Why Getting Older Might Be Life’s Biggest Plot Twist

Aging isn’t easy, and topics like dementia and medically assisted dying can be hard to talk about. The British mystery writer Richard Osman is trying to change that. Osman has reimagined the notion of aging through his best-selling “Thursday Murder Club” series, centered on four seniors living in a posh retirement community who solve murders.

In this episode, he sits down with the Opinion writer Michelle Cottle to discuss why seniors make ideal fictional detectives and how a “cozy” murder mystery is the perfect frame to explore growing old. (...)

Michelle Cottle: This week I’m talking with Richard Osman, who writes the best-selling mystery novels known as the “Thursday Murder Club” series. These books revolve around four residents of a posh retirement village in the British countryside who investigate murders in their spare time.

The fifth book, “The Impossible Fortune,” is out in the U.S. on Sept. 30, and it comes on the heels of a Netflix adaptation of the original book. But before I get too carried away, I really should introduce their creator. Richard Osman, welcome, thank you so much for doing this.

Richard Osman: It’s an absolute pleasure, Michelle. Lovely to meet you across the ocean. (...)

Cottle: One of the big things that sets these stories apart for me is the perspective of the main characters, who are all older, and it really informs their views on life and death and risk and justice. Did you know you were going to wind up delving into these existential issues when you started all this?

Osman: I really did, actually. It’s taken a long time for me to write a novel. I’ve written all sorts of things over the years, and I kept waiting for something that I knew had a little bit of depth to it, something that I could really get my teeth into. My mom lives in a retirement village, and I go there and meet all these people who’ve lived these extraordinary lives but slightly shut away from the heart of our culture. The second I had this idea, I was aware I had a gang of people who are very different from each other but a gang of people who’ve done extraordinary things.

As a huge fan of crime fiction, I knew the murders and the plots can take care of themselves, but I had a bottomless well of character, experience and stories that I could draw upon with these characters. So right from the start, I thought it was worth me having a go at this because it feels like if I get the first one right, then others will follow. I knew there was plenty for me to write about here.

Cottle: Your characters are talking about hard stuff like loss, grief, loneliness, assisted dying, dementia. I feel like you and I have come at some of the same topics from really different directions now.

As a reporter, I tend to find that readers either really identify with what I’m writing about or that they just don’t want to think about it at all — like, “I don’t want to think about my parents getting old. I don’t want to think about getting old.” But on the other hand, we are tackling these things in a way that gives people a really appealing entry point. You know, murder, friendship, cake, baking. It’s like you’re sneaking tough issues in there for us to chew over.

Osman: Yeah, sneaking the vegetables under the ketchup.

Cottle: Do you hear from readers that they’re thinking about these things?

Osman: Yeah, definitely. One of the lovely things about writing the books is you have so many conversations with people, and a subject like assisted dying, as you say, it’s fascinating. It’s probably one of the most fascinating philosophical questions we can ask ourselves as human beings.

But, yes, we don’t always want to read beyond the headline. There’s always something else we could read that’s more palatable or easier. But with this, we are reading a murder mystery, and we’re laughing at jokes, and we’re laughing at characters with each other and then suddenly think, “Oh, now I’m reading about assisted dying,” and because I’ve got a gang of people, I can write about it.

Funnily enough, I wrote two chapters in a row — one from the perspective of a character who believes in it very strongly and one from the perspective of a character who doesn’t believe in it. These two people love each other, but they happen to disagree on this.

You’re getting to discuss something that people might normally avoid, something they might change the channel on or click past to the next article. That means a lot of people come up to me in the street to talk about it. We talk about dementia, grief, all of these things, and I absolutely love those conversations.

Cottle: You had a family member who suffered through Alzheimer’s, right?

Osman: Yeah.

Cottle: Did that inform how you approach one of the main characters’ husbands? In the book, he’s suffering from dementia. Did your experience inform how you were writing some of this?

Osman: Yeah, if you talk to anybody who works with dementia patients in any way, they’ll tell you every single experience is unique. Everything is different, and the dementia often takes on the form of the person with dementia. It’s a very personal illness.

My grandfather had dementia. He was a very bright, very strong man. He had been a cop and served in the army, so he was used to being, you know, very traditionally male. And then suddenly the faculties began to go. In his final years, I would visit him often, speaking to him and noticing what he remembered and what he didn’t. The last things to remain were probably laughter and love. Those were the final parts of him that stayed, and I wanted to pay tribute to that.

I wanted to understand him — how he was thinking, what his brain was doing, which circuits were still complete and which weren’t. So really, I’m writing about him. The fact that it resonates with so many other people is wonderful. Every example of dementia is slightly different, but there’s enough we all share.

In my conversations with him, I was constantly inside his head, thinking: What is his brain doing now? Where is it reaching? What is it trying to reach, and what does it actually reach? That became the foundation for Stephen, the character in my books who suffers from dementia. I wanted to give Stephen absolute, 100 percent humanity. I wanted his thought process to feel rational within his own mind. That was what I was trying to capture — how his brain might be working. And from what people tell me, it resonates, which is all I could hope for. (...)

Cottle: You said before that you were struck that these older residents had all these amazing life experiences but were kind of now largely ignored or underestimated, which sounds sad. We hear a lot about the invisibility that comes with aging. But in some ways, you turn this on its head. Your characters can do all these crazy things and get in all sorts of trouble and basically get away with it, specifically because they’re older and people are underestimating them. I feel like you’re making a pitch for aging or —

Osman: I really am, because, as I say, things occur to me as I go along, but one of the things that occurred to me very early on is the lack of consequence for a lot of what they’re doing. A lot of us are scared throughout life because we think, “Oh, no, but what happens if I lose my job or the money starts going down or something?”

When you’re older, the worst is going to happen at some time. You’ve got that perspective. And there’s a part in the first book, I think, where one person says: The only people who can tell us what to do now are our doctors and our children, and we rarely see our children, so no one’s really telling us what to do.

In the very first book, Elizabeth says to the cops at one point: “I’ll tell you what you should do — why don’t you arrest me? Lock an 80-year-old woman in a cell. See how much fun that is for you. See how much paperwork you’ll have to do. I’ll even pretend I think you’re my grandson. Go on, do it.” And you realize there’s a real freedom in that — a kind of carte blanche to behave badly, mischievously, to open doors you shouldn’t be allowed to open. I absolutely dove into all of that and took full advantage of their ability to beguile everyone.

Cottle: See, I’m very much looking forward to being there with them. I saw an article asking rather grandly if your books might change the way that Britain thinks about growing old. And I think the piece was specifically referring to the idea that seniors could decide to move into these communities where they hang out with people their age and get involved in stuff.

But even beyond that, your characters are thumbing their noses at the idea that seniors should fade into the background. I have to think this goes over really well with your readers of a certain age.

Osman: Yeah, I think it’s fascinating, because younger readers always say: Oh, my God, thank you for making these older characters heroes. That feels so aspirational. I can’t wait until I retire.

But older readers say something completely different: Thank you for not making us the heroes. Thank you for making us flawed and mischievous. Thank you for showing us drinking at 11:30, gossiping, falling in love and out of love. Thank you for writing us as human beings.

My starting point for all of this is simple. Everyone listening will have an answer to this question: How old do you feel in your head? There’s always a number, a point where you stop aging inside yourself.

My mom is 83, and she says she feels 30. And isn’t that right? Nobody really has an old brain. People may have old bodies and deal with old-age issues, but their minds are still young — 27, 30, 35, 40. So when I write these characters, I don’t think for a single second about the fact that they’re 80. I think about the age they still are in their heads, even though they live in very different surroundings. (...)

Cottle: Your characters present old age not as a time when life becomes narrower and narrower, as it can sometimes feel when you’re aging, but as a time of reinvention, of expanding comfort zones. That’s a very comforting thought for certain middle-aged readers eyeing the road ahead. And it sounds like I’m not the only one. That idea is clearly resonating with your younger readers, too.

Osman: The age demographics reading this book are insane, because they’re about older people, yes, but they’re not read predominantly by older readers. People from all age groups are picking them up. I think part of that is wish fulfillment, because loneliness is a real issue. There’s an epidemic of loneliness among older people but also, interestingly, among people in their late teens and early 20s, though for different reasons.

