me remember the things to smile about, too.
One way to make the most of gratitude may be to reframe how people tend to think of it. A popular misconception, Emmons told me over email, is that gratitude is a positive emotion that results from something good happening to us. (This might also be part of the reason it can be hard to appreciate conditions like health that for many people remain stable day after day.) Gratitude is an emotion, but it can also be a disposition, something researchers call “trait gratitude.” Some people are more predisposed to feeling thankful than others, by virtue of factors like genetics and personality. But Emmons says this kind of “undentable thankfulness” can also be learned, by developing habits that contribute to more of a persistent, ambient awareness, rather than a conditional reaction to ever-changing circumstances.
What does this look like, practically speaking? “I don’t know that we can, with every breath we have every moment, feel grateful that we’re breathing. That’s a pretty tall order,” says Gordon. “But that’s not to say that you don’t build in a moment for it at some point in your day.” If you’re recovering from a cold, for example, you can practice pausing whenever you’re walking out the door to appreciate that your nose isn’t stuffy before just barreling on with life. Another tactic, from Emmons, is to reflect upon your worst moments, such as times you’ve been ill. “Our minds think in terms of counterfactuals,” he said, which are comparisons between the way things are and how they might have been. “When we remember how difficult life used to be and how far we have come, we set up an explicit contrast in our mind, and this contrast is fertile ground for gratefulness.”
You can also think of gratitude as an action, Emmons has written. This hews closer to the historical notion of gratitude, which as far back as the Roman days was associated with ideas like duty and reciprocity—when someone does something kind for us, we’re expected to return the favor, whether that’s thanking them, paying them back, or paying it forward. In that sense, being grateful for your body probably means doing your best to care for it (and, probably, refraining from risky behaviors like rolling the dice on discounted grocery-store sushi).
In 2015, Lauren Zalewski, the writer with fibromyalgia, founded an online community that supports people living with chronic pain by helping them to cultivate a grateful mindset. She tells me that before her diagnosis, she took her health for granted and “beat her body up.” Now, she eats vegan, takes supplements, does yoga, stretches, sleeps more, and gets sun regularly—these are the small things she has personally found helpful for managing her constant pain. “So while I am a chronically ill person,” she muses, “I consider myself pretty healthy.”
Looking back on my food-poisoning incident, I think I was primed to ruminate more deeply than usual on the topics of sickness and health. In the past two and a half years, I’ve watched COVID-19 show that anyone can get ill, perhaps seriously so. Now, as the head of the World Health Organization tells us that “the end is in sight” for the pandemic (and President Joe Biden controversially declares the pandemic over), it’s tempting to imagine that humanity is on the brink of waking up the morning after a hellish sickness.
It’s probably delusional to hope that even a global pandemic could prompt some kind of long-term collective mental shift about the impermanence of health, and of life. I didn’t become a radically different person after recovering from puking my guts out a few months ago either. But maybe the simple act of remembering the health we still have in the pandemic’s wake can make a small difference in how we go forward—if not as a society, then at least as individuals. I’m sure I’ll never fully override my tendency to take my body for granted until it’s too late. But for now, each day, I still get the golden opportunity to try. And I’d like to take it.
School is in session, pumpkin spice is in season, and Americans are heading to pharmacies for what may soon become another autumn standby: your annual COVID shot. On Tuesday, the White House announced the start of a “new phase” of the pandemic response, one in which “most Americans” will receive a COVID-19 vaccine just “once a year, each fall.” In other words, your pandemic booster is about to become as routine as your physical exam or—more to the point—your flu shot. One more health-related task has been added to your calendar, and it’s likely to remain there for the rest of your life.
From a certain standpoint, this regimen makes a lot of sense. The pandemic’s biggest surges so far have come in the winter, and a fall booster could go a long way toward mitigating the next of those surges. What’s more, the new plan greatly simplifies COVID-vaccination regimens, both for the public and for providers. “It has been bewildering in many cases to understand who is eligible for a booster, how many boosters, when, which boosters, how far apart,” Jason Schwartz, a vaccine-policy expert at Yale, told me. “I think that has held down booster uptake in some really discouraging ways.” In a sense, White House COVID-19 Response Coordinator Ashish Jha told me, the new plan just codifies the way things already worked: The last time low-risk Americans became eligible for another shot was last fall. (The elderly and immunocompromised have operated on a different schedule and will likely continue to do so, Jha said.)
