Showing posts with label Health. Show all posts
Showing posts with label Health. Show all posts

Sunday, May 17, 2026

Ben Sasse's Warning

When Ben Sasse walked onto the Senate floor in November 2015 to deliver his first speech as a member of the upper chamber, he did something unusual: He had waited a full year to speak. It’s part of a Senate tradition known as the “maiden speech.” A historian by training and a management consulting associate by early vocation, he had spent his first year in the chamber interviewing colleagues, studying how the institution functioned, and developing a diagnosis before offering it publicly. When he finally spoke, the speech landed with enough force that Sen. Mitch McConnell (R-KY) distributed the text to every Republican senator, a gesture the Senate GOP leader at the time rarely made.

“No one in this body thinks the Senate is laser-focused on the most pressing issues facing the nation,” Sasse told his colleagues. “No one.”

The indictment was bipartisan, surgical, and delivered with the calm of a man who had considered it carefully before speaking. The Senate, he argued, had surrendered its institutional identity to the rhythms of the 24-hour news cycle, to the demand for sound bites, and to the incentive to grandstand for a narrow base and raise money rather than legislate for a country. “The people despise us all,” he said. “And why is this? Because we’re not doing our job.”

It served as a warning that went unheeded, and 11 years later, we’re watching more dysfunction in government than ever before. Sasse, now dying of Stage 4 pancreatic cancer at 54, is still saying the same thing. The diagnosis has not changed the message. It has sharpened it.

Whether Sasse was a “good” or “effective” senator is debatable. Whether Washington currently has enough senators like him is not a close question.

The criticism that followed him throughout his eight-year tenure is almost entirely subjective. His critics on the Left saw a man willing to deplore Trumpism in public while voting with President Donald Trump‘s agenda in practice. His critics on the Right, particularly as the party realigned, saw a posturing institutionalist more interested in making points and serving as a pundit than in getting on board fully with the president’s policies. The most durable version of this critique runs something like: He gave great speeches and passed no significant legislation.

Yuval Levin, founding editor of National Affairs and director of Social, Cultural, and Constitutional Studies at the American Enterprise Institute, largely rejects both sets of criticisms. On the Trump question specifically, Levin is direct: “The notion that there was much more he could have done to hold Trump to account is misdirected and mistaken. He took on Trump when he disagreed with him, and when he thought Trump had exceeded his authority or violated his oath. And unlike most Senate Republican critics of Trump, he ran for reelection and won after doing that.”

The objection to the lack of signature legislation mistakes the Senate’s function for a body it was never designed to be. In the framework Sasse spent years articulating, the Senate is not primarily a factory for producing legislation. It is a deliberative institution meant to apply friction to democratic impulses in the House of Representatives, to slow things down when people want to move too fast, and to force the executive and judiciary to operate within appropriate constitutional limits. By that standard, which is closer to the Founders’ intent than the one applied by Sasse’s critics, he understood and performed his role better than most of his colleagues.

The “pundit” critique oversimplifies his actual record. Sasse served on the Senate Intelligence Committee throughout his tenure, and his work on China there was substantive and largely ahead of the political mainstream. When it was still unfashionable for a Republican to identify Beijing as a generational geopolitical threat rather than an irritating trade partner, Sasse was making that case in the committee rooms that mattered. He had genuine expertise in China’s intelligence operations and, accordingly, used his position, spending considerable time in secure facilities at times when most of his colleagues were busier developing a social media strategy.

Sen. Mark Warner (D-VA), who worked alongside him on the intelligence committee, offered perhaps the most precise characterization of what made Sasse different, telling Scott Pelley on 60 Minutes in April that Sasse “never really thought about things as conservative, liberal. He thought much more about issues, such as the future and the past.” Senate Majority Leader John Thune (R-SD) said Sasse had a “concern not just for today, but for tomorrow and the future” and that he “wasn’t distracted by all the noise that goes around us on a daily basis.” [...]

Levin, who watched Sasse’s tenure closely, offers a candid accounting of his legislative limitations. “It’s true that Ben was not an active legislator, advancing proposals, sponsoring and co-sponsoring legislation, and building coalitions,” he said. “He was active in some key committees, especially the Intelligence Committee, where it seemed to him that active engagement could make a difference. But I think he concluded this was not the case in some of his other committees and that he might be more useful as a critic and observer of the institution. No individual senator gets a lot done right now, and of course, that’s part of the frustration he had.”

But the moments that defined Sasse as a senator were the ones that did not produce legislation, and those are the moments worth examining without the usual condescension.

On the first day of Justice Brett Kavanaugh‘s Supreme Court confirmation hearings in September 2018, the chamber descended almost immediately into the theater that had by then become customary. Protesters disrupted proceedings from the gallery. Democratic senators jockeyed for camera time. The atmosphere was more performance than inquiry. Into this circus, Sasse delivered a 12-minute statement that went viral because it said plainly what almost no one in that room was willing to say: The hysteria around confirmation hearings is a symptom, not the disease. Congress had spent decades delegating its legislative authority to executive agencies and now blamed the courts for filling the vacuum.

“It is predictable now that every confirmation hearing is going to be an overblown, politicized circus,” he said. “And it’s because we’ve accepted a bad new theory about how our three branches of government should work.” The corrective he offered was simple: Congress should pass laws and stand before voters. The executive should enforce those laws. Judges should apply them, not write them. Naturally, no one disagreed out loud.

He delivered a version of the same argument at Justice Amy Coney Barrett‘s hearing in 2020. Neither speech moved the institution. Both captured something true and important about why the institution was failing, and both were widely shared by people who had largely stopped expecting a sitting senator to say anything worth sharing. The Kavanaugh statement was described in this publication at the time as the civics lesson Washington desperately needed. That it needed to be given by a freshman senator to the full Senate Judiciary Committee was Sasse’s real point.

He also understood, more clearly than most of his colleagues, that the Senate’s dysfunction was not incidental but structural. The cameras, he argued, were a bad incentive. The constant travel and time spent fundraising corroded the relationships that make effective governing possible. Most tellingly, he believed that senators had come to treat their office as the purpose of their lives rather than a temporary form of service to something larger. When Pelley noted on 60 Minutes that many senators he knew “would not be able to breathe without that job,” Sasse replied that he feared that was true and that it represented “a much, much deeper problem.” The best title a person could hold, he said, was dad, mom, neighbor, friend. Senator was “a great way to serve. It should be your 11th calling or maybe sixth, but never top.”

When he resigned from the Senate in January 2023 with four years remaining in his term to become president of the University of Florida, many observers treated it as confirmation of the pundit critique: He could not stay the course. The more honest reading is that he had concluded the institution was, as he told Pelley, “very, very unproductive” and that there were better things for him to do. “We didn’t do real things,” he said. “And it felt like the opportunity cost was really high.” He moved to Florida, then stepped down from that post roughly a year and a half later when his wife, Melissa, was diagnosed with epilepsy and required full-time care. The man who had argued that being a senator should rank no higher than sixth on a person’s list of priorities was living accordingly.

Then, on Dec. 23, 2025, he posted the news to X. “Last week I was diagnosed with metastasized, stage-four pancreatic cancer, and am gonna die.” He was 53. Doctors at MD Anderson Cancer Center had cataloged the full spread: lymphoma, vascular cancer, lung cancer, liver cancer, and pancreatic cancer, the point of origin. He had been given three to four months to live. He called it what it was: “Advanced pancreatic is nasty stuff; it’s a death sentence.”

What followed was unexpected, at least to anyone who had expected Sasse to retreat from public life. He launched a podcast called Not Dead Yet. He sat down for a conversation with New York Times columnist Ross Douthat on the latter’s Interesting Times podcast in April, which was released just days after the interview aired and subsequently circulated widely. He appeared on 60 Minutes with Pelley on April 26, his face visibly marked by his medication, a drug called daraxonrasib from Revolution Medicines that had shrunk his tumors by 76% and extended his life by months that were not supposed to exist. He credited the extra time to “providence, prayer, and a miracle drug.”

The Douthat interview was the more intimate of the two conversations and the more remarkable. Douthat asked Sasse at the close whether he felt ready to die. Sasse said he did not feel ready but that he had hope, grounded in his Reformed Christian faith, that he would be with God. The response moved Douthat visibly to tears, something Sasse responded to with his characteristic dry humor. Earlier in the conversation, Sasse reflected on what the disease had given him alongside what it had taken. “I hate pancreatic cancer,” he told Douthat. “I would never wish it on anyone, but I would never want to go back to a time in my life where I didn’t know the prayer of pancreatic cancer. I can’t keep the planets in orbit. I can’t even grow skin on my face.”

