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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?”

three different factors that might be making harder for adults today to stay thin.

First, people are exposed to more chemicals that might be weight-gain inducing. Pesticides, flame retardants, and the substances in food packaging might all be altering our hormonal processes and tweaking the way our bodies put on and maintain weight.

Second, the use of prescription drugs has risen dramatically since the ‘70s and ‘80s. Prozac, the first blockbuster SSRI, came out in 1988. Antidepressants are now one of the most commonly prescribed drugs in the U.S., and many of them have been linked to weight gain.

the microbiomes of Americans might have somehow changed between the 1980s and now. It’s well known that some types of gut bacteria make a person more prone to weight gain and obesity. Americans are eating more meat than they were a few decades ago, and many animal products are treated with hormones and antibiotics in order to promote growth. All that meat might be changing gut bacteria in ways that are subtle, at first, but add up over time.

Kuk believes the proliferation of artificial sweeteners could also be playing a role.

“There's a huge weight bias against people with obesity,” she said. “They're judged as lazy and self-indulgent. That's really not the case

If our research is correct, you need to eat even less and exercise even more” just to be same weight as your parents were at your age.

A study published earlier this year showed how the number of people going hungry in the world had increased for the first time since the turn of the century, sparking concern that climate change and conflict could reverse years of progress. Malnutrition prevents almost a fifth of children in Ghana from growing properly. The problem is particularly acute in Bentum, Apprah and Nyanyano, rural communities with scant medical facilities Roughly 815 million people were going to bed hungry last year, compared with 777 million in 2015.

Now we have a body of research that makes the connection between stress and addiction definitive. More surprising, it shows that we can change the path to addiction by changing our environment.

Neuroscientists have found that food and recreational drugs have a common target in the “reward circuit” of the brain, and that the brains of humans and other animals who are stressed undergo biological changes that can make them more susceptible to addiction.

In a 2010 study, Diana Martinez and colleagues at Columbia scanned the brains of a group of healthy controls and found that lower social status and a lower degree of perceived social support — both presumed to be proxies for stress — were correlated with fewer dopamine receptors, called D2s, in the brain’s reward circuit

The reward circuit evolved to help us survive by driving us to locate food or sex in our environment

Today, the more D2 receptors you have, the higher your natural level of stimulation and pleasure — and the less likely you are to seek out recreational drugs or comfort food to compensate

people addicted to cocaine, heroin, alcohol and methamphetamines experience a significant reduction in their D2 receptor levels that persists long after drug use has stopped. These people are far less sensitive to rewards, are less motivated and may find the world dull, once again making them prone to seek a chemical means to enhance their everyday life.

Drug exposure also contributes to a loss of self-control. Dr. Volkow found that low D2 was linked with lower activity in the prefrontal cortex, which would impair one’s ability to think critically and exercise restraint

Food, like drugs, stimulates the brain’s reward circuit. Chronic exposure to high-fat and sugary foods is similarly linked with lower D2 levels, and people with lower D2 levels are also more likely to crave such foods. It’s a vicious cycle in which more exposure begets more craving.

At this point you may be wondering: What controls the reward circuit in the first place? Some of it is genetic. We know that certain gene variations elevate the risk of addiction to various drugs. But studies of monkeys suggest that our environment can trump genetics and rewire the brain.

simply by changing the environment, you can increase or decrease the likelihood of an animal becoming a drug addict.

The same appears true for humans. Even people who are not hard-wired for addiction can be made dependent on drugs if they are stressed

Is it any wonder, then, that the economically frightening situation that so many Americans experience could make them into addicts? You will literally have a different brain depending on your ZIP code, social circumstances and stress level.

In 1990, no state in our country had an adult obesity rate above 15 percent; by 2015, 44 states had obesity rates of 25 percent or higher. What changed?

What happened is that cheap, calorie-dense foods that are highly rewarding to your brain are now ubiquitous.

Nothing in our evolution has prepared us for the double whammy of caloric modern food and potent recreational drugs. Their power to activate our reward circuit, rewire our brain and nudge us in the direction of compulsive consumption is unprecedented.

The processed food industry has transformed our food into a quasi-drug, while the drug industry has synthesized ever more powerful drugs that have been diverted for recreational use.

Fortunately, our brains are remarkably plastic and sensitive to experience. Although it’s far easier said than done, just limiting exposure to high-calorie foods and recreational drugs would naturally reset our brains to find pleasure in healthier foods and life without drugs.

Bays said Wegovy appears far safer than earlier obesity drugs that "have gone down in flames" over safety problems.

The drug carries a potential risk for a type of thyroid tumor, so it shouldn't be taken by people with a personal or family history of certain thyroid and endocrine tumors. Wegovy also has a risk of depression and pancreas inflammation.

Wegovy (pronounced wee-GOH'-vee) is a synthesized version of a gut hormone that curbs appetite. Patients inject it weekly under their skin. Like other weight-loss drugs, it's to be used along with exercise, a healthy diet and other steps like keeping a food diary.

Wegovy builds on a trend in which makers of relatively new diabetes drugs test them to treat other conditions common in diabetics. For example, popular diabetes drugs Jardiance and Novo Nordisk's Victoza now have approvals for reducing risk of heart attack, stroke and death in heart patients.

What that index didn't take into account — and what has compounded months of governmental failures — is that even before COVID-19 arrived on its shores, the U.S. was an unusually sick country for its level of wealth and development.

