Is our sleep getting worse?
I'm talking, of course, about sleep, that vital state that lets us recharge and even cleanses the day's toxins from our brains. But what happens when it doesn't come easily? And why do some people have an easier time falling and staying asleep than others?
Those are just some of the questions we answer on this week's episode of Explain It to Me , Vox's go-to hotline for all the questions you can't quite answer on your own.
To get to the root of what's keeping you up at night, we spoke with Jade Wu, a sleep psychologist who specializes in helping people with insomnia. So what constitutes a good sleeper? 'It's more complicated than you would guess, ' Wu says. 'We think of getting enough sleep as important for good sleep. But believe it or not, recently some big studies have found that the timing of your sleep can maybe matter even more.'
'If we follow middle-aged people into older age, those who sleep more at more consistent times from day-to-day have lower risk of cancer, heart disease, dementia, and overall mortality,' Wu says. 'So it's about timing, it's about quality, it's about quantity, and a host of other factors.' What are those factors? That's what we tackle this week .
Below is an excerpt of our conversation, edited for length and clarity.
You can listen to Explain It to Me on Apple Podcasts, Spotify, or wherever you get podcasts. If you'd like to submit a question, send an email to askvox@vox.com or call 1-800-618-8545.
What are the big sleep dysfunctions?
The most common problem I see is insomnia, which is just trouble falling asleep or staying asleep. And that can be from a variety of sources. A lot of times it's a life stage issue. For example, a lot of women experience sleep disruption during perimenopause and menopause.
And if you go through a job loss or you move or you go to a really fun bachelor party and you don't sleep for three nights in a row, then you find you can't get yourself back on track with sleep.
Insomnia is really in the eye of the beholder. There's not a number cutoff, like say, you take an hour to fall asleep or you have to be awake for two hours during the night to qualify. It's really if you feel like you're taking a long time to fall asleep or back to sleep, or you feel like your sleep is very restless or non-restorative. If it's been happening for more than a few weeks and it's really interfering with your functioning, then it's insomnia.
If it's been happening for more than a few weeks and it's really interfering with your functioning, then it's insomnia.
Another big issue is daytime sleepiness. This is kind of the opposite problem, where it's not that you can't fall asleep: It's that you can't stay awake really well during the day. And this can be from a variety of sources, too.
The most common is probably sleep apnea, which is a sleep disorder characterized by repeated episodes of breathing cessation or shallow breathing during sleep. And this affects everybody. It's not just older folks. It's not just people who are overweight or obese. Women actually are under-diagnosed by a significant margin — something like eight or nine out of 10 women with sleep apnea are not diagnosed. That can cause daytime sleepiness, and be a burden to your heart health and brain health. It's a really important topic that people don't pay enough attention to.
And then there are kind of more colorful sleep issues, like sleep paralysis, sleep hallucinations, sleepwalking — more of unusual things that happen at night.
We got a call from a listener named Skylar who is curious about sleep chronotypes — the time of day your body naturally winds down and falls asleep. They're a night owl and they want to know if there's a trend toward being more accommodating to people who aren't early birds.
I feel you, Skylar. I am a night owl, too, by nature. And I absolutely agree that society should be more understanding towards us night owls, because there is nothing inherently wrong with it. We all have our own chronotype: It's like height. It's kind of a bell-shaped curve. Mostly people are in the middle, and then some people are extreme morning people. Some people are extreme night owls. But society is designed by and for morning people. Those of us who are night owls struggle and we don't get to sleep at our optimal time; we often don't get enough sleep.
If you think about it evolutionarily, a tribe of early humans needed a diversity in sleep timing for everyone to stay safe. Let's say everybody fell asleep at the exact same time, slept through the night, and woke up at the same time.Then that's easy pickings for a saber-toothed tiger. We night owls should be saying, 'You're welcome' for keeping watch so the rest of you can sleep safely and soundly.
What makes someone like Skylar a night owl? What determines where on that bell curve of sleep people land?
A lot of it is genetic. Melatonin is a time-keeping hormone that our brains release. It usually ramps up in the evening, stays high through the night, and then kind of goes away in the mornings. It signals to the whole body that it's time to shut down the factories and rest and sleep, or that it's time to ramp up and get started for the day.
We night owls should be saying, 'You're welcome' for keeping watch so the rest of you can sleep safely and soundly.
For those of us who are night owls, our melatonin curve starts later and then goes away later, too. So when other people are already soundly asleep, our melatonin curves are still acting as if it's still daytime. And then in the early mornings, when other people are ready and raring to go, our melatonin is still high in our system, telling us it's still nighttime. On an individual level, there are things we can do to shift our chronotypes to better kind of fake it as a morning person and to have an easier time waking up.
What advice do you have for people like Skylar, who are night owls living in a world that's very 9-to-5?
Well, Skylar, if you can swing it, live on the East Coast and work for a company on the West Coast remotely. That's the ideal situation. I've had patients actually do that.
But if you can't swing that, the best thing is to get lots of bright light first thing in the morning. Ideally, as soon as you wake up, either use a light box or go outside. It's not enough to just open your shades or curtains. You have to actually be in broad spectrum — full sunlight for about 20 minutes. And that really helps your brain wake up and teach your circadian rhythm to start the day earlier, and to also release that melatonin earlier in the evening too.
The thing about sleep is that it's universal. Everybody needs it. But so many people have sleep problems. Why do you think it is? What is it that's so tricky about sleep?
There are so many reasons. I think we probably don't have enough time to do the whole thing. But I'd love to get on a soapbox sometime and talk about capitalism — and how that has shaped …
I love soapboxes. Yes. Climb on up there, girl.
When the Western world at least industrialized, we took on this, eight hours for work, eight hours for sleep, and eight hours for whatever you will kind of slogan. And so we started taking on expectations and constraints around our sleep that we didn't have before.
Do we sleep worse than we used to now? I think of all the screentime we have.
I imagine that we probably are a little bit worse at sleep because of everything from the 24/7 access to information we have, to little dopamine hits, to bright lights in the middle of the night, to all of these technology-enabled distractions that can really keep us up when we ought to be sleeping.
Why is getting good sleep so important? What does that do for us?
