Researchers who followed patients for 10 years after they received either the actual procedure, arthroscopic knee surgery to trim degenerative cartilage tears, or merely “sham surgery” — a skin incision — for knee pain, found that the surgery provided little or no benefit and was, in fact, associated with accelerated osteoarthritis and higher rates of reoperation. That generally meant a total knee replacement.

“I don’t know how I would defend this procedure at all,” said one of the study’s authors, Teppo Järvinen, an orthopedist and the head of the Finnish Centre for Evidence-Based Orthopaedics. “What has been shown dramatically is that patients who have this procedure have more pain — they do worse. All the scores pointed in the same direction.”

Järvinen , published in April in the New England Journal of Medicine, was the first to show the surgery left many patients worse off. Though the study was small, the results were compelling, he said, because his team picked the patients “most likely to benefit.”

The study does not apply to cartilage tears incurred from an acute pain-causing injury. It included subjects middle-aged or older who were experiencing knee pain and whose MRIs showed cartilage tears.

Evidence has been accumulating steadily for over a decade that arthroscopic knee surgery to shave torn, degenerative cartilage does not help more than physical therapy. Arthroscopic rates in Finland have dropped 90%, Järvinen said. They have been falling in the U.S., too, but at a far slower rate.

One in the U.S., which counted over 2 million meniscus surgeries from 2010 to 2020, found the number decreased by about 4% each year. Most procedures were performed on women and patients in their 50s.

In the traditional Medicare fee-for-service program, the number of procedures has declined steadily in recent years, from about 169,000 in 2014 to 91,000 in 2024, shows. These figures do not include beneficiaries in Medicare Advantage, private insurance plans that cover more than half of Medicare enrollees.

Prior studies of scans have found that in people over 50, the result of wear and tear and often not painful.

“Nothing supports the idea that a patient’s pain comes from the meniscus,” Järvinen said.

Robert Brophy, director of the Orthopaedic Clinical Research Center at Washington University in St. Louis, said that “evidence is growing for judicious use of this surgery in this population.” But, he noted, “many patients do benefit.”

All the same, he acknowledged that current practice among his peers is “all over the map.” For example, that surgery for meniscus tears in the Medicare population is far more common in the South than in the Northeast.

A massive study committee of orthopedic societies in Europe and the U.S. last June released a noting that “degenerative meniscus lesions can be treated with comparable results with either non-operative (including physical therapy) or surgical approach.” It recommended a trial of physical therapy before surgery but still endorsed the operation.

A concerted campaign by orthopedic specialty societies called the has been ongoing for years. The group advocates for protecting and maintaining long-term knee health through nonsurgical treatments, surgical repair, and other therapies.

One inherent issue in all medical specialties is that appropriate treatment is often in the eye of the physician beholder, meaning that specialists create the guidelines for when a treatment is in order. And financial considerations may influence that decision, Järvinen said.  

In the U.S., physician payments are decided by the , or RUC, a committee of the American Medical Association composed largely of specialists. Department of Health and Human Services Secretary Robert F. Kennedy Jr. and his advisers have reportedly wresting control of that committee from the association, though it’s not clear how that could be done, since the AMA owns the billing codes used to calculate patients’ charges.

Arthroscopic takes 30 to 60 minutes in the operating room, and the patients spend a few hours recovering in a surgery center or in a hospital outpatient department. Medicare allots on average $2,159 to $3,875 for the procedure, depending on where it is performed; patients pay 20% of the fee as coinsurance. There may be additional costs, for example, if more than one doctor is involved in the procedure. Commercial insurers average well more than twice that, said Marcus Dorstel, a senior vice president at the data analytics firm Turquoise Health, adding that the amount providers charge for the procedure varies widely. Those charges do not include the fees of the surgeons and the anesthesiologist.

Treating chronic knee pain has a variegated history.

Fifty years ago, the treatment for cartilage tears, from acute injury or from wear and tear, was to remove the entire piece of cartilage. At that time, doctors did not consider it a shock absorber but a useless, vestigial piece of tissue like the appendix.

Today, the first-line therapy for a painful knee with degenerative tears is physical therapy and, for some people, weight loss. Then there is arthroscopic surgery, depending on the view of the surgeon about its utility.

There is also a menu of injections: Steroids have proved scientifically valuable in the short term. And injections of stem cells and plasma-rich protein are widely offered but are controversial — and not covered by most insurance — because studies have been at best inconclusive about their benefit.

And as orthopedists are backing away from shaving off meniscus tears, they are highlighting a newer procedure — sewing the torn cartilage back into a whole. But that is typically an option for patients under 50 with acute injuries and clean tears, and it is unclear exactly which patients might benefit.

When all else fails, there’s a different surgery that’s also a big moneymaker for hospitals and doctors: knee replacement.

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“It’s a very weird time in our lives,” said Kasen, executive director of the .

Last November, a group of people were captured on surveillance video early one morning mocking a “Black Lives Matter” sign in the front window of the center, with one of them vandalizing its free pantry. That same fall, Women’s Center staff reported being harassed.

A couple of blocks down East Michigan Avenue, Strange Matter Coffee, which supports progressive causes in the community, has been confronted by “” outside its storefront. Some toted guns or cameras, sometimes chanting slogans supporting President Donald Trump, generally unnerving customers and staff, Kasen said.

In many cases, throughout the U.S. over the past few years have been driven by the deepening and disinformation-driven rebellion against responses to the covid-19 pandemic. More recently, backlash against immigration and diversity, equity, and inclusion initiatives has heightened tensions.

Last year, the documented nationwide sowing unrest through a wide range of tactics, sometimes violent. Over the last several years, the group writes, the political right has increasingly shifted toward “an authoritarian, patriarchal dedicated to eroding the value of inclusive democracy and public institutions.”

Researchers at American University’s , or PERIL, say that in online spaces, “hate is intersectional.” (For example, Pasha Dashtgard, PERIL’s director of research, explains, platforms dedicated to male supremacy are often also decidedly antisemitic.) Seemingly innocuous discussions erupt into vitriol: The release of “A Minecraft Movie” prompted tirades against an alleged trend toward casting Black women and nonbinary people.

The continued escalations drove staffers at PERIL and the Southern Poverty Law Center to approach the problem from a different angle: Treat extremism as a public health problem. are now operating in Lansing, Michigan, and Athens, Georgia, offering training, support, referrals, and resources to communities affected by hate, discrimination, and supremacist ideologies and to people susceptible to radicalization, with a focus on young people.

The team defines extremism as the belief that one’s group is in direct and bitter conflict with another of a different identity — ideology, race, gender identity or expression — fomenting an us-versus-them mentality mired in the conviction that resolution can come only through separation, domination, or extermination.

Researchers who study extremism say that, as the federal government terminates grants for violence prevention, state governments and local communities are recognizing they’re on their own. (CARE receives no federal funding.)

Aaron Flanagan, the Southern Poverty Law Center’s deputy director of prevention and partnerships, said his organization and PERIL came together about five years ago to examine a shared research question: What would it take to create a nationally scalable model to prevent youth radicalization, one that’s rooted in communities and provides solutions residents trust?

