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The most haunting memory of the pandemic for Laura, a doctor who practices internal medicine in New York, is a patient who never got COVID at all. A middle-aged man diagnosed with Stage 3 colon cancer in 2019, he underwent surgery and a round of successful chemotherapy and was due for regular checkups to make sure the tumor wasn’t growing. Then the pandemic hit, and he decided that going to the hospital wasn’t worth the risk of getting COVID. So he put it off … and put it off. “The next time I saw him, in early 2022, he required hospice care,” Laura told me. He died shortly after. With proper care, Laura said, “he could have stayed alive indefinitely.” (The Atlantic agreed to withhold Laura’s last name, because she isn’t authorized to speak publicly about her patients.)

Early in the pandemic, when much of the country was in lockdown, forgoing nonemergency health care as Laura’s patient did seemed like the right thing to do. But the health-care delays didn’t just end when America began to reopen in the summer of 2020. Patients were putting off health care through the end of the first pandemic year, when vaccines weren’t yet widely available. And they were still doing so well into 2021, at which point much of the country seemed to be moving on from COVID.

By this point, the coronavirus has killed more than 1 million Americans and debilitated many more. One estimate shows that life expectancy in the U.S. fell 2.41 years from 2019 to 2021. But the delays in health care over the past two and a half years have allowed ailments to unduly worsen, wearing down people with non-COVID medical problems too. “It just seems like my patients are sicker,” Laura said. Compared with before the pandemic, she is seeing more people further along with AIDS, more people with irreversible heart failure, and more people with end-stage kidney failure. Mental-health issues are more severe, and her patients struggling with addiction have been more likely to relapse.

Even as Americans are treating the pandemic like an afterthought, a disturbing possibility remains: COVID aside, is the country simply going to be in worse health than before the pandemic? According to health-care workers, administrations, and researchers I talked with from across the country, patients are still dealing with a suite of problems from delaying care during the pandemic, problems that in some cases they will be facing for the rest of their lives. The scope of this damage isn’t yet clear—and likely won’t come into focus for several years—but there are troubling signs of a looming chronic health crisis the country has yet to reckon with. At some point, the emergency phase of COVID will end, but the physical toll of the pandemic may linger in the bodies of Americans for decades to come.

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During those bleak pre-vaccine dark ages, going to the doctor could feel like a disaster in waiting. Many of the country’s hospitals were overwhelmed with COVID patients, and outpatient clinics had closed. As a result, in every week through July 2020, roughly 45 percent of American adults said that over the preceding month, they either put off medical care or didn’t get it at all because of the pandemic. Once they did come in, they were sicker—a trend observed for all sorts of ailments, including childhood diabetes, appendicitis, and cancer. A recent study analyzed the 8.4 million non-COVID Medicare hospitalizations from April 2020 to September 2021 and found not only that hospital admissions plummeted, but also that those admitted to hospitals were up to 20 percent more likely to die—an astonishing effect that lasted through the length of the study.

Partly, that result came about because only those who were sicker made it to the hospital, James Goodwin, one of the study’s authors and a professor at the University of Texas Medical Branch, in Galveston, told me. It was also partly because overwhelmed hospitals were giving worse care. But Goodwin estimates that “more than half the cause was people delaying medical care early in their illness and therefore being more likely to die. Instead of coming in with a urinary tract infection, they’re already getting septic. I mean, people were having heart attacks and not showing up at the hospital.”

Read: America is sliding into the long pandemic defeat

For some conditions, skipping a checkup or two may not matter all that much in the long run. But for other conditions, every doctor’s visit can count. Take the tens of millions of Americans with vascular issues in their feet and legs due to diabetes or peripheral artery disease. Their problems might lead to, say, ulcers on the foot that can be treated with regular medical care, but delays of even a few months can increase the risk of amputation. When patients came in later in 2020, it was sometimes too late to save the limb. An Ohio trauma center found that the odds of undergoing a diabetes-related amputation in 2020 were almost 11 times higher once the pandemic hit versus earlier in the year.

Although only a small percentage of Americans lost a limb, the lack of care early in the pandemic helped fuel a dangerous spike in substance-abuse disorders. In a matter of weeks or months, people’s support systems collapsed, and for some, years of work overcoming an addiction unraveled. “My patients took a huge step back, probably more than many of us realize,” Aarti Patel, a physician assistant at a Lower Manhattan community hospital, told me. One of her patients, a man in his late 50s who was five years sober, started drinking again during the pandemic and eventually landed in the hospital for withdrawal. Patients like this man, she said, “would have really difficult, long hospital stays, because they were at really high risk of DTs, alcohol seizures. Some of them even had to go to the ICU because [the withdrawal] was so severe.”

Later in the year, when doctors’ offices were up and running, “a lot of patients expressed that they didn’t want to go back for care right away,” says Kim Muellers, a graduate student at Pace University who is studying the effects of COVID on medical care in New York City, North Carolina, and Florida. Indeed, through the spring of 2021, the top reason Medicare recipients failed to seek care was they didn’t want to be at a medical facility. Other people were avoiding the doctor because they’d lost their job and health insurance and couldn’t afford the bills.

The problem, doctors told me, is that all of those missed appointments start to add up. Patients with high blood pressure or blood sugar, for example, may now be less likely to have their conditions under control—which after enough time can lead to all sorts of other ailments. Losing a limb can pose challenges for patients that will last for the rest of their lives. Relapses can put people at a higher risk for lifelong medical complications. Cancer screenings plummeted, and even a few weeks without treatment can increase the chance of dying from the disease. In other words, even short-term delays can cause long-term havoc.

Read: How long can the coronavirus keep reinfecting us?

To make matters worse, the health-care delays fueling a sicker America may not be totally over yet, either. After so many backups, some health-care systems, hobbled by workforce shortages, are scrambling to address the pent-up demand for care that patients can simply no longer put off, according to administrators and doctors from several major health systems, including Cleveland Clinic, the Veterans Health Administration, and Mayo Clinic. Disruptions in the global supply chain are forcing doctors to ration basic supplies, adding to backlogs. Amy Oxentenko, a gastroenterologist at Mayo Clinic in Arizona who helps oversee clinical practice across the entire Mayo system, says that “all of these things are just adding up to a continued delay, and I think we’ll see impacts for years to come.”

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It’s still early, and not everything that providers told me is necessarily showing up in the data. Oddly enough, the CDC’s National Health Interview Survey found that most Americans were able to see a doctor at least once during the first year of the pandemic. And the same survey has not revealed any uptick in most health conditions, including asthma episodes, high blood pressure, and chronic pain—which might be expected if America were getting sicker.

It’s even conceivable that the disturbing observations of clinicians are a statistical illusion. If for whatever reason only sicker people are now being seen by—or able to access—a doctor, then it can be true both that providers are seeing more seriously ill patients in medical facilities and that the total number of seriously ill people in the community is staying the same. The scope of the damage just isn’t yet clear: Maybe a smaller number of people will be worse off because of delayed cancer care or substance-abuse relapses, or maybe far more people—more than tens of million of Americans—will be dealing with exacerbated issues for the rest of their lives.

None of this accounts for what COVID itself is doing to Americans, of course. The health-care system is only beginning to grapple with the ways in which a past bout with COVID is a long-term risk for overall health, or the extent to which long COVID can complicate other conditions. The pandemic may feel “over” for lots of Americans, but many who made it through the gantlet of the past two-plus years may end up living sicker, and dying sooner.

This disturbing prospect is not only poised to further devastate communities; it’s also bad news for health-care workers already exhausted by COVID. Laura, the Manhattan internist who treated the colon-cancer patient, told me it’s disheartening to see so many people showing up at irreversible points in their disease. “As doctors,” she said, “our overall batting average is going down.” Aarti Patel, the physician assistant, put it in blunter terms: “Burnout is probably too simple a term. We’re in severe moral distress.”

