Walmart Inc. started out 2024 with some momentum — and is feeling more bullish about the year.
The mass market giant’s first-quarter net income jumped by more than 200 percent to $5.1 billion, or 63 cents a share. Adjusted earnings per share rose a milder 22.4 percent to 60 cents, which was still well ahead of the 52 cents analysts projected, according to Yahoo Finance.
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Revenues for the quarter ended April 30 increased 5.9 percent to $161.5 billion from $152.3 billion a year earlier, with a 3.8 percent increase in comparable store sales in the U.S.
Walmart’s global e-commerce business — which topped $100 billion in sales for the first time last year — grew by 21 percent in the quarter with orders fulfilled from the company’s store network and its third-party marketplace.
The company’s advertising business expanded by 24 percent, showing continued growth at what many see as a profit center given Walmart’s massive consumer reach.
Fashion a recently remodeled Walmart.
Inventory levels fell 2.7 percent compared with a year ago, including a 4.2 percent drop in the U.S., where the retailer is looking to operate efficiently and catering to consumers who have been hit hard by inflation.
“Our team delivered a great quarter,” said Doug McMillon, president and chief executive officer, in a statement. “Around the world our goal is simple — we’re focused on saving our customers both money and time. It’s inspiring to see how our associates are simultaneously executing the fundamentals and innovating to make shopping with us more enjoyable and convenient. We’re people-led and tech-powered, and that combination is propelling our business.”
Walmart now expects to be “at the high-end or slightly above” its previous top and bottom line guidance, calling for adjusted earnings of $2.23 to $2.37 a share and sales growth of 3 percent to 4 percent.
Investors liked what they saw and sent shares of Walmart up 4.5 percent to $62.52 in premarket trading.
Matthew Graves is not shy about promoting his success in prosecuting those who stormed the U.S. Capitol on January 6, 2021. By his count, Graves, the U.S. attorney for the District of Columbia, has charged more than 1,358 individuals, spread across nearly all 50 states and Washington, D.C., for assaulting police, destroying federal property, and other crimes. He issues a press release for most cases, and he held a rare news conference this past January to tout his achievements.
But Graves’s record of bringing violent criminals to justice on the streets of D.C. has put him on the defensive. Alone among U.S. attorneys nationwide, Graves, appointed by the president and accountable to the U.S. attorney general, is responsible for overseeing both federal and local crime in his city. In 2022, prosecutors under Graves pressed charges on a record-low 33 percent of arrests in the District. Although the rate increased to 44 percent last fiscal year and continues to increase, other cities have achieved much higher rates: Philadelphia had a 96 percent prosecution rate in 2022, while Cook County, Illinois, which includes Chicago, and New York City were both at 86 percent. D.C.’s own rate hovered in the 60s and 70s for years, until it began a sharp slide in 2016.
These figures help account for the fact that, as most major U.S. cities recorded decreases in murders last year, killings in the nation’s capital headed in the other direction: 274 homicides in 2023, the highest number in a quarter century, amounting to a nearly 50 percent increase since 2015. Violent crime, from carjackings to armed robberies, also rose last year. Some types of crime in the District are trending down so far in 2024, but the capital has already transformed from one of the safest urban centers in America not long ago to one in which random violence can take a car or a life even in neighborhoods once considered crime free.
Journalists and experts have offered up various explanations for D.C.’s defiance of national crime trends. The Metropolitan Police Department is down 467 officers from the 3,800 employed in 2020; Police Chief Pamela Smith has said it could take “more than a decade” to reach that number again. But the number of police officers hasdecreased nationwide. The coronavirus pandemic stalled criminal-court procedures in D.C., but that was also the case across the country. The 13-member D.C. city council, dominated by progressives, tightened regulations on police use of force after the murder of George Floyd in 2020, but many local councils across the country passed similar laws. Reacting to public pressure, the D.C. council this month passed, and Mayor Muriel Bowser signed, a public-safety bill that rolls back some policing restrictions and includes tougher penalties for crimes such as illegal gun possession and retail theft.
As a journalist who has covered crime in the District for four decades, I believe that one aspect of the D.C. justice system sets it apart, exacerbating crime and demanding remedy: Voters here cannot elect their own district attorney to prosecute local adult crimes.
The District’s 679,000 residents and the millions of tourists who visit the capital every year could be safer if D.C. chose its own D.A., responsive to the community’s needs and accountable to voters. D.C. residents have no say in who sits atop their criminal-justice system with the awesome discretion to bring charges or not. Giving voters the right to elect their own D.A. would not only move the criminal-justice system closer to the community. It would also reform one of the more undemocratic, unjust sections of the Home Rule Act. The 1973 law, known for granting the District limited self-government, also maintained federal control of D.C.’s criminal-justice system; the president appoints not just the chief prosecutor but also judges to superior and district courts.
“Putting prosecution into the hands of a federal appointee is a complete violation of the founding principles this country was built on,” Karl Racine, who served as D.C.’s first elected attorney general, from 2015 to 2023, told me. (The District’s A.G. has jurisdiction over juvenile crime.) “Power is best exercised locally.”
Allowing the District to elect its own D.A. would not solve D.C.’s crime problem easily or quickly. Bringing criminals to justice is enormously complicated, from arrest to prosecution to adjudication and potential incarceration; this doesn’t fall solely on Graves or any previous U.S. attorney. The change would require Congress to revise the Home Rule charter, and given the politics of the moment and Republican control of the House, it’s a political long shot. In a 2002 referendum, 82 percent of District voters approved of a locally elected D.A. Four years later, Eleanor Holmes Norton, the District’s longtime Democratic delegate to Congress, began introducing legislation to give D.C. its own prosecutor. But her efforts have gone nowhere, regardless of which party controlled Congress or the White House.
Many Republicans in Congress—as well as former President Donald Trump—like to hold up the District as a crime-ridden example of liberal policies gone wrong, and they have repeatedly called for increased federal control to make the city safer. Ironically, what distinguishes the District from every other U.S. city is that its criminal-justice system is already under federal control. If Republicans really want to make D.C. safer, they should consider empowering a local D.A. who could focus exclusively on city crime.
In two interviews, Graves defended his record of prosecuting local crime and pointed to other factors contributing to D.C.’s homicide rate. “The city is lucky to have the career prosecutors it has,” he told me. He questioned whether a locally elected D.A. would be any more aggressive on crime. But he also said he is fundamentally in favor of the District’s right to democratically control its criminal-justice system.
“I personally support statehood,” he said. “Obviously, if D.C. were a state, then part of that deal would be having to assume responsibility for its prosecutions.”
The District’s porous criminal-justice system has long afflicted its Black community in particular; in more than 90 percent of homicides here, both the victims and the suspects are Black. Since the 1980s, I have heard a constant refrain from Washingtonians east of the Anacostia River that “someone arrested Friday night with a gun in their belt is back on the street Saturday morning.”
In the District’s bloodiest days, during the crack epidemic, murders in the city mercilessly rose, peaking in 1991 at 509. From 1986 to 1990, prosecutions for homicide, assault, and robbery increased by 96 percent. Over the next two decades, homicides and violent crime gradually decreased; murders reached a low of 88 in 2012. That year, the U.S. Attorney’s Office prosecution rate in D.C. Superior Court was 70 percent. But the District’s crime rate seemed to correspond more to nationwide trends than to any dramatic changes in the prosecution rate.
The rate of federal prosecution of local crime in the District stood at 65 percent as recently as 2017 but fell precipitously during a period of turbulence in the U.S. Attorney’s Office under President Trump, when multiple people cycled through the lead-prosecutor spot. (“That is your best argument about the danger of being under federal control,” Graves told me.) After a mob attacked the U.S. Capitol in 2021 and Graves took office later that year, he temporarily redeployed 15 of the office’s 370 permanent prosecutors to press cases against the violent intruders in D.C. federal court. The prosecution rate for local crime stood at 46 percent in 2021 but plummeted to the nadir of 33 percent in 2022.
“It was a massive resource challenge,” Graves said of the January 6 prosecutions. “It’s definitely a focus of mine, a priority of mine.” But he added: “We all viewed the 33 percent as a problem.”
Graves, 48, an intense, hard-driving lawyer from eastern Pennsylvania, told me that his job, “first and foremost, is keeping the community safe.” He has a track record in the District: He joined the D.C. federal prosecutor’s operation in 2007 and worked on local violent crime before moving up to become the acting chief of the department’s fraud and public-corruption section. He went into private practice in 2016 and returned when President Joe Biden nominated him to run the U.S. Attorney’s Office, in July 2021. He has lived in the District for more than 20 years. “It’s my adopted home,” he said.