They looked to a decades-old German counterextremism model called mobile advisory centers. The objective is to equip “all levels of civil society with the skills and knowledge to recognize extremism” and to engage in conversations about addressing it, Dashtgard said.

“We’re not about, ‘How do you respond to a group of Patriot Front people marching through your town?’” Pete Kurtz-Glovas, who until June served as PERIL’s deputy director of regional partnerships, explained during a training in January. “Rather, ‘How do you respond when your son or a member of your congregation expresses some of these extremist ideas?’”

Michigan has long been considered . Timothy McVeigh and Terry Nichols, convicted of the bombing of a federal building in Oklahoma City in 1995, were associated with a militia group in the state. Some of the men charged in 2020 in the plot to had ties to a militia group calling itself the Wolverine Watchmen.

The state’s capital city and adjacent East Lansing, where Michigan State University is, are relatively progressive but have seen conflict.

Will Verchereau has a vivid recollection from the early days of the pandemic: a pickup truck speeding down the street in their Lansing neighborhood, a Confederate flag flying from it, music blasting, later joining a rolling protest that clogged streets around the Capitol to protest Whitmer’s covid lockdown directives.

Incrementally, the community has responded to these expressions of extremism. After the confrontations at Strange Matter Coffee, Verchereau, a board member of the , which advocates for and supports the LGBTQ+ community, said people banded together to talk about “how to be safe in those moments; how to de-escalate when and where possible.”

The CARE initiative reinforces such efforts. The centers offer tool kits catered to specific audiences. Among them are a to online radicalization, a , and “.”

Flanagan said the team views this public health model as separate from but complementary to law enforcement interventions. The goal is to have law enforcement as minimally engaged as possible — to detect nascent warning signs and address them before police get involved.

The resources help identify conditions that can make people more susceptible to manipulation by extremists, such as unaddressed behavioral health issues and vulnerabilities, including having experienced trauma or the loss of a loved one.

Lansing resident Erin Buitendorp witnessed protesters, some of them armed, flood the state Capitol building during the pandemic over lockdown and masking orders. She’s a proponent of the public health approach. It’s “providing people with agency and a strategy to move forward,” she said. It’s a way to channel energy “and feel like you can actually create change with community.”

Lansing and Athens were chosen for a number of reasons, including their proximity to universities that could serve as partners — and to rural communities.

In the small town of Howell, 40 miles southeast of Lansing, outside a production of the play “The Diary of Anne Frank” at an American Legion post.

In nearby DeWitt, the local school district proposed a mini lesson on pronouns for a first grade class that involved reading the picture book “They She He Me: Free to Be!” Threats against school staff followed and officials canceled the lesson. Since then, the CARE team has helped provide support to teachers there in holding conversations on contentious topics in classrooms and in dealing with skeptical parents.

“It’s really important that rural communities not be left behind,” Flanagan said. “They persistently are in America, and then they’re often simultaneously demonized for some of the most extreme, or extremist, political problems and challenges.”

The CARE team hopes to expand its program nationwide. Similar public health initiatives have been launched elsewhere, including Boston Children’s Hospital’s and the , run by New York City’s Citizens Crime Commission.

And in June a new tool, the , went live, offering guidance to help prevent violent extremism.

Pete Simi, a professor of sociology at Chapman University and a leading expert on extremism, sees a daunting task ahead, with extremism’s having become more mainstream over the past 25 years. “It’s just devastating,” he said. “It’s really startling.”

Simi said that while there was previously talk of shifts in the Overton window, the range of ideas considered politically acceptable to mainstream society, “I would say now it has been completely shattered.” Violent extremists now feel “unshackled, supported by a new administration that has their back.”

“We are in a more dangerous time now than any other in my lifetime,” Simi said.

The Rev. Pippin Whitaker ministers the Unitarian Universalist Fellowship of Athens in Georgia, which last year received a package of ammunition in the mail with no note included. She embraces framing extremism, and people’s lack of awareness of it, as a public health issue.

“If you have a germ out there,” Whitaker said, “and people aren’t aware that if you wash your hands you can protect yourself, and that it’s an actual problem, you won’t enact basic protective behavior.”

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“She had problems falling asleep, and she’d wake up in the middle of the night,” he said. “So her daughter brought her some sleep gummies” — edible cannabis candies.

“She tried a gummy after dinner and waited half an hour,” Han said.

Feeling no effects, she took another gummy, then one more — a total of four over several hours.

Han advises patients who are trying cannabis to “start low; go slow,” beginning with products that contain just 1 or 2.5 milligrams of tetrahydrocannabinol, or THC, the psychoactive ingredient that many cannabis products contain. Each of the four gummies this patient took, however, contained 10 milligrams.

The woman started experiencing intense anxiety and heart palpitations. A young person might have shrugged off such symptoms, but this patient had high blood pressure and atrial fibrillation, a heart arrhythmia. Frightened, she went to an emergency room.

Lab tests and a cardiac work-up determined the woman wasn’t having a heart attack, and the staff sent her home. Her only lingering symptom was embarrassment, Han said. But what if she’d grown dizzy or lightheaded and was hurt in a fall? He said he has had patients injured in falls or while driving after using cannabis. What if the cannabis had interacted with the prescription drugs she took?

“As a geriatrician, it gives me pause,” Han said. “Our brains are more sensitive to psychoactive substances as we age.”

Thirty-nine states and the District of Columbia now for medical reasons, and in 24 of those states, as well as the district, is also legal. As older adults’ use climbs, “the benefits are still unclear,” Han said. “But we’re seeing more evidence of potential harms.”

A wave of recent research points to reasons for concern for older users, with cannabis-related emergency room visits and hospitalizations rising, and a Canadian study finding an association between such acute care and subsequent dementia. Older people are more apt than younger ones to try cannabis for therapeutic reasons: to relieve chronic pain, insomnia, or mental health issues, though evidence of its effectiveness in addressing those conditions remains thin, experts said.

In an published June 2 in the medical journal JAMA, Han and his colleagues reported that “current” cannabis use (defined as use within the previous month) had jumped among adults age 65 or older to 7% of respondents in 2023, from 4.8% in 2021. In 2005, he pointed out, fewer than 1% of older adults reported using cannabis in the previous year.

What’s driving the increase? Experts cite the steady march of state legalization — use by older people is highest in those states — while surveys show that the of cannabis use has declined. One national survey found that a growing it safer to smoke cannabis daily than cigarettes. The authors of the study, in JAMA Network Open, noted that “these views do not reflect the existing science on cannabis and tobacco smoke.”

The cannabis industry also markets its products to older adults. The Trulieve chain gives a 10% discount, both in stores and online, to those it calls “wisdom” customers, 55 or older. Rise Dispensaries ran a yearlong cannabis education and empowerment program for two senior centers in Paterson, New Jersey, including field trips to its dispensary.

The industry has many satisfied older customers. Liz Logan, 67, a freelance writer in Bronxville, New York, had grappled with sleep problems and anxiety for years, but the conditions grew particularly debilitating two years ago, as her husband was dying of Parkinson’s disease. “I’d frequently be awake until 5 or 6 in the morning,” she said. “It makes you crazy.”

