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In the 19th century, the secularization of Western society led to the secularization of pain. It was no longer a passion to be endured but a sensation to be quashed.

The concept of pain as a purely physical phenomenon reached its zenith in the 1990s

having pain designated a “fifth vital sign,” alongside blood pressure, temperature and breathing and heart rate.

This coincided with the release of long-acting opioids like OxyContin. Doctors believed they now had an effective remedy for their patients’ suffering

looking back it’s clear that using opioids to treat chronic pain — backaches, bum knees and the like — might well be considered the worst medical mistake of our era.

ecades of research suggests that opiates provide little to no benefit for chronic noncancer pain

Why is this? Studies have shown that opioids can reduce patients’ pain thresholds.

They can also result in a condition called opioid-induced hyperalgesia, in which people feel more and more pain as they are prescribed higher and higher doses of opioids

the mind does play a pivotal role in the experience of pain. After a pain signal reaches the brain, it undergoes significant reprocessing.

How much something hurts can vary depending on factors like your expectations, your mood and how distracted you are

pain is contagious and transmittable.

Conditions like depression and anxiety greatly increase the chance of developing chronic pain, while patients who experience pain are at high risk of developing depression or anxiety

there is considerable overlap in the areas of the brain that deal with pain and emotion.

Objectively, there is no doubt that illnesses and injuries can cause immense suffering. The question is how severe that suffering is, and how long it lasts

pain sensitivity varies significantly among people, most likely as a result of genetic differences.

rug companies greatly underplayed the risks of opioids, while billions of dollars in marketing told people that pills were the only answer to their ailments.

future doctors should be taught that pain is part of the story of the person who suffers from it, not just a separate physical phenomenon.

this education should incorporate ways to avoid prescribing opioids for chronic use.

Perhaps the most important tool physicians need to manage pain is empathy.

Physical therapy that doesn’t just manipulate joints but also addresses the context pain comes alive in, encourages optimism and builds emotional resilience has been found to be more effective.

unfortunately our health system encourages doctors to see as many patients as possible as quickly as possible. We need to change how physicians are paid in order to give them the time to really talk with patients about their pain.

I felt that the pain was my body’s way of telling me that something was wrong, and I didn’t want to silence that voice with a temporary fix.

What pulled me out after almost a year of agony was not just rigorous physical therapy that molded my spine back into shape but also the kindness of my friends, my family and my future wife.

a spiritual and emotional experience alleviated through prayers rather than prescriptions.

"The Sacklers are paying $4.275 billion and they very much plan and expect to be done with this chapter," said Marshall Huebner, an attorney representing Purdue Pharma, during a hearing last week. One of the firms that would secure protection from future opioid lawsuits under the deal is Luther Strange & Associates, founded by former U.S. Sen. Luther Strange (R-Alabama) who helped Purdue Pharma pitch the bankruptcy plan to Republican state attorneys general.

In the coming weeks, more than 600,000 individuals, companies and governments with claims against Purdue Pharma will vote on the package, described by attorneys involved in the process as one of the most complicated and controversial bankruptcies ever.

The reorganization plan also includes a detailed formula that would be used to distribute hundreds of millions of dollars each year in aid to communities and individuals harmed by opioids.

But critics, including more than 20 mostly Democratic state attorneys general, say the Sacklers are improperly piggybacking on their company's bankruptcy without actually filing for bankruptcy themselves.

Again, the Sacklers have denied any wrongdoing, have never been charged with crimes. As part of their settlement with the DOJ, members of the Sackler family paid $225 million while denying the allegations.

"Raymond Sackler family members have consistently expressed their regret that OxyContin, which continues to help patients suffering from chronic pain, unexpectedly became part of the opioid crisis," the family said in a statement.

The Sacklers maintain they did nothing wrong and acted ethically. If this bankruptcy plan is approved and upheld on appeal, it's unlikely the allegations will ever be tested in court.

The landscape of addiction in America looks different today than it did decades ago. Now, we have a real chance to flip the script on opioid abuse. “I learned because of Fred. I learned,” President Trump says. “It is time to liberate our communities from this scourge of drug addiction.”