I consider it equivalent to nutrition in terms of how much it impacts our health and well-being. We really can't function well without this basic biological drive satisfied. And when it's not well satisfied, it impacts our physical health, our mental health, our performance, our functioning, our relationships, our sense of creativity, our connections with other people. It just impacts everything. See More: Even Better
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Vox
7 hours ago
- Vox
Can't commit to vegetarianism but want animals to suffer less? You've got options.
is a senior reporter for Vox's Future Perfect and co-host of the Future Perfect podcast. She writes primarily about the future of consciousness, tracking advances in artificial intelligence and neuroscience and their staggering ethical implications. Before joining Vox, Sigal was the religion editor at the Atlantic. Your Mileage May Vary is an advice column offering you a unique framework for thinking through your moral dilemmas. It's based on value pluralism — the idea that each of us has multiple values that are equally valid but that often conflict with each other. To submit a question, fill out this anonymous form. Here's this week's question from a reader, condensed and edited for clarity: I typically eat vegetarian, and have considered going fully vegan out of concern for animal welfare. But lately my on-again, off-again gastrointestinal problems have been acting up, and I've had to go back on a more restricted diet to manage my symptoms — no spice, no garlic or onions, nothing acidic, and nothing caffeinated. Sticking to a 'bland' diet is hard enough, but doing so while vegetarian is very difficult when things like tomatoes and onions and grapefruits are off the table. I know a lot of people with these issues eat fish or meat, and some medical professionals recommend drinking chicken bone broth to soothe flare-ups. I don't want to abandon my commitment to animal welfare while my gut sorts itself out, but my food options are limited right now. How should I approach this? Dear Would-Be Vegetarian, You're not alone in finding it hard to stick to a purely vegetarian diet. Only 5 percent of American adults say they're vegetarian or vegan. What's more, one study found that 84 percent of people who adopt those diets actually go back to eating meat at some point. And most of them aren't even dealing with the gastrointestinal problems you face. So, it speaks to the depth of your moral commitment that you're really wrestling with this. I'll have some concrete suggestions for you in a bit, but first I want to emphasize that how you approach the question of meat-eating will depend on your underlying moral theory. There's a classic split in moral philosophy between deontologists and utilitarians. A deontologist is someone who thinks an action is moral if it's fulfilling a duty — and we have universal duties like, 'always treat others as ends in themselves, never as means to an end.' From that perspective, killing an animal for food would be inherently morally wrong, because you're treating the animal as a means to an end. Meanwhile, a utilitarian is someone who thinks that an action is moral if it produces good consequences — and behaving morally means producing the most happiness or well-being possible, or reducing the most suffering possible. Utilitarian philosophers like Peter Singer argue that we should be reducing, and ideally eliminating, the suffering that animals endure at our hands. Deontologists and utilitarians are often pitted against each other, but they actually have one big thing in common: They both believe in a universal moral principle — whether it's 'always treat others as ends in themselves' or 'always maximize happiness.' A lot of people find that comforting, because it offers certainty about how we should act. Even if acting morally requires hard sacrifices, it's incredibly soothing to think 'If I just do X, then I'll know for sure that I'm being a good person!' But these moral theories assume that all the complexity of human life can be reduced to one tidy formula. Can it, really? Have a question you want me to answer in the next Your Mileage May Vary column? Feel free to email me at or fill out this anonymous form! Newsletter subscribers will get my column before anyone else does and their questions will be prioritized for future editions. Sign up here! Another school of philosophy — pragmatism — says we should be skeptical of fixed moral principles. Human life is so complicated, with many different factors at play in any ethical dilemma, so we should be pluralistic about what makes outcomes valuable instead of acting like the only thing that matters is maximizing a single value (say, happiness). And human society is always evolving, so a moral idea that makes sense in one context may no longer make sense in a different context. To a pragmatist, moral truths are contingent, not universal and unchanging. I think one pragmatist who can really help you out is the University of Michigan's Elizabeth Anderson. In a 2005 essay applying pragmatism to the question of eating meat, the philosopher points out that for most of human history, we couldn't have survived and thrived without killing or exploiting animals for food, transportation, and energy. The social conditions for granting animals moral rights didn't really exist on a mass scale until recently (although certain non-Western societies did ascribe moral worth to some animals). 'The possibility of moralizing our relations to animals (other than our pets),' Anderson writes, 'has come to us only lately, and even then not to us all, and not with respect to all animal species.' In other words, Anderson doesn't think there's some universal rule like 'eating animals is inherently morally wrong.' It's our social and technological circumstances that have made us more able than before to see animals as part of our moral circle. She also doesn't believe there's a single yardstick — like sentience or intelligence — by which we can judge how much of our moral concern an animal deserves. That's because moral evaluation isn't just about animals' intrinsic capacities, but also about their relationships to us. It matters whether we've made them dependent on us by domesticating them, say, or whether they live independently in the wild. It also matters whether they're fundamentally hostile to us. Killing bedbugs? Totally fine! They may be sentient, but, Anderson writes, 'We are in a permanent state of war with them, without possibility of negotiating for peace. To one-sidedly accommodate their interests…would amount to surrender.' Anderson's point is not that animals' intelligence and sentience don't matter. It's that lots of other things matter, too, including our own ability to thrive. With this pragmatic approach in mind, you can consider how to balance your concern for animal welfare with your concern for your own welfare. Instead of thinking in terms of a moral absolute that would force you into a 'purist' diet no matter the cost to you, you can consider a 'reducetarian' diet, which allows you to ease your own struggle while also taking care for animals seriously. The key thing to realize is that some types of animal consumption cause a lot less suffering than others. For one thing, if you're eating meat, try to buy the pasture-raised kind and not the kind that comes from factory farms — the huge industrialized facilities that supply 99 percent of America's meat. In these facilities, animals are tightly packed together and live under unbelievably harsh and unsanitary conditions. They're also often mutilated without pain relief: Think pigs being castrated, cows being dehorned, and hens being debeaked. Oh, and chickens have been bred to be so big that they're in constant pain; they live miserable lives from start to finish. A pasture-raised label doesn't mean an animal has been spared all of the harms of modern agriculture — it doesn't guarantee that pain relief is used for painful procedures, and farm animals across different production systems have been bred to maximize production, which can take a toll on their welfare. And of course they'll ultimately meet the same fate as those raised on factory farms — slaughter. But your goal here is to meaningfully reduce, not 