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When Rafy Evans, 25, was a teenager, she adopted a mantra to guide her blossoming career aspirations: “I want my work to be about my life, and I want my life to be about my work.”

Evans came of age in what she calls the “girlboss” era, idolizing female entrepreneurs like Nasty Gal’s Sophia Amoruso and Glossier’s Emily Weiss. After graduating college, she threw herself into demanding jobs in Los Angeles’ influencer economy, building a reputation for being available 24/7 and valuing career achievement above all else.

Today, however, Evans’ teenage slogan makes her cringe. After reading a recently published book that made her question the large role work played in her life, she quit her job in June and took a couple months off to rest and recover from burnout (a huge privilege, she acknowledges). She is currently building healthy boundaries between her personal life and her new job in public relations, and is working on “unlearning” the always-on mindset with which she started her career. “I’m just trying to achieve more peace,” she says. “That’s my big goal in everything that I’m doing.”

Evans isn’t alone in taking a step back from the corporate grind. First came the “Great Resignation,” followed recently by the phenomenon of “quiet quitting.” Many surveys have also pointed to a sense of malaise and fatigue sweeping the American workforce, apparently culminating in a common desire to do less.

Read More: Why a Class on Doing Nothing Is So Popular

For example, more than half of surveyed workers said they’re questioning the purpose of their jobs and the role work should play in their lives in a January report from research firm Gartner. As of July, roughly half of U.S. workers were looking for a new job, according to the Society for Human Resource Management (SHRM), and 29% of those who had recently resigned said they did so because they wanted better work-life balance. In the second quarter of 2022, only about a third of U.S. workers said they were engaged with their jobs, while almost 20% said they were actively disengaged—the lowest ratio of engagement to disengagement in about a decade, according to Gallup research. That could be because, according to other SHRM research, more than half of U.S. workers feel exhausted at the end of the day. It’s not hard to imagine how that exhaustion turns into a desire for a less-stressful job.

In essays and news articles, many people have described their newly lax attitudes toward work as a loss of ambition. But it’s hard to say whether ambition is actually dropping across the U.S. population, according to Timothy Judge, a professor at the Ohio State University’s Fisher College of Business who has studied the concept. There are some objective measures of ambition, and it can be measured in research if it’s well-defined, but Judge says that’s not often done. Some surveys that ask people to self-report their own ambition, however, suggest it’s alive and well. In a 2022 CNBC/Momentive poll, about half of female respondents and two-thirds of Black women described themselves as “very ambitious.”

Meanwhile, the idea of phoning it in at work is nothing new. The concept today known as “quiet quitting”—basically, staying at a job but doing the bare minimum—has shown up in research (often under some variation of the name “work withdrawal”) for decades, says John Kammeyer-Mueller, a professor at the University of Minnesota’s Carlson School of Management. Still, recent data on quit rates, work attitudes, and employee engagement do suggest our collective relationship with work has hit a rocky patch, Kammeyer-Mueller says.

As with nearly any societal shift observed over the last three years, the pandemic is one obvious explanation. But what, exactly, about the COVID-19 era has made people want to stop striving?

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For many people, the COVID-19 pandemic served as a giant pause button—and not everyone is eager to hit “play” again, says Natasha Crosby, a Texas-based therapist. “The pandemic forced people to slow down and actually evaluate their lives and how they were spending their time,” Crosby says. When they stopped for a moment, many high-achieving people saw all the things they’d been missing—time with loved ones, time to relax, time for hobbies—and decided there was a better way to live, Crosby says.

Remote work is a major factor in the current cultural shift, Kammeyer-Mueller agrees, but he thinks it’s for a different reason. Despite the narrative that working from home turns people into slackers, Kammeyer-Mueller thinks the problem is actually that people are working too much at home, burning out, and pulling back from their careers as a result. Being physically separated from coworkers may also make people feel less committed to their jobs, which zaps their motivation to put in extra effort, he says.