The quick fix, in both cases, is community. Of course, not everyone wants that, and that’s fine. Where my mom lives, if you don’t want to see anyone, you just shut your front door. But if you do want company, you open it, and that feels like something to aspire to. The fact that these books put that idea into the world — that later years can be lived in community — feels positive. We don’t have to fade into the background as we get older. We don’t have to disappear. We can grow, become more visible, even noisier. We can become more trouble, in the best way, as we age.

Cottle: That’s my goal.

Osman: That’s my goal as well. That’s sort of everyone’s goal, isn’t it? To just continue causing trouble... At every stage of life, we’re told what it’s supposed to be about. As kids, it’s education — getting to high school, then the right college. In our 20s, it’s climbing the ladder, getting promoted, earning more money. Then it becomes about raising a family, building a community, watching the next generation grow. But eventually, you reach an age where they’ve run out of instructions. There’s no one telling you, “Now the point of life is X.” And you realize: Oh, I can just do what I want. I could have done that all along. What was I thinking?

That’s the moment you finally understand: I’m allowed to have fun. I’m allowed to be with people, to laugh, to enjoy myself. Yes, I still want to look after others and make sure my community is safe and cared for, but I’m also allowed to have fun.

And that feels like a revolutionary act.

by Michelle Cottle and Richard Osman, NY Times |  Read more:

Image: via

[ed. There's still quite a bit of ageism around, I don't know if it's getting better or worse.  I'm old and this all feels very familiar.]

10 Questions to Answer Before You Die

There are endless questions you could ask, but these are the ones (split into 5 questions to ask and 5 actions to take before you die) I’ve seen make the biggest difference for the person dying, and for the people left to live without them. And none of which require a lawyer or a ton of money—just a little intention.

5 questions to ask:

1. What method of body disposition feels right for me?

Most people haven’t given much thought to what they’d like to happen to their body after they die—but it’s one of the most important end-of-life decisions you’ll make, both for yourself and for your loved ones. The options include, but aren’t limited to:

• Cremation (flame or water)
• Natural or conventional burial
• Human composting
• Donation to science
• Launch your cremains (yes, the correct term is “cremains,” not ashes, because cremated remains are actually the decedents' pulverized bones) into space
• Turn your cremains into a diamond

There are more options than you might think, and we’re working on building something to help you explore them in an approachable, easy way.

Choosing ahead of time saves your people from having to make a big financial and emotional decision while in shock and grief. Without your guidance, they’re left to guess about what you “would’ve wanted” or how much money is “meaningful enough” or appropriate to spend. Your choice gives them relief, confidence, and one less decision to make during an overwhelming time that can be akin to experiencing a traumatic brain injury.

2. What kind of goodbye would feel meaningful for me and for the people who love me?

Before you say, “I don’t want a funeral” or “I don’t care,” remember: your funeral isn’t just for you—it’s also for the people you love the most in this world.

Ceremony and ritual—big or small—is hugely important for helping people process loss. Denying them that moment could lead to delayed or complicated grief. It doesn’t need to be traditional, elaborate, or expensive, but it does need to be intentional. Encourage your loved ones to have a ceremony or gathering in your honor, and if you’re worried about it being “too much of a fuss,” leave instructions for something simple, and start saving money (the average funeral costs $8,000) to pay for it or contribute. Don’t know where to start? Book a conversation with me.

3. Who should be notified if I die tomorrow?

Consider right now: If you were to get in a lethal accident tomorrow, who would you want to be notified first? And if you already have a list, are these contacts still accurate? Divorce, estrangement, death, or the passing of time can all shift who belongs on this list.

Make sure the person you’d want handling your affairs (going through your phone and your things) has access to the information they will need, and you’ve had a conversation with them about the two questions above. This is one of the most overlooked—and most practical—pieces of end-of-life planning.

4. Who do I trust to make medical decisions if I can’t?

Imagine you're in a car accident and end up unconscious, kept alive by machines. The hospital calls your emergency contact—maybe it’s your mom, who lives out of state and wants to keep you alive at all costs (can you blame her?). Meanwhile, your partner or best friend, whom you’ve had this conversation with, is in the waiting room, desperate to advocate for you, but they can’t, because you never named them as your Medical Power of Attorney (MPA). So doctors default to “next of kin,” and suddenly a medical crisis becomes a conflict. One person wants to “do everything,” another insists you wouldn’t want to live like this...Grief turns into blame, and families are torn apart. Everyone thinks this stuff only happens to other people, but it happens every day. Do yourself and your family a favor, and get it sorted in advance.

The person you name as your MPA does not necessarily have to be your spouse or even related to you, but whoever it is, they need to be informed of your wishes. So, if you become unconscious or unable to speak, they’re the ones the doctors will ask to make the hard decisions.

5. Is there anything I’ve left unsaid? Who do I need to say it to?

This one is personal: If you had a year left to live, what truths would you speak? Who would you thank? Apologize to? Forgive?

Regret is one of the heaviest things we leave behind. Don’t wait for the “right” moment. Say what needs to be said—now.

5 Things you can do right now that will make your inevitable death easier:

6. Set up your iPhone Legacy Contact & Gmail Inactive Account Manager.

This is one of the easiest (and most overlooked) things you can do. It ensures that when you die, someone you appoint and trust can access your phone or email (without it, your loved ones might get locked out of everything), which is crucial for closing accounts, alerting contacts, and sorting through photos. Think of it as naming your digital next of kin. And choose wisely—this is also the person who’ll have access to all your stuff, so make sure it’s someone you trust to delete anything you wouldn’t want to see the light of day.

You can set this up in under 5 minutes in your Apple ID settings or Gmail account settings. And some social media platforms, like Facebook and Instagram, also let you assign a “legacy contact” to manage or memorialize your profile. It’s a small step that can prevent a lot of stress for the people you love.

7. Set up a password manager—and share the master password.

Your entire digital life is locked behind passwords—almost everything you own or use is tied to one: your bank details, subscriptions, social media, phone, and computer, etc. A password manager (like 1Password) helps you organize and secure them all in one place.

When you die, the people left behind will need these passwords to access, manage, and close your accounts. Giving one trusted person access to your master password ensures they can do all of that without jumping through legal hoops, or getting locked out because they had to guess your password and they guessed wrong too many times. It’s a small act of preparation that prevents a whole lot of chaos.

8. Name a guardian for your kids or pets.

If something happened to you tomorrow, who would care for your children? Who would take in your dog? Who would clean out your apartment? Don’t assume they’ll say yes, or that they know.

The first step and time to have these conversations is before a crisis. Not after. For pets, it’s not legally required, but for kids, this designation should be followed up with a legal document (typically your will) to make it official. Without it, a court could decide who gets custody, and that may not align with your wishes.

9. Make a bank account “payable on death” (POD).

You don’t need a will to do this. You can go to your bank (some might even let you do it online) and add a beneficiary to your account with a single form. This allows the people you trust to access funds immediately—for emergency flights, funeral costs, food, and childcare.

10. Write down what matters most.

Inspired by the letters my mom wrote me on her deathbed to open for future milestones (one of which I have coming up very soon—my wedding), I do something similar on every flight. I review notes I’ve made in my phone for the people I love, just in case. Because if the plane does go down, and I die (or when I eventually die), I want them to know: how much they meant to me, and what sign I will try to use to communicate with them after I’m gone.

A few sentences can change everything for the people you love. It doesn’t have to be long, and it can look however you want it to:

• A memoir or series of stories about your life
• A simple love note
• A list of your favorite things (songs, movies, books, vacations, etc)

by Maura McInerney-Rowley, Hello, Mortal |  Read more:

Image: uncredited

[ed. Good advice for future reference.]

Can This Tree Still Save Us?

ʻUlu, bia, uru, mā: Breadfruit has been lauded as a climate-resilient solution to world food security. That’s not proving true in the Marshall Islands, where some have relied on it for centuries.

A breadfruit tree stands in the middle of Randon Jother’s property, its lanky trunks feeding a network of sinewy limbs. The remnants of this season’s harvest weigh heavy on its branches. Its vibrant leaves and football-sized fruit may appear enormous to the untrained eye, but Jother is concerned.