The “prayer of pancreatic cancer,” as Sasse uses the phrase, is something like the acknowledgment of dependence that most people spend their healthiest years avoiding. He is not unusual among the terminally ill in arriving at that acknowledgment. He is unusual in the way he has extended it outward, into public argument, into the same institutional critique he was making in November 2015. On 60 Minutes, he was asked what Congress was missing, and he named the artificial intelligence revolution, the future of work, and the complete absence of 2030 or 2050 thinking in either party. Then, without prompting, he returned to the frame he had always used. “The Senate needs to be less like Instagram. The Senate needs to be more deliberative, and that means less smack-down nonsense,” he told Pelley, adding, “The Senate should be plodding, and steady, and boring, and trustworthy.”

by Jay Caruso, Washington Examiner |  Read more:
Image: uncredited via
[ed. I knew very little about Ben Sasse before reading an article about daraxonrasib, the new breakthrough drug given to him in his treatment for aggressive pancreatic cancer. It goes without saying that Congress would be an entirely different place if there were more people like him. See also: Pancreatic cancer just met its match (Works in Progress):]

***
"For most of the last half-century, a diagnosis of metastatic pancreatic cancer was a death sentence. In December 2025, former Nebraska Senator Ben Sasse announced he had been diagnosed with stage four pancreatic cancer that had spread to his lungs, liver and other organs, and was given three to four months to live from the time of diagnosis. With little to lose, he enrolled in a clinical trial for an experimental drug. Four months later, he reported a 76 percent reduction in tumor volume, describing the drug, daraxonrasib, as a ‘miracle’. His face, ravaged by a severe skin rash from the treatment, told a more complicated story. Yet he was alive and grateful to be able to talk to his family.

A few days after Sasse’s interview, in April 2026, Revolution Medicines announced Phase 3 trial results for daraxonrasib showing the drug had roughly doubled survival in patients with metastatic pancreatic cancer compared to standard chemotherapy. For a disease where median survival has long been measured in months and where little had changed for decades, that result represents a genuine turning point.

But the significance extends beyond pancreatic cancer. Daraxonrasib is among the first drugs in an emerging generation designed to target RAS, a protein implicated in roughly a quarter of all human cancers and long considered beyond reach, in all its mutant forms. And it belongs to a broader class of medicines, molecular glues, that are beginning to show what becomes possible when drugs no longer depend on finding a ready-made pocket in their target. Several compounds in this class are now in clinical development, each probing a different protein that previous generations of drugs could not touch."

Wednesday, May 13, 2026

Intervention Time

via: X
[ed. Surreal. Republicans continue their silence and make excuses. The entire nuclear arsenal at his disposal. Nothing to see here. For more, including pictures and videos, see: If You Have to Tell People You’re the G.O.A.T., Then You Are Not (Larry Johnson). Then there's this - below:]

Tuesday, May 12, 2026

Change in Private-Sector Jobs Since December, 2023


Healthcare and Social Assistance have added nearly 1.8 million private-sector jobs in the US since the end of 2023 while all of other industries combined have lost 127,800 jobs.
Source:

[ed. We all know about the jobs boom in data center construction, but it appears to be a blip in the overall big picture. With an increasingly aging population, more AI-related job losses, a dysfuctional if not entirely broken healthcare system (and Congress), etc. Human support industries will likely be the bedrock of whatever economy exists/persists going forward.]

Thursday, May 7, 2026

Hantavirus Update

A working timeline: 
  • Mid-March: Dutch couple possibly contract virus on bird watching landfill excursion.
  • April 1: MV Hondius departs southern Argentina.
  • April 6: Dutch man falls ill.
  • April 11: He dies.
  • April 24: St. Helena. Man’s body is taken off ship and wife flies with it to South Africa. The Dutch woman is already sick before boarding flight to South Africa.
  • April 26: The Dutch woman dies in SA at a hospital.
  • April 27: A British man who is sick is flown from Ascension Island to South Africa.
  • May 2: A German woman dies on the MV Hondius.
Meanwhile, we have people leaving the ship and flying all over the world:

Some Hantavirus Cruise Passengers Are Back in the U.S. MedPage Today

Two British people self isolating at home after leaving cruise ship in St Helena BBC. “The UKHSA also said British people currently on the ship would be flown home on a charter flight, probably from the Canary Islands, as long as they didn’t have symptoms.”

Patient with a hantavirus infection being treated in hospital Switzerland Federal Office of Public Health (press release)

Passenger with hantavirus was briefly on board a KLM aircraft in Johannesburg KLM (press release)

Spanish passenger on the ‘Hondius’: ‘There are 23 people who got off on Saint Helena and have been wandering around El Pais

by Conor Gallagher, Naked Capitalism | Read more:
[ed. Time to pull that old "definition of insanity" cliche' out again. Even if this does eventually burn out, it appears we've learned very little in the last few years.]

Monday, May 4, 2026

How YouTube Took Over the American Classroom

Amy Warren's “mom siren” went off when her seventh-grader in Wichita, Kan., seemed to know too much about Fortnite, a battling-and-shooting videogame he is barred from playing.

When Warren signed into his school Google account, she was aghast: Her son Ben had accessed more than 13,000 YouTube videos during school hours from December 2024 through February 2025, according to viewing data she provided the Journal.

His feed was rife with inappropriate content. Videos glorifying gun culture, asking about silencers on Nerf guns, “head shots” where children realistically portray being killed, a video with sexually explicit jokes about neighbors sleeping together.

YouTube had served up “shorts”—video after video that it algorithmically determined that he might like.

“It made me cry,” Warren said. “All of a sudden it’s this kind of gun slop, by no fault of his own. ” She later ran for school board and won in November, eager to galvanize change.

American public schools are awash in YouTube. According to more than 45 families, school administrators, clinicians and educators across the country interviewed by The Wall Street Journal, schools’ overreliance on the Google-owned platform for educational content has created a gateway for students to get sucked into an infinite scroll of videos on school-issued devices.

YouTube during snack time, dismissal and indoor recess. YouTube to teach drawing to first-graders. YouTube to read a book to class. YouTube under the covers at night, watching hamster videos on school-issued Chromebooks. A survey touted by YouTube executives shows that 94% of teachers have used YouTube in their roles...

The concern about YouTube arrives during a crisis in education. American math and reading scores have slid to their lowest point in decades. Many educators, families and learning scientists say they can no longer blame pandemic learning loss; the decline has coincided with a dramatic increase in school screen time, turbocharged by the embrace of 1:1 devices by more than 88% of public schools, according to government survey data. YouTube and Meta recently lost a landmark social-media addiction trial, with a jury finding the companies negligent for operating products that harmed children. YouTube said it’s appealing the ruling.

Chromebooks—primed for Google software and YouTube—have about 60% of the K-12 mobile device market, according to Futuresource Consulting. Apple iPads are also a popular school device. YouTube is a top-viewed website on school devices, sometimes accounting for half of student traffic, according to administrators and web-filtering companies.

YouTube says school administrators control what students watch at school, and it supports districts deciding what’s best for their children. “Our tools allow administrators to block the platform entirely or restrict access to teacher-assigned videos only, with no ads, recommendations, or browsing,” said YouTube spokesperson José Castañeda. But some districts and teachers said Google’s tools and content filters haven’t met their needs for a variety of reasons.

In some school districts, including Wichita, efforts to block all or part of the platform proved futile. Students found workarounds: logging out of their district accounts, sharing YouTube links in Google Slides and Docs and other backdoors in, parents, teachers and students say. Google says it’s fixed the Slides and Docs bug.

When Warren asked about blocking YouTube altogether from student devices last spring, she heard back that teachers depended on it for parts of lesson plans.

Wichita Public Schools is “working to restrict open YouTube browsing,” a spokeswoman said, after learning over time that the platform’s own “restricted” content-filtering mode “isn’t sufficient for the way algorithms and short-form content have evolved.”

In Ben Warren’s science class, nearly all educational content has been on the iPad: instead of live science experiments, the teacher showed a YouTube video. “Everything is a simulated experience,” the now-eighth grader says. “I would rather use paper and pencil. It’s easier to focus.”