But “people are still motivated to achieve things; they just don’t want to do it at work as much anymore,” Kammeyer-Mueller says. Anecdotally, he’s noticed many people doubling down on hobbies and creative projects, instead of pulling extra hours at the office.

Read More: Forget Physique. Mental Health Is the Newest, Hottest Fitness Goal

Of course, not everyone was able to work from home and find new hobbies during the pandemic—and renouncing ambition is an undeniably privileged position to be in, since many people can’t afford to slow down. Nonetheless, it isn’t just remote office workers who are going through a reckoning, federal data show. From April 2020 to November 2021, quit rates were highest among people working in industries like food service, hospitality, and retail.

In many cases, however, hourly and essential workers aren’t quitting because of “angst about ambition,” says Stefanie O’Connell Rodriguez, a journalist who writes a newsletter about ambition. They’re quitting because they don’t want to work jobs that provide few benefits and barely pay the bills. That may help explain why workers at Amazon and Starbucks are unionizing, and why many Great Resigners are taking advantage of labor shortages to negotiate for better-paying jobs.

Even for privileged, white-collar office workers, O’Connell Rodriguez thinks it’s not as simple as people spontaneously “losing” their ambition. She believes the current discourse is about a rupture in the social contract, a mass realization brought on by the pandemic that working hard doesn’t always guarantee stability and enough savings to weather an emergency. “It’s a reckoning with the workplace, and it’s a reckoning with the social safety net more broadly,” she says. “When your health care is tied to your employment and you get laid off in a pandemic,” it’s natural to reevaluate the way you spend most of your waking hours.

Read More: The Pandemic Changed Paid Sick Leave, But Not For Everyone

Income inequality is also worse than it’s ever been, adds Jacques Forest, a psychologist and professor at the University of Quebec in Montreal who studies motivation and ambition. When a handful of very rich people hold more wealth than the vast majority of the population, he says, it leads to questions like, ‘Why should I kill myself at my job’” if it won’t pay off?

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Is it healthy to break up with ambition? Here, too, opinions vary.

In 2012, Judge, the Ohio State professor, and Kammeyer-Mueller, the University of Minnesota professor, published a study based on data from a group of 700 people who agreed to be tracked for decades. They found that ambition was strongly linked to career achievement, and was also associated—albeit to a lesser extent—with life satisfaction. “Usually when somebody describes someone else as ‘ambitious,’ it insinuates [something] derogatory,” Judge says. “But I think the evidence does not necessarily support that view.” Instead, his research suggests that ambitious people are just as likely to be happy as their more easygoing counterparts.

“Ambition, in and of itself, is not bad,” Forest agrees. The “what” and “why” behind that ambition—the goal someone is striving toward and their motivation for doing so—often matter more. In scientific research, ambition is often assessed by measuring someone’s desire for higher education, career success, prestige, or income. But striving outside the professional realm may actually be healthier, Forest says.

Forest is a proponent of self-determination theory, which argues that humans’ key psychological needs are autonomy, competence, and relatedness (or connection with other people). Self-determination research suggests that ambition can be positive if it fulfills those needs, such as through doing work that feels meaningful or pushing for productive changes in one’s community. But if people are striving due to external motivators—like money, prestige, or social status—they’re likely to feel unfulfilled and may even act in antisocial ways, research shows. (There are exceptions, such as people who aspire to make enough money to lift themselves out of poverty or give charitably, Forest says.)

Read More: Why Doctors Are Prescribing Nature Walks for Stress

To Forest, it’s a good thing that many people are thinking critically about work and, in some cases, choosing to scale back. “When you see people renounce ambition, that’s [usually] the mainstream American capitalist ambition,” he says. “And if people are dropping out of this, that’s good news.”

Still, work is inescapable for most of us. And O’Connell Rodriguez thinks it’s dangerous for people to think they’ve simply stopped being ambitious on an individual level without considering larger cultural factors, like unsustainable workloads, unfair or unsafe working conditions, and health care being tied to employment. “When you misdiagnose the problem, you cannot come up with an effective solution,” O’Connell Rodriguez says. “It takes the responsibility away from the employer, from the culture, and the government to address everything that is contributing to this burnout, resignation, and loss of ambition.” Burnout researchers have known for years that workers can’t “self-care” their way out of the problem; employers have to make systemic changes for sustained progress.