They used to be longer than his hand and forearm combined. He points to his bicep, to show how fat they once were. Now they’re small and malformed by most people’s standards here in the Marshall Islands. Mā, the Marshallese term for breadfruit, used to ripen in May. Now they come in June, sometimes July.

 

It’s been headed this way for the past seven years, Jother says as he toes the tree’s abundant leaf litter. It’s a concerning development on this uniquely agricultural and fertile part of Majuro Atoll, home to the country’s highest point: eight feet above sea level.

“I think it’s the salt,” Jother says. His home is less than 100 yards from Majuro lagoon, a body of seawater that threatens to overflow onto the land during a storm or king tide, which over the past decade years has happened several times in Majuro and across the islands. The Pacific Ocean also threatens to salt the island’s ever precious groundwater, which Jother says is already happening. When he showers, he can feel it in his hair, on his skin.

The record heat waves, massive droughts and an increasing number of unpredicted and intense weather events don’t help his trees either.

Most assume the assailant is climate change, to which researchers and experts have said the Indigenous Pacific crop would be almost immune — a potential salve for the world’s imperiled food system. For places like Hawaiʻi, they have predicted breadfruit growing conditions may even get better.

But here, on Majuro and throughout the Marshall Islands, the future appears bleak for a crop that has helped sustain populations for more than 2,000 years.

 

Rice has overtaken the fruit’s status as the preferred staple over the past century, along with other ultraprocessed imports, a change that feeds myriad health complications, including outsized rates of diabetes, making non-communicable diseases the leading cause of death across these islands.

The diseases are a Pacific-wide issue, one Marshall Islands health and agriculture officials are eager to counter with a return to a traditional diet. Climate change is working against them. (...)

Mā is part of an important trinity for the Marshall Islands, which also includes coconut (ni) and pandanus (bōb), that made their way to the islands’ shores on Micronesian seafarers’ boats somewhere between 2,000 and 3,000 years ago.

Six varieties are most common in the Marshall Islands, though at least 20 are found throughout the islands. Hundreds more breadfruit types can be found in the Pacific, tracing back to the breadnut, a tree endemic to the southwestern Pacific island of New Guinea.

The tree provided security for island populations, requiring little upkeep to offer abundant harvests. Each tree produces anywhere from 350 to 1,100 pounds of breadfruit a year, with two harvest seasons. Every tree produces half a million calories in protein and carbohydrates.

 

Like many Pacific island countries, the mā tree’s historic uses were diverse. Its coarse leaves sanded and smoothed vessels made with the tree’s buoyant wood. Its roots were part of traditional medicine. The fruit was cooked underground and roasted black over coals. And it was preserved, to make bwiro, a tradition that survives through people like Angelina Mathusla.

For Mathusla, who lives just over a mile from farmer Jother, making bwiro is a process that comes with every harvest.

The process begins with a pile of petaaktak, a variety of breadfruit common around Majuro and valued for its size and lack of seeds. On this occasion, a relative rhythmically cleaves the football-sized mā in half with a machete, then into smaller pieces, before tossing them into a pile next to a group of women. Some wear gloves to avoid the sticky white latex that seeps from the fruit’s dense, white flesh, used by their forebears to seal canoes or catch birds.

Mā trees use that latex to help heal or protect themselves against diseases and insects. The tree’s adaptation to the atolls and their soils has traditionally been partly thanks to symbiotic relationships with other flora. (...)

A Shallow Body Of Research

Four framed photographs hang on a whitewashed wall of Diane Ragone’s Kauaʻi home. Two black-and-white photos, taken by her late videographer husband, show Jimi Hendrix and Jerry Garcia playing guitar on stage. The other two are of breadfruit.

Now in the throes of writing a memoir, of sorts, Ragone is revisiting almost 40 years of records — photos and videos, and journal entries, some of which leave her asking “Damn, why was I so cryptic?”

But Ragone’s research, since her arrival to Hawaiʻi from Virginia in 1979, forms the bedrock of most modern research into the tree’s history and its survival throughout the Pacific. The most obvious example spans 10 acres in Hāna, on Maui, where more than 150 cultivars of the fruit Ragone collected thrive at the National Tropical Botanical Garden’s Kahanu Garden.

Less obvious is how her work has helped researchers like Noa Kekuewa Lincoln track the plant’s place in global history and the environment. Lincoln, who says “Diane’s kind of considered the Queen of Breadfruit,” has been central to more recent research into how the plant will survive in the future.

Together with others, they act as breadfruit evangelists, promoting the crop as a poverty panacea and global warming warrior — a touchstone for Pacific islanders not only to their past but a more sustainable future.

Ragone, as the founding director of the 22-year-old Breadfruit Institute, helped distribute more than 100,000 trees around the world, to equatorial nations with poverty issues and suitable climes, like Liberia, Zambia and Haiti. But it all started in Hawaiʻi with just over 10,000 young breadfruit.

 

In some places, rising temperatures and changes in rainfall will actually help breadfruit, according to research from Lincoln and his Indigenous Cropping Systems Laboratory, which assessed the trees’ performance under different climate change projections through 2070.

Running climate change scenarios on 1,200 trees across 56 sites in Hawaiʻi, Lincoln’s lab found breadfruit production would largely remain the same for the next 45 years.

“Nowhere in Hawaiʻi gets too hot for it,” Lincoln says. “Pretty much as soon as you leave the coast, you start getting declining yields because it’s too cold.”

Compare breadfruit to other traditional staples — rice, wheat, soybeans, corn. The plant grows deep roots and lives for decades, requires little upkeep or annual planting, resists most environmental stressors and can withstand high temperatures.

Few nations know the urgency of climate change better than the Marshall Islands, its islands and atolls a bellwether for how heat, drought, intense and sporadic natural disasters and sea level rise can upend lives.

The trees can even survive some saltwater intrusion, according to Lincoln’s research. But a consistent presence of salt is another matter, attacking the roots and making trees unable to absorb freshwater and nutrients. As roots rot, leaves and fruit die.

“The salinity,” Ragone says, before letting out a sigh. “How do you even address the salinity issue?”.

Marshall Islands government officials have turned to the International Atomic Energy Association for help, asking its experts about using nuclear radiation to create mutant hybrids of the nation’s most important crops — giant swamp taro, sweet potatoes and, of course, breadfruit.

The technique has been used for almost a century by the atomic association and Food and Agriculture Organization of the United Nations, predominantly on rice and barley, never on breadfruit or for a Pacific nation.

They have their work cut out for them. To find a viable candidate, immune to salty soils and heat, about 2,000 plants would need to be irradiated, according to Cinthya Zorrilla of the atomic energy association’s Centre of Nuclear Techniques in Food and Agriculture. One of those plants, once mutated, might exhibit the desired traits. (...)

Even if those obstacles were overcome, it wouldn’t be a quick fix. Hybridizing plants through radiation can take about 10 years, Zorrilla says, with a need to compare, contrast and correlate results from labs and field plots and laboratories. For breadfruit, the timeframe may be even longer.

“It’s really complicated,” Zorilla says. “All this is a huge investment, in monetary terms and also in time.”

by Thomas Heaton, Honolulu Civil Beat |  Read more:

Images: Thomas Heaton/Chewy Lin

My Mom and Dr. DeepSeek

Every few months, my mother, a 57-year-old kidney transplant patient who lives in a small city in eastern China, embarks on a two-day journey to see her doctor. She fills her backpack with a change of clothes, a stack of medical reports, and a few boiled eggs to snack on. Then, she takes a 1.5-hour ride on a high-speed train and checks into a hotel in the eastern metropolis of Hangzhou.

At 7 a.m. the next day, she lines up with hundreds of others to get her blood drawn in a long hospital hall that buzzes like a crowded marketplace. In the afternoon, when the lab results arrive, she makes her way to a specialist’s clinic. She gets about three minutes with the doctor. Maybe five, if she’s lucky. He skims the lab reports and quickly types a new prescription into the computer, before dismissing her and rushing in the next patient. Then, my mother packs up and starts the long commute home.

DeepSeek treated her differently.

by Viola Zhou, Rest of World |  Read more:

Image: Ard Su 

Fighting a Health Insurance Denial

Seven tips to help.