Looking online for edible cannabis products, Logan found that gummies containing cannabidiol, known as CBD, alone didn’t help, but those with 10 milligrams of THC did the trick without noticeable side effects. “I don’t worry about sleep anymore,” she said. “I’ve solved a lifelong problem.”

But studies in the United States and Canada, which use for adults nationally in 2018, show climbing rates of cannabis-related health care use among older people, both in and in hospitals.

In California, for instance, cannabis-related by those 65 or older rose, to 395 per 100,000 visits in 2019 from about 21 in 2005. In Ontario, acute care (meaning emergency visits or hospital admissions) resulting from cannabis use increased fivefold in middle-aged adults from 2008 to 2021, and more than .

“It’s not reflective of everyone who’s using cannabis,” cautioned Daniel Myran, an investigator at the Bruyère Health Research Institute in Ottawa and lead author of the Ontario study. “It’s capturing people with more severe patterns.”

But since other studies have shown among some cannabis users with heart disease or diabetes, “there’s a number of warning signals,” he said.

For example, a disturbing proportion of older veterans who currently use cannabis , a recent JAMA Network Open study found.

As with other substance use disorders, such patients “can tolerate high amounts,” said the lead author, Vira Pravosud, a cannabis researcher at the Northern California Institute for Research and Education. “They continue using even if it interferes with their social or work or family obligations” and may experience withdrawal if they stop.

Among 4,500 older veterans (with an average age of 73) seeking care at Department of Veterans Affairs health facilities, that more than 10% had reported cannabis use within the previous 30 days. Of those, 36% fit the criteria for mild, moderate, or severe , as established in the Diagnostic and Statistical Manual of Mental Disorders.

VA patients differ from the general population, Pravosud noted. They are much more likely to report substance misuse and have “higher rates of chronic diseases and disabilities, and mental health conditions like PTSD” that could lead to self-medication, she said.

Current VA policies don’t require clinicians to ask patients about cannabis use. Pravosud thinks that they should.

Moreover, “there’s increasing evidence of a potential effect on memory and cognition,” said Myran, citing his team’s study of Ontario patients with cannabis-related conditions going to emergency departments or being admitted to hospitals.

Compared with others of the same age and sex who were seeking care for other reasons, these patients (ages 45 to 105) had 1.5 times the risk of a dementia diagnosis within five years, and 3.9 times the risk of that for the general population.

Even after adjusting for chronic health conditions and sociodemographic factors, those seeking acute care resulting from cannabis use had a 23% than patients with noncannabis-related ailments, and a 72% higher risk than the general population.

None of these studies were randomized clinical trials, the researchers pointed out; they were observational and could not ascertain causality. Some cannabis research doesn’t specify whether users are smoking, vaping, ingesting or rubbing topical cannabis on aching joints; other studies lack relevant demographic information.

“It’s very frustrating that we’re not able to provide more individual guidance on safer modes of consumption, and on amounts of use that seem lower-risk,” Myran said. “It just highlights that the rapid expansion of regular cannabis use in North America is outpacing our knowledge.”

Still, given the health vulnerabilities of older people, and the far greater potency of current cannabis products compared with the weed of their youth, he and other researchers urge caution.

“If you view cannabis as a medicine, you should be open to the idea that there are groups who probably shouldn’t use it and that there are potential adverse effects from it,” he said. “Because that is true of all medicines.”

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When she tried to call her other dog, “I couldn’t speak,” she said. As she walked downstairs to let them into the yard, “I noticed that my right hand wasn’t working.”

But she went back to bed, “which was totally stupid,” said Kramer, now 54, an office manager in Muncie, Indiana. “It didn’t register that something major was happening,” especially because, reawakening an hour later, “I was perfectly fine.”

So she “just kind of blew it off” and went to work.

It’s a common response to the neurological symptoms that signal a TIA, a transient ischemic attack or ministroke. At least experience one each year, with the incidence .

Because the symptoms disappear quickly, usually within minutes, people don’t seek immediate treatment, putting them at high risk for a bigger stroke.

Kramer felt some arm tingling over the next couple of days and saw her doctor, who found nothing alarming on a CT scan. But then she started “jumbling” her words and finally had a relative drive her to an emergency room.

By then, she could not sign her name. After an MRI, she recalled, “my doctor came in and said, ‘You’ve had a small stroke.’”

Did those early-morning aberrations constitute a TIA? Might a 911 call and an earlier start on anticlotting drugs have prevented her stroke? “We don’t know,” Kramer said. She’s doing well now, but faced with such symptoms again, “I would seek medical attention.”

Now, a large epidemiological study by researchers at the University of Alabama-Birmingham and the University of Cincinnati, published in JAMA Neurology, points to another : Over five years, study participants’ performance on cognitive tests after a TIA drops as steeply as it does among victims of a full-on stroke.

“If you have one stroke or one TIA, with no other event over time and no other change in your medical status, the rate of cognitive decline is the same,” said Victor Del Bene, a neuropsychologist and lead author of the study.

An by Eric Smith, a neurologist at the University of Calgary, was pointedly headlined “Transient Ischemic Attack — Not So Transient After All!”

The study showed that even if the symptoms resolve — typically within 15 minutes to an hour — TIAs set people on a different cognitive slope later in life, Smith said in an interview: “a long-lasting change in people’s cognitive ability, possibly leading to dementia.”

The study, analyzing findings from data on more than 30,000 participants, followed three groups of adults age 45 or older with no history of stroke or TIA. “It’s been a hard group to study because you lack the baseline data of how they were functioning prior to the TIA or stroke,” Del Bene said.

With this longitudinal study, however, researchers could separate those who went on to have a TIA from a group who went on to suffer a stroke and also from an asymptomatic control group. The team adjusted their findings for a host of demographic variables and health conditions.

Immediately after a TIA, “we don’t see an abrupt change in cognition,” as measured by cognitive tests administered every other year, Del Bene said. The stroke group showed a steep decline, but the TIA and control group participants “were more or less neck and neck.”

Five years later, the picture was different. People who had experienced TIAs were cognitively better off than those who had suffered strokes. But both groups were experiencing cognitive decline, and at equally steep rates.

After accounting for various possible causes, the researchers concluded that the cognitive drop reflected not demographic factors, chronic illnesses, or normal aging, but the TIA itself.

“It’s not dementia,” Del Bene said of the decline after a TIA. “It may not even be mild cognitive impairment. But it’s an altered trajectory.”

Of course, most older adults do have other illnesses and risk factors, like heart disease, diabetes, or smoking. “These things together work synergistically to increase the risk for cognitive decline and dementia over time,” he said.

The findings reinforce long-standing concerns that people experiencing TIAs don’t respond quickly enough to the incident. “These events are serious, acute, and dangerous,” said Claiborne Johnston, a neurologist and chief medical officer of Harbor Health in Austin, Texas.

After a TIA, neurologists put the risk of a subsequent stroke within 90 days at 5% to 20%, with half that risk occurring in the first 48 hours.