Still, some public-health experts worry that the White House is jumping the gun. Back in April, a number of them toldStat News’s Helen Branswell they were concerned that the U.S. would adopt such a policy without the data needed to support it. When the White House made its announcement on Tuesday, many felt their concerns had been vindicated. “We’ve had twists and turns and surprises every single step of the way with COVID, and the idea that we’re going to have one shot and then we’re done is not really consistent with how things have worked in the past,” Walid Gellad, a professor at the University of Pittsburgh School of Medicine, told me. The plan, in his view, glosses over considerable uncertainties.
For one thing, it assumes that the virus will follow an annual schedule with peaks in the fall and winter—not unlikely, but also not a given. For another, we still don’t have a firm grasp on the magnitude or duration of the benefits offered by the new Omicron-specific vaccine. For all we know, Gellad told me, the added protection afforded to someone who gets the shot tomorrow may have largely dissipated by New Year’s Eve.
And that’s not to mention the massive uncertainty presented by the specter of future variants. In a briefing Tuesday, Jha acknowledged that “new variant curveballs” could change the government’s plans. But the announcement itself includes no such caveats, which some public-health experts worry could cause problems if course corrections are needed down the line. For all we know, new variants could necessitate more frequent updates, or, if viral mutation slows, we might not even need annual shots, Paul Thomas, an immunologist at St. Jude Children’s Research Hospital, in Tennessee, told me.
If the routine the White House describes sounds a lot like flu shots, that’s no accident. The announcement explicitly recommends that COVID vaccines be taken between Labor Day and Halloween—“just like your annual flu shot.” That comparison, though, is part of what concerns critics, who worry that the shift into a more flu-like framework will entail the adoption of a vaccines-only approach to COVID prevention. Many of the interventions that have proved so effective over the past two and a half years—masking, distancing, widespread testing—have not traditionally been a major part of our flu-season protocols. If we treat COVID like flu, the thinking goes, such interventions risk falling even further by the wayside. The announcement, which makes no mention of any other prevention tactics, doesn’t offer much reassurance to the contrary.
But that reading, Jha told me, is “just clearly wrong.” Although vaccines are “the central pillar of our strategy,” he said, testing, masking, and improving indoor air quality are all important as well. But as my colleague Katherine Wu has written, the country has been relying more and more on vaccines—and less and less on the other interventions at our disposal—for some time. Even if you do read the new policy as an abnegation of masking, ventilation, and the like, it may not functionally be much of a departure from the status quo.
For now, Thomas said, the White House’s plan makes sense—as long as it stays sensitive to changing circumstances. “We keep learning new things about this virus,” he told me. “The rate of mutation is changing. The spread through the population is changing.” And as such, he said, our response must be flexible.
The White House announcement seems like a good-faith attempt to balance competing priorities: on the one hand, the need to communicate uncertainty and acknowledge complexity; on the other, the need to keep the message from getting so complex that it confuses people to the point that they tune it out entirely. In this case, the administration seems to have come down on the side of simplicity. That could be a mistake, Gellad says—one that public-health authorities have made over and over throughout the pandemic. “When you try and make things simple and understandable and present them without sufficient uncertainty,” he told me, “you get into trouble when things change.”
The most haunting memory of the pandemic for Laura, a doctor who practices internal medicine in New York, is a patient who never got COVID at all. A middle-aged man diagnosed with Stage 3 colon cancer in 2019, he underwent surgery and a round of successful chemotherapy and was due for regular checkups to make sure the tumor wasn’t growing. Then the pandemic hit, and he decided that going to the hospital wasn’t worth the risk of getting COVID. So he put it off … and put it off. “The next time I saw him, in early 2022, he required hospice care,” Laura told me. He died shortly after. With proper care, Laura said, “he could have stayed alive indefinitely.” (The Atlantic agreed to withhold Laura’s last name, because she isn’t authorized to speak publicly about her patients.)
Early in the pandemic, when much of the country was in lockdown, forgoing nonemergency health care as Laura’s patient did seemed like the right thing to do. But the health-care delays didn’t just end when America began to reopen in the summer of 2020. Patients were putting off health care through the end of the first pandemic year, when vaccines weren’t yet widely available. And they were still doing so well into 2021, at which point much of the country seemed to be moving on from COVID.