Those changes are happening in some industries, buoyed by unionization efforts and employees pushing for higher salaries and better working conditions. But the progress has been slow and hard-won, leading some people who can afford to step back to forgo corporate ladder-climbing in favor of more satisfying social, family, or personal lives. That’s not necessarily bad, O’Connell Rodriguez says, but it’s also a choice people shouldn’t have to make.

“How do we enable a system,” she asks, “where we’re allowed to experience ambition in all facets of our lives?”

Evans, the public-relations rep redefining her relationship to work, is asking herself similar questions. She wonders how her life might look now if she’d had a more balanced outlook in her teens and early twenties, rather than buying into hustle culture. She’d probably have carved out more time for her personal writing, she thinks, and devoted more time to leisure and relationships that had nothing to do with networking.

She’s trying to find those things now, and is determined not to let her career take over her life again. “I look back now,” she says, “and I don’t know why I ever glorified your life being like this.”

Write to Jamie Ducharme at [email protected].

(PORTLAND, Maine) — Wildlife agencies in the U.S. are finding elevated levels of a class of toxic chemicals in game animals such as deer—and that’s prompting health advisories in some places where hunting and fishing are ways of life and key pieces of the economy.

Authorities have detected the high levels of PFAS, or per- and polyfluoroalkyl substances, in deer in several states, including Michigan and Maine, where legions of hunters seek to bag a buck every fall. Sometimes called “forever chemicals” for their persistence in the environment, PFAS are industrial compounds used in numerous products, such as nonstick cookware and clothing.

The U.S. Environmental Protection Agency launched an effort last year to limit pollution from the chemicals, which are linked to health problems including cancer and low birth weight.

Read More: Want to Stop the Next Pandemic? Start Protecting Wildlife Habitats

But discovery of the chemicals in wild animals hunted for sport and food represents a new challenge that some states have started to confront by issuing “do not eat” advisories for deer and fish and expanding testing for PFAS in them.

“The fact there is an additional threat to the wildlife—the game that people are going out to hunt and fish—is a threat to those industries, and how people think about hunting and fishing,” said Jennifer Hill, associate director of the Great Lakes Regional Center for the National Wildlife Federation.

PFAS chemicals are an increasing focus of public health and environmental agencies, in part because they don’t degrade or do so slowly in the environment and can remain in a person’s bloodstream for life.

The chemicals get into the environment through production of consumer goods and waste. They also have been used in firefighting foam and in agriculture. PFAS-tainted sewage sludge has long been applied to fields as fertilizer and compost.

In Maine, where the chemicals were detected in well water at hundreds of times the federal health advisory level, legislators passed a law in 2021 requiring manufacturers to report their use of the chemicals and to phase them out by 2030. Environmental health advocates have said Maine’s law could be a model for other states, some working on their own PFAS legislation.

California Gov. Gavin Newsom, a Democrat, signed a bill in September that bans the chemicals from cosmetics sold in the state. And more than 20 states have proposed or adopted limits for PFAS in drinking water, according to the National Conference of State Legislatures.

Read More: How to Find Out If Your Drinking Water Is Safe

More testing will likely find the chemicals are present in other game animals besides deer, such as wild turkeys and fish, said David Trahan, executive director of the Sportsman’s Alliance of Maine, a hunting and outdoors advocacy group.

The discovery could have a negative impact on outdoor tourism in the short term, Trahan said. “If people are unwilling to hunt and fish, how are we going to manage those species?” he said. “You’re getting it in your water, you’re getting it in your food, you’re getting it in wild game.”

Maine was one of the first states to detect PFAS in deer. The state issued a “do not eat” advisory last year for deer harvested in the Fairfield area, about 80 miles (129 kilometers) north of Portland, after several of the animals tested positive for elevated levels.