Graves attributes D.C.’s rising murder rate in large part to the fact that the number of illegal guns in D.C. “rocketed up” in 2022 and 2023: Police recovered more than 3,100 illegal firearms in each of those years, compared with 2,300 in 2021. “D.C. doesn’t appropriately hold people accountable for illegally possessing firearms,” he told me. According to Graves, D.C. judges detain only about 10 percent of defendants charged with illegal possession of a firearm.
He attributed his office’s low prosecution rates to two main causes: first, pandemic restrictions that dramatically cut back on in-person jury trials, including grand juries, where prosecutors must present evidence to bring indictments. Without grand juries, Graves said, prosecutors could not indict suspects who were “sitting out in the community.” Second, the District’s crime lab lost its accreditation in April 2021 and was out of commission until its partial reinstatement at the end of 2023. Without forensic evidence, prosecutors struggled to trace DNA, drugs, firearm cartridges, and other evidence, Graves explained: “It was a massive mess that had nothing to do with our office.” Police and prosecutors were unable to bring charges for drug crimes until the Drug Enforcement Agency agreed in March 2022 to handle narcotics testing.
Even with these impediments, Graves said his office last year charged 90 percent of “serious violent crime” cases in D.C., including 137 homicides, in part by increasing the number of prosecutors handling violent crime cases in 2022 and 2023.
But accepting Graves’s explanations doesn’t account for at least 18 murder suspects in 2023 who had previously been arrested but were not detained—either because prosecutors had dropped charges or pleaded down sentences (in some cases before Graves’s tenure), or because judges released the defendants. (The 18 murder suspects were tracked by the author of the anonymous DC Crime Facts Substack and confirmed in public records.) “Where the office does not go forward with a firearms case at the time of arrest, it is either because of concerns about whether the stop that led to the arrest was constitutional or because there is insufficient evidence connecting the person arrested to the firearm,” Graves told me in an email.
Last month, the National Institute for Criminal Justice Reform, a research and advocacy nonprofit, released a report showing that in 2021 and 2022, homicide victims and suspects both had, on average, more than six prior criminal cases, and that most of those cases had been dismissed. Police and nonprofit groups working to tamp down violence described “a feeling of impunity among many people on the streets that may be encouraging criminal behavior.” Police “also complained of some cases not being charged or when they are, the defendant being allowed to go home to await court proceedings,” according to the report, which cited interviews with more than 70 Metropolitan Police Department employees.
“Swift and reliable punishment is the most effective deterrent,” Vanessa Batters-Thompson, the executive director of the DC Appleseed Center for Law and Justice, a nonprofit that advocates for increased local governance, told me.
In January, the Justice Department announced that it would “surge” more federal prosecutors and investigators to “target the individuals and organizations that are driving violent crime in the nation’s capital,” in the words of U.S. Attorney General Merrick Garland. Graves welcomed the move, which he said has added about 10 prosecutors so far and will create a special unit to analyze crime data that could provide investigators with leads. Similar “surges” have been deployed in Memphis and Houston.
“But [D.C. has] no control over what that surge is,” Batters-Thompson said—how large or long-lasting it is. Even if federal crime fighters make a dent in the District’s violence and homicide rates, the effort would amount to a temporary fix.
Electing a D.A. for D.C. would not only take Congress reforming the Home Rule Act. There’s also the considerable expense of creating a district attorney’s office and absorbing the cost now borne by the federal government. (It’s an imperfect comparison, but the D.C. Office of the Attorney General’s operating budget for fiscal year 2024 is approximately $154 million.) Republicans in control of the House are more intent on repealing the Home Rule Act than granting District residents more autonomy.
But if Republicans want D.C. to tackle its crime problem, why shouldn’t its residents—like those of Baltimore, Philadelphia, Denver, Boston, Seattle, and elsewhere—be able to elect a district attorney dedicated to that effort? Crime is often intimate and neighborhood-based, especially in a relatively small city such as the District. Effective prosecution requires connection and trust with the community, both to send a message about the consequences of bad behavior and to provide victims and their families with some solace and closure. Those relationships are much more difficult to forge with a federally appointed prosecutor whose jurisdiction is split between federal and local matters, and who is not accountable to the people he or she serves.
Racine, the former D.C. attorney general, was regularly required to testify in oversight hearings before the city council. Graves doesn’t have to show up for hearings before the District’s elected council, though he couldn’t help but note to me that progressive council members have in the past accused D.C.’s criminal-justice system of being too punitive.
Graves told me that his office has a special community-engagement unit, that he attends community meetings multiple times a month, and that his office is “latched up at every level” with the police, especially with the chief, with whom Graves said he emails or talks weekly.
“Given our unique role,” he said, “we have to make ourselves accountable to the community.”
Sounds like the perfect platform to run on for D.C.’s first elected district attorney.
The last time I stepped on a plane for vacation, for fun, was more than three years ago. I haven’t been able to visit California, whose coast I adore. Nor Rome, where my husband and I lived for some time.
And yet, I’m told, I’ve been on a journey. Two journeys, actually: First, a “traumatic-brain-injury journey,” experienced at Johns Hopkins Hospital after I banged my head and developed trouble with my balance and gait. More recently, I’ve been a traveling companion on my husband’s “cancer journey” at Memorial Sloan Kettering, in New York City.
These are two of the highest-ranked hospitals in the country. The care was excellent in both places. But neither of these journeys resembled our bike ride in Ireland or the wine-tasting trip in Sonoma a few years before.
So much of being seriously ill has been rebranded in American health care as a kind of adventure. Experts speak of stroke journeys. Hospital systems invite people on kidney-transplant journeys. The language has trickled down into advertising: Take a hair-loss journey or a weight-loss journey (newly popular thanks to Wegovy and similar drugs). The heart-failure journey even comes with a map.
A map? But on these journeys, you don’t get to go anywhere—except maybe the hospital or doctor’s office, which is likely, too, to have bought into the travel concept. In the past two decades, American hospitals have gotten into the business of hotel-like hospitality (illness can be fun!) rather than confine themselves to the business of disease (what a downer). And although the care might stay solid, the focus on luxurious amenities and the fancy new buildings that house them is one of the factors that have helped send costs for patients soaring that much higher, to prices well above those in other developed countries.
In this version of health care, I’m no longer a patient. I’m a client, a customer, or (worse) a guest, no matter that I didn’t choose this journey cum illness. I appreciate a little luxury and privacy as much as the next person. But, at a time when Americans’ life spans are getting shorter and four in 10 adults say they’ve delayed or gone without necessary care because of cost, is it worth it?
In recent years, tight budgets, staffing shortages, and burnout have hit American hospitals. At the same time, many health centers in the U.S.—including the most prestigious ones, and even some community hospitals—have morphed into seven-star hotels. New hospital buildings, such as recent projects at the University of Michigan Medical Center and Valley Hospital in Paramus, New Jersey, offer all-private rooms, in many cases with couches and flatscreen TVs. A hospital might now boast about its views, high-thread-count sheets, or food provided by a Michelin-starred chef.
Those commissioning and designing these pavilions cite research showing that private rooms are better for healing, because they offer a better chance at sleep and a lower chance of infection. (Actually, the evidence is pretty murky.)
But we’re suckers for this type of thing, and the industry knows that even small comforts can make us feel better, regardless of whether we’re actually getting better. Back in 2008, researchers at the National Bureau of Economic Research estimated that a hospital investing in amenities would increase demand by 38 percent, whereas a similar investment in clinical quality would lead to only a 13 percent increase. More recently, hospital executives told The Boston Globe that the main reason hospitals have moved in this direction is that “people’s expectations have changed,” and it creates a “competitive advantage” that can be marketed to potential customers.
And so the Mayo Clinic now offers complimentary concierge services, which can help with recommending nearby restaurants and finding pet care. I think that’s the hospitality version of what used to be called the hospital “help desk,” whose function was merely to explain to visitors how to get to patient rooms. Cleveland Clinic, which employs a team of curators, owns one of the largest contemporary-art collections in the region, and its leaders see that collection as one tool for “positively affecting patient outcomes.” Patients at Cedars-Sinai can experience its “therapeutic art collection” of Chagalls, Picassos, and Oldenburgs.
Hospital food has gotten so good that in some area,s people go to their local hospital for haute cuisine rather than medical needs. And when you look at the numbers on your hospital bill, remember that all of this adds up. For the amount that American patients (or their insurers) pay for some luxury hospital journeys, they could sign up for a Virgin Galactic suborbital joy ride.
This transformation from hospital to hospitality has filled up hospital C-suites with chief experience officers, whose function is to “manage patients’ experiences throughout their healthcare journey,” as described by the publication HealthTech. The Cleveland Clinic was the first major academic medical center to add one, back in 2007; now some health systems hire for this and similar positions directly from the hospitality industry, picking people who’d previously been managers at a Ritz-Carlton or a Trump hotel. 
