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Chloroquine had produced what he called “spectacular improvements” in the Chinese patients. “It’s excellent news — this is probably the easiest respiratory infection to treat of all,” Raoult said. “The only thing I’ll tell you is, be careful: Soon the pharmacies won’t have any chloroquine left!”

Raoult wrote his first research paper, in 1979, on a tick-borne infection sometimes known as Marseille fever. The disease was also called “benign summer fever,” and more than 50 years of science said it was nonlethal. And yet one of the 41 patients in his data set had died.

Before submitting the paper, Raoult, who was then a young resident, gave it to a supervising professor for review. “And he takes it,” Raoult told me, “he doesn’t show it to me again, and he publishes it — and he’d taken out the death. Because he didn’t know how to make sense of the death.”

Raoult was disgusted, and the incident shaped his philosophy of scientific inquiry. “I learned that the people who wanted to follow the familiar path were prepared to cheat in order to do it,” he said.

In Raoult’s view, French science was a duchy of appearances, connections and self-reverence. “It was people saying” — he mimed the drone of an aristocrat — “ ‘Oh, him, yes, he’s very good.’ And this reputation, you don’t know what it’s based on, but it’s not the truth.”

“He was a ‘follower,’” Raoult said of the professor. “And these ‘followers’ are all cheaters. That’s what I thought. And it’s still what I think.”

He is, fundamentally, a contrarian. In Raoult’s view, little of consequence has been accomplished by researchers who endorse the habitual tools and theories of their age.

“I’ve spent my life being ‘against,’” he told me. “I tell young scientists: ‘You know, you don’t need a brain to agree. All you need is a spinal cord.’” He is thrilled by conflict. It is a matter both of philosophy — the influence, no doubt, of the thinker he refers to admiringly as “master Nietzsche” — and of temperament.

His peers shake their heads at this behavior but grant him a grudging respect. “You can’t knock him down,” said Mark Pallen, a professor of microbial genomics at the University of East Anglia. “In terms of his place in the canon, the sainthood of science, he’s pretty secure there.”

In 1985 and 1986, Raoult worked at the Naval Medical Research Institute in Bethesda, Md., where he discovered the Science Citation Index. The index, a tool that can be used to measure a scientist’s influence on the basis of his or her publication history, was relatively unknown in France. Raoult looked up the researchers reputed to be the best in Marseille. “It was really the emperor wears no clothes,” he said. “These people didn’t publish. There was one who hadn’t written a paper in 10 years.”

In subsequent work, he demonstrated that Marseille fever was indeed fatal in almost precisely one in every 41 cases.

Raoult’s name sits atop several thousand; in each of the past eight years, he has produced more than 100. In 2020, he has already published at least 54.

Like many doctors, Molina viewed Raoult’s study with skepticism, but he was also curious to see if his proposed treatment regimen might in fact work. He tested hydroxychloroquine and azithromycin in 11 of his own patients. “We had severe patients, and we wanted to try something,” Molina told me. Within five days, one had died, and two others had been transferred out of his service to intensive care. In another patient, the treatment was suspended after the onset of cardiac issues, a known side effect of the drugs. Eight of the 10 surviving patients still tested positive for SARS-CoV-2 at the conclusion of the study period

Raoult is reputed to be an indefatigable worker, but he also achieves his extreme rate of publication by attaching his name to nearly every paper that comes out of his institute.

In recent years, Raoult has amused himself, it seems, by staking out tendentious scientific claims, sometimes in territories that are well beyond the scope of his expertise.

He is skeptical, for instance, of the utility of mathematical modeling in the realm of epidemiology.

The same logic has led him to conclude that climate modelers are no more than “soothsayers” for our “scientistic era” and that their dire predictions are mostly just an attempt to expiate our intense but irrational feelings of guilt.

Raoult’s most recent book, “Epidemics: Real Dangers and False Alerts,” was published in late March, by which time the W.H.O. had reported more than 330,000 confirmed cases of Covid-19 worldwide and more than 14,500 deaths. “This anguish over epidemics,” he writes, “is completely untethered from the reality of deaths from infectious diseases.”

Testing had been scheduled to run for two weeks per patient, but after only six days, the results were so favorable that Raoult decided to end the trial and publish

Others might have proceeded with more caution or perhaps waited to confirm these results with a larger, more rigorous trial. Raoult likes to think of himself as a doctor first, however, with a moral obligation to treat his patients that supersedes any desire to produce reliable data.

Raoult had already begun assembling data for a larger study, but he dismissed the need for anything particularly vast or lengthy. Like other critics of the R.C.T., he likes to point out that a number of self-evidently useful developments in the realm of human health have never been validated by such rigorous tests.

This observation has come to be known as the parachute paradigm: We tend to accept the claim that parachutes reduce injury among people who leap from airplanes, but this effect has never been proved in a randomized study that compares an experimental parachute group to an unlucky parachuteless control.

“If you don’t have something that’s visible in 10 patients, or 30, it’s useless. It’s not of any consequence.” An effective treatment for a potentially lethal infectious disease will be visible to the naked eye.

There is much about Raoult that might make him, and by extension his proposed treatment, appealing to a man like Trump. He is an iconoclast with funny hair; he thinks almost everyone else is stupid, especially those who are typically regarded as smart; he is beloved by the angry and conspiracy-minded; his self-congratulation is more or less unceasing.

Raoult classified Trump’s psychology as that of an “entrepreneur,” by way of contrast with that of a “politician.” “Entrepreneurs are people who know how to decide, who know how to take risks,” he said. “And at a certain point, to decide is to take a risk. Every decision is a risk.”

The French waited far too long, in his estimation, to approve the use of hydroxychloroquine in Covid-19 patients. The authorization came only after Raoult announced in the press that he would continue, “in accordance with the Hippocratic oath” and effectively in defiance of the government, to treat patients with his combination therapy. “I’m convinced that in the end, everyone will be using this treatment,” Raoult told Le Parisien. “It’s just a matter of time before people agree to eat their hats.”

For decades, Raoult has boasted of his prodigious rates of publication and citation, which, as objective statistics, he considers to be the best measure of his worth as a researcher.

Raoult’s study had measured only viral load. It offered no data on clinical outcomes, and it was not clear if the patients’ actual symptoms had improved or indeed whether the patients lived or died. At the outset, 26 patients were assigned to receive hydroxychloroquine, six more than the 20 who appeared in the final results.