When Google brought Chromebooks into classrooms early last decade, they were heralded as a boon for bringing low-income students online. School districts adopted the devices and with them, Google’s suite of workplace software. Chromebooks quickly became used for everything from gamified math practice to standardized tests.

To Google, the K-to-12 market and Chromebooks were a critical entry point for building lifelong brand loyalty, according to internal documents released during the social media trials. The company trained its eyes on children under 13 as the world’s fastest-growing internet audience. YouTube sought to close the 80 million-hours-per-day viewing gap between school days and weekends, according to a 2016 document entitled “YouTube edu opportunities”: “Increasing usage in schools M-F could decrease this gap!”

A Google user experience team two years later detailed ills affecting viewer well-being, based on external research. Among them: addictive gaming content was being sought out by “inappropriately-aged children,” children were entering therapy after watching sexually graphic content, and overexposure to videos “decreased attention spans.”

By 2019, the company was aware “the YouTube experience in K-12 schools is broken” due to ads and inappropriate content. A restricted mode used to police content was under-resourced and “trivially easy for students to bypass,” internal exchanges said.

An effort that year to regulate YouTube on children’s privacy grounds by the Federal Trade Commission was halfhearted due in part to its importance in education, ending in “absolute regulatory failure,” said Erie Meyer, former chief technologist at the FTC.

The pandemic enmeshed YouTube deeper into schools. Chromebook shipments exploded, driven by schools spending federal Covid aid on the devices. 

by Shalini Ramachandran, Wall Street Journal |  Read more:
Image: Colin E. Braley for WSJ
[ed. See also: Classroom Cope (The Point) - AI as another teaching tool:]
***
"As for outcomes: it is one thing to say that in-class practice is the best we can do in the age of AI; it is quite another to credit AI with “reviving” writing. There is nothing, nothing, to celebrate about teachers and students being forced to resort to degraded forms of learning, practice and assessment. We might as well credit a basketball hoop in the prison yard with reviving organized sports. It’s a good thing that the inmates are given a chance to exercise. It is better than nothing."

Saturday, May 2, 2026

I Mean, Why Shouldn’t We All Smoke Cigarettes Again?

Lately, I’ve been thinking about smoking. All the time. It started sometime after we kidnapped the president of Venezuela but before we watched Alex Pretti get shot and killed by Customs and Border Protection agents. Or maybe it was between their detaining young Liam Ramos in his bunny hat and their releasing that tranche of Epstein files and nothing happening. I definitely felt it a couple of weeks ago as I headed inside a fancy dinner party the same day our president had, via social media, threatened to wipe out all of Iranian civilization if the Strait of Hormuz wasn’t open by 8 p.m. The invitation was for 6:30 p.m.

Anyway, it’s hard to pinpoint exactly when it started. But with each passing day of this absolutely deranged year, my desire to contemplate how to make sense of it all while puffing on a cigarette grows.

Like many ideas of middling wisdom, this one was fed to me by the algorithm. A woman named Stephanie Wittels Wachs was suddenly on my Instagram scroll, reminiscing, longingly, about smoking in the ’90s. Obviously, she clarified, she wasn’t going to smoke; she was just thinking about it. Because smoking kills you. And if she died, she figured, who would take care of her kids? Very solid point, I thought. Then I remembered: I don’t have any kids.

I certainly remember smoking in the ’90s — it was divine. Before we stood around staring down at our phones, we used to stand around staring at each other. Talking and talking while we blew smoke in one another’s faces.

In those early years, I was a student at an artsy Brooklyn high school in Midwood. We were “teens” in chronology only — we worked jobs, we went clubbing, we rode the subway at all hours of the night. And generally, in varying degrees, we smoked. The serious smokers were committed. You’d find them out in the school courtyard no matter the weather. Often, they were the benevolent suppliers to those of us who merely flirted with the idea of being serious smokers. Happy, if you joined them outside “for a smoke,” to trade a stick of nicotine for some interesting gossip you might have heard. Sometimes, we even smoked with our teachers. Usually, they were from the English department.

The irony of my current jonesing for a cigarette is that I was, in those days, a dabbler at best. Mainly seduced by the smell of a clove cigarette, usually found in the hands of somebody from Park Slope. But I loved the culture of the whole thing: the intimacy of someone getting close to light you up. The matches, the Zippos. The way, over the course of five minutes, small talk could fall into something like deep conversation.

There was a reason I never crossed the Rubicon into “big smoker” territory though, one I’ve been contemplating a lot in the wake of my craving: I had big dreams then. I yearned deeply to get out of Brooklyn. To get into some kind of a college and become some sort of interesting adult. It was all very vague. But the future was the thing I was really invested in. And I knew enough to know that required focus. And discipline. And that commitment to “being a smoker” seemed to take up a lot of time. All those trips outside. All those minutes, burning into ash, that I felt I probably should be spending doing something that might help with my undefined tomorrow.

In my 20s, the smoking got sexy. Dive bars and chic lounges, where we’d now have cocktails and ash into ashtrays and steal matchbooks with which to help one another light future cigarettes. Since nobody seemed to care that smoking was bad for us, our paternalistic mayor, Michael Bloomberg, decided he needed to care for us. Public indoor smoking was banned, and, inadvertently, we were armed with a new way to flirt. There was nothing better than breaking off from a crowd of friends with an invitation outside to share a cigarette. I realize now the excitement wasn’t in the cigarette. It was in the possibility that it raised. Would this be a brief excursion to the sidewalk? Or might it end the next morning, in a bed you didn’t really know, sharing smoke-tinged kisses?

Smoking, in this phase of life, went hand in hand with chaos. The kind that is welcome when you are trying to create from your young adult existence something like a life. Every potential mistake was also a potential opportunity. Because maybe you woke up and never saw the person next to you again. Or maybe you fell in love and married them and ended up having kids and getting a few promotions at work and being a big success.

Either way, since I was just a casual smoker, I hardly noticed that one by one, everyone decided that the mayor was right. Smoking was, obviously, very bad for you. We had jobs we needed to turn into careers. Futures ahead of us that we needed to be optimally prepared for. We no longer had chaos; we had lives. Cleanses became cool; the in-crowd suddenly put a premium on personal purification. Cigarettes became signifiers of calamity, the perfect pairing with a broken iPhone screen. Our bodies weren’t just temples, we seemed to realize. They were functioning machines that could run like well-oiled engines. We had many decades to look forward to! And that required discipline and order: eating well and exercising and sleeping more and drinking less. And, quite obviously, not smoking.

By my mid-30s, who could believe anybody ever used to stand outside in the cold like that? What were we thinking? I’d often wonder. We now had better things to do with our time. And our hands. Like work. And check our phones. And go to spin classes and get brunch and check our phones. Or unwind from a long week of work with a yoga class. And then check our phones. Or pull out our laptop and do some work. And then check our phones. Or get together with the friends we barely got to see and then sit around and take out our phones.

Because we were not just working. We were working toward something. Charging toward a tomorrow when every girl could also be a boss if she worked hard enough. The narrow space found between working or mindlessly wandering the internet researching diets that would maximize our lifespans or shopping for serums and masks to make us look rejuvenated and vital. Preparing ourselves for the promised land of success. Readying ourselves to be perpetually “booked and busy.”

Recently, a friend my age was visiting me. She was helping me shop for clothes for my upcoming book tour. Rushing from one appointment to the next, when she suddenly stopped and pulled out a cigarette. “Do you mind?” she asked. Of course I didn’t. Instead, I salivated. Dying to ask for one, but remaining a good girl. Committed to my health. Committed to my future!

“When did you start smoking again?” I asked as I wrapped my arm in hers. We walked and talked, and she told me of a trip to Italy and questioning, at almost 50, how much damage a few cigarettes a week could really do to her. Her kids were basically teenagers; how much longer did she really need to stay perfectly healthy for? She meant this nihilistically and practically. We got to our next destination and just stood together while she finished her ciggy. It felt utterly luxurious. Slowing down and taking the time to take a drag.

So, yeah, part of this smoking thing is a yearning for the past. Not in an effort to recapture my youth, but to recapture an approach to time and life. I can’t personally slow down technology or fix media or the demands of capitalism or any of the other existential things that have crept into our lives, slowly and insidiously, and worn us down and numbed us in the name of productivity. But maybe what I can do is stop what I’m doing, ask somebody to come outside, and take five minutes to slow down with me while I engage in the very dangerous act of holding a flaming stick to my face. This could be my rebellion. Is it really any worse for us than the numbing digital go-go-go it feels we’ve all been engaged in?

