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Consider RCR Arquitectes’ choice to run its shop in a town of 30,000 people, instead of the nearby metropolis Barcelona. It’s quaint in that way—practically mom-and-pop. Yet, the firm’s three architects work collaboratively, building open structures that anyone can enjoy, the jury says. It’s a much lighter declaration than choosing, say, a woman like Jeanne Gang or an Iranian practice like Admun Studio.

RCR Arquitectes’s buildings evoke the same sentiment, by letting light and greenery inside.

as soon as law firms begin measuring their performance by the revenue each attorney generates, money begins to supplant all other means of assessing performance.

To professionals who choose careers in fields such as law, medicine, and teaching, it is demoralizing to be treated as a unit of production. Even some of the lawyers earning millions of dollars report that they find little or no fulfillment in the work they do.

by stoking the flames of competition between law firms and attorneys, the current system has engrained what economists call a “zero-sum” mentality. There is only a relatively fixed quantity of legal work to be done, and for one firm or attorney to command more of it, others must make due with less.

As a professional, a lawyer represents her clients in the courtroom, in her office and at the negotiating table. She operates with an appreciation for her role in the adversarial judicial process, the need to educate clients about the limits and purpose of the law, and the importance of helping clients create frameworks to work together to form organizations, build businesses, and plan for the future. Doing these things well provides a sense of meaning and value in work.

As a mere service provider, by contrast, her role is to provide a discrete technical service—usually assumed to be the same as any other lawyer would provide—for a fee. Her success is measured not in the professional insight and practical wisdom she offers but in the technical efficiency with which she provides services and her ability to attract other clients willing to pay her to do the same. The sense of professional fulfillment associated with the role of service provider is small at best. 

These articles are submitted to a group from Translators Without Borders that produces medical articles for Wikipedias in languages spoken in countries that often lack high-quality medical information. Examples include an article in Javanese on dengue fever and one in Hindi on urinary tract infection. Creating these high-quality medical articles fits neatly with efforts by the Wikimedia Foundation to make deals with cellphone carriers to provide Wikipedia content free of data charges, especially in the developing world

“If we want to get high-quality information to all the world’s population, Wikipedia is not just a viable option, but the only viable option,” Dr. Azzam said.

There might be other explanations. With any infection, there are four basic questions to ask when looking at broad differences in death rates. Is the virus different here versus there? NO. Right now, there is no evidence that the virus is mutating toward a more potent strain in the US.Is one country diagnosing the virus sooner than another? YES. As above, this may be skewing German and South Korean results by identifying asymptomatic and mildly symptomatic persons unlikely to require medical care. Hospitalization rates by country, currently not tracked, would help sort out the contribution of aggressive testing to survival rates. Is the infected patient different here versus there? YES. South Korea (young patients) and Italy (old patients) are unique in the outbreak, and the characteristics in Iran are not well known. All other countries with specific information, from China to even the US epicenter of New York City, have shown the same basic distribution with respect to age, sex (more men than women) and smoking. Is the health care system different here versus there? OH YES. Health care system differences at the country level are hard to examine: information is sparse and, given the 50,000-foot view, possibly misleading. However, health care experts typically can rely on "structural measures" to determine the quality of a hospital or a state or a country.

The World Bank tracks health care information by country on three relevant structural measures (though recentness of information varies country to country), each measured per 1,000 general population: doctors, nurses and hospital beds. They and other sources also track two other relevant variables: lifespan per country and health care spending per individual. Neither of these demonstrate differences in affected Western European countries that might explain a difference in Covid-19 survival.

Among the nine countries with the highest number of Covid-19 cases, the country that has the highest nurse rate also has the lowest death rate from the disease. Germany has 13.2 nurses per 1,000 (echoing a trend for high nurse numbers throughout Northern Europe) far above the other heavily Covid-19 affected countries. This may be just another armchair epidemiologist observation of course. But higher numbers of nurses may reflect one of two beneficial factors (or both): first, that nurses, the backbone of hospital (and especially ICU) care, are essential to patient management and, ultimately, survival.

Either way, it is a reminder that Covid-19 will continue to reveal the strengths and weaknesses of health care systems across the world. The current observed differences also mandate that, when we finally are out from underneath the weight of the current crisis, we must work to determine how we can deliver better health care to large populations across the world.

It also calls on each doctor to pledge to learn about the social determinants of health "to use my voice as a physician to advocate for a more equitable health care system from the local to the global level."

Some doctors have said they worry that the proliferation of different versions of physician oaths could weaken their intended effect on the profession

At the meeting, my colleague Dr. Benard P. Dreyer, professor of pediatrics at New York University and a past president of the Academic Pediatric Association, called on pediatricians to take on poverty as a serious underlying threat to children’s health. He was prompted, he told me later, by the widening disparities between rich and poor, and the gathering weight of evidence about the importance of early childhood, and the ways that deprivation and stress in the early years of life can reduce the chances of educational and life success.