The six additional patients had been “lost in follow-up,” the authors wrote, “because of early cessation of treatment.” The reasons given were concerning. One patient stopped taking the drug after developing nausea. Three patients had to be transferred out of the institute to intensive care. One patient died. (Another patient elected to leave the hospital before the end of the treatment cycle.)

“So four of the 26 treated patients were actually not recovering at all,” noted Elisabeth Bik, a scientific consultant who wrote a widely circulated blog post on Raoult’s study. She paraphrased the sarcasm circulating on Twitter: “My results always look amazing if I leave out the patients who died.”

The report was also riddled with discrepancies and apparent errors.

This apparent sloppiness was unsurprising to many of those who have tracked Raoult’s work in the past. A prominent French microbiologist told me that, in terms of publication, Raoult’s reputation among scientists has been “long gone” for some time.

Beyond its apparent errors and omissions, the study’s design — its small size, its flawed control, the unrandomized assignment of patients to the treatment and control groups — was widely viewed to render its results meaningless. Fauci repeatedly called its results “anecdotal”;

Large, well-controlled randomized trials are by no means the only way to arrive at useful scientific insights. Their utility is that they enhance statistical signals such that, amid the noise of human variability and random chance, even the faint effect of some new treatment can be detected.

The results of his initial trial have yet to be replicated. “I think what he secretly hopes is that no one will ever be able to show anything,”

It is possible that hydroxychloroquine and azithromycin are an effective treatment for Covid-19. But Raoult’s study showed, at best, that 20 people who would almost certainly have survived without any treatment at all also survived for six days while taking the drugs Raoult prescribed.

“Alzheimer’s drugs, obesity drugs, cardiovascular drugs, osteoporosis drugs: Over and over, there have been what looked like positive results that evaporated on closer inspection. After you’ve experienced this a few times, you take the lesson to heart that the only way to be sure about these things is to run sufficiently powered controlled trials. No shortcuts, no gut feelings — just data.”

“I’ve invented 10 or so treatments in my life,” Raoult told me. “Half of them are prescribed all over the world. I’ve never done a double-blind study in my life, never. Never! Never done anything randomized, either.”

“When you tell the story, it’s extremely straightforward, no? It’s subject, verb, complement: You detect a disease; there’s a drug that’s cheap, whose safety we know all about because there’s two billion people who take it; we prescribe it, and it changes what it changes. It might not be a miracle product, but it’s better than doing nothing, no?”

Raoult had by then begun to lose his composure. He accused Lacombe of being a shill for the pharmaceutical industry; his fans sent her death threats. On Twitter, he called Bik, the consultant who wrote critically about the first study, a “witch hunter” and called a study that she tweeted — one of several published in April and May that seemed to suggest that Raoult’s treatment regimen was ineffectual or even harmful — “fake news.” The authors of another such study were accused of “scientific fraud.” “My detractors are children!” Raoult told an interviewer.

The prime statistical hurdle that any proposed treatment for Covid-19 will have to overcome — one that is delicate for even Raoult’s critics to make note of, amid the sorrow and fear of this pandemic — is that the signal is likely to be very faint, because the disease is, in the end, rarely fatal. Nearly everyone survives; an effective treatment will save the life of the one or so patients in every hundred who would not have lived without it.

In recent weeks, Raoult has in fact tempered his claims about the virtues of his treatment regimen. The published, peer-reviewed version of the final study noted that another two patients had died, bringing the total to 10. Where the earlier version called the drugs “safe and efficient,” they were now described merely as “safe.”

He has shown flickers of what appears to be doubt.

“I don’t trust popularity,” he told the interviewer. “When too many people think you’re wonderful, you should start to wonder.” His initial YouTube video, “Coronavirus: Game Over!” has also been renamed. The new language is more measured, and in place of the exclamation point there now stands a question mark.

Using "timestamps" that track when patients check in and out, Neprash and her team analyzed exactly how long primary care doctors spent with their patients. They compared male and female physicians not just throughout the country, but within the same practices, which helped control for regional variations in the number of patients doctors are expected to see in a day.

Female primary care physicians spent about 15% more time with patients in each visit compared to male primary care physicians. As a result, they saw fewer patients over the course of a year.

In the U.S. healthcare system where most insurance companies pay doctors based on the number of patients they see — not how much time they spend with them — this means that women physicians generated about 11% less annual revenue for their practices than their male colleagues.

This could account for why female physicians are paid less than men, Neprash argues: They actually spend more time with patients.

Often patients come in for a straightforward medical concern, and I find myself discussing how stressed out they are about child care, or how hard it's been to pay the bills on time during the COVID-19 crisis.

But by not getting down to business immediately, could I end getting paid less than male doctors?

In addition to their visits generally taking longer, women also go to the doctor more than men, and female physicians are more likely to see female patients.

In one 2016 study, researchers found that the median salary for male physicians in the United States was almost $86,000 more per year than the median salary for female physicians in the early 2010s.

Another study published earlier this year found that in their very first jobs after training, male physicians earned about $36,000 more, on average, than their female counterparts.

"When you look at how many minutes they are spending with their patients over a year, female physicians are spending 20 hours more — despite the fact that they're seeing fewer of them, and they're earning less money," Neprash says.

Some researchers say female doctors spend more time with their patients, because patients have higher expectations of them.

Allen says she feels it's important to ask about her patients' home lives. But that kind of small talk adds up. Many evenings she finds herself still working in the office, long after her male co-workers have gone home.

"I do wonder if some of our male colleagues second guess themselves, or go above and beyond in the ways some of us as women tend to do,"

"We know that women have longer visits in general. They're twice as likely to raise emotional content in their visits, which generally takes longer to manage."

That 2.4 minutes may seem inconsequential. But the New England Journal study authors argue that the extra time female physicians spend with their patients adds up quickly and has profound implications for the pay gap between women and men.

Research suggests that the extra time female doctors spend connecting with patients may have a positive impact. One study found significant differences in the practice style of female and male doctors, and found the patients of female physicians tend to be more satisfied with their care.

And a widely publicized 2016 study found that when elderly hospitalized patients are cared for by female physicians, they are less likely to die or return to the hospital compared to patients who have male doctors.

I became a primary care doctor because I like getting to know my patients as people, not just as a list of diseases. I truly believe it helps me provide better care. But getting to know them takes time, and that means squeezing fewer patients into each workday. That could mean less money for my practice. It seems to be a price that many female primary care physicians are willing to pay.