The American Hospital Association acknowledges and defends the transformation. “These are not just ‘nice to haves,’” Nancy Foster, AHA’s vice president of quality and patient-safety policy, wrote to me in an email. “Actions hospitals can take to reduce stress and provide other psychological support can have a meaningful impact on one’s physical and behavioral health, including the ability to recover more rapidly.” But pretending that illness is an Abercrombie & Kent safari is actually harmful. These amenities have a cost, and they are not worth nearly what we’re paying for them as we’re billed for $100,000 joint replacements and $9,000 CT scans. Room charges in many hospitals can exceed $1,000 a night. And “facility fees” for outpatient procedures and even office visits can reach hundreds of dollars, and simply don’t exist elsewhere. A hospital’s function is to diagnose and to heal, at a price that sick people can afford. I dream of a no-frills Target- or Ikea-like hospital for care.
That doesn’t mean hospitals need to resemble prisons. Hospitals certainly have room to improve on breakfasts featuring Lilliputian plastic cups of orange juice and rubbery eggs. But to understand one of the many reasons Americans pay so much for health care, consider this: The best hospitals in Europe are utilitarian structures that most resemble urban high schools. When I got stitches for a deep cut in my forehead in Gemelli Hospital—where the pope gets health care—I sat on a gurney in a big dark room with other patients.
Instead of providing free coffee and a piano in a soaring, art-filled marble lobby, how about focusing on the very basic things that health systems in the U.S. should do, but—in my experience—in many cases do not, like making it easier for patients to schedule appointments? Shortening the now lengthy wait times to see physicians who take insurance plans? Paying for adequate staffing on nights and weekends, so patients don’t linger in bed pointlessly for two days until social workers return on Monday? Or ending those two-day stays in emergency rooms when all inpatient beds are full? (Hotels aspire to run at full occupancy to maximize revenue; hospitals, I’d argue, should not.)
This winter, I’m planning a journey where I’m looking forward to some good food and art. We haven’t yet determined the exact destination, but it will not be a U.S. hospital.
If you have children, you probably already understand them to be very adorable food-waste machines. If you do not have children, I have five, so let me paint you a picture. On a recent Tuesday night, the post-dinner wreckage in my house was devastating. Peas were welded to the floor; my 5-year-old had decided that he was allergic to chicken and left a pile of it untouched on his plate. After working all day, making the meal in the first place, and then spending dinnertime convincing five irrational, tiny people to try their vegetables, I didn’t even have the energy to convince them to take their plates into the kitchen, let alone box up their leftovers for tomorrow. So I did exactly what I’m not supposed to do, according to the planet’s future: I threw it all out, washed the dishes, and flopped into bed, exhausted.
Tens of millions of tons of food that leaves farms in the United States is wasted. Much of that waste happens at the industrial level, during harvesting, handling, storage, and processing, but a staggering amount of food gets wasted at home, scraped into the garbage can at the end of a meal or tossed after too long in the crisper drawer. According to a 2020 Penn State University study, almost a third of the food that American households buy is wasted.
On the individual level, all of this waste is expensive, annoying, and gross. In the aggregate, it’s unfortunate, given that about a fifth of American families reported not having enough to eat last year. But it’s also bad for the planet. Every step of the modern food-production process generates greenhouse gases. Before they ended up in the trash, all of those slimy vegetables and uneaten hunks of chicken were grown using water and farmland and pesticides and fertilizer. They were most likely packed in plastic and paper, and then stored and transported using fossil fuels and electricity. Throwing away food means throwing away all of the resources it requires, but the problems don’t end there: As food rots in landfills and open dumps, it emits methane, a greenhouse gas much more potent than carbon dioxide. According to the United Nations, food loss and waste accounts for about 8 to 10 percent of global greenhouse-gas emissions.
Some amount of food waste is probably inevitable, especially with young kids. “The very youngest children … are still kind of understanding what they like, with novel foods and healthy foods. We want to give them that opportunity,” Brian Roe, a farm-management professor and the director of the Food Waste Collaborative at Ohio State University, told me. “You need to waste a little bit of food while they develop palates.”
More saliently, Roe’s research indicates that food waste is often inversely proportional to spare time: We get busy, we eat out, and our well-intended groceries head to the trash. His data show a 280 percent increase in food waste from February 2021 to February 2022, right as pandemic restrictions were loosening and people with the income to do so started eating out more. In other words, as soon as people had the option to eat without cooking, they did. “When you’ve got more kids and more craziness and a time crunch, all of a sudden, what you thought was going to be 40 minutes to prep dinners is out the window,” he told me. Thus, “those ingredients are more likely to go to waste.”
Wasting less food starts at the grocery store: Most financially secure families simply need less food than they buy. The sustainability consultant Ashlee Piper told me that she likes to take a picture of her fridge and pantry before heading to the store, in order to avoid buying duplicates. She also recommends shopping not for your “aspirational life” but for the one you are actually living: If, realistically, you’re never going to make your own pasta or pack gourmet lunches for your kids, don’t shop for those meals. “There’s no lunchbox sheriff,” she told me. (Comforting!)
Once you unpack the groceries, experts say to be strategic about making perishable foods highly visible, accessible, and appetizing. Julia Rockwell, a San Francisco mom and sustainability expert, recommends an “Eat Me” station, whether it’s a basket, a bowl, a tray, or a section of the refrigerator, which she says is especially helpful for teenagers, inclined as they are to “go full claws into the fridge.” A designated place for high-urgency snacks reminds them, “Here’s a yogurt that you missed, or here’s a half of a banana, or here’s the things let’s go to first,” she told me. Leftovers and soon-to-spoil foods also make great dinners or lunches for younger kids, who will be happy to snack on items that don’t necessarily go together in a traditional meal.
If you’re cleaning out your fridge and pantry strictly according to expiration dates, stop: If a food is past its expiration date but looks and smells fine, it probably is; most of the time, expiration dates are an indicator of quality, not safety. (Deli meats and unpasteurized cheeses are notable exceptions.) Brush up on the language of food packaging—“best by” is just a suggestion, while “expiration” is the date the manufacturer has decided when quality will begin to decline. Frozen food is pretty much always safe, and packaged foods and canned goods without swelling, dents, or rust can last for years, though they may not taste as good. (You can conceal your less-than-fresh nonperishables in another meal, such as adding older ground beef from the freezer to a chili. When in doubt about, say, an older vegetable, Roe says, “coat it in panko and fry it up.”)
And whatever you’re feeding your kids, experts repeatedly told me, you should probably be feeding them less. How many blueberries does your pickiest kid really eat at the breakfast table? And how many do you put on their plate that you wish they’d eat? The difference in this pint-size math equation is an essential factor in food-waste management for families. Jennifer Anderson, a mom and registered dietician, discourages “wishful portions.” “You know the amount you want your child to eat, so you put that much on their plate … Take that amount, cut it in half, then cut it in half again,” she told me. “A practical portion is a quarter of what you wish they would eat.”
Since talking to Anderson, I’ve kept her advice in mind. I still spend more time than I’d like trying to convince my kids to eat yellow peppers when they’ve decided the red ones are the only acceptable type. But the math is simple: Smaller portions on their plate means fewer leftovers in the trash later, and I’ve noticed a real difference.
And I still find myself dumping plates of picked-over food into the trash or compost. But I move on to the next meal with more grace and less guilt for having helped my kids become little stewards of a healthier planet. I want them to understand that our food comes from somewhere, and that not eating it has consequences. That doesn’t mean guilting them for not liking dragon fruit, or demanding that they clean their plate at every meal, or scaring them about climate change. It’s more like bringing them along, helping them participate in a family project with planetary implications. Wish me luck with the peppers.
This story is part of the Atlantic Planet series supported by HHMI’s Science and Educational Media Group.
As the chair of the department of obstetrics and gynecology at UT Southwestern Medicine, Catherine Spong is used to seeing a lot of baby bumps. But through her decades of practice, she’s been fascinated by a different kind of bump: Year after year after year, she and her colleagues deliver a deluge of babies from June through September, as much as a 10 percent increase in monthly rates over what they see from February through April. “We call it the summer surge,” Spong told me.
Her hospital isn’t alone in this trend. For decades, demographers have documented a lift in American births in late summer, and a trough in the spring. I see it myself in my own corner of the world: In the past several weeks, the hospital across the street from me has become a revolving door of new parents and infants. When David Lam, an economist at the University of Michigan who helped pioneer several early U.S. studies on seasonal patterns of fertility, first analyzed his data decades ago, “we were kind of surprised how big it was,” he told me. Compare the peak of some years to their nadir, he said, and it was almost like looking at the Baby Boom squished down into 12 months.
Birth seasonality has been documented since the 1820s, if not earlier. But despite generations of study, we still don’t fully understand the reasons it exists, or why it differs so drastically among even neighboring countries. Teasing apart the contributions of biology and behavior to seasonality is messy because of the many factors involved, says Micaela Martinez, the director of environmental health at the nonprofit WE ACT for Environmental Justice, who has been studying seasonality for years. And even while researchers try to track it, the calendar of human fertility has been changing. As our species has grown more industrialized, claimed more agency over reproduction, and reshaped the climate we are living in, seasonality, in many places, is shifting or weakening.