By June, the province’s chief coroner said fatalities between March and May were 25% higher than the median monthly rates of 2019. The province estimates that, if the number of opioid-related deaths continues to increase at current rates for the rest of the year, 2,271 will die in 2020, a 50% jump from last year.

In the U.S., opioid deaths have risen almost continually for three decades and hit a record of more than 72,000 last year, according to federal government projections.

In Vancouver, overdose deaths fell almost 40% in 2019 to 247, accounting for much of the overall reduction in Canada. But by October of this year, the city had already surpassed last year’s total, with 291 dead, according to the British Columbia Coroners Service.

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.

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 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

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

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.

"The medical evidence is clear: access to medication-assisted treatment, including buprenorphine that can be prescribed in office-based settings, is the gold standard for treating individuals suffering from opioid use disorder,"

The administration's move comes at a time when the U.S. is again facing record levels of drug overdose deaths, according to the Centers for Disease Control and Prevention.

More than 83,000 people died of drug overdoses in the U.S. in the 12 months ending in June 2020, the CDC said.

"As emergency physicians, we see every day the devastating effects that the opioid crisis has had on the communities we serve—a crisis that has unfortunately only worsened during the COVID-19 pandemic,"

The American Medical Association also praised the move, saying it will allow earlier intervention by doctors treating patients suffering addiction.

"With this change, office-based physicians and physician-led teams working with patients to manage their other medical conditions can also treat them for their opioid use disorder,"

Harris also said allowing doctors to treat opioid addiction as they treat other medical conditions, without additional regulatory hurdles, will reduce the stigma that has often shaped the healthcare response to substance use disorders.

doctors who possess a Drug Enforcement Administration registration will still be limited to treating no more than 30 in-state patients with buprenorphine for addiction treatment at any one time.

The guidelines are not considered a new law or federal regulation, making it very easy for the President-elect Joe Biden administration to walk back this policy if so desired. Giroir told Stat News that he thinks that scenario is unlikely, saying, "I doubt it seriously."

, to take an obvious example, politics has helped transform the environment for gay people.

And yet: Gay people are still, depending on the study, between two and ten times more likely than straight people to take their own lives. We’re twice as likely to have a major depressive episode.

The extraordinary suffering gay men once lived with — and still do in the vast majority of the world — is no longer. We can thank politics and culture for that.

But the struggle of being a small minority, of being male, and of being human endures. Growing up gay and different, especially in our teens, will always be traumatic to a greater or lesser degree.

Some more thoughts about intersectionality as a religion. The first is that I’m not the only person noticing the evolution of elite private colleges into de facto religious institutions. Jonathan Haidt decries a modern auto-da-fe here. Michael Rectenwald argues for re-secularizing the university here. William Deresiewicz in the American Scholar homes in on one key thinker in the entire matrix of “social constructionism”:

The presiding presence is Michel Foucault, with his theories of power, discourse, and the social construction of the self, who plays the same role on the left as Marx once did.

The assumption, on elite college campuses, is that we are already in full possession of the moral truth. This is a religious attitude. It is certainly not a scholarly or intellectual attitude.

(How about we substitute the now tired term political correctness with the less euphemistic repressive tolerance?)

Analytically, it makes sense to see how various inequalities are related — such as race and wealth.

But an individual is so much more than a compounding sum of group identities. We don’t just vary in racial or gender demographics. We have different individual genetics, upbringings, religions, levels of attractiveness, interests, ambitions, dumb luck, and on and on

Aspects of our personal identities that liberate us can be just as potent and revealing as those that oppress us.

What’s also revealing is where the intolerance is strongest. Brookings’s Richard Reeves and Dimitrios Halikias have crunched the numbers. The answer is: the most expensive colleges. Specifically:

The average enrollee at a college where students have attempted to restrict free speech comes from a family with an annual income $32,000 higher than that of the average student in America.

Worse, as Deresiewicz explains: [L]ower-income whites belong disproportionately to precisely those groups whom it is acceptable and even desirable, in the religion of the colleges, to demonize: conservatives, Christians, people from red states.

In the psychic economy of the liberal elite, the white working class plays the role of the repressed. The recent presidential campaign may be understood as the return of that repressed—and the repressed, when it returns, is always monstrous.