The state is now expanding the testing to more animals across a wider area, said Nate Webb, wildlife division director at the Maine Department of Inland Fisheries and Wildlife. “Lab capacity has been challenging,” he said, “but I suspect there will be more facilities coming online to help ease that burden — in Maine and elsewhere in the country.”

Wisconsin has tested deer, ducks and geese for PFAS, and as a result issued a “do not eat” advisory for deer liver around Marinette, about 55 miles (89 kilometers) north of Green Bay. The state also asked fishermen to reduce consumption of Lake Superior’s popular rainbow smelt to one meal per month.

Some chemicals, including PFAS, can accumulate in the liver over time because the organ filters the chemicals from the blood, Wisconsin’s natural resources department told hunters. New Hampshire authorities have also issued an advisory to avoid consuming deer liver.

Read More: Industrial Farming Causes Climate Change. The ‘Slow Food’ Movement Wants to Stop It

Michigan was the first state to assess PFAS in deer, said Tammy Newcomb, senior executive assistant director for the Michigan Department of Natural Resources.

The state issued its first “do not eat” advisory in 2018 for deer taken in and near Oscoda Township. Michigan has since issued an advisory against eating organs, such as liver and kidneys, from deer, fish or any other wild game anywhere in the state. It has also studied waterfowl throughout the state in areas of PFAS surface water contamination.

The state’s expanded testing also has proven beneficial because it helped authorities find out which areas don’t have a PFAS problem, Newcomb said.

“People like to throw up their arms and say we can’t do anything about it. I like to point to our results and say that’s not true,” Newcomb said. “Finding PFAS as a contaminant of concern has been the exception and not the rule.”

The chemical has also been found in shellfish that are collected recreationally and commercially. Scientists from the Florida International University Institute of Environment sampled more than 150 oysters from around the state and detected PFAS in every one, according to their study in August. Natalia Soares Quinete, an assistant professor in the institute’s chemistry and biochemistry department, described the chemicals as “a long-term poison” that jeopardizes human health.

Dr. Leo Trasande, a professor of pediatrics at NYU Grossman School of Medicine who has studied PFAS, said the best way to avoid negative health effects is reducing exposure. But, Trasande said that’s difficult to do because the chemicals are so commonplace and long-lasting in the environment.

“If you’re seeing it in humans, you’re likely going to see the effects in animals,” he said.

Wildlife authorities have tried to inform hunters of the presence of PFAS in deer with posted signs in hunting areas as well as advisories on social media and the internet. One such sign, in Michigan, told hunters that high amounts of PFAS “may be found in deer and could be harmful to your health.”

Kip Adams, chief conservation officer for the National Deer Association, said the discovery of PFAS in states like Maine and Michigan is very concerning to hunters.

“With the amount of venison my family eats, I can’t imagine not being able to do that,” Adams said. “To this point, everything we’ve done has been about sharing information and making sure people are aware of it.”

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Associated Press climate and environmental coverage receives support from several private foundations. See more about AP’s climate initiative here. The AP is solely responsible for all content.

Contact us at [email protected].

The Centers for Disease Control and Prevention reported that American life expectancy had taken a nosedive during the pandemic, with the biggest drop occurring among non-Hispanic American Indians and Alaska Natives. It was reassuring to see coverage of this terrible trend; but largely absent was the context and history underlying these disparities. The reasons why indigenous people were hit hardest by COVID-19 go beyond the fact that they also have very high rates of underlying comorbidities—like obesity, high blood pressure, diabetes, and cardiovascular disease. Instead the roots of health disparities among indigenous people are inextricably linked with the complex history of our nation’s mistreatment of indigenous peoples.

I cared for Native patients at Indian Health Service and tribal health facilities in Arizona, New Mexico, and Maine before the COVID-19 pandemic. I saw firsthand how the doctrine of Manifest Destiny—the belief that colonial settlers had a divine right to eliminate indigenous peoples and appropriate their lands—has been an engine for sickness and death, even today, centuries after our nation was founded.