High blood pressure, obesity and metabolic disorders are all on the rise in the U.S.

Healthy life expectancy — the number of years people can expect to live without disability — is 65.5 years in the U.S., more than two decades fewer than in Japan.

65,700 Americans died of drug overdoses in 2019, more than double the number in 2010. Those deaths account for more than half of all drug overdose fatalities worldwide and held down life expectancy in the U.S.

Mortality for mothers and children under 5 is 6.5 per 1,000 live births in the U.S., compared to 4.9 for other wealthy countries.

All in all, more than 40% of American adults have a pre-existing health condition that puts them at higher risk of severe COVID-19.

A study published in August found cardiovascular disease can double a patient's risk of dying from COVID-19, while diabetics — who number more than 30 million in the U.S. — are 1.5 times more likely to die.

Context: Lancet Editor-in-Chief Richard Horton has called COVID-19 a "syndemic" — a synergistic epidemic of a new and deadly infectious disease and numerous underlying health problems. The U.S. is squarely in the heart of that syndemic.

Those conditions are particularly prevalent in minority communities with unequal health care access that have disproportionately suffered from COVID-19.

A report from McKinsey earlier this month estimated that poor health costs the U.S. economy about $3.2 trillion a year

For every $1 invested in targeting population health, the U.S. stands to gain almost $4 in economic benefit, and altogether health improvements could add up to a 10% boost to U.S. GDP by 2040.

The bottom line: There is no excuse for the way the U.S. has mishandled COVID-19, but the seeds of this catastrophe were planted well before the novel coronavirus arrived on American shores.

2. How movement spread COVID-19

What's happening: Researchers in Germany studied the effect of entry bans and mandatory quarantines on COVID-19 mortality, and found the earlier such measures were implemented, the greater the effect they had on limiting deaths.

Of note: The study found mandatory quarantines for incoming travelers were more effective than outright entry bans, largely because such bans often exempted citizens and permanent residents, while quarantines usually applied to everyone.

The U.S. lost track of at least 1,600 people flying in from China in just the first few days after the ban went into effect, according to reporting from the AP.

Border controls are of little use if governments don't track and quarantine travelers coming from infected areas.

The bottom line: A virus only moves with its host. One lesson we should learn for future pandemics is that restricting that movement is key to controlling a new pathogen, even though the costs of such controls will only grow in a globalized world.

They will expand the presence of low- and no-calorie drinks, as well as drinks sold in smaller portions, and use their promotional skills to educate consumers and encourage them to reduce the calories they are drinking.

The program will cover company-owned vending machines and coolers in convenience stores, as well as fountain soda dispensers like those found in fast-food restaurants and movie theaters. The companies control almost all of those machines, in addition to about one-third of vending machines and 80 percent of coolers.

It also will spill into grocery stores in end-of-aisle promotions and other marketing. “We’ll use the most critical levers we have at our disposal, and the focus really will be on transforming the beverage landscape in the U.S. over the next 10 years,”

“While they’re making this pledge, they are totally dug in, fighting soda tax initiatives in places like Berkeley and San Francisco that have exactly the same goal,” said Professor Nestle, who has just finished a book about the industry.

From 2000 to 2013, calories consumed through sugary drinks fell 12 percent, according to Beverage Digest, attributed to declining soda sales and increased consumption of water and low-calorie drinks.

“I suspect they’re promising what’s going to happen anyway,” said Kelly Brownell, an expert on obesity and dean of the Sanford School of Public Policy at Duke University. “All the trends are showing decreased consumption of high-calorie beverages, and so what better way to get a public relations boost than to promise to do what’s happening anyway?”

one particularly cherished aspect of our diet might not just be an unhealthful indulgence but actually be toxic, that when you bake your children a birthday cake or give them lemonade on a hot summer day, you may be doing them more harm than good, despite all the love that goes with it.

I’ve spent much of the last decade doing journalistic research on diet and chronic disease — some of the more contrarian findings, on dietary fat, appeared in this magazine —– and I have come to conclusions similar to Lustig’s.

Republicans are the party of Big Energy and Big Food: they dominate contributions from extractive industries and agribusiness. And they are, in particular, the party of Big Pizza.

pizza partisanship tells you a lot about what is happening to American politics as a whole.

Why should pizza, of all things, be a divisive issue

The immediate answer is that it has been caught up in the nutrition wars

the pizza sector has chosen instead to take a stand for the right to add extra cheese.

The rhetoric of this fight is familiar. The pizza lobby portrays itself as the defender of personal choice and personal responsibility. It’s up to the consumer, so the argument goes, to decide what he or she wants to eat, and we don’t need a nanny state telling us what to do.

it doesn’t hold up too well once you look at what’s actually at stake in the pizza disputes.

what do contributions in the last election cycle say? The Democrats are, not too surprisingly, the party of Big Labor (or what’s left of it) and Big Law: unions and lawyers are the most pro-Democratic major interest groups.

Nutrition, where increased choice can be a bad thing, because it all too often leads to bad choices despite the best of intentions, is one of those areas — like smoking — where there’s a lot to be said for a nanny state.

diet isn’t purely a personal choice, either; obesity imposes large costs on the economy as a whole.

But you shouldn’t expect such arguments to gain much traction

For one thing, free-market fundamentalists don’t want to hear about qualifications to their doctrine

Also, with big corporations involved, the Upton Sinclair principle applies: It’s difficult to get a man to understand something when his salary depends on his not understanding it

nutritional partisanship taps into deeper cultural issues.