When Sally Nix found out that her health insurance company wouldn’t pay for an expensive, doctor-recommended treatment to ease her neurological pain, she prepared for battle.

It took years, a chain of conflicting decisions, and a health insurer switch before she finally won approval. She started treatment in January and now channels time and energy into helping other patients fight denials.

“One of the things I tell people when they come to me is: ‘Don’t panic. This isn’t a final no,’” said Nix, 55, of Statesville, N.C.

To control costs, nearly all health insurers use a system called prior authorization, which requires patients or their providers to seek approval before they can get certain procedures, tests and prescriptions.

Denials can be appealed, but nearly half of insured adults who received a prior authorization denial in the last two years reported the appeals process was either somewhat or very difficult, according to a July poll published by KFF, a health information nonprofit that includes KFF Health News.

“It’s overwhelming by design,” because insurers know confusion and fatigue cause people to give up, Nix said. “That’s exactly what they want you to do.”

The good news is you don’t have to be an insurance expert to get results, she said. “You just need to know how to push back.”

Here are tips to consider when faced with a prior authorization denial:

1. Know your insurance plan.

Do you have insurance through your job? A plan purchased through healthcare.gov? Medicare? Medicare Advantage? Medicaid?

These distinctions can be confusing, but they matter a great deal. Different categories of health insurance are governed by different agencies and are therefore subject to different prior authorization rules.

For example, federal marketplace plans, as well as Medicare and Medicare Advantage plans, are regulated by the U.S. Department of Health and Human Services. Employer-sponsored plans are regulated by the Department of Labor. Medicaid plans, administered by state agencies, are subject to both state and federal rules.

Learn the language specific to your policy. Health insurance companies do not apply prior authorization requirements uniformly across all plans. Read your policy closely to make sure your insurer is following its own rules, as well as regulations set by the state and federal government.

2. Work with your provider to appeal.

Kathleen Lavanchy, who retired in 2024 from a job at an inpatient rehabilitation hospital in the Philadelphia area, spent much of her career communicating with health insurance companies on behalf of patients.

Before you contact your health insurer, call your provider, Lavanchy said, and ask to speak to a medical care manager or someone in the office who handles prior authorization appeals.

The good news is that your doctor’s office may already be working on an appeal.

Medical staffers can act as “your voice,” Nix said. “They know all the language.”

You or your provider can request a “peer-to-peer” review during the appeals process, which allows your doctor to discuss your case over the phone with a medical professional who works for the insurance company.

3. Be organized.

Many hospitals and doctors use a system called MyChart to organize medical records, test results, and communications so that they are easily accessible. Similarly, patients should keep track of all materials related to an insurance appeal — records of phone calls, emails, snail mail, and in-app messages.

Everything should be organized, either digitally or on paper, so that it can be easily referenced, Nix said. At one point, she said, her own records proved that her insurance company had given conflicting information. The records were “the thing that saved me,” she said.

“Keep an amazing paper trail,” she said. “Every call, every letter, every name.”

Linda Jorgensen, executive director of the Special Needs Resource Project, a nonprofit offering online resources for patients with disabilities and their families, has advised patients who are fighting a denial to specifically keep paper copies of everything.

“If it isn’t on paper, it didn’t happen,” she said.

Jorgensen, who serves as a caregiver to an adult daughter with special needs, created a free form you can print to help guide you when taking notes during phone calls with your insurance company. She advised asking the insurance representative for a “ticket number” and their name before proceeding with the conversation.

The silver lining is that most denials, if appealed, are overturned. (...)

For the sake of speed, some people are turning to artificial intelligence for help crafting customizable appeal letters. (...)

4. Find an advocate.

Many states operate free consumer assistance programs, available by phone or email, which can help you file an appeal. They can explain your benefits and may intervene if your insurance company isn’t complying with requirements.

Beyond that, some nonprofit advocacy groups, such as the Patient Advocate Foundation, might help. On the foundation’s website is guidance about what to include in an appeal letter. For those battling severe disease, foundation staffers can work with you one-on-one to fight a denial.

by Lauren Sausser, LA Times | Read more:
Image: Helen Quach/Los Angeles Times

[ed. PSA for future reference.]

Canada is Killing Itself

The country gave its citizens the right to die. Doctors are struggling to keep up with demand.

The euthanasia conference was held at a Sheraton. Some 300 Canadian professionals, most of them clinicians, had arrived for the annual event. There were lunch buffets and complimentary tote bags; attendees could look forward to a Friday-night social outing, with a DJ, at an event space above Par-Tee Putt in downtown Vancouver. “The most important thing,” one doctor told me, “is the networking.”

Which is to say that it might have been any other convention in Canada. Over the past decade, practitioners of euthanasia have become as familiar as orthodontists or plastic surgeons are with the mundane rituals of lanyards and drink tickets and It’s been so long s outside the ballroom of a four-star hotel. The difference is that, 10 years ago, what many of the attendees here do for work would have been considered homicide.

When Canada’s Parliament in 2016 legalized the practice of euthanasia—Medical Assistance in Dying, or MAID, as it’s formally called—it launched an open-ended medical experiment. One day, administering a lethal injection to a patient was against the law; the next, it was as legitimate as a tonsillectomy, but often with less of a wait. MAID now accounts for about one in 20 deaths in Canada—more than Alzheimer’s and diabetes combined—surpassing countries where assisted dying has been legal for far longer.

It is too soon to call euthanasia a lifestyle option in Canada, but from the outset it has proved a case study in momentum. MAID began as a practice limited to gravely ill patients who were already at the end of life. The law was then expanded to include people who were suffering from serious medical conditions but not facing imminent death. In two years, MAID will be made available to those suffering only from mental illness. Parliament has also recommended granting access to minors.

At the center of the world’s fastest-growing euthanasia regime is the concept of patient autonomy. Honoring a patient’s wishes is of course a core value in medicine. But here it has become paramount, allowing Canada’s MAID advocates to push for expansion in terms that brook no argument, refracted through the language of equality, access, and compassion. As Canada contends with ever-evolving claims on the right to die, the demand for euthanasia has begun to outstrip the capacity of clinicians to provide it.

There have been unintended consequences: Some Canadians who cannot afford to manage their illness have sought doctors to end their life. In certain situations, clinicians have faced impossible ethical dilemmas. At the same time, medical professionals who decided early on to reorient their career toward assisted death no longer feel compelled to tiptoe around the full, energetic extent of their devotion to MAID. Some clinicians in Canada have euthanized hundreds of patients.

The two-day conference in Vancouver was sponsored by a professional group called the Canadian Association of MAiD Assessors and Providers. Stefanie Green, a physician on Vancouver Island and one of the organization’s founders, told me how her decades as a maternity doctor had helped equip her for this new chapter in her career. In both fields, she explained, she was guiding a patient through an “essentially natural event”—the emotional and medical choreography “of the most important days in their life.” She continued the analogy: “I thought, Well, one is like delivering life into the world, and the other feels like transitioning and delivering life out.” And so Green does not refer to her MAID deaths only as “provisions”—the term for euthanasia that most clinicians have adopted. She also calls them “deliveries.”

Gord Gubitz, a neurologist from Nova Scotia, told me that people often ask him about the “stress” and “trauma” and “strife” of his work as a MAID provider. Isn’t it so emotionally draining? In fact, for him it is just the opposite. He finds euthanasia to be “energizing”—the “most meaningful work” of his career. “It’s a happy sad, right?” he explained. “It’s really sad that you were in so much pain. It is sad that your family is racked with grief. But we’re so happy you got what you wanted.”

Has Canada itself gotten what it wanted? Nine years after the legalization of assisted death, Canada’s leaders seem to regard MAID from a strange, almost anthropological remove: as if the future of euthanasia is no more within their control than the laws of physics; as if continued expansion is not a reality the government is choosing so much as conceding. This is the story of an ideology in motion, of what happens when a nation enshrines a right before reckoning with the totality of its logic. If autonomy in death is sacrosanct, is there anyone who shouldn’t be helped to die?

by Elaina Plott Calabro, The Atlantic | Read more:
Image: Johnny C.Y. Lam

Did Your Cancer Treatment Just Get Taken Away?