All of which is presciently foretold in Coming Apart, a book about soaring inequality and elite isolation … by the man, Charles Murray, the students refused to hear.

Fifteen years ago, middle-aged whites in the United States were neck and neck with their German counterparts. Now, middle-aged white Americans are 45 percent more likely to die than middle-aged Germans.

the gap in mortality between white middle-aged Americans and middle-aged Germans is about 125 deaths per 100,000 people now. Every year, of 100,000 Germans between the ages of 45 and 54, about 285 die. In the United States, it's more than 410.

Most of the increase in white deaths is concentrated among those who never finished college. These are the same people who have been pummeled by the economy in recent decades. It’s gotten more difficult for them to find jobs, and what jobs they do come across nowadays don’t pay as well.

“For too many years, the ideological opposition to harm reduction has cost lives,” said Dr. Carolyn Bennett, the federal minister of mental health and addictions, at a news conference on Tuesday.

British Columbia has been a leader in Canada’s harm reduction movement.

Decriminalization will allow police to focus on organized crime and drug traffickers, instead of individual users, said Sheila Malcolmson, the provincial minister of mental health and addictions. “We will take this year ahead to ready our justice and health systems,” she added.

The exemption will go into effect on Jan. 31, 2023, and will expire after three years.

“I think making drug use easier for them is kind of like palliative care,” said Mr. Doucette, who spent 35 years working for the Royal Canadian Mounted Police before retiring, most of which he spent in drug enforcement. “It’s just condemning them to a slow death because of drugs, whereas if you get them off drugs, get them a life back, they can enjoy life.”

British Columbia has one of the highest per capita rates of drug death across North America, at 42.8 deaths per 100,000 people in 2021, according to provincial data.

In the U.S., the 10 states with the highest level of drug overdose, have rates ranging between 39.1 deaths per 100,000 in Connecticut, to 81.4 deaths per 100,000 in West Virginia, according to the latest mortality data, for 2020, by the Centers for Disease Control.

So 1 kilogram of AMB-FUBINACA could be portioned out over 15,625 doses, with a typical street price of $35. That means the dealer stands to make close to $500,000.

As soon as the drug shows up on the radar of authorities, the makers move on to the next compound.

And if the dangers of synthetic cannabinoids have researchers concerned, the risks of designer opioids are perhaps even greater.

Just last month, the federal Drug Enforcement Administration issued an alert for a new designer drug called Pink, which had been responsible for 46 deaths, including 31 in New York and 10 in North Carolina.

“Pink belongs to a family of deadly synthetic opioids far more potent than morphine,” according to the agency. “It is usually imported to the United States, mainly from illicit labs in China.”

while it is not in the interest of dealers to kill their clients, as these synthetic compounds become increasingly potent, the risks will continue to grow.

“No compound that has been made yet has the potential to kill thousands of people,” he said. “But that is a scenario that is becoming more and more close to reality.”

he argued that sluggish wage growth may result from workers losing bargaining power as union representation declines and fewer employers come to dominate many labor markets.

he country has already tried an aggressive enforcement approach to drug crimes — the four-decade-plus war on drugs — and among experts and law enforcement officers , it is almost universally acknowledged as a massive failure in economic and practical terms

Even more concerning, the war on drugs has been disproportionately waged against black and brown people . Escalating the possible sentence for drug crimes to death would just amplify the many injustices already present in a broken system.

He doesn’t recognize that most of our opioid deaths result from drugs that are made in the United States or shipped in from China 

And that self-centered self-assuredness is the slender framework supporting his enthusiasm for adopting the bloodthirsty edicts of a genuine despot and a notoriously repressive quasi-police state

hese policy proposals (such as they are) are terrible ideas considered on their own. But it’s something of an accomplishment to have them combine quite as gruesomely as “more firearms in schools” and “shoot all drug dealers” might — at least Singapore’s tougher gun-control laws prevent the kind of “good guy with a gun” vigilantism that Trump regularly invokes

the government has got to teach children that they’ll die if they take drugs and they’ve got to make drug dealers fear for their lives.”