When Tony Blair became prime minister of Britain, amid growing socioeconomic disparities, he made it a national goal to cut child poverty in half in 10 years. It took a coalition of political support and a combination of measures that increased income, especially in families with young children (minimum wage, paid maternity and paternity leaves, tax credits), and better services — especially universal preschool programs. By 2010, reducing child poverty had become a goal across the British political spectrum, and child poverty had fallen to 10.6 percent of children below the absolute poverty line (similar to the measure used in the United States), down from 26.1 percent in 1999.

Dr. Dreyer said: “Income matters. You get people above the poverty level, and they actually are better parents. It’s critical to get people out of poverty, but in addition our focus has to be on also giving families supports for other aspects of their lives — parenting, interventions in primary care, universal preschool.”

Robert H. Dugger, managing partner of Hanover Investment Group, who made the economic case for investing in young children. “History shows that productivity increases when people are able to access their rights to life, liberty and the pursuit of happiness,” Mr. Dugger told me. “There is no economic recovery strategy stronger than committing to early childhood and K-through-12 investment.”

the mouth feel of soda and many other food items, especially those high in fat, is second only to the bliss point in its ability to predict how much craving a product will induce.

He organized focus-group sessions with the people most responsible for buying bologna — mothers — and as they talked, he realized the most pressing issue for them was time. Working moms strove to provide healthful food, of course, but they spoke with real passion and at length about the morning crush, that nightmarish dash to get breakfast on the table and lunch packed and kids out the door.

as the focus swung toward kids, Saturday-morning cartoons started carrying an ad that offered a different message: “All day, you gotta do what they say,” the ads said. “But lunchtime is all yours.”

When it came to Lunchables, they did try to add more healthful ingredients. Back at the start, Drane experimented with fresh carrots but quickly gave up on that, since fresh components didn’t work within the constraints of the processed-food system, which typically required weeks or months of transport and storage before the food arrived at the grocery store. Later, a low-fat version of the trays was developed, using meats and cheese and crackers that were formulated with less fat, but it tasted inferior, sold poorly and was quickly scrapped.

One of the company’s responses to criticism is that kids don’t eat the Lunchables every day — on top of which, when it came to trying to feed them more healthful foods, kids themselves were unreliable. When their parents packed fresh carrots, apples and water, they couldn’t be trusted to eat them. Once in school, they often trashed the healthful stuff in their brown bags to get right to the sweets.

This idea — that kids are in control — would become a key concept in the evolving marketing campaigns for the trays. In what would prove to be their greatest achievement of all, the Lunchables team would delve into adolescent psychology to discover that it wasn’t the food in the trays that excited the kids; it was the feeling of power it brought to their lives.

The prevailing attitude among the company’s food managers — through the 1990s, at least, before obesity became a more pressing concern — was one of supply and demand. “People could point to these things and say, ‘They’ve got too much sugar, they’ve got too much salt,’ ” Bible said. “Well, that’s what the consumer wants, and we’re not putting a gun to their head to eat it. That’s what they want. If we give them less, they’ll buy less, and the competitor will get our market. So you’re sort of trapped.”

at last count, including sales in Britain, they were approaching the $1 billion mark. Lunchables was more than a hit; it was now its own category

he holds the entire industry accountable. “What do University of Wisconsin M.B.A.’s learn about how to succeed in marketing?” his presentation to the med students asks. “Discover what consumers want to buy and give it to them with both barrels. Sell more, keep your job! How do marketers often translate these ‘rules’ into action on food? Our limbic brains love sugar, fat, salt. . . . So formulate products to deliver these. Perhaps add low-cost ingredients to boost profit margins. Then ‘supersize’ to sell more. . . . And advertise/promote to lock in ‘heavy users.’ Plenty of guilt to go around here!”

men in the eastern part of Finland had the highest rate of fatal cardiovascular disease in the world. Research showed that this plague was not just a quirk of genetics or a result of a sedentary lifestyle — it was also owing to processed foods. So when Finnish authorities moved to address the problem, they went right after the manufacturers. (The Finnish response worked. Every grocery item that was heavy in salt would come to be marked prominently with the warning “High Salt Content.” By 2007, Finland’s per capita consumption of salt had dropped by a third, and this shift — along with improved medical care — was accompanied by a 75 percent to 80 percent decline in the number of deaths from strokes and heart disease.)

I tracked Lin down in Irvine, Calif., where we spent several days going through the internal company memos, strategy papers and handwritten notes he had kept. The documents were evidence of the concern that Lin had for consumers and of the company’s intent on using science not to address the health concerns but to thwart them. While at Frito-Lay, Lin and other company scientists spoke openly about the country’s excessive consumption of sodium and the fact that, as Lin said to me on more than one occasion, “people get addicted to salt

the marketing team was joined by Dwight Riskey, an expert on cravings who had been a fellow at the Monell Chemical Senses Center in Philadelphia, where he was part of a team of scientists that found that people could beat their salt habits simply by refraining from salty foods long enough for their taste buds to return to a normal level of sensitivity. He had also done work on the bliss point, showing how a product’s allure is contextual, shaped partly by the other foods a person is eating, and that it changes as people age. This seemed to help explain why Frito-Lay was having so much trouble selling new snacks. The largest single block of customers, the baby boomers, had begun hitting middle age. According to the research, this suggested that their liking for salty snacks — both in the concentration of salt and how much they ate — would be tapering off.