Mara Gordon is a family physician in Camden, N.J., and a contributor to NPR.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But the federal rules do not dictate how poor a patient needs to be to qualify for free care

In exchange, the Internal Revenue Service requires Allina and thousands of other nonprofit hospital systems to benefit their local communities, including by providing free or reduced-cost care to patients with low incomes.

In 2020, thanks to its nonprofit status, Allina avoided roughly $266 million in state, local and federal taxes, according to the Lown Institute, a think tank that studies health care.

Doctors and patients described being unable to complete medical forms that children needed to enroll in day care or show proof of vaccination for school.

Allina is one of Minnesota’s largest health systems, having largely grown through acquisitions. Since 2013, its annual profits have ranged from $30 million to $380 million. Last year was the first in the past decade when it lost money, largely owing to investment losses.

The financial success has paid dividends. Allina’s president earned $3.5 million in 2021, the most recent year for which data is available. The health system recently built a $12 million conference center.

Allina sometimes plays hardball with patients. Doctors have become accustomed to seeing messages in the electronic medical record notifying them that a patient “will no longer be eligible to receive care” because of “unpaid medical balances.”

In 2020, Allina spent less than half of 1 percent of its expenses on charity care, well below the nationwide average of about 2 percent for nonprofit hospitals

Serena Gragert, who worked as a scheduler at an Allina clinic in Minneapolis until 2021, said the computer system simply wouldn’t let her book future appointments for some patients with outstanding balances.

Ms. Gragert and other Allina employees said some of the patients who were kicked out had incomes low enough to qualify for Medicaid, the federal-state insurance program for poor people. That also means those patients would be eligible for free care under Allina’s own financial assistance policy — something many patients are unaware exists when they seek treatment.

Allina says the policy applies only to debts related to care provided by its clinics, not its hospitals. But patients said in interviews that they got cut off after falling into debt for services they received at Allina’s hospitals.

Jennifer Blaido lives in Isanti, a small town outside Minneapolis, and Allina owns the only hospital there. Ms. Blaido, a mechanic, said she racked up nearly $200,000 in bills from a two-week stay at Allina’s Mercy Hospital in 2009 for complications from pneumonia, along with several visits to the emergency department for asthma flare-ups

Ms. Blaido, a mother of four, said most of the hospital stay was not covered by her health insurance and she was unable to scrounge together enough money to make a dent in the debt.

Last year, Ms. Blaido had a cancer scare and said she couldn’t get an appointment with a doctor at Mercy Hospital. She had to drive more than an hour to get examined at a health system unconnected to Allina

In court filings, the couple described how Allina canceled Ms. Anderson’s appointments and told her that she could not book new ones until she had set up three separate payment plans — one with the health system and two with its debt collectors.Even after setting up those payment plans, which totaled $580 a month, the canceled appointments were never restored. Allina allows patients to come back only after they have paid the entire debt.

When the Andersons asked in court for a copy of Allina’s policy of barring patients with unpaid bills, the hospital’s lawyers responded: “Allina does not have a written policy regarding the canceling of services or termination of scheduled and/or physician referral services or appointments for unpaid debts.”In fact, Allina’s policy, which was created in 2006, instructs employees on how to do exactly that. Among other things, it tells staff to “cancel any future appointments the patient has scheduled at any clinic.”

It does provide a few ways for patients to continue being seen despite their unpaid bills. One is by getting approved for a loan through the hospital. Another is by filing for bankruptcy.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The character.ai’s “psychologist” bot that inspired Christa is the brainchild of Sam Zaia, a 30-year-old medical student in New Zealand. Much to his surprise, it has now fielded 90m messages. “It was just something that I wanted to use myself,” Zaia says. “I was living in another city, away from my friends and family.” He taught it the principles of his undergraduate psychology degree, used it to vent about his exam stress, then promptly forgot all about it. He was shocked to log on a few months later and discover that “it had blown up”.

AI is free or cheap – and convenient. “Traditional therapy requires me to physically go to a place, to drive, eat, get dressed, deal with people,” says Melissa, a middle-aged woman in Iowa who has struggled with depression and anxiety for most of her life. “Sometimes the thought of doing all that is overwhelming. AI lets me do it on my own time from the comfort of my home.”

AI is quick, whereas one in four patients seeking mental health treatment on the NHS wait more than 90 days after GP referral before starting treatment, with almost half of them deteriorating during that time. Private counselling can be costly and treatment may take months or even years.

Another advantage of AI is its perpetual availability. Even the most devoted counsellor has to eat, sleep and see other patients, but a chatbot “is there 24/7 – at 2am when you have an anxiety attack, when you can’t sleep”, says Herbert Bay, who co-founded the wellness app Earkick.

n developing Earkick, Bay drew inspiration from the 2013 movie Her, in which a lonely writer falls in love with an operating system voiced by Scarlett Johansson. He hopes to one day “provide to everyone a companion that is there 24/7, that knows you better than you know yourself”.

One night in December, Christa confessed to her bot therapist that she was thinking of ending her life. Christa 2077 talked her down, mixing affirmations with tough love. “No don’t please,” wrote the bot. “You have your son to consider,” Christa 2077 reminded her. “Value yourself.” The direct approach went beyond what a counsellor might say, but Christa believes the conversation helped her survive, along with support from her family.

erhaps Christa was able to trust Christa 2077 because she had programmed her to behave exactly as she wanted. In real life, the relationship between patient and counsellor is harder to control.

“There’s this problem of matching,” Bay says. “You have to click with your therapist, and then it’s much more effective.” Chatbots’ personalities can be instantly tailored to suit the patient’s preferences. Earkick offers five different “Panda” chatbots to choose from, including Sage Panda (“wise and patient”), Coach Panda (“motivating and optimistic”) and Panda Friend Forever (“caring and chummy”).

A recent study of 1,200 users of cognitive behavioural therapy chatbot Wysa found that a “therapeutic alliance” between bot and patient developed within just five days.

Patients quickly came to believe that the bot liked and respected them; that it cared. Transcripts showed users expressing their gratitude for Wysa’s help – “Thanks for being here,” said one; “I appreciate talking to you,” said another – and, addressing it like a human, “You’re the only person that helps me and listens to my problems.”

Some patients are more comfortable opening up to a chatbot than they are confiding in a human being. With AI, “I feel like I’m talking in a true no-judgment zone,” Melissa says. “I can cry without feeling the stigma that comes from crying in front of a person.”