100 percent eliminate, the harms. And at least pasture-raised animals have gotten to roam around in a field and engage in natural behaviors up until the end. It's a similar story for fish, by the way. More than half of the fish we eat comes from fish farms, which are basically just underwater factory farms. Wild-caught fish is not perfect — slow, suffocating deaths are common — but it's better than farmed. The caveat here is that a lot of the welfare labels you'll see on animal products are basically a con. And some certification schemes have similar names, so you have to pay close attention. If you see the label 'Certified Humane,' that's genuinely higher-welfare — but don't mistake it for 'American Humane Certified,' which is really not. And be wary of putting much stock in labels like 'cage-free' or 'free-range.' They're better than nothing, but because the terms are often ill-defined and unenforced, they're not as meaningful as you might think. Here's a good guide to separating the real deal from the advertising spin. Another classic recommendation among animal welfare advocates is to eat bigger animals — in other words, go for beef rather than chicken. That's both because of how miserable chickens' lives are on factory farms and because, as Vox's Kelsey Piper has written, it just takes way more chicken lives than cow lives to feed people. Cows are huge, producing about 500 pounds of beef apiece, while a chicken yields only a few pounds of meat. So, every year, the average American eats about 23 chickens and just over one-tenth of one cow. That said, cows take a heavier toll on the climate than chickens do, so you don't want to eat tons of beef either. The environment is also one of the key values at stake in our consumption choices, so that has to factor in, too. Of course, another possibility — to the extent that this works with your gastrointestinal issues — is to reach for low-fiber plant-based foods like tofu, seitan, and the smorgasbord of newer products now available (like Beyond and Impossible burgers). But assuming you're going to eat meat, it's a good idea to set some clear parameters and standards around your reducetarian diet. A lot of reducetarians — myself included — have fallen into the trap of saying, 'I'll reduce how much meat I eat,' but forgetting to quantify what that means. That can lead you to eat more meat than you'd intended. So it's probably better to commit to something like 'weekday vegetarian' or 'vegan before six' — you can check out the Reducetarian Foundation for suggestions. At the end of the day, remember that there's a plurality of values at stake here, and no one of them necessarily trumps all the others. If you feel that eating some meat is important for your well-being right now, and you try to do that in ways that keep suffering for animals to a minimum, I don't think you need to feel bad about that. That's because you won't be shirking your values: You'll be recognizing that your values are plural, and you're doing your best to balance between them. That may be the best any of us can really do. Bonus: What I'm reading The blogger Bentham's Bulldog recently published a piece titled ' How to cause less suffering while eating animals .' It contains some of the same recommendations I mentioned above, but the underlying ethical framework is different and it makes one recommendation I didn't: 'offsetting' your meat consumption by donating to highly effective animal charities . I worry that offsetting might create a moral hazard, as with people offsetting their carbon emissions and then potentially feeling free to fly more. But it's worth considering, particularly if you pair it with clear parameters around your reducetarian diet. This Aeon essay answers a question I've often wondered about: Why haven't other animals — say, birds — developed complex civilizations like we humans have? Why don't they build rocket ships, argue about economic policy, and play canasta? I'm grateful to the evolutionary biologist who wrote this piece for finally giving me a satisfying answer. I can't stop thinking about this post on how AI companies may have designed chatbots to play an underspecified 'helpful assistant' character who, due to being underspecified, looks to the internet for examples of how to play that role, finds tons of science fiction about cheesy robots, and thus starts to behave like a cheesy sci-fi robot (ChatGPT will say things like, 'Gee, that really tickles my circuits!'). This post is mega-long, deeply trippy, and worth reading.
The Intercept
2 days ago
- The Intercept
'A Purely Manmade Famine': How Israel Is Starving Gaza
As the Israeli government weighs, once again, expanding its genocidal military campaign in Gaza, the enclave is sliding into a full-scale famine. 'We're seeing a purely manmade famine,' says Bob Kitchen, vice president of emergencies at the International Rescue Committee. 'The Gaza Strip is surrounded by very fertile farming territory. All of the countries around Gaza have more than enough food.' This week on the Intercept Briefing, Intercept reporter Jonah Valdez speaks with Kitchen about what U.N.-backed hunger experts have called a 'worst-case scenario.' Kitchen lays out how Israel's ongoing war, combined with severe restrictions on humanitarian aid and commercial access, has created near-impossible conditions for food and medical supplies to enter Gaza — accelerating a crisis that could soon be irreversible. 'The only thing that's changed is the war, the restrictions on humanitarian aid, the restrictions on the market economy where commercial traffic can't get in,' says Kitchen. 'That's the only thing that is driving the hunger right now.' Listen to the full conversation of The Intercept Briefing on Apple Podcasts, Spotify, or wherever you listen. Transcript Jonah Valdez: Welcome to The Intercept Briefing. I'm Jonah Valdez. Since Israel began choking off aid to Gaza nearly six months ago, U.N.-backed hunger experts issued their gravest warning yet: that a worst-case famine scenario was unfolding. There are three criteria that must be met for a famine to be officially declared: widespread extreme food shortages, high levels of acute malnutrition, and the extent of malnutrition related-mortality. The first two are evident — the third is hard to confirm. But Palestinians in Gaza did not need this confirmation. At least 18,000 children have been hospitalized for acute malnutrition since the beginning of this year. Though officials say the vast majority of malnourished children can't reach medical care. At least 175 people — 92 children and 82 adults — have died of hunger in Gaza in recent weeks, according to Gaza health officials. And over 1500 people have been killed in the last few months while trying to access food — many near distribution sites that were supposed to provide safety. This is a crisis created by Israel's policy — one that aid organizations say could be solved. To help us understand what's happening on the ground and what it would take to address this crisis, we're joined by Bob Kitchen from the International Rescue Committee. He is the vice president of global emergency and humanitarian actions in the Occupied Palestinian Territories. Bob, thanks for joining us. Bob Kitchen: Thanks for having me. Jonah Valdez: So we're speaking on Wednesday, August 6th, and you've worked in humanitarian crises around the world for over two decades. How does what you're seeing in Gaza compare to other famines you've witnessed and what makes this situation unique? Bob Kitchen: Well, I was just gonna say unprecedented, 'unique' is a good term. When we see famines normally, it's normally as a result of the intersection of conflict and then some form of natural disaster, natural hazard where the man-made conflict turbocharges the effects of climate — where whether it's a drought, where food has failed, the crop has failed, where farmers can't get to market because of insecurity. What we're seeing now is not that. We're seeing a purely manmade famine where Gaza, the Gaza Strip, is surrounded by very fertile farming territory. All of the countries around Gaza have more than enough food. So the only thing that's changed is the war, the restrictions on humanitarian aid, the restrictions on the market economy where commercial traffic can't