Riskey realized that he and his colleagues had been misreading things all along. They had been measuring the snacking habits of different age groups and were seeing what they expected to see, that older consumers ate less than those in their 20s. But what they weren’t measuring, Riskey realized, is how those snacking habits of the boomers compared to themselves when they were in their 20s. When he called up a new set of sales data and performed what’s called a cohort study, following a single group over time, a far more encouraging picture — for Frito-Lay, anyway — emerged. The baby boomers were not eating fewer salty snacks as they aged. “In fact, as those people aged, their consumption of all those segments — the cookies, the crackers, the candy, the chips — was going up,” Riskey said. “They were not only eating what they ate when they were younger, they were eating more of it.” In fact, everyone in the country, on average, was eating more salty snacks than they used to. The rate of consumption was edging up about one-third of a pound every year, with the average intake of snacks like chips and cheese crackers pushing past 12 pounds a year

Riskey had a theory about what caused this surge: Eating real meals had become a thing of the past.

“We looked at this behavior, and said, ‘Oh, my gosh, people were skipping meals right and left,’ ” Riskey told me. “It was amazing.” This led to the next realization, that baby boomers did not represent “a category that is mature, with no growth. This is a category that has huge growth potential.”

The food technicians stopped worrying about inventing new products and instead embraced the industry’s most reliable method for getting consumers to buy more: the line extension.

He zeroed right in on the Cheetos. “This,” Witherly said, “is one of the most marvelously constructed foods on the planet, in terms of pure pleasure.” He ticked off a dozen attributes of the Cheetos that make the brain say more. But the one he focused on most was the puff’s uncanny ability to melt in the mouth. “It’s called vanishing caloric density,” Witherly said. “If something melts down quickly, your brain thinks that there’s no calories in it . . . you can just keep eating it forever.”

Frito-Lay acquired Stacy’s Pita Chip Company, which was started by a Massachusetts couple who made food-cart sandwiches and started serving pita chips to their customers in the mid-1990s. In Frito-Lay’s hands, the pita chips averaged 270 milligrams of sodium — nearly one-fifth a whole day’s recommended maximum for most American adults — and were a huge hit among boomers.

There’s a paradox at work here. On the one hand, reduction of sodium in snack foods is commendable. On the other, these changes may well result in consumers eating more. “The big thing that will happen here is removing the barriers for boomers and giving them permission to snack,” Carey said. The prospects for lower-salt snacks were so amazing, he added, that the company had set its sights on using the designer salt to conquer the toughest market of all for snacks: schools

The company’s chips, he wrote, were not selling as well as they could for one simple reason: “While people like and enjoy potato chips, they feel guilty about liking them. . . . Unconsciously, people expect to be punished for ‘letting themselves go’ and enjoying them.” Dichter listed seven “fears and resistances” to the chips: “You can’t stop eating them; they’re fattening; they’re not good for you; they’re greasy and messy to eat; they’re too expensive; it’s hard to store the leftovers; and they’re bad for children.” He spent the rest of his memo laying out his prescriptions, which in time would become widely used not just by Frito-Lay but also by the entire industry.

Dichter advised Frito-Lay to move its chips out of the realm of between-meals snacking and turn them into an ever-present item in the American diet. “The increased use of potato chips and other Lay’s products as a part of the regular fare served by restaurants and sandwich bars should be encouraged in a concentrated way,”

the largest weight-inducing food was the potato chip. The coating of salt, the fat content that rewards the brain with instant feelings of pleasure, the sugar that exists not as an additive but in the starch of the potato itself — all of this combines to make it the perfect addictive food. “The starch is readily absorbed,” Eric Rimm, an associate professor of epidemiology and nutrition at the Harvard School of Public Health and one of the study’s authors, told me. “More quickly even than a similar amount of sugar. The starch, in turn, causes the glucose levels in the blood to spike” — which can result in a craving for more.

If Americans snacked only occasionally, and in small amounts, this would not present the enormous problem that it does. But because so much money and effort has been invested over decades in engineering and then relentlessly selling these products, the effects are seemingly impossible to unwind.

Todd Putman, who worked at Coca-Cola from 1997 to 2001, said the goal became much larger than merely beating the rival brands; Coca-Cola strove to outsell every other thing people drank, including milk and water. The marketing division’s efforts boiled down to one question, Putman said: “How can we drive more ounces into more bodies more often?”

the cost to collect molecular data from each blood sample was about $2,500 — which did not include the cost of analysis. But the price for tests similar to Dr. Snyder’s will also decline in the future

Dr. Church looks forward to the day when current research becomes a routine clinical procedure that combines inherited genomic information with analyses of RNA, proteins, metabolites and microbes in our bodies.

Dr. Snyder is a co-founder of a company, Personalis, in Palo Alto, Calif., that is developing software and other tools to interpret genomes after sequencing

“It’s throughout all the private schools here,” said DeAnsin Parker, a New York psychologist who treats many adolescents from affluent neighborhoods like the Upper East Side. “It’s not as if there is one school where this is the culture. This is the culture.”

The D.E.A. lists prescription stimulants like Adderall and Vyvanse (amphetamines) and Ritalin and Focalin (methylphenidates) as Class 2 controlled substances — the same as cocaine and morphine — because they rank among the most addictive substances that have a medical use.

