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He also disagreed with Friedman’s nemeses, the Keynesians, who worried that nations wouldn’t be able to fine-tune spending and taxing policy for domestic conditions if they had to keep their currencies in sync with the dollar.

Although the United States’ share of global domestic product has shrunk since the aftermath of World War II, the dollar continues to play a dominant role in financial flows. “Around half of all cross-border bank loans and international debt securities are denominated in U.S. dollars,”

the world today is closer to Kindleberger’s vision than he or his intellectual opponents could have imagined

What’s more, the Federal Reserve has become in effect the world’s central bank: When the Fed raises rates aggressively, as it’s doing now, other central banks tend to follow sui

t the British Empire really was an empire; London bankers were happy to extend loans to British companies operating in the colonies because they were subject to British law. That enabled the colonies to develop somewhat, albeit under Britain’s thumb. The United States has less control over borrowers in emerging markets. Kindleberger’s goal was “to get the economic boost of imperialism, but without the political and social downside of actual imperialism,” Mehrling wrote.

Roosevelt worsened and extended the Depression in 1933 by torpedoing central bankers’ efforts to stabilize exchange rates between currencies.

In contrast, Paul Volcker, who chaired the Fed from 1979 to 1987, comes across as a hero in the book for working with other central bankers and finance officials to resume international cooperation after the Nixon shock of 1971.

There’s a concept in economics of the optimal currency area. In theory, the area of a shared currency, such as the euro, should be big enough to encompass a lot of economic activity but not so big that it includes nations that are disparate and require different economic policies. To Kindleberger, no area could be too big. He thought the whole world was an optimal currency area.

In essence, his goal was to duplicate on the world stage what was achieved in the United States by a mentor of his, Henry Parker Willis, who was a designer of the Federal Reserve System that knitted the nation together financially.

Kindleberger was realistic enough to observe that nationalist politics was an obstacle. “While the optimum scale of economic activity is getting larger and larger, the optimum social scale appears to be shrinking,” he once wrote. Elsewhere, he wrote: “Whereas the economic logic of the payment system pushes toward hierarchy and centralization, the political logic of subglobal and subnational groupings pushes toward autarky and pluralism.”

it’s hard to miss the strong smell here of a thorough repudiation, up and down the ballot, of the post-Trump Republican Party, of the January 6 insurrectionists, and of a cultural agenda that seems to many Americans regressive and repressive.

But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.

Medicare Advantage, a private-sector alternative to traditional Medicare, was designed by Congress two decades ago to encourage health insurers to find innovative ways to provide better care at lower cost.

by next year, more than half of Medicare recipients will be in a private plan.

a New York Times review of dozens of fraud lawsuits, inspector general audits and investigations by watchdogs shows how major health insurers exploited the program to inflate their profits by billions of dollars.

The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.

As a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve.

Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.

The government now spends nearly as much on Medicare Advantage’s 29 million beneficiaries as on the Army and Navy combined. It’s enough money that even a small increase in the average patient’s bill adds up: The additional diagnoses led to $12 billion in overpayments in 2020, according to an estimate from the group that advises Medicare on payment policies — enough to cover hearing and vision care for every American over 65.

Another estimate, from a former top government health official, suggested the overpayments in 2020 were double that, more than $25 billion.

The increased privatization has come as Medicare’s finances have been strained by the aging of baby boomers

Medicare Advantage plans can limit patients’ choice of doctors, and sometimes require jumping through more hoops before getting certain types of expensive care.

At conferences, companies pitched digital services to analyze insurers’ medical records and suggest additional codes. Such consultants were often paid on commission; the more money the analysis turned up, the more the companies kept.

they often have lower premiums or perks like dental benefits — extras that draw beneficiaries to the programs. The more the plans are overpaid by Medicare, the more generous to customers they can afford to be.

Many of the fraud lawsuits were initially brought by former employees under a federal whistle-blower law that allows them to get a percentage of any money repaid to the government if their suits prevail. But most have been joined by the Justice Department, a step the government takes only if it believes the fraud allegations have merit. Last year, the department’s civil division listed Medicare Advantage as one of its top areas of fraud recovery.

In contrast, regulators overseeing the plans at the Centers for Medicare and Medicaid Services, or C.M.S., have been less aggressive, even as the overpayments have been described in inspector general investigations, academic research, Government Accountability Office studies, MedPAC reports and numerous news articles,

Congress gave the agency the power to reduce the insurers’ rates in response to evidence of systematic overbilling, but C.M.S. has never chosen to do so. A regulation proposed in the Trump administration to force the plans to refund the government for more of the incorrect payments has not been finalized four years later. Several top officials have swapped jobs between the industry and the agency.

The popularity of Medicare Advantage plans has helped them avoid legislative reforms. The plans have become popular in urban areas, and have been increasingly embraced by Democrats as well as Republicans.

“You have a powerful insurance lobby, and their lobbyists have built strong support for this in Congress,”

Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care.

“Even when they’re playing the game legally, we are lining the pockets of very wealthy corporations that are not improving patient care,”

In theory, if the insurers could do better than traditional Medicare — by better managing patients’ care, or otherwise improving their health — their patients would cost less and the insurers would make more money.

But some insurers engaged in strategies — like locating their enrollment offices upstairs, or offering gym memberships — to entice only the healthiest seniors, who would require less care, to join. To deter such tactics, Congress decided to pay more for sicker patients.

Almost immediately, companies saw ways to exploit that system. The traditional Medicare program provided no financial incentive to doctors to document every diagnosis, so many records were incomplete

Under the new program, insurers began rigorously documenting all of a patient’s health conditions — say depression, or a long-ago stroke — even when they had nothing to do with the patient’s current medical care.

But for insurers that already dominate health care for workers, the program is strikingly lucrative: A study from the Kaiser Family Foundation, a research group unaffiliated with the insurer Kaiser, found the companies typically earn twice as much gross profit from their Medicare Advantage plans as from other types of insurance.

The insurers also began hiring agencies that sent doctors or nurses to patients’ homes, where they could diagnose them with more diseases.

Cigna hired firms to perform similar at-home assessments that generated billions in extra payments, according to a 2017 whistle-blower lawsuit, which was recently joined by the Justice Department. The firms told nurses to document new diagnoses without adjusting medications, treating patients or sending them to a specialist

Nurses were told to especially look for patients with a history of diabetes because it was not “curable,” even if the patient now had normal lab findings or had undergone surgery to treat the condition.

Adding the code for a single diagnosis could yield a substantial payoff. In a 2020 lawsuit, the government said Anthem instructed programmers to scour patient charts for “revenue-generating” codes. One patient was diagnosed with bipolar disorder, although no other doctor reported the condition, and Anthem received an additional $2,693.27, the lawsuit said. Another patient was said to have been coded for “active lung cancer,” despite no evidence of the disease in other records; Anthem was paid an additional $7,080.74. The case is continuing.

The most common allegation against the companies was that they did not correct potentially invalid diagnoses after becoming aware of them. At Anthem, for example, the Justice Department said “thousands” of inaccurate diagnoses were not deleted. According to the lawsuit, a finance executive calculated that eliminating the inaccurate diagnoses would reduce the company’s 2017 earnings from reviewing medical charts by $86 million, or 72 percent.

Some of the companies took steps to ensure the extra diagnoses didn’t lead to expensive care. In an October 2021 lawsuit, the Justice Department estimated that Kaiser earned $1 billion between 2009 and 2018 from additional diagnoses, including roughly 100,000 findings of aortic atherosclerosis, or hardening of the arteries. But the plan stopped automatically enrolling those patients in a heart attack prevention program because doctors would be forced to follow up on too many people, the lawsuit said.

Kaiser, which both runs a health plan and provides medical care, is often seen as a model system. But its control over providers gave it additional leverage to demand additional diagnoses from the doctors themselves, according to the lawsuit.

At meetings with supervisors, he was instructed to find additional conditions worth tens of millions of dollars. “It was an actual agenda item and how could we get this,” Dr. Taylor said.