get in. That's the only thing that is driving the hunger right now. JV: And I want to ask you more about those conditions specifically. But first, could you tell us more about the work IRC is doing on the ground to help alleviate hunger and malnutrition? BK: People very rarely die of just hunger. As people get more and more hungry, their system becomes more and more prone to communicable diseases. People normally die of dehydration as a result of dirty water. So our primary focus is on distributing clean water, helping with the sanitation system — so installing and maintaining latrines, cleaning up solid waste and sewers. And then as a secondary priority that is urgent in and of itself, we're looking at nutritional screenings. So we're doing massive screening campaigns to identify particularly children who are themselves slipping into acute malnutrition, and then either helping them or referring them into inpatient care so they can try and stabilize and recover. JV: And as you alluded to, aid organizations, as you know, have been clear that this isn't a supply problem and there's enough food and medical supplies available elsewhere, but the crisis stems from the conditions that the Israeli government has created that prevent aid from reaching people who need it. Can you walk us through the specific logistical barriers your team is facing? BK: It starts with the fact that there's tens of thousands of tons of food waiting to go into Gaza — prepositioned in Jordan, in Egypt, all around, ready to go in. But before any aid is allowed into Gaza, we all have to ask for permission with the government of Israel. It's a long, bureaucratic process. And at the moment, a lot of aid is turned down. It's rejected. It's not allowed in. So for us, for example, we have multiple trucks of what's called RUTF, reinforced therapeutic feeding supplies, that we use to help particularly children, as I said, stabilize and begin the process of recovery from acute malnutrition. We have trucks full of it. We have pharmaceutical supplies ready to go, and we've been asking for permission for almost six months to bring these trucks across the border from Jordan and in through Israel, into the Gaza Strip. It would help thousands of people, particularly children, and we have not been given that permission, so they're just sitting waiting. And that is our situation, but it's mirrored across the tens, hundreds of U.N. agencies and international and local organizations that are trying to provide assistance to the 2 million civilians on the ground who have run out of food. JV: And I want to zoom in a little bit on what you said about these trucks just sitting there and you've been asking for permission for six months, you said. It's worth mentioning the Israeli government, its defenders, and the Gaza Humanitarian Foundation have all propagated this line that aid restrictions are necessary to prevent Hamas from stealing aid and they have to do this for security purposes and that the United Nations is refusing to actually distribute the aid, there's no blockage — despite ever providing evidence to back any of these claims. What do you and IRC make of these explanations and justification for the ongoing blockade? BK: Well, not to put too blunt a point on it, I think they're incorrect. I think they're wrong. I think the humanitarian community, comprised of the United Nations and international organizations like the IRC, have decades of experience working in complex war zones where resources are scant and parties to the conflict frequently try and get their hands on aid. And we have a history of being able to ensure the delivery of humanitarian assistance, food, water, medicines to civilians. We are audited all of the time, all around the world. And what's called aid diversion, where food supplies is stolen by parties to the conflict, is a big issue for auditors. They look at it and take it very seriously, and we pass with flying colors, all of these audits because we know what we're doing. What's more ironic is that we have collectively decades of experience of doing this inside Gaza. I was particularly struck in the last couple of weeks by a New York Times report where a government of Israel, an IDF person, spoke to the fact that based on their assessment there's no evidence of aid diversion. There's no evidence of aid being stolen, of it benefiting Hamas. That seems to be a pretty clear statement to the fact that the previous system run by the United Nations, run by international NGOs, were successful in getting aid through to civilians. And that has now, not completely but almost stopped and has been replaced by another system run by the Gaza Humanitarian Foundation that is struggling to feed less than a quarter of the population. And while they do it, many people are being killed. JV: Right. Right. And thanks for mentioning other coverage disputing some of the lines coming from the Israeli government. I'm wondering if there's anything else, as far as what you would want people to understand about this crisis, that isn't getting through in most media coverage. BK: I think the starting point for me is the fear of providing material support to a terror group is legitimate. But we have a proven track record that the military of Israel has said that — in its own words — is not providing material support to Hamas. And the one thing I know for sure is that you don't create terrorists by feeding very hungry children — it's the inverse. If you don't feed children, if you don't feed a population to the point where they're starving, that's where anger really festers, that's where resistance really builds. So in the overarching theory of change of defeating Hamas, this is not going to work. JV: The IRC website says, 'Gaza is not just experiencing hunger — it is enduring a slow, systematic death by starvation.' The IRC [is] also warning the Israeli government that its 'tactical pause and limited humanitarian corridors will not meaningfully alleviate Gaza's catastrophic hunger crisis.' Could you talk more again about the role the Israeli government is playing in creating and perpetuating this crisis? BK: I will do, but let me just say some things about that statement. JV: Please. BK: It's not just about food. If you reflect on what I said to start with — that people very rarely die of just hunger, it's normally complications that come alongside that. It therefore is not just food that is urgently required. It's food. It's medicine. It's oral rehydration salts to help people recover. It's IVs. It's the materials that we require to be able to give people jerry cans so they can safely store water. It's getting money, cash in to pay our staff and to buy things. Delivering aid to 2 million people who have suffered nearly two years of real violence — it takes everything that a society needs because there's nothing left inside Gaza. So under international humanitarian law, states are obliged to ensure the provision of food, medicine, and water. They're failing to do that at the moment. We're collectively failing to do that because of the restrictions that have been placed on us. But it takes a lot more than that to mitigate the risks that this population is facing after such a long time. And it's the bureaucratic impediments that we have to navigate are broad and well-seated. So requesting aid, getting aid across the primary checkpoint, close to Rafah, getting it — everything is searched, offloaded and searched, put back onto trucks. That's the first major hurdle. But then getting it into Gaza, moving it away from the 'border,' from the checkpoint, and across the territory to where so many people are still based itself is complex because there is a war going on. The pauses that have been declared are short-term. They're focused primarily in the west of the territory, which is on the opposite side of the strip from where the majority of aid is crossing. 