The number of prescriptions for A.D.H.D. medications dispensed for young people ages 10 to 19 has risen 26 percent since 2007, to almost 21 million yearly, according to IMS Health, a health care information company — a number that experts estimate corresponds to more than two million individuals.

While these medicines tend to calm people with A.D.H.D., those without the disorder find that just one pill can jolt them with the energy and focus to push through all-night homework binges and stay awake during exams afterward. “It’s like it does your work for you,”

But abuse of prescription stimulants can lead to depression and mood swings (from sleep deprivation), heart irregularities and acute exhaustion or psychosis during withdrawal, doctors say. Little is known about the long-term effects of abuse of stimulants among the young

the pills eventually become an entry to the abuse of painkillers and sleep aids.

“Once you break the seal on using pills, or any of that stuff, it’s not scary anymore — especially when you’re getting A’s,” said the boy who snorted Adderall in the parking lot. He spoke from the couch of his drug counselor, detailing how he later became addicted to the painkiller Percocet and eventually heroin.

“Children have prefrontal cortexes that are not fully developed, and we’re changing the chemistry of the brain. That’s what these drugs do

merely giving a friend an Adderall or Vyvanse pill is the same as selling it and can be prosecuted as a felony.

Doctors and teenagers from more than 15 schools across the nation with high academic standards estimated that the portion of students who do so ranges from 15 percent to 40 percent.

“These are academic steroids. But usually, parents don’t get the steroids for you.”

“They’re the quote-unquote good kids, basically.”

After 30 minutes, the buzz began, she said: laser focus, instant recall and the fortitude to crush any test in her path.

“It wasn’t that hard of a decision. Do I want only four hours of sleep and be a mess, and then underperform on the test and then in field hockey? Or make the teachers happy and the coach happy and get good grades, get into a good college and make my parents happy?”

Madeleine estimated that one-third of her classmates at her small school, most of whom she knew well, used stimulants without a prescription to boost their scholastic performance. Many students across the United States made similar estimates for their schools, all of them emphasizing that the drugs were used not to get high, but mostly by conscientious students to work harder and meet ever-rising academic expectations.

Every school identified in this article was contacted regarding statements by its students and stimulant abuse in general. Those that responded generally said that they were concerned about some teenagers turning to these drugs, but that their numbers were far smaller than the students said.

This is one of the more vexing problems with stimulants in high schools, experts said — the drugs enter the schools via students who get them legally, if not legitimately.

Newer long-lasting versions like Adderall XR and Vyvanse allow parents to give children a single dose in the morning, often unaware that the pills can go down a pants pocket as easily as the throat. Some students said they took their pills only during the week and gave their weekend pills to friends.

She said many parents could push as hard for prescriptions as their children did, telling her: “My child is not doing well in school. I understand there are meds he can take to make him smarter.”

“They’re the A students, sometimes the B students, who are trying to get good grades,”

Asked if the improper use of stimulants was cheating, students were split. Some considered that the extra studying hours and the heightened focus during exams amounted to an unfair advantage. Many countered that the drugs “don’t give you the answers” and defended their use as a personal choice for test preparation, akin to tutoring.

One consensus was clear: users were becoming more common, they said, and some students who would rather not take the drugs would be compelled to join them because of the competition over class rank and colleges’ interest.

“Junior and senior year is a whole new ballgame,” the boy said. “I promised myself I wouldn’t take it, but that can easily, easily change. I can be convinced.”

the new regulation so far hasn't had a chilling effect on medical innovation: "Even though the Federal Joint Committee ruled 27 prescription drugs to have no added benefit, only five of these drugs have left the German market as a result."

Bahr's approach to pharmaceutical price regulation is market-driven, if you think about it. Why not force drug makers to compete with each other to prove they're providing added bang for patients' buck? Evzio, meet invisible hand.

The American style of drug pricing, meanwhile, is like shopping for clothes with a blindfold on, as Princeton economics professor Uwe Reinhardt put it. "In a truly competitive market, both the prices and the inherent qualities of the goods or services being traded are known to all parties ahead of any trade," he wrote in the Times' Economix blog. "By contrast, in the American healthcare market, both the price and the quality of health care have been kept studiously hidden from patients."

That percentage was up to 37 by 2003. Today, half of America's homeless are over 50.

In fact, people born in the second half of the baby boom (1955-1964) have had an elevated risk of homelessness compared to other age groups throughout their lives.

funded by the National Institute on Aging, has been asking 350 participants in a study we've been conducting since July 2013 in Oakland, California.

In the United States, more than 30 percent of renters and 23 percent of homeowners aged 50 and older spend more than half of their household income on rent.

California has the highest housing costs of any large state, and they are rising faster than elsewhere. It is not surprising that Oakland has a large homeless population.

common perception of homelessness is that it is a problem that afflicts only those with mental health and substance use problems.

They are also disproportionately people of color: Oakland's population is 28 percent African American, but 80 percent of our study participants are.

One of our participants spoke of the shock of losing his job after 27 years:

As research shows, homeless people in their 50's and 60's have similar or worse health problems than people in the general population who are in their 70's and 80's.