Biden calls for a $15 minimum wage, increased Social Security benefits for the poorest Americans, and strengthening the power of unions to organize and bargain. He advocates a substantial program to tackle infrastructure, and a sweeping gun control plan.

He proposes to assist low-income schools by tripling the amount of federal assistance to fund universal pre-K and raise teachers’ salaries. A frequent critic, German Lopez of Vox, describes his proposal for criminal justice reform as “one of the most comprehensive among presidential campaigns, taking on various parts of the criminal justice system at once.” And he is committed to fighting voter suppression and expanding the right to vote.

When it comes to the environment, even the progressive Sunrise Movement (which supports Sanders) calls Biden’s plan to combat climate change “comprehensive.” Focused on achieving clean energy and eliminating harmful emissions, it would cost $1.7 trillion over a decade—which, while far less the cost of the Green New Deal, represents a giant leap forward.

His immigration plan is smart and balanced. While avoiding the extremes of decriminalizing the border or abolishing ICE, it protects Dreamers, provides a pathway to citizenship for undocumented immigrants, welcomes increased immigration, and reverses our shameful and sadistic maltreatment of asylum seekers and their children.

How does Biden propose to raise revenue? By tax increases of $3.4 trillion over a decade, virtually all derived from raising rates for corporations and wealthy—including treating capital gains as ordinary income.

The relevant question is not how all this compares to Sanders’s unachievable wish list, but to the reality of America under Donald Trump. Anyone who dismisses the difference is not a progressive, but a myopic and politically-infantile purist.

Still, at its heart this election is about one man: Trump. That’s why it’s imperative that Biden daily remind voters, in style and substance, that he is Trump’s antithesis: decent, dignified, compassionate, and competent; a man they can trust.

To a great extent, Biden is less a leader than a vehicle. Which means that his campaign will need to present Biden at his best—the warm and engaging guy who looks like a “can-do” president.

As a child, Biden struggled to conquer a congenital stutter he fights against still, which may explain some of his verbal tics in debate. To control stuttering requires immense concentration and willpower: that Biden became a politician is a triumph—and something of a wonder

that’s the Biden his campaign needs voters to internalize: a leader with the resilience to conquer adversity and come out stronger and more compassionate than before. Which is a pretty fair metaphor for the America which, millions hope, will follow Donald Trump.

A Morning Consult poll in February showed that 30 percent of independent voters were less likely to support Biden because of controversy regarding his son. Republican senators are primed to use their subpoena power to “investigate” Hunter and thereby deep-dye the damage to his father, undercutting his appeal as an ordinary guy who exemplifies middle-class values.

“It’s supposed to be going down, as it is in other countries,” said the lead author of the report, Steven H. Woolf, director emeritus of the Center on Society and Health at Virginia Commonwealth University. “The fact that that number is climbing, there’s something terribly wrong.”

The opioid epidemic is a major driver of the worrisome numbers, but far from the sole cause. The study found that improvements in life expectancy, largely because of lower rates of infant mortality, began to slow in the 1980s, long before the opioid epidemic became a national tragedy

Some of it may be due to obesity, some of it may be due to drug addiction, some of it may be due to distracted driving from cellphones

Given the breadth and pervasiveness of the trend, “it suggests that the cause has to be systemic, that there’s some root cause that’s causing adverse health across many different dimensions for working-age adults.”

The risk of death from drug overdoses increased 486 percent for midlife women between 1999 and 2017; the risk increased 351 percent for men in that same period. Women also experienced a bigger relative increase in risk of suicide and alcohol-related liver disease.

The all-cause death rate — meaning deaths per 100,000 people — rose 6 percent from 2010 to 2017 among working-age people in the United States

There’s something more fundamental about how people are feeling at some level — whether it’s economic, whether it’s stress, whether it’s deterioration of family,” she said. “People are feeling worse about themselves and their futures, and that’s leading them to do things that are self-destructive and not promoting health.”

. The general trend: Life expectancy improved a great deal for several decades, particularly in the 1970s, then slowed down, leveled off, and finally reversed course after 2014, decreasing three years in a row.

