Group items tagged

Robots can already exceed human accuracy on some surgical tasks, like placing a pin into a bone (a particularly risky task during knee and hip replacements). The hope is that automated robots can bring greater accuracy to other tasks, like incisions or suturing, and reduce the risks that come with overworked surgeons.

Surgical robots are equipped with cameras that record three-dimensional video of each operation. The video streams into a viewfinder that surgeons peer into while guiding the operation, watching from the robot’s point of view.

But this process came with its own asterisk. When the system told the robot where to move, the robot often missed the spot by millimeters. Over months and years of use, the many metal cables inside the robot’s twin arms have stretched and bent in small ways, so its movements were not as precise as they needed to be.

The ordinary fixes—the kind that draw on people’s will, and require eating less and moving more—rarely have a large or lasting effect. Indeed, America itself has suffered through a long, maddening history of failed attempts to change its habits on a national scale: a yo-yo diet of well-intentioned treatments, policies, and other social interventions that only ever lead us back to where we started

Through it all, obesity rates keep going up; the diabetes epidemic keeps worsening.

The most recent miracle, for Barb as well as for the nation, has come in the form of injectable drugs. In early 2021, the Danish pharmaceutical company Novo Nordisk published a clinical trial showing remarkable results for semaglutide, now sold under the trade names Wegovy and Ozempic.

Patients in the study who’d had injections of the drug lost, on average, close to 15 percent of their body weight—more than had ever been achieved with any other drug in a study of that size. Wadden knew immediately that this would be “an incredible revolution in the treatment of obesity.”

Many more drugs are now racing through development: survodutide, pemvidutide, retatrutide. (Among specialists, that last one has produced the most excitement: An early trial found an average weight loss of 24 percent in one group of participants.

In the United States, an estimated 189 million adults are classified as having obesity or being overweight

The drugs don’t work for everyone. Their major side effects—nausea, vomiting, and diarrhea—can be too intense for many patients. Others don’t end up losing any weight

For the time being, just 25 percent of private insurers offer the relevant coverage, and the cost of treatment—about $1,000 a month—has been prohibitive for many Americans.

The drugs have already been approved not just for people with diabetes or obesity, but for anyone who has a BMI of more than 27 and an associated health condition, such as high blood pressure or cholesterol. By those criteria, more than 140 million American adults already qualify

if this story goes the way it’s gone for other “risk factor” drugs such as statins and antihypertensives, then the threshold for prescriptions will be lowered over time, inching further toward the weight range we now describe as “normal.”

How you view that prospect will depend on your attitudes about obesity, and your tolerance for risk

The first GLP-1 drug to receive FDA approval, exenatide, has been used as a diabetes treatment for more than 20 years. No long-term harms have been identified—but then again, that drug’s long-term effects have been studied carefully only across a span of seven years

the data so far look very good. “These are now being used, literally, in hundreds of thousands of people across the world,” she told me, and although some studies have suggested that GLP-1 drugs may cause inflammation of the pancreas, or even tumor growth, these concerns have not borne out.

adolescents are injecting newer versions of these drugs, and may continue to do so every week for 50 years or more. What might happen over all that time?

“All of us, in the back of our minds, always wonder, Will something show up?  ” Although no serious problems have yet emerged, she said, “you wonder, and you worry.”

in light of what we’ve been through, it’s hard to see what other choices still remain. For 40 years, we’ve tried to curb the spread of obesity and its related ailments, and for 40 years, we’ve failed. We don’t know how to fix the problem. We don’t even understand what’s really causing it. Now, again, we have a new approach. This time around, the fix had better work.

The fen-phen revolution arrived at a crucial turning point for Wadden’s field, and indeed for his career. By then he’d spent almost 15 years at the leading edge of research into dietary interventions, seeing how much weight a person might lose through careful cutting of their calories.

But that sort of diet science—and the diet culture that it helped support—had lately come into a state of ruin. Americans were fatter than they’d ever been, and they were giving up on losing weight. According to one industry group, the total number of dieters in the country declined by more than 25 percent from 1986 to 1991.

Rejecting diet culture became something of a feminist cause. “A growing number of women are joining in an anti-diet movement,” The New York Times reported in 1992. “They are forming support groups and ceasing to diet with a resolve similar to that of secretaries who 20 years ago stopped getting coffee for their bosses.

Now Wadden and other obesity researchers were reaching a consensus that behavioral interventions might produce in the very best scenario an average lasting weight loss of just 5 to 10 percent

National surveys completed in 1994 showed that the adult obesity rate had surged by more than half since 1980, while the proportion of children classified as overweight had doubled. The need for weight control in America had never seemed so great, even as the chances of achieving it were never perceived to be so small.

Wadden wasn’t terribly concerned, because no one in his study had reported any heart symptoms. But ultrasounds revealed that nearly one-third of them had some degree of leakage in their heart valves. His “cure for obesity” was in fact a source of harm.

In December 1994, the Times ran an editorial on what was understood to be a pivotal discovery: A genetic basis for obesity had finally been found. Researchers at Rockefeller University were investigating a molecule, later named leptin, that gets secreted from fat cells and travels to the brain, and that causes feelings of satiety. Lab mice with mutations in the leptin gene—importantly, a gene also found in humans—overeat until they’re three times the size of other mice. “The finding holds out the dazzling hope,”

In April 1996, the doctors recommended yes: Dexfenfluramine was approved—and became an instant blockbuster. Patients received prescriptions by the hundreds of thousands every month. Sketchy wellness clinics—call toll-free, 1-888-4FEN-FEN—helped meet demand. Then, as now, experts voiced concerns about access. Then, as now, they worried that people who didn’t really need the drugs were lining up to take them. By the end of the year, sales of “fen” alone had surpassed $300 million.

It was nothing less than an awakening, for doctors and their patients alike. Now a patient could be treated for excess weight in the same way they might be treated for diabetes or hypertension—with a drug they’d have to take for the rest of their life.

the article heralded a “new understanding of obesity as a chronic disease rather than a failure of willpower.”

News had just come out that, at the Mayo Clinic in Minnesota, two dozen women taking fen-phen—including six who were, like Barb, in their 30s—had developed cardiac conditions. A few had needed surgery, and on the operating table, doctors discovered that their heart valves were covered with a waxy plaque.