There is no doubt that a big part of human birth seasonality is behavioral. People have more sex when they have more free time; they have less sex when they’re overworked or overheated or stressed. Certain holidays have long been known to carry this effect: In parts of the Western world with a heavy Christian presence, baby boomlets fall roughly nine months after Christmas; the same patterns have been spotted with Spring Festival and Lunar New Year in certain Chinesecommunities. (Why these holidays strike such a note, and not others, isn’t entirely clear, experts told me.)
In addition to free time, family-focused celebrations probably help set the mood, Luis Rocha, a systems scientist at Binghamton University, told me. Cold weather might help people get snuggly around Christmastime, too, but it’s not necessary; Rocha’s studies and others have shown the so-called Christmas effect in southern-hemisphere countries as well. No matter whether Christmas falls in the winter or summer, around the end of December, Google searches for sex skyrocket and people report more sexual activity on health-tracking apps. In a few countries, including the U.S., condom sales rise too.
But cultural norms have never been able to explain everything about the Homo sapiens birth calendar. “It’s pretty common for mammals to have a specific breeding season” dictated by all sorts of environmental cues, Martinez told me. Deer, for instance, mate in the fall, triggered by the shortening length of daylight, effectively scheduling their fawns to be born in the spring; horses, whose gestations are longer, breed as the days lengthen in the spring and into summer, so they can foal the following year.
Humans, of course, aren’t horses or deer. Our closest relatives among primates “are much more flexible” about when they mate, Élise Huchard, a behavioral ecologist at the University of Montpellier, in France, told me. But those apes are not immune to their surroundings, and neither are we. All sorts of hormones in the human body, including reproductive ones, wax and wane with the seasons. Researchers in the United States and Australia have found that couples hoping to conceive via in vitro fertilization have a higher chance of success if the eggs are retrieved during the summer. At the same time, summer conceptions appear to be less common, or less successfully carried to term, in somecountries, a trend that sharpens at lower latitudes and, Lam told me, during hotter years. The subsequent spring lulls may be explained in part by heat waves dissuading people from sex. But Alan Barreca, an economist at UCLA, suspects that ultrahigh temperatures may also physiologically compromisefertility, potentially by affecting factors such as sperm quantity and quality, ovulation success, or the likelihood of early fetal loss.
No matter its exact drivers, seasonality is clearly weakening in manycountries, Martinez told me; in some parts of the world, it may be entirely gone. The change isn’t uniform or entirely understood, but it’s probably to some extent a product of just how much human lifestyles have changed. In many communities that have historically planted and harvested their own food, people may have been more disinclined to, and less physically able to, conceive a child when labor demands were high or when crops were scarce—trends that are still prominent in certain countries today. People in industrial and high-income areas of the modern world, though, are more shielded from those stressors and others, in ways that may even out the annual birth schedule, Kathryn Grace, a geographer at the University of Minnesota, told me. The heat-driven dip in America’s spring births, for instance, has softened substantially in recent decades, likely due in part to increased access to air-conditioning, Lam said. And as certain populations get more relaxed about religion, the cultural drivers of birth times may be easing up, too, several experts told me. Sweden, for example, appears to have lost the “Christmas effect” of December sex boosting September births.
Advances in contraception and fertility treatments have also put much more of fertility under personal control. People in well-resourced parts of the world can now, to a decent degree, realize their preferences for when they want their babies to be born. In Sweden, parents seem to avoid November and December deliveries because that would make their child among the youngest in their grade (which carries a stereotype of potentially having major impacts on their behavioral health, social skills, academics, and athletic success). In the U.S., people have reported preferring to give birth in the spring; there’s also a tax incentive to deliver early-winter babies before January 1, says Neel Shah, the chief medical officer of Maven Clinic, a women’s health and fertility clinic in New York.
Humans aren’t yet, and never will be, completely divorced from the influences of our surroundings. We are also constantly altering the environment in which we reproduce—which could, in turn, change the implications of being born during a particular season. Births are not only more common at certain times of the year; they can also be riskier, because of the seasonal perils posed to fetuses and newborns, Mary-Alice Doyle, a social-policy researcher at the London School of Economics, told me. Babies born during summer may be at higher risk of asthma, for instance—a trend that’s likely to get only stronger as heat waves, wildfires, and air pollution become more routine during the year’s hottest months.
The way we manage infectious disease matters too. Being born shortly after the peak of flu season—typically winter, in temperate parts of the world—can also be dangerous: Infections during pregnancy have been linked to lower birth weight, preterm delivery, even an increased likelihood of the baby developing certain mental-health issues later on. Comparable concerns exist in the tropics, where mosquitoes, carrying birth-defect-causing viruses such as dengue or Zika, can wax and wane with the rainy season. The more humans allow pathogens to spill over from wildlife and spread, the bigger these effects are likely to be.
Children born in the spring—in many countries, a more sparsely populated group—tend to be healthier on several metrics, Barreca told me. It’s possible that they’re able to “thread the needle,” he said, between the perils of flu in winter and extreme heat in summer. But these infants might also thrive because they are born to families with more socioeconomic privilege, who could afford to beat the heat that might have compromised other conceptions. As heat waves become more intense and frequent, people without access to air-conditioning might have an even harder time getting pregnant in the summer.
The point of all this isn’t that there is a right or wrong time of year to be born, Grace told me. If seasonality will continue to have any sway over when we conceive and give birth, health-care systems and public-health experts might be able to use that knowledge to improve outcomes, shuttling resources to maternity wards and childhood-vaccination clinics, for instance, during the months they might be in highest demand.
Humans may never have had as strict a breeding season as horses and deer. But the fact that so many people can now deliver safely throughout the year is a testament to our ingenuity—and to our sometimes-inadvertent power to reshape the world we live in. We have, without always meaning to, altered a fundamental aspect of human reproduction. And we’re still not done changing it.
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Three years ago, while the nation’s attention was on the 2020 presidential election, voters in Oregon took a dramatic step back from America’s long-running War on Drugs. By a 17-point margin, Oregonians approved Ballot Measure 110, which eliminated criminal penalties for possessing small amounts of any drug, including cocaine, heroin, and methamphetamine. When the policy went into effect early the next year, it lifted the fear of prosecution for the state’s drug users and launched Oregon on an experiment to determine whether a long-sought goal of the drug-policy reform movement—decriminalization—could help solve America’s drug problems.
Early results of this reform effort, the first of its kind in any state, are now coming into view, and so far, they are not encouraging. State leaders have acknowledged faults with the policy’s implementation and enforcement measures. And Oregon’s drug problems have not improved. Last year, the state experienced one of the sharpest rises in overdose deaths in the nation and had one of the highest percentages of adults with a substance-use disorder. During one two-week period last month, three children under the age of 4 overdosed in Portland after ingesting fentanyl.
For decades, drug policy in America centered on using law enforcement to target people who sold, possessed, or used drugs—an approach long supported by both Democratic and Republican politicians. Only in recent years, amid an epidemic of opioid overdoses and a national reconsideration of racial inequities in the criminal-justice system, has the drug-policy status quo begun to break down, as a coalition of health workers, criminal-justice-reform advocates, and drug-user activists have lobbied for a more compassionate and nuanced response. The new approach emphasizes reducing overdoses, stopping the spread of infectious disease, and providing drug users with the resources they need—counseling, housing, transportation—to stabilize their lives and gain control over their drug use.
Oregon’s Measure 110 was viewed as an opportunity to prove that activists’ most groundbreaking idea—sharply reducing the role of law enforcement in the government’s response to drugs—could work. The measure also earmarked hundreds of millions of dollars in cannabis tax revenue for building a statewide treatment network that advocates promised would do what police and prosecutors couldn’t: help drug users stop or reduce their drug use and become healthy, engaged members of their communities. The day after the measure passed, Kassandra Frederique, executive director of the Drug Policy Alliance, one of the nation’s most prominent drug-policy reform organizations, issued a statement calling the vote a “historic, paradigm-shifting win” and predicting that Oregon would become “a model and starting point for states across the country to decriminalize drug use.”
But three years later, with rising overdoses and delays in treatment funding, even some of the measure’s supporters now believe that the policy needs to be changed. In a nonpartisan statewide poll earlier this year, more than 60 percent of respondents blamed Measure 110 for making drug addiction, homelessness, and crime worse. A majority, including a majority of Democrats, said they supported bringing back criminal penalties for drug possession. This year’s legislative session, which ended in late June, saw at least a dozen Measure 110–related proposals from Democrats and Republicans alike, ranging from technical fixes to full restoration of criminal penalties for drug possession. Two significant changes—tighter restrictions on fentanyl and more state oversight of how Measure 110 funding is distributed—passed with bipartisan support.