Nothing about this grim fate was inevitable. Laura told me that “going to the doctor mid-pandemic may have posed a small risk in terms of COVID, but not going was risky in terms of letting disease go unchecked. And in retrospect it seems that many people didn’t quite get that.” But there didn’t have to be such a stark trade-off between fighting a pandemic and maintaining health care for other medical conditions.

Some hospitals—at least the better-resourced ones—figured out how to avoid the worst kind of delays. Mayo Clinic, for example, is one of a number of systems with a sophisticated triage algorithm that prioritizes patients needing acute care. In the spring of 2021, Cleveland Clinic launched a massive outreach blitz to schedule some 86,000 appointments, according to Lisa Yerian, the chief improvement officer. And the Veterans Health Administration provided iPads to thousands of veterans who lacked other means of accessing the internet in the spring of 2020, ensuring a more seamless transition to virtual care, Joe Francis, who directs health-care analytics, told me. Thanks in part to these efforts, Francis said, high-risk patients at the VHA were being seen at pre-pandemic levels a mere six months into the pandemic.

These health-care systems also suggest a path forward. America may still be able to stave off the worst of the collateral damage by reaching the patients who have fallen through the cracks—and already the data suggest that these patients tend to be disproportionately Black, Hispanic, and low-income. Tragically, it’s too late for some Americans: People who died of cancer can’t come back to life; amputated limbs can’t regrow. Others still have plenty of time. Hypertension that’s currently uncontrolled can be tamped down before causing an early heart attack; drinking that’s gotten out of hand can be corralled before it leads to liver failure in a decade; undetected tumors can be spotted in time for treatment. An uptick in premature death and disability, summed over millions of Americans, could strain the health-care system for years. But it’s still possible to prevent an acute public-health crisis from seeding an even bigger chronic one.

Pick a memory. It could be as recent as breakfast or as distant as your first day of kindergarten. What matters is that you can really visualize it. Hold the image in your mind.

Now consider: Do you see the scene through your own eyes, as you did at the time? Or do you see yourself in it, as if you’re watching a character in a movie? Do you see it, in other words, from a first-person or a third-person perspective? Usually, we associate this kind of distinction with storytelling and fiction-writing. But like a story, every visual memory has its own implicit vantage point. All seeing is seeing from somewhere. And sometimes, in memories, that somewhere is not where you actually were at the time.

This fact is strange, even unsettling. It cuts against our most basic understanding of memory as a simple record of experience. For a long time, psychologists and neuroscientists did not pay this fact much attention. That has changed in recent years, and as the amount of research on the role of perspective has multiplied, so too have its potential implications. Memory perspective, it turns out, is tied up in criminal justice, implicit bias, and post-traumatic stress disorder. At the deepest level, it helps us make sense of who we are.

The distinction between first- and third-person memories dates back at least as far as Sigmund Freud, who first commented on it near the end of the 19th century. Not for another 80 years, though, did the first empirical studies begin fleshing out the specifics of memory perspective. And it was only in the 2000s that the field really started picking up steam. What those early studies found was that third-person memories were far less unusual than once thought. The phenomenon is associated with a number of mental disorders, such as depression, anxiety, and schizophrenia, but it is not merely a symptom of pathology; even among healthy people, it is quite common.

Just how common is tricky to quantify. Peggy St. Jacques, a psychology professor at the University of Alberta who studies perspective in memory, told me that roughly 90 percent of people report having at least one third-person memory. For the average person, St. Jacques estimates, on the basis of her research, that about a quarter of memories from the past five years are third-person. (At least a couple of papers have found that women tend to have more third-person memories than men do, but a third study turned up no statistically significant difference; on the whole, research on possible demographic disparities is scant.) In certain rare cases, people may have only third-person memories. As you try to recall your own, be warned that things can get confusing fast. Perhaps you can call to mind early-childhood scenes that you picture from a third-person perspective. But it’s hard to know whether these are genuine memories translated from the first person to the third person, or third-person scenes constructed from stories or photographs. To some people, third-person memories are second nature; to others, they sound like science fiction.

Why any given memory gets recalled from one perspective rather than the other is the result of a whole bunch of intersecting factors. People are more likely to remember experiences in which they felt anxious or self-conscious—say, when they gave a presentation in front of a crowd—in the third person, St. Jacques told me. This makes sense: When you’re imagining how you look through an audience’s eyes in the moment, you’re more likely to see yourself through their eyes at the time of recall. Researchers have also repeatedly found that the older a memory is, the more likely you are to recall it from the third person. This, too, is fairly intuitive: If first-person recollection is the ability to adopt the position—and inhabit the experience—of your former self, then naturally you’ll have more trouble seeing the world the way you did as a 6 year old than the way you did last week. The tendency for older memories to be translated into the third person may also have to do with the fact that the more distant the memory is, the less detail you’ll likely have, and the less detail you have, the less likely you are to be able to reassume the vantage point from which you originally witnessed the scene, David Rubin, a Duke University psychology professor who has published dozens of papers on autobiographical memory, told me.

Less intuitive, perhaps, is the reverse: People are able to recall a scene in greater detail when they’re asked to take a first-person perspective than when they’re asked to take a third-person perspective. “Sometimes in a courtroom, an eyewitness to a holdup might be asked to recall what happened from the perspective of the clerk,” St. Jacques told me. But if her research is any indication, such tactics may blur rather than sharpen the witness’s memory. “Our research suggests that might actually be more likely to make the memory less vivid, make the eyewitness less likely to remember the specifics.”

Even without an examiner’s instructions, such an eyewitness might be predisposed to recall the robbery in the third person: Researchers have found that people often translate traumatic or emotionally charged memories out of the first person. This may be because first-person memories tend to elicit stronger emotional reactions at the time of recall, and by taking a third-person perspective, we can distance ourselves from the painful experience, Angelina Sutin, a psychologist at Florida State University, told me. It may also be a function of the information at our disposal. In charged situations, Rubin said, people tend to zero in on the object of their anger or fear. Take the bank-robbery scenario: The police “want the teller to describe the person who’s robbing them, and instead he describes in great detail the barrel of the gun pointed at his head.” He can’t remember much beyond that. And so, lacking the information necessary to situate himself in his original perspective, he floats.

This distancing effect has some fairly mind-bending potential applications, none more so, perhaps, than to the problem of near-death experiences. For many years, philosophers and psychologists have documented instances of people reporting that, in moments of trauma, they felt as though they were floating outside—usually above—their body. Rubin points out, however, that such reports are not in-the-moment descriptions but after-the-fact accounts. So he has a controversial idea: What in retrospect seems like an out-of-body experience may in fact be only the trauma-induced translation of a first-person memory into a third-person memory, one so compelling that it deceives you into thinking the experience itself occurred in the third person. The recaller, in this theory, is like a person peering through a convex window, mistaking a distortion of the glass for a distortion of the world.

Traumatic dissociations are dramatic but by no means isolated cases of what Rubin calls the “constructive nature of the world.” In a 2019 review article on memory perspective, St. Jacques noted that shifting your vantage and fabricating an entirely new scene rely on the same mental processes occurring in the same regions of the brain. So similar are recollecting the past and projecting into the future that some psychologists lump them into a single category: “mental time travel.” Both are acts of construction. The distinction between memory and imagination blurs.