It starts with a little bump on your neck. You notice it when your hand brushes against it while you’re washing your hair, but at first you don’t pay it much attention. Then your spouse looks at your neck and asks you “What’s that?” It’s a little brown bump, maybe a mole. You think that maybe you should get it checked out by a dermatologist, but you forget to make an appointment, because work has just been so busy lately.

Then a few weeks later you look at the bump again, and it looks noticeably bigger. This time you call the dermatologist, but the soonest they can get you in is three weeks from now. By the time you’re in the doctor’s office, the bump is at least double the size it was when you noticed it. The doctor is tense and concerned, and he does a biopsy. Five days later you get the result over the phone: Melanoma.

“That’s cancer, right?” you ask, just to confirm, feeling something fall away in the pit of your stomach. “Yes,” the doctor’s assistant confirms. “That’s cancer.”

Cancer. The word is like the fall of an axe, cutting off the future you had imagined for yourself. Now instead, the days ahead are filled with surgeries, chemotherapy, radiation, CT scans, MRIs. You will never again entirely be free of the eternal gnawing fear of discovering that the cancer has spread. Your hair is going to fall out, you’re going to go under the knife, you’re going to be weak and sick. You’re going to to read everything there is to read about cancer, and it still won’t help. It may go into remission, or you may die, but your life will never read the same.

This story reflects the sad reality of life for millions of Americans. Cancer is the second most common cause of death, just barely behind heart disease, killing over 600,000 every year. And every year, almost 2 million Americans are diagnosed with new cases of cancer. Some kinds, like prostate cancer, are usually manageable; others, like pancreatic cancer and glioblastoma, are practically death sentences.

Now, there’s a common myth that cancer is an intractable disease that will never succumb to modern medicine. In 1971, President Richard Nixon launched the so-called “War on Cancer”; for many years, it was fashionable to say that cancer had won the war. But in fact, since around 1990, humanity has been making steady gains. Thanks to advances in early detection, screening, and various treatments, as well as the drop in smoking and a vaccine against a virus that causes cervical cancer, death rates have fallen at every age for almost every type of cancer. For a while this was masked by an increase in lung cancer from the smoking boom, but now that’s over too:

The problem is that since the population is growing steadily older, overall death rates are still higher than they were in Nixon’s day:

We’re delaying death from cancer, but not eliminating it.

In recent years, however, an explosion of new therapies has promised to accelerate our progress in treating the disease, changing the very nature of what it means to have cancer. The most promising of these are immunotherapies — medical techniques that use the body’s own immune system to attack cancer cells. And of those therapies, one of the most promising is mRNA vaccines.

Yes, mRNA vaccines — the same kind of technology that we used to vaccinate Americans against Covid during the pandemic. But it works a little differently. These mRNA cancer vaccines aren’t something that everyone takes in advance, to prevent themselves from getting cancer — instead, they’re a type of therapy that you take after you get diagnosed with the disease. Often, the vaccines are personalized, meaning that they develop a specific vaccine for your particular cancer.

mRNA vaccines, in combination with other therapies, promise to contain many cancers, turning them from a death sentence into a manageable, non-fatal disease. These vaccines are currently in development to fight all of the biggest killers: lung cancer, colon cancer, pancreatic cancer, breast cancer, and melanoma. They’re even being used against glioblastoma, the most aggressive and common type of brain cancer. There are even some tantalizing results suggesting that mRNA could soon be used to create a universal cancer therapy.

Imagine how the story I told at the top of this post would go in an age of highly effective mRNA therapies. Instead of being sentenced to years of gut-wrenching fear, possibly followed by an agonizing death, someone diagnosed with cancer would simply sigh and realize that they would have to spend a bunch of money on treatments for the foreseeable future. That is the world toward which science is taking us.

And yet now all of this is in danger. The MAGA movement, which now holds near-absolute political power in America, has gone to war against mRNA technology. RFK Jr., Trump’s Secretary of Health and Human Services and a prominent vaccine skeptics, just canceled a large amount of federal funding:

The Department of Health and Human Services (HHS) announced this week it is beginning a "coordinated wind-down" of federally funded mRNA vaccine development.

This includes terminating awards and contracts with pharmaceutical companies and universities and canceling 22 investment projects worth nearly $500 million. While some final-stage contracts will be allowed to be completed, no new mRNA-based projects will be initiated, the HHS said.

Officially, all of the cancelled funding is supposedly for mRNA vaccines for upper respiratory illness — basically, Covid and anything that looks remotely like Covid. So officially, cancer research isn’t being cancelled — yet. But cancer researchers are terrified that this move will derail their whole field, and with good reason. The chilling effect of this funding cancellation will cause a general loss of enthusiasm for the technology.

If you’re a researcher developing an mRNA treatment for lung cancer, how would you rate your chances of RFK Jr. approving your therapy for mass use when it has “mRNA” in the name? If you’re a private funding organization, do you really want to fund a technology that the government — and a large chunk of the American electorate — has an irrational vendetta against? What lab is going to want to allocate resources toward a field that’s marked for destruction? And what aspiring researcher is going to want to dedicate their career to it? (...)

So it’s very possible that thanks to RFK Jr., the Trump administration, and the MAGA movement writ large, cancer vaccines will not be available nearly as soon as it looked like they would just a few months ago. Eventually, the technology will be developed, with some combination of funding from Europe, China, private companies, and so on. But in the meantime, many people — including many Americans — will experience the nightmare of a traditional cancer diagnosis, like what I described at the top of this post.

Why is this happening? Why is the U.S. government attacking the technology that offers us the greatest chance to defeat one of humanity’s oldest and most terrible scourges?

It’s pretty easy to trace the reasons historically. During the pandemic, the antivax movement took over the American right — possibly because of fear of needles, possibly as a macho way to express bravery against the virus itself, possibly because of instinctive dread of modern technology or expert consensus or government recommendations. But whatever the reason, Trump — despite having authorized the project that created mRNA vaccines, and despite wanting to take some deserved credit for defeating Covid — was forced to accede to the wave of antivax sentiment, and to ally with it in order to win reelection in 2024. Part of that meant hiring RFK Jr. and putting him in charge of HHS — a political marriage of convenience.

But fundamentally, it’s hard to fathom just how America arrived at this juncture. We’ve certainly seen both sides of the U.S. political divide embrace blatant lies in order to express solidarity. For the right, the biggest lie was always that climate change isn’t happening, or isn’t caused by humans. Climate denial might seem like a lie without consequences — after all, the worst harms from climate change are going to arrive decades in the future. But because green energy technologies also happened to become cheap, the right-wing dogma that anything “green” is bad is causing the MAGA movement to oppose the cheapest and most reliable energy sources available:

Not having cheap energy is certainly bad. But dying of cancer? You’d think that would be a bridge too far, even for Trump’s followers. But recall how during the Covid pandemic, right-wing types died in droves because they refused to take the life-saving vaccine: 

by Noah Smith, Noahpinion |  Read more:

Image: OurWorldInData

Silence on SNAP

Poverty and hunger will rise as a result of the Trump administration’s unprecedented cuts to the US federal “food stamps” program, according to experts. Low-income workers who rely on the aid are braced for dire consequences.

Katie Giede, a single mother and waitress in Conyers, Georgia, is one of the 42 million Americans who use the supplemental nutrition assistance program (Snap). Even with the maximum benefit permitted, she struggles to afford food for her and her child.

She makes $3 an hour plus tips at the fast-food chain Waffle House, where she has worked for 11 years. The company deducts meals from workers’ pay check per shift, regardless of whether they eat one or not.

“Our pay is already so little that we’re struggling with everything,” Giede told the Guardian. “Single mothers like myself are reliant upon the benefits like Snap and Medicaid. So when you go and you cut that as well, now you have mothers out here that are not only worried at night because they already can’t afford housing or a vehicle, but we’re also worried what is our kid is going to eat? Because we no longer have help.”

Giede said she received $450 a month for her and her child. She said working too many hours or receiving too much income was a constant concern, due to eligibility cut-offs.

According to an analysis by the Urban Institute, at the end of 2024, even the maximum Snap benefit would not cover the cost of a modestly priced meal in 99% of all counties in the US.

“I dread that trip to the grocery store every week, because you have to sit down and you really have to budget,” said Giede. “Every time you go, you’re having to make the choice between something that’s healthy or something that’s cheaper, just so you can get enough to last all week.