By this point, the coronavirus has killed more than 1 million Americans and debilitated many more. One estimate shows that life expectancy in the U.S. fell 2.41 years from 2019 to 2021. But the delays in health care over the past two and a half years have allowed ailments to unduly worsen, wearing down people with non-COVID medical problems too. “It just seems like my patients are sicker,” Laura said. Compared with before the pandemic, she is seeing more people further along with AIDS, more people with irreversible heart failure, and more people with end-stage kidney failure. Mental-health issues are more severe, and her patients struggling with addiction have been more likely to relapse.
Even as Americans are treating the pandemic like an afterthought, a disturbing possibility remains: COVID aside, is the country simply going to be in worse health than before the pandemic? According to health-care workers, administrations, and researchers I talked with from across the country, patients are still dealing with a suite of problems from delaying care during the pandemic, problems that in some cases they will be facing for the rest of their lives. The scope of this damage isn’t yet clear—and likely won’t come into focus for several years—but there are troubling signs of a looming chronic health crisis the country has yet to reckon with. At some point, the emergency phase of COVID will end, but the physical toll of the pandemic may linger in the bodies of Americans for decades to come.
During those bleak pre-vaccine dark ages, going to the doctor could feel like a disaster in waiting. Many of the country’s hospitals were overwhelmed with COVID patients, and outpatient clinics had closed. As a result, in every week through July 2020, roughly 45 percent of American adults said that over the preceding month, they either put off medical care or didn’t get it at all because of the pandemic. Once they did come in, they were sicker—a trend observed for all sorts of ailments, including childhooddiabetes, appendicitis, and cancer. A recent study analyzed the 8.4 million non-COVID Medicare hospitalizations from April 2020 to September 2021 and found not only that hospital admissions plummeted, but also that those admitted to hospitals were up to 20 percent more likely to die—an astonishing effect that lasted through the length of the study.
Partly, that result came about because only those who were sicker made it to the hospital, James Goodwin, one of the study’s authors and a professor at the University of Texas Medical Branch, in Galveston, told me. It was also partly because overwhelmed hospitals were giving worse care. But Goodwin estimates that “more than half the cause was people delaying medical care early in their illness and therefore being more likely to die. Instead of coming in with a urinary tract infection, they’re already getting septic. I mean, people were having heart attacks and not showing up at the hospital.”
For some conditions, skipping a checkup or two may not matter all that much in the long run. But for other conditions, every doctor’s visit can count. Take the tens of millions of Americans with vascular issues in their feet and legs due to diabetes or peripheral artery disease. Their problems might lead to, say, ulcers on the foot that can be treated with regular medical care, but delays of even a few months can increase the risk of amputation. When patients came in later in 2020, it was sometimes too late to save the limb. An Ohio trauma center found that the odds of undergoing a diabetes-related amputation in 2020 were almost 11 times higher once the pandemic hit versus earlier in the year.
Although only a small percentage of Americans lost a limb, the lack of care early in the pandemic helped fuel a dangerous spike in substance-abuse disorders. In a matter of weeks or months, people’s support systems collapsed, and for some, years of workovercoming an addiction unraveled. “My patients took a huge step back, probably more than many of us realize,” Aarti Patel, a physician assistant at a Lower Manhattan community hospital, told me. One of her patients, a man in his late 50s who was five years sober, started drinking again during the pandemic and eventually landed in the hospital for withdrawal. Patients like this man, she said, “would have really difficult, long hospital stays, because they were at really high risk of DTs, alcohol seizures. Some of them even had to go to the ICU because [the withdrawal] was so severe.”
Later in the year, when doctors’ offices were up and running, “a lot of patients expressed that they didn’t want to go back for care right away,” says Kim Muellers, a graduate student at Pace University who is studying the effects of COVID on medical care in New York City, North Carolina, and Florida. Indeed, through the spring of 2021, the top reason Medicare recipients failed to seek care was they didn’t want to be at a medical facility. Other people were avoiding the doctor because they’d lost their job and health insurance and couldn’t afford the bills.