At some level, people generally understand this, but rarely do we get so incontrovertible an example as with third-person memories. If you and a friend try to recall the decor at the restaurant where you got dinner last month, you might find that you disagree on certain points. You think the wallpaper was green, your friend thinks blue, one of you is wrong, and you’re both sure you’re right. With third-person memories, though, you know the memory is distorted, because you could not possibly have been looking at yourself at the time. If, without even realizing it, you can change something so central as the perspective from which you view a memory, how confident can you really be in any of the memory’s details?

In this way, third-person memories are sort of terrifying. But shifts in perspective are more than mere deficiencies of memory. In her lab at Ohio State University, the psychologist Lisa Libby is investigating the relationship between memory perspective and identity—that is, the way shifts in our memory play a role in how we make sense of who we are. In one experiment, Libby asked a group of female undergraduates whether they were interested in STEM. The students then participated in a science activity, some in a version designed to be engaging, others in a version designed to be boring. Afterward, when she surveyed the undergrads about how they’d found the exercise, she instructed some to recall it from a first-person perspective and others from a third-person perspective. The first-person group’s answers corresponded to how interesting the task really was; the third-person group’s corresponded to whether they’d said they liked STEM in the initial survey.

Libby’s takeaway: Each type of memory seems to have its own function. “One way to think about the two perspectives is that they help you represent … two different components of who you are as a person,” Libby told me. Remembering an event from a first-person perspective puts you in an experiential frame of mind. It helps you recall how you felt in the moment. Remembering an event from a third-person perspective puts you in a more narrative frame of mind. It helps you contextualize your experience by bringing it in line with your prior beliefs and fitting it into a coherent story. Memory is the—or at least a—raw material of identity; perspective is a tool we use to mold it.

Maybe the most interesting thing about all of this is what it suggests about the human proclivity for narrative. When we shift our memories from one perspective to another, we are, often without even realizing it, shaping and reshaping our experience into a story, rendering chaos into coherence. The narrative impulse, it seems, runs even deeper than we generally acknowledge. It is not merely a quirk of culture or a chance outgrowth of modern life. It’s a fact of psychology, hardwired into the human mind.

This article was featured in One Story to Read Today, a newsletter in which our editors recommend a single must-read from The Atlantic, Monday through Friday. Sign up for it here.      

At Sunrise Mart, a small Japanese grocery with a branch in Brooklyn’s Sunset Park, you can’t miss the mountain of KitKats. The shop sells all kinds of fresh foods and imported snacks, but as soon as you step inside, you’re toe-to-toe with an enormous heap of colorful bags of the chocolate bars, rising up from the floor in the store’s most prominent real estate. The bags offer flavors such as lychee, chocolate orange, and cheesecake. At $10 each, they’re a little expensive. That doesn’t seem to matter. When I visited the store this spring in search of soup ingredients, multiple shoppers buzzed around me on an otherwise slow weekday afternoon, snapping up bag after bag.

I’d never had anything but a standard American KitKat before, but I’d heard so many people rave about the Japanese versions that stumbling on the opportunity to try them myself seemed like money I couldn’t afford not to spend. I stuffed two bags of the pistachio and matcha flavors in my tote and headed for the subway, feeling like I’d just unearthed some kind of treasure. When I got home, I pulled out both, plus a few other packages of impulse-purchased Asian candy that I’d scooped up (you know, while I was there), and staged my own little taste test on my kitchen counter. Their flavors and textures differed from the candy I’d been eating for my entire life. They were all great. Matcha won.

Without realizing it, I’d repeated a ritual that’s become pretty common, both online and in real life. YouTube and TikTok videos of Americans taste-testing candies from Europe, Asia, and Latin America rack up millions of views. At Economy Candy, a Manhattan confectioner that stocks a huge variety of sweets, new customers come in every day, brandishing their phones, fiending to try candies from far-flung locales that they heard about on the internet or that their roommate tried on vacation. Skye Greenfield Cohen, who runs the store with her husband, told me that as recently as five years ago, Economy Candy had only a few racks of imports. “That meant halvah from the Middle East, Turkish delight, those kinds of grandmalike candy that were more nostalgic for a homeland, rather than fun,” she said. Now imports from around the world make up about a third of the store’s inventory.

On one level, it’s not difficult to understand why any type of candy, foreign or domestic, becomes popular. Candy is engineered to entice and delight, and it’s mostly pretty cheap. But American shoppers don’t exactly lack domestic candy options; any average grocery store’s checkout line is bursting with Snickers, Twizzlers, M&Ms, and Skittles. The hunger for foreign treats can’t be entirely explained by the vagaries of social-media virality, either. According to one estimate, since 2009, the annual value of America’s non-chocolate candy imports has grown by hundreds of millions of dollars; in 2019, it crossed the $2 billion threshold for the first time. Some logistical and cultural factors help explain the United States’ imported-candy boom. But first and foremost, Americans seem to love foreign sweets because they’re having the same revelation I had in my kitchen with my green KitKats: The international stuff puts most domestic candy to shame.

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In the early 2010s, executives at the American division of the Japanese confectioner Morinaga & Company noticed something strange happening in Utah. The company’s Hi-Chew brand of fruit-flavored candies, which was then difficult to find in much of the United States, was selling extraordinarily well in Salt Lake City. The success was welcome—Morinaga wanted to expand its market in the U.S.—but it didn’t immediately make sense. At the time, the majority of the company’s American sales came from West Coast cities with large Asian populations, where the candies were stocked by grocers who catered to people who already knew and liked them. Salt Lake City, which is almost three-quarters white, was anomalously enamored of the intensely chewy little fruit nuggets.

The company eventually figured out what was going on: According to Teruhiro Kawabe, Morinaga America’s president, missionaries from the Church of Latter-Day Saints were coming home from stints in Japan, where Hi-Chew has been omnipresent for decades, and buying up as much of the candy as they could find. “They got to know the candy in the Japanese grocery stores, and they got addicted,” Kawabe told me. Soon their friends and families were, too. The Salt Lake City scenario wasn’t exactly replicable, but Kawabe said that it served as proof of concept: Americans would love the candy, if the company could get it in front of them.

Getting a particular product in front of shoppers, though, is much easier said than done, especially when it comes to things that are largely unknown or thought to have a niche audience. Candy purchases tend to be spur-of-the-moment decisions made at checkout counters, and that real estate is limited and has long been spoken for by conglomerates such as Hershey and Mars, which make much of the candy that Americans have been eating for their entire life. To take a shot at mainstream American success, Hi-Chew’s makers did the usual stuff that consumer-products businesses do: They hired retail consultants, switched distributors, that kind of thing. But they also set their sights on a very important group: Major League Baseball players, the only people who routinely spend time chewing snacks in extreme close-up on TV. Morinaga supplied Japanese players in the league with Hi-Chew, Kawabe told me, focusing first on teams in markets where major retailers were headquartered. The gambit worked; ESPN reported on just how obsessed the 2015 Yankees squad was with the little fruit candies. Walgreens and CVS picked up the brand after it became popular with the Chicago Cubs and Boston Red Sox. Regular people tried the newly plentiful and suddenly trendy candy, and then insisted that their brother or spouse or co-workers try it. Hi-Chew’s U.S. sales grew from $8 million in 2012 to more than $100 million in 2021, according to Kawabe.

This success story might feel a little bit too convenient, but baseball players’ mid-2010s Hi-Chew mania was well documented—and, apparently, ongoing. Moreover, explosive American growth in the past decade has been common among foreign candy brands. Sales of gummy candies from the German confectioner Haribo more than doubled from 2011 to 2017. Ferrero, the Italian parent company of Kinder chocolates, says that the line’s U.S. sales are growing by double digits annually. The European chocolate brands Milka and Cadbury are now owned by the American Oreo-maker Mondelez—an advantage over other confectioners when navigating import and retail red tape.