“Feeling back to normal doesn’t mean you can ignore this, or delay and discuss it with your primary care doctor at your next visit,” Johnston said. The symptoms should prompt a 911 call and an emergency room evaluation.

How to recognize a TIA? Tracy Madsen, an epidemiologist and emergency medicine specialist at the University of Vermont, promotes the BE FAST acronym: balance loss, eyesight changes, facial drooping, arm weakness, speech problems. The “T” is for time, as in don’t waste any.

“We know a lot more about how to prevent a stroke, as long as people get to a hospital,” said Madsen, vice chair of an American Heart Association committee that, in 2023, for TIAs.

The statement called for more comprehensive and aggressive testing and treatment, including imaging, risk assessment, anticlotting and other drugs, and counseling about lifestyle changes that reduce stroke risk.

Unlike other urgent conditions, a TIA may not look dramatic or even be visible; patients themselves have to figure out how to respond.

Karen Howze, 74, a retired lawyer and journalist in Reno, Nevada, didn’t realize that she’d had several TIAs until after a doctor noticed weakness on her right side and ordered an MRI. Years later, she still notices some effect on “my ability to recall words.”

Perhaps “transient ischemic attack” is too reassuring a label, Johnston and a co-author argued in in JAMA. They suggested that giving a TIA a scarier name, like “minor ischemic stroke,” would more likely prompt a 911 call.

The experts interviewed for this column all endorsed the idea of a name that includes the word “stroke.”

Changing medical practice is “frustratingly slow,” Johnston acknowledged. But whatever the nomenclature, keeping BE FAST in mind could lead to more examples like Wanda Mercer, who shared her experience in .

In 2018, she donated at the bloodmobile outside her office in Austin, where she was a systems administrator for the University of Texas, then walked two blocks to a restaurant for lunch. “Waiting in line, I remember feeling a little lightheaded,” she said. “I woke up on the floor.”

Reviving, she assured the worried restaurant manager that she had merely fainted after giving blood. But the manager had already called an ambulance — this was smart move No. 1.

The ER doctors ran tests, saw no problems, gave Mercer intravenous fluids, and discharged her. “I began to tell my colleagues, ‘Guess what happened to me at lunch!’” she recalled. But, she said, she had lost her words: “I couldn’t articulate what I wanted to say.”

Smart move No. 2: Co-workers, , called the EMTs for the second time. “I was reluctant to go,” Mercer said. “But they were right.” This time, emergency room doctors diagnosed a minor stroke.

Mercer has had no recurrences. She takes a statin and a baby aspirin daily and sees her primary care doctor annually. Otherwise, at 73, she has retired to an active life of travel, pickleball, running, weightlifting, and book groups.

“I’m very grateful,” she said, “that I have a happy story to tell.”

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Americans’ health has long been unequal, but shows that the disparity between the life expectancies of different populations has nearly doubled since 2000. “This is like comparing very different countries,” said Tom Bollyky, director of the global health program at the Council on Foreign Relations and an author of the study.

Called “Ten Americas,” the analysis published late last year in The Lancet found that “one’s life expectancy varies dramatically depending on where one lives, the economic conditions in that location, and one’s racial and ethnic identity.” The worsening health of specific populations is a key reason the country’s — at 75 years for men and 80 for women — is the shortest among wealthy nations.

To deliver on pledges from the new Trump administration to make America healthy again, policymakers will need to fix problems undermining life expectancy across all populations.

“As long as we have these really severe disparities, we’re going to have this very low life expectancy,” said Kathleen Harris, a sociologist at the University of North Carolina. “It should not be that way for a country as rich as the U.S.”

Since 2000, the average life expectancy of many American Indians and Alaska Natives has been steadily shrinking. The same has been true since 2014 for Black people in low-income counties in the southeastern U.S.

“Some groups in the United States are facing a health crisis,” Bollyky said, “and we need to respond to that because it’s worsening.”

Heart disease, car fatalities, diabetes, covid-19, and other common causes of death are directly to blame. But research shows that the , their behaviors, and their environments heavily influence why some populations are at higher risk than others.

Native Americans in the West — defined in the “Ten Americas” study as more than a dozen states excluding California, Washington, and Oregon — were among the poorest in the analysis, living in counties where a person’s annual income averages below about $20,000. Economists have shown that people with low incomes generally .

Studies have also linked the stress of poverty, to detrimental coping behaviors like and And reservations often lack grocery stores and , which makes it hard to buy and cook healthy food.

About 1 in 5 Native Americans in the Southwest don’t have health insurance, according to a . Although the Indian Health Service provides coverage, the report says the program is weak due to chronic underfunding. This means people may delay or skip treatments for chronic illnesses. Postponed medical care contributed to the outsize toll of covid among Native Americans: About 1 of every died of the disease at the peak of the pandemic.

“The combination of limited access to health care and higher health risks has been devastating,” Bollyky said.

At the other end of the spectrum, the study’s category of Asian Americans maintained the longest life expectancies since 2000. As of 2021, it was 84 years.

Education may partly underlie the reasons certain groups live longer. “People with more education are more likely to seek out and adhere to health advice,” said Ali Mokdad, an epidemiologist at the Institute for Health Metrics and Evaluation at the University of Washington, and an author of the paper. Education also offers more opportunities for full-time jobs with health benefits. “Money allows you to take steps to take care of yourself,” Mokdad said.

The group with the highest incomes in most years of the analysis was predominantly composed of white people, followed by the mainly Asian group. The latter, however, maintained the highest rates of college graduation, by far. About half finished college, compared with fewer than a third of other populations.

The study suggests that education partly accounts for differences among white people living in low-income counties, where the individual income averaged less than $32,363. Since 2000, white people in low-income counties in southeastern states — defined as those in Appalachia and the Lower Mississippi Valley — had far lower life expectancies than those in upper midwestern states including Montana, Nebraska, and Iowa. (The authors provide details on how the groups were defined and delineated in .)

Opioid use and HIV rates didn’t account for the disparity between these white, low-income groups, Bollyky said. But since 2010, more than 90% of white people in the northern group were high school graduates, compared with around 80% in the southeastern U.S.

The education effect didn’t hold true for Latino groups compared with others. Latinos saw lower rates of high school graduation than white people but lived longer on average. This long-standing trend recently changed among Latinos in the Southwest because of covid. Hispanic or Latino and Black people were as likely to die from the disease.

On average, Black people in the U.S. have long experienced worse health than other races and ethnicities in the United States, except for Native Americans. But this analysis reveals a steady improvement in Black people’s life expectancy from 2000 to about 2012. During this period, the gap between Black and white life expectancies shrank.

This is true for all three groups of Black people in the analysis: Those in low-income counties in southeastern states like Mississippi, Louisiana, and Alabama; those in highly segregated and metropolitan counties, such as Queens, New York, and Wayne, Michigan, where many neighborhoods are almost entirely Black or entirely white; and Black people everywhere else.

Better drugs to treat high blood pressure and HIV help account for the improvements for many Americans between 2000 to 2010. And Black people, in particular, saw steep rises in high school graduation and gains in college education in that period.

However, progress stagnated for Black populations by 2016. Disparities in wealth grew. By 2021, Asian and many white Americans had the highest incomes in the study, living in counties with per capita incomes around $50,000. All three groups of Black people in the analysis remained below $30,000.