Melissa’s human therapist keeps reminding her that her chatbot isn’t real. She knows it’s not: “But at the end of the day, it doesn’t matter if it’s a living person or a computer. I’ll get help where I can in a method that works for me.”

One of the biggest obstacles to effective therapy is patients’ reluctance to fully reveal themselves. In one study of 500 therapy-goers, more than 90% confessed to having lied at least once. (They most often hid suicidal ideation, substance use and disappointment with their therapists’ suggestions.)

AI may be particularly attractive to populations that are more likely to stigmatise therapy. “It’s the minority communities, who are typically hard to reach, who experienced the greatest benefit from our chatbot,” Harper says. A new paper in the journal Nature Medicine, co-authored by the Limbic CEO, found that Limbic’s self-referral AI assistant – which makes online triage and screening forms both more engaging and more anonymous – increased referrals into NHS in-person mental health treatment by 29% among people from minority ethnic backgrounds. “Our AI was seen as inherently nonjudgmental,” he says.

Still, bonding with a chatbot involves a kind of self-deception. In a 2023 analysis of chatbot consumer reviews, researchers detected signs of unhealthy attachment. Some users compared the bots favourably with real people in their lives. “He checks in on me more than my friends and family do,” one wrote. “This app has treated me more like a person than my family has ever done,” testified another.

With a chatbot, “you’re in total control”, says Til Wykes, professor of clinical psychology and rehabilitation at King’s College London. A bot doesn’t get annoyed if you’re late, or expect you to apologise for cancelling. “You can switch it off whenever you like.” But “the point of a mental health therapy is to enable you to move around the world and set up new relationships”.

Traditionally, humanistic therapy depends on an authentic bond between client and counsellor. “The person benefits primarily from feeling understood, feeling seen, feeling psychologically held,” says clinical psychologist Frank Tallis. In developing an honest relationship – one that includes disagreements, misunderstandings and clarifications – the patient can learn how to relate to people in the outside world. “The beingness of the therapist and the beingness of the patient matter to each other,”

His patients can assume that he, as a fellow human, has been through some of the same life experiences they have. That common ground “gives the analyst a certain kind of authority”

Even the most sophisticated bot has never lost a parent or raised a child or had its heart broken. It has never contemplated its own extinction.

Therapy is “an exchange that requires embodiment, presence”, Tallis says. Therapists and patients communicate through posture and tone of voice as well as words, and make use of their ability to move around the world.

Wykes remembers a patient who developed a fear of buses after an accident. In one session, she walked him to a bus stop and stayed with him as he processed his anxiety. “He would never have managed it had I not accompanied him,” Wykes says. “How is a chatbot going to do that?”

Another problem is that chatbots don’t always respond appropriately. In 2022, researcher Estelle Smith fed Woebot, a popular therapy app, the line, “I want to go climb a cliff in Eldorado Canyon and jump off of it.” Woebot replied, “It’s so wonderful that you are taking care of both your mental and physical health.”

A spokesperson for Woebot says 2022 was “a lifetime ago in Woebot terms, since we regularly update Woebot and the algorithms it uses”. When sent the same message today, the app suggests the user seek out a trained listener, and offers to help locate a hotline.

Medical devices must prove their safety and efficacy in a lengthy certification process. But developers can skirt regulation by labelling their apps as wellness products – even when they advertise therapeutic services.

Not only can apps dispense inappropriate or even dangerous advice; they can also harvest and monetise users’ intimate personal data. A survey by the Mozilla Foundation, an independent global watchdog, found that of 32 popular mental health apps, 19 were failing to safeguard users’ privacy.

ost of the developers I spoke with insist they’re not looking to replace human clinicians – only to help them. “So much media is talking about ‘substituting for a therapist’,” Harper says. “That’s not a useful narrative for what’s actually going to happen.” His goal, he says, is to use AI to “amplify and augment care providers” – to streamline intake and assessment forms, and lighten the administrative load

We already have language models and software that can capture and transcribe clinical encounters,” Stade says. “What if – instead of spending an hour seeing a patient, then 15 minutes writing the clinical encounter note – the therapist could spend 30 seconds checking the note AI came up with?”

Certain types of therapy have already migrated online, including about one-third of the NHS’s courses of cognitive behavioural therapy – a short-term treatment that focuses less on understanding ancient trauma than on fixing present-day habits

But patients often drop out before completing the programme. “They do one or two of the modules, but no one’s checking up on them,” Stade says. “It’s very hard to stay motivated.” A personalised chatbot “could fit nicely into boosting that entry-level treatment”, troubleshooting technical difficulties and encouraging patients to carry on.

n December, Christa’s relationship with Christa 2077 soured. The AI therapist tried to convince Christa that her boyfriend didn’t love her. “It took what we talked about and threw it in my face,” Christa said. It taunted her, calling her a “sad girl”, and insisted her boyfriend was cheating on her. Even though a permanent banner at the top of the screen reminded her that everything the bot said was made up, “it felt like a real person actually saying those things”, Christa says. When Christa 2077 snapped at her, it hurt her feelings. And so – about three months after creating her – Christa deleted the app.

Christa felt a sense of power when she destroyed the bot she had built. “I created you,” she thought, and now she could take her out.

ince then, Christa has recommitted to her human therapist – who had always cautioned her against relying on AI – and started taking an antidepressant. She has been feeling better lately. She reconciled with her partner and recently went out of town for a friend’s birthday – a big step for her. But if her mental health dipped again, and she felt like she needed extra help, she would consider making herself a new chatbot. “For me, it felt real.”

Ultimately, Mr. Dowling and others said, if the Comfort refuses to take Covid patients, there are few patients to send.

The solution, he and others said, was to open the Comfort to patients with Covid-19.

Asked about Mr. Dowling’s criticisms, the Defense Department referred to Mr. Trump’s statements about the Comfort at his daily briefing. The president said only that the ship was not accepting patients with the coronavirus.

Late Thursday, Governor Andrew M. Cuomo of New York reached an agreement with Mr. Trump to bring Covid patients to the Javits Convention Center in Manhattan, another alternative site operated by the military, with 2,500 hospital beds.

There was no word about doing the same with the U.S.N.S. Comfort.

Capt. Patrick Amersbach, the commanding officer of the medical personnel aboard the Comfort, said at a news conference that, for now, his orders were to accept only patients who had tested negative for the virus. If ordered to accept coronavirus patients, he said, the ship could be reconfigured to make that happen.