Americans had been prescribed regular fenfluramine since 1973, and the newer drug, dexfenfluramine, had been available in France since 1985. Experts took comfort in this history. Using language that is familiar from today’s assurances regarding semaglutide and other GLP-1 drugs, they pointed out that millions were already on the medication. “It is highly unlikely that there is anything significant in toxicity to the drug that hasn’t been picked up with this kind of experience,” an FDA official named James Bilstad would later say in a Time cover story headlined “The Hot New Diet Pill.

“I know I can’t get any more,” she told Williams. “I have to use up what I have. And then I don’t know what I’m going to do after that. That’s the problem—and that is what scares me to death.” Telling people to lose weight the “natural way,” she told another guest, who was suggesting that people with obesity need only go on low-carb diets, is like “asking a person with a thyroid condition to just stop their medication.”

She’d gone off the fen-phen and had rapidly regained weight. “The voices returned and came back in a furor I’d never heard before,” Barb later wrote on her blog. “It was as if they were so angry at being silenced for so long, they were going to tell me 19 months’ worth of what they wanted me to hear. I was forced to listen. And I ate. And I ate. And ate.”

For Barb, rapid weight loss has brought on a different metaphysical confusion. When she looks in the mirror, she sometimes sees her shape as it was two years ago. In certain corners of the internet, this is known as “phantom fat syndrome,” but Barb dislikes that term. She thinks it should be called “body integration syndrome,” stemming from a disconnect between your “larger-body memory” and “smaller-body reality.

In 2003, the U.S. surgeon general declared obesity “the terror within, a threat that is every bit as real to America as the weapons of mass destruction”; a few months later, Eric Finkelstein, an economist who studies the social costs of obesity, put out an influential paper finding that excess weight was associated with up to $79 billion in health-care spending in 1998, of which roughly half was paid by Medicare and Medicaid. (Later he’d conclude that the number had nearly doubled in a decade.

In 2004, Finkelstein attended an Action on Obesity summit hosted by the Mayo Clinic, at which numerous social interventions were proposed, including calorie labeling in workplace cafeterias and mandatory gym class for children of all grades.

he message at their core, that soda was a form of poison like tobacco, spread. In San Francisco and New York, public-service campaigns showed images of soda bottles pouring out a stream of glistening, blood-streaked fat. Michelle Obama led an effort to depict water—plain old water—as something “cool” to drink.

Soon, the federal government took up many of the ideas that Brownell had helped popularize. Barack Obama had promised while campaigning for president that if America’s obesity trends could be reversed, the Medicare system alone would save “a trillion dollars.” By fighting fat, he implied, his ambitious plan for health-care reform would pay for itself. Once he was in office, his administration pulled every policy lever it could.

Michelle Obama helped guide these efforts, working with marketing experts to develop ways of nudging kids toward better diets and pledging to eliminate “food deserts,” or neighborhoods that lacked convenient access to healthy, affordable food. She was relentless in her public messaging; she planted an organic garden at the White House and promoted her signature “Let’s Move!” campaign around the country.

An all-out war on soda would come to stand in for these broad efforts. Nutrition studies found that half of all Americans were drinking sugar-sweetened beverages every day, and that consumption of these accounted for one-third of the added sugar in adults’ diets. Studies turned up links between people’s soft-drink consumption and their risks for type 2 diabetes and obesity. A new strand of research hinted that “liquid calories” in particular were dangerous to health.

when their field lost faith in low-calorie diets as a source of lasting weight loss, the two friends went in opposite directions. Wadden looked for ways to fix a person’s chemistry, so he turned to pharmaceuticals. Brownell had come to see obesity as a product of our toxic food environment: He meant to fix the world to which a person’s chemistry responded, so he started getting into policy.

The social engineering worked. Slowly but surely, Americans’ lamented lifestyle began to shift. From 2001 to 2018, added-sugar intake dropped by about one-fifth among children, teens, and young adults. From the late 1970s through the early 2000s, the obesity rate among American children had roughly tripled; then, suddenly, it flattened out.

although the obesity rate among adults was still increasing, its climb seemed slower than before. Americans’ long-standing tendency to eat ever-bigger portions also seemed to be abating.

sugary drinks—liquid candy, pretty much—were always going to be a soft target for the nanny state. Fixing the food environment in deeper ways proved much harder. “The tobacco playbook pretty much only works for soda, because that’s the closest analogy we have as a food item,

that tobacco playbook doesn’t work to increase consumption of fruits and vegetables, he said. It doesn’t work to increase consumption of beans. It doesn’t work to make people eat more nuts or seeds or extra-virgin olive oil.

Careful research in the past decade has shown that many of the Obama-era social fixes did little to alter behavior or improve our health. Putting calorie labels on menus seemed to prompt at most a small decline in the amount of food people ate. Employer-based wellness programs (which are still offered by 80 percent of large companies) were shown to have zero tangible effects. Health-care spending, in general, kept going up.

From the mid-1990s to the mid-2000s, the proportion of adults who said they’d experienced discrimination on account of their height or weight increased by two-thirds, going up to 12 percent. Puhl and others started citing evidence that this form of discrimination wasn’t merely a source of psychic harm, but also of obesity itself. Studies found that the experience of weight discrimination is associated with overeating, and with the risk of weight gain over time.

obesity rates resumed their ascent. Today, 20 percent of American children have obesity. For all the policy nudges and the sensible revisions to nutrition standards, food companies remain as unfettered as they were in the 1990s, Kelly Brownell told me. “Is there anything the industry can’t do now that it was doing then?” he asked. “The answer really is no. And so we have a very predictable set of outcomes.”

she started to rebound. The openings into her gastric pouch—the section of her stomach that wasn’t bypassed—stretched back to something like their former size. And Barb found ways to “eat around” the surgery, as doctors say, by taking food throughout the day in smaller portions

Bariatric surgeries can be highly effective for some people and nearly useless for others. Long-term studies have found that 30 percent of those who receive the same procedure Barb did regain at least one-quarter of what they lost within two years of reaching their weight nadir; more than half regain that much within five years.

if the effects of Barb’s surgery were quickly wearing off, its side effects were not: She now had iron, calcium, and B12 deficiencies resulting from the changes to her gut. She looked into getting a revision of the surgery—a redo, more or less—but insurance wouldn’t cover it

She found that every health concern she brought to doctors might be taken as a referendum, in some way, on her body size. “If I stubbed my toe or whatever, they’d just say ‘Lose weight.’ ” She began to notice all the times she’d be in a waiting room and find that every chair had arms. She realized that if she was having a surgical procedure, she’d need to buy herself a plus-size gown—or else submit to being covered with a bedsheet when the nurses realized that nothing else would fit.