Last year, the inspector general’s office noted that one company “stood out” for collecting 40 percent of all Medicare Advantage’s payments from chart reviews and home assessments despite serving only 22 percent of the program’s beneficiaries. It recommended Medicare pay extra attention to the company, which it did not name, but the enrollment figure matched UnitedHealth’s.

Even before the first lawsuits were filed, regulators and government watchdogs could see the number of profitable diagnoses escalating. But Medicare has done little to tamp down overcharging.

Several experts, including Medicare’s advisory commission, have recommended reducing all the plans’ payments.

Congress has ordered several rounds of cuts and gave C.M.S. the power to make additional reductions if the plans continued to overbill. The agency has not exercised that power.

The agency does periodically audit insurers by looking at a few hundred of their customers’ cases. But insurers are fined for billing mistakes found only in those specific patients. A rule proposed during the Trump administration to extrapolate the fines to the rest of the plan’s customers has not been finalized.

Ted Doolittle, who served as a senior official for the agency’s Center for Program Integrity from 2011 to 2014, said officials at Medicare seemed uninterested in confronting the industry over these practices. “It was clear that there was some resistance coming from inside” the agency, he said. “There was foot dragging.”

few analysts expect major legislative or regulatory changes to the program.

“Medicare Advantage overpayments are a political third rail,” said Dr. Richard Gilfillan, a former hospital and insurance executive and a former top regulator at Medicare, in an email. “The big health care plans know it’s wrong, and they know how to fix it, but they’re making too much money to stop. Their C.E.O.s should come to the table with Medicare as they did for the Affordable Care Act, end the coding frenzy, and let providers focus on better care, not more dollars for plans.”

economist J. Bradford DeLong ’82, Ph.D. ’87, looking back on the twentieth century two decades after its end, comes to a similar conclusion but on different grounds.

DeLong, professor of economics at Berkeley, looks to matters of “contingency” and “choice”: at key junctures the economy suffered “bad luck,” and the actions taken by the responsible policymakers were “incompetent.”

these were “the most consequential years of all humanity’s centuries.” The changes they saw, while in the first instance economic, also “shaped and transformed nearly everything sociological, political, and cultural.”

DeLong’s look back over the twentieth century energetically encompasses political and social trends as well; nor is his scope limited to the United States. The result is a work of strikingly expansive breadth and scope

labeling the book an economic history fails to convey its sweeping frame.

The century that is DeLong’s focus is what he calls the “long twentieth century,” running from just after the Civil War to the end of the 2000s when a series of events, including the biggest financial crisis since the 1930s followed by likewise the most severe business downturn, finally rendered the advanced Western economies “unable to resume economic growth at anything near the average pace that had been the rule since 1870.

d behind those missteps in policy stood not just failures of economic thinking but a voting public that reacted perversely, even if understandably, to the frustrations poor economic outcomes had brought them.

Within this 140-year span, DeLong identifies two eras of “El Dorado” economic growth, each facilitated by expanding globalization, and each driven by rapid advances in technology and changes in business organization for applying technology to economic ends

from 1870 to World War I, and again from World War II to 197

fellow economist Robert J. Gordon ’62, who in his monumental treatise on The Rise and Fall of American Economic Growth (reviewed in “How America Grew,” May-June 2016, page 68) hailed 1870-1970 as a “special century” in this regard (interrupted midway by the disaster of the 1930s).

Gordon highlighted the role of a cluster of once-for-all-time technological advances—the steam engine, railroads, electrification, the internal combustion engine, radio and television, powered flight

Pessimistic that future technological advances (most obviously, the computer and electronics revolutions) will generate productivity gains to match those of the special century, Gordon therefore saw little prospect of a return to the rapid growth of those halcyon days.

DeLong instead points to a series of noneconomic (and non-technological) events that slowed growth, followed by a perverse turn in economic policy triggered in part by public frustration: In 1973 the OPEC cartel tripled the price of oil, and then quadrupled it yet again six years later.

For all too many Americans (and citizens of other countries too), the combination of high inflation and sluggish growth meant that “social democracy was no longer delivering the rapid progress toward utopia that it had delivered in the first post-World War II generation.”

Frustration over these and other ills in turn spawned what DeLong calls the “neoliberal turn” in public attitudes and economic policy. The new economic policies introduced under this rubric “did not end the slowdown in productivity growth but reinforced it.

the tax and regulatory changes enacted in this new climate channeled most of what economic gains there were to people already at the top of the income scale

Meanwhile, progressive “inclusion” of women and African Americans in the economy (and in American society more broadly) meant that middle- and lower-income white men saw even smaller gains—and, perversely, reacted by providing still greater support for policies like tax cuts for those with far higher incomes than their own.

Daniel Bell’s argument in his 1976 classic The Cultural Contradictions of Capitalism. Bell famously suggested that the very success of a capitalist economy would eventually undermine a society’s commitment to the values and institutions that made capitalism possible in the first plac

In DeLong’s view, the “greatest cause” of the neoliberal turn was “the extraordinary pace of rising prosperity during the Thirty Glorious Years, which raised the bar that a political-economic order had to surpass in order to generate broad acceptance.” At the same time, “the fading memory of the Great Depression led to the fading of the belief, or rather recognition, by the middle class that they, as well as the working class, needed social insurance.”

what the economy delivered to “hard-working white men” no longer matched what they saw as their just deserts: in their eyes, “the rich got richer, the unworthy and minority poor got handouts.”

As Bell would have put it, the politics of entitlement, bred by years of economic success that so many people had come to take for granted, squeezed out the politics of opportunity and ambition, giving rise to the politics of resentment.

The new era therefore became “a time to question the bourgeois virtues of hard, regular work and thrift in pursuit of material abundance.”

DeLong’s unspoken agenda would surely include rolling back many of the changes made in the U.S. tax code over the past half-century, as well as reinvigorating antitrust policy to blunt the dominance, and therefore outsize profits, of the mega-firms that now tower over key sectors of the economy

He would also surely reverse the recent trend moving away from free trade. Central bankers should certainly behave like Paul Volcker (appointed by President Carter), whose decisive action finally broke the 1970s inflation even at considerable economic cost

Not only Galbraith’s main themes but many of his more specific observations as well seem as pertinent, and important, today as they did then.

What will future readers of Slouching Towards Utopia conclude?

If anything, DeLong’s narratives will become more valuable as those events fade into the past. Alas, his description of fascism as having at its center “a contempt for limits, especially those implied by reason-based arguments; a belief that reality could be altered by the will; and an exaltation of the violent assertion of that will as the ultimate argument” will likely strike a nerve with many Americans not just today but in years to come.

what about DeLong’s core explanation of what went wrong in the latter third of his, and our, “long century”? I predict that it too will still look right, and important.

As a result, many, like Lindsey, spiraled into emergency rooms and even police custody. Federal data show a nationwide surge of kids in mental health crisis during the pandemic — a surge that's further taxing an already overstretched safety net.

The Centers for Disease Control and Prevention found that, from April to October 2020, hospitals across the U.S. saw a 24% increase in the proportion of mental health emergency visits for children ages 5 to 11, and a 31% increase for children ages 12 to 17.

When states and communities fail to provide children the services they need to live at home, kids can deteriorate and even wind up in jail, like Lindsey. At that point, Glawe says, the cost and level of care required will be even higher, whether that's hospitalization or long stays in residential treatment facilities.

But given that many states have seen their revenues drop due to the pandemic, there's a concern services will instead get cut — at a time when the need has never been greater.

World Health Organization data published in September showed there were twice as many cholera cases in 2022 than in 2021. Outbreaks were recorded in countries where cholera had been under control for years, including Yemen and Lebanon.

2. Mosquitoes on the march

Rising temperatures and frequent floods also unlock new places where disease-carrying insects thrive. The mosquitoes that carry the viruses that cause dengue fever and mala

Nor is the disease confined to developing countries. There are fears that it is spreading in southern Europe, partly owing to the warm weather. More than 8 billion people could be at risk of malaria and dengue fever by 2080, scientists have warned.