None of these companies pulled off the same tactic with baseball players, but their rise seems to have followed similar patterns. Greenfield Cohen, from Economy Candy, said sales growth largely happens by word of mouth. This is helped along by the increasing popularity of international travel and the internet’s ability to serve niche products to a potentially large pool of previously untapped buyers. European candy in particular benefits from these dynamics—millions of American tourists visit the continent every year, and destination-specific candies are a common gift for returning travelers to bring home to loved ones. (That’s how I first tried Hi-Chew way back in 2002, although my high-school best friend had gone on a family trip to the exotic land of Tampa, not Japan.) Now the barrier between trying one piece of interesting candy—or even just hearing someone rave about it—and keeping a stockpile in your pantry or desk drawer is as low as it’s ever been.

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Of course, candy also needs to taste good for people to like it. All the word of mouth in the world won’t permanently increase sales of a bad product. Once people try candy from other parts of the world, they return to it because it is, in some very real ways, better than its domestic competitors.

Have you ever had a matcha KitKat? Its physical form is identical to that of a regular KitKat, except instead of chocolate, it’s blanketed in bright green. Where many Americans would expect the familiar, slightly bland flavor of milk chocolate, there’s an earthy, creamy sweetness—perfect for people who, like me, get a little queasy after a few pieces of sickly sweet Halloween candy. With Hi-Chews, each wrapped in tiny squares of plain-white waxed paper, the flavors are important—and far more varied than in popular American fruit candies—but the primary feature is the texture. Chewing one feels like you’ve encountered a Starburst that fights back. It’s delicious.

The reasons for foreign candy’s superiority are varied—and more surprising than you might expect. In some cases, yes, a candy is better because it is fundamentally different, on a chemical level, than what’s available in America. Europe’s strict regulations on chocolate quality mean that it offers something that’s not really comparable to a Hershey bar (and that Europeans are generally enthusiastic to tell you how much American chocolate sucks). The European Union also bans certain food additives that the FDA allows, which can yield slightly different results in all kinds of finished products, including candy.

These cases seem to be the exception, not the rule, however. Ali Bouzari, a culinary scientist and co-founder of the product-development firm Pilot R&D, doesn’t buy the idea that inherently superior quality is the reason that so many people are charmed by imported sweets. “The basic tools of commercial candy manufacture are pretty universal, and the ingredients that people work with are fully globalized,” Bouzari told me. German brands, Japanese brands, and American brands likely all source their grape flavorings, for example, from the same vendors. What’s different—and what makes foreign candies so enticing—instead mostly seems to be in the implementation. Imported candies tend to embrace flavors and textures that American candies don’t. “I will always first go for the melon stuff” when shopping in an East Asian grocery store, Bouzari said. “This is candy inspired by a culture that thinks about melons more than we do.” Every part of the world has some kind of confection that it does particularly well: Scandinavians produce more flavors and textures of licorice than most Americans could dream of. Mexican candy frequently includes savory or spicy flavors. Candies from a number of East and South Asian countries tend to feature a far wider array of fruit flavors than are available in the West.

The flavorings and ingredients that go into these candies are likely available to American manufacturers from the vendors they’re already using, according to Bouzari. Foreign producers develop products primarily for their domestic markets, so they make different choices and end up with results that can feel idiosyncratic—sometimes thrillingly so—to the American palate. As food culture has globalized, those palates have become more adventurous, especially in larger metropolitan areas, where more types of food have become more widely available in restaurants and grocery stores than ever before. Meanwhile, Bouzari told me, major U.S. manufacturers haven’t really kept up. They depend on appealing to as broad a swath of the country’s atypically diverse population as possible—not just across racial and ethnic lines, but across the country’s many local and regional food cultures. The results are candies that tend to be highly sweet and pretty bland, forgoing flavors and textures that brands believe might alienate white Americans in particular.

All that being said, American tastes have a way of bending the world to their will. Once a foreign confectioner achieves a certain level of American success, it usually ends up adjusting its products for the American market, even if only a little. Kawabe, Morinaga America’s president, told me that some of the Hi-Chew flavors sold in mainstream U.S. retailers vary slightly from what’s available in Japan. When Americans buy grape candy, for example, their flavor expectations are just different from when the Japanese buy the same thing. Candy companies that want huge U.S. sales growth, for better or worse, need to meet people where they are.

The most salient difference between foreign and domestic candy might not be chemical or methodological, but rather philosophical. New American products could theoretically embrace the lessons of imported candy and snatch up some of its growing domestic market share. But in Bouzari’s experience, much of the candy being developed domestically, such as low-carb candy from brands like Smart Sweets and Highkey, isn’t trying to delight consumers, but to placate their health fears by engineering it into diet food. “Candy is meant to be edible, ephemeral entertainment,” he said. “If you try to turn it into food, you get caught in a weird no-man’s-land where it’s neither the complete entertainment that it should be, and it’s not as nourishing as it should be.”

For Americans who want something fun and novel and sweet, overseas might just be the most logical place to look right now. “In most other places I’ve been in the world, there is a more well-adjusted relationship to hedonism in food than we have here,” Bouzari said. “Other people spend less time trying to figure out how to eat gummy bears with no sugar.”

WASHINGTON — The U.S. on Wednesday authorized its first update to COVID-19 vaccines, booster doses that target today’s most common omicron strain. Shots could begin within days.

The move by the Food and Drug Administration tweaks the recipe of shots made by Pfizer and rival Moderna that already have saved millions of lives. The hope is that the modified boosters will blunt yet another winter surge.

“You’ll see me at the front of the line,” FDA vaccine chief Dr. Peter Marks told The Associated Press shortly before his agency cleared the new doses.

Until now, COVID-19 vaccines have targeted the original coronavirus strain, even as wildly different mutants emerged. The new U.S. boosters are combination, or “bivalent,” shots. They contain half that original vaccine recipe and half protection against the newest omicron versions, called BA.4 and BA.5, that are considered the most contagious yet.

The combination aims to increase cross-protection against multiple variants.

“It really provides the broadest opportunity for protection,” Pfizer vaccine chief Annaliesa Anderson told the AP.

Read More: An N95 Is the Best Mask for Omicron. Here’s Why

The updated boosters are only for people who have already had their primary vaccinations, using the original vaccines. Doses made by Pfizer and its partner BioNTech are for anyone 12 and older while Moderna’s updated shots are for adults — if it has been at least two months since their last primary vaccination or their latest booster. They’re not to be used for initial vaccinations.

There’s one more step before a fall booster campaign begins: The Centers for Disease Control and Prevention must recommend who should get the additional shot. An influential CDC advisory panel will debate the evidence Thursday — including whether people at high risk from COVID-19 should go first.

“As we head into fall and begin to spend more time indoors, we strongly encourage anyone who is eligible to consider receiving a booster dose with a bivalent COVID-19 vaccine to provide better protection against currently circulating variants,” FDA Commissioner Dr. Robert Califf said in a statement.

The U.S. has purchased more than 170 million doses from the two companies. Pfizer said it could ship up to 15 million of those doses by the end of next week.

The big question is whether people weary of vaccinations will roll up their sleeves again. Just half of vaccinated Americans got the first recommended booster dose, and only a third of those 50 and older who were urged to get a second booster did so.

It’s time for U.S. authorities to better explain that the public should expect an updated COVID-19 vaccination every so often, just like getting a fall flu shot or a tetanus booster after stepping on a rusty nail, said University of Pennsylvania immunologist E. John Wherry.

“We need to rebrand it in a societally normal-looking way,” rather than a panicked response to new mutants, Wherry said. “Give a clear, forward-looking set of expectations.”