And, truth be told, unlike in my high-school days, I’m no longer certain that the future I’ve been preserving myself for is all that promising. Sure, I can eat as clean as I want, but does it matter when there are forever chemicals in the soil? If we’re walking into dinner parties wondering if the third course will include nuclear war, is there really a point in sacrificing a quick thrill in the now?

Which is, perhaps, the biggest part of it all. If smoking loves chaos, then perhaps it is the perfect new-old bad habit for our moment. A moment that is surely being ruled by Eris, the goddess of chaos, upsetter of norms and apple carts. She is meant to be a foil for the western need to find order in everything. She insists that the only truth is chaos. Our lives may have all been in perfect order, but does it matter if the world in which we live in is burning out of control? And if it doesn’t matter, then, I suppose, why not just smoke?

by Xochitl Gonzalez, The Cut | Read more:
Image: Getty
[ed. Do you really want to live that long anyway? With all the indignities that an advanced age inflicts? It ain't pretty. See also: The Most Important Charts in the World (Zvi):]

Wednesday, April 29, 2026

On Health Care Price Transparency

(from the comments)...

A doctor on billing practices:

Generally such figures do not reside within the physicians’ office. On our side of the table we do some procedure with multiple specifications and generate some CPT code(s) (e.g. a lap cholycystectomy is 47562, add on a common bile duct exploration and it becomes a 47564, and if you just do cholangiography it becomes a 47563). Generally, we couple that with an ICD-10 code that specifies your exact disease (K80 for simple stones, K81 for cholecystitis, etc.). We then dump those codes into a computer.

Can either of those change? Absolutely, we find a bunch of friable neovasculature around the gallbladder, congrats you likely have cancer which means this surgery is now both a different CPT code and a different ICD-10 set. Maybe only one does – we find the gallbladder lacks an obstructing stone, but does have transmural inflammation then you get a new ICD-10 code. If we find that you actually have multiple obstructing stones and we need to go deeper into the biliary tree, then those are different CPTs.

Regardless, we do what is medically indicated, document the codes used.

At this point, unless your physician keeps billing fully in house, those get handled by a processer. Often, bills from multiple providers get handled by one processor who in turn gives insurance companies bills to their specifications. Often this involves a bunch things – where was the surgery done (through very complicated rules, critical access hospitals, for example, can charge more for the same surgery because the government wants to keep them solvent lest a bunch of people lose their local emergency room and OR), who was doing it (e.g. there is a different rate if you have medical trainees involved), and of course stuff about you (e.g. complex patients get reimbursed at higher rates with the expectation that, on average, the higher rates cover higher complication rates and insurance doesn’t incentvize surgeons to make all their complex patients drive for hours and hours). Then we get to the big buys – buyers. For Medicare, there are some committees that appear to be overwhelmingly ignorant of actual medical practice but they set baseline reimbursements for these CPT/ICD-10 combos. Those then get adjusted to account for regional costs, equity concerns, and only God knows what all else. These are normally set near the break even point on national average. Medicaid, typically, uses those rates as a baseline and then cuts them (hence why many physicians won’t take new Medicaid patients, the reimbursement rates often leave folks at a net loss). Private insurers add another layer of negotiation where they use their monopsony power to extract lower rates while, allegedly, assuring physicians of volume. The range of these negotiations can be exceedingly wide – insurers can have modifiers for quality of care (e.g. how many folks come back in the perioperative period), timeliness of care, and so on and so forth.

Okay, so somebody has haggled set a rate and we just assume that get the bog standard lap chole we have a price?

Of course not.

See that is just what has agreed, in theory, these medical services will be reimbursed at. Actual reimbursement involves a non-negligable risk on non-payment (e.g. insurance denies and the patient cannot or will not pay), delayed payment (and having to utilize credit lines to cover payroll when a large insurer has an IT glitch and doesn’t pay for two weeks is quite expensive), and of course variable legal and compliance costs. You might also be hit with clawbacks, partial payments, and a host of other payment uncertainty.

Okay, but’s lest assume a single CPT/ICD-10 setup, a prenegotiated rate that is paid on time without further processing costs, and everything is chill there. We got a price yet?

Of course not.

See all of the above is for just the surgeon’s professional fees – i.e. what is being paid for use of his hands. The OR itself? That’s a completely different bucket of money that has its own set of billing and negotiations. Facility fees make the professional fees look straight forward and simple.

But we are done now? Right?

Of course not.

See those were the professional fees for your surgeon. You also need an anesthesiologist (and/or his minions). And guess what, yep completely different bucket of money and price negotiation.

But we are done now?

Well, no. There may be different negotiations for lab fees (e.g. where does the CBC get billed), for tissue pathology, for any post-operative hospital services, and of course medications (which are billed completely differently if outpatient or inpatient) to name a few of the more common options.

There isn’t “a” price for a surgery. There are, potentially, a dozen diferent prices that can be combined in a multitude of ways with some buckets covered by one payer and other parts covered by another (and things get crazy fun when you have overlapping payers).

But aren’t there cash only surgical places with listed prices? Yes. And they have an extremely limited set of procedures with everything owned in house – i.e. a setup that is pretty much illegal to set up de novo post Obamacare.

Why does everyone have all these bizarre negotations. Why don’t you just pay the surgeon everything and then he pays the hospital, the anesthesiologist, the pathologist, etc. from that cut? Because that is an invitation for your surgeon to be charged with a crime. It is federal crime to underbill or to underbill when it comes to government monies (and in many states, private insurance monies). We are required not just to I Pencil up a price, but to make that price transparent to regulators. If a hospital wants to grant me cheaper OR time because I have reliable stream of patients, keep the OR cleaner (reducing turnaround time enough to fit another case per day in), and don’t create ancillary malpractice risk at the going rate … the hospital risks being tagged with inducement. If I negotiate a cheaper rate with the lab for my patients’ tests, it is considered prima facie evidence for kickbacks and I then have a positive burden to prove that I am not getting clandestine remuneration from the lab.

Separate, disjointed, billing through bureaucratic negotiation is legible. It is legible to the courts, to regulators, and to malpractice insurers.

But doesn’t all this massive change efficiency of care delivery?

Not that I can easily see. I have personal experience with IHS, TriCare, Kaiser, the VA, and for-profit, non-profit, and even prison care; full Beveridge like IHS is often the least efficient.

So where do cash prices come from? Outside of cash only practices, those are overwhelmingly fictions that somebody pulled out of their nether regions in a likely futile attempt to BS the counterparty to an insurance negotiation.

Why is this all so complicated:

1. Principle agent. The patient has a wildly different incentive structure than the collective payer (insurance or government) and American healthcare is insanely deferential to the patient compared to alternatives. The folks with the most direct control feel at most a small fraction of the price pain have near zero incentive to economize for anything big.
2. Taxes. The original sin of American healthcare was making insurance, rather than medical procedures themselves, tax deductible. This creates very strong incentives for people to bundle non-healthcare into insurance premiums in hard to define manners (e.g. is a health insurer offering a rebate for gym membership incentivizing exercise, allowing folks who would already have gym memberships to pay pre-tax, or just selecting for healthier patients).
3. People are terrified of physician abuse. Most folks, even other physicians, have a very hard time knowing if their physician is taking them for a ride. So they turn to something powerful to regulate physicians. But, not knowing what actually matters, these folks find it extremely hard to navigate market transactions. Healthcare would far rather have 100 unattributable deaths and 2x costs than to have 1 attributable death that regulation could avoid.
4. A complete disconnect between what folks experience for prices (e.g. my tape easily costs 10x more than department store specials, my EMR internal word processor is an order of magnitude more expensive than MSWord let alone Emacs or the like) and how medical expenses run.
5. A failure to appreciate the costs of having things on standby. We have folks ready incase a simple IR procedure perfs the vessel walls. We have countless folks handy in case your infusion leads to anaphylaxis. Or your blood transfusion moves on to TRALI. Just opening the doors typically means that we need to have a few dozen physicians and their support staff available at all times. I’ve seen a simple gallbladder turn into a massive transfusion with staging, SICU, and the whole works. I have seen STD treatment turn into a catastrophic emergency of the sort that gets Derm to come in at oh ass hundred.

None of those go away if we post prices. And a lot of people will be upset – somebody will decry us pricing differently for different patients – everyone deserves the same care at the same cost. Somebody will decry us for not pricing differently enough – people should be reward for making good decisions.