3. Human-animal contact

Many existing diseases will get more dangerous, but new illnesses could also emerge as people are increasingly forced into areas where there is wildlife. Diseases can jump from animals to humans. These diseases, such as Ebola, avian flu and Sars, are called “zoonoses” and they make up the majority of new illnesses.

Scientists have found that the climate crisis is helping to circulate diseases between species that previously did not encounter each other. As the planet heats up, many animal species are forced to move into new areas to find suitable conditions.

It has been estimated that zoonoses are responsible for as many as 2.5bn cases of human illness and 2.7m human deaths worldwide each year, and that animals have played a major part in nearly every major disease outbreak since 1970.

4. Severe weather events

Although governments are getting better at preparing for severe weather events, nine out of 10 deaths linked to weather disasters since 1970 happened in small island nations and developing countries in Africa, Asia and South America.

5. The air that we breathe

Outside air pollution has been linked to numerous cancers and diseases and is estimated to be responsible for more than 4m premature deaths globally each year.

Changing weather patterns are expected to make this already bad situation worse as more dust, rain and wildfire smoke are added to the mix. Children are especially likely to get sick from air pollution because their brains, lungs and other organs are still developing.

6. The psychological cost

Environmental deterioration has a knock-on effect on the economic and social systems that keep society productive and happy, setting in motion a downward spiral of psychological hardship.

If crops are destroyed during extreme weather events, children may get less nutritious food, the consumption of which is linked to psychological conditions such as anxiety and depression.

When people can’t get the help they need, they may self-medicate with alcohol or drugs, which in turn makes them more likely to engage in risky behaviour (such as unprotected sex) that could result in infections such as HIV, or illnesses that can result from spending time in crowded places, such as tuberculosis.

In 2021, scientists studying evidence of a potential link between heat exposure and mental health found a 2.2% increase in mental health-related mortality per 1C rise in temperature.

7. Salty water and perilous pregnancies

Drinking water is becoming saltier. One reason for this is that sea levels are rising, so there is more sea water flowing into rivers and other sources of fresh water during floods and tropical storms.

Taking in too much salt can lead to high blood pressure (hypertension). Over time, this condition damages the body’s veins, arteries and major organs (including the brain, heart, kidneys and eyes) since they’re working so much harder overall.

Hypertension is doubly dangerous for pregnant women and their babies

8. Food insecurity

More frequent and severe droughts and floods make it harder to grow the grains, fruit and vegetables that people need to eat to stay healthy. Small island states in the Caribbean, Atlantic, Pacific and Indian Ocean bear the brunt of the effects of the crisis, in part because most people live close to sea level.

As a result, people who live in one of the 39 small island nations are the most likely to die from one of the four main NCDs: cancer, diabetes, heart disease and lung disease.

9. The stress of extreme heat

The scorching temperatures this year broke records in Europe, China and North America. Heat is one of the most dangerous effects of the climate crisis and the top cause of weather-related deaths in the U

When it gets too hot, the body’s temperature rises faster than it can cool itself down, less blood flows to other organs, and the kidneys have to work harder. This puts strain on the heart and can lead to organ failure. Heatstroke is the most serious heat-related illness.

In particular, people whose jobs require long hours of physical labour in the sun face an increased risk of kidney disease as temperatures rise, research suggests. Repeated instances of heat stress can lead to permanent damage and chronic kidney disease.

In June, the Guardian revealed how young migrant workers were returning to Nepal with chronic kidney disease after working in extreme heat conditions in the Gulf and Malaysia. “One factor highlighted again and again is heat. Prolonged exposure to h

10. Millions on the move

It’s hard to predict exactly how many people will be on the move because of the climate crisis, but extreme weather events are likely to make conditions worse for the more than 100 million displaced people around the world.

If nothing changes, the number of people who need humanitarian aid to recover from floods, storms and droughts could double by 2050,

That means more than 200 million people will need aid annually. The displacement of millions of people also means cramped and often unsanitary living. For example, more than 900,000 Rohingya refugees live in makeshift shelters in Bangladesh, often built on unstable ground that’s prone to landslides.

This is what connects figures as disparate as Jordan Peterson and J.D. Vance and Peter Thiel and Donald Trump. These are the ideas that unite both the mainstream and the weirder figures of the so-called postliberal right, from Patrick Deneen to the writer Bronze Age Pervert.

I think the Republican Party’s collapse into incoherence reflects the fact that much of the modern right is reactionary, not conservative

As Paul Valéry, the French poet, once said, “Ancient Greece is the most beautiful invention of the modern age.” To treat Andreessen’s essay as an argument misses the point. It’s a vibe. And the vibe is reactionary.

It’s a coalition obsessed with where we went wrong: the weakness, the political correctness, the liberalism, the trigger warnings, the smug elites. It’s a coalition that believes we were once hard and have become soft; worse, we have come to lionize softness and punish hardness.

The story of the reactionary follows a template across time and place. It “begins with a happy, well-ordered state where people who know their place live in harmony and submit to tradition and their God,” Mark Lilla writes in his 2016 book, “The Shipwrecked Mind: On Political Reaction.”

He continues:Then alien ideas promoted by intellectuals — writers, journalists, professors — challenge this harmony, and the will to maintain order weakens at the top. (The betrayal of elites is the linchpin of every reactionary story.) A false consciousness soon descends on the society as a whole as it willingly, even joyfully, heads for destruction. Only those who have preserved memories of the old ways see what is happening. Whether the society reverses direction or rushes to its doom depends entirely on their resistance.

The Silicon Valley cohort Andreessen belongs to has added a bit to this formula. In their story, the old way that is being lost is the appetite for risk and inequality and dominance that drives technology forward and betters human life. What the muscled ancients knew and what today’s flabby whingers have forgotten is that man must cultivate the strength and will to master nature, and other men, for the technological frontier to give way

Now Andreessen has distilled the whole ideology to a procession of stark bullet points in his latest missive, the buzzy, bizarre “Techno-Optimist Manifesto.”

it’s the pairing of the reactionary’s sodden take on modern society with the futurist’s starry imagining of the bright tomorrow. So call it what it is: reactionary futurism

Andreessen’s argument is simple: Technology is good. Very good. Those who stand in its way are bad.

“The Enemy.” The list is long, ranging from “anti-greatness” to “statism” to “corruption” to “the ivory tower” to “cartels” to “bureaucracy” to “socialism” to “abstract theories” to anyone “disconnected from the real world … playing God with everyone else’s lives”

So who is it, exactly, who extinguishes the dancing star within the human soul?

Our present society has been subjected to a mass demoralization campaign for six decades — against technology and against life — under varying names like “existential risk,” “sustainability,” “E.S.G.,” “sustainable development goals,” “social responsibility,” “stakeholder capitalism,” “precautionary principle,” “trust and safety,” “tech ethics,” “risk management,” “degrowth,” “the limits of growth.”

The enemy, in other words, is anything or anyone who might seek to yoke technology to social goals or structures

For years, I’ve been arguing for politics to take technology more seriously, to see new inventions as no less necessary than social insurance and tax policy in bringing about a worthier world. Too often, we debate only how to divvy up what we already have. We have lost the habit of imagining what we could have; we are too timid in deploying the coordinated genius and muscle of society

I’ve been digging into the history of where and when we lost faith in technology and, more broadly, growth. At the core of that story is an inability to manage, admit or even see when technologies or policies go awry

The turn toward a less-is-more politics came in the 1970s, when the consequences of reckless growth became unignorable

Did we, in some cases, overcorrect? Absolutely. But the only reason we can even debate whether we overcorrected is because we corrected: The Clean Air Act and the Clean Water Act and a slew of other bills and regulations did exactly what they promised.