Few people consider Measure 110 “a success out of the gate,” Tony Morse, the policy and advocacy director for Oregon Recovers, told me. The organization, which promotes policy solutions to the state’s addiction crisis, initially opposed Measure 110; now it supports funding the policy, though it also wants more state money for in-patient treatment and detox services. As Morse put it, “If you take away the criminal-justice system as a pathway that gets people into treatment, you need to think about what is going to replace it.”
Many advocates say the new policy simply needs more time to prove itself, even if they also acknowledge that parts of the ballot measure had flaws; advocates worked closely with lawmakers on the oversight bill that passed last month. “We’re building the plane as we fly it,” Haven Wheelock, a program supervisor at a homeless-services provider in Portland who helped put Measure 110 on the ballot, told me. “We tried the War on Drugs for 50 years, and it didn’t work … It hurts my heart every time someone says we need to repeal this before we even give it a chance.”
Workers from the organization Central City Concern hand out Narcan in Portland, Oregon, on April 5. (Jordan Gale)
Measure 110 went into effect at a time of dramatic change in U.S. drug policy. Departing from precedent, the Biden administration has endorsed and increased federal funding for a public-health strategy called harm reduction; rather than pushing for abstinence, harm reduction emphasizes keeping drug users safe—for instance, through the distribution of clean syringes and overdose-reversal medications. The term harm reduction appeared five times in the ballot text of Measure 110, which forbids funding recipients from “mandating abstinence.”
Matt Sutton, the director of external relations for the Drug Policy Alliance, which helped write Measure 110 and spent more than $5 million to pass it, told me that reform advocates viewed the measure as the start of a nationwide decriminalization push. The effort started in Oregon because the state had been an early adopter of marijuana legalization and is considered a drug-policy-reform leader. Success would mean showing the rest of the country that “people did think we should invest in a public-health approach instead of criminalization,” Sutton said.
To achieve this goal, Measure 110 enacted two major changes to Oregon’s drug laws. First, minor drug possession was downgraded from a misdemeanor to a violation, similar to a traffic ticket. Under the new law, users caught with up to 1 gram of heroin or methamphetamine, or up to 40 oxycodone pills, are charged a $100 fine, which can be waived if they call a treatment-referral hotline. (Selling, trafficking, and possessing large amounts of drugs remain criminal offenses in Oregon.) Second, the law set aside a portion of state cannabis tax revenue every two years to fund a statewide network of harm-reduction and other services. A grant-making panel was created to oversee the funding process. At least six members of the panel were required to be directly involved in providing services to drug users; at least two had to be active or former drug users themselves; and three were to be “members of communities that have been disproportionately impacted” by drug criminalization, according to the ballot measure.
Backers of Measure 110 said the law was modeled on drug policies in Portugal, where personal drug possession was decriminalized two decades ago. But Oregon’s enforcement-and-treatment-referral system differs from Portugal’s. Users caught with drugs in Portugal are referred to a civil commission that evaluates their drug use and recommends treatment if needed, with civil sanctions for noncompliance. Portugal’s state-run health system also funds a nationwide network of treatment services, many of which focus on sobriety. Sutton said drafters of Measure 110 wanted to avoid anything that might resemble a criminal tribunal or coercing drug users into treatment. “People respond best when they’re ready to access those services in a voluntary way,” he said.
Almost immediately after taking effect, Measure 110 encountered problems. A state audit published this year found that the new law was “vague” about how state officials should oversee the awarding of money to new treatment programs, and set “unrealistic timelines” for evaluating and funding treatment proposals. As a result, the funding process was left largely to the grant-making panel, most of whose members “lacked experience in designing, evaluating and administrating a governmental-grant-application process,” according to the audit. Last year, supporters of Measure 110 accused state health officials, preoccupied with the coronavirus pandemic, of giving the panel insufficient direction and resources to handle a flood of grant applications. The state health authority acknowledged missteps in the grant-making process.
The audit described a chaotic process, with more than a dozen canceled meetings, potential conflicts of interest in the selection of funding recipients, and lines of applicant evaluations left blank. Full distribution of the first biennial payout of cannabis tax revenue—$302 million for harm reduction, housing, and other services—did not occur until late 2022, almost two years after Measure 110 passed. Figures released by the state last month show that, in the second half of 2022, recipients of Measure 110 funding provided some form of service to roughly 50,000 “clients,” though the Oregon Health Authority has said that a single individual could be counted multiple times in that total. (A study released last year by public-health researchers in Oregon found that, as of 2020, more than 650,000 Oregonians required, but were not receiving, treatment for a substance-use disorder.)
Meanwhile, the new law’s enforcement provisions have proved ineffectual. Of 5,299 drug-possession cases filed in Oregon circuit courts since Measure 110 went into effect, 3,381 resulted in a recipient failing to pay the fine or appear in court and facing no further penalties, according to the Oregon Judicial Department; about 1,300 tickets were dismissed or are pending. The state audit found that, during its first 15 months in operation, the treatment-referral hotline received just 119 calls, at a cost to the state of $7,000 per call. A survey of law-enforcement officers conducted by researchers at Portland State University found that, as of July 2022, officers were issuing an average of just 300 drug-possession tickets a month statewide, compared with 600 drug-possession arrests a month before Measure 110 took effect and close to 1,200 monthly arrests prior to the outbreak of COVID-19.
“Focusing on these tickets even though they’ll be ineffective—it’s not a great use of your resources,” Sheriff Nate Sickler of Jackson County, in the rural southern part of the state, told me of his department’s approach.
Advocates have celebrated a plunge in arrests. “For reducing arrests of people of color, it’s been an overwhelming success,” says Mike Marshall, the director of Oregon Recovers. But critics say that sidelining law enforcement has made it harder to persuade some drug users to stop using. Sickler cited the example of drug-court programs, which multiple studies have shown to be highly effective, including in Jackson County. Use of such programs in the county has declined in the absence of criminal prosecution, Sickler said: “Without accountability or the ability to drive a better choice, these individuals are left to their own demise.”
The consequences of Measure 110’s shortcomings have fallen most heavily on Oregon’s drug users. In the two years after the law took effect, the number of annual overdoses in the state rose by 61 percent, compared with a 13 percent increase nationwide, according to the Centers for Disease Control and Prevention. In neighboring Idaho and California, where drug possession remains subject to prosecution, the rate of increase was significantly lower than Oregon’s. (The spike in Washington State was similar to Oregon’s, but that comparison is more complicated because Washington’s drug policy has fluctuated since 2021.) Other states once notorious for drug deaths, including West Virginia, Indiana, and Arkansas, are now experiencing declines in overdose rates.
In downtown Portland this spring, police cleared out what The Oregonian called an “open-air drug market” in a former retail center. Prominent businesses in the area, including the outdoor-gear retailer REI, have closed in recent months, in part citing a rise in shoplifting and violence. Earlier this year, Portland business owners appeared before the Multnomah County Commission to ask for help with crime, drug-dealing, and other problems stemming from a behavioral-health resource center operated by a harm-reduction nonprofit that was awarded more than $4 million in Measure 110 funding. In April, the center abruptly closed following employee complaints that clients were covering walls with graffiti and overdosing on-site. A subsequent investigation by the nonprofit found that a security contractor had been using cocaine on the job. The center reopened two weeks later with beefed-up security measures.
Portland’s Democratic mayor, Ted Wheeler, went so far as to attempt an end run around Measure 110 in his city. Last month, Wheeler unveiled a proposal to criminalize public drug consumption in Portland, similar to existing bans on open-air drinking, saying in a statement that Measure 110 “is not working as it was intended to.” He added, “Portland’s substance-abuse problems have exploded to deadly and disastrous proportions.” Wheeler withdrew the proposal days later after learning that an older state law prohibits local jurisdictions from banning public drug use.
Despite shifting public opinion on Measure 110, many Oregon leaders are not ready to give up on the policy. Earlier this month, Oregon Governor Tina Kotek signed legislation that strengthens state oversight of Measure 110 and requires an audit, due no later than December 2025, of about two dozen aspects of the measure’s performance, including whether it is reducing overdoses. Other bills passed by the legislature’s Democratic majority strengthened criminal penalties for possession of large quantities of fentanyl and mandated that school drug-prevention programs instruct students about the risks of synthetic opioids. Republican proposals to repeal Measure 110 outright or claw back tens of millions of dollars in harm-reduction funding were not enacted.
The fallout from Measure 110 has received some critical coverage from media outlets on the right. “It is predictable,” a scholar from the Hudson Institute told Fox News. “It is a tragedy and a self-inflicted wound.” (Meanwhile, in Portugal, the model for Oregon, some residents are raising questions about their own nation’s decriminalization policy.) But so far Oregon’s experience doesn’t appear to have stopped efforts to bring decriminalization to other parts of the United States. “We’ll see more ballot initiatives,” Sutton, of the Drug Policy Alliance, said, adding that advocates are currently working with city leaders to decriminalize drugs in Washington, D.C.