The problem, doctors told me, is that all of those missed appointments start to add up. Patients with high blood pressure or blood sugar, for example, may now be less likely to have their conditions under control—which after enough time can lead to all sorts of other ailments. Losing a limb can pose challenges for patients that will last for the rest of their lives. Relapses can put people at a higher risk for lifelong medical complications. Cancer screenings plummeted, and even a few weeks without treatment can increase the chance of dying from the disease. In other words, even short-term delays can cause long-term havoc.
To make matters worse, the health-care delays fueling a sicker America may not be totally over yet, either. After so many backups, some health-care systems, hobbled by workforceshortages, are scrambling to address the pent-up demand for care that patients can simply no longer put off, according to administrators and doctors from several major health systems, including Cleveland Clinic, the Veterans Health Administration, and Mayo Clinic. Disruptions in the global supply chain are forcing doctors to ration basic supplies, adding to backlogs. Amy Oxentenko, a gastroenterologist at Mayo Clinic in Arizona who helps oversee clinical practice across the entire Mayo system, says that “all of these things are just adding up to a continued delay, and I think we’ll see impacts for years to come.”
It’s still early, and not everything that providers told me is necessarily showing up in the data. Oddly enough, the CDC’s National Health Interview Survey found that most Americans were able to see a doctor at least once during the first year of the pandemic. And the same survey has not revealed any uptick in most health conditions, including asthma episodes, high blood pressure, and chronic pain—which might be expected if America were getting sicker.
It’s even conceivable that the disturbing observations of clinicians are a statistical illusion. If for whatever reason only sicker people are now being seen by—or able to access—a doctor, then it can be true both that providers are seeing more seriously ill patients in medical facilities and that the total number of seriously ill people in the community is staying the same. The scope of the damage just isn’t yet clear: Maybe a smaller number of people will be worse off because of delayed cancer care or substance-abuse relapses, or maybe far more people—more than tens of million of Americans—will be dealing with exacerbated issues for the rest of their lives.
None of this accounts for what COVID itself is doing to Americans, of course. The health-care system is only beginning to grapple with the ways in which a past bout with COVID is a long-term risk for overall health, or the extent to which long COVID can complicate other conditions. The pandemic may feel “over” for lots of Americans, but many who made it through the gantlet of the past two-plus years may end up living sicker, and dying sooner.
This disturbing prospect is not only poised to further devastate communities; it’s also bad news for health-care workers already exhausted by COVID. Laura, the Manhattan internist who treated the colon-cancer patient, told me it’s disheartening to see so many people showing up at irreversible points in their disease. “As doctors,” she said, “our overall batting average is going down.” Aarti Patel, the physician assistant, put it in blunter terms: “Burnout is probably too simple a term. We’re in severe moral distress.”
Nothing about this grim fate was inevitable. Laura told me that “going to the doctor mid-pandemic may have posed a small risk in terms of COVID, but not going was risky in terms of letting disease go unchecked. And in retrospect it seems that many people didn’t quite get that.” But there didn’t have to be such a stark trade-off between fighting a pandemic and maintaining health care for other medical conditions.
Some hospitals—at least the better-resourced ones—figured out how to avoid the worst kind of delays. Mayo Clinic, for example, is one of a number of systems with a sophisticated triage algorithm that prioritizes patients needing acute care. In the spring of 2021, Cleveland Clinic launched a massive outreach blitz to schedule some 86,000 appointments, according to Lisa Yerian, the chief improvement officer. And the Veterans Health Administration provided iPads to thousands of veterans who lacked other means of accessing the internet in the spring of 2020, ensuring a more seamless transition to virtual care, Joe Francis, who directs health-care analytics, told me. Thanks in part to these efforts, Francis said, high-risk patients at the VHA were being seen at pre-pandemic levels a mere six months into the pandemic.
These health-care systems also suggest a path forward. America may still be able to stave off the worst of the collateral damage by reaching the patients who have fallen through the cracks—and already thedatasuggest that these patients tend to be disproportionately Black, Hispanic, and low-income. Tragically, it’s too late for some Americans: People who died of cancer can’t come back to life; amputated limbs can’t regrow. Others still have plenty of time. Hypertension that’s currently uncontrolled can be tamped down before causing an early heart attack; drinking that’s gotten out of hand can be corralled before it leads to liver failure in a decade; undetected tumors can be spotted in time for treatment. An uptick in premature death and disability, summed over millions of Americans, could strain the health-care system for years. But it’s still possible to prevent an acute public-health crisis from seeding an even bigger chronic one.