It is telling that Andreessen groups sustainability and degrowth into the same bucket of antagonists

Degrowth is largely, though not wholly, skeptical of technological solutions to our problems

But the politics of sustainability — as evidenced in legislation like the Inflation Reduction Act — have settled into another place entirely: a commitment to solving our hardest environmental problems by driving technology forward, by investing and deploying clean energy infrastructure at a scale unlike anything the government has done since the 1950s.

Andreessen focuses at some length on the nuclear future he believes we’ve been denied —

but curiously ignores the stunning advances in solar and wind and battery power that public policy has delivered.

He yearns for a kind of person, not just a kind of technology. “We believe in ambition, aggression, persistence, relentlessness — strength,” he writes, italics included. “We believe in merit and achievement. We believe in bravery, in courage.”

There are ways in which these virtues have become undervalued, in which the left, in particular, has a dysfunctional relationship with individual achievement and entrepreneurial élan.

Andreessen’s ideas trace an odd, meme-based philosophy that has flourished in some corners of the internet known as effective accelerationism

“Effective accelerationism aims to follow the ‘will of the universe’: leaning into the thermodynamic bias towards futures with greater and smarter civilizations that are more effective at finding/extracting free energy from the universe,”

“E/acc has no particular allegiance to the biological substrate for intelligence and life, in contrast to transhumanism.” OK!

Take Andreessen’s naming of trust and safety teams as among his enemies.

That, in a way, is my core disagreement with Andreessen. Reactionary futurism is accelerationist in affect but deccelerationist in practice

How has that worked out? A new analysis by Similarweb found that traffic to twitter.com fell in the United States by 19 percent from September 2022 to September 2023 and traffic on mobile devices fell by almost 18 percent. Indications are that advertising revenue on the platform is collapsing.

Andreessen spends much of his manifesto venerating the version of markets that you hear in the first few weeks of Econ 101, before the professor begins complicating the picture with all those annoying market failures

Throughout his essay, Andreessen is at pains to attack those who might slow the development of artificial intelligence in the name of safety, but nothing would do more to freeze progress in A.I. than a disaster caused by its reckless deployment

It is hard to read Andreessen’s manifesto, with its chopped-up paragraphs and its blunt jabs of thought delivered for maximum engagement and polarization, and not feel that Andreessen now reflects the medium in which he has made his home: X. He doesn’t just write in the way the medium rewards. He increasingly seems to think in its house style, too.

One reason I left Twitter long ago is that I noticed that it was a kind of machine for destroying trust. It binds you to the like-minded but cuts you from those with whom you have even modest disagreements

There is a reason that Twitter’s rise was conducive to politics of revolution and reaction rather than of liberalism and conservatism. If you are there too often, seeing the side of humanity it serves up, it is easy to come to think that everything must be burned down.

Musk purchased Twitter (in an acquisition that Andreessen Horowitz helped finance) and gutted its trust and safety teams. The result has been a profusion of chaos, disinformation and division on his platform

Treating so much of society with such withering contempt will not speed up a better future. It will turn people against the politics and policies of growth, just as it did before. Trust is the most essential technology of all.

Not only have pro-Palestinian rallies been stopped or broken up by police

ermany’s unwavering official support for the Israeli government’s actions leaves scant room for humanity. It is also counter-productive, serving to spread fear, Islamophobia and, yes, antisemitism

In addition to banning Hamas-related symbols schools are now free to also ban “symbols, gestures and expressions of opinion that do not yet reach the limit of criminal liability”, which includes the keffiyeh, the Palestinian flag and “free Palestine” stickers and badges.

The stifling of opposition to the killing of civilians in Gaza even extends to Jewish people. A Jewish Israeli woman who held up a placard in a Berlin square calling for an end to violence was approached by German police in a matter of seconds and taken away in a police van. She was later released. Anyone showing solidarity with Palestinians is automatically suspected of being a tacit Hamas sympathiser.

German education senator Katharina Günther-Wünsch has also sent out an email to schools saying that “any demonstrative behaviour or expression of opinion that can be understood (italics are mine) as approving the attacks against Israel or supporting the terrorist organisations that carry them out, such as Hamas or Hezbollah, represents a threat to school peace in the current situation and is prohibited

Having grown up in the shadow of collective guilt for Nazi war crimes, many German intellectuals seem almost to welcome an opportunity to atone for ancestral sins. The atonement, of course, will fall on the backs of Palestinian children.

It should come under the “stating the obvious” category, but still has to be underlined: historically, Islamophobia has only led to more terrorism. Having grown up in Bosnia, I can tell you with absolute certainty that the vicious circle is never-ending. There is always another dead body to be weaponised.

Living in Germany, I see it as my human responsibility to call it out for its one-sidedness, its hypocrisy and its acquiesence in the ethnic cleansing of Gaza. Walking by Lucie’s stone every day, I am reminded of that responsibility. I am reminded of what silence can do and how long it can haunt a place and a people. I come from a silent place soaked in blood. I never thought I would feel that same silence in Germany.

I am appalled by Hamas’s actions and offer my thoughts for their victims, but I have no say in what they do. None of my taxes go to the funding of Hamas. Some of my taxes, however, do fund the bombing of Gaza. In the period between 2018 and 2022, Israel imported $2.7bn-worth of weapons from the US and Germany.

Either you are against fascism in all its forms, or you’re a hypocrite. You condemn a terrorist organisation as well as the terrorism committed by a government

He argues that the tools of social media are just too sharp for young minds. On digital platforms teens parade themselves, often to an audience of strangers, and this is leading to addiction, paranoia and despair

For girls, the effect is especially acute. ‘What we’re seeing is a very sharp, sudden change in girls’ mental health all around the Anglosphere and the Nordic countries,’ he says. A big change was evident from 2013, when physical friendship groups started to be supplanted by smartphones and online chat. ‘But you cannot grow up in networks. You have to grow up in communities.’

boys who have religion in their lives seem to be less susceptible. ‘If you’re a kid who’s a religious conservative, on average, your mental health is not really much worse than it was ten years ago

But if you’re a secular liberal girl, you’re probably more than twice as likely to have a mental health problem.’

a University of Michigan survey into ‘self-derogation’ – i.e., how likely teenagers are to say they are ‘no good’ or ‘can’t do anything right’. Figures had been stable for years but started rising sharply ten years ago – except for among boys who identified as conservative and said that religion was important to them.

irls simply use social media more. But Professor Haidt also thinks they are more likely to buy into what he calls the ‘three great untruths’ of social media

The first is that they are fragile and can be harmed by speech and words.

Next, that their emotions, and especially their anxieties, are reliable guides to reality.

And finally, that society is one big battle between victims and oppressors. All this, he says, is the subtext to social media discourse.

‘It’s what I’ve been calling the phone-based child,’

So we had playdates in childhood, up until around 2010.’ In Britain, he says, the number of children who went on real-life playdates then fell sharply.

Social media is a bit of a misnomer, he says. It’s no longer about connecting people, but ‘performing on a platform’. Perhaps this is fine for grown-ups, but not for children, ‘where they can say things in public, including to strangers, and then be publicly shamed by potentially millions of people

Children should not be on social networks. They should be playing in person. Social media platforms should never be accessed by children until they’re 18. It’s just insane that we let kids do these things.’

I ask if he thinks all platforms are equally dangerous

‘TikTok is probably the worst for their intellectual development. I think it literally reduces their ability to focus on anything while stuffing them with little bits of stuff that was selected by an algorithm for emotional arousal. Not for truth.’

if you get your news from social media (which many people do – in the UK, Instagram has overtaken all newspapers as a news source), this can change your view of the world, especially as the algorithms tend to promote the most provocative views.

If asked to choose whether they side more with Israel or Hamas, ‘the great majority of Americans side with Israel, except for Gen Z, which is split 50-50’,

‘There was a Twitter thread recently showing how if you look at what people are saying on TikTok, you can understand why

TikTok and Twitter are incredibly dangerous for our democracy. I’d say they’re incompatible with the kind of liberal democracy that we’ve developed over the last few hundred years.’