Supporters of Measure 110 are now seeking to draw attention to what they say are the policy’s overlooked positive effects. This summer, the Health Justice Recovery Alliance, a Measure 110 advocacy organization, is leading an effort to spotlight expanded treatment services and boost community awareness of the treatment-referral hotline. Advocates are also coordinating with law-enforcement agencies to ensure that officers know about local resources for drug users. “People are hiring for their programs; outreach programs are expanding, offering more services,” Devon Downeysmith, the communications director for the group, told me.
An array of services around the state have been expanded through the policy: housing for pregnant women awaiting drug treatment; culturally specific programs for Black, Latino, and Indigenous drug users; and even distribution of bicycle helmets to people unable to drive to treatment meetings. “People often forget how much time it takes to spend a bunch of money and build services,” said Wheelock, the homeless-services worker, whose organization received more than $2 million in funding from Measure 110.
Still, even some recipients of Measure 110 funding wonder whether one of the law’s pillars—the citation system that was supposed to help route drug users into treatment—needs to be rethought. “Perhaps some consequences might be a helpful thing,” says Julia Pinsky, a co-founder of Max’s Mission, a harm-reduction nonprofit in southern Oregon. Max’s Mission has received $1.5 million from Measure 110, enabling the organization to hire new staff, open new offices, and serve more people. Pinsky told me she is proud of her organization’s work and remains committed to the idea that “you shouldn’t have to go to prison to be treated for substance use.” She said that she doesn’t want drug use to “become a felony,” but that some people aren’t capable of stopping drug use on their own. “They need additional help.”
Brandi Fogle, a regional manager for Max’s Mission, says her own story illustrates the complex trade-offs involved in reforming drug policy. Three and a half years ago, she was a homeless drug user, addicted to heroin and drifting around Jackson and Josephine Counties. Although she tried to stop numerous times, including one six-month period during which she was prescribed the drug-replacement medication methadone, she told me that a 2020 arrest for drug possession was what finally turned her life around. She asked to be enrolled in a 19-month drug-court program that included residential treatment, mandatory 12-step meetings, and a community-service project, and ultimately was hired by Pinsky.
Since Measure 110 went into effect, Fogle said, she has gotten pushback from members of the community for the work Max’s Mission does. She said that both the old system of criminal justice and the new system of harm reduction can benefit drug users, but that her hope now is to make the latter approach more successful. “Everyone is different,” Fogle said. “Drug court worked for me because I chose it, and I wouldn’t have needed drug court in the first place if I had received the kind of services Max’s Mission provides. I want to offer people that chance.”
In the dark, early days of the coronavirus pandemic, Michael Toce noticed a surprising trend. As a pediatric-emergency-medicine doctor at Boston Children’s Hospital, he was seeing lots of kids who had taken too much medication. The problem wasn’t that they’d overdosed on opioids or painkillers or marijuana. Instead, they’d swallowed too much melatonin, an over-the-counter supplement used as a sleep aid. The ill effects of this mistake seemed mild at the worst—drowsiness, nausea, vomiting—but the number of kids who were affected was going up, up, up.
Other doctors around the country were observing something similar. In 2022, a group in Michigan invited Toce to collaborate on a study of the phenomenon. Their findings, published last June, were striking. Over the prior 10 years, the number of annual calls to poison control for pediatric melatonin overdoses had risen by 530 percent. By 2020, poison control was receiving more calls about pediatric overdoses on melatonin than on any other substance. Just last month, in a broader study based on emergency-room data over a similar period, researchers at the CDC reported a 420 percent increase in visits for pediatric melatonin ingestions. Meanwhile, the overdose numbers for other substances plummeted during the 2010s: Tylenol, down 53 percent; opioids, down 54 percent; many cough and cold medications, down 72 percent. The question is: What sets melatonin apart?
The most obvious answer is its recent surge in popularity. From 2009 to 2018, American melatonin use increased fivefold, and from 2016 to 2020, U.S. sales of the supplement rose from $285 million to $821 million. A pandemic-era surge in diagnosed sleep disorders may have only accelerated this growing popularity. The year before melatonin usage began to rise, the CDC launched an initiative to reduce pediatric overdoses as a whole. It promoted the widespread adoption of flow restrictors and child-resistant packaging, and ran campaigns to educate parents about medication safety and storage. It’s possible that melatonin overdoses are rarer now than they would have been without the CDC’s safety initiative, but are still increasing on account of the supplement’s overall success in the marketplace.
Those changes in demand are “definitely a factor” in the associated surge in overdoses, says Pieter Cohen, a doctor and supplements expert at Cambridge Health Alliance, in Somerville, Massachusetts. Whether they account for all of the surge or most of it or merely some of it remains a mystery. Several other factors would also seem to be involved, Cohen told me. For starters, many melatonin supplements come in an appetizing gummy form. So do all sorts of vitamins and minerals for kids—vitamin A, vitamin C, calcium, zinc—but melatonin is not a vitamin or a mineral. It’s an active hormone, and the body has not developed great mechanisms for coping with its intake in excess, Cohen said.
Nearly all of the patients Toce saw had eaten gummies, and most of those identified in the CDC’s emergency-room study were 3 to 5 years old. Maribeth Lovegrove, the researcher who led the CDC research, told me that for most medications, pediatric overdoses are concentrated among children under 2 years old. This discrepancy is telling, she said. Babies don’t know what they’re eating and often put random stuff in their mouth; slightly older kids, such as the ones who have been taking too much melatonin, may be more likely to mistake gummies for candy.
Supplements are regulated by the FDA more as foods than as medications. That means that, the CDC’s safety initiative notwithstanding, melatonin’s packaging doesn’t have to be child resistant. The fact that it is marketed as a “natural” supplement may also lead parents to assume that it’s safe, Lovegrove said. And the actual quantity of melatonin contained in each gummy—as well as how that relates to the dosage advertised on the packaging—isn’t strictly regulated either, Cohen told me. Last month, he published a study with researchers from the University of Mississippi showing that many melatonin-gummy brands contain wildly different amounts of the hormone than they claim to. One contained three and a half times more than advertised; another contained no melatonin at all. A Canadian study from 2017 that looked at melatonin supplements more generally, not just at gummies, reached a similar conclusion. In at least one case, these discrepancies have led to a lawsuit.
Although the overwhelming majority of overdoses that the Michigan group identified were as mild as the ones Toce had seen, a small percentage were not. Nearly 300 children required intensive care, five had to be put on ventilators, and two died. Toce found this, too, to be surprising. “When you take too much of anything, you’re always going to have some degree of an upset stomach, some nausea, vomiting,” he told me. But there is no known mechanism by which melatonin could cause more severe complications, and Toce said it’s hard to know whether the supplement really played a role at all. Perhaps some other ingredient in the gummies caused the bad reactions, or maybe it was something else entirely—an unfortunate coincidence of timing.
Michael Beuhler, a doctor who co-authored a paper investigating seven children’s deaths in North Carolina potentially related to melatonin, thinks they were most likely caused by melatonin overdoses, paired perhaps with some unusual susceptibility among the victims. “You don’t want to say melatonin definitely, 100 percent caused these deaths,” Beuhler told me, but “this is the type of thing that should be making people hit the pause button, especially when using it in small children.” For the moment, Cohen said, the exact source of deadly outcomes remains “a big mystery.”
A mystery made even harder to solve by the murkiness of the supplement industry. The industry has many well-known problems: a lack of scientific evidence for the benefits of certain products, a habit of misleading marketing, a deep reliance on magical thinking. But the recent spate of pediatric melatonin overdoses represents another big one: the products’ maddening irregularity. If no one knows what’s in the supplements, doctors may never understand whether or how they cause serious harm.
No country has a perfect COVID vaccination rate, even this far into the pandemic, but America’s record is particularly dismal. About a third of Americans—more than a hundred million people—have yet to get their initial shots. You can find anti-vaxxers in every corner of the country. But by far the single group of adults most likely to be unvaccinated is Republicans: 37 percent of Republicans are still unvaccinated or only partially vaccinated, compared with 9 percent of Democrats. Fourteen of the 15 states with the lowest vaccination rates voted for Donald Trump in 2020. (The other is Georgia.)
We know that unvaccinated Americans are more likely to be Republican, that Republicans in positions of power led the movement against COVID vaccination, and that hundreds of thousands of unvaccinated Americans have died preventable deaths from the disease. The Republican Party is unquestionably complicit in the premature deaths of many of its own supporters, a phenomenon that may be without precedent in the history of both American democracy and virology.