Obesity is a significant part of the story. The average woman in America today weighs as much as the average man half a century ago, and men now weigh about 30 pounds more

Princeton professors Anne Case and Angus Deaton, whose much-publicized report in 2015 highlighted the death rates in middle-aged whites, published a paper in 2017 pointing to a widening gap in health associated with levels of education, a trend dating to the 1970s. Case told reporters their research showed a “sea of despair” in the United States among people with only a high school diploma or less. She declined to comment on the new report.

“When they get up into their 20s, 30s and 40s, they’re carrying the risk factors of obesity that were acquired when they were children. We didn’t see that in previous generations.”

Most people in the United States are overweight — an estimated 71.6 percent of the population ages 20 and older, according to the CDC. That figure includes the 39.8 percent who are obese, defined as having a body mass index of 30 or higher in adults (18.5 to 25 is the normal range). Obesity is also rising in children; nearly 19 percent of the population ages 2 to 19 is obese.

The average life expectancy in the United States fell behind that of other wealthy countries in 1998 and since then, the gap has grown steadily. Experts refer to this gap as America’s “health disadvantage.”

Death rates from suicide, drug overdoses, liver disease and dozens of other causes have been rising over the past decade for young and middle-aged adults, driving down overall life expectancy in the United States for three consecutive years, according to a strikingly bleak study published Tuesday that looked at the past six decades of mortality data.

The 33,000 excess deaths are an estimate based on the number of all-cause midlife deaths from 2010 to 2017 that would be expected if mortality was unchanged vs. the number of deaths actually recorded by medical examiners.

Outside researchers praised the study for knitting together so much research into a sweeping look at U.S. mortality trends.“This report has universal relevance. It has broad implications for all of society,” said Howard Koh, a professor of public health at Harvard University who was not part of the research team.

The average life expectancy in the United States fell behind that of other wealthy countries in 1998, and since then the gap has grown steadily. Experts refer to this gap as the United States’ “health disadvantage.”

For example, in the late 1960s and early ’70s, cigarette companies aggressively marketed to women, and the health effects of that push may not show up for decades.

Obesity is a significant part of the story. The average woman in the United States today weighs as much as the average man half a century ago, and men now weigh about 30 pounds more. Most people in the United States are overweight — an estimated 71.6 percent of the population age 20 and older, according to the CDC. That figure includes the 39.8 percent who are obese, defined as having a body mass index of 30 or higher in adults (18.5 to 25 is the normal range). Obesity is also rising in children; nearly 19 percent of the population age 2 to 19 is obese.

or decades, the country’s leading oil and gas companies have understood the science of climate change and the dangers posed by fossil fuels. Year after year, top executives heard it from their own scientists whose warnings were explicit and often dire.

In 1979, an Exxon study said that burning fossil fuels “will cause dramatic environmental effects” in the coming decades.“The potential problem is great and urgent,” it concluded.

o investigate the lengths of the oil and gas industry’s deceptions – and the disastrous consequences for communities across the country – the Guardian is launching a year-long series tracking the unprecedented efforts to hold the fossil fuel industry to account.

the legal reasoning behind foreign court judgments are unlikely to carry much weight in the US and domestic law is largely untested. In 2018, a federal court knocked back New York City’s initial attempt to force big oil to cover the costs of the climate crisis by saying that its global nature requires a political, not legal, remedy.

Among them is a 1988 Exxon memo laying out a strategy to push for a “balanced scientific approach”, which meant giving equal weight to hard evidence and climate change denialism. That move bore fruit in parts of the media into the 2000s as the oil industry repositioned global heating as theory, not fact, contributing to the most deep-rooted climate denialism in any developed country.

Other climate lawsuits, including one filed in Minnesota, allege the oil firms’ campaigns of deception and denial about the climate crisis amount to fraud. Minnesota is suing Exxon, Koch Industries and an industry trade group for breaches of state law for deceptive trade practices, false advertising and consumer fraud over what the lawsuit characterises as distortions and lies about climate science.

Farber said cases rooted in claims that the petroleum industry lied have the most promising chance of success.“To the extent the plaintiffs can point to misconduct, like telling everybody there’s no such thing as climate change when your scientists have told you the opposite, that might give the courts a greater feeling of comfort that they’re not trying to take over the US energy system,” he said.