Long run, healthcare is going to get more expensive. I expect it will eventually be on part with mortgage payments (you know you live in your body 24/7). But there is an evergreen fantasy that … if only … then we could reduce prices.

You can’t. You can, maybe, make them rise more slowly, normally for harsh tradeoffs Americans won’t stand. And just about every significant intervention that really moves the price needle … is either selection (e.g. health share ministries have wildly healthier populations because they are heavily selected about drugs, promiscuity, and the rest) or given entirely back by the patient dying later. And the handful of things to do pass muster (e.g. HPV vaccination, Hep C treatment) … it becomes yet another morass of how much to pay whom.

Healthcare is not a normal market. We should stop pretending it could be one.

[ed. Hence single payer, or Mediare for All. It won't solve everything, but having the government and all its various compliance mechanisms working to cut costs can't hurt.]

***
Comment: There is plenty of data from which to compute averages and provide a published estimate against which performance can be tracked. That's what consumers of professional services do in actual free markets. Making every transaction in this sector a Persian rug bazaar involving third parties with no input from the actual consumer is not how you lower costs.

Response:

It is, however, one of the more common ways to comply with regulations, liability mitigation, and uncompetitive negotiations.

The other alternative is to vertically integrate a market under and a mono(dou)poly and put all the service lines and fee sources under one roof. This has the advantage that one entity on the provider side does have all the costs and profits on one balance sheet ... but so far it is, at best, a complete bust for lowering prices (and at worst actively raises them through local monopoly power).

There is one set of constraints on healthcare that makes this a hash. It is the nature of payments, the nature of regulations, the nature of malpractice risk, and a heavy dose of inertia.

But with no single problem we also see no hope for one singular quick fix.

If you want me to lower costs (in the short term): let me own a hospital with 50 fellow physicians, allow us malpractice liability protection provided we hit prespecified milestones (and I largely don't care what you pick as long as the traditional hospitals have to meet them too), create financial incentives for patients to economize, and allow us to charge patients more aggressive for different risk and cost profiles.

Long run, all of those will fall, but our healthcare billing system wasn't built for efficiency or even naked profit maximization. It was built for regulatory compliance and navigating the insurance premium tax exemption from WWII.

***
Comment: Wait a minute here. The reason some engineering project can't be estimated in advance is because it's hard to know how many people it will take and how long. It's because it is estimating an unknown that might take 4 years or 4 months. A SURGERY should be easier to estimate. Yes, you might cut open the patient and decide the problem is cancer and not gallstones. Or they are a woman and not a man, but the surgery isn't suddenly going to take 4 years longer.. It's not going to take 4 days longer either. Of course .... if the GOVERNMENT is involved then they might get wildly different costs. But it isn't the complex nature of surgery that makes the estimate difficult. And you might say, well finding out it's cancer means a whole new cost structure .... yes it does. But THAT given surgery shouldn't change so vastly in price because of it. The new diagnosis is an entirely new issue. My MECHANIC can figure out how to call me an give a new estimate if he's there to change the oil and finds out the engine block is cracked.

No. The problems with pricing have been CREATED by massive government regulations.


Engineering projects don't have to change workforces halfway through. I have seen a surgical procedure swap successively from IR to vascular surgery to cardiothoracic surgery to neurosurg to transplant (this did not end well for the patient).

And that is part of the thing. If your mechanic encounters a cracked engine block, he waits, orders a new one, and then recommences work at leisure. Your surgeon, is diagnosing the car, while is going 80 down the freeway, has to fix the crack (because replacement parts are generally unavailable and insanely expensive for OEM if they are) without slowing down while the engine is running, and then has to make certain that his method of repair won't compromise the running of the car.

Mind you running through different surgeons often means calling in different teams (surgical assists very often specialize de facto if not de jure). And the bills mount quickly. Last time I saw the numbers, each marginal minute of OR time works out to ~$100 of extra costs (most of which is labor). And that is excluding the cost of bumping somebody off the schedule; if you are the penultimate case of the day and the system doesn't have slack to run later into the night you might well run 80 minutes over and then force us to scrub a three hour, high cost procedure which then mucks up even more OR times the following day.

Like the OR is the hotel problem are crack. Hospitals generate massive revenue by keeping ORs in constant use (spread the overhead over more patients) and a quadrupling of OR time is not going to quadruple the cost of a surgery to the system - it will often cost far, far more than.

And there are other margins. We get a bit leery about undertaking certain, technically "elective" procedures when the SICU is too full. If we are short on anesthesia folks that can bump out other patients too. If this is not a trauma I, surgical novelty can mean burning through our blood product inventory, and if that gets bad enough that means putting the ED on diversion (in which case we are paying for a lot of ED staff who are generating no revenue).

For stuff like OR, hospital efficiency is only as good as the weakest leak and because everything is often on a tight timetable with little margin (because margin costs more money) small failures can cascade to far bigger costs.

Which, generally, is not such an issue for the engineers. After all, if work halts on building one dam, it frees up labor and resources for another.

Can we just build that into the prices? Yes. And that is what vertically integrated shops do and they average the truly horrific cases over a lot of surgeons.

But for a single surgeon's office? Yeah, no. If they quote you the full range of possible costs it will likely span three orders of magnitude for the cheap stuff.

Which is part of why separate billing works. If you go in and they find you need a different surgeon, it isn't like folks have prenegotiated every possible permutation of who else needs to take care of you. They find something wonky, they call in the cavalry, and then separate bills are generated for each.

Like I've worked with engineers to build a hospital. The number and interactions of their own unknowns was simply an order of magnitude or two lower.

***
If people want wildly cheaper healthcare they already know how to do it: don't smoke, exercise, eat not complete garbage, get married, have lots of sex, have kids, go to church, hang out in person with friends, sleep soundly with a steady schedule, get educated/earn lots of money, don't do drugs, drink no more than one standard drink a night (and like just one or two a week), don't engage in crime, get car with a bunch of safety technology, live close to work/get a remote job, don't gamble ... like all of these have good correlational data and when you do two-thirds of them you almost invariably end up having a way cheaper life course expenses (e.g. most of the above are correlated with lower odds of needing institutional memory care). Some of it is given back because you live longer ... but people know this. They just have a hard time giving up vices (i.e. things where the immediate reward is too tempting for them to hold out to get their preferred long run payout) or actually prefer the less healthy habits.

[ed. What a system, eh? Everyone in the business of billing medical reimbusement is incentivized to make it as complex and opaque as possible. Every major medical procedure now risks financial catastrophe.]

Sunday, April 26, 2026

Engineering the Disposable Diaper

Adventures in product design.

For the mothers of the baby boom, pediatrician Benjamin Spock’s child care handbook was a practical, confidence-boosting essential. Originally published in 1946 as The Common Sense Book of Baby and Child Care, Dr Spock’s baby book sold more than 500,000 copies in its first six months. By the time the second edition came out in 1957, with the simplified title Baby and Child Care, Dr Spock was selling a million copies a year. My mother, who was 24 when I arrived in 1960, still remembers the book’s reassuring tone.

‘You know more than you think you do’, the author told readers. ‘We know for a fact’, he wrote with medical authority, ‘that the natural loving care that kindly parents give to their children is a hundred times more valuable than their knowing how to pin a diaper on just right’.

Dr Spock went on to provide detailed instructions on the practical intricacies of parenthood, including diapers. Buy at least two dozen, he counseled, more if you aren’t washing them daily. Six dozen would cover all contingencies. With a diagram, he showed how to fold a diaper and explained how to position it on a boy versus a girl. ‘When you put in the pin’, he advised, ‘slip two fingers of the other hand between the baby and the diaper to prevent sticking him’. The book covered when to change the diapers and what to do with the dirties.
You want a covered pail partially filled with water to put used diapers in as soon as removed. If it contains soap or detergent, this helps in removing stains. Be sure the soap is well dissolved, to prevent lumps of soap from remaining in the diapers later. When you remove a soiled diaper, scrape the movement off into the toilet with a knife, or rinse it by holding it in the toilet while you flush it (hold tight).

You wash the diapers with mild soap or mild detergent in [the] washing machine or washtub (dissolve the soap well first), and rinse 2 or 3 or 4 times. The number of rinsings depends on how soon the water gets clear and on how delicate the baby’s skin is. If your baby’s skin isn’t sensitive, 2 rinsings may be enough.
On this subject, the 1957 edition contains two telling differences from the original. In 1946, Dr Spock recommended the knife method to those without flush toilets. And starting with the second edition, he advised new parents to buy an automatic washer and dryer if they could possibly afford them. ‘They save hours of work each week, and precious energy’, he wrote. ‘Energy’ in this case referred not to electricity or gas but to maternal stamina.