Obviously, nothing about being a Republican makes someone inherently anti-vaccine. Many Republicans—in fact, most of them—have gotten their first two shots. But the wildly disproportionate presence of Republicans among the unvaccinated reveals an ugly and counterintuitive aspect of the GOP campaign against vaccination: At every turn, top figures in the party have directly endangered their own constituents. Trump disparaged vaccines while president, even after orchestrating Operation Warp Speed. Other politicians, such as Texas Governor Greg Abbott, made all COVID-vaccine mandates illegal in their state. More recently, Florida Governor Ron DeSantis called for a grand jury to investigate the safety of COVID vaccines. The right-wing media have leaned even harder into vaccine skepticism. On his prime-time Fox News show, Tucker Carlson has regularly questioned the safety of vaccines, inviting guests who have called for the shots to be “withdrawn from the market.”
Breaking down the cost of vaccine hesitancy would be simple if we could draw a causal relationship between Republican leaders’ anti-vaccine messaging and the adoption of those ideas by Americans, and then from those ideas to deaths due to non-vaccination. Unfortunately, we don’t have the data to do so. Individual vaccine skepticism cannot be traced back to a single source, and even if it could, we don’t know exactly who is unvaccinated and what their political affiliations are.
What we do have is a patchwork of estimations and correlations that, taken together, paint a blurry but nevertheless grim picture of how Republican leaders spread the vaccine hesitancy that has killed so many people. We know that as of April 2022, about 318,000 people had died from COVID because they were unvaccinated, according to research from Brown University. And the close association between Republican vaccine hesitancy and higher death rates has beendocumented. One study estimated that by the fall of 2021, vaccine uptake accounted for 10 percent of the totaldifference between Republican and Democratic deaths. But that estimate has changed—and even likely grown—over time.
Partisanship affected outcomes in the pandemic even before we had vaccines. A recent study found that from October 2020 to February 2021, the death rate in Republican-leaning counties was up to three times higher than that of Democratic-leaning counties, likely because of differences in masking and social distancing. Even when vaccines came around, these differences continued, Mauricio Santillana, an epidemiology expert at Northeastern University and a co-author of the study, told me. Follow-up research published in Lancet Regional Health Americas in October looked at deaths from April 2021 to March 2022 and found a 26 percent higher death rate in areas where voters leaned Republican. “There are subsequent and very serious [partisan] patterns with the Delta and Omicron waves, some of which can be explained by vaccination,” Bill Hanage, a co-author of the paper and an epidemiologist at Harvard, told me in an email.
But to understand why Republicans have died at higher rates, you can’t look at vaccine status alone. Congressional districts controlled by a trifecta of Republican leaders—state governor, Senate, and House—had an 11 percent higher death rate, according to the Lancet study. A likely explanation, the authors write, could be that in the post-vaccine era, those leaders chose policies and conveyed public-health messages that made their constituents more likely to die. Although we still can’t say these decisions led to higher death rates, the association alone is jarring.
One of the most compelling studies comes from researchers at Yale, who published their findings as a working paper in November. They link political party and excess-death rate—the percent increase in deaths above pre-COVID levels—among those registered as either Democrats or Republicans, providing a more granular view. They chose to analyze data from Florida and Ohio from before and after vaccines were available. Looking at the period before the vaccine, researchers found a 1.6 percentage-point difference in excess death rate among Republicans and Democrats, with a higher rate among Republicans. But after vaccines became available, that gap widened dramatically to 10.4 percentage points, again with a higher Republican excess death rate. “When we compare individuals who are of the same age, who live in the same county in the same month of the pandemic, there are differences correlated with your political-party affiliation that emerge after vaccines are available,” Jacob Wallace, an assistant professor of public health at Yale who co-authored the paper, told me. “That’s a statement we can confidently make based on the study and we couldn’t before.”
Even with this new research, it is difficult to determine just how many people died as a result of their political views. In the “excess death” study, researchers dealt only with rates of excess death, not actual death-toll numbers. Overall, excess deaths represent a small share of deaths. “On the scale of national registration for both parties,” Wallace said, “we’re talking about relatively small numbers and differences in deaths” when you look at excess death rates alone.
The absolute number of Republican deaths is less important than the fact that they happened needlessly. Vaccines could have saved lives. And yet, the party that describes itself as pro-life campaigned against them. Democrats are not without fault, though. The Biden administration’s COVID blunders are no doubt to blame for some of the nation’s deaths. But on the whole, Democratic leaders have mostly not promoted ideas or enforced policies around COVID that actively chip away at life expectancy. It is a tragedy that the Republican push against basic lifesaving science has cut lives short and continues to do so. The partisan divide in COVID deaths, Hanage said, is just “another example of how the partisan politics of the U.S. has poisoned the well of public health.”
What’s most concerning about all of this is that partisan disparities in death rates were also apparent before COVID. People living in Republican jurisdictions have been at a health disadvantage for more than 20 years. From 2001 to 2019, the death rate in Democratic counties decreased by 22 percent, according to a recent study; in Republican counties, it declined by only 11 percent. In the same time period, the political gap in death rates increased sixfold.
Health outcomes have been diverging at the state level since the ’90s, Steven Woolf, an epidemiologist at Virginia Commonwealth University, told me. Woolf’s worksuggests that over the decades, state policy decisions on health issues such as Medicaid, gun legislation, tobacco taxes, and, indeed, vaccines have likely had a stronger impact on state health trajectories than other factors. COVID’s high Republican death rates are not an isolated phenomenon but a continuation of this trend. As Republican-led states pushed back on lockdowns, the impact on population death rates was observed within weeks, Woolf said.
If the issue is indeed systemic, that doesn’t bode well for the future. Other factors could explain the higher death rate in Republican-leaning places—more poverty, less education, worse socioeconomic conditions—, though Woolf said isn’t convinced that those factors aren’t related to bad state health policy too. In any case, the long-term decline of health in red states indicates that there is an ongoing problem at a high level in Republican-led places, and that something has gone awry. “If you happen to live in certain states, your chances for living a long life are going to be much higher than if you’re an American living in a different state,” Woolf said.
Unfortunately, this trend shows no signs of breaking. The anti-science messaging that fuels such a divide is popular with Republican leaders because it plays so well with their constituents. Far-right crowds cheer for missed vaccine targets and jokes about executing scientific leaders. In an environment where partisanship trumps all—including trying to save people’s lives—such messaging is both politically effective and morally abhorrent. The data, however imperfect, demand a reckoning with the consequences of such a strategy not only during the pandemic but over the past few decades, and in the years to come. But to acknowledge how many Republicans didn’t have to die would mean giving credence to scientific and medical expertise. So long as America remains locked in a poisonous partisan battle in which science is wrongly dismissed as being associated with the left, the death toll will only rise.
As a pulmonary specialist, I spend most of my clinical time in the hospital—which, during pandemic surges, has meant many long days treating critically ill COVID-19 patients in the ICU. But I also work in an outpatient clinic, where I also treat those same sorts of patients after they’re discharged: people who survived weeks-long hospitalizations but have been dealing ever since with lung damage. Such patients often face the same social and economic factors that made them vulnerable to COVID-19 to begin with, and they require attentive care.
Patients like these undoubtedly suffer what researchers have been calling post-acute sequelae of SARS-CoV-2, or PASC—which, according to one highly publicized recent CDC study, afflicts some 20 percent of COVID-19 survivors ages 18 to 64. Other studies have yielded lower estimates of the condition also called long COVID, and while differences in study methodology account for some of this variability, there’s a more fundamental issue eluding efforts to uncover the one “true” estimate of the likelihood of this condition. Quite simply, long COVID isn’t any one thing.
The wide spectrum of conditions that fall under the umbrella of long COVID impedes researchers’ ability to interpret estimates of national prevalence based on surveys of symptoms, which conflate different problems with different causes. More importantly, however, an incomplete and constrained perspective on what long COVID is or isn’t limits Americans’ understanding of who is suffering and why, and of what we can do to improve patients’ lives today.
The cases of long COVID that turn up in news reports, the medical literature, and in the offices of doctors like me fall into a few rough (and sometimes overlapping) categories. The first seems most readily explainable: the combination of organ damage, often profound physical debilitation, and poor mental health inflicted by severe pneumonia and resultant critical illness. This serious long-term COVID-19 complication gets relatively little media attention despite its severity. The coronavirus can cause acute respiratory distress syndrome, the gravest form of pneumonia, which can in turn provoke a spiral of inflammation and injury that can end up taking down virtually every organ. I have seen many such complications in the ICU: failing hearts, collapsed lungs, failed kidneys, brain hemorrhages, limbs cut off from blood flow, and more. More than 7 million COVID-19 hospitalizations occurred in the United States before the Omicron wave, suggesting that millions could be left with damaged lungs or complications of critical illness. Whether these patients’ needs for care and rehabilitation are being adequately (and equitably) met is unclear: Ensuring that they are is an urgent priority.