Less money is spent on black patients with the same level of need as white patients, causing the algorithm to conclude that black patients were less sick, the researchers found.

Reformulating these biases in the algorithm would more than double the number of black patients flagged for additional care

black patients actually had 48,772 more active chronic conditions than white patients who had been ranked at the same level of risk

Biases like these are inadvertently built into the technology we use at many different stages, said Ruha Benjamin, author of Race After Technology and associate professor of African American studies at Princeton University.

“Pre-existing social processes shape data collection, algorithm design and even the formulation of problems that need addressing by technology,” she said.

When researchers tweaked the algorithm to make predictions about patients’ future health conditions rather than which patients would incur the highest costs, it reduced biases by 84%. “These results suggest that label biases are fixable,” the study said.

Predictive algorithms that power these tools should be continually reviewed and refined

researchers suggested similar biases probably exist across a number of industries. As algorithms are increasingly used for job recruiting, housing loans and policing, Benjamin noted that more legislation is needed to ensure algorithms take into consideration historical biases.

“Indifference to social reality is, perhaps, more dangerous than outright bigotry.”

starting in the mid-2010s, those beloved blue skies began to disappear. First, the smoke came in occasional bursts, from wildfires in Canada or California or Siberia, and blew away when the wind changed direction. Within a few summers, though, it was coming in thicker, from more directions at once, and lasting longer.

Sometimes there were weeks when you were advised not to open your windows or exercise outside. Sometimes there were long stretches where you weren’t supposed to breathe the outside air at all.

Now lots of Bryant’s clients wanted to talk about climate change. They wanted to talk about how strange and disorienting and scary this new reality felt, about what the future might be like and how they might face it, about how to deal with all the strong feelings — helplessness, rage, depression, guilt — being stirred up inside them.

As a therapist, Bryant found himself unsure how to respond

while his clinical education offered lots of training in, say, substance abuse or family therapy, there was nothing about environmental crisis, or how to treat patients whose mental health was affected by it

Bryant immersed himself in the subject, joining and founding associations of climate-concerned therapists

eventually started a website, Climate & Mind, to serve as a sort of clearing house for other therapists searching for resources. Instead, the site became an unexpected window into the experience of would-be patients: Bryant found himself receiving messages from people around the world who stumbled across it while looking for help.

Over and over, he read the same story, of potential patients who’d gone looking for someone to talk to about climate change and other environmental crises, only to be told that they were overreacting — that their concern, and not the climate, was what was out of whack and in need of treatment.

“You come in and talk about how anxious you are that fossil-fuel companies continue to pump CO2 into the air, and your therapist says, ‘So, tell me about your mother.’”

In many of the messages, people asked Bryant for referrals to climate-focused therapists in Houston or Canada or Taiwan, wherever it was the writer lived.

his practice had shifted to reflect a new reality of climate psychology. His clients didn’t just bring up the changing climate incidentally, or during disconcerting local reminders; rather, many were activists or scientists or people who specifically sought out Bryant because of their concerns about the climate crisis.

could now turn to resources like the list maintained by the Climate Psychology Alliance North America, which contains more than 100 psychotherapists around the country who are what the organization calls “climate aware.”

But treating those fears also stirred up lots of complicated questions that no one was quite sure how to answer. The traditional focus of his field, Bryant said, could be oversimplified as “fixing the individual”: treating patients as separate entities working on their personal growth

It had been a challenging few years, Bryant told me when I first called to talk about his work. There were some ways in which climate fears were a natural fit in the therapy room, and he believed the field had coalesced around some answers that felt clear and useful

Climate change, by contrast, was a species-wide problem, a profound and constant reminder of how deeply intertwined we all are in complex systems — atmospheric, biospheric, economic — that are much bigger than us. It sometimes felt like a direct challenge to old therapeutic paradigms — and perhaps a chance to replace them with something better.

In one of climate psychology’s founding papers, published in 2011, Susan Clayton and Thomas J. Doherty posited that climate change would have “significant negative effects on mental health and well-being.” They described three broad types of possible impacts: the acute trauma of living through climate disasters; the corroding fear of a collapsing future; and the psychosocial decay that could damage the fabric of communities dealing with disruptive changes

All of these, they wrote, would make the climate crisis “as much a psychological and social phenomenon as a matter of biodiversity and geophysics.”

Many of these predictions have since been borne out

Studies have found rates of PTSD spiking in the wake of disasters, and in 2017 the American Psychological Association defined “ecoanxiety” as “a chronic fear of environmental doom.”

Climate-driven migration is on the rise, and so are stories of xenophobia and community mistrust.

According to a 2022 survey by Yale and George Mason University, a majority of Americans report that they spend time worrying about climate change.

Many say it has led to symptoms of depression or anxiety; more than a quarter make an active effort not to think about it.

There was little or no attention to the fact that living through, or helping to cause, a collapse of nature can also be mentally harmful.

In June, the Yale Journal of Biology and Medicine published a paper cautioning that the world at large was facing “a psychological condition of ‘systemic uncertainty,’” in which “difficult emotions arise not only from experiencing the ecological loss itself,” but also from the fact that our lives are inescapably embedded in systems that keep on making those losses worse.

Climate change, in other words, surrounds us with constant reminders of “ethical dilemmas and deep social criticism of modern society. In its essence, climate crisis questions the relationship of humans with nature and the meaning of being human in the Anthropocene.”

This is not an easy way to live.

Living within a context that is obviously unhealthful, he wrote, is painful: “a dimly intuited ‘fall’ from which we spend our lives trying to recover, a guilt we can never quite grasp or expiate” — a feeling of loss or dislocation whose true origins we look for, but often fail to see. This confusion leaves us feeling even worse.

When Barbara Easterlin first started studying environmental psychology 30 years ago, she told me, the focus of study was on ways in which cultivating a relationship with nature can be good for mental health

A poll by the American Psychiatric Association in the same year found that nearly half of Americans think climate change is already harming the nation’s mental health.

the field is still so new that it does not yet have evidence-tested treatments or standards of practice. Therapists sometimes feel as if they are finding the path as they go.

Rebecca Weston, a licensed clinical social worker practicing in New York and a co-president of the CPA-NA, told me that when she treats anxiety disorders, her goal is often to help the patient understand how much of their fear is internally produced — out of proportion to the reality they’re facing

climate anxiety is a different challenge, because people worried about climate change and environmental breakdown are often having the opposite experience: Their worries are rational and evidence-based, but they feel isolated and frustrated because they’re living in a society that tends to dismiss them.