'The only solution is an overwhelming amount of aid to go in.' So getting in through an active war zone is possible, but it's not straightforward. And then we're distributing and moving within a population of 2 million that we spent the last 15 minutes talking about extreme levels of hunger — so there is matching levels of desperation. So it is an increasingly insecure place where it is difficult to move around in trucks that have aid in with people surrounding you that are desperate, without them trying to access the aid themselves. So it is a multilayered and complex situation and frankly, the only solution is an overwhelming amount of aid to go in, in a way that is sustained. It will take months of unimpeded and free-flowing aid to catch up with the needs of people so that things can settle down. JV: Right. And you know, you mentioned the desperation. I'm wondering if you could walk us through more of those logistical challenges on the ground that continue in getting aid delivered to Palestinians. There was a stat published by the United Nations that since May, 2,604 U.N. aid trucks have entered the strip, but only a small fraction of those have actually reached their destination. And of course, I think it's worth mentioning that GHF and the Israeli government has said, well, this looting is more evidence that Hamas is doing the looting, that they're stealing aid. Talk about the desperation, the logistical challenges that these aid groups are facing. BK: So it's the right question to ask, and my answer is going to be both understandable and unacceptable at the same time. We don't tolerate crime, we don't tolerate the theft of humanitarian aid — but that's what we're facing right now. As you cross into Gaza — I was there last year, went into Gaza during the war and saw it firsthand — that as soon as the trucks cross the Israeli checkpoint and go into Gaza, they're entering a territory that no longer has law enforcement. What was provided, the police were Hamas. They have been killed. They've taken the uniforms off, they're hiding. They're no longer on the streets for sure. So what you are then faced with as a truck driver, whether you work for the commercial sector or whether you work for NGOs and U.N. agencies, is a very large number of people that are desperate, who will do almost anything to get their hands on food and other aid supplies. Whether to feed their family — that's the majority now — or whether to sell onto the market to make some food, to make some money. Now, the reality is that that crowd that I'm discussing is made up of both criminals who have organized themselves into gangs, unknown armed elements — I don't know their identity. But then there is also civilians, who are taking desperate actions because of the desperation they feel. So, writ large, it's a dangerous situation. High number of aid convoys that have gone in have been looted and others have just not been able to get into the territory because it's so dangerous. So they're able to cross the checkpoint and then they're parked up. So when [the] government of Israel say X number of trucks have passed through the checkpoint — there is a large number of trucks on any given day that are waiting to try and seek some safety before they proceed along one road that is preyed upon on a daily basis by criminals and civilians and other armed elements that are looting the trucks. So it's a very difficult situation, but I will say you can track it back to there is nothing in Gaza. There is no food, there is no commercial traffic coming in, so there's nothing on the market. Inflation is something like 700 percent. Bags of flour sell at close to a hundred dollars at the moment. People don't have any money. There's no work, they have no food. So it is both understandable and unacceptable at the same time. And the only solution is to open multiple gates so it's not just one gate and one road; and flood the Gaza Strip with food and water and medicine. So the level of desperation, the level of criminal opportunity goes down because there's things on the market and people are getting the aid they need. [BREAK] JV: Could you tell me about the major disparity between what's accessible now versus other points of the conflict, specifically during the ceasefire? We're talking GHF, Gaza Humanitarian Foundation, is operating, I believe, four aid sites right now, which is dwarfed by — BK: A drop in the ocean. JV: Right, right. BK: That's the word you're looking for — a drop in the ocean. JV: A drop in the ocean. How many aid sites were there previously? I mean, hundreds right? BK: Hundreds. UNRWA, the U.N. office for the Occupied Palestinian Territories, operated more than 100 sites for distribution. And then alongside them, organizations like the IRC and many other international groups and then Palestinian organizations had their own distribution sites. So there's a number of very bad, worrying things going on here. Number one, it is no longer an issue of the cost of food and other supplies being prohibitive on the market. It's just the fact that there is nothing on the market anymore. No matter how much money you have, you can't readily buy food off the market. So, for example, my staff on the ground in Gaza, we employ just less than 60 Palestinians on the ground — they can't find food. Their children are now starving. Two things that I have never done in the 25 years I've been in the humanitarian industry is number one: I am now serving one meal a day in the office to try desperately to give my staff some food for them to be able to survive. So I'm finding ways to afford and to import food into the Gaza Strip, specifically for my staff. I have done that in other locations where there is no food because of a natural disaster. I've done that when we're just right out in the middle of the desert. I've never done that when there is plentiful food within 25 kilometers. The other thing I'm doing is I'm opening my nutritional programs to the children of my staff. These are well-paid professionals, highly educated, receiving an NGO salary. But they can no longer find the food to be able to feed their children, and their children are officially falling into acute malnutrition. So we're having to open up our programs to our own staff children. We've never done that before. And it speaks to the desperation of the situation and how unacceptable the situation we face is. So in addition to my staff, this is being faced by people across the Gaza Strip. So you asked about the GHF distribution sites, there's some very important things that you should be aware of. Number one, we've seen a decrease from what I was just saying about there being hundreds of distribution sites to only four — which in itself is crazy to try and serve that number of people from just four sites. No wonder they have crowd control issues, no wonder it's a very dangerous situation. What is more worrying is that all of those four sites are in the south of the Gaza Strip, so people are being forced to either move permanently from the north of the Garza Strip down into the south, so there's a greater concentration of desperation, mouths to feed. There's no resources, but whatever resources there are, they're now stretched even further because of the density of the population who have walked down. And if they do try and travel down and then return, they're crossing multiple checkpoints that the government of Israel has installed, which themselves are very dangerous. So either the profile of the population is being forced to change, where people are traveling to the south to find food. Or people are taking double risks by moving down north, south across the strip, across multiple checkpoints before they even take on the danger of going to the Gaza Humanitarian Foundation sites, which themselves are extremely dangerous. JV: Could you talk more about from a health care standpoint of the actual physical toll and the health toll on the body that something like malnutrition has in the short term, in the long term, up until someone's death, or if they happen to survive it? BK: I will flag that I am neither a doctor or a nutritionist. I am proudly a generalist. So I'll tell you what I know, and this is born of working in some of the most severe food security situations around the world, but I'm not a doctor. So there's two groups that we are most concerned about. Obviously under 5s are where we really focus a lot of our attention on because of two pressures. Number one, when you've yet to reach the age of 5, your system is developing in an accelerated fashion and requires nutrition to be able to do so. So if you are starved of nutrients — of food — your development is profoundly and