Manifest Destiny was widespread attack on indigenous lands and peoples. The U.S. military forced relocations of Native peoples disrupting native foodways of hunting, fishing, gathering, and farming. The military intentionally targeted indigenous food sources, destroying crops and livestock. “We were seen as the enemy. And so we were fed like prisoners of war,” said Martin Reinhardt, a professor at Northern Michigan University. The people were given measly rations of flour, sugar, salt, and lard—the ingredients to make fry bread, what many think is a traditional indigenous food, but is in fact a food of oppression, cooked up out of necessity. Later, the U.S. government would provide “commodity foods”—mystery meat, canned vegetables, and yellow cheese—to fulfill their treaty obligations. These commodity foods would become staples of Native kitchens and lead to sky-high rates of obesity, high blood pressure, diabetes, and cardiovascular disease among indigenous peoples.

In the 1800s and early 1900s, as settlers moved west, the federal government dammed rivers and built reservoirs, siphoning water away from the tribes. “The Hoover Dam providing electricity, damming up Colorado River. So you have access to power, access to water. And this is how the West was created,” said Amber Crotty, a Navajo Nation Council delegate. Water is a precious commodity, especially out west. Without access to safe water, indigenous people haul water by truck over long distances or turn to unsafe sources tainted by contaminants ranging from bacteria to uranium. They might not wash their hands or bathe as frequently, increasing their risk for various infections. It’s hard to prepare food safely. They might drink diabetes-promoting sugar-sweetened beverages because they’re cheaper than bottled water.

Indigenous lands have also been under the assault of extractive industries in search of natural resources like uranium and oil. Abandoned uranium mines now dot the southwest. The radioactive waste still hasn’t been cleaned up. Native people exposed to the toxins suffer from higher rates of lung cancer and other cancers, scarring of the lungs, asthma and emphysema, blood disorders, birth defects, and more. In other parts of the country, the oil and gas industry has driven up cancer rates while also destroying the shoreline, displacing indigenous peoples yet again.

Missing in the media coverage of dropping American life expectancy was that among indigenous people, deaths from unintentional injuries, mostly drug overdose deaths, were almost tied with deaths from COVID-19, followed closely by chronic liver disease and cirrhosis, largely related to alcohol use.

Long before the so-called “diseases of despair”—alcohol-related liver disease, drug overdoses, and suicide—drove down life expectancy among low-income, less-educated white non-Hispanic Americans at the beginning of the 21st century, these same afflictions were killing indigenous peoples. The causes are similar: the destruction of a way of life and the decline of family and community. Despair comes from “the loss of meaning, of dignity, of pride, and of self-respect,” write Anne Case and Angus Deaton in Deaths of Despair and the Future of Capitalism. Family separations and the loss of cultural knowledge and identity caused an epidemic of despair among indigenous peoples that’s been passed down over generations.

The attack on indigenous peoples evolved over time. It began with overt genocide—“the only good Indian is a dead one” said General Philip Sheridan in the 1860s. Then came the era of assimilation. “Kill the Indian in him, and save the man,” said Captain R. H. Pratt, the founder of the Carlisle Indian Industrial School, which like so many other Indian boarding schools, sought to “civilize” Native children. Indigenous children were separated from their families and sent to boarding schools or fostered or adopted out to non-Native families. Later in the 20th century, more sophisticated tools were used to control the population, like contraception and even forced sterilization. Indigenous peoples have “…a fear that white doctors don’t have your best interests at heart. And those are not fears that came from nowhere. Those are fears that were passed down from generation to generation,” said Sarah Deer, a Muskogee Creek citizen and a professor at the University of Kansas. Just as mistrust has been a barrier to engagement with the health care system among other communities of color, so, too, is it among indigenous communities.

The violence against Native peoples continues. They are twice as likely to be victims of homicide as other racial and ethnic groups in the U.S., and more than 40% of those murder victims are killed by someone of another race, in sharp contrast to homicide victims of other races who are largely killed by persons of their same race. About half of indigenous women experience intimate partner violence and sexual violence, with over 95% non-Native perpetrators. “Non-natives, in particular white men, know they can come into tribal communities and they can hunt us as Native women with impunity, because they know that we can’t touch them,” said Lisa Brunner, an enrolled member of the White Earth Ojibwe Nation in Minnesota.