A wealth gap between Black and white people has historical roots, stretching back to the days of slavery, Jim Crow laws, and policies that prevented Black people from owning property in neighborhoods that are better served by public schools and other services. For Native Americans, a historical wealth gap can be traced to a near annihilation of the population and mass displacement in the 19th and 20th centuries.

Inequality has continued to rise for several reasons, such as a between predominantly white corporate leaders and low-wage workers, who are disproportionately people of color. And reporting from ºÚÁϳԹÏÍø News shows that decisions not to expand Medicaid have jeopardized the health of hundreds of thousands of people living in poverty.

Researchers have studied the potential health benefits of reparation payments to address historical injustices that led to racial wealth gaps. One estimates that such payments could reduce premature death among Black Americans by 29%.

Less controversial are interventions tailored to communities. Obesity often begins in childhood, for example, so policymakers could invest in after-school programs that give children a place to socialize, be active, and eat healthy food, Harris said. Such programs would need to be free for children whose parents can’t afford them and provide transportation.

But without policy changes that boost low wages, decrease medical costs, put safe housing and strong public education within reach, and ensure access to reproductive health care including abortion, Harris said, the country’s overall life expectancy may grow worse.

“If the federal government is really interested in America’s health,” she said, “they could grade states on their health metrics and give them incentives to improve.”

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Babies too young to be vaccinated had the highest covid hospitalization rate of any age group except people over 75.

The study looked at infant medical data from October 2022 to April 2024 in 12 states and underscores the critical importance of vaccinating pregnant people. It also echoes what physicians have anecdotally reported for more than three years — that people are still skeptical of covid vaccines due to persistent misinformation.

Of the 1,470 infants sick enough to be hospitalized due to covid, severe outcomes occurred “frequently,” according to the report. Excluding newborns hospitalized at birth, about 1 in 5 infants hospitalized with covid required intensive care, and nearly 1 in 20 required a ventilator.

“These aren’t necessarily high-risk, ill newborns. These are just regular, full-term, healthy newborn kids who happen to get covid and wind up on a ventilator in the hospital,” said , a professor of clinical obstetrics and gynecology and the director of the Infectious Diseases in Pregnancy Program at the David Geffen School of Medicine at UCLA.

Babies can’t get the covid vaccination until they are at least 6 months old. That leaves a “huge window” when infants are most vulnerable, Silverman said. so they on to their newborns is an effective way of protecting babies during that time. Vaccination during pregnancy also protects pregnant people from severe disease.

But persistent vaccine misinformation online has led to skepticism among Silverman’s pregnant patients.

“The most frustrating response that I get from folks is that they need to do more research before they think about getting the covid vaccine,” Silverman said. “We have dozens and dozens of studies showing the safety of the mRNA vaccine. I don’t know how much more research we can provide to skeptics.”

Among the 1,000-plus babies hospitalized with covid, the median age was just 2 months old, according to the report. Nine of the infants died.

South Carolina pediatrician said she plans to share the study with families she cares for. “There absolutely is a proportion of the population who will look at this and say, ‘Hey, wow, I should get that vaccine. It could protect my baby,’” she said.

Greenhouse believes the new data could solidify the risk of skipping the vaccine when she speaks to families.

“I think that it might help to convince some parents when you can actually show them hospitalization numbers and you can show them intensive care numbers and you can show them mechanical ventilation numbers,” Greenhouse said. “Those things are a big deal.”

Often, Greenhouse waits to be informed that a person is pregnant before bringing up the updated covid shot. Now she’s rethinking that strategy. “As pediatricians we do get moms in our office who are pregnant and we have an opportunity to intervene and to do some education and make them understand how important this is,” she said.

Physicians can encourage vaccination by making it as easy and simple as possible, Silverman said. He encouraged fellow doctors to offer the shots in their offices, rather than sending patients to pharmacies or other providers.

“We lose probably 30 to 40% of vaccination opportunities once someone has to leave the office to get a vaccine,” Silverman said.

But offering covid shots in their clinics leaves some doctors with a difficult calculation. They are struggling to predict how many patients will be interested in the vaccine and may not be able to return all their excess doses. Many providers can’t afford to lose money on doses that won’t be used, but they still need to order enough to vaccinate vulnerable patients who want the shot.

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“I am very confident there are more people being infected than we know about,” said Gregory Gray, the infectious disease researcher at the University of Texas Medical Branch who led the study, and under review to be published in a leading infectious disease journal. “Largely, that’s because our surveillance has been so poor.”

As bird flu cases go underreported, health officials risk being slow to notice if the virus were to become more contagious. A large surge of infections outside of farmworker communities would trigger the government’s flu surveillance system, but by then it might be too late to contain.

“We need to figure out what we can do to stop this thing,” Gray said. “It is not just going away.”

The Centers for Disease Control and Prevention bases decisions on its surveillance. For example, the agency has bird flu vaccines on hand but has decided against offering them to farmworkers, citing a low number of cases.

But testing for bird flu among farmworkers remains rare, which is why Gray’s research stands out as the first to look for signs of prior, undiagnosed infections in people who had been exposed to sick dairy cattle — and who had become ill and recovered.

Gray’s team detected signs of prior bird flu infections in workers from two dairy farms that had outbreaks in Texas earlier this year. They analyzed blood samples from 14 farmworkers who had not been tested for the virus and found antibodies against it in two. This is a nearly 15% hit rate from only two dairy farms out of more than 170 with bird flu outbreaks in 13 states this year.

One of the workers with antibodies had been taking medicine for a lingering cough when he agreed to allow researchers to analyze his blood in April. The other had recently recovered from a respiratory illness. She didn’t know what had caused it but told researchers that untested farmworkers around her had been sick too.

Richard Webby, director of the World Health Organization Collaborating Center for Influenza at St. Jude Children’s Research Hospital in Memphis, Tennessee, said the results confirmed his suspicions that the 13 human bird flu cases reported this year by the CDC were an undercount.

“Maybe what we see isn’t exactly the tip of the iceberg, but it’s certainly not the whole story,” Webby said.

Little Testing of Farmworkers

Although small, the study gives fresh urgency to reports of undiagnosed ailments among farmworkers and veterinarians. The CDC has warned that if people are infected by the seasonal flu and the bird flu simultaneously, the two types of viruses could swap genes in a way that allows the bird flu to spread between people as easily as seasonal varieties.

No evidence suggests that’s happening now. And asymptomatic cases of the bird flu appear to be rare, according to a described by the CDC on July 19. Researchers analyzed blood samples from 35 workers from dairy farms that had outbreaks in Michigan, and none showed signs of missed infections. Unlike the study in Texas, these workers hadn’t fallen sick.

“It’s a small study, but a first step,” said Natasha Bagdasarian, Michigan’s chief medical executive. She said that the state was boosting outreach to test farmworkers but its efforts were complicated by systemic issues like precarious employment that renders them vulnerable to getting fired for calling out sick.

Without more assistance for farmworkers, and cooperation between the government and the livestock industry, Gray said, the U.S. risks remaining in the dark about this virus.