Here’s the rub: The original vaccines still offer strong protection against severe disease and death from COVID-19 for most generally healthy people, especially if they got that important first booster dose. It’s not clear just how much more benefit an updated booster will bring — beyond a temporary jump in antibodies capable of fending off an omicron infection.

One reason: The FDA cleared the modifications ahead of studies in people, a step toward eventually handling COVID-19 vaccine updates more like yearly flu shots.

First, FDA checked human studies of earlier Pfizer and Moderna attempts to update their vaccines — shots matching the omicron strain that struck last winter. That recipe change was safe, and substantially boosted antibodies targeting the earlier variant — better than another dose of the original vaccine — while adding a little protection against today’s genetically distinct BA.4 and BA.5 omicron versions.

Read More: Need Another Reason to Exercise? It Could Protect You from COVID-19

But FDA ordered the companies to brew even more up-to-date doses that target those newest omicron mutants instead, sparking a race to roll out shots in less than three months. Rather than waiting a few more months for additional human studies of that recipe tweak, Marks said animal tests showed the latest update spurs “a very good immune response.”

The hope, he said, is that a vaccine matched to currently spreading variants might do a better job fighting infection, not just serious illness, at least for a while.

What’s next? Even as modified shots roll out, Moderna and Pfizer are conducting human studies to help assess their value, including how they hold up if a new mutant comes along.

And for children, Pfizer plans to ask FDA to allow updated boosters for 5- to 11-year-olds in early October.

It’s the first U.S. update to the COVID-19 vaccine recipe, an important but expected next step — like how flu vaccines get updated every year.

And the U.S. isn’t alone. Britain recently decided to offer adults over 50 a different booster option from Moderna, a combo shot targeting that initial BA.1 omicron strain. European regulators are considering whether to authorize one or both of the updated formulas.

AP Health Writer Matthew Perrone contributed to this report.

Contact us at [email protected].

The recent return of polio has hit like something of an epidemiological thunderclap. It was in 1979 that polio was officially declared eradicated in the U.S.—an early step in a multi-generational effort to wipe out the disease around the world. On July 21, however, the New York State Department of Health announced a case of polio in an unvaccinated man in Rockland County, and since then, circulating poliovirus has been found in wastewater there and in neighboring Orange County, as well as in New York City. In London, the virus was also found in wastewater in February, and in Jerusalem, a case of the disease turned up that same month.

The three cases, though seemingly isolated, point to a troubling trend—one that goes against more than three decades of progress in eradicating the disease. In 1988, polio was endemic in 125 countries and led to the death or paralysis of 350,000 people—mostly children—each year, according to the World Health Organization (WHO). But thanks to a massive vaccination push by the WHO, Rotary International, UNICEF, the U.S. Centers for Disease Control and Prevention (CDC), and more, polio is now endemic in just two countries—Afghanistan and Pakistan—which have seen only 18 cases between them so far this year.

Polio, however, is creeping back, and health officials are now on the alert for what Raul Andino-Pavlovsky, a professor of microbiology and immunology at the University of California, San Francisco, calls a “silent epidemic” of the disease around the world. “This is just the tip of the iceberg,” he warns.

Adds Yvonne Maldonado, a professor of global health and infectious disease at Stanford University School of Medicine, “The case we saw [in New York] was unusual but a red flag that we need to be on the lookout for potential outbreaks. We do run the risk of developing more cases of paralytic disease.”

The bad news is that polio is stalking us anew. The good news is that just in the past year, a new vaccine has been added to the arsenal of existing polio vaccines—one that, properly deployed, could halt a new global outbreak of polio before it can get started. No matter what, the reappearance of the disease has raised a host of challenges—all of which need to be met if we’re to keep polio contained.

What’s behind the current outbreak?

Multiple factors have played a role in the return of polio—not the least of which is complacency, especially in the U.S. and other developed countries. When a majority of people alive have never encountered a case of a given disease, it’s easy to put it out of mind. “People don’t remember polio, they don’t see it,” says Ian Lipkin, professor of epidemiology at Columbia University’s Mailman School of Public Health. “There’s something about our species that just allows us to forget about the importance of these things.”

That can lead to a slow erosion in vaccine compliance—something that the numbers bear out in the U.S. Nationwide, 92.6% of children are fully vaccinated against polio by age 2, according to the CDC. Broadly speaking, that’s an encouraging figure, but vaccination rates vary state to state and even county to county. In Oklahoma, for example, polio vaccination rates are just 79.5%, and in South Carolina, the figure is 80.3%. In the Rockland County zip code where the case of polio turned up in June, the vaccination rate stands at an alarmingly low 37.3%.

The COVID-19 pandemic has also played a role in the return of the disease. “During the COVID era, families didn’t see their doctors or pediatricians as frequently as they normally would,” says Dr. William Schaffner, professor of infectious diseases at Vanderbilt University School of Medicine in Nashville, Tenn. “That has resulted in children falling behind in their routine vaccination schedules.”

According to Maldonado, the fall-off has been minimal, with just a 1% decline in polio vaccination rates among children since the pandemic began. But when it comes to infectious diseases, even a single percent can matter a lot. “It translates to tens of thousands of kids who aren’t completely vaccinated,” Maldonado says, “and those children are at risk for diseases that really shouldn’t exist in well-resourced countries.”

Read More: Polio Is Back. Here’s How to Keep Yourself Safe

The vaccine paradox

The irony of polio’s comeback is that the very vaccination campaign the CDC estimates has prevented 16 million cases of paralysis and 1.5 million deaths since 1988 is also partly responsible for the new resurgence. There are two kinds of polio vaccines. The first, known as the inactivated polio vaccine (IPV)—administered by injection—uses a killed virus to familiarize the body with the disease and prime it to recognize and attack a live virus if it ever encounters it. The other, known as the oral polio vaccine (OPV)—administered by mouth—uses an attenuated, or weakened, virus that can do the same job of priming the immune system, without actually causing the disease. The advantage of the OPV is that it’s easier and cheaper to administer, which is why it’s used in global eradication campaigns. The big disadvantage is that on rare occasions, the weakened vaccine can revert to its virulent strain. That can potentially lead to the disease in the person who received the vaccine, and even if it doesn’t, the reinvigorated virus is shed in feces, entering wastewater and potentially infecting other people. For that reason, the U.S. switched to the IPV exclusively in 2000—even though cases of viral reversion were exceedingly rare.

“The crude estimate was one in 3 million doses of oral vaccine administered would lead to a case of polio in the U.S. before 2000,” Schaffner says. “It’s rare, but it’s not inconsequential.”

Indeed it’s not. Genetic sequencing revealed that the virus that caused the recent cases in New York and Jerusalem and was found in wastewater in London was so-called circulating vaccine-derived poliovirus (cVDPV). So far this year, cVDPV has led to 535 other cases of polio in 18 other countries, according to the Global Polio Eradication Initiative (GPEI).

But the IPV has its problems too—in addition to its comparative difficulty of administration. The OPV, since it’s taken orally, establishes what’s known as gut immunity. Assuming the person who receives the vaccine is not among the unlucky few in whom the virus reverts to its virulent form, there is no viral replication in the intestinal system and thus no virus shed in the feces. The IPV protects the recipient from ever contracting polio, but does not prevent intestinal replication and spread if that person ever picks up a cVDPV.

Andino-Pavlovsky believes that sampling wastewater in any part of the world where the IPV is used would likely turn up some circulating vaccine-derived poliovirus that IPV recipients contracted, replicated, and shed, endangering unvaccinated people. “In Europe, in America, in Australia—every place where people are using the inactivated vaccine—it is likely,” he says.