Barb grew angrier and more direct about her needs—You’ll have to find me a different chair, she started saying to receptionists. Many others shared her rage. Activists had long decried the cruel treatment of people with obesity: The National Association to Advance Fat Acceptance had existed, for example, in one form or another, since 1969; the Council on Size & Weight Discrimination had been incorporated in 1991. But in the early 2000s, the ideas behind this movement began to wend their way deeper into academia, and they soon gained some purchase with the public.

“Our public-health efforts to address obesity have failed,” Eric Finkelstein, the economist, told me.

Others attacked the very premise of a “healthy weight”: People do not have any fundamental need, they argued, morally or medically, to strive for smaller bodies as an end in itself. They called for resistance to the ideology of anti-fatness, with its profit-making arms in health care and consumer goods. The Association for Size Diversity and Health formed in 2003; a year later, dozens of scholars working on weight-related topics joined together to create the academic field of fat studies.

As the size-diversity movement grew, its values were taken up—or co-opted—by Big Business. Dove had recently launched its “Campaign for Real Beauty,” which included plus-size women. (Ad Age later named it the best ad campaign of the 21st century.) People started talking about “fat shaming” as something to avoid

By 2001, Bacon, who uses they/them pronouns, had received their Ph.D. and finished a rough draft of a book, Health at Every Size, which drew inspiration from a broader movement by that name among health-care practitioners

But something shifted in the ensuing years. In 2007, Bacon got a different response, and the book was published. Health at Every Size became a point of entry for a generation of young activists and, for a time, helped shape Americans’ understanding of obesity.

Some experts were rethinking their advice on food and diet. At UC Davis, a physiologist named Lindo Bacon who had struggled to overcome an eating disorder had been studying the effects of “intuitive eating,” which aims to promote healthy, sustainable behavior without fixating on what you weigh or how you look

The heightened sensitivity started showing up in survey data, too. In 2010, fewer than half of U.S. adults expressed support for giving people with obesity the same legal protections from discrimination offered to people with disabilities. In 2015, that rate had risen to three-quarters.

In Bacon’s view, the 2000s and 2010s were glory years. “People came together and they realized that they’re not alone, and they can start to be critical of the ideas that they’ve been taught,” Bacon told me. “We were on this marvelous path of gaining more credibility for the whole Health at Every Size movement, and more awareness.”

that sense of unity proved short-lived; the movement soon began to splinter. Black women have the highest rates of obesity, and disproportionately high rates of associated health conditions. Yet according to Fatima Cody Stanford, an obesity-medicine physician at Harvard Medical School, Black patients with obesity get lower-quality care than white patients with obesity.

That system was exactly what Bacon and the Health at Every Size movement had set out to reform. The problem, as they saw it, was not so much that Black people lacked access to obesity medicine, but that, as Bacon and the Black sociologist Sabrina Strings argued in a 2020 article, Black women have been “specifically targeted” for weight loss, which Bacon and Strings saw as a form of racism

But members of the fat-acceptance movement pointed out that their own most visible leaders, including Bacon, were overwhelmingly white. “White female dietitians have helped steal and monetize the body positive movement,” Marquisele Mercedes, a Black activist and public-health Ph.D. student, wrote in September 2020. “And I’m sick of it.”

Tensions over who had the standing to speak, and on which topics, boiled over. In 2022, following allegations that Bacon had been exploitative and condescending toward Black colleagues, the Association for Size Diversity and Health expelled them from its ranks and barred them from attending its events.

As the movement succumbed to in-fighting, its momentum with the public stalled. If attitudes about fatness among the general public had changed during the 2000s and 2010s, it was only to a point. The idea that some people can indeed be “fit but fat,” though backed up by research, has always been a tough sell.

Although Americans had become less inclined to say they valued thinness, measures of their implicit attitudes seemed fairly stable. Outside of a few cities such as San Francisco and Madison, Wisconsin, new body-size-discrimination laws were never passed.

In the meantime, thinness was coming back into fashion

In the spring of 2022, Kim Kardashian—whose “curvy” physique has been a media and popular obsession—boasted about crash-dieting in advance of the Met Gala. A year later, the model and influencer Felicity Hayward warned Vogue Business that “plus-size representation has gone backwards.” In March of this year, the singer Lizzo, whose body pride has long been central to her public persona, told The New York Times that she’s been trying to lose weight. “I’m not going to lie and say I love my body every day,” she said.

Among the many other dramatic effects of the GLP-1 drugs, they may well have released a store of pent-up social pressure to lose weight.

If ever there was a time to debate that impulse, and to question its origins and effects, it would be now. But Puhl told me that no one can even agree on which words are inoffensive. The medical field still uses obesity, as a description of a diagnosable disease. But many activists despise that phrase—some spell it with an asterisk in place of the e—and propose instead to reclaim fat.

Everyone seems to agree on the most important, central fact: that we should be doing everything we can to limit weight stigma. But that hasn’t been enough to stop the arguing.

Things feel surreal these days to just about anyone who has spent years thinking about obesity. At 71, after more than four decades in the field, Thomas Wadden now works part-time, seeing patients just a few days a week. But the arrival of the GLP-1 drugs has kept him hanging on for a few more years, he said. “It’s too much of an exciting period to leave obesity research right now.”

When everyone is on semaglutide or tirzepatide, will the soft-drink companies—Brownell’s nemeses for so many years—feel as if a burden has been lifted? “My guess is the food industry is probably really happy to see these drugs come along,” he said. They’ll find a way to reach the people who are taking GLP‑1s, with foods and beverages in smaller portions, maybe. At the same time, the pressures to cut back on where and how they sell their products will abate.

the triumph in obesity treatment only highlights the abiding mystery of why Americans are still getting fatter, even now

Perhaps one can lay the blame on “ultraprocessed” foods, he said. Maybe it’s a related problem with our microbiomes. Or it could be that obesity, once it takes hold within a population, tends to reproduce itself through interactions between a mother and a fetus. Others have pointed to increasing screen time, how much sleep we get, which chemicals are in the products that we use, and which pills we happen to take for our many other maladies.

“The GLP-1s are just a perfect example of how poorly we understand obesity,” Mozaffarian told me. “Any explanation of why they cause weight loss is all post-hoc hand-waving now, because we have no idea. We have no idea why they really work and people are losing weight.”