irreversibly impacted, so that results in wasting and stunting. So you may not be able to fulfill your potential of growth. Your organs will not develop in the way they're supposed to. So there is a chance of long-term illness. So that is profoundly serious for this population in the long term, given the number of children who are still in that developmental phase. The other pressure that young kids face is that they're so much more vulnerable to food security. They have less reserves. So if a kid under 5 doesn't get the food they need, they more rapidly move toward the danger zone of severe acute malnutrition where intervention is urgently required, and without it, they will pass away. So what that looks like for them and in a slower way for older children and then adults because of the reserves that we develop as we grow older, is that your system starts to close down. So the body prioritizes getting nutrition, nutrients to your brain. So your major organs start to close down, you are very susceptible to outbreaks and diseases that are sadly common in this type of environment. So, as I said earlier, people rarely die of just acute hunger. What they normally die of is diarrhea — acute watery diarrhea — where they're eating in unsanitary environments. The food is dirty, their hands are dirty as they're eating, or they're drinking contaminated water. That gives them — what we would see as an upset stomach — what they see is a life-threatening disease because as soon as you get acute watery diarrhea or diarrhea of any form, your system is rapidly becoming dehydrated. And that is a cause of death when you're that hungry. JV: Not to mention individuals who may have preexisting conditions. BK: Oh, for sure. JV: I'm wondering if you could say more about people with injuries from airstrikes or military operations. How it's even more— I've seen reporting [say] that it's more difficult to recover from those injuries when malnourished or lacking food. BK: I'm not a doctor, but this is not brain surgery. This is simple math. Your body requires more good nutrients to recover from injury, to rebuild bones or heal wounds, or recover even just from trauma. So when you don't have those, the healing process is slow or non-existent. And because of the trauma that your body's trying to handle and trying to keep the systems running, you have less resilience and therefore things start closing down more rapidly. It's terrible for the individuals who have already suffered violence and injuries to now not get the nutrients they need to recover. JV: Right. And in preparing for this interview, one of your colleagues mentioned that there's a real potential for a lost generation in Gaza. What does that mean? BK: They're probably referring to what I was referring to before: the children who [are] unable to develop in the way they need to, whether that's physical or brain power. Brain function is affected by lack of nutrition, lack of growth — developmental. So there's a real risk of physical constraints. But it doesn't need to be even that. It can be: We're now two years into there not being any schools. So there is a generation of children who are not only deeply traumatized, but they also don't have access to education. They don't have the ability to continue to develop, have normal relationships with other kids, [and] have normal relationships with anyone because of the violence that they're surrounded by. JV: Thanks for that. So last month, as I'm sure you know, more than 100 humanitarian aid and human rights organizations signed a letter urging for governments to act — to push the Israeli government for an immediate ceasefire and to end the siege, and immediate flood of aid. Things we've talked about here in this conversation. And I noticed that IRC was notably absent from the letter, which included other notable organizations such as Doctors Without Borders, Amnesty International, MedGlobal, CARE. I'm wondering, I just want to give you a chance to explain IRC's thinking around this issue and why IRC didn't join other aid groups in making these calls in that letter at least. BK: Yeah, it's a simple answer. Much of that letter is right on the money. We agree with it completely, but as an organization, we prioritize the continuation of delivery of services on the ground. So we've chosen to prioritize staff safety and program continuity over signing joint letters such as that one. JV: On a similar topic, as you know, some humanitarian organizations, a growing number of organizations are using the word 'genocide' to describe what's happening in Gaza. I'm wondering where does IRC stand on that? BK: We stand as a humanitarian organization. We [are] approaching 100 years of experience helping communities affected by conflict around the world. But we're a humanitarian organization rather than a human rights organization. We don't feel as though we have the mandate or expertise to be able to define, to make that decision ourselves. We'll leave that to the responsible courts and member states who have to judge that. I hope they do soon. JV: Yeah. And speaking of courts and this shift in the past week that we've been seeing in tone across the globe from the U.K., France, and Canada signaling they're ready to accept Palestinian statehood to a U.S. Senate vote last week where a record number of Democrats voted against a weapons deal with Israel. And new polls showing the majority of Americans disapprove of Israel's offensive in Gaza. I'm wondering in terms of accountability, who has the power to change the situation that we laid out, that you laid out in the conversation today, and what pressure points exist to make that happen? And more specifically, what can the U.S. government and other western governments as well as average Americans do in this moment? BK: Yeah, I think it's going to take — a very American sports term — but a full court press from all member states, international governments, to convey to the government of Israel that it's enough that 2 million civilians are suffering and are dying. And the violence on October 7 was unforgivable. But more violence is not the answer. More death is not the answer. So the only route forward is a ceasefire and the release of all of the hostages immediately. And, as we discussed before, an overwhelming flood of humanitarian aid going into Gaza to protect against more loss of life. JV: And to close, are there any final thoughts that you wanted to share? BK: Only to say thank you for your interest. It is part of what we were just discussing. The whole world needs to convey through their governments, through their elected officials, that there's been enough suffering, there's been enough loss of life, and the way forward is a ceasefire, and that needs to happen now. That won't happen unless elected officials hear from people — interested members of the population — saying enough. So they can then turn around. I think your question earlier about the U.S. government, I think the U.S. government is one of the only governments in the world that has the influence still to say to the government of Israel that we understand your suffering. We understand the need to get your people back, the hostages back, but the route forward is the ceasefire and it needs to happen now. JV: Well, thanks for joining me on the Intercept Briefing. BK: Thank you for having me. JV: That does it for this episode of The Intercept Briefing. We want to hear from you. Share your story with us at 530-POD-CAST. That's 530-763-2278. You can also email us at podcasts at the intercept dot com. This episode was produced by Laura Flynn. Sumi Aggarwal is our executive producer. Ben Muessig is our editor-in-chief. Chelsey B. Coombs is our social and video producer. Fei Liu is our product and design manager. Nara Shin is our copy editor. Will Stanton mixed our show. Legal review by Shawn Musgrave. And transcript by Anya Mehta. Slip Stream provided our theme music. You can support our work at Your donation, no matter the amount, makes a real difference. If you haven't already, please subscribe to The Intercept Briefing wherever you listen to podcasts. And tell all of your friends about us, and better yet, leave us a rating or review to help other listeners find us. Until next time, I'm Jonah Valdez. Thanks for listening.