A new vaccine

Even with the drawbacks to both vaccines, getting vaccinated is obviously better than not getting vaccinated, since all vaccine recipients are protected against contracting symptomatic polio. But the OPV and IPV do exist in a state of tension, with one producing vaccine-derived virus and the other contributing to its spread. For that reason, the WHO and other global health organizations call for an eventual switchover to the IPV exclusively—a move that would mean there would be no vaccine-derived virus to be picked up and shed at all.

“We need to stop giving the live virus so it stops circulating,” says Maldonado.

That, however, is not practical at the moment—not while there are still millions of babies and children who need vaccines in the developing world, where the IPV remains too pricey and skilled vaccinators who can administer injections are in far shorter supply than field workers who require little special training to administer drops to the mouth. As a stopgap, the WHO, the Bill and Melinda Gates Foundation, and the U.K.’s National Institute for Biological Standards and Control have come together to develop a new oral vaccine that is far more stable than previous versions, reducing the likelihood of the attenuated virus used in the drops ever reverting to its virulent state.

Andino-Pavlovsky, who was part of the team that designed the vaccine, explains that it works by targeting the spot on the viral genome that is responsible for reversion to virulence. In existing OPVs, that part of the genome needs to go through just a single mutation to go from being harmless to dangerous.

“What we basically did was modify this sequence,” he says, “so a single point mutation cannot cause reversion; a virus now has to go through four or five different changes before acquiring a more virulent phenotype. Basically, it’s a numbers game.” As Andino-Pavlovsky earlier described it to the journal Nature, “It’s like putting the virus in an evolutionary cage.”

The vaccine that contains that caged virus went into use in March 2021 and so far, 450 million doses have been administered in 22 countries. “The new vaccine is as effective as the previous one in generating immunity,” says Andino-Pavlovsky, “[and is] able to stop the silent epidemic.”

The goal, ultimately, is to drive polio over the cliff to extinction—as smallpox was in 1980—with a slow phase-out of all OPV, universal use of IPV, and the eradication of any form of poliovirus circulating anywhere in the world. The current return of the disease is a reminder that that job is not nearly done. Until it is, an old scourge will haunt us anew.

Correction: The original version of this story misstated the introduction date and distribution of the new polio vaccine. Rollout of the vaccine began in March 2021, not the end of 2021; and 450 million doses have been administered in 22 countries, not 180 million doses in 13 countries.

Write to Jeffrey Kluger at [email protected].

How long does a work break need to be to make you feel better?

Not very long at all, according to a new research review on “micro-breaks,” which the authors defined as a break of 10 minutes or less. The findings were published on Aug. 31 in the journal PLOS ONE. People who took breaks experienced statistically significant boosts in their wellbeing—making them feel more vigorous and less fatigued. The results, based on a review of 22 previously published studies that included 2,335 participants, indicate that those who took micro-breaks had about 60% better odds of feeling energetic, according to Patricia Albulescu and Coralia Sulea, co-authors of the study and researchers at the West University of Timisoara in Romania.

The research was less conclusive on whether micro-breaks improve work performance, however. The benefits varied from study to study and across different kinds of tasks, and ultimately the effect wasn’t statistically significant, although the researchers found that there was improvement as the breaks got longer.

However, there’s robust evidence that for your average worker with a sedentary job, little breaks can have a big impact, says John P. Trougakos, professor of organizational behavior and HR management in the department of management at University of Toronto-Scarborough, and an expert on breaks. (He was not involved in the new review.) By combining both short and long breaks into the work day, workers will feel better and produce better quality work.

Here’s what to know about micro-breaks, and how they can improve your work day.

Why micro-breaks are important

Trougakos argues that the studies in the new review miss an important factor: fatigue tends to worsen over time. Since the experiments in the 22 studies were constrained by time, it wasn’t possible to measure the ways in which being tired at work can create a vicious performance cycle.

“The more fatigued you get, the more effort you have to put in to keep performing. So you actually are expending more and more effort and doing it less and less efficiently,” says Trougakos. “Short breaks, whether it’s a 10-minute break, a 5-minute break, standing up and stretching, you’re kind of giving the person a chance to stop the depletion cycle, but also re-energize themselves a little bit.”

Overall, Trougakos says, while there hasn’t been much research on micro-breaks and performance, science suggests that short breaks are important. That includes studies with an ergonomics angle, which have found that resting your eyes and stretching is necessary to avoid eye strain and skeletal fatigue—discomforts that can distract and drain workers. Not taking sufficient breaks can also negatively affect workers’ sleep quality and life outside of work, and gradually lead them to feel burned out. Studies suggest highly productive employees tend to work in relatively short spurts, with long breaks—according to one study published by a productivity tracker company, spending 52 minutes working for every 17 minutes of break. “The idea is: you don’t work more to be more productive; you work smarter to be more productive,” Trougakos says.

The ideal breaks

The breaks you need might depend on what you’re doing; for instance, activities you enjoy might drain you less than a task you hate or that causes you a lot of stress. As a general rule, however, Trougakos recommends spending about 90 minutes working, followed by a 15- or 20-minute break. Over the course of that working period, you’d also be taking micro-breaks. Trougakos suggests a short stretch break every 20 or 30 minutes, as well as a break to “get away from the task” somewhere in the middle of those 90 minutes.

But what is the best way to rest during these short breaks? While there’s evidence that some things are good for everyone, like stretching, relaxing, or light to moderate physical activity (think: taking a walk), Trougakos says, the best break depends on an individual’s preferences. For instance, an extrovert might choose to grab a coffee with their work friends, while an introvert might duck outside with a book. The key, he says, is that you have control over what you do during your break.

To be sure, Trougakos admits that some managers and companies will be nervous about permitting their employees to take so many breaks. Flexibility is key—employees have different needs for breaks, which might vary depending on the task or even from day to day. However, in many cases, Trougakos argues that the shift to hybrid schedules and working from home has given organizations and workers a novel opportunity: to branch out and find new ways to work to maximize productivity. While permitting break flexibility might feel counterintuitive to companies, it actually fits with what most employers value: to “get people to be fully productive, but also be healthy and have a balanced life,” Trougakos says.

Contact us at [email protected].

In two votes, each 13-1, the immunization committee of the U.S. Centers for Disease Control and Prevention (CDC) recommended that Americans receive an Omicron-specific booster dose of the COVID-19 vaccine. Following a day-long discussion of the available data on Sept. 1, the panel recommended boosters from two manufacturers—Pfizer-BioNTech and Moderna, both of whom make mRNA-based vaccines; the new booster made by Pfizer-BioNTech is for people 12 years and older, and the Moderna shot is for adults 18 years and older. The group also advised that people wait until at least two months after their previous dose before getting one of the two new booster shots. Within hours of the vote, CDC director Dr. Rochelle Walensky accepted the committee’s advice to recommend the new booster.

The Omicron boosters can “help restore protection that has waned since previous vaccination and were designed to provide broader protection against newer variants,” she said in a statement announcing her decision. “This recommendation followed a comprehensive scientific evaluation and robust scientific discussion. If you are eligible, there is no bad time to get your COVID-19 booster and I strongly encourage you to receive it.”

The CDC’s guidance comes a day after the U.S. Food and Drug Administration (FDA) authorized the Omicron-specific shots by both companies.

The booster is the first to target a variant of the SARS-CoV-2 virus. All vaccines that have been approved by the FDA and recommended by the CDC until this point, as well as booster doses that the agencies have authorized, targeted the original virus that emerged in 2019. The latest Omicron booster targets the BA.4 and BA.5 subvariants of the virus, which now account for nearly all new infections of COVID-19 in the U.S.