The new drugs—and the “new understanding of obesity” that they have supposedly occasioned—could end up changing people’s attitudes toward body size. But in what ways

When the American Medical Association declared obesity a disease in 2013, Rebecca Puhl told me, some thought “it might reduce stigma, because it was putting more emphasis on the uncontrollable factors that contribute to obesity.” Others guessed that it would do the opposite, because no one likes to be “diseased.”

why wasn’t there another kind of nagging voice that wouldn’t stop—a sense of worry over what the future holds? And if she wasn’t worried for herself, then what about for Meghann or for Tristan, who are barely in their 40s? Wouldn’t they be on these drugs for another 40 years, or even longer? But Barb said she wasn’t worried—not at all. “The technology is so much better now.” If any problems come up, the scientists will find solutions.

He didn’t realize that the air actually didn’t need to be sterilized, and he gives up the donkey engine in later years.

The solution that is thrown out there is that they should burn these hospitals down and start anew because the crisis is growing.

It originally was a cure-all. It was actually used more commonly to cure gonorrhea, until it was finally turned into mouthwash.

Lister is the only person who will do it. He performed this mastectomy on his dining-room table in his house in Glasgow.

Did you have this in the back of your mind while writing about Lister, the way science can work in cycles?

The biggest pushback from Lister came from his own colleagues.

many of the new salaried arrangements have evolved from hospitals looking for new revenues, and could have the opposite effect. For example, when doctors’ practices are bought by a hospital, a colonoscopy or stress test performed in the office can suddenly cost far more because a hospital “facility fee” is tacked on. Likewise, Mr. Smith said, many doctors on salary are offered bonuses tied to how much billing they generate, which could encourage physicians to order more X-rays and tests.

“From the hospital end there’s a big feeding frenzy, a lot of bidding going on to bring in doctors,” Mr. Mechanic said. “And physicians are going in so they don’t have to worry

The base salaries of physicians who become employees are still related to the income they can generate, ranging from under $200,000 for primary care doctors to $575,000 in cardiology to $663,000 in neurosurgery,

Dr. Jacowitz said that the economics drove the choice and that the only other option would have been to bring in more revenue by practicing bad medicine — ordering more heart tests on patients who did not need them

“The question now is how to shift the compensation from a focus on volume to a focus on quality,” said Mr. Smith of Merritt Hawkins. He said that 35 percent of the jobs he recruits for currently have such incentives, “but it’s pennies, not enough to really influence behavior.”

And suppose it takes five days between a person’s getting infected and their infecting others. After 30 days, the more transmissible virus is now causing 26, or 64, times as many new cases as the less transmissible one.

Not every case will be mild, though, and even a small hospitalization rate on top of a huge case number will be a big number.

Now, as my colleague Ed Yong reports, Omicron could push a collapsing health-care system further into disaster. Hospitals are already dealing with the flu and other winter viruses. They’re already canceling elective surgeries.

If there are no changes to behavior or policy, this year’s winter wave would peak at about double the hospitalizations of last winter at its worst, and 20 percent more deaths, according to the most pessimistic of projections

The most optimistic projection sees a caseload similar to last winter’s, but hospitalizations and deaths at about half of where they were back then, assuming the vaccines keep up their very high protection against severe illness.

If that holds, it’s a “huge decrease,” Meyers says, and one that matches the assumptions of her team’s grimmer—but not grimmest—projections. When they modeled scenarios where vaccine effectiveness against hospitalization dropped by about that much, they saw a difference of tens of thousands of deaths.

Very preliminary data from South Africa’s largest health insurer suggest that two doses of the Pfizer-BioNTech vaccine were 70 percent effective at preventing hospitalization from Omicron infections, down from 93 percent before.

Vaccine protection against severe illness should be more durable than it is against infection, but may still take a hit

The available evidence on Omicron’s inherent severity is likely to be biased in ways that make it appear more promising. First of all, hospitalizations lag infections.

Second, the first people infected may skew young and are thus more likely to have mild cases regardless of the variant

third, some of the mildness attributed to the virus may result instead from existing immunity. In South Africa, where doctors are reporting relatively low hospitalizations compared with previous waves, many cases are probably reinfections

The South Africa health-insurer data suggest that Omicron might carry a 29 percent lower risk of hospitalization than the original virus, when adjusted for risk factors including age, sex, vaccination status, and documented prior infection—but many prior infections may be undocumented, which would make the reduction in risk seem bigger than it really is. (A recent analysis of early U.K. cases found “at most, limited changes in severity compared with Delta.”)

Either way, in the short run, we will have a massive number of Omicron cases on top of a massive number of Delta cases. Together they will infect huge numbers of people, vaccinated or not

The record-tampering charges accused Mr. Daleiden and Ms. Merritt of making and presenting fake California driver’s licenses, with the intent to defraud, for their April meeting at Planned Parenthood in Houston.

Abortion opponents claimed that the videos, which were released starting in July, revealed that Planned Parenthood was engaged in the illegal sale of body parts — a charge that the organization has denied and that has not been supported in numerous congressional and state investigations triggered by the release of the videos.

In a statement on Monday night, Mr. Daleiden said: “The Center for Medical Progress uses the same undercover techniques that investigative journalists have used for decades in exercising our First Amendment rights to freedom of speech and of the press, and follows all applicable laws. We respect the processes of the Harris County district attorney, and note that buying fetal tissue requires a seller as well. Planned Parenthood still cannot deny the admissions from their leadership about fetal organ sales captured on video for all the world to see.”

The release of the videos last summer created a furor and gave new strength to the conservative drive to defund Planned Parenthood. The organization was forced to apologize for the casual tone that one of its officials had used to discuss a possible transfer of fetal tissue to what she believed was a legitimate medical company. But Planned Parenthood said the fees being discussed were to cover costs and were legal. Advertisement Continue reading the main story Advertisement Continue reading the main story

In spite of this, the Stockholm Consensus, which was adopted by the IOC in 2004, required transgender Olympic hopefuls to wait “two years after gonadectomy [removal of the gonads]” to be eligible for competition.

the Women’s Sports Foundation, and the It Takes a Team! campaign noted that “any athletic advantages a transgender girl or woman arguably may have as a result of her prior testosterone levels dissipate after about one year of estrogen therapy.”

The standards have been in place and uncontested for 38 years.

Pediatric heart experts appointed by the state to look out for children with heart defects took exception.