The point our study highlights is that the systems set up in the 1980s were not designed to serve an aging population.

An individual who has spent 30 years rotating between institutional care and the streets requires different services than a 54-year-old man who has become homeless for the first time after a period of extended unemployment.

Blondness, then, exists as a complicated form of self-expression. It can signal youth, beauty, privilege, and conformity. But it can also represent rebellion, independence, and the demand to be looked at and respected. It’s a choice that’s both distinctly personal and deeply intertwined with what society has taught people to value. Rankine and Lucas have a term for that: complicit freedom

The data also revealed that the death rate was higher among patients with cardiac injury versus those without: 42 of the patients with cardiac injury, or 51.2%, died versus 15 of those without, or 4.5%.

Also, acute inflammatory responses due to an infection can lead to reduced blood flow in patients with preexisting cardiovascular diseases, the researchers noted. They wrote that "based on these lines of evidence, we hypothesize that an intense inflammatory response superimposed on preexisting cardiovascular disease may precipitate cardiac injury."Investigating inflammation

"Even though they're not dying from that cardiac injury, something about that biomarker is providing some prognostic value beyond other risk factors that were controlled, so it could still be important in terms of identifying high-risk patients that enter the hospital with Covid-19," Gump said.

To better understand that mechanism, Madjid said that he has looked to flu viruses.

The finding's in Wednesday's JAMA Cardiology paper "make a lot of sense," Kevin Heffernan, director of the Human Performance Laboratory at Syracuse University in New York, who was not involved in the study, wrote in an email on Wednesday.

A separate study published in the New England Journal of Medicine in 2018 found a significant association between respiratory infections, especially influenza, and acute heart attack, he said.

Inflammation appears to be the mechanism that best explains the association between cardiac injury and Covid-19, said Dr. Mohammad Madjid, a cardiologist and assistant professor at McGovern Medical School at UTHealth in Houston.

"To date, many patients with COVID-19 are still hospitalized in China and other countries, such as Italy and Iran.

Therefore, we should be ready for the reemergence of COVID-19 or other coronaviruses."

On Friday, Major League Baseball turned up the heat, announcing that it is was pulling July’s All-Star Game and the M.L.B. draft out of the state.

The Senate minority leader, Mitch McConnell, has proclaimed corporations’ meddling “stupid” and released this ominous statement: “Corporations will invite serious consequences if they become a vehicle for far-left mobs to hijack our country from outside the constitutional order. Businesses must not use economic blackmail to spread disinformation and push bad ideas that citizens reject at the ballot box.”

As you’d imagine, the late-night comedians are having a field day with this mess. “Republicans say they’re going to boycott baseball,” riffed Jimmy Fallon on Monday. “They’re already boycotting the N.F.L. and the N.B.A. Soon their only sports will be golf and Jarts.”

Traditionally, a scientist submits her paper to a journal, which sends it to a (surprisingly small) group of peers for (several rounds of usually anonymous) comments; if the paper passes this (typically months-long) peer-review gantlet, it is published (often behind an expensive paywall). Languid and opaque, this system is ill-suited to a fast-moving outbreak. But biomedical scientists can now upload preliminary versions of their papers, or “preprints,” to freely accessible websites, allowing others to immediately dissect and build upon their results. This practice had been slowly gaining popularity before 2020, but proved so vital for sharing information about COVID‑19 that it will likely become a mainstay of modern biomedical research. Preprints accelerate science, and the pandemic accelerated the use of preprints. At the start of the year, one repository, medRxiv (pronounced “med archive”), held about 1,000 preprints. By the end of October, it had more than 12,000.

The U.S. is now catching up. In April, the NIH launched a partnership called ACTIV, in which academic and industry scientists prioritized the most promising drugs and coordinated trial plans across the country. Since August, several such trials have started.

Researchers have begun to uncover how SARS‑CoV‑2 compares with other coronaviruses in wild bats, the likely reservoir; how it infiltrates and co-opts our cells; how the immune system overreacts to it, creating the symptoms of COVID‑19. “We’re learning about this virus faster than we’ve ever learned about any virus in history,” Sabeti said.

Similar triumphs occurred last year—in other countries. In March, taking advantage of the United Kingdom’s nationalized health system, British researchers launched a nationwide study called Recovery, which has since enrolled more than 17,600 COVID‑19 patients across 176 institutions. Recovery offered conclusive answers about dexamethasone and hydroxychloroquine and is set to weigh in on several other treatments. No other study has done more to shape the treatment of COVID‑19.

SARS‑CoV‑2’s genome was decoded and shared by Chinese scientists just 10 days after the first cases were reported. By November, more than 197,000 SARS‑CoV‑2 genomes had been sequenced. About 90 years ago, no one had even seen an individual virus; today, scientists have reconstructed the shape of SARS‑CoV‑2 down to the position of individual atoms

Respiratory viruses, though extremely common, are often neglected. Respiratory syncytial virus, parainfluenza viruses, rhinoviruses, adenoviruses, bocaviruses, a quartet of other human coronaviruses—they mostly cause mild coldlike illnesses, but those can be severe. How often? Why? It’s hard to say, because, influenza aside, such viruses attract little funding or interest.