The Omicron BA.4/5 booster represents a dramatic change in the way health officials are hoping to protect the public. Rather than recommending booster doses every few months, as they’ve been advising since the vaccines became available in late 2020, they are now hoping to shift to an immunization schedule that mimics that for influenza, with an annual shot. The newly authorized Omicron booster will replace existing boosters of the original COVID-19 vaccine. All people 12 years or older will be eligible to get one, regardless of how many previous booster doses they have received so far.

In recommending the booster shot, the CDC’s panel of independent vaccine experts acknowledged that while they have authorized boosters before, this one is different in a number of ways. Not only is it the first to target a variant of the virus, it’s also the first to contain genetic material against two versions of the virus—the original, or ancestral strain, and Omicron BA.4 and BA.5, in a so-called bivalent vaccine. In the case of both Pfizer-BioNTech’s and Moderna’s booster, the dose is the same as the previous boosters that have been authorized, but split between the original and Omicron BA.4/5 strains.

Perhaps most concerning for the committee members, the boosters from both companies have not been tested yet in people, which means that there is no direct evidence that the shots will actually protect people from getting seriously sick with COVID-19. Both Pfizer-BioNTech and Moderna developed Omicron boosters after an FDA panel of experts met in June and requested that the vaccine manufacturers target the BA.4 and BA.5 subvariants. The companies had developed a booster that combined the original strain and an earlier version of Omicron, BA.1, and showed that it helped boost virus-fighting antibody levels against Omicron. But given that BA.4 and BA.5 quickly overtook BA.1 in causing infections, the FDA requested a bivalent vaccine including BA.4 and BA.5. Both companies submitted data to the FDA in August from animal studies showing that their boosters raised antibody levels in mice.

FDA and CDC scientists stress that the animal data is sufficient to recommend the newest booster, given the totality of evidence supporting the safety and effectiveness of previous versions of the vaccines so far. They point to the real-world data involving millions of people who have been vaccinated and boosted up to two times with the original vaccine, as well as data on the bivalent BA.1 booster that never made it to market. Dr. Doran Fink, deputy clinical director of the division of vaccines and related products applications at FDA, opened the discussion by telling the members that, “FDA in its authorization considered the totality of evidence, which consisted primarily of an extrapolation approach based on data from clinical trials with similar bivalent vaccine formulations consisting of the original and Omicron BA.1 sub lineage component, as well as extensive experience with the use of the original monovalent vaccine both as a primary series and as boosters. Additionally, FDA considered supportive data from some animal studies that provided additional reassurance about our extrapolation approach.”

That’s a different approach than that taken by U.K. and Canadian health authorities, who decided to authorize the bivalent booster made by Moderna against the BA.1 subvariant.

That leaves some public health experts in the U.S. concerned about recommending the Omicron BA.4/BA.5 booster. Dr. Pablo Sanchez, professor of pediatrics at Ohio State University and the lone dissenter in voting against recommending the new Omicron booster, said: “I feel we really need human data. It’s a new vaccine, a new platform, and there is a lot of vaccine hesitancy already, so we need human data. I really feel this is premature and wish we had seen that human data.”

Sanchez, however, acknowledged that he would still probably get the booster, since he was convinced by the FDA’s argument that the available evidence, even if it’s indirect, suggests the new shot is both safe and potentially effective. There’s also the fact that every year, the annual flu shot is approved without data demonstrating effectiveness against the latest influenza strains circulating, making the immunization a bit of a gamble, albeit a calculated one. “I would remind the committee that every year, we recommend influenza vaccines based on new strains without clinical studies being done,” said Dr. Melinda Wharton, from the CDC’s National Center for Immunization and Respiratory Diseases and executive secretary of the CDC commmittee. “In a lot of ways, this is analogous to that.”

In favor of recommending a change in the booster, CDC researchers documented that people immunized with the original vaccine and boosters have waning, and in some cases very little, protection from getting infected with the Omicron BA./BA.5 subvariant. While the original vaccines and boosters are protecting people from getting sick enough to need hospitalization, even that protection appears to be diminishing, as more fully immunized people are getting moderately ill after getting infected with BA.4/BA.5. Modeling presented by CDC scientists also showed that if health authorities were to wait another few months, until November, for human studies to be complete on the BA.4/5 booster, about 137,000 more people would be hospitalized and nearly 10,000 people would die of COVID-19.

That’s the reason behind the government’s push to authorize the new booster, but it’s not clear if the public will follow health officials’ advice and rush to get boosted—especially in an environment in which people are weary of repeated boosters and increasingly skeptical of their effectiveness. As more people become infected with the highly transmissible Omicron BA.4/5 variant, they believe that their immunity from having been sick trumps the need to get boosted. And some health officials aren’t convinced that BA.4/5 booster provides that much additional protection from disease compared to the original vaccine, which becomes even more questionable when it comes to people who have been immunized and boosted, and who have recently been infected with Omicron BA.4/5, as many Americans have recently. Dr. Paul Offit, a professor at Children’s Hospital of Philadelphia and a member of the FDA’s vaccine expert committee, does not feel there is enough data to support recommending the new booster, and likely won’t line up for this shot. “The authorization and recommendation by the CDC doesn’t change the data, which is uncomfortably scant,” he tells TIME. “We still have no human data on this vaccine. I don’t plan to get this vaccine, mostly because I don’t think I need it. I have had three previous doses and one mild natural infection.”

Some of the data presented to the CDC committee members addressed this question of how much incremental benefit most people, who are vaccinated and boosted, will get from the Omicron-specific booster. While it makes biological sense to match the booster shot to the circulating virus, which is currently the Omicron BA.4/5 subvariant, the studies haven’t been completed yet. The early data in animals are encouraging, suggesting that boosting with the Omicron-specific shot may help people build broader immunity to not just the original strain but also to multiple variants, including Alpha, Beta, Delta, and Omicron, but mouse data can’t substitute for human trials.

Both companies are conducting human studies and expect to have that information in a few months, but in the meantime, people will have to make their own decisions about how comfortable they are with getting the newest booster dose. “I think this is a big step forward toward simplification,” Wharton told the committee. “I hope we are moving toward something that is simpler and will not require such frequent changes going forward. Clearly we are not there yet, but I think this is a big step forward.”

The U.S. government has already purchased 170 million doses of the Omicron BA.4/5 booster from the two manufacturers, and Pfizer-BioNTech has already shipped 100,000 doses to 62 sites that arrived on Sept. 1. After the Labor Day weekend, the company expects to deliver 3 million doses to more than 3,000 sites. Moderna is manufacturing 66 million doses to meet the government’s order, but has not reported how many have been shipped so far.

Contact us at [email protected].

During the past 60 years, experts have documented a steep rise in the incidence of both ulcerative colitis and Crohn’s disease—the two medical conditions that make up most cases of inflammatory bowel disease (IBD). For decades, this rise was confined to North America, Western Europe, and other industrialized nations. While there’s some evidence that the rise in IBD has slowed down or even plateaued in those places, IBD is becoming increasingly common in newly industrialized countries in Asia and other parts of the world.

There’s no question that genetic factors play a part in a person’s risk for inflammatory bowel disease—and especially for Crohn’s disease. But the increases in IBD incidence and the disease’s pronounced geographical patterns strongly suggest that environmental factors are also at play. “Following World War II, we’ve seen a rapid rise in IBD incidence throughout the developed world,” says Dr. Gilaad Kaplan, a professor and gastroenterologist at the University of Calgary in Canada. “Something about a Western lifestyle seems to be allowing this disease to flourish.” What is that something? That’s the unsolved mystery.

There are several theories—or rather, suspects. Researchers have found associations between IBD and air pollution, food additives, early-life antibiotic exposures, and other environmental variables. Kaplan says that several of these risk factors, not just one, likely underpin the increases in IBD. And they all have one thing in common: the gut microbiome. “Most people feel that what’s driving the inflammatory response we’re seeing, where the body’s immune system attacks the bowels, lies in the intestinal microbiome,” he says.