The public nuisance claim, also pursued by Honolulu, San Francisco and Rhode Island, follows a legal strategy with a record of success in other types of litigation. In 2019, Oklahoma’s attorney general won compensation of nearly half a billion dollars against the pharmaceutical giant Johnson & Johnson over its false marketing of powerful prescription painkillers on the grounds it created a public nuisance by contributing to the opioid epidemic in the state.

Exxon set up equipment on a supertanker, the Esso Atlantic, to monitor carbon dioxide in seawater and the air. In 1982, the company’s scientists drew up a graph accurately plotting an increase in the globe’s temperature to date.

“The 1980s revealed an established consensus among scientists,” the Minnesota lawsuit against Exxon says. “A 1982 internal Exxon document … explicitly declares that the science was ‘unanimous’ and that climate change would ‘bring about significant changes in the earth’s climate’.”Then the monitoring on the Esso Atlantic was suddenly called off and other research downgraded.

Year after year, Exxon scientists recorded the evidence about the dangers of burning fossil fuels. In 1978, its science adviser, James Black, warned that there was a “window of five to ten years before the need for hard decisions regarding changes in energy strategy might become critical”.

newspapers to sow doubt. One in the New York Times in 2000, under the headline “Unsettled Science”, compared climate data to changing weather forecasts. It claimed scientists were divided, when an overwhelming consensus already backed the evidence of a growing climate crisis, and said that the supposed doubts meant it was too soon to act.

Exxon’s chairman and chief executive, Lee Raymond, told industry executives in 1996 that “scientific evidence remains inconclusive as to whether human activities affect global climate”.“It’s a long and dangerous leap to conclude that we should, therefore, cut fossil fuel use,” he said.Documents show that his company’s scientists were telling Exxon’s management that the real danger lay in the failure to do exactly that.

In 2019, Martin Hoffert, a professor of physics at New York University, told a congressional hearing that as a consultant to Exxon on climate modelling in the 1980s, he worked on eight scientific papers for the company that showed fossil fuel burning was “increasingly having a perceptible influence on Earth’s climate”.

Exxon worked alongside Chevron, Shell, BP and smaller oil firms to shift attention away from the growing climate crisis. They funded the industry’s trade body, API, as it drew up a multimillion-dollar plan to ensure that “climate change becomes a non- issue” through disinformation. The plan said “victory will be achieved” when “recognition of uncertainties become part of the ‘conventional wisdom’”.

The fossil fuel industry also used its considerable resources to pour billions of dollars into political lobbying to block unfavourable laws and to fund front organisations with neutral and scientific-sounding names, such as the Global Climate Coalition (GCC). In 2001, the US state department told the GCC that President George W Bush rejected the Kyoto protocol to reduce greenhouse gas emissions “in part, based on input from you”.

“Big oil was engaged in exactly the same type of behaviour that the tobacco companies engaged in and were found liable for fraud on a massive scale,” said Eubanks. “The cover-up, the denial of the problem, the funding of scientists to question the science. The same pattern. And some of the same lawyers represent both tobacco and big oil.”

the racial contract is a codicil rendered in invisible ink, one stating that the rules as written do not apply to nonwhite people in the same way.

The Declaration of Independence states that all men are created equal; the racial contract limits this to white men with property

The law says murder is illegal; the racial contract says it’s fine for white people to chase and murder black people if they have decided that those black people scare them.

“The terms of the Racial Contract,” Mills wrote, “mean that nonwhite subpersonhood is enshrined simultaneously with white personhood.”

as the process in the Arbery case shows, the racial contract most often operates unnoticed, relying on Americans to have an implicit understanding of who is bound by the rules, and who is exempt from them.

Donald Trump’s 2016 election campaign, with its vows to enforce state violence against Mexican immigrants, Muslims, and black Americans, was built on a promise to enforce terms of the racial contract that Barack Obama had ostensibly neglected, or violated by his presence.

Struggling white farmers in Iowa taking billions in federal assistance are hardworking Americans down on their luck; struggling single parents in cities using food stamps are welfare queens.

Black Americans struggling in the cocaine epidemic are a “bio-underclass” created by a pathological culture; white Americans struggling with opioid addiction are a national tragedy.