COVID‑19 has developed a terrifying mystique because it seems to behave in unusual ways. It causes mild symptoms in some but critical illness in others. It is a respiratory virus and yet seems to attack the heart, brain, kidneys, and other organs. It has reinfected a small number of people who had recently recovered. But many other viruses share similar abilities; they just don’t infect millions of people in a matter of months or grab the attention of the entire scientific community

Thanks to COVID‑19, more researchers are looking for these rarer sides of viral infections, and spotting them.

These factors pull researchers toward speed, short-termism, and hype at the expense of rigor—and the pandemic intensified that pull. With an anxious world crying out for information, any new paper could immediately draw international press coverage—and hundreds of citations.

“There’s a perception that they’re just colds and there’s nothing much to learn,” says Emily Martin of the University of Michigan, who has long struggled to get funding to study them. Such reasoning is shortsighted folly. Respiratory viruses are the pathogens most likely to cause pandemics, and those outbreaks could potentially be far worse than COVID‑19’s.

Their movements through the air have been poorly studied, too. “There’s this very entrenched idea,” says Linsey Marr at Virginia Tech, that viruses mostly spread through droplets (short-range globs of snot and spit) rather than aerosols (smaller, dustlike flecks that travel farther). That idea dates back to the 1930s, when scientists were upending outdated notions that disease was caused by “bad air,” or miasma. But the evidence that SARS‑CoV‑2 can spread through aerosols “is now overwhelming,”

Another pandemic is inevitable, but it will find a very different community of scientists than COVID‑19 did. They will immediately work to determine whether the pathogen—most likely another respiratory virus—moves through aerosols, and whether it spreads from infected people before causing symptoms. They might call for masks and better ventilation from the earliest moments, not after months of debate

They will anticipate the possibility of an imminent wave of long-haul symptoms, and hopefully discover ways of preventing them. They might set up research groups to prioritize the most promising drugs and coordinate large clinical trials. They might take vaccine platforms that worked best against COVID‑19, slot in the genetic material of the new pathogen, and have a vaccine ready within months

the single-minded focus on COVID‑19 will also leave a slew of negative legacies. Science is mostly a zero-sum game, and when one topic monopolizes attention and money, others lose out.

Long-term studies that monitored bird migrations or the changing climate will forever have holes in their data because field research had to be canceled.

negligence has left COVID‑19 long-haulers with few answers or options, and they initially endured the same dismissal as the larger ME community. But their sheer numbers have forced a degree of recognition. They started researching, cataloging their own symptoms. They gained audiences with the NIH and the World Health Organization. Patients who are themselves experts in infectious disease or public health published their stories in top journals. “Long COVID” is being taken seriously, and Brea hopes it might drag all post-infection illnesses into the spotlight. ME never experienced a pivot. COVID‑19 might inadvertently create one

Other epistemic trespassers spent their time reinventing the wheel. One new study, published in NEJM, used lasers to show that when people speak, they release aerosols. But as the authors themselves note, the same result—sans lasers—was published in 1946, Marr says. I asked her whether any papers from the 2020 batch had taught her something new. After an uncomfortably long pause, she mentioned just one.

The incentives to trespass are substantial. Academia is a pyramid scheme: Each biomedical professor trains an average of six doctoral students across her career, but only 16 percent of the students get tenure-track positions. Competition is ferocious, and success hinges on getting published

Conservationists who worked to protect monkeys and apes kept their distance for fear of passing COVID‑19 to already endangered species.

Among scientists, as in other fields, women do more child care, domestic work, and teaching than men, and are more often asked for emotional support by their students. These burdens increased as the pandemic took hold, leaving women scientists “less able to commit their time to learning about a new area of study, and less able to start a whole new research project,

published COVID‑19 papers had 19 percent fewer women as first authors compared with papers from the same journals in the previous year. Men led more than 80 percent of national COVID‑19 task forces in 87 countries. Male scientists were quoted four times as frequently as female scientists in American news stories about the pandemic.

American scientists of color also found it harder to pivot than their white peers, because of unique challenges that sapped their time and energy.

Science suffers from the so-called Matthew effect, whereby small successes snowball into ever greater advantages, irrespective of merit. Similarly, early hindrances linger. Young researchers who could not pivot because they were too busy caring or grieving for others might suffer lasting consequences from an unproductive year. COVID‑19 “has really put the clock back in terms of closing the gap for women and underrepresented minorities,”

In 1848, the Prussian government sent a young physician named Rudolf Virchow to investigate a typhus epidemic in Upper Silesia. Virchow didn’t know what caused the devastating disease, but he realized its spread was possible because of malnutrition, hazardous working conditions, crowded housing, poor sanitation, and the inattention of civil servants and aristocrats—problems that require social and political reforms. “Medicine is a social science,” Virchow said, “and politics is nothing but medicine in larger scale.”

entists discovered the microbes responsible for tuberculosis, plague, cholera, dysentery, and syphilis, most fixated on these newly identified nemeses. Societal factors were seen as overly political distractions for researchers who sought to “be as ‘objective’ as possible,” says Elaine Hernandez, a medical sociologist at Indiana University. In the U.S., medicine fractured.