At one level, there is a clear correlation between lifestyles and partisan orientation: heavier states tend to vote Republican, and the G.O.P. lean is especially pronounced in what the Centers for Disease Control and Prevention call the “diabetes belt” of counties, mostly in the South, that suffer most from that particular health problem

At a still deeper level, health experts may say that we need to change how we eat, pointing to scientific evidence, but the Republican base doesn’t much like experts, science, or evidence. Debates about nutrition policy bring out a kind of venomous anger — much of it now directed at Michelle Obama, who has been championing school lunch reforms — that is all too familiar if you’ve been following the debate over climate change.

It is, instead, a case study in the toxic mix of big money, blind ideology, and popular prejudices that is making America ever less governable.

They worried that a vaccine would initially elude scientists, that weary citizens would abandon restrictions despite the risks, that the virus would be with us from now on.

Most experts believed that once the crisis was over, the nation and its economy would revive quickly. But there would be no escaping a period of intense pain.

Exactly how the pandemic will end depends in part on medical advances still to come. It will also depend on how individual Americans behave in the interim. If we scrupulously protect ourselves and our loved ones, more of us will live. If we underestimate the virus, it will find us.

More Americans may die than the White House admits.

The epidemiological model often cited by the White House, which was produced by the University of Washington’s Institute for Health Metrics and Evaluation, originally predicted 100,000 to 240,000 deaths by midsummer. Now that figure is 60,000.

The institute’s projection runs through Aug. 4, describing only the first wave of this epidemic. Without a vaccine, the virus is expected to circulate for years, and the death tally will rise over time.

Fatality rates depend heavily on how overwhelmed hospitals get and what percentage of cases are tested. China’s estimated death rate was 17 percent in the first week of January, when Wuhan was in chaos, according to a Center for Evidence-Based Medicine report, but only 0.7 percent by late February.

Various experts consulted by the Centers for Disease Control and Prevention in March predicted that the virus eventually could reach 48 percent to 65 percent of all Americans, with a fatality rate just under 1 percent, and would kill up to 1.7 million of them if nothing were done to stop the spread.

A model by researchers at Imperial College London cited by the president on March 30 predicted 2.2 million deaths in the United States by September under the same circumstances.

China has officially reported about 83,000 cases and 4,632 deaths, which is a fatality rate of over 5 percent. The Trump administration has questioned the figures but has not produced more accurate ones.

The tighter the restrictions, experts say, the fewer the deaths and the longer the periods between lockdowns. Most models assume states will eventually do widespread temperature checks, rapid testing and contact tracing, as is routine in Asia.

In this country, hospitals in several cities, including New York, came to the brink of chaos.

Only when tens of thousands of antibody tests are done will we know how many silent carriers there may be in the United States. The C.D.C. has suggested it might be 25 percent of those who test positive. Researchers in Iceland said it might be double that.

China is also revising its own estimates. In February, a major study concluded that only 1 percent of cases in Wuhan were asymptomatic. New research says perhaps 60 percent were.

The virus may also be mutating to cause fewer symptoms. In the movies, viruses become more deadly. In reality, they usually become less so, because asymptomatic strains reach more hosts. Even the 1918 Spanish flu virus eventually faded into the seasonal H1N1 flu.

The lockdowns will end, but haltingly.

it is likely a safe bet that at least 300 million of us are still vulnerable.

Until a vaccine or another protective measure emerges, there is no scenario, epidemiologists agreed, in which it is safe for that many people to suddenly come out of hiding. If Americans pour back out in force, all will appear quiet for perhaps three weeks.

The gains to date were achieved only by shutting down the country, a situation that cannot continue indefinitely. The White House’s “phased” plan for reopening will surely raise the death toll no matter how carefully it is executed.

Every epidemiological model envisions something like the dance

On the models, the curves of rising and falling deaths resemble a row of shark teeth.

Surges are inevitable, the models predict, even when stadiums, churches, theaters, bars and restaurants remain closed, all travelers from abroad are quarantined for 14 days, and domestic travel is tightly restricted to prevent high-intensity areas from reinfecting low-intensity ones.

In his wildly popular March 19 article in Medium, “Coronavirus: The Hammer and the Dance,” Tomas Pueyo correctly predicted the national lockdown, which he called the hammer, and said it would lead to a new phase, which he called the dance, in which essential parts of the economy could reopen, including some schools and some factories with skeleton crews.

Even the “Opening Up America Again” guidelines Mr. Trump issued on Thursday have three levels of social distancing, and recommend that vulnerable Americans stay hidden. The plan endorses testing, isolation and contact tracing — but does not specify how these measures will be paid for, or how long it will take to put them in place.

On Friday, none of that stopped the president from contradicting his own message by sending out tweets encouraging protesters in Michigan, Minnesota and Virginia to fight their states’ shutdowns.

China did not allow Wuhan, Nanjing or other cities to reopen until intensive surveillance found zero new cases for 14 straight days, the virus’s incubation period.

Compared with China or Italy, the United States is still a playground.Americans can take domestic flights, drive where they want, and roam streets and parks. Despite restrictions, everyone seems to know someone discreetly arranging play dates for children, holding backyard barbecues or meeting people on dating apps.