Jacobs recommended the hospital stop performing heart surgery on babies younger than 6 months

Those babies had surgery at St. Mary's, but when their health spiraled downward, they were transferred to other hospitals.

In 2013 and 2014, Tenet contributed $50,000 each year to Let's Get to Work, Scott's political action committee. The next largest Tenet contribution those years to a state candidate's PAC was $25,000.

Doctors outside the state said they were surprised that Florida would move to repeal its own safety standards for children

An internationally renowned cardiac expert agreed that the standards are necessary

In December, a judge ruled in the state's favor and said the standards for pediatric heart hospitals could be taken off the books.

These are not real stories. Taking Aunt Jemima off of a syrup bottle, rebranding Mr. Potato Head or changing the name of the Washington football team, doesn't tell us anything foreboding about our culture other than the fact that, like all cultures, it evolves.

Americans are suffering: While the hyper-wealthy may be thriving, the pandemic has widened already extreme American inequality into a yawning chasm; while liberal Democrats want to tax ultra-millionaires and billionaires and more moderate ones want to increase corporate taxes to get some assistance to the many who are struggling, Republican lawmakers who spent their time in power supporting Trump's tax cuts for the rich now say we can't afford a relief package.

An 11-year-old boy froze to death in Texas last month when the state's power system failed; the Biden administration is currently worried that their infrastructure package will face vast right-wing opposition. Our health care system is so broken that a 7-year-old girl in Alabama has started a lemonade stand to pay for the brain surgery she needs; the GOP continues to attack the Affordable Care Act and undermine any effort to move toward a universal health care system.

Clinton did not mention Gabbard by name but said she believes one candidate is "the favorite of the Russians."

Clinton was referring to the GOP grooming Gabbard, not Russians.

Gabbard reacted by tweeting that Clinton is “the queen of warmongers, embodiment of corruption, and personification of the rot that sickened the Democratic Party for so long."

Trump attacked Clinton for the suggestion earlier this week, and said Clinton and other Democrats claim everyone opposed to them is a Russian agent.

ratic presidential candidate Tulsi Gabbard said Thursday that she will not run for re-election for her U.S. representative seat, saying she wants to focus on trying to secure her party’s nomination to challenge President Donald Trump.Gabbard, who represents Hawaii, made the announcement in a video and email to supporters."I believe that I can best serve the people of Hawaii and our country as your president and commander-in-chief," Gabbard said in the video.Let our news meet your inbox. The news and stories that matters, delivered weekday mornings.Sign UpThis site is protected by recaptcha Privacy Policy | Terms of Service She also expressed gratitude to the people of Hawaii for her nearly seven years in Congress.In January, Hawaii state Sen. Kai Kahele, a Democrat, said he would run for Gabbard's seat, NBC affiliate KHNL of Honolulu reported.An Iowa Democratic caucus poll out this week put Gabbard at 3 percent, with former Vice President Joe Biden, Massachusetts Sen. Elizabeth Warren, and South Bend, Indiana, Mayor Pete Buttigieg in the top three spots.She is in a crowded field of Democrats seeking the nomination to run for president. Another candidate, U.S. Rep. Tim Ryan, D-Ohio, ended his long-shot presidential campaign Thursday.RecommendedvideovideoMcConnell: If the House impeaches Trump, Senate will hold trial 'until we finish'2020 Election2020 ElectionTim Ryan drops out of presidential raceHillary Clinton recently suggested that she believed Republicans were grooming one of the Democrats for a third-party candidacy. Clinton did not mention Gabbard by name but said she believes one candidate is "the favorite of the Russians."

Largely an office procedure when widespread screening was first recommended, colonoscopies have moved into surgery centers — which were created as a step down from costly hospital care but are now often a lucrative step up from doctors’ examining rooms — where they are billed like a quasi operation.

The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees.

While several cheaper and less invasive tests to screen for colon cancer are recommended as equally effective by the federal government’s expert panel on preventive care — and are commonly used in other countries — colonoscopy has become the go-to procedure in the United States. “We’ve defaulted to by far the most expensive option, without much if any data to support it,”

Hospitals, drug companies, device makers, physicians and other providers can benefit by charging inflated prices, favoring the most costly treatment options and curbing competition that could give patients more, and cheaper, choices. And almost every interaction can be an opportunity to send multiple, often opaque bills with long lists of charges: $100 for the ice pack applied for 10 minutes after a physical therapy session, or $30,000 for the artificial joint implanted in surgery.

Even doctors often do not know the costs of the tests and procedures they prescribe. When Dr. Michael Collins, an internist in East Hartford, Conn., called the hospital that he is affiliated with to price lab tests and a colonoscopy, he could not get an answer. “It’s impossible for me to think about cost,” he said

The more than $35,000 annually that Ms. Yapalater and her employer collectively pay in premiums — her share is $15,000 — for her family’s Oxford Freedom Plan would be more than sufficient to cover their medical needs in most other countries. She and her husband, Jeff, 63, a sales and marketing consultant, have three children in their 20s with good jobs. Everyone in the family exercises, and none has had a serious illness.

A major factor behind the high costs is that the United States, unique among industrialized nations, does not generally regulate or intervene in medical pricing, aside from setting payment rates for Medicare and Medicaid, the government programs for older people and the poor. Many other countries deliver health care on a private fee-for-service basis, as does much of the American health care system, but they set rates as if health care were a public utility or negotiate fees with providers and insurers nationwide, for example.

“In the U.S., we like to consider health care a free market,” said Dr. David Blumenthal, president of the Commonwealth Fund and a former adviser to President Obama. ”But it is a very weird market, riddled with market failures.”

Consumers, the patients, do not see prices until after a service is provided, if they see them at all. And there is little quality data on hospitals and doctors to help determine good value, aside from surveys conducted by popular Web sites and magazines. Patients with insurance pay a tiny fraction of the bill, providing scant disincentive for spending.

The United States spends about 18 percent of its gross domestic product on health care, nearly twice as much as most other developed countries. The Congressional Budget Office has said that if medical costs continue to grow unabated, “total spending on health care would eventually account for all of the country’s economic output.”

Instead, payments are often determined in countless negotiations between a doctor, hospital or pharmacy, and an insurer, with the result often depending on their relative negotiating power. Insurers have limited incentive to bargain forcefully, since they can raise premiums to cover costs.

“People think it’s like other purchases: that if you pay more you get a better car. But in medicine, it’s not like that.”