New departments of sociology and cultural anthropology kept their eye on the societal side of health, while the nation’s first schools of public health focused instead on fights between germs and individuals. This rift widened as improvements in hygiene, living standards, nutrition, and sanitation lengthened life spans: The more social conditions improved, the more readily they could be ignored.

The ideological pivot away from social medicine began to reverse in the second half of the 20th century.

Politicians initially described COVID‑19 as a “great equalizer,” but when states began releasing demographic data, it was immediately clear that the disease was disproportionately infecting and killing people of color.

These disparities aren’t biological. They stem from decades of discrimination and segregation that left minority communities in poorer neighborhoods with low-paying jobs, more health problems, and less access to health care—the same kind of problems that Virchow identified more than 170 years ago.

In March, when the U.S. started shutting down, one of the biggest questions on the mind of Whitney Robinson of UNC at Chapel Hill was: Are our kids going to be out of school for two years? While biomedical scientists tend to focus on sickness and recovery, social epidemiologists like her “think about critical periods that can affect the trajectory of your life,” she told me. Disrupting a child’s schooling at the wrong time can affect their entire career, so scientists should have prioritized research to figure out whether and how schools could reopen safely. But most studies on the spread of COVID‑19 in schools were neither large in scope nor well-designed enough to be conclusive. No federal agency funded a large, nationwide study, even though the federal government had months to do so. The NIH received billions for COVID‑19 research, but the National Institute of Child Health and Human Development—one of its 27 constituent institutes and centers—got nothing.

The horrors that Rudolf Virchow saw in Upper Silesia radicalized him, pushing the future “father of modern pathology” to advocate for social reforms. The current pandemic has affected scientists in the same way

COVID‑19 could be the catalyst that fully reunifies the social and biological sides of medicine, bridging disciplines that have been separated for too long.

“To study COVID‑19 is not only to study the disease itself as a biological entity,” says Alondra Nelson, the president of the Social Science Research Council. “What looks like a single problem is actually all things, all at once. So what we’re actually studying is literally everything in society, at every scale, from supply chains to individual relationships.”

Doctors in the top 10 percent averaged $1.3 million

And those in the top 1 percent averaged an astounding $4 million, though most of that (85 percent) came from business income or capital gains.

In certain specialties, doctors see substantially more in their peak earning years: Neurosurgeons (about $920,000), orthopedic surgeons ($789,000) and radiation oncologists ($709,000) all did especially well for themselves. Specialty incomes cover 2005 to 2017 and are expressed in 2017 dollars.

family-practice physicians made around $230,000 a year. General practice ($225,000) and preventive-medicine ($224,000) doctors earned even less — though that’s still enough to put them at the top of the heap among all U.S. earners.

“There is this sense of, well, if you show that physician incomes put them at the top of the income distribution, then you’re somehow implying that they’re instead going into medicine because they want to make money. And that narrative is uncomfortable to people.”

why did those figures ruffle so many physician feathers?

“You can want to help people and you can simultaneously want to earn money and have a nicer lifestyle and demand compensation for long hours and long training. That’s totally normal behavior in the labor market.”

Yale University economist Jason Abaluck notes that when he asks the doctors and future doctors in his health economics classes why they earn so much, answers revolve around the brutal training required to enter the profession. “Until they finish their residency, they’re working an enormous number of hours and their lifestyle is not the lifestyle of a rich person,” Abaluck told us.

why do physicians make that much?

On average, doctors — much like anyone else — behave in ways that just happen to drive up their income. For example, the economists found that graduates from the top medical schools, who can presumably write their own ticket to any field they want, tend to choose those that pay the most.

“Our analysis shows that certainly physicians respond to earnings when choosing specialties,” Polyakova told us. “And there’s nothing wrong with that, in my opinion.

“In general, U.S. physicians are making about 50 percent more than German physicians and about more than twice as much as U.K. physicians,

Grover said the widest gaps were “really driven by surgeons and a handful of procedural specialties,” doctors who perform procedures with clear outcomes, rather than preventing disease or treating chronic condition

“we’re not about prevention, you know?” he said, noting that his own PhD is in public health. “I wish it was different, but it ain’t!”

The United States has fewer doctors per person than 27 out of 31 member countries tracked by the Organization for Economic Cooperation and Development

In 1970, based on a slightly different measure that’s been tracked for longer, America had more licensed physicians per person than all but two of the 10 countries for which we have data. What caused the collapse?

the United States has far fewer residency slots than qualified med school graduates, which means thousands of qualified future physicians are annually shut out of the residency pipeline, denied their chosen career and stuck with no way to pay back those quarter-million-dollar loans.

“I’d like to see an in-depth analysis of the effect of the government capping the number of residency spots and how it’s created an artificial ‘physician shortage’ even though we have thousands of talented and graduated doctors that can’t practice due to not enough residency spots,”

Such an analysis would begin with a deeply influential 1980 report,

That report, by a federal advisory committee tasked with ensuring the nation had neither too few nor too many doctors, concluded that America was barreling toward a massive physician surplus. It came out just before President Ronald Reagan took office, and the new administration seemed only too eager to cut back on federal spending on doctor-training systems.

ssociation of American Medical Colleges (AAMC), a coalition of MD-granting medical schools and affiliated teaching hospitals, slammed the brakes on a long expansion. From 1980 to around 2004, the number of medical grads flatlined, even as the American population rose 29 percent.