Recently, a second category of long COVID has made headlines. It includes the new onset of recognized medical conditions—like heart disease, a stroke, or a blood clot—after a mild COVID-19 infection. It might seem odd that an upper respiratory tract infection could trigger a heart attack. Yet this pattern has been well described after other common respiratory-virus infections, particularly influenza. Similarly, various types of infections can lead to blood clots in the legs, which can travel (dangerously) to the lungs. Respiratory infections are not hermetically sealed from the rest of the body; acute inflammation arising in one location can sometimes have consequences elsewhere.
But mild COVID-19 is so common that measuring the prevalence of such complications—which also regularly occur in people without COVID-19—can be tricky. Well-controlled investigations are needed to disentangle causation and correlation, particularly because social disadvantage is associated both with COVID exposure and illnesses of basically every organ system. Some such studies, which analyzed giant electronic-health-record databases, have suggested that even mild COVID-19 is at least correlated with a startlingly wide spectrum of seemingly every illness, including diabetes, asthma, and kidney failure; basically every type of heart disease; alcohol-, benzodiazepine-, and opioid-use disorders; and much more.
To be clear, this research generally suggests that such complications occur far less often after mild COVID-19 cases than severe ones, and the extent to which the coronavirus causes each such complication remains unclear. In other words, we can surmise that at least some of these complications (particularly vascular complications, which have been well-described in many studies) are likely a consequence of COVID-19, but we can’t say with certainty how many. And more importantly, we don’t yet understand why some people with mild COVID recover easily while others go on to experience such complications. However, an estimated 81 percent of Americans have now been infected at least once, so the public-health ramifications are large even if COVID causes only some of the aforementioned recognized diseases, and even if our individual risk of complications after a mild infection is modest. Regardless of cause, patients who do develop any such chronic diseases require attentive, ongoing medical care—a challenge in a nation where 30 million are uninsured and even more underinsured.
Another category of long COVID is something rather more quotidian, if still very distressing for those experiencing it: respiratory symptoms that last longer than expected after an acute upper-respiratory infection caused by the coronavirus, but that are not associated with lung damage, critical illness, or a new diagnosis like a heart attack or diabetes. Symptoms such as shortness of breath and chest pain are common months after run-of-the-mill pneumonia unconnected to the coronavirus, for instance, while many patients who contract non-COVID-related upper respiratory infections subsequently report a protracted cough or a lingering loss of their sense of smell. That a COVID-related airway infection sometimes has similar consequences only stands to reason.
However, none of these may be what most people think of when long COVID is invoked. Some may even argue that such syndromes are not, in fact, long COVID at all, even if they cause long-term suffering. “Long Covid is not a condition for which there are currently accepted objective diagnostic tests or biomarkers,” wrote Steven Phillips and Michelle Williams in the New England Journal of Medicine. “It is not blood clots, myocarditis, multisystem inflammatory disease, pneumonia, or any number of well-characterized conditions caused by Covid-19.” Instead, for some the term may invoke a chronic illness—a complex of numerous unexplained, potentially debilitating symptoms—even among those who may barely have felt sick with COVID in the acute phase. Symptoms may vary widely, and include severe fatigue, cognitive issues often described as brain fog, shortness of breath, “internal tremors,” gastrointestinal problems, palpitations, dizziness, and many other issues around the body—all typically following a mild acute respiratory infection. If the other forms of long COVID seem more easily explainable, this type is often characterized as a medical mystery.
Teasing apart which kind of long COVID a person has is important, both to advance our understanding of the illness and to best care for people. Yet lumping and splitting varieties of long COVID into categories is not easy. A given patient’s case might have features of more than one of the types that I’ve described here. Some patient advocates and researchers have tended to exclude patients in the first category—that is, survivors of protracted critical illness—from their conception of COVID long-haulers. I would argue that, insofar as we define long COVID as lasting damage and symptoms imposed by SARS-CoV-2, the full variety of severe long-term manifestations should be included in its scope. “Clinical phenotyping” studies now under way may eventually help scientists and doctors better understand the needs of different types of patients, but patients in all categories deserve better care today.
The biological mechanisms by which an acute coronavirus upper respiratory infection might lead to a bewildering range of chronic, burdensome symptoms even in the aftermath of mild infections are debated. Some scientists, for instance, believe that the virus causes an autoimmune disease akin to lupus. Meanwhile, one group of researchers has argued that even a mild respiratory infection from SARS-CoV-2 causes tiny clots to block tiny blood vessels all over the body, depriving tissues of oxygen throughout the body. Still others believe that the coronavirus causes a chronic infection, as such viruses as HIV or hepatitis C do. Meanwhile, some have emphasized the possibility of structural brain damage. While some published studies have provided support for each theory, none has been adequately validated as a central unifying thesis. Each is, however, worth continuing to explore.
A recently published investigation, conducted at the National Institutes of Health, suggests that clinicians and scientists should consider additional possibilities as potential drivers of symptoms for at least some patients. The researchers found far higher levels of physical symptoms and mental distress among subjects who had had COVID (many with long COVID) than among those who had not. Yet symptoms could not be explained by basically any test results: Researchers found effectively no substantive differences in markers of inflammation or immune activation, in objective neurocognitive testing, or in heart, lung, liver, or kidney function. And yet these patients were suffering from such symptoms as fatigue, shortness of breath, concentration and memory problems, chest pain, and more. Notably, researchers did not identify viral persistence in the bodies of patients reporting troublesome symptoms.
What this means in practice is that there are some people suffering from long COVID symptoms without evidence of structural damage to the body, autoimmunity, or chronic infection. Psychosocial strain and suffering, moreover, appears common in this population. Even pointing this out is sensitive territory—it leads some people to wrongly suggest that long COVID is less severe or concerning than those suffering from it describe, or even to question the reality of the illness. And, understandably, the invocation of psychosocial factors as potential contributing factors to suffering for some individuals may make patients feel as though they are being second-guessed. The reality, though, is that psychosocial strain is an important driver of physical symptoms and suffering—one that clinicians should treat with empathy. All suffering, after all, is ultimately produced and perceived in one place: our brain.
Severe depression, for instance, can inflict debilitating and severe physical symptoms of every sort, including crushing fatigue and withering brain fog, and is itselflinked to having had COVID-19. And notably, a recent study in JAMA Psychiatry found that pre-infection psychosocial distress—e.g. depression, anxiety, or loneliness—was associated with a 30–50 percent increase in the risk of long COVID among those infected, even after adjustment for various factors. A false separation of brain and body has long plagued medicine, but it does not reflect biological reality: After all, diverse neuropsychiatric processes are associated with numerous “physical” changes, ranging from reduced blood flow to the brain to high (or low) levels of the stress hormone cortisol.
Illnesses of any cause that result in protracted time off one’s feet can also instigate (likely in conjunction with other factors) reversible cardiovascular deconditioning, wherein the blood volume contracts and the amount of blood ejected by the heart with each squeeze falls—changes that can lead to a racing heart rate or faintness when standing, as decadesofstudieshaveshown. Diverse neurological symptoms can also be produced by a glitch in the function rather than the structure of the brain—or what has been described as problems of brain “software” rather than “hardware”—resulting in conditions known as functional neurological disorders. Similar glitches, known as functional respiratory disorders, can disturb our breathing patterns or cause shortness of breath, even when our lungs are structurally normal. My point is not to speculate on some overarching hypothesis to explain all symptoms among all patients with long COVID. The whole point is that there’s unlikely to be just one. And there is still much to learn.
Research is underway to better understand this spectrum of illnesses, and their causes. But whichever diverse factors might be contributing to patients’ symptoms, we can take steps—both among clinicians and as a society—to improve lives now. Social supports can be as important as medical interventions: For those unable to work, qualification for disability assistance should not depend on a particular lab or lung-function test result. All patients with long-COVID symptoms deserve and require high-quality medical care without onerous cost barriers that may bankrupt them, which further compounds suffering. Universal healthcare is, that is to say, desperately needed to respond to this pandemic and its aftermath.
Additionally, while no specific long-COVID medications have emerged, some treatments may be helpful for improving certain symptoms regardless of the specific type of illness, such as physical rehabilitative treatments for those with shortness of breath or reduced exercise tolerance. Ensuring universal access to such specialized rehabilitative care is essential as we enter the next stage of this pandemic. So is helping patients avoid the emerging cottage industry of dodgy providers hawking unproven long-COVID therapies. Health-care professionals also need more education about the broad spectrum of COVID-19-related issues, both to improve care and reduce stigmatization of patients with all types of this illness.
Doctors and scientists still have much to learn about symptoms that continue—or first turn up—months or weeks after an initial COVID infection. What’s clear today is that long COVID can be many different things. That may confound our efforts to categorize it and discuss its implications, but the sheer variety should not get in the way of carefor all who are suffering.