Even with rigorous measures, Asian countries have had trouble keeping the virus under control

But if too many people get infected at once, new lockdowns will become inevitable. To avoid that, widespread testing will be imperative.

Reopening requires declining cases for 14 days, the tracing of 90 percent of contacts, an end to health care worker infections, recuperation places for mild cases and many other hard-to-reach goals.

Immunity will become a societal advantage.

Imagine an America divided into two classes: those who have recovered from infection with the coronavirus and presumably have some immunity to it; and those who are still vulnerable.

“It will be a frightening schism,” Dr. David Nabarro, a World Health Organization special envoy on Covid-19, predicted. “Those with antibodies will be able to travel and work, and the rest will be discriminated against.”

Soon the government will have to invent a way to certify who is truly immune. A test for IgG antibodies, which are produced once immunity is established, would make sense

Dr. Fauci has said the White House was discussing certificates like those proposed in Germany. China uses cellphone QR codes linked to the owner’s personal details so others cannot borrow them.

As Americans stuck in lockdown see their immune neighbors resuming their lives and perhaps even taking the jobs they lost, it is not hard to imagine the enormous temptation to join them through self-infection

My daughter, who is a Harvard economist, keeps telling me her age group needs to have Covid-19 parties to develop immunity and keep the economy going,”

It would be a gamble for American youth, too. The obese and immunocompromised are clearly at risk, but even slim, healthy young Americans have died of Covid-19.

The virus can be kept in check, but only with expanded resources.

Resolve to Save Lives, a public health advocacy group run by Dr. Thomas R. Frieden, the former director of the C.D.C., has published detailed and strict criteria for when the economy can reopen and when it must be closed.

once a national baseline of hundreds of thousands of daily tests is established across the nation, any viral spread can be spotted when the percentage of positive results rises.

To keep the virus in check, several experts insisted, the country also must start isolating all the ill — including mild cases.

“If I was forced to select only one intervention, it would be the rapid isolation of all cases,”

In China, anyone testing positive, no matter how mild their symptoms, was required to immediately enter an infirmary-style hospital — often set up in a gymnasium or community center outfitted with oxygen tanks and CT scanners.

There, they recuperated under the eyes of nurses. That reduced the risk to families, and being with other victims relieved some patients’ fears.

Still, experts were divided on the idea of such wards

Ultimately, suppressing a virus requires testing all the contacts of every known case. But the United States is far short of that goal.

In China’s Sichuan Province, for example, each known case had an average of 45 contacts.

The C.D.C. has about 600 contact tracers and, until recently, state and local health departments employed about 1,600, mostly for tracing syphilis and tuberculosis cases.

China hired and trained 9,000 in Wuhan alone. Dr. Frieden recently estimated that the United States will need at least 300,000.

There will not be a vaccine soon.

any effort to make a vaccine will take at least a year to 18 months.

the record is four years, for the mumps vaccine.

for unclear reasons, some previous vaccine candidates against coronaviruses like SARS have triggered “antibody-dependent enhancement,” which makes recipients more susceptible to infection, rather than less. In the past, vaccines against H.I.V. and dengue have unexpectedly done the same.

A new vaccine is usually first tested in fewer than 100 young, healthy volunteers. If it appears safe and produces antibodies, thousands more volunteers — in this case, probably front-line workers at the highest risk — will get either it or a placebo in what is called a Phase 3 trial.

It is possible to speed up that process with “challenge trials.” Scientists vaccinate small numbers of volunteers, wait until they develop antibodies, and then “challenge” them with a deliberate infection to see if the vaccine protects them.

Normally, it is ethically unthinkable to challenge subjects with a disease with no cure, such as Covid-19.

“Fewer get harmed if you do a challenge trial in a few people than if you do a Phase 3 trial in thousands,” said Dr. Lipsitch, who recently published a paper advocating challenge trials in the Journal of Infectious Diseases. Almost immediately, he said, he heard from volunteers.

The hidden danger of challenge trials, vaccinologists explained, is that they recruit too few volunteers to show whether a vaccine creates enhancement, since it may be a rare but dangerous problem.

if a vaccine is invented, the United States could need 300 million doses — or 600 million if two shots are required. And just as many syringes.

“People have to start thinking big,” Dr. Douglas said. “With that volume, you’ve got to start cranking it out pretty soon.”

Treatments are likely to arrive first.

The modern alternative is monoclonal antibodies. These treatment regimens, which recently came very close to conquering the Ebola epidemic in eastern Congo, are the most likely short-term game changer, experts said.

as with vaccines, growing and purifying monoclonal antibodies takes time. In theory, with enough production, they could be used not just to save lives but to protect front-line workers.

Having a daily preventive pill would be an even better solution, because pills can be synthesized in factories far faster than vaccines or antibodies can be grown and purified.

Goodbye, ‘America First.’

A public health crisis of this magnitude requires international cooperation on a scale not seen in decades. Yet Mr. Trump is moving to defund the W.H.O., the only organization capable of coordinating such a response.

And he spent most of this year antagonizing China, which now has the world’s most powerful functioning economy and may become the dominant supplier of drugs and vaccines. China has used the pandemic to extend its global influence, and says it has sent medical gear and equipment to nearly 120 countries.

This is not a world in which “America First” is a viable strategy, several experts noted.

“If President Trump cares about stepping up the public health efforts here, he should look for avenues to collaborate with China and stop the insults,”

If we alienate the Chinese with our rhetoric, I think it will come back to bite us,” he said.“What if they come up with the first vaccine? They have a choice about who they sell it to. Are we top of the list? Why would we be?”