Federal support for residencies was also ratcheted down, making it expensive or impossible for hospitals to provide enough slots for all the medical school graduates hitting the market each year. That effort peaked with the 1997 Balanced Budget Act which, among other things, froze funding for residencies — partially under the flawed assumption that HMOs would forever reduce the need for medical care in America, Orr writes. That freeze has yet to fully unwind.

or decades, many policymakers believed more doctors caused higher medical spending. Orr says that’s partly true, but “the early studies failed to differentiate between increased availability of valuable medical services and unnecessary treatment and services.”

“In reality, the greater utilization in places with more doctors represented greater availability, both in terms of expanded access to primary care and an ever-growing array of new and more advanced medical services,” he writes. “The impact of physician supply on levels of excessive treatment appears to be either small or nonexistent.”

“People have a narrative that physician earnings is one of the main drivers of high health-care costs in the U.S.,” Polyakova told us. “It is kind of hard to support this narrative if ultimately physicians earn less than 10 percent of national health-care expenditures.”

Polyakova and her collaborators find doctor pay consumes only 8.6 percent of overall health spending. It grew a bit faster than inflation over the time period studied, but much slower than overall health-care costs.

Regardless, the dramatic limits on medical school enrollment and residencies enjoyed strong support from the AAMC and the AMA. We were surprised to hear both organizations now sound the alarm about a doctor shortage. MD-granting medical schools started expanding again in 2005.

it’s because states have responded to the shortage by empowering nurse practitioners and physician assistants to perform tasks that once were the sole province of physicians. Over the past 20 years, the number of registered nurses grew almost twice as quickly as the number of doctors, and the number of physician assistants grew almost three times as rapidly, our analysis showed.

While there still aren’t enough residency positions, we’re getting more thanks in part to recent federal spending bills that will fund 1,200 more slots over the next few years.

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. 

They also died of covid at higher rates than other health-care workers, and they experience high rates of burnout, “an occupational syndrome characterized by a high degree of emotional exhaustion and depersonalization, and a low sense of personal accomplishment at work,” according to the World Health Organization

high stress and anxiety are the “antecedents” to burnout. But you know you’ve hit the nadir when you become emotionally detached from your work. “It’s almost like a loss of meaning,” she said.

In April 2020, Miller said the public was “exalting nurses as these superheroes and angels,” while nurses themselves were tweeting about “the horrible working conditions, enormous amount of death without any break … being mentally and completely worn down and exhausted.”

Miller said nurses are experiencing “collective trauma,” a conclusion she reached by studying their social media usage through the pandemic

Before the pandemic, between a third and half of nurses and physicians already reported symptoms of burnout. A covid impact study published in March 2022 by the American Nurses Foundation found this number had risen to 60 percent among acute-care nurses. “Reports of feeling betrayed, undervalued, and unsupported have risen,

Miller and Groves also found a fivefold increase in references to quitting between the 2020 study and the 2021 study. “Our profession will never be the same,” Miller told me. “If you talked to any nurse who worked bedside through the pandemic, that’s what they’ll tell you.” From this, she says, has grown a desire to be heard. “We feel emboldened. We’re not as willing to be silent anymore.”

then, in late February 2013, Duke was abruptly fired. She’d posted a photo on Instagram showing an ER where hospital staff had just saved the life of a man hit by a subway train. It looked like a hurricane had blown through. There were no people in the photo, but Duke titled the post, “Man vs. 6 train.” She told me she wanted to showcase “the amazing things doctors and nurses do to save lives … the f---ing real deal.”

Duke says her superiors called her an “amazing nurse and team member” before they told her that “it was time to move on.” Her director handed her a printout of the Instagram post. According to Duke, he acknowledged that she hadn’t violated HIPAA or any hospital policies but said she’d been insensitive and unprofessional. She was escorted out of the building by security. When the episode aired, it showed Duke crying on the sidewalk outside the hospital.

She’d reposted the photo, with permission, from a male doctor’s Instagram account. He faced no repercussions. She now admits her caption was rather “cold” — especially compared with the doctor’s, “After the trauma.” In hindsight, she said, she might have been more sensitive. Maybe not even posted the photo at all. And yet this frustrates her. Why shouldn’t the public see nursing culture for what it really is? Man vs. 6 Train. “That’s ER speak,” she told me. “We say ‘head injury in room five.’ We don’t say ‘Mr. Smith in room five. We talk and think by mechanism of injury.”

But this is at odds with the romanticized image of the nurturing nurse — which hospitals often want to project. In some cases, nurses are explicitly told not to be forthright with their patients. “I know nurses in oncology who are not allowed to say to a patient and their family, ‘This will be the fourth clinical trial, but we all know your family member is dying,”

“The most frequent question is, ‘Katie, I have to get out of the hospital, but I don’t know what else to do.’” Her advice: “You have to create your own definition of what being a nursing professional means to you.” She has a ready list of alternative jobs, including “med spa” owner, educational consultant and YouTuber.