Any endocrinologist or other physician who rejects this approach is alleged to be endangering the health and even the life of his patients.

Research shows that some 80% of children with “gender dysphoria” eventually come to terms with their sex without surgical or pharmaceutical intervention

But are these patients really “transgender”

Multiple studies have found that most kids who are confused or distressed about their sex end up realizing they’re gay—nearly two-thirds in a 2021 study of boys

This makes sense: Gay kids often don’t conform to traditional sex roles. But gender ideology holds that feminine boys and masculine girls may be “born in the wrong body.”

In this light, “gender-affirming care” looks a lot like conversion therapy.

Now it takes the form of rendering teenagers sterile and sexually dysfunctional for life.

linicians from the main U.K. transgender service referred to prescribing puberty blockers as “transing the gay away”—a play on the description of old-fashioned conversion-therapy as “praying the gay away.” A clinician who resigned from the U.K. service accused it of “institutional homophobia.” Clinicians at the service had a “dark joke” that “there would be no gay people left at the rate Gids”—the Gender Identity Service—“was going.”

Consistent with conversion therapy, physicians are telling young gays and lesbians that something is wrong with them, based on a regressive view of what it is to be male or female

The resulting interventions often create lifelong medical problems, both physical and mental. Contrary to advocates’ claims, there’s no evidence that puberty blockers, cross-sex hormones, or surgeries reduce the risk of suicide.

Children who take this road face a lifetime of pain, infertility and anguish

society has been told that accepting transgender identity is the same as accepting gays and lesbians. But it isn’t. Even well-intentioned acceptance of transgender identity disproportionately harms them

But only a handful of cancers—of the breast, lung, colon and cervix—have screening tests recommended by the U.S. Preventive Services Task Force

Many companies are developing blood tests that can detect cancer signals before symptoms occur, and Grail’s is the most advanced. A study found it can identify more than 50 types of cancer 52% of the time and the 12 deadliest cancers in Stages I through III 68% of the time.

There’s a hitch. The test costs $949 and isn’t covered by Medicare or most private insurance.

The trouble is that this cancer is almost never caught early. There’s no routine screening for it, and symptoms don’t develop until it is advanced. Mr. Royse, 64, had no idea he was sick until he took a blood test called Galleri, produced by the Menlo Park, Calif., startup Grail. He had surgery and chemotherapy and is now cancer-free.

Mr. Royse visited Grail’s website, which referred him to a telemedicine provider who ordered a test. Another telemedicine doctor walked him through his results, which showed a cancer signal likely emanating from the pancreas, gallbladder, stomach or esophagus.

An MRI revealed a suspicious mass on his pancreas, which a biopsy confirmed was cancerous. Mr. Royse had three months of chemotherapy, surgery and another three months of chemotherapy, which ended last February. Because pancreatic cancer often recurs, he gets CT and MRI scans every three months. In addition, he has signed up for startup Natera’s Signatera customized blood test, which checks DNA specific to the patient’s cancer and can signal its return before signs are visible on the scans

Grail’s test likewise looks for DNA shed by cancer cells, which is tagged by molecules called methyl groups that are specific to a cancer’s origin. Grail uses genetic sequencing and machine learning to recognize links between DNA methyl groups and particular cancers

The test “is based on how much DNA is being shed by tumor,” Grail’s president, Josh Ofman, says. “Some tumors shed a lot of DNA. Some shed almost none.

ut slow-growing tumors typically aren’t shedding a lot of DNA.” That reduces the probability that Grail’s test will identify indolent cancers that pose no immediate danger.

Grail’s test has a roughly 0.5% false-positive rate, meaning 1 in 200 patients who don’t have cancer will get a positive signal

Its positive predictive value is 43%, so that of every 100 patients with a positive signal, 43 actually have cancer

the legislation’s price tag could reduce political support. According to one private company’s estimate, the test could cost the government $39 billion to $145 billion over a decade. Mr. Goldman counters that analysts usually overestimate the costs and underestimate the benefits of medical interventions.

Because Grail uses machine learning to detect DNA-methylation cancer linkages, the Grail test’s accuracy should improve as more tests and patient data are collected

regulators may balk at approving the test, and insurers at covering it, until it becomes cheaper and more reliable.

How would the FDA weigh the risk that a false positive on a test like Grail’s could require invasive follow-up testing against the dire but hard-to-quantify risk that a deadly cancer wouldn’t be caught until it’s much harder to treat? It’s unclear.

some experts urge the FDA to require large randomized controlled trials before approving blood cancer tests. “Multicancer screening would entail tremendous costs and potentially substantial harms,” H. Gilbert Welch and Tanujit Dey of Brigham and Women’s Hospital wrote

Dr. Welch and Mr. Dey also suggested that companies should be required to prove their tests reduce overall mortality, even though the FDA doesn’t require drugmakers to prove their products reduce deaths or extend life. Clinical trials for the mRNA Covid vaccines didn’t show they reduced deaths.

One alternative is to rely on real-world studies, which Grail is already doing. One study of patients 50 and older without signs of cancer showed that the test doubled the number of cancers detected.

One recurring problem he has seen: “Epidemiologists are always getting cancer wrong,” he says. “Epidemiologists a decade ago said U.S. overtreats cancers. Well, no, the EU undertreats cancer.”

A 2012 study that he co-authored found that the higher U.S. spending on cancer care relative to Europe between 1983 and 1999 resulted in significantly higher survival rates for American patients than for those in Europe

By his study’s calculation, U.S. spending on cancer treatments during that period resulted in $556 billion in net benefits owing to reduced mortality.

He expects Galleri and other multicancer early-detection tests to reduce deaths and produce public-health and economic benefits that exceed their monetary costs

Expanding access to multicancer early-detection tests could also help solve the chicken-and-egg problem of drug development. Because few patients are diagnosed at early stages of some cancers, it’s hard to develop treatments for them

the positive predictive value for some recommended cancer screenings is far lower. Fewer than 1 in 10 women with an abnormal finding on a mammogram are diagnosed with breast cancer.

Mr. Royse makes the same point with personal force. “I would be dead right now if not for multicancer early-detection testing,” Mr. Royse told an FDA advisory committee last fall. “The longer the FDA waits, the more people are going to die. It’s that simple.”

The modern Keynesian state is broke, paralyzed and mired in empty ritual incantations about stimulating “demand,” even as it fosters a mutant crony capitalism that periodically lavishes the top 1 percent with speculative windfalls.