Tribal reservations are often in remote places. The FBI doesn’t go out to investigate unless a major crime has been committed, and even then, U.S. Attorneys Offices are far less likely to prosecute crimes perpetrated in Indian Country, including violent crime, than elsewhere. “…[I]magine your own community where certain people didn’t have to abide by the law. And what does that do to a community, when that happens?” said Alfred Urbina, attorney general for the Pascua Yaqui tribe. Victims of violent crime are more likely to adopt high-risk coping behaviors like alcohol and drug use. They’re also more likely to experience poor mental health, chronic pain, diabetes, high blood pressure, and other chronic conditions.

Much of this history has been brushed aside and forgotten. What we’re left with are public health statistics taken out of context and medical diagnoses whose socio-pathophysiology we don’t fully understand. And so, our prescriptions and treatment plans fail. Victor Lopez-Carmen, a Hunkpati Dakota-Yaqui student at Harvard Medical School, says he’s often been told, “[I]f we only will stop eating the bad foods, if we’ll only stop smoking, if only stop drinking, if we’ll only behave ourselves, then we’ll have better health outcomes.” But that’s not why Native people are sick and dying.

Contact us at [email protected].

One of my favorite places on earth is the Ali’i Kula Lavender farm on Maui. I went there on a lark, not even expecting to enjoy it. My wife dragged me there on a trip years ago—she’s a huge essential oils fan and particularly lavender oil fan—and I fell in love. It’s acre upon acre of rolling hills covered in lavender fields, Buddhist shrines, meandering trails, and great views of the ocean. And always, in the background and foreground, is the fragrant scent of lavender. Any stress melts away (not that the stress is much an issue in Hawaii) and you’re perfectly content just wandering calmly through the fields. Every time you brush against a plant the scent intensifies and follows you for a bit.

The stress-melting effects couldn’t have just been from the lavender—the walking, the fresh air, the fact that I was on vacation in Hawaii all played a large role—but the lavender was also a factor.

But how? Are there ways to get those same benefits without visiting a lavender farm in the middle of the Pacific Ocean?

Yes. Lavender oil, or lavender essential oil, contains the essence of the lavender plant—all the aromatic constituents that provide the pharmacological effects we see from the whole plant.

The Benefits of Lavender Oil

Lavender Oil Reduces Anxiety

Lavender oil aromatherapy is one of the most common treatments for surgery or medical treatment-related anxiety.

In dental patients nervous about treatment, lavender oil aromatherapy reduces anxiety. This is also effective in children with anxiety undergoing dental treatment. Other studies confirm this effect.

Not all studies are positive. The pre-surgery lavender oil inhalation for general anxiety sometimes works, sometimes doesn’t, but the balance of evidence shows that it probably helps. One interesting study found that lavender oil aromatherapy before a medical procedure reduced anxiety, stress, and pain levels while improving oxygen saturation.

Oral lavender oil can also work. Oral lavender oil seems just as effective (without the side effects, like drowsiness and extreme addiction) as Xanax at reducing general anxiety. In Germany, oral lavender oil is considered to be a legitimate treatment for anxiety disorders.a

It’s mixed, then, but I think the evidence is fairly strong that lavender oil can reduce anxiety in people.

Lavender Oil Lowers Stress

It seems that reduction in stress I felt wasn’t just placebo or a result of me being on vacation in Hawaii. The bulk of published research finds that lavender has real effects on biomarkers and subjective sensations of stress.

In one study, smelling either lavender or rosemary essential oils for 5 minutes lowered cortisol levels in human subjects. Lavender was far more potent than rosemary, with a 1000x dilution of lavender being just as effective as a 10x dilution of rosemary.

In another study, lavender essential oil inhalation was also effective at reducing math test-induced rises in a biological stress marker.