Might it just be the case, I ask, that there’s less of a stigma around mental health now, so teenagers are far more likely to admit that they have problems?

why is it, then, that right around 2013 all these girls suddenly start checking into psychiatric inpatient units? Or suicide – they’re making many more suicide attempts. The level of self-harm goes up by 200 or 300 per cent, especially for the younger girls aged ten to 14

we see very much the same curves, at the same time, for behaviour. Suicide, certainly, is not a self-report variable. This is real. This is the biggest mental health crisis in all of known history for kids.’

he increased number of suicides since 2010 is so large that I suspect this is among the largest public health threats to children since the major diseases were wiped out

In Britain, suicide rates started rising in 2014, up about 20 per cent for boys (to 420 a year) and 60 per cent for girls (to 160 a year).

What should parents do? They know that if they try to remove their teenager’s smartphone, their child will accuse them of destroying his or her social life. ‘That’s a perfect statement of what we call a collective action problem,’

‘Any one person doing the right thing is in big trouble. But why do we ever let our kids on social media? It’s only down to the dynamic you just said.’ New norms are needed, he says. And his book will suggest four.

Rule one, he says: no smartphones before the age of 14.

‘Give them a flip phone. Millennials had flip phones. They texted each other

Rule two: no social media before 16

His third rule: no phones in schools.

finally: more unsupervised play. ‘Both of our countries freaked out in the 1990s, locked up our kids because we lost trust in each other. We thought everyone was a child molester or a rapist.’ Children and teens could do with six or seven hours each day out of contact with their parents, he argues. Keeping them inside risks more harm than the outside world would pose.

“A grieving process allows us to heal. When we deny that process, that’s when the numbness sets in. Then beyond that we start feeling symptoms of anxiety, and beyond that — depression,” said Whaley-Perkins. “So it’s really important for people who are vulnerable or have previous traumas that you don’t wait to see if it’s going to go away. Healing is extraordinarily important.”AdvertisementAccording to Whaley-Perkins, a community should be a group of people that provide safety, can be trusted, and where one can be vulnerable with their feelings. For many in Philadelphia, where they practice their faith is also where communities resides.

“Unless we change fundamentally how we educate our society, unfortunately people will still find a way to do these things,” said Shemtov. “We are all different — but we were all created by God with a purpose. Everybody has to start where they can start. If you’re not in the position to make national or local change, we can all change how we treat ou

As the country reckons with how to move forward, interfaith leaders in Philadelphia look to balance healing with collective action. To Chad Dion Lassiter, who is a national race relations expert and executive director of Pennsylvania Human Relations Commission, taking care of oneself, of one’s community, and finding the motivation to take action are made possible by taking the healing process seriously.

They were offering nearly unlimited cheap debt to keep the wheels of finance turning, and when that didn’t help, the Fed began purchasing massive quantities of government debt outright.

Investors dumped whatever they could, including ostensibly “risk-free” U.S. Treasury securities. As a global dash for dollars unfolded, Treasurys were no longer serving as the market’s traditional shock absorbers, amplifying extreme turmoil on Wall Street.

By week’s end, the Dow had plunged more than 10,000 points since mid-February as investors struggled to get their arms around what a halt to global commerce would mean for businesses that would soon have no revenue.

“It was sheer, unadulterated panic, of a magnitude that was far worse than in 2008 and 2009. Far worse,”

The idea of shutting down markets was especially discouraging: “It was a profoundly un-American thing to contemplate, to just shut everything down, and almost fatalistic—that we’re not going to get out of this.”

nearly two years later, most agree that the Fed’s actions helped to save the economy from going into a pandemic-induced tailspin.

“My thought was—I remember this very clearly—‘O.K. We have a four-or-five-day chance to really get our act together and get ahead of this. We’re gonna try to get ahead of this,’” Mr. Powell recalled later. “And we were going to do that by just announcing a ton of stuff on Monday morning.”

It worked. The Fed’s pledges to backstop an array of lending, announced on Monday, March 23, would unleash a torrent of private borrowing based on the mere promise of central bank action—together with a massive assist by Congress, which authorized hundreds of billions of dollars that would cover any losses.

If the hardest-hit companies like Carnival, with its fleet of 104 ships docked indefinitely, could raise money in capital markets, who couldn’t?

on April 9, where he shed an earlier reluctance to express an opinion about government spending policies, which are set by elected officials and not the Fed. He spoke in unusually moral terms. “All of us are affected,” he said. “But the burdens are falling most heavily on those least able to carry them…. They didn’t cause this. Their business isn’t closed because of anything they did wrong. This is what the great fiscal power of the United States is for—to protect these people as best we can from the hardships they are facing.”

They were extraordinary words from a Fed chair who during earlier, hot-button policy debates said the central bank needed to “stay in its lane” and avoid providing specific advice.

To avoid a widening rift between the market haves (who had been given access to Fed backstops) and the market have-nots (who had been left out because their debt was deemed too risky), Mr. Powell had supported a decision to extend the Fed’s lending to include companies that were being downgraded to “junk” status in the days after it agreed to backstop their bonds.

Most controversially, Mr. Powell recommended that the Fed purchase investment vehicles known as exchange-traded funds, or ETFs, that invest in junk debt. He and his colleagues feared that these “high-yield” bonds might buckle, creating a wave of bankruptcies that would cause long-term scarring in the economy.

Mr. Powell decided that it was better to err on the side of doing too much than not doing enough.

, Paul Singer, who runs the hedge-fund firm Elliott Management, warned that the Fed was sowing the seeds of a bigger crisis by absolving markets of any discipline. “Sadly, when people (including those who should know better) do something stupid and reckless and are not punished,” he wrote, “it is human nature that, far from thinking that they were lucky to have gotten away with something, they are encouraged to keep doing the stupid thing.”

The breathtaking speed with which the Fed moved and with which Wall Street rallied after the Fed’s announcements infuriated Dennis Kelleher, a former corporate lawyer and high-ranking Senate aide who runs Better Markets, an advocacy group lobbying for tighter financial regulations.

This is a ridiculous discussion no matter how heartfelt Powell is about ‘we can’t pick winners and losers’—to which my answer is, ‘So instead you just make them all winners?’”

“Literally, not only has no one in finance lost money, but they’ve all made more money than they could have dreamed,” said Mr. Kelleher. “It just can’t be the case that the only thing the Fed can do is open the fire hydrants wide for everybody

Mr. Powell later defended his decision to purchase ETFs that had invested in junk debt. “We wanted to find a surgical way to get in and support that market because it’s a huge market, and it’s a lot of people’s jobs… What were we supposed to do? Just let them die and lose all those jobs?” he said. “If that’s the biggest mistake we made, stipulating it as a mistake, I’m fine with that. It wasn’t time to be making finely crafted judgments,” Mr. Powell said. He hesitated for a moment before concluding. “Do I regret it? I don’t—not really.”

“We didn’t know there was a vaccine coming. The pandemic is just raging. And we don’t have a plan,” said Mr. Powell. “Nobody in the world has a plan. And in hindsight, the worry was, ‘What if we can’t really fully open the economy for a long time because the pandemic is just out there killing people?’”

Mr. Powell never saw this as a particularly likely outcome, “but it was around the edges of the conversation, and we were very eager to do everything we could to avoid that outcome,”

The Fed’s initial response in 2020 received mostly high marks—a notable contrast with the populist ire that greeted Wall Street bailouts following the 2008 financial crisis. North Carolina Rep. Patrick McHenry, the top Republican on the House Financial Services Committee, gave Mr. Powell an “A-plus for 2020,” he said. “On a one-to-10 scale? It was an 11. He gets the highest, highest marks, and deserves them. The Fed as an institution deserves them.”

The pandemic was the most severe disruption of the U.S. economy since the Great Depression. Economists, financial-market professionals and historians are only beginning to wrestle with the implications of the aggressive response by fiscal and monetary policy makers.

Altogether, Congress approved nearly $5.9 trillion in spending in 2020 and 2021. Adjusted for inflation, that compares with approximately $1.8 trillion in 2008 and 2009.