The future is bleak. The greatest construction boom in recorded history — China’s money dump on infrastructure over the last 15 years — is slowing. Brazil, India, Russia, Turkey, South Africa and all the other growing middle-income nations cannot make up for the shortfall in demand. The American machinery of monetary and fiscal stimulus has reached its limits. Japan is sinking into old-age bankruptcy and Europe into welfare-state senescence. The new rulers enthroned in Beijing last year know that after two decades of wild lending, speculation and building, even they will face a day of reckoning, too.

what’s at hand is a Great Deformation, arising from a rogue central bank that has abetted the Wall Street casino, crucified savers on a cross of zero interest rates and fueled a global commodity bubble that erodes Main Street living standards through rising food and energy prices — a form of inflation that the Fed fecklessly disregards in calculating inflation.

The way out would be so radical it can’t happen. It would necessitate a sweeping divorce of the state and the market economy. It would require a renunciation of crony capitalism and its first cousin: Keynesian economics in all its forms. The state would need to get out of the business of imperial hubris, economic uplift and social insurance and shift its focus to managing and financing an effective, affordable, means-tested safety net.

All this would require drastic deflation of the realm of politics and the abolition of incumbency itself, because the machinery of the state and the machinery of re-election have become conterminous. Prying them apart would entail sweeping constitutional surgery: amendments to give the president and members of Congress a single six-year term, with no re-election; providing 100 percent public financing for candidates; strictly limiting the duration of campaigns (say, to eight weeks); and prohibiting, for life, lobbying by anyone who has been on a legislative or executive payroll. It would also require overturning Citizens United and mandating that Congress pass a balanced budget, or face an automatic sequester of spending.

It would also require purging the corrosive financialization that has turned the economy into a giant casino since the 1970s. This would mean putting the great Wall Street banks out in the cold to compete as at-risk free enterprises, without access to cheap Fed loans or deposit insurance. Banks would be able to take deposits and make commercial loans, but be banned from trading, underwriting and money management in all its forms.

It would require, finally, benching the Fed’s central planners, and restoring the central bank’s original mission: to provide liquidity in times of crisis but never to buy government debt or try to micromanage the economy. Getting the Fed out of the financial markets is the only way to put free markets and genuine wealth creation back into capitalism.

If this sounds like advice to get out of the markets and hide out in cash, it is.

If there is one thing that economists know, it is that market concentration drives prices up — and quality and innovation down.

hospitals raise prices by about 40 percent after the merger of nearby rivals.

Other studies have found that hospital mergers increase the number of uninsured in the vicinity. Still others even suggest that market concentration may hurt the quality of care.

recent evidence suggests that health care costs are not being driven by intensive use of high-tech procedures as much as by rising prices for even the most humdrum treatments, which are today among the most expensive in the world.

the rising health care spending of Americans under 65 in the last two years has been driven entirely by rising prices; not by more use. The unit price of inpatient care jumped 5.9 percent last year, while the price for outpatient services increased 9.6 percent.

Corporate America could help more. Large companies, like Wal-Mart Stores, Lowe’s and PepsiCo, have cut deals with hospitals like the Mayo Clinic or the Cleveland Clinic to provide specialized care, including cardiac care or spinal surgery, for all their workers across the nation. This will allow them to get around the market power of local hospitals. Others could follow their example.

The Affordable Care Act could help reduce prices too. Forced to compete on price, plans in the new health insurance exchanges will pressure medical providers to limit costs, much as H.M.O.’s did briefly in the 1990s. The “Cadillac tax” on high-end health plans will also encourage some companies to drop high-priced policies.

Merger activity has jumped in anticipation of the law’s coming fully into effect. “Hospitals want to maintain their revenue streams and enhance their bargaining leverage,” said Professor Gaynor. “This is a way to do so.”

Through social media, “sharing with friends” is rationalized to the point of relentless efficiency. The current apex of such rationalization is frictionless sharing: we no longer need to perform the labor of telling our individual friends about what we read online, or of copy-pasting links and emailing them to “the list,” or of clicking a button for one-step posting of links on our Facebook walls. With frictionless sharing, all we have to do is look, or listen; what we’ve read or watched or listened to is then “shared” or “scrobbled” to our Facebook, Twitter, Tumblr, or whatever other online profiles. Whether we share content actively or passively, however, we feel as though we’ve done our half of the friendship-labor by ‘pushing’ the information to our walls, streams, and tumblelogs. It’s then up to our friends to perform their halves of the friendship-labor by ‘pulling’ the information we share from those platforms.

We’re busy people; we like the idea of making one announcement on Facebook and being done with it, rather than having to repeat the same story over and over again to different friends individually. We also like not always having to think about which friends might like which stories or songs; we like the idea of sharing with all of our friends at once, and then letting them sort out amongst themselves who is and isn’t interested. Though social media can create burdensome expectations to keep up with strong ties, weak ties, and everyone in between, social media platforms can also be very efficient. Using the same moment of friendship-labor to tend multiple friendships at once kills more birds with fewer stones.

sometimes we like the devolution of friendship. When we have to ‘pull’ friendship-content instead of receiving it in a ‘push’, we can pick and choose which content items to pull. We can ignore the baby pictures, or the pet pictures, or the sushi pictures—whatever it is our friends post that we only pretend to care about

Within devolved friendship interactions, it takes less effort to be polite while secretly waiting for someone to please just stop talking.

While I won’t go so far as to say they’re definitely ‘problems,’ there are two major things about devolved friendship that I think are worth noting. The first is the non-uniform rationalization of friendship-labor, and the second is the depersonalization of friendship-labor.

In short, “sharing” has become a lot easier and a lot more efficient, but “being shared with” has become much more time-consuming, demanding, and inefficient (especially if we don’t ignore most of our friends most of the time). Given this, expecting our friends to keep up with our social media content isn’t expecting them to meet us halfway; it’s asking them to take on the lion’s share of staying in touch with us. Our jobs (in this role) have gotten easier; our friends’ jobs have gotten harder.

The second thing worth noting is that devolved friendship is also depersonalized friendship.

Personal interaction doesn’t just happen on Spotify, and since I was hoping Spotify would be the New Porch, I initially found Spotify to be somewhat lonely-making. It’s the mutual awareness of presence that gives companionate silence its warmth, whether in person or across distance. The silence within Spotify’s many sounds, on the other hand, felt more like being on the outside looking in. This isn’t to say that Spotify can’t be social in a more personal way; once I started sending tracks to my friends, a few of them started sending tracks in return. But it took a lot more work to get to that point, which gets back to the devolution of friendship (as I explain below).