Your gastrointestinal tract is populated by billions of ­microorganisms that are critical to the health and functioning of your gut. These bacteria help digest the foods you eat, and the metabolites they produce help regulate your immune system. Kaplan says that a robust and diverse microbiome is a hallmark of a healthy GI tract, while anything that disrupts or imbalances the microbiome is associated with GI dysfunction, including IBD. “A lot of the environmental risk factors that have been studied widely are now being looked at through the lens of the microbiome,” he says. This new perspective is yielding important insights, including some related to the treatment of IBD.

Here you’ll find a rundown of the environmental risk factors that researchers have linked to IBD, as well as expert guidance on limiting those risks.

Air pollution and IBD

For a first-of-its-kind study published in 2010, researchers examined the association between ambient air pollution and the incidence of IBD. They found that young people who had grown up around high concentrations of nitrogen dioxide were more than twice as likely as other kids to develop Crohn’s disease.

Since that groundbreaking study, more work has linked air pollution to higher rates of IBD. “We’ve found that early-life exposures to both nitrogen dioxide and ozone are associated with increased risks,” says Eric Lavigne, a senior epidemiologist at Health Canada (the Canadian government’s equivalent of the U.S. Department of Health and Human Services).

Both of these pollutants are associated with automobile traffic. Fuel-­burning cars and trucks emit nitrogen dioxide in their exhaust. When that nitrogen dioxide mixes with heat and sunlight, it undergoes a chemical reaction that produces ozone. “In areas where there’s a lot of traffic, we might see elevated levels of this combination,” Lavigne says. “Living in close proximity to those areas may be a risk factor for IBD.”

How could air pollution affect gut health? Research has shown that after breathing in pollutants, the lungs may actually push these out into the throat so that they’re swallowed. This process is known as mucociliary clearance. Once in the gut, Lavigne says, these pollutants may cause damage to the gut’s microbiota in ways that promote inflammation.

Based on his and others’ work, he says that air pollution exposures during childhood—not in utero or in adulthood—seem to pose the greatest IBD risks. Keeping away from heavily trafficked roads, especially on hot sunny days, is one way to avoid these risks. “Levels of these pollutants are highest within 50 meters”—about 160 feet—“of busy roads,” he says.

Lavigne has also looked at the effect of parks and other urban green spaces on air-­pollution risks. His research found that kids who grew up near green spaces were at reduced risk for IBD. “Particles in the air may get trapped by the leaves from trees, and so having more trees and greener environments might actually create a buffer that reduces people’s exposures,” he explains.

Read More: The Connection Between IBD and Aging

Food choices and dietary exposures

The stuff you swallow can affect the composition of your micro­biome, and therefore your gut health. And researchers have identified a number of diet-­related variables that appear to play a role in IBD risk.

Some of the strongest work involves the very first foods a newborn ingests. “Breastfeeding seems to be very important,” Kaplan says. Research has shown that kids who are breast-fed, as opposed to formulafed, are more than 25% less likely to develop IBD. “As an infant, when you have breast milk, there seem to be tangible benefits that support the development of a robust and diverse microbiome,” he explains.

Beyond infancy, there’s evidence that consuming sugary beverages—especially soft drinks—increases a person’s risks for ulcerative colitis. The more soda someone consumes, the more their risk goes up. On the other hand, eating vegetables is associated with lower rates of ulcerative colitis, while eating whole fruits or other fiber-rich foods seems to reduce a person’s risks for Crohn’s disease.

“There’s also some really interesting research on preservatives that prolong a food’s shelf life,” Kaplan says. A 2021 study in the journal BMJ found that higher intakes of ultra-­processed foods—soft drinks, but also salty snack foods, processed meats, and other packaged goods—were associated with a steep rise in IBD. Compared with people who ate less than one serving of these foods per day, those who ate five or more servings were at nearly double the risk of IBD.

“Things like emulsifiers and additives and heavily processed food particles could actually lead to alterations to the microbiome that may be associated with risk for IBD,” Kaplan says. “Choosing whole foods and staying away from things that are processed or packaged may reduce your risks.”

Read More: How to Maintain Your Social Life When You Have IBD

Early-life hygiene and antibiotics

Antibiotics can save lives when someone has a bacterial infection. But these medicines kill indiscriminately—meaning they take out good bacteria as well as bad. And there’s evidence that when taken early in life while a child’s micro­biome is still forming, anti­biotics may cause imbalances that promote IBD.

“Antibiotics can alter the composition of the human gut micro­biota by decreasing taxonomic richness and diversity,” wrote the authors of a 2019 research review in the journal Gastro­enterology. They cited work linking early-life use of broad-­spectrum antibiotics—basically anything but penicillin—to a more than 50% increase in IBD risk.

“If you have a bacterial infection, you need antibiotics,” Kaplan says. But too often, these drugs are prescribed when they’re not really needed—for example, when a child has a respiratory-­tract infection that would likely resolve on its own without anti­biotics. Doctors are increasingly aware of the risks posed by antibiotic overuse. But parents still need to be wary, he says.

Meanwhile, while hygiene is usually considered a good thing—and not just a good thing but a safety measure that has saved countless lives—there’s strong evidence that being too clean, especially during infancy and childhood, may actually weaken the gut micro­biome. The “hygiene hypothesis,” as it’s called, argues that kids who interact with siblings, farm animals, pets, dirt, and other sources of germs tend to have healthier and more resilient gut microbial ecosystems, and research has linked all of these factors to lower rates of IBD (as well as allergies and autoimmune diseases).

“Early-life exposure [to germs] has an important programming role on the microbiome and immune system,” says Dr. ­Emeran Mayer, founding director of the Microbiome Center at the University of California, Los Angeles. The theory is that when the developing microbiome encounters germs and bacteria, this exposure trains its sensitivity and reactivity in ways that lower a person’s risks for IBD. And so raising kids in squeaky-­clean environments and apart from other children, animals, or sources of germs could imperil their gut health as well as their immune competency. (Some experts have even speculated that COVID-19 safety measures, like the heavy use of hand sanitizers, may inadvertently lead to an increase in IBD among young people.)

A complicated puzzle

While researchers have made a lot of progress in the study of IBD’s environmental risk factors, they say the relationship between a person’s gut health and these variables is immensely complicated. “Someone’s risks may be completely different when in utero or in childhood or in adulthood,” Kaplan points out. He offers cigarette smoking as an example. It may be that smoking during adolescence, more so than in adulthood, is a greater risk factor for gut disorders. Or vice versa. A person’s risk may also depend on the amount they smoke, as well as on their genetic predisposition for GI disease. “There are so many variables that create so much heterogeneity,” he says. “Saying that this is a risk factor and this is not is very difficult to do.”

With that caveat in mind, Kaplan says there are steps every­one can take to reduce their IBD risks. “These are often things that promote healthy living in general,” he says. “Eating more whole foods, getting regular physical activity, and trying to reduce stress in your life are all on the checklist I go through with patients.” For those who live in parts of the country where sunlight is sparse, he says that taking a ­vitamin D supplement may be helpful. “If you look at people who have IBD, you often see a vitamin D deficiency,” he explains. This may just be a by-product of the condition—not its cause. Still, he says that taking a 1,000-IU daily supplement is a low-risk bulwark against gut issues that may be related to a deficiency.

Read More: Fecal Transplants: a New Treatment for IBD

The role of external factors like diet, drugs, and pollution in IBD is complex. But medical science is making big strides in considering the impacts of environmental factors. “It’s pretty revolutionary the way the field has opened up,” Mayer says.

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