“There are so many people in this country that rely on these benefits, and with these cuts, half of the people that are surviving right now off of this are going to lose their benefits. That’s not even just people not eating a little bit. They’re already not eating enough, so we’re going to lose lives over this. It’s those of us at the bottom that are really feeling it.”

Waffle House did not respond to multiple requests for comment.

Trump’s “big, beautiful bill” set the stage for significant cuts to Snap by shifting higher administrative costs to each state, expanding work reporting requirements and imposing restrictions on non-citizen eligibility.

Many lower-wage workers have grown more reliant on Snap in recent years. US food prices rose by 23.6% between 2020 and 2024, according to official data. While inflation has since moderated, grocery costs remain high.

As a result of the latest Snap changes, states will be responsible for 75% of administrative costs of handling the program from 2027, up from 50% cost-sharing with the federal government, which is likely to strain state budgets.

From 2028, for the first time states will be forced to pick up some of the multibillion-dollar bill for Snap benefits. The state of New York, for example, faces a budget impact of about $1.2bn, according to the Food Research and Action Center (Frac), a non-profit advocacy group.

While such shifting costs have raised fears that states will cut back Snap support, expanded work requirements have sparked concern that few people will be eligible. Analysis by the Urban Institute found about 22.3 million US families are set to lose some or all of their Snap benefits.

“This is a very targeted, well-thought-out plan of dismantling the Snap program that federal policy makers won’t take responsibility for, because it is the states, it is the governors who will have to cut resources for Snap, who will have to cut the program in order to say we can’t operate this because of what’s happening at the federal level,” said Gina Plata-Nino, Snap deputy director at the Frac.

“Snap is a very important ecosystem at the local level, at the state level and the federal level, because billions of dollars go into states, and this federal money supports local economies,” she added. “All of these proposals threaten this very delicate balance.”

The White House deferred comment to the office of management and budget, which did not respond to multiple requests for comment.

States across the US are braced for stark consequences. “We’re going to have worse hunger and ultimately, worse poverty,” said Seth DiStefano, policy outreach director at the West Virginia Center on Budget and Policy. “There are entire regions of West Virginia where there aren’t 20 hours a week [expanded Snap work requirement] of anything to apply for. What do you tell those families?

“We’re talking families with kids now that are going to be subjected to these harsh work reporting requirements. We’re talking folks in their 60s, literally in communities where there are no jobs, none, and ripping away the one outlet to their basic needs that’s available to them.”

Among the employers with the most workers reliant on Snap is Walmart, the largest private employer in the US, as much of its workforce receives only part-time hours.

Christina Gahagan, 66, has worked at Walmart for a decade in western New York at several stores. She is currently based at a store in Geneseo, New York.

“I would say at least 50% of the people in my store rely on food stamps to make ends meet for their families,” said Gahagan. “They’re always trying to figure out where the best deals are, coupon clipping at lunch and reading circulars to see who’s got the best deal on whatever, just to make their money stretch.” (...)

“Walmart is the largest employer in the US. We rival Amazon almost dollar for dollar in what we do. You would think a company like that could shell out a little bit more money per hour for associates in the store across the board, so that there aren’t people who are having to depend so heavily on public assistance.”

Walmart did not respond to multiple requests for comment.

by Michael Sainato, The Guardian | Read more:
Image:Richard Levine/Alamy
[ed. No one wants to comment on a new bureaucracy to process and administer oversight requirements? Jobs! Remember who did this the next time you vote.]

Why Jolly Ranchers Are Banned in the UK but Not the US

On June 11, the UK’s Food Standards Agency (FSA) issued an alert declaring several candies manufactured by The Hershey Company “unsafe to eat.” Four products from the flagship Jolly Rancher brand—Hard Candy, “Misfits” Gummies, Hard Candy Fruity 2 in 1, and Berry Gummies—contain mineral oil hydrocarbons, banned from food in the UK.

The offending substances are mineral oil aromatic hydrocarbons (MOAH) and mineral oil saturated hydrocarbons (MOSH). Both are derived from crude oil and are often used in confectionery to reduce stickiness and enhance the candy’s shine. “Consuming mineral oil regularly and over time could pose a risk to your health,” says Tina Potter, head of incidents at the FSA. “If you’ve eaten them, there is no need for concern, but don’t eat any more.”

Nevertheless, the FSA has branded the consumption of these sweets a “toxicological concern.” MOSH have been found to accumulate in the tissue of certain species of lab rat, causing adverse effects in the liver. But MOAH are more concerning—the UK’s FSA, alongside the European Union, considers some of these compounds to be genotoxic carcinogens—substances that can cause cancer by altering cells’ genetic material. (...)

Enforcement will likely take time. But in the US, MOAH remain permitted by the Food and Drug Administration (FDA). “The key takeaway from all of this is [that] mineral oil is allowed and deemed safe for use in food in the US,” says Todd Scott, senior manager of communications at The Hershey Company. “Mineral oil is not an ingredient in the recipe. We use it as a processing aid to keep the candy from sticking to the mold.”

MOAH are just one of a number of chemical compounds banned by the UK and EU that are deemed safe for Americans. Much of the discrepancy lies in the FDA’s “generally recognized as safe” (GRAS) loophole. In the US, any new food additive is subject to premarket review and approval by the FDA—unless the substance is generally recognized, among qualified experts, as having been adequately shown to be safe under the conditions of its intended use.

These assessments, however, are often completed in private labs and sometimes even by the manufacturer of the chemicals themselves—and manufacturers aren’t required by law to submit their GRAS determination or supporting data to the FDA. The assessments don’t require third-party experts, either. In a 2023 study of 403 GRAS notices filed by the FDA between 2015 and 2020, an average of 30 percent relied on the opinion of a manufacturer’s in-house employee.

Adopted in 1958, the GRAS exemption was intended to cover the use of commonplace ingredients, explains Jensen Jose, regulatory counsel for the nonprofit watchdog Center for Science in the Public Interest, based in Washington, DC. “It was so you wouldn’t require a new piece of legislation every time you added salt to a sandwich.”

However, as the food industry’s appetite for additives grew over the following decades, the GRAS rule came to cover a widening array of ingredients—with the manufacturers of these additives left effectively to govern themselves. “The hope is that they conduct scientific studies of their own,” says Jennifer Pomeranz, a public health lawyer and associate professor at New York University’s School of Global Public Health. “But legally speaking, no one’s checking.” In theory, Pomeranz says, “a company can add a new ingredient and not even list its chemical compound on the packet.”

The result is that a host of additives, recognized as safe under FDA regulations, are banned by other governments over safety fears. “Compounds are added to food for shelf life, aesthetics, and convenience,” says Lindsay Malone, a registered dietitian nutritionist and instructor in the Department of Nutrition at the School of Medicine at Case Western Reserve University. “Even down to how easily food comes out of the plastic container.”

Compounds that carry health risks line the shelves of US grocery stores, consumed by Americans every day. Take butylated hydroxytoluene (BHT), for example, a preservative that has been linked to hormone disruption. It’s often found in cereals, dried snacks, and packaged cake mixes. Meanwhile a packet of chewing gum, potato chips, or processed meat may include butylated hydroxyanisole (BHA), a probable carcinogen. Both are exempt from FDA regulations through the GRAS loophole.

In isolation, compounds like BHT, BHA, and MOAH aren’t necessarily dangerous. Public health advocates are more concerned about their cumulative effect—a lifetime of eating common, addictive, harmful compounds. 

by Alex Christian, Wired |  Read more:

Image: Washington Post/Getty

[ed. Clear as mud. I like JRs, and the stated risks seem fairly low. It's almost impossible to find hard candies anymore (check out your local shelves). Everything's soft, gummy, chewy, or sour. Ack.]

Of Mice, Mechanisms, and Dementia

“The scientific paper is a ‘fraud’ that creates “a totally misleading narrative of the processes of thought that go into the making of scientific discoveries.”

This critique comes not from a conspiracist on the margins of science, but from Nobel laureate Sir Peter Medawar. A brilliant experimentalist whose work on immune tolerance laid the foundation for modern organ transplantation, Sir Peter understood both the power and the limitations of scientific communication.