Disposable diapers did exist, but they accounted for a mere one percent of US diaper changes. They were expensive, specialty products and not that great. ‘The full-sized ones are rather bulky’, noted Dr Spock. ‘The small ones that fit into a waterproof cover do not absorb as much urine as a cloth diaper and do not retain a bowel movement as well’. Disposables were mostly used for travel, when washing diapers wasn’t an option.

But even as the second edition of Baby and Child Care was hitting bookstores and supermarket racks, change was afoot. After buying Charmin Paper Company in 1957, Procter & Gamble began looking for ideas for new paper products.

Motivated by the less pleasant aspects of spending time with his new grandchild, the company’s director of exploratory development, Victor Mills, suggested disposable diapers. After analyzing existing products and conducting consumer research, P&G created a dedicated diaper research group.

The research this group conducted, like that of its successors and competitors, wasn’t glamorous. It didn’t advance basic science. It wasn’t even an obvious route to profit. (One percent of the market!) It was a high-stakes gamble that required solving difficult engineering problems. How that happened represents the kind of hidden progress that leads to everyday abundance.

P&G’s first design flopped. Tested in the extreme heat of a Dallas summer, the pleated absorbent pad with plastic pants made babies miserable and left them with heat rashes. Starting over, the group had a one piece diaper ready for testing in March 1959. With an improved rayon moisture barrier between the baby and the absorbent tissue wadding, the new diaper was softer and more comfortable. An initial test of 37,000 hand-assembled prototypes went well, with about two thirds of the parents deeming the disposables as good or better than cloth. The next step was mass production.

Designing one well-functioning disposable was hard enough. Turning out hundreds a minute was practically impossible. ‘I think it was the most complex production operation the company had ever faced’, an engineer recalled.
There was no standard equipment. We had to design the entire production line from the ground up. It seemed a simple task to take three sheets of material – plastic back sheet, absorbent wadding, and water repellent top sheet – fold them in a zigzag pattern and glue them together. But glue applicators dripped glue. The wadding generated dust. Together they formed sticky balls and smears which fouled the equipment. The machinery could run only a few minutes before having to be shut down and cleaned.
Eventually, the diaper team mastered the process. In December 1961, Pampers went on the market in Peoria, Illinois. Once again, the test failed.

This time mothers liked the diapers. But the price was way too high for a single use item: ten cents a diaper, equivalent to about one dollar today. By contrast, diaper delivery services, which served about five percent of the market, charged no more than five cents a diaper. Home laundry costs ran to one or two cents.

Lowering the price of a diaper required much larger volumes. Aiming at about six cents a diaper, P&G engineers spent several years developing what Harvard Business School’s Michael E. Porter described as ‘a highly sophisticated block-long, continuous-process machine that could assemble diapers at speeds of up to a remarkable 400 a minute’. After successfully testing Pampers at 5.5 cents each, P&G began a national rollout in 1966. By 1973, disposables accounted for 42 percent of the US diaper market. [...]

The success of Pampers drew competitors into the growing market. ‘Any diaper maker that carved out a modest market share against Procter & Gamble could expect sales to triple as a result of sheer market growth’, write business historians Thomas Heinrich and Bob Batchelor in Kotex, Kleenex, Huggies, a history of Kimberly-Clark. But there was a catch. The bulky diapers took up so much space on shelves that stores rarely stocked more than two brands, plus maybe a discounted private label. Second place meant profits, third place disaster.

by Virginia Postrel, Works in Progress | Read more:
Image: A nurse demonstrating to young immigrant mothers how to diaper their babies: Israel Government (1950)

Tuesday, April 21, 2026

Into the Wood Chipper

The destruction of USAID was just as dumb as it seemed

On February 5, 2025, after USAID’s name had been taken off the building, after most of its staff had seemingly been placed on leave (it was hard to be sure—HR couldn’t confirm because they were also largely locked out of the system), Nicholas Enrich was called in to justify the agency’s global health programming to the Trump administration’s newly-appointed USAID leadership.

According to Enrich, he spoke for about five minutes about USAID’s lifesaving health work: diagnosis and treating HIV and malaria, immunizing children, responding to emerging pandemics. His presentation was met by silence, which senior official Ken Jackson eventually broke. “Wow, there really is so much that USAID does that we never knew,” Jackson said.

Joel Borkert, USAID’s Trump-appointed acting chief of staff, agreed: “I had no idea you did all this. As a Republican, when I think of what USAID does in global health, I assumed it was just, you know, abortions.”

Adam Korzeniewski, the White House liaison to USAID, was similarly enlightened, and he had an idea. To help raise attention to the importance of programs to fight drug-resistant tuberculosis, “he suggested that [they] draft a simple, ‘Barney-style’ set of slides to help the political leadership grasp the dangers, referring to the purple dinosaur of children’s television.”

Korzeniewski acknowledged that most of the relevant officials weren’t “health people,” but he didn’t think that applied to him—he had recently read a book on smallpox. Enrich writes that Korzeniewski had another idea, too:
“One thing I thought of while you were talking,” he added, gesticulating wildly with his hands to conjure the image in his mind. “If you can make one of those maps like they have in Outbreak, where it shows the red growing over time as the disease spreads? You know, like the zombie apocalypse? That would be great, very effective.”
Much of Nicholas Enrich’s new book proceeds like this, describing a process so surreal that it verges on the comical until you remember that millions of lives were in the balance. Into the Wood Chipper: A Whisteblower’s Account of How the Trump Administration Shredded USAID follows the 42-day spell that took Enrich from a relatively anonymous USAID worker to its highest-ranking health official to the author of a widely-reported memo detailing the deadly consequences of the destruction of USAID.

Into the Wood Chipper occupies the somewhat unique genre of civil service thriller, only to then verge into horror. More than anything, it was a 206-page reminder that what happened was so, so murderously dumb.

by Tim Hirschel-Burns, Together But Apart |  Read more:
Image: uncredited
[ed. See also: Everyone is misunderstanding what happened to USAID (TBA):]
***
The problem is that the development sector’s reckoning with the destruction of USAID has been largely unmoored from what actually happened. The post-mortems have tended to follow a similar recipe: a dash of lamentation and a spoonful of self-flagellation, topped with one cup of the author’s pre-existing policy preferences—all of which bear a tenuous relationship to what actually doomed USAID...

When Trump took office and DOGE went into USAID, even they didn’t plan on destroying it. But two weeks later, USAID was functionally dead. In the end, the administration terminated 83% of USAID projects, shuttered USAID as an independent agency, and kept on just 300 of USAID’s over 10,000 staff in the State Department.

Monday, April 13, 2026

Why Your Job’s Complexity Level May Affect Your Risk of Dementia

Getting an education is important for a lot of reasons, but there might be one reason you haven’t heard — it could lower your risk of dementia later in life. Decades of research have supported this claim, with one study showing that each additional year of formal education lowers the risk of Alzheimer’s disease or other types of dementia by 7 percent.

Now, a growing body of evidence suggests that the jobs we hold throughout our lives may matter just as much or more than years of education. Having a job that involves high levels of decision-making or creativity, rather than repetitive or manual tasks, could help keep the mind sharp and active.

“Many studies suggest that, if people are working in complex jobs during their lifetime, they have a lower likelihood of developing dementia in later life,” said Jinshil Hyun, assistant professor of neurology at Albert Einstein College of Medicine.

Roles like managers, teachers, lawyers and doctors are considered high complexity jobs, while clerical, transportation and assembly line work have lower complexity. The findings are consistent with the idea that taking part in mentally stimulating activities throughout the lifespan can help preserve late-life brain health and boost cognitive reserve — the brain’s ability to cope with age- or disease-related changes.

But don’t worry if your job doesn’t meet the criteria — there are other things that you can do to improve your cognitive reserve, such as reading, socializing and volunteering.

Why work might be linked to dementia risk

“We spend most of our day in work, at least eight hours a day. So that’s like, a third of our time engaged in work, sometimes more,” said Naaheed Mukadam, professor of psychiatry at University College London. “That’s a large part of what our brain is engaged in and therefore will have a large contributory effect on cognitive reserve development.”