By late 2021, it was clear that many private-sector forecasters and economists at the Fed had misjudged both the speed of the recovery and the ways in which the crisis had upset the economy’s equilibrium. Washington soon faced a different problem. Disoriented supply chains and strong demand—boosted by government stimulus—had produced inflation running above 7%.

because the pandemic shock was akin to a natural disaster, it allowed Mr. Powell and the Fed to sidestep concerns about moral hazard—that is, the possibility that their policies would encourage people to take greater risks knowing that they were protected against larger losses. If a future crisis is caused instead by greed or carelessness, the Fed would have to take such concerns more seriously.

The high inflation that followed in 2021 might have been worse if the U.S. had seen more widespread bankruptcies or permanent job losses in the early months of the pandemic.

an additional burst of stimulus spending in 2021, as vaccines hastened the reopening of the economy, raised the risk that monetary and fiscal policy together would flood the economy with money and further fuel inflation.

The surge in federal borrowing since 2020 creates other risks. It is manageable for now but could become very expensive if the Fed has to lift interest rates aggressively to cool the economy and reduce high inflation.

The Congressional Budget Office forecast in December 2020 that if rates rose by just 0.1 percentage point more than projected in each year of the decade, debt-service costs in 2030 would rise by $235 billion—more than the Pentagon had requested to spend in 2022 on the Navy.

its low-rate policies have coincided with—and critics say it has contributed to—a longer-running widening of wealth inequality.

In 2008, household wealth fell by $8 trillion. It rose by $13.5 trillion in 2020, and in the process, spotlighted the unequal distribution of wealth-building assets such as houses and stocks.

Without heavy spending from Washington, focused on the needs of the least well-off, these disparities might have attracted more negative scrutiny.

Finally, the Fed is a technocratic body that can move quickly because it operates under few political constraints. Turning to it as the first line of defense in this and future crises could compromise its institutional independence.

Step one, he said, was to get in the fight and try to win. Figuring out how to exit would be a better problem to have, because it would mean they had succeeded.

“We have a recovery that looks completely unlike other recoveries that we’ve had because we’ve put so much support behind the recovery,” Mr. Powell said last month. “Was it too much? I’m going to leave that to the historians.”

The final verdict on the 2020 crisis response may turn on whether Mr. Powell is able to bring inflation under control without a painful recession—either as sharp price increases from 2021 reverse on their own accord, as officials initially anticipated, or because the Fed cools down the economy by raising interest rates.

Last year he went to the UK for a month and ended up staying nearly eight, finding an antidote to American’s poison.

“I still haven’t fully recovered from my stroke, and what goes on in this country, I couldn’t talk about it. I got in the middle of it. Tucker Carlson [a host on Fox News] was killing me every fucking night.”

also invited UK journalists to disseminate a warning: don’t let British politics become as polarised and debased as the American system.

“You still like each other, you still respect each other, you still value public debate: your democracy is still functioning,”

“Ours has seized up and I don’t know how to get ours flowing again. Be thankful that you don’t have our poison … I’m very afraid of the American system being hopelessly damaged.”

You all have proven that there’s still a desire for substance in politics, not just slogans and soundbites, and thank God you haven’t completely embraced American politics because your elections are of substance rather than style.

“I know that you guys are critical of the UK in recent times for being too American in your elections. You’re not. We are becoming more and more superficial. You are still substantial.”

Later he plays a video clip of one of his US focus groups descending into angry shouting and recriminations, a glimpse of a society that seems to be falling apart. He comments: “The worst of the worst. This is my warning to you. This is shit. This is a disaster and it will come to you if you let it happen.”

“Boris Johnson has written more books than Donald Trump has read. Boris is the real Trump. He understands the hopes and dreams of the public. He gets the historic context. He can wax poetically about 2,000 years ago, 200 years ago and two years ago. Trump could not do that.

“Biden does not understand the hopes and dreams of the average American,” says the messaging expert, who remains on the centre-right. “He does not empathise with them. His team is ideological rather than emotional and so he’s missing all this. It’s how people feel even more than how they think; feeling is a deeper emotion and Biden is not connecting to them at all.

Luntz argues that he overpromised. “He created unrealistic expectations. He’s a very arrogant human being and very flawed and the combination of flaws and arrogance is a really unhealthy cocktail.”

Wasn’t Biden supposed to be Mr Empathy? “There’s nothing about him that screams empathy. There’s everything about him that screams someone who’s already made up their mind.”

He identifies six issues that will determine voters’ choices: crime, immigration, shortages, prices, education and the January 6 insurrection. “Democrats have a huge problem on five out of the six.”

Today, after the catharsis of his stroke, Luntz finds plenty of blame to go around. He casts a harsh light on the media, social media and his own younger self. In an infamous 2003 memo, for example, he advised George W Bush’s Republican party to abandon the phrase “global warming” in favour of “climate change” because it is “less frightening”

The Great Rethink. It is a study of America voters’ attitudes and disillusionment with their leaders. “The only thing we agree on is that politicians suck,” Luntz says. “If you’re American, this is a very depressing time right now.”

nother offers some words to use (I am your voice, accountability, fact-based) and words to lose (agenda, I’m listening, transparency).

Luntz argues that even in a polarised society such as America, every parent asks the same question: will my child/grandchild be happy

Perhaps rather optimistically, he urges politicians to focus on children as “the great unifier”

“If you want to bring people together, you do it over their children. You guys are divided on just about everything; this crushes that divide. This brings people together and it’s not been done before.

“I don’t see anything wrong with it; I don’t blame other people for doing it,” Carter says over dinner. “It just never had been my ambition to be rich.”

Carter decided that his income would come from writing, and he has written 33 books, about his life and career, his faith, Middle East peace, women’s rights, aging, fishing, woodworking, even a children’s book written with his daughter, Amy Carter, called “The Little Baby Snoogle-Fleejer.”

Carter costs U.S. taxpayers less than any other ex-president, according to the General Services Administration, with a total bill for him in the current fiscal year of $456,000, covering pensions, an office, staff and other expenses.

Carter is the only president in the modern era to return full-time to the house he lived in before he entered politics — a two-bedroom rancher assessed at $167,000, less than the value of the armored Secret Service vehicles parked outside.

Ex-presidents often fly on private jets, sometimes lent by wealthy friends, but the Carters fly commercial. Stuckey says that on a recent flight from Atlanta to Los Angeles, Carter walked up and down the aisle greeting other passengers and taking selfies.

“He doesn’t like big shots, and he doesn’t think he’s a big shot,” said Gerald Rafshoon, who was Carter’s White House communications director.

With book income and the $210,700 annual pension all former presidents receive, the Carters live comfortably. But his books have never fetched the massive sums commanded by more recent presidents.

The federal government pays for an office for each ex-president. Carter’s, in the Carter Center in Atlanta, is the least expensive, at $115,000 this year. The Carters could have built a more elaborate office with living quarters, but for years they slept on a pullout couch for a week each month. Recently, they had a Murphy bed installed.

Carter doesn’t even have federal retirement health benefits because he worked for the government for four years — less than the five years needed to qualify, according to the GSA. He says he receives health benefits through Emory University, where he has taught for 36 years.

Carter’s office costs a fraction of Obama’s, which is $536,000 a year. Clinton’s costs $518,000, George W. Bush’s is $497,000 and George H.W. Bush’s is $286,000, according to the GSA.

“He didn’t feel suited to the grandeur,” Eizenstat said. “Plains is really part of his DNA. He carried it into the White House, and he carried it out of the White House.”

“I am a great admirer of Harry Truman. He’s my favorite president, and I really try to emulate him,” says Carter, who writes his books in a converted garage in his house. “He set an example I thought was admirable.”

The Jimmy Carter National Historic Site is essentially the entire town, drawing nearly 70,000 visitors a year and $4 million into the county’s economy.