In subjects undergoing needle insertion, those who wore an oxygen mask with lavender oil aroma pumped through it experienced less subjective stress. Furthermore, the pain of getting injected was reduced.

Subjects in another study watched a stressful video. Half of them underwent lavender oil aromatherapy during the video while half did not. Those who got the lavender oil had reduced stress markers compared to those who didn’t get the lavender oil.

After heart surgery, however, lavender oil aromatherapy has little to no effect on most markers of stress, other than a mild reduction in blood pressure.

Lavender Oil Increases Wound Healing

Lavender oil actually increases expression of an essential wound healing factor known as transforming growth factor beta. After wounding rats (I know, it sounds bad), researchers applied lavender oil to the wound. By day four, collagen deposition had increased along with the presence of fibroblasts (which help lay down collagen).

Overall, the bulk of research finds that lavender oil can speed up wound healing, increase growth factors at the wound site, and improve collagen synthesis. Even when it doesn’t speed up healing any better than control, it does appear better at reducing pain and improving comfort during the healing process. Slow wave sleep is very important for learning, memory consolidation, and muscle recovery.

Other studies have found that lavender oil inhalation can improve sleep quality, counter insomnia, and even increase melatonin levels. Wearing a lavender oil aromatherapy patch at night improves wakefulness in the morning.

If you’re interested in using aromatherapy for sleep, my wife loves the Vagus Nerve Pillow Mist. I can never bring myself to buy it for myself, but I’ll certainly borrow hers for a spray or two. Spray this stuff on your pillow before bed and you’ll get a great night’s sleep. This isn’t just lavender oil, but the lavender oil is quite prominent and responsible for many of the effects.

How to Use Lavender Oil

There are a few different ways to use lavender oil.

Aromatherapy

The simplest way to do “aromatherapy” is to open the bottle of lavender oil and smell it. Quite literally just hold it up to your nose and sniff whenever you get a hankering. However, most studies have subjects smell the lavender for 5-10 minutes for the strongest effects. You can also use a diffuser or wear an aromatherapy patch.

Oral

Most lavender oils aren’t meant to be consumed orally. I’m not saying they’ll hurt you, but that’s not their intended use so I can’t suggest that you try it. You can take a dedicated oral lavender oil supplement.

Massage

Simply add a few drops of lavender oil to your massage oil of choice—about 2 drops for every tablespoon of carrier oil. Olive oil, jojoba, MCT, avocado, or coconut all make great massage oils.

Direct application

If you’re trying to heal a wound, directly apply a drop or two of lavender oil mixed in a tablespoon of carrier oil (just like the massage oil) and apply that to the wound.

Who Shouldn’t Use Lavender Oil?

For most people, lavender oil is a risk-free essential oil that may help with wound healing, anxiety, stress, and sleep.

I would caution against using lavender oil products on children, as lavender oil may have estrogenic effects if used to excess. A number of studies have even found links between lavender oil exposure and early breast growth—in both girls and boys. To be fair, the children in these studies were exposed to high levels of lavender fragrance on a daily basis for years on end.

I would also recommend against using lavender oil on a daily basis, particularly for men. Use as needed, not chronically. You don’t want chronic estrogen increases.

That’s about it, folks. I hope you have good success if you give lavender oil a try.

Take care.

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As a pulmonary specialist, I spend most of my clinical time in the hospital—which, during pandemic surges, has meant many long days treating critically ill COVID-19 patients in the ICU. But I also work in an outpatient clinic, where I also treat those same sorts of patients after they’re discharged: people who survived weeks-long hospitalizations but have been dealing ever since with lung damage. Such patients often face the same social and economic factors that made them vulnerable to COVID-19 to begin with, and they require attentive care.

Patients like these undoubtedly suffer what researchers have been calling post-acute sequelae of SARS-CoV-2, or PASC—which, according to one highly publicized recent CDC study, afflicts some 20 percent of COVID-19 survivors ages 18 to 64. Other studies have yielded lower estimates of the condition also called long COVID, and while differences in study methodology account for some of this variability, there’s a more fundamental issue eluding efforts to uncover the one “true” estimate of the likelihood of this condition. Quite simply, long COVID isn’t any one thing.