Poor European immigrants who flocked to an America with virtually no immigration restrictions came “the right way”; poor Central American immigrants evading a baroque and unforgiving system are gang members and terrorists.

The coronavirus epidemic has rendered the racial contract visible in multiple ways. Once the disproportionate impact of the epidemic was revealed to the American political and financial elite, many began to regard the rising death toll less as a national emergency than as an inconvenience.

The lives of workers at the front lines of the pandemic—such as meatpackers, transportation workers, and grocery clerks—have been deemed so worthless that legislators want to immunize their employers from liability even as they force them to work under unsafe conditions.

In East New York, police assault black residents for violating social-distancing rules; in Lower Manhattan, they dole out masks and smiles to white pedestrians.

The implied terms of the racial contract are visible everywhere for those willing to see them. A 12-year-old with a toy gun is a dangerous threat who must be met with lethal force; armed militias drawing beads on federal agents are heroes of liberty.

by mid-April, conservative broadcasters were decrying the restrictions, small bands of armed protesters were descending on state capitols, and the president was pressing to lift the constraints.

the pandemic has introduced a new clause to the racial contract. The lives of disproportionately black and brown workers are being sacrificed to fuel the engine of a faltering economy, by a president who disdains them. This is the COVID contract.

In the interim, data about the demographics of COVID-19 victims began to trickle out. On April 7, major outlets began reporting that preliminary data showed that black and Latino Americans were being disproportionately felled by the coronavirus. That afternoon, Rush Limbaugh complained, “If you dare criticize the mobilization to deal with this, you’re going to be immediately tagged as a racist.”

That night, the Fox News host Tucker Carlson announced, “It hasn’t been the disaster that we feared.” His colleague Brit Hume mused that “the disease turned out not to be quite as dangerous as we thought.” The nationwide death toll that day was just 13,000 people; it now stands above 70,000, a mere month later.

That more and more Americans were dying was less important than who was dying.

The disease is now “infecting people who cannot afford to miss work or telecommute—grocery store employees, delivery drivers and construction workers,”

Containing the outbreak was no longer a question of social responsibility, but of personal responsibility. From the White House podium, Surgeon General Jerome Adams told “communities of color” that “we need you to step up and help stop the spread.”

Public-health restrictions designed to contain the outbreak were deemed absurd. They seemed, in Carlson’s words, “mindless and authoritarian,” a “weird kind of arbitrary fascism.” To restrict the freedom of white Americans, just because nonwhite Americans are dying, is an egregious violation of the racial contract.

majority-black counties “account for more than half of coronavirus cases and nearly 60 percent of deaths.” The disproportionate burden that black and Latino Americans are bearing is in part a direct result of their overrepresentation in professions where they risk exposure, and of a racial gap in wealth and income that has left them more vulnerable to being laid off. Black and Latino workers are overrepresented among the essential, the unemployed, and the dead.

“Due to the meatpacking, though, that’s where Brown County got the flare,” Roggensack interrupted to clarify. “It wasn’t just the regular folks in Brown County.”

Roggensack was drawing a line between “regular folks” and the workers who keep them fed, mobile, safe, and connected. And America’s leaders have treated those workers as largely expendable, praising their valor while disregarding their safety.

In South Dakota, where a Smithfield plant became the site of an outbreak infecting more than 700 workers, a spokesperson told BuzzFeed News that the issue was their “large immigrant population.”

“We can’t keep our country closed down for years,” Trump said Wednesday. But that was no one’s plan. The plan was to buy time to take the necessary steps to open the country safely. But the Trump administration did not do that, because it did not consider the lives of the people dying worth the effort or money required to save them.

the only tension between stopping the virus and reviving the economy is one the Trump administration and its propaganda apparatus have invented. Economists are in near-unanimous agreement that the safest path requires building the capacity to contain the virus before reopening the economy—precisely because new waves of deaths will drive Americans back into self-imposed isolation, destroying the consumer spending that powers economic growth

The frame of war allows the president to call for the collective sacrifice of laborers without taking the measures necessary to ensure their safety, while the upper classes remain secure at home.