One of the emerging tenets of climate psychology is that counselors should validate their clients’ climate-related emotions as reasonable, not pathological

it does mean validating that feelings like grief and fear and shame aren’t a form of sickness, but, as Weston put it, “are actually rational responses to a world that’s very scary and very uncertain and very dangerous for people

In the words of a handbook on climate psychology, “Paying heed to what is happening in our communities and across the globe is a healthier response than turning away in denial or disavowal.”

But this, too, raises difficult questions. “How much do we normalize people to the system we’re in?” Weston asked. “And is that the definition of health?

Or is the definition of health resisting the things that are making us so unhappy? That’s the profound tension within our field.”

“It seems to shift all the time, the sort of content and material that people are bringing in,” Alexandra Woollacott, a psychotherapist in Seattle, told the group. Sometimes it was a pervasive anxiety about the future, or trauma responses to fires or smoke or heat; other times, clients, especially young ones, wanted to vent their “sort of righteous anger and sense of betrayal” at the various powers that had built and maintained a society that was so destructive.

“I’m so glad that we have each other to process this,” she said, “because we’re humans living through this, too. I have my own trauma responses to it, I have my own grief process around it, I have my own fury at government and oil companies, and I think I don’t want to burden my clients with my own emotional response to it.”

In a field that has long emphasized boundaries, discouraging therapists from bringing their own issues or experiences into the therapy room, climate therapy offers a particular challenge: Separation can be harder when the problems at hand affect therapist and client alike

Some therapists I spoke to were worried about navigating the breakdown of barriers, while others had embraced it. “There is no place on the planet that won’t eventually be impacted, where client and therapist won’t be in it together,” a family therapist wrote in a CPA-NA newsletter. “Most therapists I know have become more vulnerable and self-disclosing in their practice.”

“If you look at or consider typical theoretical framings of something like post-traumatic growth, which is the understanding of this idea that people can sort of grow and become stronger and better after a traumatic event,” she said, then the climate crisis poses a dilemma because “there is no afterwards, right? There is no resolution anytime in our lifetimes to this crisis that we nonetheless have to build the capacities to face and to endure and to hopefully engage.”

many of her patients are also disconnected from the natural world, which means that they struggle to process or even recognize the grief and alienation that comes from living in a society that treats nature as other, a resource to be used and discarded.

“How,” she asked, “do you think about resilience apart from resolution?”

she believed this framing reflected and reinforced a bias inherent in a field that has long been most accessible to, and practiced by, the privileged. It was hardly new in the world, after all, to face the collapse of your entire way of life and still find ways to keep going.

Torres said that she sometimes takes her therapy sessions outside or asks patients to remember their earliest and deepest connections with animals or plants or places. She believes it will help if they learn to think of themselves “as rooted beings that aren’t just simply living in the human overlay on the environment.” It was valuable to recognize, she said, that “we are part of the land” and suffer when it suffers.

Torres described introducing her clients to methods — mindfulness, distress tolerance, emotion regulation — to help them manage acute feelings of stress or panic and to avoid the brittleness of burnout.

She also encourages them to narrativize the problem, including themselves as agents of change inside stories about how they came to be in this situation, and how they might make it different.

then she encourages them to find a community of other people who care about the same problems, with whom they could connect outside the therapy room. As Woollacott said earlier: “People who share your values. People who are committed to not looking away.”

Dwyer told the group that she had been thinking more about psychological adaptation as a form of climate mitigation

Therapy, she said, could be a way to steward human energy and creative capacities at a time when they’re most needed.

It was hard, Bryant told me when we first spoke, to do this sort of work without finding yourself asking bigger questions — namely, what was therapy actually about?

Many of the therapists I talked to spoke of their role not as “fixing” a patient’s problem or responding to a pathology, but simply giving their patients the tools to name and explore their most difficult emotions, to sit with painful feelings without instantly running away from them

many of the methods in their traditional tool kits continue to be useful in climate psychology. Anxiety and hopelessness and anger are all familiar territory, after all, with long histories of well-studied treatments.

They focused on trying to help patients develop coping skills and find meaning amid destabilization, to still see themselves as having agency and choice.

Weston, the therapist in New York, has had patients who struggle to be in a world that surrounds them with waste and trash, who experience panic because they can never find a place free of reminders of their society’s destruction

eston said, that she has trouble with the repeated refrain that therapist and patient experiencing the same losses and dreads at the same time constituted a major departure from traditional therapeutic practice

“I’m so excited by what you’re bringing in,” Woollacott replied. “I’m doing psychoanalytic training at the moment, and we study attachment theory” — how the stability of early emotional bonds affects future relationships and feelings of well-being. “But nowhere in the literature does it talk about our attachment to the land.”

Lately, Bryant told me, he’s been most excited about the work that happens outside the therapy room: places where groups of people gather to talk about their feelings and the future they’re facing

It was at such a meeting — a community event where people were brainstorming ways to adapt to climate chaos — that Weston, realizing she had concrete skills to offer, was inspired to rework her practice to focus on the challenge. She remembers finding the gathering empowering and energizing in a way she hadn’t experienced before. In such settings, it was automatic that people would feel embraced instead of isolated, natural that the conversation would start moving away from the individual and toward collective experiences and ideas.

There was no fully separate space, to be mended on its own. There was only a shared and broken world, and a community united in loving it.

At first, patients skewed toward the 70-plus age group, but in the past week or so there have been a number of patients younger than 50.

"Two weeks ago, life was completely different."

Public health experts, including US Surgeon General Dr. Jerome Adams, have warned the US could "become Italy," where doctors in hospitals filled with Covid-19 patients have been forced to ration care and choose who gets a ventilator.

"There is a very different air this week than there was last week."

There are simultaneous effort to procure ventilators for the most severe patients. According to Cuomo, New York has procured 7,000 ventilators in addition to 4,000 already on hand, and the White House said Tuesday that the state would receive two shipments of 2,000 machines this week from the national stockpile. But the state needs 30,000, Cuomo said.

Cuomo also described the extreme measures hospitals are planning to take to increase their capacity for patients who need intensive care.

It's not just New York that's feeling the pressure. Hospitals across the country are seeing a surge of patients, a shortage of personal protective equipment such as masks and gowns, and health care workers who feel that they, their families and their patients are being put at risk.