Once the pandemic has passed, the national recovery may be swift. The economy rebounded after both world wars, Dr. Mulder noted.

In one of the most provocative analyses in his follow-up article, “Coronavirus: Out of Many, One,” Mr. Pueyo analyzed Medicare and census data on age and obesity in states that recently resisted shutdowns and counties that voted Republican in 2016.

He calculated that those voters could be 30 percent more likely to die of the virus.

In the periods after both wars, Dr. Mulder noted, society and incomes became more equal. Funds created for veterans’ and widows’ pensions led to social safety nets, measures like the G.I. Bill and V.A. home loans were adopted, unions grew stronger, and tax benefits for the wealthy withered.

If a vaccine saves lives, many Americans may become less suspicious of conventional medicine and more accepting of science in general — including climate change

their explanation begins by dismantling several others.

Was the source of the problem America’s all-too-ready supply of prescription opioids?

About a million Americans now use heroin daily or near-daily. Many others use illicitly obtained synthetic opioids like fentanyl.

As Case and Deaton note, most people who abuse or become addicted to opioids continue to lead functional lives and many eventually escape their dependence

The oversupply of opioids did not create the conditions for despair. Instead, it appears, the oversupply fed upon a white working class already adrift.

although opioid deaths plateaued, at least temporarily, in 2018, suicides and alcohol-related deaths continue upward.

Could deaths of despair be related to the rising incidence of obesity?

Case and Deaton report that we’re seeing the same troubling health trends “among the underweight, normal weight, overweight, and obese.”

Is the problem poverty?

Overdose deaths are most common in high-poverty Appalachia and along the low-poverty Eastern Seaboard, in places such as Massachusetts, New Hampshire, Delaware, and Connecticut. Meanwhile, some high-poverty states, such as Arkansas and Mississippi, have been less affected. Black and Hispanic populations are poorer but less affected, too.

How about income inequality? Case and Deaton have found that patterns of inequality, like patterns of poverty, simply don’t match the patterns of mortality by race or region.

A consistently strong economic correlate, by contrast, is the percentage of a local population that is employed

In the late nineteen-sixties, Case and Deaton note, all but five per cent of men of prime working age, from twenty-five to fifty-four, had jobs; by 2010, twenty per cent did not.

What Case and Deaton have found is that the places with a smaller fraction of the working-age population in jobs are places with higher rates of deaths of despair—and that this holds true even when you look at rates of suicide, drug overdoses, and alcohol-related liver disease separately. They all go up where joblessness does.

Conservatives tend to offer cultural explanations

People are taking the lazy way out of responsibilities, the argument goes, and so they choose alcohol, drugs, and welfare and disability checks over a commitment to hard work, family, and community. And now they are paying the price for their hedonism and decadence—with addiction, emptiness, and suicide.

Yet, if the main problem were that a large group of people were withdrawing from the workforce by choice, wages should have risen in parallel.

Case and Deaton argue that the problem arises from the cumulative effect of a long economic stagnation and the way we as a nation have dealt with it

For the first few decades after the Second World War, per-capita U.S. economic growth averaged between two and three per cent a year. In the nineties, however, it dipped below two per cent. In the early two-thousands, it was less than one per cent. This past decade, it remained below 1.5 per cent.

Different populations have experienced this slowdown very differently

Anti-discrimination measures improved earnings and job prospects for black and Hispanic Americans. Though their earnings still lag behind those of the white working class, life for this generation of people of color is better than it was for the last.

Not so for whites without a college education. Among the men, median wages have not only flattened; they have declined since 1979. The work that the less educated can find isn’t as stable: hours are more uncertain, and job duration is shorter

Among advanced economies, this deterioration in pay and job stability is unique to the United States.

The United States has provided unusually casual access to means of death.

The problem isn’t that people are not the way they used to be. It’s that the economy and the structure of work are not the way they used to be

Today, about seventy-five per cent of college graduates are married by age forty-five, but only sixty per cent of non-college graduates are

Nonmarital childbearing has reached forty per cent among less educated white women.

Religious institutions previously played a vital role in connecting people to a community. But the number of Americans who attend religious services has declined markedly over the past half century, falling to just one-third of the general population today.

Case and Deaton see a picture of steady economic and social breakdown, amid over-all prosperity.

climate—the amount of social and economic instability not only in your life but also in your family and community—matters, too. Émile Durkheim pointed out more than a century ago that despair and then suicide result when people’s material and social circumstances fall below their expectations.

why has the steep rise in deaths of despair been so uniquely American

In the past four decades, Americans without bachelor’s degrees—the majority of the working-age population—have seen themselves become ever less valued in our economy. Their effort and experience provide smaller rewards than before, and they encounter longer periods between employment.

The availability of opioids has indeed played a role, and the same goes for firearms

The U.S. has also embraced automation and globalization with greater alacrity and fewer restrictions than other countries have. Displaced workers here get relatively little in the way of protection and support.

And we’ve enabled capital to take a larger share of the economic gains. “Economists long thought that the ratio of wages to profits was an immutable constant, about two to one,” Case and Deaton point out. But since 1970, they find, it has declined significantly.

A more unexpected culprit identified by Case and Deaton is our complicated and costly health-care system.