I’ve been thinking since, however, on what it means to view our friends as “generalized others.” I may now feel like less of like “creepy stalker” when I click on a song in someone’s Spotify feed, but I don’t exactly feel ‘shared with’ either. Far as I know, I’ve never been SpotiVaguebooked (or SubSpotified?); I have no reason to think anyone is speaking to me personally as they listen to music, or as they choose not to disable scrobbling (if they make that choice consciously at all). I may have been granted the opportunity to view something, but it doesn’t follow that what I’m viewing has anything to do with me unless I choose to make it about me. Devolved friendship means it’s not up to us to interact with our friends personally; instead it’s now up to our friends to make our generalized broadcasts personal.

When we consider the lopsided rationalization of ‘sharing’ and ‘shared with,’ as well as the depersonalization of frictionless sharing and generalized broadcasting, what becomes clear is this: the social media deck is stacked in such a way as to make being ‘a self’ easier and more rewarding than being ‘a friend.’

It’s easy to share, to broadcast, to put our selves and our tastes and our identity performances out into the world for others to consume; what feedback and friendship we get in return comes in response to comparatively little effort and investment from us. It takes a lot more work, however, to do the consumption, to sift through everything all (or even just some) of our friends produce, to do the work of connecting to our friends’ generalized broadcasts so that we can convert their depersonalized shares into meaningful friendship-labor.

We may be prosumers of social media, but the reward structures of social media sites encourage us to place greater emphasis on our roles as share-producers—even though many of us probably spend more time consuming shared content than producing it. There’s a reason for this, of course; the content we produce (for free) is what fuels every last ‘Web 2.0’ machine, and its attendant self-centered sociality is the linchpin of the peculiarly Silicon Valley concept of “Social” (something Nathan Jurgenson and I discuss together in greater detail here). It’s not super-rewarding to be one of ten people who “like” your friend’s shared link, but it can feel rewarding to get 10 “likes” on something you’ve shared—even if you have hundreds or thousands of ‘friends.’ Sharing is easy; dealing with all that shared content is hard.

t I wonder sometimes if the shifts in expectation that accompany devolved friendship don’t migrate across platforms and contexts in ways we don’t always see or acknowledge. Social media affects how we see the world—and how we feel about being seen in the world—even when we’re not engaged directly with social media websites. It’s not a stretch, then, to imagine that the affordances of social media platforms might also affect how we see friendship and our obligations as friends most generally.

Gloves and soap have vanished from some hospitals. Often, cancer medicines are found only on the black market. There is so little electricity that the government works only two days a week to save what energy is left.

At the University of the Andes Hospital in the mountain city of Mérida, there was not enough water to wash blood from the operating table. Doctors preparing for surgery cleaned their hands with bottles of seltzer water.

The hospital has no fully functioning X-ray or kidney dialysis machines because they broke long ago. And because there are no open beds, some patients lie on the floor in pools of their blood.

This nation has the largest oil reserves in the world, yet the government saved little money for hard times when oil prices were high.

So without water, gloves, soap or antibiotics, a group of surgeons prepared to remove an appendix that was about to burst, even though the operating room was still covered in another patient’s blood.

In April, the authorities arrested its director, Aquiles Martínez, and removed him from his post. Local news reports said he was accused of stealing equipment meant for the hospital, including machines to treat people with respiratory illnesses, as well as intravenous solutions and 127 boxes of medicine.

In a supply room, cockroaches fled as the door swung open.

Ms. Parucho, a diabetic, was unable to receive kidney dialysis because the machines were broken. An infection had spread to her feet, which were black that night. She was going into septic shock.

A holiday had been declared by the government to save electricity, and the blood bank took donations only on workdays.

For the past two and a half months, the hospital has not had a way to print X-rays. So patients must use a smartphone to take a picture of their scans and take them to the proper doctor.

Near him, a handwritten sign read, “We sell antibiotics — negotiable.” A black-market seller’s number was listed.

The ninth floor of the hospital is the maternity ward, where the seven babies had died the day before. A room at the end of the hall was filled with broken incubators.

The day of the power blackout, Dr. Rodríguez said, the hospital staff tried turning on the generator, but it did not work.

The joy he takes in humiliating women is not something he even bothers to disguise. He told the journalist Timothy L. O’Brien, “My favorite part [of the movie Pulp Fiction] is when Sam has his gun out in the diner and he tells the guy to tell his girlfriend to shut up. Tell that bitch to be cool. Say: ‘Bitch be cool.’ I love those lines.” Or as he elegantly summed up his view to New York magazine in the early ’90s, “Women, you have to treat them like shit.”

Women labor under a cloud of Trump’s distrust. “I have seen women manipulate men with just a twitch of their eye—or perhaps another body part,” he wrote in Trump: The Art of the Comeback. Working moms are particularly lacking in loyalty, he believes, and thus do not make for good employees. “She’s not giving me 100 percent. She’s giving me 84 percent, and 16 percent is going towards taking care of children,

This is one reason that evangelicals, both men and women, gravitate to Trump, despite his obvious lack of interest in religion and blatantly loose morals. He represents the possibility of a return to patriarchy, to a time when men were men, and didn’t have to apologize for it

In 1989, Trump had returned home from a painful scalp-reduction surgery, intended to remove a bald spot. His ex-wife Ivana had suggested the doctor—and he blamed her for his suffering. He held her arms and began pulling hair from her scalp, then tore off her clothes. Hurt writes: “Then he jams his penis inside her for the first time in more than sixteen months. Ivana is terrified … It is a violent assault. According to versions she repeats to some of her closest confidantes, ‘he raped me.’ ” When the story resurfaced last summer, Trump’s campaign disavowed it. When Hurt was writing his book, Trump’s lawyers forced the author to include a statement from Ivana in the book, “A Note to Readers,” which softens the account but doesn’t disavow it: “As a woman, I felt violated, as the love and tenderness, which he normally exhibited towards me, was absent. I referred to this as a ‘rape,’ but I do not want my words to be interpreted in a literal or criminal sense.”

The scene offers a graphic summation of Trump’s retrograde beliefs and real brutality. What’s worse, the same spirit informs his politics—the rampant cruelty, the violent impulses, the thirst for revenge, the absence of compassion. Misogyny isn’t an incidental part of Donald Trump. It’s who he is.