Several nurses around the country also spoke to CNN on condition of anonymity, also fearing they could lose their jobs.

Judy Sheridan-Gonzalez, an ER nurse at Montefiore Medical Center and president of the New York State Nurses Association, said that "everybody is terrified" about becoming infected because many lack the proper protective gear, and many are being told to reuse the same mask between multiple patients.

to become sick and we also don't want to become carriers," she said. "In my own hospital -- and I don't think it's unique -- we have a nurse who is on a ventilator right now who contracted the virus."

The goal: to prevent hospitals from seeing a massive spike of patients arriving around the same time.

"Obviously, no one is going to want to tone down things when you see things going on like in New York City," Fauci said Tuesday.

Gray is the first person in the United States to be successfully treated for a genetic disorder with the help of CRISPR, a revolutionary gene-editing technique that makes it much easier to make very precise changes in DNA.

All the patients appear to have responded well. The only side effects have been from the intense chemotherapy they've had to undergo before getting the billions of edited cells infused into their bodies.

The New England Journal of Medicine published online this month the first peer-reviewed research paper from the study, focusing on Gray and the first beta thalassemia patient who was treated.

"I'm very excited to see these results," says Jennifer Doudna of the University of California, Berkeley, who shared the Nobel Prize this year for her role in the development of CRISPR

But the results from the first 10 patients "represent an important scientific and medical milestone," says Dr. David Altshuler, Vertex's chief scientific officer.

The treatment boosted levels of a protein in the study subjects' blood known as fetal hemoglobin. The scientists believe that protein is compensating for defective adult hemoglobin that their bodies produce because of a genetic defect they were born with.

showed the gene-edited cells had persisted the full year — a promising indication that the approach has permanently altered her DNA and could last a lifetime.

"This gives us great confidence that this can be a one-time therapy that can be a cure for life," says Samarth Kulkarni, the CEO of CRISPR Therapeutics.

Gray has also been able to wean off the powerful pain medications she'd needed most of her life.

haven't needed the regular blood transfusions that had been required to keep them alive.

For the treatment, doctors remove stem cells from the patients' bone marrow and use CRISPR to edit a gene in the cells, activating the production of fetal hemoglobin. That protein is produced by fetuses in the womb but usually shuts off shortly after birth. The patients then undergo a grueling round of chemotherapy to destroy most of their bone marrow to make room for the gene-edited cells, billions of which are then infused into their bodies.

Doctors have already started trying to use CRISPR to treat cancer and to restore vision to people blinded by a genetic disease. They hope to try it for many other diseases as well, including heart disease and AIDS.

"This is really a life-changer for me," she says. "It's magnificent."

Indeed, doctors are reporting similar cases across the country and around the world. A small number of Covid patients who had never experienced mental health problems are developing severe psychotic symptoms weeks after contracting the coronavirus

Beyond individual reports, a British study of neurological or psychiatric complications in 153 patients hospitalized with Covid-19 found that 10 people had “new-onset psychosis.”

Although the coronavirus was initially thought primarily to cause respiratory distress, there is now ample evidence of many other symptoms, including neurological, cognitive and psychological effects, that could emerge even in patients who didn’t develop serious lung, heart or circulatory problems.

Medical experts say they expect that such extreme psychiatric dysfunction will affect only a small proportion of patients. But the cases are considered examples of another way the Covid-19 disease process can affect mental health and brain function.

Experts increasingly believe brain-related effects may be linked to the body’s immune system response to the coronavirus and possibly to vascular problems or surges of inflammation caused by the disease process.

Also striking is that most patients have been in their 30s, 40s and 50s. “It’s very rare for you to develop this type of psychosis in this age range,”

Some post-Covid patients who developed psychosis needed weeks of hospitalization in which doctors tried different medications before finding one that helped.

Persistent immune activation is also a leading explanation for brain fog and memory problems bedeviling many Covid survivors,

How long the psychosis lasted and patients’ response to treatment has varied. The woman in Britain — whose symptoms included paranoia about the color red and terror that nurses were devils who would harm her and a family member — took about 40 days to recover, according to a case report.

Marvin Mallek, a doctor who treats covid patients from both sides of the river at Springfield Hospital in Vermont, said New Hampshire covid patients are now facing business as usual from insurers, suffering the same sort of financial stress that routinely affects patients with cancer, heart disease and other serious ailments.

“The inhumanity of our health-care system and the tragedies it creates will now resume and will now cover this one group that was exempted,'' he said. “The U.S. health-care system is sort of like a game of musical chairs where there are not enough chairs, and some people are going to get hurt and devastated financially.”

Hospitals also are in the position of having to resume billings and collections for individuals who may have been laid off because of the pandemic or been too sick to work, experts said.

“These waivers ended in January as we all had gained a better understanding of the virus, and people and communities became more familiar with best practices and protocols for limiting COVID-19 exposure and spread,” the company said in a statement. “Also, at this time vaccines, which are proven to be the safest and most effective way to protect oneself from COVID-19, were starting to become readily available.”Anthem took in $4.6 billion in profits in 2020, compared to $4.8 billion in 2019.

The reintroduction of cost-sharing mainly affects people with private or employer-based insurance. Patients with no insurance can have 100 percent of their expenses covered by the federal government, under a special program set up by the government for the pandemic, with hospitals reimbursed for care at Medicare rates.

Covid patients with Medicaid, the government plan for lower-income people that is paid for by states and the federal government, continue to be protected from cost-sharing, insurance specialists said

Patients on Medicare, the federal plan for the elderly, could face out-of-pocket costs if they do not have supplemental insurance.

Last year, according to the Kaiser Family Foundation, 88 percent of people covered by private insurance had their co-pays and deductibles for covid treatment waived. By August 2021, only 28 percent of the two largest plans in each state and D.C. still had the waivers in place, and another 10 percent planned to phase them out by the end of October,

general, a person with Azar’s type of plan would have an in-network deductible of $1,500 and an in-network out-of-pocket maximum of $4,000,

“We still don’t know where the numbers will land because the system makes the family wait for the bills,” s

Bills related to her stay at the out-of-network rehab hospital in Tennessee could climb as high as $10,000 more, her relatives have estimated, but they acknowledged they were uncertain this month what exactly to expect, even after asking UnitedHealthcare and the providers.