The focus of Case and Deaton’s indictment is on the fact that America’s health-care system is peculiarly reliant on employer-provided insurance.

As they show, the premiums that employers pay amount to a perverse tax on hiring lower-skilled workers.

According to the Kaiser Family Foundation, in 2019 the average family policy cost twenty-one thousand dollars, of which employers typically paid seventy per cent.

“For a well-paid employee earning a salary of $150,000, the average family policy adds less than 10 percent to the cost of employing the worker,” Case and Deaton write. “For a low-wage worker on half the median wage, it is 60 percent.”

between 1970 and 2016, the earnings that laborers received fell twenty-one per cent. But their total compensation, taken to include the cost of their benefits (in particular, health care), rose sixty-eight per cent. Increases in health-care costs have devoured take-home pay for those below the median income.

this makes American health care itself a prime cause of our rising death rates.

we must change the way we pay for health care. Instead of preserving a system that discourages employers from hiring, retaining, and developing workers without bachelor’s degrees, we need to make health-care payments proportional to wages—as with tax-based systems like Medicare.

So far, the American approach to the rise in white working-class mortality has been to pour resources into addiction-treatment centers and suicide-prevention programs. Yet the rates of suicide and addiction remain sky-high. It’s as if we’re using pressure dressings on a bullet wound to the chest instead of getting at the source of the bleeding.

Case and Deaton want us to recognize that the more widespread response is a sense of hopelessness and helplessness. And here culture does play a role.

When it comes to people whose lives aren’t going well, American culture is a harsh judge: if you can’t find enough work, if your wages are too low, if you can’t be counted on to support a family, if you don’t have a promising future, then there must be something wrong with you

We Americans are reluctant to acknowledge that our economy serves the educated classes and penalizes the rest. But that’s exactly the situation, and “Deaths of Despair” shows how the immiseration of the less educated has resulted in the loss of hundreds of thousands of lives, even as the economy has thrived and the stock market has soared.

capitalism, having failed America’s less educated workers for decades, must change, as it has in the past. “There have been previous periods when capitalism failed most people, as the Industrial Revolution got under way at the beginning of the nineteenth century, and again after the Great Depression,” they write. “But the beast was tamed, not slain.”

Today, the battles are over an employer-based system for financing health care, corporate governance that puts shareholders’ interests ahead of workers’, tax plans that benefit capital holders over wage earners.

We are better at addressing fast-moving crises than slow-building ones. It wouldn’t be surprising, then, if we simply absorbed current conditions as the new normal.

Case and Deaton report that poor health is becoming more common for each new generation of middle-aged, less-educated white Americans. And they are going downhill faster.

Case said the new research found a “sea of despair” across America. A striking feature is the rise in physical pain.

The nation’s obesity epidemic may be another sign of stress and physical pain, she continued: “People may want to soothe the beast. They may do that with alcohol, they may do that with drugs, they may do that with food.”

white men today are about twice as likely as they were in 1999 to die from one of the “diseases of despair,” while women are about four times as likely.

Deaton cited suicide as an action that could be triggered not by a single event but by a cumulative series of disappointments: “Your family life has fallen apart, you don’t know your kids anymore, all the things you expected when you started out your life just haven’t happened at all.”

“It’s just a background of continuous decline. You’re worse off than your parents,” Lleras-Muney said. “Whereas for Hispanics, or immigrants like myself” — she is from Colombia — “or blacks, yes, circumstances are bad, but they’ve been getting better.”

declining health of white, working-class Americans suggests that Republican plans to replace the Affordable Care Act are akin to bleeding a sick patient. As he put it, “Treat the fever by causing an even bigger fever.”

Graphs accompanying the new paper suggest that death rates for blacks with only a high school education began rising around 2010 in many age groups, as if following the trend that began about a decade earlier among whites.

ess-educated white Americans tend to be strikingly pessimistic when interviewed about their prospects.

white mortality rates fell in the biggest cities, were constant in big-city suburbs and rose in all other areas. The Washington Post’s analysis published last year highlighted the same geographical signature, with a break in death rates between the two most urban classifications (big cities and big-city suburbs) and the four less urban classifications, which The Post described as an urban-rural divide.

That urban-rural divide appears to have widened, particularly in recent years, the CDC reported.

Americans are still eating far too few fruits and vegetables and far too much junk food, even if they are eating somewhat less of it, experts say.

By 2003, 60 percent of Americans said they wanted to lose weight, according to Gallup, up from 52 percent in 1990 and 35 percent in the 1950s.

Consumption of fruits and vegetables remains low; consumption of desserts remains high. Instead, people appear to be eating a little less of everything. Although consumption in nearly every category has been “cut some,” said Mr. Popkin, “the food part of our diet is horrendous and remains horrendous.”

In severe cases, however, the clash between the virus and the immune system rages much longer. Other parts of the body, including those not directly affected by the virus, become collateral damage, prompting serious and potentially life-threatening symptoms

On Friday, the president received an experimental antibody cocktail developed by drug maker Regeneron. The next day he began a course of the antiviral remdesivir. Experts say such treatments might be best administered early in infection, to rein in the virus before it runs amok.

If the innate immune system makes early progress against the virus, the infection may be mild. But if the body’s defenses flag, the coronavirus may continue replicating, ratcheting up the viral load. Faced with a growing threat, innate immune cells will continue to call for help, fueling a vicious cycle of recruitment and destruction. Prolonged, excessive inflammation can cause life-threatening damage to vital organs like the heart, kidneys and lungs.