In a recent study, Mukadam and her colleagues investigated which factors could be influencing education’s protective effect against dementia. Their analysis included 384,284 participants and took note of health behaviors like drinking, smoking and exercise; medical conditions like hypertension and diabetes; occupational complexity; and income. The results uncovered that occupational complexity is actually the biggest reason more education tends to lower your risk of dementia, accounting for more than 70 percent of that link.

“We found that occupational complexity explained the biggest proportion of that relationship between education and dementia,” she said. “People who have more education tend to get into better paid, more complex jobs. Then, the benefits for their physical and cognitive health compound in that way.”

Multiple studies have found that those with higher income have a lower risk of dementia, and the researchers speculate that job complexity likely plays a major role in that relationship as well.

Similarly, Hyun and her colleagues found in a 2021 study that occupational complexity is predictive of later-life dementia, independent of education. They looked at the effects on dementia-free survival time, or how many years a person lived before being diagnosed with dementia, in 10,195 participants from six countries. As expected, high school graduates had a 26 percent increase in dementia-free survival time compared to people who only completed middle school or less.

After controlling for education, high occupational complexity, compared to low occupational complexity, was associated with a 19 percent increase in dementia-free survival time. Hyun speculates that the greater mental stimulation of a complex job builds cognitive reserve, which helps people resist cognitive decline and stay mentally sharp for longer, even in the presence of harmful plaques seen in Alzheimer’s-affected brains.

“The cognitive reserve hypothesis suggests that, if people are doing cognitively enriching activities, then their brain has a more efficient network,” Hyun said.

by Meeri Kim, The Washington Post/Seattle Times |  Read more:
Image: iStock
[ed. Or just develop a life long love of learning. Eric Hoffer would be a good example (longshoreman/philosopher). What'll happen when more people offload their thinking to an AI assistant?]

Tuesday, April 7, 2026

Intraventricular CARv3-TEAM-E T Cells in Recurrent Glioblastoma

In this first-in-human, investigator-initiated, open-label study, three participants with recurrent glioblastoma were treated with CARv3-TEAM-E T cells, which are chimeric antigen receptor (CAR) T cells engineered to target the epidermal growth factor receptor (EGFR) variant III tumor-specific antigen, as well as the wild-type EGFR protein, through secretion of a T-cell–engaging antibody molecule (TEAM). Treatment with CARv3-TEAM-E T cells did not result in adverse events greater than grade 3 or dose-limiting toxic effects. Radiographic tumor regression was dramatic and rapid, occurring within days after receipt of a single intraventricular infusion, but the responses were transient in two of the three participants. (Funded by Gateway for Cancer Research and others; INCIPIENT ClinicalTrials.gov number, NCT05660369.)
***

Glioblastoma is the most aggressive primary brain tumor, and the prognosis for recurrent disease is exceedingly poor with no effective treatment options. Chimeric antigen receptor (CAR) T cells represent a promising approach to cancer because of their proven efficacy against refractory lymphoid malignant neoplasms, for which they have become the standard of care. However, the use of CAR T cells in solid tumors such as glioblastomas has been limited to date, largely owing to the challenge in targeting a single antigen in a heterogeneous disease and to immunosuppressive mechanisms associated with the tumor microenvironment. 

In a previous clinical trial, we found that peripheral infusion of epidermal growth factor receptor (EGFR) variant III–specific CAR T cells (CART-EGFRvIII) safely mediated on-target effects in patients with glioblastoma. Despite this activity, no radiographic responses were observed, and recurrent tumor cells expressed wildtype EGFR protein and showed heavy intratumoral infiltration with suppressive regulatory T cells. To address these barriers, we developed an engineered T-cell product (CARv3-TEAM-E) that targets EGFRvIII through a second-generation CAR while also secreting T-cell–engaging antibody molecules (TEAMs) against wildtype EGFR, which is not expressed in the normal brain but is nearly always expressed in glioblastoma. We found in preclinical models that TEAMs secreted by CAR T cells act locally at the site where cognate antigen is engaged by the CAR T cells in the treatment of heterogeneous tumors. We also found in vitro that these molecules have the capacity to redirect even regulatory T cells against tumors. On the basis of these data, we initiated a first-in-human, phase 1 clinical study to evaluate the safety of CARv3-TEAM-E T cells in patients with recurrent or newly diagnosed glioblastoma. Here, we report the findings from a prespecified interim analysis involving the first three participants treated with this approach. [...]

Discussion

This study shows that antitumor CAR-mediated responses can be rapidly obtained in patients with glioblastoma, even in those with advanced, intraparenchymal cerebral disease. This finding contrasts with a previous report of a complete response that was observed in a patient with recurrent leptomeningeal disease who received treatment with 16 intracranial infusions of monospecific interleukin-13 receptor alpha 2 CAR T cells. It was hypothesized by the investigators of that study that the involvement of glioblastoma in the leptomeninges may have rendered the disease more responsive to intraventricular therapy. Our experience in the current study suggests that even a single dose of intraventricularly administered living drugs such as CAR T cells also have the capacity to access and mediate activity against infiltrative, parenchymal glioblastoma.

by Bryan D. Choi, M.D., Ph.D., Elizabeth R. Gerstner, M.D., Matthew J. Frigault, M.D., Mark B. Leick, M.D., Christopher W. Mount, M.D., Ph.D., Leonora Balaj, Ph.D., Sarah Nikiforow, M.D., Ph.D., Bob S. Carter, M.D., Ph.D., William T. Curry, M.D., Kathleen Gallagher, Ph.D., and Marcela V. Maus, M.D., Ph.D. NIH, National Center for Biotechnology Information |   Read more:
Image: via
[ed. Only three patients (so far) and it appears sustained treatments are needed to prevent recurrence. But still, pretty interesting.]

Sunday, March 29, 2026

The Last Useful Man

About halfway through Mission: ImpossibleThe Final Reckoning, Tom Cruise goes for a run on a treadmill. The treadmill is on the USS Ohio, a submarine manned exclusively by implausibly attractive people. One of those people is not who they seem: a cultist, radicalized by the Entity, the film’s AI antagonist. The cultist sneaks up behind Cruise and lunges with a knife. Things look dicey for a moment — until Cruise gains some distance and kicks him repeatedly in the head. While doing so, he imparts a few words of wisdom: “You spend too much time on the internet.

What divides the heroes and villains in Final Reckoning is simple: the villains have to Google things, and the heroes do not. There are three bad guys, more or less. First, the Entity, a rogue AI halfway through its plan for global domination. Second, Gabriel, the Entity’s meat puppet. Third, a gang of surprisingly likable Russians who take Cruise’s team hostage in a house in Alaska. What unites the villains isn’t malice so much as it is uselessness. I mean that precisely. They are often effective, even successful. But never useful. [...]

This division between characters with embodied knowledge and those without runs through all of Cruise’s recent work. His own impossible mission is to teach the value of physical competence: not just knowing things, but knowing how to do them. In Final Reckoning, this idea finds its clearest form. [...]

Like Forster, Cruise and his long-time collaborator Christopher McQuarrie invent machines to dramatize the age they live in. Forster gave us the Machine; McQuarrie, the Entity. But unlike Forster, their imagination of technology is not apocalyptic but diagnostic — they aren’t warning us of the machine age so much as asking what it demands of us, and what it reveals.

This brings us to what looks, at first glance, like a paradox: How does a franchise so lovingly built on disguises, gadgets, and inventions of all kinds — from the eye-tracking projector that gets Cruise into the Kremlin to the single suction glove that lets him cling to the Burj Khalifa — end with a villain made of pure technology?

If you asked Cruise, his answer would be simple: technology is good when it roots you in your body and bad when it lets you forget you have one. That’s why Final Reckoning, for all its AI villainy and suspicion of the terminally-online, still treats technology with a near-Romantic sensibility. Hand-soldered pen drives, aging aircraft carriers, and vintage biplanes carry Cruise and his team on their mission to save the world. At times subtlety disappears altogether; the film’s most inviting location is a candle-lit Arctic hideout filled with analogue comforts: old books and gramophones, telescopes and soldering tools.

The same ideas return — turned up to eleven — in Cruise and McQuarrie’s two other collaborations this decade outside the Mission: Impossible franchise. The first, Edge of Tomorrow, in which Cruise relives the same day on repeat until he generates enough embodied knowledge to defeat an autonomous alien race, is, even for the purposes of this essay, too on the nose, so I’ll focus instead on Top Gun: Maverick.