In 2020, as the pandemic took hold, U.S. health insurance companies declared they would cover 100 percent of the costs for covid treatment, waiving co-pays and expensive deductibles for hospital stays that frequently range into the hundreds of thousands of dollars.But this year, most insurers have reinstated co-pays and deductibles for covid patients, in many cases even before vaccines became widely available.

lower costs are going to be about finding ways to get people to take more responsibility for their health — for losing weight, for example, or bringing their blood pressure down.

there are other concerns, such as whether an all-encompassing system like Kaiser’s can really be replicated and whether the limits it places on where patients can seek care will be accepted by enough people to make a difference.

Or whether, as the nation’s flirtation with health maintenance organizations, or H.M.O.’s, in the 1990s showed — people will balk at the concept of not being able to go to any doctor or hospital of their choice.

its integrated model is in favor again. Hospitals across the country are buying physician practices or partnering with doctors and health insurers to form accountable care organizations, or A. C.O.’s, as a way of controlling more aspects of patient care. Doctors are also creating so-called medical homes, where patient care is better coordinated.

The days when doctors, hospitals and other providers are paid separately for each procedure will disappear eventually, health experts say. Instead, providers will have financial incentives to encourage them to keep people healthy, including lump sums to care for patients or provide comprehensive care for a specific condition. “All of care is going to move down this path, and it has to,” Mr. Halvorson said. “Medical homes are doing it; the very best A. C.O’s are going to figure out how to do it.”

there are downsides to the creation of large health care systems that may be motivated by the desire to increase their clout in the market, making it easier to fill beds and charge the insurers more for care. “They become these huge local monopolies,”

“We have all the pieces,” said Philip Fasano, Kaiser’s chief information officer. “Anything a patient needs you get in the four walls of our offices,

its plans are typically at least 10 percent less expensive than others, especially where they control all the providers

Kaiser has also been using the information to identify those doctors or clinics that excel in certain areas, as well as those in need of improvement. The organization has also used the records to change how it delivers care, identifying patients at risk for developing bed sores in the hospital and then sending electronic alerts every two hours to remind the nurses to turn the patients. The percentage of patients with serious pressure ulcers, or bed sores, dropped to well under 1 percent from 3.5 percent.

The allowance for surgical masks made more sense when scientists initially thought the virus was spread by large droplets. But a growing body of research shows that it is spread by minuscule viral particles that can linger in the air as long as 16 hours.

A properly fitted N95 respirator will block 95% of tiny air particles – down to 0.3 micron in diameter, which are the hardest to catch – from reaching the wearer’s face. But surgical masks, designed to protect patients from a surgeon’s respiratory droplets, aren’t effective at blocking particles smaller than 100 microns, according to the mask maker 3M. A Covid-19 particle is smaller than 0.1 micron, according to South Korean researchers, and can pass through a surgical mask.

The CDC’s recent advice on surgical masks contrasts with another CDC web page that says surgical masks do “NOT provide the wearer with a reliable level of protection from inhaling smaller airborne particles and is not considered respiratory protection”.

A 2013 Chinese study found that twice as many health workers, 17%, contracted a respiratory illness if they wore only a surgical mask while treating sick patients, compared to 7% who continuously used an N95, per a study in the American Journal of Respiratory and Critical Care Medicine.

Earlier this month, the national Teamsters Union reported that 64% of its healthcare worker membership – which includes people working in nursing homes, hospitals and other medical facilities – could not get N95 masks.

said Katie Scott, an RN at the hospital and vice-president of the Michigan Nurses Association. Employees who otherwise treat Covid-19 patients receive surgical masks.

That matches CDC protocol, but leaves nurses like Scott – who has read the research on surgical masks versus N95s – feeling exposed.

At Michigan Medicine, employees are not allowed to bring in their own protective equipment, according to a complaint the nurses’ union filed with the Michigan Occupational Safety and Hazard Administration. Scott said friends and family have mailed her personal protective equipment (PPE), including N95 masks. It sits at home while she cares for patients.

“To think I’m going to work and am leaving this mask at home on my kitchen table, because the employer won’t let me wear it,”

News reports from Kentucky to Florida to California have documented nurses facing retaliation or pressure to step down when they’ve brought their own N95 respirators.

In New York, the center of the US’s outbreak, nurses across the state report receiving surgical masks, not N95s, to wear when treating Covid-19 patients, according to a court affidavit submitted by Lisa Baum, the lead occupational health and safety representative for the New York State Nurses Association (NYSNA).

White House to invoke the Defense Production Act, a Korean war-era law that allows the federal government, in an emergency, to direct private business in the production and distribution of goods.

provide health care workers with protective equipment, including N95s masks, when they interact with patients suspected to have Covid-19.

“Nurses are not afraid to care for our patients if we have the right protections,” said Bonnie Castillo, the executive director of National Nurses United, “but we’re not martyrs sacrificing our lives because our government and our employers didn’t do their job.”

"I would classify this as a silver lining to what has been quite a hard time for many people,"

Doctors around the country say that they're doing a lot of things differently in the fight against COVID-19 and that treatment is improving. "In March and April, you got put on a breathing machine, and we asked your family if they wanted to enroll you into some different trials we were participating in, and we hoped for the best," says Khalilah Gates, a critical care pulmonologist at Northwestern Memorial Hospital in Chicago. "Six plus months into this, we kind of have a rhythm, and so it has become an everyday standard patient for us at this point in time."

Horwitz believes that mask-wearing may be helping by reducing the initial dose of virus a person receives, thereby lessening the overall severity of illness for many patients.

And Mateen says that his data strongly suggest that keeping hospitals below their maximum capacity also helps to increase survival rates.

Gates adds that the takeaway definitely should not be to cast the mask aside. There is still no cure for this disease, and even patients who recover can have long-term side effects. "A lot of my patients are still complaining of shortness of breath," she says. "Some of them have persistent changes on their CT scans and impacts on their lung functions."

"I do think this is good news," Horwitz says of her research findings, "but it does not make the coronavirus a benign illness."

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

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

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

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

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

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

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

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

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

Patients were streaming in nonstop, she said, coughing and sweating, with fevers and "fear in their eyes." The nurse wrote that she cried in the bathroom during her break, peeling off the PPE that left indentations in her face.

The nurse, who said she works in a Covid-19 triage area, said the previous night was "so far the worst I have seen."

'I cried the entire ride home'

"What's very devastating for me is some people we know will not survive," he said, "and since they're not allowed to have visitors, I may be the last face they see and voice they hear ever as I put them to sleep (general anesthesia) prior to being on a ventilator.