Eventually, a second wave of immune cells and molecules arrives, more targeted than their early counterparts and able to home in on the coronavirus and the cells it infects.

A typical immune response launches its defense in two phases. First, a cadre of fast-acting fighters rushes to the site of infection and attempts to corral the invader. This so-called innate response buys the rest of the immune system time to mount a second, more tailored attack, called the adaptive response, which kicks in about a week later, around the time the first wave begins to wane.

On Sunday, President Trump’s doctors reported that he had also received a course of dexamethasone, a steroid that broadly blunts the immune response by curbing the activity of several cytokines. Dexamethasone has been shown to reduce death rates in hospitalized Covid-19 patients who are ill enough to require ventilation or supplemental oxygen. But it is far less likely to help and may even harm patients at an earlier stage of infection, or those who have milder disease. Experts say that administering dexamethasone inappropriately, or too soon, could undermine a helpful immune response, allowing the virus to ravage the body.

At 74 years old and about 240 pounds, Mr. Trump occupies a high-risk age group and verges on obesity, a condition that can exacerbate the severity of Covid-19. Men also tend to have a poorer disease prognosis.

Over the past four decades, governments have slashed budgets and privatized basic services. This has two important consequences for public health

First, people are unlikely to trust institutions that do little for them.

second, public health is no longer viewed as a collective endeavor, based on the principle of social solidarity and mutual obligation. People are conditioned to believe they’re on their own and responsible only for themselves.

an important source of vaccine hesitancy is the erosion of the idea of a common good.

compared with white Americans, communities of color do experience the American health care system differently. But a closer look at the data reveals a more complicated picture.

Since the spring, when most American adults became eligible for Covid vaccines, the racial gap in vaccination rates between Black and white people has been halved. In September, a national survey found that vaccination rates among Black and white Americans were almost identical.

Other surveys have determined that a much more significant factor was college attendance: Those without a college degree were the most likely to go unvaccinated.

Education is a reliable predictor of socioeconomic status, and other studies have similarly found a link between income and vaccination.

It turns out that the real vaccination divide is class.

“People are thinking, ‘If the government isn’t going to do anything for us,’” said Elden, “‘then why should we participate in vaccines?’”

during the 1950s polio campaigns, for example, most people saw vaccination as a civic duty.

But as the public purse shrunk in the 1980s, politicians insisted that it’s no longer the government’s job to ensure people’s well-being; instead, Americans were to be responsible only for themselves and their own bodies

Entire industries, such as self-help and health foods, have sprung up on the principle that the key to good health lies in individuals making the right choices.

Without an idea of the common good, health is often discussed using the language of “choice.”

there are problems with reducing public health to a matter of choice. It gives the impression that individuals are wholly responsible for their own health.

This is despite growing evidence that health is deeply influenced by factors outside our control; public health experts now talk about the “social determinants of health,” the idea that personal health is never simply just a reflection of individual lifestyle choices, but also the class people are born into, the neighborhood they grew up in and the race they belong to.

food deserts and squalor are not easy problems to solve — certainly not by individuals or charities — and they require substantial government action.

Many medical schools teach “motivational interviewing,”

the deeper problem:

Being healthy is not cheap. Studies indicate that energy-dense foods with less nutritious value are more affordable, and low-cost diets are linked to obesity and insulin resistance.

Another problem with reducing well-being to personal choice is that this treats health as a commodity.

This isn’t surprising, since we shop for doctors and insurance plans the way we do all other goods and services

mothers devoted many hours to “researching” vaccines, soaking up parental advice books and quizzing doctors. In other words, they act like savvy consumers

When thinking as a consumer, people tend to downplay social obligations in favor of a narrow pursuit of self-interest. As one parent told Reich, “I’m not going to put my child at risk to save another child.”

Such risk-benefit assessments for vaccines are an essential part of parents’ consumer research.

Vaccine uptake is so high among wealthy people because Covid is one of the gravest threats they face. In some wealthy Manhattan neighborhoods, for example, vaccination rates run north of 90 percent.

For poorer and working-class people, though, the calculus is different: Covid-19 is only one of multiple grave threats.

When viewed in the context of the other threats they face, Covid no longer seems uniquely scary.

Most of the people we interviewed in the Bronx say they are skeptical of the institutions that claim to serve the poor but in fact have abandoned them.

he and his friends find reason to view the government’s sudden interest in their well-being with suspicion. “They are over here shoving money at us,” a woman told us, referring to a New York City offer to pay a $500 bonus to municipal workers to get vaccinated. “And I’m asking, why are you so eager, when you don’t give us money for anything else?”

These views reinforce the work of social scientists who find a link between a lack of trust and inequality. And without trust, there is no mutual obligation, no sense of a common good.

The experience of the 1960s suggests that when people feel supported through social programs, they’re more likely to trust institutions and believe they have a stake in society’s health.

While the reasons vary by country, the underlying causes are the same: a deep mistrust in local and international institutions, in a context in which governments worldwide have cut social services.

In one Syrian city, for example, the health care system now consists of one public hospital so underfunded that it is notorious for poor care, a few private hospitals offering high-quality care that are unaffordable to most of the population, and many unlicensed and unregulated private clinics — some even without medical doctors — known to offer misguided health advice. Under such conditions, conspiracy theories can flourish; many of the city’s residents believe Covid vaccines are a foreign plot.