Vox
2 days ago
- Vox
How 'the Grim Reaper effect' stops our government from saving lives
is a senior correspondent and head writer for Vox's Future Perfect section and has worked at Vox since 2014. He is particularly interested in global health and pandemic prevention, anti-poverty efforts, economic policy and theory, and conflicts about the right way to do philanthropy. Last summer, the Congressional Budget Office released a report under the unassuming name 'Budgetary Effects of Policies That Would Increase Hepatitis C Treatment.' I read it because I am the type of person who is interested in the budgetary effects of policies that would increase hepatitis C treatment. Embedded in the report, though, was a point that will be important for just about anything the federal government tries to do to save the lives of Americans. Hep C is a nasty viral infection whose effects are, for a virus, unusually long-lasting. Untreated, it causes serious liver damage over the course of decades, leading to much higher rates of cirrhosis and liver cancer, all of which is very expensive to treat. But in the 2010s, a number of extremely effective antivirals, which randomized trials show cure upwards of 95 percent of chronic infections, came on the market. Like most new drugs, these antivirals are under patent and quite expensive; as of 2020, the cost of an eight-to-twelve week course of the drugs, usually enough to cure an infection, was between $11,500 and $17,000. Yet CBO concludes that the drugs are so effective, and the costs of treating patients with hep C who haven't been cured are so massive, that expanding treatment with these drugs reduces federal spending on hep C treatment and associated complications overall. Doubling the number of Medicaid patients getting the drugs would increase federal spending by $4 billion over 10 years. But over the same decade, the federal government would save $7 billion through reduced need for treatments like liver transplants and ongoing care for chronic cases. Put like that, this starts to sound like one of the rarest discoveries in federal budgeting: a free lunch. That means a policy that is good on its own merits (saving lives and preventing debilitating chronic disease) but also saves the government money. But the most interesting part of the report to me comes at the end. 'An increase in hepatitis C treatment could also affect the federal budget in other ways—for example, by leading to improved longevity and lower rates of disability,' the authors note. The latter point is pretty straightforward: If hepatitis C leads to disabilities that make people eligible for disability insurance and subsidized health coverage, then reduced hep C means lower spending on those programs. But (and this is me speculating, so blame me and not the CBO if I'm wrong) that effect is probably swamped by that of 'improved longevity.' Simply put: curing hep C means people live longer, which means they spend more years collecting Social Security, Medicare, and other benefits. That could mean that whatever cost savings the actual hep C treatment produces might be wiped out by the fact that the people whose lives are being saved will be cashing retirement checks for longer. I like to call it the Grim Reaper effect. The US runs a large budget deficit. It also provides far more generous benefits to seniors than to children or working-age adults. Per the Urban Institute's regular report on government spending for children, the ratio of per capita spending on senior citizens to per capita spending on children is over 5 to 1. Put together, the deficit and the elder-biased composition of federal spending implies something that is equally important and macabre: helping people live longer lives will, all else being equal, be bad for the federal budget. In an increasingly aging country, hep C is not the first place where the Grim Reaper effect has been felt, and it won't be the last. I don't have an easy fix for the situation, but it feels important to at least understand. Logan's Run economics One of the first and clearest cases of this longevity dilemma in budgeting came with cigarettes. The history of mass cigarette smoking in the US is surprisingly short. Per the CDC, American adults were only smoking 54 cigarettes annually per capita as of 1900. By 1963, that number had grown to 4,345. The development of automatic rolling machines, milder forms of tobacco, and mass marketing meant millions of working and middle-class Americans became pack-a-day smokers. But while the per capita average floated around 4,000 from the late '40s to the early '70s, it then began a precipitous decline. In 2022, the most recent year for which the Federal Trade Commission released data, Americans bought 173.5 billion cigarettes, or 667 per adult, less than a sixth of the peak, while fewer than 12 percent of American adults now smoke. Cigarettes are, of course, deadly, but they kill with a lag, usually after decades of regular smoking. That meant that in the late 1980s and 1990s, the US started to hit peak cigarette deaths, as adults who came of age during the smoking era started to get lung cancer and emphysema en masse, at numbers that less-addicted subsequent generations wouldn't match. The male death rate from lung cancer peaked in 1990, and the female death rate peaked in 1998. A flurry of economic research at the time tried to make sense of what this meant for the federal budget. Smoking harms your health. But it also shortens your lifespan. A useful 1998 Congressional Budget Office report noted that most research found that, over their lives, smokers spend more in health care costs (including more that goes on the federal tab) than non-smokers, even accounting for their shorter lifespans. But that picture changed once you added in pensions and other non-health spending. Economists John Shoven, Jeffrey Sundberg, and John Bunker in 1989 estimated that the average male smoker saved Social Security $20,000 (about $60,000 today) in benefits not paid. The figure for women, who live longer than men on average but earn less in wages and thus in Social Security, was about half that. 'It seems likely that the Federal budget currently benefits from smoking,' two Congressional Research Service researchers concluded in 1994, when the 'benefits' of early death to Social Security and Medicare were included. Malcolm Gladwell, in a thoughtful 1990 treatment of the problem in the Washington Post, was catchier: 'Not Smoking Could be Hazardous to Pension System.' Decades later, the CBO did a fuller analysis of the budgetary consequences of smoking in the aftermath of the large cigarette tax increase President Obama signed in early 2009 and proposals for further hikes. At first blush, the revenue raised from a cigarette tax should be easy to estimate: multiply annual cigarette sales by the amount of the tax. But obviously raising the price of the good will reduce the amount people buy; one major reason for cigarette taxes, after all, is to deter smoking. The CBO used a price elasticity of -0.3, meaning that a 10 percent increase in cigarette prices reduces the number sold by 3 percent. But the 2012 report was meant to go a step or two further, according to then-director Doug Elmendorf, who explained the backstory in a recent conversation with me. 