But the workers who signed up to harvest food, deliver packages, stack groceries, drive trains and buses, and care for the sick did not sign up for war, and the unwillingness of America’s political leadership to protect them is a policy decision, not an inevitability

Trump is acting in accordance with the terms of the racial contract, which values the lives of those most likely to be affected less than the inconveniences necessary to preserve them.

Collective solidarity in response to the coronavirus remains largely intact—most Americans support the restrictions and are not eager to sacrifice their lives or those of their loved ones for a few points of gross domestic product. The consistency across incomes and backgrounds is striking in an era of severe partisan polarization

But solidarity with the rest of the nation among elite Republicans—those whose lives and self-conceptions are intertwined with the success of the Trump presidency—began eroding as soon as the disproportionate impact of the outbreak started to emerge.

One way or another, everyone pays for health care. It accounts for about 18 percent of G.D.P. — nearly $11,000 per person. Individuals directly pay about a quarter, the federal and state governments pay nearly half, and most of the rest is paid by employers.

Many Americans think their health insurance is a gift from their employers — a “benefit” bestowed on lucky workers by benevolent corporations. It would be more accurate to think of employer-provided health insurance as a tax.

Rising health care costs account for much of the half-century decline in the earnings of men without a college degree, and contribute to the decline in the number of less-skilled jobs.

Employer-based health insurance is a wrecking ball, destroying the labor market for less-educated workers and contributing to the rise in “deaths of despair.”

We face a looming trillion-dollar federal deficit caused almost entirely by the rising costs of Medicaid and Medicare, even without the recent coronavirus relief bill.

Rising costs are an untenable burden on our government, too. States’ payments for Medicaid have risen from 20.5 percent of their spending in 2008 to 28.9 percent in 2019. To meet those rising costs, states have cut their financing for roads, bridges and state universities. Without those crucial investments, the path to success for many Americans is cut off

Every year, the United States spends $1 trillion more than is needed for high quality care.

executives at hospitals, medical device makers and pharmaceutical companies, and some physicians, are very well paid.

American doctors control access to their profession through a system that limits medical school admissions and the entry of doctors trained abroad — an imbalance that was clear even before the pandemic

Hospitals, many of them classified as nonprofits, have consolidated, with monopolies over health care in many cities, and they have used that monopoly power to raise prices

These are all strategies that lawmakers and regulators could put a stop to, if they choose.

The health care industry has armored itself, employing five lobbyists for each elected member of Congress. But public anger has been building — over drug prices, co-payments, surprise medical bills — and now, over the fragility of our health care system, which has been laid bare by the pandemic

A single-payer system is just one possibility. There are many systems in wealthy countries to choose from, with and without insurance companies, with and without government-run hospitals. But all have two key characteristics: universal coverage — ideally from birth — and cost control.

In the United States, public funding is likely to play a significant role in any treatments or vaccines that are eventually developed for Covid-19. Americans should demand that they be available at a reasonable price to everyone — not in the sole interest of drug companies.

We are believers in free-market capitalism, but health care is not something it can deliver in a socially tolerable way.

They choose not to. And so we Americans have too few doctors, too few beds and too few ventilators — but lots of income for providers

America is a rich country that can afford a world-class health care system. We should be spending a lot of money on care and on new drugs. But we need to spend to save lives and reduce sickness, not on expensive, income-generating procedures that do little to improve health. Or worst of all, on enriching pharma companies that feed the opioid epidemic.

Medical device manufacturers have also consolidated, in some cases using a “catch and kill” strategy to swallow up nimbler start-ups and keep the prices of their products high.

Ambulance services and emergency departments that don’t accept insurance have become favorites of private equity investors because of their high profits

Britain, for example, has the National Institute for Health and Care Excellence, which vets drugs, devices and procedures for their benefit relative to cost

At the very least, America must stop financing health care through employer-based insurance, which encourages some people to work but it eliminates jobs for less-skilled workers

Our system takes from the poor and working class to generate wealth for the already wealthy.

passed a coronavirus bill including $3.1 billion to develop and produce drugs and vaccines.

The industry might emerge as a superhero of the war against Covid-19, like the Royal Air Force in the Battle of Britain during World War II.

illions have lost their paychecks and their insurance