Consider the familiar structure of a scientific paper: Introduction (background and hypothesis), Methods, Results, Discussion, Conclusion. This format implies that the work followed a clean, sequential progression: scientists identified a gap in knowledge, formulated a causal explanation, designed definitive experiments to fill the gap, evaluated compelling results, and most of the time, confirmed their hypothesis.

Real lab work rarely follows such a clear path. Biological research is filled with what Medawar describes lovingly as “messing about”: false starts, starting in the middle, unexpected results, reformulated hypotheses, and intriguing accidental findings. The published paper ignores the mess in favour of the illusion of structure and discipline. It offers an ideal version of what might have happened rather than a confession of what did.

The polish serves a purpose. It makes complex work accessible (at least if you work in the same or a similar field!). It allows researchers to build upon new findings.

But the contrived omissions can also play upon even the most well-regarded scientist’s susceptibility to the seduction of story. As Christophe Bernard, Director of Research at the Institute of Systems Neuroscience (Marseilles, Fr.) recently explained,

“when we are reading a paper, we tend to follow the reasoning and logic of the authors, and if the argumentation is nicely laid out, it is difficult to pause, take a step back, and try to get an overall picture.”

Our minds travel the narrative path laid out for us, making it harder to spot potential flaws in logic or alternative interpretations of the data, and making conclusions feel far more definitive than they often are.

Medawar’s framing is my compass when I do deep dives into major discoveries in translational neuroscience. I approach papers with a dual vision. First, what is actually presented? But second, and often more importantly, what is not shown? How was the work likely done in reality? What alternatives were tried but not reported? What assumptions guided the experimental design? What other interpretations might fit the data if the results are not as convincing or cohesive as argued?

And what are the consequences for scientific progress?

In the case of Alzheimer’s research, they appear to be stark: thirty years of prioritizing an incomplete model of the disease’s causes; billions of corporate, government, and foundation dollars spent pursuing a narrow path to drug development; the relative exclusion of alternative hypotheses from funding opportunities and attention; and little progress toward disease-modifying treatments or a cure.

The incomplete Alzheimer’s model I’m referring to is the amyloid cascade hypothesis, which proposes that Alzheimer’s is the outcome of protein processing gone awry in the brain, leading to the production of plaques that trigger a cascade of other pathological changes, ultimately causing the cognitive decline we recognize as the disease. Amyloid work continues to dominate the research and drug development landscape, giving the hypothesis the aura of settled fact.

However, cracks are showing in this façade. In 2021, the FDA granted accelerated approval to aducanumab (Aduhelm), an anti-amyloid drug developed by Biogen, despite scant evidence that it meaningfully altered the course of cognitive decline. The decision to approve, made over near-unanimous opposition from the agency’s advisory panel, exposed growing tensions between regulatory optimism and scientific rigor. Medicare’s subsequent decision to restrict coverage to clinical trials, and Biogen’s quiet withdrawal of the drug from broader marketing efforts in 2024, made the disconnect impossible to ignore.

Meanwhile, a deeper fissure emerged: an investigation by Science unearthed evidence of data fabrication surrounding research on Aβ*56, a purported toxic amyloid-beta oligomer once hailed as a breakthrough target for disease-modifying therapy. Research results that had been seen as a promising pivot in the evolution of the amyloid cascade hypothesis, a new hope for rescuing the theory after repeated clinical failures, now appears to have been largely a sham. Treating Alzheimer’s by targeting amyloid plaques may have been a null path from the start.

When the cracks run that deep, it’s worth going back to the origin story—a landmark 1995 paper by Games et al., featured on the cover of Nature under the headline “A mouse model for Alzheimer’s.” It announced what was hailed as a breakthrough: the first genetically engineered mouse designed to mimic key features of the disease.

In what follows, I argue that the seeds of today’s failures were visible from the beginning if one looks carefully. I approach this review not as an Alzheimer’s researcher with a rival theory, but as a molecular neuroscientist interested in how fields sometimes converge around alluring but unstable ideas. Foundational papers deserve special scrutiny because they become the bedrock for decades of research. When that bedrock slips beneath us, it tells a cautionary story: about the power of narrative, the comfort of consensus, and the dangers of devotion without durable evidence. It also reminds us that while science is ultimately self-correcting, correction can be glacial when careers and reputations are staked on fragile ground.

The Rise of the Amyloid Hypothesis

In the early 1990s, a new idea began to dominate Alzheimer’s research: the amyloid cascade hypothesis.

First proposed by Hardy and Higgins in a 1992 Science perspective, the hypothesis suggested a clear sequence of disease-precipitating events: protein processing goes awry in the brain → beta-amyloid (Aβ) accumulates → plaques form → plaques trigger a cascade of downstream events, including neurofibrillary tangles, inflammation, synaptic loss, neuronal death, resulting in observable cognitive decline.

The hypothesis was compelling for several reasons. First, the discovery of the enzymatic steps by which amyloid precursor protein (APP) is processed into Aβ offered multiple potential intervention points—ideal for pharmaceutical drug development.

Second, the hypothesis was backed by powerful genetic evidence. Mutations in the APP gene on chromosome 21 were associated with early-onset Alzheimer’s. The case grew stronger with the observation that more than 50% of individuals with Down syndrome, who carry an extra copy of chromosome 21 (and thus extra APP), develop Alzheimer’s-like pathology by age 40.

Thus, like any robust causal theory, the amyloid cascade hypothesis offered explicit, testable predictions. As Hardy and Higgins outlined, if amyloid truly initiates the Alzheimer’s cascade, then genetically engineering mice to produce human amyloid should trigger the full sequence of events: plaques first, then tangles, synapse loss, and neuronal death, then cognitive decline. And the sequentiality matters: amyloid accumulation should precede other pathological features. At the time, this was a thrilling possibility.

Pharmaceutical companies were especially eager: if the hypothesis proved correct, stopping amyloid should stop the disease. The field awaited the first transgenic mouse studies with enormous anticipation.

How—with Unlimited Time and Money and a Little Scientific Despair—to Make a Transgenic Mouse

“Mouse Model Made” was the boastful headline to the independent, introductory commentary Nature solicited to accompany the 1995 Games paper’s unveiling of the first transgenic mouse set to “answer the needs” of Alzheimer’s research. The scientific argument over whether amyloid caused Alzheimer’s had been “settle[d]” by the Games paper, “perhaps for good.”

In some ways, the commentary’s bravado seemed warranted. Why? Because in the mid-’90s, creating a transgenic mouse was a multi-stage, treacherous gauntlet of molecular biology. Every step carried an uncomfortably high chance of failure. If this mouse, developed by Athena Neurosciences (a small Bay Area pharmaceutical company) was valid, it was an extraordinary technical achievement portending a revolution in Alzheimer’s care.

First Rule of Making a Transgenic Mouse: Don’t Talk About How You Made a Transgenic Mouse

How did Athena pull it off? Hard to say! What's most remarkable about the Games paper is what's not there. Scan through the methods section and you'll find virtually none of the painstaking effort required to build the Alzheimer’s mouse. Back in the ‘90s, creating a transgenic mouse took years of work, countless failed attempts, and extraordinary technical skill. In the Games paper, this effort is compressed into a few sparse sentences describing which gene and promoter (nearby gene instruction code) the research team used to make the mouse. The actual details are relegated to scientific meta-narrative—knowledge that exists only in lab notebooks, daily conversations between scientists, and the muscle memory of researchers who perform these techniques thousands of times.

The thin description wasn’t atypical for a publication from this era. Difficult experimental methods were often encapsulated in the single phrase "steps were carried out according to standard procedures," with citations to entire books on sub-cloning techniques or reference to the venerable Manipulating the Mouse Embryo: A Laboratory Manual (We all have this on our bookshelf, yes?) The idea that there were reliable "standard procedures" that could ensure success was farcical—an understatement that other scientists understand as code for "we spent years getting this to work; good luck figuring it out ;)."

So, as an appreciation of what it takes to make progress on the frontiers of science, here is approximately what’s involved.

Prerequisites: Dexterity, Glassblowing, and Zen Mastery

Do you have what it takes to master transgenic mouse creation? Well, do you have the dexterity of a neurosurgeon? Because you’ll be micro-manipulating fragile embryos with the care of someone defusing a bomb—except the bomb is smaller than a grain of sand, and you need to keep it alive. Have you trained in glass-blowing? Hope so, because you’ll need to handcraft your own micropipettes so you can balance an embryo on the pipette tip. Yes, really.