'The effects of making people healthier are good for those people, obviously, but also perhaps good for the federal budget because the federal government pays for a lot of health care. If you're healthier, you don't need so much health care.' But at the same time, 'It was clear that if people were healthier, they would live longer, and that could have budgetary costs. It wasn't obvious offhand what the balance of those effects would be.' The 2012 CBO report tried to put all these effects together: the effect of lower smoking on reducing health-care spending (including government-funded spending) due to a healthier population, the effect on Social Security and other benefit spending from resulting longer lifespans, the effect of lower smoking rates on wages, and tax revenue from those wages. (The latter is often not included in formal CBO scores, as it tips closer to 'dynamic' scoring where the effect of legislation on the overall economy is included.) Over the first 10 years after a hike in the cigarette tax, they found that having a healthier population was more of a blessing than a curse, budget-wise. The health effects of a cigarette tax hike reduced federal health spending by over $900 million over a decade, even after accounting for people living longer and claiming more years of Medicare. By contrast, retirement programs only spent $183 million more because people lived longer. Swamping all that was a $2.9 billion increase in tax revenue from a healthier population capable of working and earning more. But that's just the 10-year effect. As the decades pass, the effect of longevity would grow and grow. First, Medicare costs would start to rise, as the cost of a longer-lived population began to swamp the cost savings of that population being healthier overall. (Even people who've been healthy for a long time can run up major health spending at the end of their now longer lives.) Social Security costs would keep rising, too. Fifty years in, these costs would overwhelm the benefits, and the cigarette tax's health effects would start costing the budget, on average. The point isn't 'cigarette taxes are good' or 'cigarette taxes are bad.' The point is that even a policy that saves lives isn't necessarily a slam dunk from the hard-eyed perspective of budget policy. Recent years provided a possibly even darker example. In 2022, the Medicare Trustees pushed back the date they expected the program's Hospital Insurance Trust Fund to be depleted by two years. They had several reasons, but a major one was that Covid-19 had killed hundreds of thousands of Medicare patients prematurely. Not only that, but 'Medicare beneficiaries whose deaths were identified as related to COVID had costs that were much higher than the average Medicare beneficiary prior to the onset of the pandemic.' Put another way: Covid killed off Medicare's sickest, and most expensive, enrollees. That meant the program was left with an overall healthier population, which by itself lowered medical costs by 2.9 percent in 2021. Similarly, a paper by a team of health economists earlier this year estimated that the 1.4 million excess deaths in the US due to Covid had the net effect of boosting the Social Security trust fund to the tune of $156 billion. That represented $219 billion in benefits that no longer needed to be sent, minus $44 billion in lower payroll tax revenues and $25 billion in new benefits to surviving family members. It all reminds one of Logan's Run, in which people are killed off upon hitting age 30 lest they take up too many of society's resources. That movie is a dystopia — but as a budget proposal, it'd score very well. It's good to save lives, actually The economists and agencies doing this math are, of course, only doing their jobs. We need to know what government programs will cost over the near- and long-run. These effects on health and life and death matter to those calculations. 'Members of Congress regularly thought that we were ghoulish for talking about how, if people live longer, there'll be higher benefits for Social Security,' Elmendorf recalls. 'But it's not ghoulish. Obviously, we want to live longer and members of Congress should try to help all Americans live longer. CBO's job — an analyst's job in general — is just to be honest about the likely effects.' But the fact that increased human longevity on its own worsens the budget picture should lead to some reflection. For one thing, it suggests that sometimes we should embrace policies simply because they're the right thing to do, even if they don't pay for themselves. Recall the hepatitis C treatments that prevent expensive long-term expenses for Medicaid, but might add on new costs by extending the benefits' lifespans. It's possible that, upon taking the latter into account, expanding access to hep C drugs costs the government money on net. It's a free lunch no longer. That's not a reason not to embrace the policy, though. Lots of things the government does cost money. The military doesn't pay for itself. K–12 schools don't pay for themselves. Smithsonian Museums don't pay for themselves. That doesn't mean those aren't important functions that it makes sense to put some of our tax dollars toward. Hep C treatment, I think, fits in that list, even if it's not literally free from a budget standpoint. Congress should also allow agencies like the CBO to do more to symmetrically account for the positive budgetary effects of longevity, along with the negatives. People who live longer, after all, often earn wages in those new years of life, wages that generate income and payroll tax revenues for the federal government. Moreover, people at the end of their careers are earning more money and hence paying more taxes than young people, meaning life extension helping people in their 50s and 60s might be especially good for tax revenue. The problem is that the CBO generally considers 'how many workers paying taxes are there' to be an economic effect and only considers it in special 'dynamic' scores of legislation, in which the economic consequences of them are taken into account. Dynamic scoring has been a topic of great controversy for decades, going back at least to the Bush II administration, but the rule Congress sets for CBO on when to use dynamic scoring results in CBO applying dynamic scoring very rarely in practice. A middle ground option, though, would be something called 'population change' scoring, in which CBO considers the direct effects of a change in the population (through longer lifespans, say, or immigration) on the level of employment and tax revenue, without doing a full, more complicated dynamic score. That would make its accounting of the effects of longer lives less biased: the budgetary benefits would be counted alongside the costs. We should also consider the aspects of our budget situation that make the longevity effect a reality. One is the US's long-standing, bipartisan choice to run massive budget deficits, even during relative boom times. One arithmetic consequence of that choice is that it makes the continued existence of every American a net loss for the country's books. That's not the main reason to avoid large deficits during booms, but it's a somewhat toxic byproduct all the same. The other aspect driving this effect is the choice to invest government resources very heavily in seniors relative to other age groups. This is due in large measure to the US choice to provide universal health care for seniors but not other age groups, and due to our lack of investment in very young children and working-age adults compared to other rich nations. There is no law of nature saying the US has to weigh its priorities that way. As long as we do, the numbers will imply that it's better for the budget for people to die before they get old.