Carter has used his post-presidency to support human rights, global health programs and fair elections worldwide through his Carter Center, based in Atlanta. He has helped renovate 4,300 homes in 14 countries for Habitat for Humanity, and with his own hammer and tool belt, he will be working on homes for low-income people in Indiana later this month.

Carter’s gait is a little unsteady these days, three years after a diagnosis of melanoma on his liver and brain. At a 2015 news conference to announce his illness, he seemed to be bidding a stoic farewell, saying he was “perfectly at ease with whatever comes.”

In October, he will become the second president ever to reach 94; George H.W. Bush turned 94 in June. These days, Carter is sharp, funny and reflective.

The Carters walk every day — often down Church Street, the main drag through Plains, where they have been walking since the 1920s.

“I grew up in church with him,” says Maya Wynn. “He’s a nice guy, just like a regular person.”

“He’s a good ol’ Southern gentleman,” says David Lane.

Carter says this place formed him, seeding his beliefs about racial equality. His farmhouse youth during the Great Depression made him unpretentious and frugal. His friends, maybe only half-joking, describe Carter as “tight as a tick.”

That no-frills sensibility, endearing since he left Washington, didn’t work as well in the White House. Many people thought Carter scrubbed some of the luster off the presidency by carrying his own suitcases onto Air Force One and refusing to have “Hail to the Chief” played.

Stuart E. Eizenstat, a Carter aide and biographer, said Carter’s edict eliminating drivers for top staff members backfired. It meant that top officials were driving instead of reading and working for an hour or two every day.

That’s less than half the $952,000 budgeted for George H.W. Bush; the three other living ex-presidents — Clinton, George W. Bush and Obama — cost taxpayers more than $1 million each per year.

When Carter looks back at his presidency, he says he is most proud of “keeping the peace and supporting human rights,” the Camp David accords that brokered peace between Israel and Egypt, and his work to normalize relations with China. In 2002, he was awarded the Nobel Peace Prize for his efforts.

“I always told the truth,” he says.

Carter says he thinks the Supreme Court’s Citizens United decision has “changed our political system from a democracy to an oligarchy. Money is now preeminent. I mean, it’s just gone to hell now.”

He says he believes that the nation’s “ethical and moral values” are still intact and that Americans eventually will “return to what’s right and what’s wrong, and what’s decent and what’s indecent, and what’s truthful and what’s lies.”

They are asked if there is anything they want but don’t have. “I can’t think of anything,” Carter says, turning to Rosalynn. “And you?” “No, I’m happy,” she says.

They watch Atlanta Braves games or “Law and Order.” Carter just finished reading “The Innovators” by Walter Isaacson. They have no chef and they cook for themselves, often together. They make their own yogurt.

Besides teenage girls, another new group was referred to us: young people from the inpatient psychiatric unit, or the emergency department, of St. Louis Children’s Hospital. The mental health of these kids was deeply concerning—there were diagnoses like schizophrenia, PTSD, bipolar disorder, and more. Often they were already on a fistful of pharmaceuticals.

Being put on powerful doses of testosterone or estrogen—enough to try to trick your body into mimicking the opposite sex—-affects the rest of the body. I doubt that any parent who's ever consented to give their kid testosterone (a lifelong treatment) knows that they’re also possibly signing their kid up for blood pressure medication, cholesterol medication, and perhaps sleep apnea and diabetes. 

There are rare conditions in which babies are born with atypical genitalia—cases that call for sophisticated care and compassion. But clinics like the one where I worked are creating a whole cohort of kids with atypical genitals—and most of these teens haven’t even had sex yet. They had no idea who they were going to be as adults. Yet all it took for them to permanently transform themselves was one or two short conversations with a therapist.

Other girls were disturbed by the effects of testosterone on their clitoris, which enlarges and grows into what looks like a microphallus, or a tiny penis. I counseled one patient whose enlarged clitoris now extended below her vulva, and it chafed and rubbed painfully in her jeans. I advised her to get the kind of compression undergarments worn by biological men who dress to pass as female. At the end of the call I thought to myself, “Wow, we hurt this kid.”

How little patients understood what they were getting into was illustrated by a call we received at the center in 2020 from a 17-year-old biological female patient who was on testosterone. She said she was bleeding from the vagina. In less than an hour she had soaked through an extra heavy pad, her jeans, and a towel she had wrapped around her waist. The nurse at the center told her to go to the emergency room right away.

We found out later this girl had had intercourse, and because testosterone thins the vaginal tissues, her vaginal canal had ripped open. She had to be sedated and given surgery to repair the damage. She wasn’t the only vaginal laceration case we heard about.

Bicalutamide is a medication used to treat metastatic prostate cancer, and one of its side effects is that it feminizes the bodies of men who take it, including the appearance of breasts. The center prescribed this cancer drug as a puberty blocker and feminizing agent for boys. As with most cancer drugs, bicalutamide has a long list of side effects, and this patient experienced one of them: liver toxicity. He was sent to another unit of the hospital for evaluation and immediately taken off the drug. Afterward, his mother sent an electronic message to the Transgender Center saying that we were lucky her family was not the type to sue.

Here’s an example. On Friday, May 1, 2020, a colleague emailed me about a 15-year-old male patient: “Oh dear. I am concerned that [the patient] does not understand what Bicalutamide does.” I responded: “I don’t think that we start anything honestly right now.”

There are no reliable studies showing this. Indeed, the experiences of many of the center’s patients prove how false these assertions are. 

Many encounters with patients emphasized to me how little these young people understood the profound impacts changing gender would have on their bodies and minds. But the center downplayed the negative consequences, and emphasized the need for transition. As the center’s website said, “Left untreated, gender dysphoria has any number of consequences, from self-harm to suicide. But when you take away the gender dysphoria by allowing a child to be who he or she is, we’re noticing that goes away. The studies we have show these kids often wind up functioning psychosocially as well as or better than their peers.” 

When a female takes testosterone, the profound and permanent effects of the hormone can be seen in a matter of months. Voices drop, beards sprout, body fat is redistributed. Sexual interest explodes, aggression increases, and mood can be unpredictable. Our patients were told about some side effects, including sterility. But after working at the center, I came to believe that teenagers are simply not capable of fully grasping what it means to make the decision to become infertile while still a minor.

To begin transitioning, the girls needed a letter of support from a therapist—usually one we recommended—who they had to see only once or twice for the green light. To make it more efficient for the therapists, we offered them a template for how to write a letter in support of transition. The next stop was a single visit to the endocrinologist for a testosterone prescription. 

The doctors privately recognized these false self-diagnoses as a manifestation of social contagion. They even acknowledged that suicide has an element of social contagion. But when I said the clusters of girls streaming into our service looked as if their gender issues might be a manifestation of social contagion, the doctors said gender identity reflected something innate.

Frequently, our patients declared they had disorders that no one believed they had. We had patients who said they had Tourette syndrome (but they didn’t); that they had tic disorders (but they didn’t); that they had multiple personalities (but they didn’t).

The girls who came to us had many comorbidities: depression, anxiety, ADHD, eating disorders, obesity. Many were diagnosed with autism, or had autism-like symptoms. A report last year on a British pediatric transgender center found that about one-third of the patients referred there were on the autism spectrum.

This concerned me, but didn’t feel I was in the position to sound some kind of alarm back then. There was a team of about eight of us, and only one other person brought up the kinds of questions I had. Anyone who raised doubts ran the risk of being called a transphobe. 

I certainly saw this at the center. One of my jobs was to do intake for new patients and their families. When I started there were probably 10 such calls a month. When I left there were 50, and about 70 percent of the new patients were girls. Sometimes clusters of girls arrived from the same high school. 

Until 2015 or so, a very small number of these boys comprised the population of pediatric gender dysphoria cases. Then, across the Western world, there began to be a dramatic increase in a new population: Teenage girls, many with no previous history of gender distress, suddenly declared they were transgender and demanded immediate treatment with testosterone. 

Soon after my arrival at the Transgender Center, I was struck by the lack of formal protocols for treatment. The center’s physician co-directors were essentially the sole authority.