In many developing nations, international aid organizations are stepping in to offer vaccines. These institutions are sometimes more equitable than governments, but they are often oriented to donor priorities, not community needs.

“We have starvation and women die in childbirth.” one tribal elder told us, “Why do they care so much about polio? What do they really want?”

In America, anti-vaccine movements are as old as vaccines themselves; efforts to immunize people against smallpox prompted bitter opposition in the turn of the last century. But after World War II, these attitudes disappeared. In the 1950s, demand for the polio vaccine often outstripped supply, and by the late 1970s, nearly every state had laws mandating vaccinations for school with hardly any public opposition.

What changed? This was the era of large, ambitious government programs like Medicare and Medicaid.

The anti-measles policy, for example, was an outgrowth of President Lyndon Johnson’s Great Society and War on Poverty initiatives.

Research shows that private systems not only tend to produce worse health outcomes than public ones, but privatization creates what public health experts call “segregated care,” which can undermine the feelings of social solidarity that are critical for successful vaccination drives

Only then do the ideas of social solidarity and mutual obligation begin to make sense.

The types of social programs that best promote this way of thinking are universal ones, like Social Security and universal health care.

If the world is going to beat the pandemic, countries need policies that promote a basic, but increasingly forgotten, idea: that our individual flourishing is bound up in collective well-being.

compared with the citizens of these nations, American infants are less likely to turn 5, American teenagers are less likely to turn 30, and American 30-somethings are less likely to survive to retirement.

I called the U.S. the rich death trap of the modern world. The “rich” part is important to observe and hard to overstate. The typical American spends almost 50 percent more each year than the typical Brit, and a trucker in Oklahoma earns more than a doctor in Portugal.

A series about big problems and big solutions

the typical American is 100 percent more likely to die than the typical Western European at almost every age from birth until retirement.

magine I offered you a pill and told you that taking this mystery medication would have two effects. First, it would increase your disposable income by almost half. Second, it would double your odds of dying in the next 365 days. To be an average American is to fill a lifetime prescription of that medication and take the pill nightly.

A series about big problems and big solutions

1.8 figure as “the U.S. death ratio”—the annual mortality rate in the U.S., as a multiple of similarly rich countries.

By the time an American turns 18, the U.S. death ratio surges to 2.8. By 29, the U.S. death ratio rockets to its peak of 4.22, meaning that the typical American is more than four times more likely to die than the average resident in our basket of high-income nations.

The average American my age, in his mid-to-late 30s, is roughly six times more likely to die in the next year than his counterpart in Switzerland.

The average U.S. death ratio stays higher than three for practically the entire period between ages 30 and 50, meaning that the typical middle-aged American is roughly three times more likely to die within the year than his counterpart in Western Europe or Australia.

One could tell a similar story about drug

America suffers not from a monopoly on despair and aggression, but from an oversupply of instruments of death. We have more drug-overdose deaths than any other high-income country because we have so much more fentanyl, even per capita

Americans drive more than other countries, leading to our higher-than-average death rate from road accidents

I expected that these three culprits—guns, drugs, and cars—would explain most of our death ratio

he argued that Americans’ health (and access to health care) seems to be the most important factor. America’s prevalence of cardiovascular and metabolic disease is so high that it accounts for more of our early mortality than guns, drugs, and cars combined.

Disentangling America’s health issues is complicated, but I can offer three data points

First, American obesity is unusually high, which likely leads to a larger number of early and middle-aged death

Second, Americans are unusually sedentary. We take at least 30 percent fewer steps a day than people do in Australia, Switzerland, and Japan

Finally, U.S. access to care is unusually unequal—and our health-care outcomes are unusually tied to income.

voters and politicians in the U.S. care so much about freedom in that old-fashioned ’Merica-lovin’ kind of way that we’re unwilling to promote public safety if those rules constrict individual choice. That’s how you get a country with infamously laissez-faire firearms laws, more guns than people, lax and poorly enforced driving laws, and a conservative movement that has repeatedly tried to block, overturn, or limit the expansion of universal health insurance on the grounds that it impedes consumer choice.

Among the rich, this hyper-individualistic mindset can manifest as a smash-and-grab attitude toward life, with surprising consequences for the less fortunate. For example, childhood obesity is on the rise at the same time that youth-sports participation is in decline among low-income kids

What seems to be happening at the national level is that rich families, seeking to burnish their child’s résumé for college, are pulling their kids out of local leagues so that they can participate in prestigious pay-to-play travel teams. At scale, these decisions devastate the local youth-sports leagues for the benefit of increasing by half a percentage point the odds of a wealthy kid getting into an Ivy League school.

The problem with the Freedom and Individualism Theory of Everything is that, in many cases, America’s problem isn’t freedom-worship, but actually something quite like its opposite: overregulation

In medicine, excessive regulation and risk aversion on the part of the FDA and Institutional Review Boards have very likely slowed the development and adoption of new lifesaving treatments.

Are Americans unusually sedentary because they love freedom so very much? It’s possible, I guess. But the more likely explanation is that restrictive housing policies have made it too hard for middle- and low-income families to live near downtown business districts, which forces many of them to drive more than they would like, thus reducing everyday walking and exercise.

America is caught in a lurch between oversight and overkill, sometimes promoting individual freedom, with luridly fatal consequences, and sometimes blocking policies and products, with subtly fatal consequences.