And most importantly, do you sincerely believe that outcomes are irrelevant, and only the endless, repetitive journey matters? If so, congratulations! You may already be a Zen master, which will come in handy when you’re objectively failing your boss’s expectations every single day for what feels like an eternity. Success, when it finally comes, will be indistinguishable from sheer, dumb luck, but the stochastic randomness won’t stop you from searching frantically through your copious notes to see if you can pinpoint the variable that made it finally work!

Let’s go a little deeper so we can understand why the Games team's achievement was considered so monumental—and why almost everyone viewed the results in the best possible light.

by Anonymous, Astral Codex Ten |  Read more:

Image: via

Gerontocracy is Everywhere

You’ve probably heard it said of American politics: we're stuck in a gerontocracy.

And it’s true. Our political system, especially at the federal level, is largely run by the elderly. The current president is 78. His predecessor, famously, left office at 82. Congress is older than ever, with a quarter of its members over 70. The age of the federal judiciary is a record 69 years old. Senior moments from Joe Biden, Mitch McConnell, and the late Dianne Feinstein have lodged in the public consciousness and rattled civic trust.

The discourse here is well-worn, but it frequently misses a crucial point: Some of the same forces that have created our political gerontocracy — medical advances enabling graceful aging, combined with a generation unwilling to relinquish power — have also allowed the old to tighten their grip on other areas of American life.

The median age in America is rising, but the percentage of older workers has grown at a faster rate. This is most apparent when you look at positions within elite society, such as tenured academics and corporate executives.

In other words, step outside Washington and you’ll find that gerontocracy is everywhere. (...)

Several years ago, Derek Thompson wrote a piece exploring why our elite workforce is aging. The simplest explanation, applicable across many professions, is that wealthy Americans are living longer, healthier lives. For example, the richest quartile of men has gained 0.2 years of life expectancy annually throughout the 21st century. But Thompson emphasizes that “many positions and institutions are getting older much faster than that.”

One simple explanation that fits across all these fields is that white-collar work just isn’t that physically demanding, which makes it easier for older workers to stick around. But there are also some more specific dynamics at play. For high-status professionals like CEOs, it might be less about physical ability and more about identity. As Derek Thompson puts it, we’re living in an era of “workism,” where the most affluent people have actually cut back on leisure and now report the longest workweeks in the country.

This theory could apply to our aging scientific researchers and academics too, but there’s another compelling explanation worth considering. According to the landmark paper, The Burden of Knowledge, it now takes researchers a much longer time to master the foundational knowledge in their field. For example, Einstein was only 26 when he published the Theory of Relativity, and it’s hard to imagine someone that young making such a seismic contribution to physics today.

There is also a growing body of research that finds a direct link between aging researchers and a slowdown in scientific innovation. Thompson theorizes in his piece that “as academia and funding institutions get older, they develop an implicit ageism against younger researchers, who they assume are too naive to do paradigm-shifting work in established domains.”

And that brings us to the most important question.

How bad is the gerontocracy?

I spoke to labor economists and experts in business management to get some perspective on this question. First, there is strong evidence that older leaders are likely to be less effective decision-makers. Extensive research shows a decline in executive function that begins at age 60. Economists Rosemond Desire and Scott Seavey conducted a survey that looked at CEOs of 17,000 firms between 1992 and 2018. Overall, they found “a strong and consistently negative relationship between CEO age and managerial ability.” Another study by researchers Brandon Cline and Adam Yore found that even after adjusting for the fact that younger CEOs are attracted to faster-growing companies, every additional year in CEO age was associated with a 0.3% decrease in the value of the firm.

This problem isn’t restricted to CEOs. Another study by researchers at Ohio State University analyzed 5.6 million biomedical research publications and concluded that the work of biomedical scientists makes less of an impact in the field as the scientists get older. This is consistent with the finding that we generally become less creatively productive after we leave middle age.

To be clear, this sweeping generalization obviously doesn’t apply to every individual. Warren Buffett is crushing the stock market well into his 90s. Dr. Richard Bond was just awarded the prestigious Shaw Prize at the age of 75 for his research estimating the age and mass of the universe. I’m not asking anyone to quit their job because of their age, nor am I ignoring the fact that ageism is still very real. Gerontocracy might rule at the top, but less senior workers are still regularly pushed out of jobs due to their age. I do think, though, that we need to be cognizant of how an aging elite might handicap our economic and intellectual growth. And how in certain cases, older workers occupying senior positions might deny younger workers the opportunity of career advancement.

Joseph Fuller, a professor of management practice at Harvard Business School, told me he could see this leading to “a lack of upward mobility for younger academics in certain disciplines.” But also cautioned about making any sweeping statements, because, “It's very occupationally specific and industry specific.”

The U.S. economy is enormous, with millions of workers hired and fired each month, so of course it’s important to avoid over generalizing. But the economist Nicola Bianchi looked at 35 years of income survey data from the US and found that the pay gap between workers over 55 and those under 35 increased by 61 percent between 1979 and 2018. His explanation is intuitive: “Older workers have accrued more promotions and have been occupying those slots for longer, which means younger workers cannot reach those levels anymore.”

Sixty-one percent is a striking number. But even if it’s only directionally correct, it suggests a serious shift in how opportunity is distributed, with younger workers increasingly locked out of the best-paying roles.

The future of the gerontocracy

In each of my conversations about the gerontocracy and the labor market, the topic of generative intelligence came up repeatedly. Whether you’re an AI evangelist or a doubter, it’s impossible to deny that AI will have some impact on the workplace. And I think there’s a strong case to be made that it could either entrench or reduce the power of older workers.

Let’s start with the worst-case scenario.

If AI is at least, as Benedict Evans put it, a collection of infinite interns, then it’s coming for the positions typically held by people one to three years out of college first. But the function of a new associate position at Accenture or a computer programmer at Amazon isn’t just to handle entry-level tasks; it’s also to prepare employees to move towards the middle, and eventually to higher management level positions at the company. Take those away, and you’re not just automating grunt work, you’re cutting off the ability for younger workers to gain a foothold in the workforce.

Guy Berger, a labor market economist and senior advisor at the Burning Glass Institute, doesn’t see this future as inevitable, but he did offer a fairly pessimistic theory: “Organizations find themselves saying this is really good at cutting out young people. We can save resources. And have AI agents run by a bunch of people in their late 30s and early 40s. Then, 20 years later, 70-year-olds are still running things, with no new crop coming in behind them.”

To be clear, there is no evidence that the incorporation of generative AI in the workplace is driving this trend. But there’s been some indication that this future could be around the corner. The accounting firm PwC cut 1,500 jobs and reduced on-campus recruiting after making a billion-dollar investment with OpenAI. Kevin Roose reported that one tech company is no longer hiring for positions below midlevel engineer. The labor market research firm Oxford Economics recently released a report stating, “There are signs that entry-level positions are being displaced by artificial intelligence at higher rates.” (...)

The comparative adoption rates of AI in the 2020s versus personal computers in the 1980s underscore Fuller’s point. AI is entering the workplace much faster than computers once did. And while this acceleration is driven primarily by younger, more educated workers, a Federal Reserve survey finds adoption is “widespread across gender, age, education, industries, and occupations.” If senior level white-collar workers become quickly fluent in using AI to enhance their productivity, it’s possible to imagine them using it to extend their careers even longer. As a result, the upper-echelon of the labor market becomes increasingly calcified.

Addressing the gerontocracy

There is no single fix for gerontocracy, largely because, as Fuller emphasized, aging labor is a sector-specific problem that will require sector-specific solutions.

For example, the gerontocracy narrative doesn't accurately fit the make-up of the employees or executives who steer our world-beating tech companies. Nevertheless, certain sectors remain dominated by older workers, who cling to power because of status, a hefty paycheck, or some combination of the two. This is having a measurable impact on the wages of younger workers and is likely, to an extent, suppressing dynamism in the American economy. (...)

So are there any fixes?

by Ben Krauss, Slow Boring |  Read more:

Image: New Yorker