“There’s a lot of genomic studies and laboratory work, but farms are where the real action is,” Gray said, “and we’re not watching.”

Communication Breakdown

A dairy worker in Colorado told ºÚÁϳԹÏÍø News that he sought medical care about a month ago for eye irritation — a common symptom of the bird flu. The doctor conducted a usual checkup, complete with a urine analysis. But the farmworker hadn’t heard of the bird flu, and the clinician didn’t mention it or test for the virus. “They told me I had nothing,” he said in Spanish, speaking on the condition of anonymity because he feared retaliation from employers.

This dairy worker and two in Texas said their employers have not provided goggles, N95 masks, or aprons to protect them from milk and other fluids that could be contaminated with the virus. Buying their own gear is a tall order because money is tight.

As is going to the doctor. One worker in Texas said he didn’t seek care for piercing headaches and a sore throat because he doesn’t have health insurance and can’t afford the cost. He guessed the symptoms were from laboring long hours in sweltering barns with limited water. “They don’t give you water or anything,” he said. “You bring your own bottles.” But there’s no way to know the cause of symptoms — whether bird flu or something else — without testing.

About a fifth of workers on livestock farms are uninsured, , and a similar share have household incomes of less than $40,000 a year.

The three farmworkers hadn’t heard of the bird flu from their employers or state health officials, never mind offers of tests. The CDC boasted in a that, through its partnership with Meta, the company that owns Facebook and Instagram, bird flu posts have flickered across computer and smartphone screens more than 10 million times.

Such outreach is lost on farmworkers who aren’t scrolling, don’t speak English or Spanish, or are without smartphones and internet access, said Bethany Boggess Alcauter, director of research and public health programs at the National Center for Farmworker Health. She and others said that offers of protective gear from health officials weren’t reaching farms.

“We’ve heard that employers have been reticent to take them up on the offer,” said Christine Sauvé, policy and engagement manager at the Michigan Immigrant Rights Center. “If this starts to transmit more easily person to person, we’re in trouble,” she said, “because farmworker housing units are so crowded and have poor ventilation.”

Clinics might alert health officials if sick farmworkers seek medical care. But many farmworkers don’t because they lack health insurance and could be fired for missing work.

“The biggest fear we hear about is retaliation from employers, or that someone might be blacklisted from other jobs,” Sauvé said.

Flu Surveillance

The CDC assesses the current bird flu situation as a low public health risk because the country’s flu surveillance system hasn’t flagged troubling alerts.

The system scans for abnormal increases in hospital visits. Nothing odd has turned up there. It also analyzes a subset of patient samples for unusual types of flu viruses. Since late February, the agency has assessed about 36,000 samples. No bird flu.

However, Samuel Scarpino, an epidemiologist who specializes in disease surveillance, said this system would miss many emerging health threats because, by definition, they start with a relatively small number of infections. Roughly 200,000 people work on farms with livestock in the United States, according to the CDC. That’s a mere 0.1% of the country’s population.

Scarpino said the CDC’s surveillance would be triggered if people started dying from the bird flu. The 13 known cases have been mild. And the system will probably pick up surges if the virus spreads beyond farmworkers and their closest contacts — but by then it may be too late to contain.

“We don’t want to find ourselves in another covid situation,” Scarpino said, recalling how schools, restaurants, and businesses needed to close because the coronavirus was too widespread to control through testing and targeted, individual isolation. “By the time we were catching cases,” he said, “there were so many that we were only left with bad options.”

Troubling Signs

Researchers warn that the H5N1 bird flu virus has evolved to be more infectious to mammals, including humans, in the past couple of years. This drives home the need to keep an eye on what’s happening as the outbreak spreads to dairy farms across the country.

The bird flu virus appears be spreading mainly through milk and milking equipment. But for the first time, researchers reported that it spread inefficiently through the air between a few laboratory ferrets kept inches apart. And in , some cows were infected by breathing in virus-laden microscopic droplets — the sort of thing that could happen if an infected cow was coughing in close proximity to another.

Cows do, in fact, cough. The new study from Texas notes that cattle coughed during outbreaks on the farms and showed other signs of respiratory illness.

Other observations were ominous: About half of some 40 cats on one farm died suddenly at the peak of its outbreak, probably from lapping up raw milk suffused with bird flu virus.

Most people diagnosed with the bird flu have been infected from animals. In his new study, Gray saw a hint that the virus may occasionally spread from person to person, but he added that this remains conjecture. One of the two people who had antibodies worked in the farm’s cafeteria adjacent to the milking parlor — alongside farmworkers but not cattle.

“We need to find ways to have better surveillance,” he said, “so we can make informed decisions rather than decisions based on guesswork.”

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“It’s a walking billboard,” said Moultrie, a health care advocate who serves on the community advisory board for In Our DNA SC, a study underway at the university that aims to enroll 100,000 South Carolinians — including a representative percentage of Black people — in genetics research. The goal is to better understand how genes affect health risks such as cancer and heart disease.

Moultrie, who is Black and has participated in the research project himself, used the opportunity at the dental clinic to encourage the women to sign up and contribute their DNA. He keeps brochures about the study in his car and at the barbershop he visits weekly for this reason. It’s one way he wants to help solve a problem that has plagued the field of genetics research for decades: The data is based mostly on DNA from white people.

Project leaders in Charleston told ºÚÁϳԹÏÍø News in 2022 that they hoped to enroll participants who reflect the demographic diversity of South Carolina, where just under 27% of residents identify as Black or African American. To date, though, they’ve failed to hit that mark. Only about 12% of the project’s participants who provided sociodemographic data identify as Black, while an additional 5% have identified as belonging to another racial minority group.

“We’d like to be a lot more diverse,” acknowledged Daniel Judge, principal investigator for the study and a cardiovascular genetics specialist at the Medical University of South Carolina.

Lack of diversity in genetics research has real health care implications. Since the completion more than 20 years ago of the Human Genome Project, which mapped most human genes for the first time, close to 90% of genomics studies have been conducted using DNA from participants of European descent, . And while human beings of all races and ancestries are more than 99% genetically identical, even small differences in genes can spell big differences in health outcomes.

“Precision medicine” is a term used to describe how genetics can improve the way diseases are diagnosed and treated by considering a person’s DNA, environment, and lifestyle. But if this emerging field of health care is based on research involving mostly white people, “it could lead to mistakes, unknowingly,” said Misa Graff, an associate professor in epidemiology at the University of North Carolina and a genetics researcher.

In fact, that’s already happening. In 2016, for example, that some Black patients had been misdiagnosed with a potentially fatal heart condition because they’d tested positive for a genetic variant thought to be harmful. That variant is much more common among Black Americans than white Americans, the research found, and is considered likely harmless among Black people. Misclassifications can be avoided if “even modest numbers of people from diverse populations are included in sequence databases,” the authors wrote.

The genetics research project in Charleston requires participants to complete an online consent form and submit a saliva sample, either in person at a designated lab or collection event or by mail. They are not paid to participate, but they do receive a report outlining their DNA results. Those who test positive for a genetic marker linked to cancer or high cholesterol are offered a virtual appointment with a genetics counselor free of charge.