At first, the patient population was tipped toward what used to be the “traditional” instance of a child with gender dysphoria: a boy, often quite young, who wanted to present as—who wanted to be—a girl. 

During the four years I worked at the clinic as a case manager—I was responsible for patient intake and oversight—around a thousand distressed young people came through our doors. The majority of them received hormone prescriptions that can have life-altering consequences—including sterility. 

I left the clinic in November of last year because I could no longer participate in what was happening there. By the time I departed, I was certain that the way the American medical system is treating these patients is the opposite of the promise we make to “do no harm.” Instead, we are permanently harming the vulnerable patients in our care.

Today I am speaking out. I am doing so knowing how toxic the public conversation is around this highly contentious issue—and the ways that my testimony might be misused. I am doing so knowing that I am putting myself at serious personal and professional risk.

Almost everyone in my life advised me to keep my head down. But I cannot in good conscience do so. Because what is happening to scores of children is far more important than my comfort. And what is happening to them is morally and medically appalling.

For almost four years, I worked at The Washington University School of Medicine Division of Infectious Diseases with teens and young adults who were HIV positive. Many of them were trans or otherwise gender nonconforming, and I could relate: Through childhood and adolescence, I did a lot of gender questioning myself. I’m now married to a transman, and together we are raising my two biological children from a previous marriage and three foster children we hope to adopt. 

The center’s working assumption was that the earlier you treat kids with gender dysphoria, the more anguish you can prevent later on. This premise was shared by the center’s doctors and therapists. Given their expertise, I assumed that abundant evidence backed this consensus. 

All that led me to a job in 2018 as a case manager at The Washington University Transgender Center at St. Louis Children's Hospital, which had been established a year earlier. 

Mr. Bogle has some hard news for investors. The basic appeal of index funds—their ability to deliver the market return without shifting an arm and leg to Wall Street’s army of helpers—will only become more important given the decade of depressed returns he sees ahead.

Don’t imagine a revisitation of the ’80s or ’90s, when stocks returned 18% a year and investors, after the industry’s rake-off, imagined they “had the greatest manager in the world” because they got 14%. Those planning on a comfy retirement or putting a kid through college will have to save more, work to keep costs low, and—above all—stick to the plan.

The mutual-fund industry is slowly liquidating itself—except for Vanguard. Mr. Bogle happily supplies the numbers: During the 12 months that ended May 31, “the fund industry took in $87 billion . . . of which $224 billion came into Vanguard.” In other words, “in the aggregate, our competitors experienced capital outflows of $137 billion.”

That said, Mr. Bogle finds today’s stock scene puzzling. Shares are highly priced in historical terms; earnings and economic growth he expects to disappoint for at least the next decade (he sees no point in trying to forecast further). And yet he advises investors to stay invested and weather the storm: “If we’re going to have lower returns, well, the worst thing you can do is reach for more yield. You just have to save more.”

He also knows the heartache of having just about everything he has saved tied up in volatile, sometimes irrational markets, especially now. “We’re in a difficult place,” he says. “We live in an extremely risky world—probably more risky than I can recall.”

Then why invest at all? Maybe it would be better to sell and stick the cash in a bank or a mattress. “I know of no better way to guarantee you’ll have nothing at the end of the trail,” he responds. “So we know we have to invest. And there’s no better way to invest than a diversified list of stocks and bonds at very low cost.”

Mr. Bogle’s own portfolio consists of 50% stocks and 50% bonds, the latter tilted toward short- and medium-term. Keep an eagle eye on costs, he says, in a world where pre-cost returns may be as low as 3% or 4%. Inattentive investors can expect to lose as much as 70% of their profits to “hidden” fund management costs in addition to the “expense ratios” touted in mutual-fund prospectuses. (These hidden costs include things like sales load, transaction costs, idle cash and inefficient taxes.)

Mr. Bogle relies on a forecasting model he published 25 years ago, which tells him that investors over the next decade, thanks largely to a reversion to the mean in valuations, will be lucky to clear 2% annually after costs. Yuck.

Investing, he says, always is “an act of trust—in the ability of civilization and the U.S. to continue to flourish; in the ability of corporations to continue, through efficiency and entrepreneurship and innovation, to provide substantial returns.” But nothing, not even American greatness, is guaranteed, he adds

what he calls the financial buccaneer type, an entrepreneur more interested in milking what’s left of the active-management-fee gravy train than in providing low-cost competition for Vanguard—which means Vanguard’s best days as guardian of America’s nest egg may still lie ahead.

the growth of indexing is obviously unwelcome writing on the wall for Wall Street professionals and Vanguard’s profit-making competitors like Fidelity, which have never been able to give heart and soul to low-churn indexing because indexing doesn’t generate large fees for executives and shareholders of management companies.

the United States and several major European countries have declared a series of financial penalties and sanctions against Russia that are without modern precedent for a major economy. These policies are triggering a financial catastrophe in Russia.

Only 12 countries in the world have more total exports. Russia trades oil, gas, and coal to much of Europe and wheat to the Middle East and Africa.

The sanctions imposed so far amount to a kind of siege of a country that depends on access to global markets.

The country is sealed off—from Western trade, Western travel, and (apart from energy exports) most Western business.

Tajikistan, a small Central Asian country north of Afghanistan, relies on remittances from Russia for more than 20 percent of its GDP. That means if workers in Russia stop sending money to their families in Tajikistan, that country’s economy could nose-dive into a depression.

Economic crises can spark political revolutions, and Tajikistan shares a border with China’s westernmost province, Xinjiang. Russia’s crisis could, then, become a Central Asian economic crisis, which could become a Chinese political problem. What happens in Russia will not stay in Russia.

This is a delayed but inescapable consequence of China’s birth trends from the era of the notorious one-child policy (1980-2015)

Beijing thus far has ignored this looming crisis because planners don’t prepare for things they don’t track. Officials don’t regard data on the family as relevant to statecraft or security. So statistics tally males and females—not uncles, sisters, cousins, widows.

We estimate past patterns and project trends through demographic modeling—simulations replicating China’s available population numbers—while “building” family trees consistent with those figures. We can approximate nationwide changes in China’s extended family networks in the past with reasonable validity and describe what lies ahead with fair confidence.

we are only now living through the era of “peak kin” in China. In terms of sheer numbers, Chinese networks of blood relatives were never nearly as thick as at the start of the 21st century.

Because of dramatic postwar improvements in health and mortality, men and women in their 40s today have on average five times as many living cousins as in 1960.

China’s “kin explosion” may be an important, heretofore unobserved factor in China’s remarkable economic performance since Mao Zedong’s death in 1976.

China is now on the cusp of a severe and unavoidable “kin crash,” driven by prolonged subreplacement fertility

China’s rising generations will likely have fewer living relatives than ever before in Chinese history.

A “kin famine” will thus unfold unforgivingly over the next 30 years—starting now. As it intensifies, the Chinese family—the most important institution protecting Chinese people against adversity in bad times and helping them seize opportunity in good times—will increasingly falter in both these crucial functions.

China’s withering of the family is set to collide with a tsunami of new social need from the country’s huge elderly population, whose ranks will more than double between 2020 and 2050

By 2050 living parents and in-laws will outnumber children for middle-aged Chinese men and women. Thus exigency may overturn basic familial arrangements that have long been taken for granted. The focus of the family in China will necessarily turn from the rearing of the young to the care of the old.

The reliability and durability of familial bonds of duty will be an increasingly critical question—perhaps even a matter of life and death for many, including frail and impecunious elders in the Chinese hinterlands

growing numbers of men in decades ahead will enter old age without spouses or children—the traditional sources of support for the elderly.

by 2050, 18% of China’s men in their 60s will have no living descendants, twice the fraction today.

who will look after these unfortunates?

Still worse than the macroeconomic implications of old-age dependency may be the effect of China’s family crisis on the so-called micro-foundations of the national economy—the little things that make markets work.