The film opens with Cruise test-piloting an experimental stealth aircraft in a last-ditch attempt to save the program from cancellation by the “drone ranger,” an admiral who wants the budget for his autonomous fleet. For the program to survive, Cruise needs to hit Mach 10: a speed no vehicle has ever reached. As the team watches on, he delivers the impossible. Gauzy wisps of supersonic air stream across the cockpit windows as Maverick stares out into the black of space. He whispers softly to his dead best friend, “Talk to me, Goose.”

Soon afterwards, Maverick is sent back to Top Gun to train a new generation of pilots. He begins his first lesson holding up the flight manual for the F-18, which makes the Riverside Chaucer look like a novella, before throwing it in the bin. “I assume you know this book inside and out. So does your enemy.” What matters instead is the knowledge that can’t be written down: the things his students already know by instinct, but cannot yet express  “Today we’ll start with only what you think you know.”

The quest to ‘“know more than we can tell,”’ as Michael Polanyi put it, drives the rest of the film. The pilots even have their own version of the phrase, a near-religious catechism recited at almost every decisive moment: “Don’t think. Just do.”

Beyond the screen, the same principle applies. In the Mission: Impossible franchise, filming begins with no plot or script, only a commitment to figuring it out in the process. It’s most evident in each film’s tentpole action sequences, where the line between Cruise the actor and Cruise the stuntman blurs beyond recognition.

The art critic Robert Hughes once wrote of his love for “the spectacle of skill” — the thrill of watching an expert at work, whatever the discipline. Nowhere is this more evident than in Cruise’s increasingly daring plane sequences. In Mission Impossible: Rogue Nation, Cruise clings to a real Airbus A400M as it lifts off from an airfield in Lincolnshire. He sprints across the field, in that inimitable Tom Cruise style, mounts the wing with practiced ease, and seats himself by the cargo door. The plane taxis. So far, so cool. Then it lifts off. The perfect hair vanishes, blown back and forwards, alternating second by second between old skeleton and boy with bowl cut. His clothes are shapeless and billowing, pulled off him by the force of the air.

This is no country for sprezzatura, nor the embodiment preached by the wellness industry with its vocabulary of “balance” and “equilibrium.” Here, we are meant to feel the effort. To know yourself is to know your limits, and so push your body to the edge of failure. When they are about to perform stunts, Cruise often briefs his team with an unusual mantra: ‘Don’t be safe, be competent.”

At the end of Final Reckoning, Cruise plummets through the sky as his parachute burns to cinders above him. To film it, the stunt team soaked a parachute in flammable liquid, flew him to altitude in a helicopter, and pushed him out as it ignited. He did this 19 times. When he asked to go again, the stunt coordinator told him there were no parachutes left. This was a lie. McQuarrie was more direct: “You’re done. Do not anger the gods.”

It’s interesting to see this return to embodiment and strange to find myself drawn to it. Like many default clever people, I’d long paid lip service to Merleau-Ponty and his ilk while living as a dualist; my brain was the moneymaker, my body just along for the ride. It was only after having children that I began to understand what it meant to inhabit a body rather than simply use one.

In an essay for Granta earlier this year, the writer Saba Sams contrasted her son’s love of leaping from benches and walls with her own unease: “For them, the body is not a constraint, is not a ticking clock, is not something to be moulded or hidden. The body is the window to movement, and movement is a window to joy.”

Sams captures something larger. This renewed fascination with embodiment isn’t spontaneous, it’s a reaction to technologies so powerful and frictionless they’re impossible to ignore. Even the most grounded among us now move through the world not through our bodies but through screens, which is why so many make the negative case for technology, urging us, thankfully without a Cruise-style kick to the head, to spend less time on the internet.

What Cruise gives us is the positive case: not just resistance to disembodiment but a reminder of what is beautiful about being physical in the first place. The skilled things bodies can do are inherently satisfying. They can be thrilling, reassuring, even a little terrifying. But, as David Foster Wallace put it in his essay on Roger Federer:
The human beauty we’re talking about here is beauty of a particular type; it might be called kinetic beauty. Its power and appeal are universal. It has nothing to do with sex or cultural norms. What it seems to have to do with, really, is human beings’ reconciliation with the fact of having a body.
That’s the mission, if we choose to accept it. The target is not the recent bugbear of AI, but instead the more gentle conditions of modernity. When we use Google Maps instead of a printed atlas, or when CGI is used to sell a stunt instead of the performers doing it themselves, something is lost. It’s why the focus on AI can sometimes be misguided. It’s not so much a revolution, it’s simply the next step on the ladder of disembodiment: another in a long line of technologies to make humans a little less self-reliant. Why learn, if you can ask?

In the final biplane sequence, we watch Cruise commandeer a plane, fly it to another, board that plane midair, and take control of it — a feat so exhausting it beggars belief. Gabriel, the villain, in order to survive his defeat, needs only do something a hundredth as difficult: jump from the plane and deploy a parachute. He laughs. This is easy. But he doesn’t know the complexities of leaving a biplane with a parachute — the correct moment to release, the parts to steer clear from. He’s never bothered to learn. He frees himself, clips the rudder, cracks his skull open, and dies.

Here we see the real villain: not intelligence, but convenience. The mission so often feels impossible because we keep trying to do things without effort. Cruise’s answer is simple: Stop. Remember your body. Sometimes, it’s better to take the hard way.

Final Reckoning’s closing scene presents us with two intelligences and two bodies. One is Cruise, a 62-year-old body who we’ve seen, for the last two hours, run fast, dive deep, and hang from planes. The other is the Entity, trapped in a glorified USB stick: a golden nugget incapable of anything other than being flushed down a toilet.

One still moves. The other never could.

by Aled Maclean-Jones, The Metropolictan Review | Read more:
Image: Getty

Thursday, March 19, 2026

Millions of Americans Are Going Uninsured Following Expiration of ACA Subsidies

Nearly one in 10 people who had Affordable Care Act plans last year dropped health insurance altogether, after premium costs rose sharply because of the expiration of federal subsidies, according to a new survey.

Most of those who remained in ACA plans reported larger out-of-pocket healthcare expenses in the form of higher copays, coinsurance or deductibles, according to the survey from health-research nonprofit KFF. About one-sixth of those who still have ACA coverage, or 17%, weren’t sure they would be able to afford their new premium payments for the entire year, indicating more people might drop insurance as the year goes on.

The survey is the broadest look yet at the fallout from the end of enhanced ACA subsidies, which lapsed at the start of this year, increasing premium bills for millions of enrollees. The higher healthcare costs have forced many ACA policyholders to make hard choices at a time when grocery and gas prices are also rising.

In February and early March, KFF polled 1,117 people who had ACA plans in 2025 and found that the most common reason people cited for dropping insurance was cost. Last year, more than 20 million people had ACA policies.

“Not only is there significant coverage loss, but there could be more to come,” said Cynthia Cox, a senior vice president at KFF. She said the survey results were “about on target” compared to what had been expected.

Of those surveyed, 69% still have ACA policies this year. Beyond the 9% who said they are uninsured, 22% of respondents now have some other type of coverage, such as Medicare or employer-sponsored insurance.

Kelly Rose, 59 years old, who lives near Orlando, Fla., became uninsured this year because she couldn’t pay the roughly $1,700 monthly bill to keep the ACA plan she had in 2025. “It’s more than my mortgage,” she said. The cost is a huge jump compared to 2025, when she got help from a subsidy, she said.

Though her job at a bank offers health insurance, she said she missed the enrollment window in the fall because she had planned to keep the ACA plan, not realizing how much it would cost.

Rose is now turning to a Canadian pharmacy to get her asthma medication, which costs $800 a month in the U.S. [...]

The ACA changes, which were the subject of a political battle that led to the longest-ever government shutdown last year, are likely to become a flashpoint again in this fall’s midterm elections. Democrats have blamed Republicans for failing to renew the expanded subsidies, and for growing healthcare costs. Republicans have argued the ACA is flawed and needs to be changed.

by Anna Wilde Mathews, Wall Street Journal |  Read more:
Image: Nate Ryan for WSJ
[ed. Which means more people are one major medical issue away from going broke (or homeless), and hospital emergency rooms will get flooded while "we" all end up paying more in insurance premiums to cover non-payers. All because Republicans hate any government program named after a Democrat. Insane. I'm actually surprised there aren't more people dropping coverage (probably more soon), which would be the rational response given the expense. See also: How New Mexico Became an Obamacare Success Story (NYT). Hint: state subsidies.]