Some research projects require more time from their volunteers, which can skew the pool of participants, Graff said, because not everyone has the luxury of free time. “We need to be even more creative in how we obtain people to help contribute to studies,” she said.

Moultrie said he recently asked project leaders to reach out to African American media outlets throughout the Palmetto State to explain how the genetics research project works and to encourage Black people to participate. He also suggested that when researchers talk to Black community leaders, such as church pastors, they ought to persuade those leaders to enroll in the study instead of simply passing the message along to their congregations.

“We have new ideas. We have ways we can do this,” Moultrie said. “We’ll get there.”

Other ongoing efforts are already improving diversity in genetics research. At the National Institutes of Health, a program called “All of Us” aims to analyze the DNA of more than 1 million people across the country to build a diverse health database. So far, that program has enrolled more than 790,000 participants. Of these, more than 560,000 have provided DNA samples and about 45% identify as being part of a racial or ethnic minority group.

“Diversity is so important,” said Karriem Watson, chief engagement officer for the . “When you think about groups that carry the greatest burden of disease, we know that those groups are often from minoritized populations.”

Diverse participation in All of Us hasn’t come about by accident. NIH researchers strategically partnered with community health centers, faith-based groups, and Black fraternities and sororities to recruit people who have been historically underrepresented in biomedical research.

In South Carolina, for example, the NIH works with Cooperative Health, a network of federally qualified health centers near the state capital that serve many patients who are uninsured and Black, to recruit patients for All of Us. Eric Schlueter, chief medical officer of Cooperative Health, said the partnership works because their patients trust them.

“We have a strong history of being integrated into the community. Many of our employees grew up and still live in the same communities that we serve,” Schlueter said. “That is what is part of our secret sauce.”

So far, Cooperative Health has enrolled almost 3,000 people in the research program, about 70% of whom are Black.

“Our patients are just like other patients,” Schlueter said. “They want to be able to provide an opportunity for their children and their children’s children to have better health, and they realize this is an opportunity to do that.”

Theoretically, researchers at the NIH and the Medical University of South Carolina may be trying to recruit some of the same people for their separate genetics studies, although nothing would prevent a patient from participating in both efforts.

The researchers in Charleston acknowledge they still have work to do. To date, In Our DNA SC has recruited about half of the 100,000 people it hopes for, and of those, about three-quarters have submitted DNA samples.

Caitlin Allen, a program investigator and a public health researcher at the medical university, acknowledged that some of the program’s tactics haven’t succeeded in recruiting many Black participants.

For example, some patients scheduled to see providers at the Medical University of South Carolina receive an electronic message through their patient portal before an appointment, which includes information about participating in the research project. But studies show that racial and ethnic minorities are less likely to engage with their electronic health records than white patients, Allen said.

“We see low uptake” with that strategy, she said, because many of the people researchers are trying to engage likely aren’t receiving the message.

The study involves four research coordinators trained to take DNA samples, but there’s a limit to how many people they can talk to face-to-face. “We’re not necessarily able to go into every single room,” Allen said.

That said, in-person community events seem to work well for enrolling diverse participants. In March, In Our DNA SC research coordinators collected more than 30 DNA samples at a bicentennial event in Orangeburg, South Carolina, where more than 60% of residents identify as Black. Between the first and second year of the research project, Allen said, In Our DNA SC doubled the number of these community events that research coordinators attended.

“I would love to see it ramp up even more,” she said.

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At the top of the list of worries is a chemical called 6PPD, which is added to rubber tires to help them last longer. When tires wear on pavement, 6PPD is released. It reacts with ozone to become a different chemical, 6PPD-q, which can be extremely toxic — so much so that it has been linked to repeated fish kills in Washington state.

The trouble with tires doesn’t stop there. Tires are made primarily of natural rubber and synthetic rubber, but they contain hundreds of other ingredients, often including steel and heavy metals such as copper, lead, cadmium, and zinc.

As car tires wear, the rubber disappears in particles, both bits that can be seen with the naked eye and microparticles. Testing by a British company, Emissions Analytics, found that a car’s tires emit 1 trillion ultrafine particles per kilometer driven — from 5 to 9 pounds of rubber per internal combustion car per year.

And what’s in those particles is a mystery, because tire ingredients are proprietary.

“You’ve got a chemical cocktail in these tires that no one really understands and is kept highly confidential by the tire manufacturers,” said Nick Molden, CEO of Emissions Analytics. “We struggle to think of another consumer product that is so prevalent in the world and used by virtually everyone, where there is so little known of what is in them.”

Regulators have only begun to address the toxic tire problem, though there has been some action on 6PPD.

The chemical was identified by a team of researchers, led by scientists at Washington State University and the University of Washington, who were trying to determine why coho salmon returning to Seattle-area creeks to spawn were dying in large numbers.

Working for the Washington Stormwater Center, the scientists tested some 2,000 substances to determine which one was causing the die-offs, and in 2020 they announced they’d found the culprit: 6PPD.

The Yurok Tribe in Northern California, along with two other West Coast Native American tribes, have petitioned the Environmental Protection Agency to prohibit the chemical. The EPA said it is considering new rules governing the chemical. “We could not sit idle while 6PPD kills the fish that sustain us,” said Joseph L. James, chairman of the Yurok Tribe, in a statement. “This lethal toxin has no place in any salmon-bearing watershed.”

California has begun taking steps to regulate the chemical, last year classifying tires containing it as a “priority product,” which requires manufacturers to search for and test substitutes.

“6PPD plays a crucial role in the safety of tires on California’s roads and, currently, there are no widely available safer alternatives,” said Karl Palmer, a deputy director at the state’s Department of Toxic Substances Control. “For this reason, our framework is ideally suited for identifying alternatives to 6PPD that ensure the continued safety of tires on California’s roads while protecting California’s fish populations and the communities that rely on them.”

The U.S. Tire Manufacturers Association says it has mobilized a consortium of 16 tire manufacturers to carry out an analysis of alternatives. Anne Forristall Luke, USTMA president and CEO, said it “will yield the most effective and exhaustive review possible of whether a safer alternative to 6PPD in tires currently exists.”

Molden, however, said there is a catch. “If they don’t investigate, they aren’t allowed to sell in the state of California,” he said. “If they investigate and don’t find an alternative, they can go on selling. They don’t have to find a substitute. And today there is no alternative to 6PPD.”

California is also studying a request by the California Stormwater Quality Association to classify tires containing zinc, a heavy metal, as a priority product, requiring manufacturers to search for an alternative. Zinc is used in the vulcanization process to increase the strength of the rubber.

When it comes to tire particles, though, there hasn’t been any action, even as the problem worsens with the proliferation of electric cars. Because of their quicker acceleration and greater torque, electric vehicles wear out tires faster and emit an estimated 20% more tire particles than the average gas-powered car.

A in Southern California found tire and brake emissions in Anaheim accounted for 30% of PM2.5, a small-particulate air pollutant, while exhaust emissions accounted for 19%. Tests by Emissions Analytics have found that tires produce up to 2,000 times as much particle pollution by mass as tailpipes.

These particles end up in water and air and are often ingested. Ultrafine particles, even smaller than PM2.5, are also emitted by tires and can be inhaled and travel directly to the brain. suggests tire microparticles should be classified as a pollutant of “high concern.”

In a , researchers at Imperial College London said the particles could affect the heart, lungs, and reproductive organs and cause cancer.

People who live or work along roadways, often low-income, are exposed to more of the toxic substances.

Tires are also a major source of microplastics. of microplastics entering the ocean come from the synthetic rubber in tires, according to a report from the Pew Charitable Trusts and the British company Systemiq.

And there are still a great many unknowns in tire emissions, which can be especially complex to analyze because heat and pressure can transform tire ingredients into other compounds.

One outstanding research question is whether 6PPD-q affects people, and what health problems, if any, it could cause. A published in Environmental Science & Technology Letters found high levels of the chemical in urine samples from a region of South China, with levels highest in pregnant women.

The discovery of 6PPD-q, Molden said, has sparked fresh interest in the health and environmental impacts of tires, and he expects an abundance of new research in the coming years. “The jigsaw pieces are coming together,” he said. “But it’s a thousand-piece jigsaw, not a 200-piece jigsaw.”

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These hunters, however, are not just on the front lines of an American tradition. Infectious disease researchers say they are also on the front lines of what could be a serious threat to public health: chronic wasting disease.

The neurological disease, which is contagious, rapidly spreading, and always fatal, is caused by misfolded proteins called prions. It currently is known to infect only members of the cervid family — elk, deer, reindeer, caribou, and moose.

Animal disease scientists are alarmed about the rapid spread of CWD in deer. shows that the barrier to a spillover into humans is less formidable than previously believed and that the prions causing the disease may be evolving to become more able to infect humans.

A response to the threat is ramping up. In 2023, a coalition of researchers began “working on a major initiative, bringing together 68 different global experts on various aspects of CWD to really look at what are the challenges ahead should we see a spillover into humans and food production,” said , an expert in infectious disease at the University of Minnesota and a leading authority on CWD.

“The bottom-line message is we are quite unprepared,” Osterholm said. “If we saw a spillover right now, we would be in free fall. There are no contingency plans for what to do or how to follow up.”

The team of experts is planning for a potential outbreak, focusing on public health surveillance, lab capacity, prion disease diagnostics, surveillance of livestock and wildlife, risk communication, and education and outreach.

Despite the concern, tens of thousands of infected animals have been eaten by people in recent years, yet there have been no known human cases of the disease.

Many hunters have wrestled with how seriously to take the threat of CWD. “The predominant opinion I encounter is that no human being has gotten this disease,” said Steve Rinella, a writer and the founder of MeatEater, a media and lifestyle company focused on hunting and cooking wild game.

They think, “I am not going to worry about it because it hasn’t jumped the species barrier,” Rinella said. “That would change dramatically if a hunter got CWD.”

Other prion diseases, such as bovine spongiform encephalopathy, also known as mad cow disease, and Creutzfeldt-Jakob disease, have affected humans. Mad cow claimed the lives of , mostly in the United Kingdom and France. Some experts believe Parkinson’s and Alzheimer’s also may be caused by prions.

First discovered in Colorado in captive deer in 1967, CWD has since spread widely. It has been found in animals in at least 32 states, four Canadian provinces, and four other foreign countries. It was for the first time in Yellowstone National Park.

Prions behave very differently than viruses and bacteria and are virtually impossible to eradicate. Matthew Dunfee, director of the Chronic Wasting Disease Alliance, said experts call it a “disease from outer space.”

Symptoms are gruesome. The brain deteriorates to a spongy consistency. Sometimes nicknamed “zombie deer disease,” the condition makes infected animals stumble, drool, and stare blankly before they die. There is no treatment or vaccine. And it is extremely difficult to eradicate, whether with disinfectants or with high heat — it even survives autoclaving, or medical sterilization.

Cooking doesn’t kill prions, said Osterholm. Unfortunately, he said, “cooking concentrates the prions. It makes it even more likely” people will consume them, he said.

Though CWD is not known to have passed to humans or domestic animals, experts are very concerned about both possibilities, which Osterholm’s group just received more than $1.5 million in funding to study. CWD can infect more parts of an animal’s body than other prion diseases like mad cow, which could make it more likely to spread to people who eat venison — if it can jump to humans.

Researchers estimate that between 7,000 and 15,000 infected animals are unknowingly consumed by hunter families annually, a number that increases every year as the disease spreads across the continent. While testing of wild game for CWD is available, it’s cumbersome and the tests are not widely used in many places.

A major problem with determining whether CWD has affected humans is that it has a long latency. People who consume prions may not contract the resulting disease until many years later — so, if someone fell sick, there might not be an apparent connection to having eaten deer.

Prions are extremely persistent in the environment. They can remain in the ground for many years and even be taken up by plants.

Because the most likely route for spillover is through people who eat venison, quick testing of deer and other cervid carcasses is where prevention is focused. Right now, a hunter may drive a deer to a check station and have a lymph node sample sent to a lab. It can be a week or more before results come in, so most hunters skip it.

Montana, for example, is famous for its deer hunting. CWD was first detected in the wild there in 2017 and now has spread across much of the state. Despite warnings and free testing, Montana wildlife officials have not seen much concern among hunters. “We have not seen a decrease in deer hunting because of this,” said Brian Wakeling, game management bureau chief for the Montana Department of Fish, Wildlife & Parks. In 2022 Montana hunters killed nearly 88,000 deer. Just 5,941 samples were taken, and 253 of those tested positive.

Experts believe a rapid test would greatly increase the number of animals tested and help prevent spillover.

Because of the importance of deer to Indigenous people, several tribal nations in Minnesota are working with experts at the University of Minnesota to come up with ways to monitor and manage the disease. “The threat and potential for the spread of CWD on any of our three reservations has the ability to negatively impact Ojibwe culture and traditions of deer hunting providing venison for our membership,” said , a tribal biologist for the White Earth Nation, in a statement announcing the program. (The other groups referenced are the Leech Lake Band of Ojibwe and Red Lake Band of Chippewa.) “Tribes must be ready with a plan to manage and mitigate the effects of CWD … to ensure that the time-honored and culturally significant practice of harvesting deer is maintained for future generations.”

is an assistant professor in the College of Veterinary Medicine at the University of Minnesota and co-director of the . The center was formed to study numerous aspects of prions as part of the push to get ahead of possible spillover. “Our mission is to learn everything we can about not just CWD but other prionlike diseases, including Parkinson’s and Alzheimer’s disease,” he said. “We are studying the biology and ecology” of the misfolded protein, he said. “How do prions move within the environment? How can we help mitigate risk and improve animal health and welfare?”

Part of that mission is new technology to make testing faster and easier. Researchers have developed a way for hunters to do their own testing, though it can take weeks for results. There’s hope for, within the next two years, a test that will reduce the wait time to three to four hours.

“With all the doom and gloom around CWD, we have real solutions that can help us fight this disease in new ways,” said Larsen. “There’s some optimism.”

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