From the April 2021 issue: Unlocking the mysteries of long COVID

The wide spectrum of conditions that fall under the umbrella of long COVID impedes researchers’ ability to interpret estimates of national prevalence based on surveys of symptoms, which conflate different problems with different causes. More importantly, however, an incomplete and constrained perspective on what long COVID is or isn’t limits Americans’ understanding of who is suffering and why, and of what we can do to improve patients’ lives today.

The cases of long COVID that turn up in news reports, the medical literature, and in the offices of doctors like me fall into a few rough (and sometimes overlapping) categories. The first seems most readily explainable: the combination of organ damage, often profound physical debilitation, and poor mental health inflicted by severe pneumonia and resultant critical illness. This serious long-term COVID-19 complication gets relatively little media attention despite its severity. The coronavirus can cause acute respiratory distress syndrome, the gravest form of pneumonia, which can in turn provoke a spiral of inflammation and injury that can end up taking down virtually every organ. I have seen many such complications in the ICU: failing hearts, collapsed lungs, failed kidneys, brain hemorrhages, limbs cut off from blood flow, and more. More than 7 million COVID-19 hospitalizations occurred in the United States before the Omicron wave, suggesting that millions could be left with damaged lungs or complications of critical illness. Whether these patients’ needs for care and rehabilitation are being adequately (and equitably) met is unclear: Ensuring that they are is an urgent priority.

Recently, a second category of long COVID has made headlines. It includes the new onset of recognized medical conditions—like heart disease, a stroke, or a blood clot—after a mild COVID-19 infection. It might seem odd that an upper respiratory tract infection could trigger a heart attack. Yet this pattern has been well described after other common respiratory-virus infections, particularly influenza. Similarly, various types of infections can lead to blood clots in the legs, which can travel (dangerously) to the lungs. Respiratory infections are not hermetically sealed from the rest of the body; acute inflammation arising in one location can sometimes have consequences elsewhere.

But mild COVID-19 is so common that measuring the prevalence of such complications—which also regularly occur in people without COVID-19—can be tricky. Well-controlled investigations are needed to disentangle causation and correlation, particularly because social disadvantage is associated both with COVID exposure and illnesses of basically every organ system. Some such studies, which analyzed giant electronic-health-record databases, have suggested that even mild COVID-19 is at least correlated with a startlingly wide spectrum of seemingly every illness, including diabetes, asthma, and kidney failure; basically every type of heart disease; alcohol-, benzodiazepine-, and opioid-use disorders; and much more.

To be clear, this research generally suggests that such complications occur far less often after mild COVID-19 cases than severe ones, and the extent to which the coronavirus causes each such complication remains unclear. In other words, we can surmise that at least some of these complications (particularly vascular complications, which have been well-described in many studies) are likely a consequence of COVID-19, but we can’t say with certainty how many. And more importantly, we don’t yet understand why some people with mild COVID recover easily while others go on to experience such complications. However, an estimated 81 percent of Americans have now been infected at least once, so the public-health ramifications are large even if COVID causes only some of the aforementioned recognized diseases, and even if our individual risk of complications after a mild infection is modest. Regardless of cause, patients who do develop any such chronic diseases require attentive, ongoing medical care—a challenge in a nation where 30 million are uninsured and even more underinsured.

Another category of long COVID is something rather more quotidian, if still very distressing for those experiencing it: respiratory symptoms that last longer than expected after an acute upper-respiratory infection caused by the coronavirus, but that are not associated with lung damage, critical illness, or a new diagnosis like a heart attack or diabetes. Symptoms such as shortness of breath and chest pain are common months after run-of-the-mill pneumonia unconnected to the coronavirus, for instance, while many patients who contract non-COVID-related upper respiratory infections subsequently report a protracted cough or a lingering loss of their sense of smell. That a COVID-related airway infection sometimes has similar consequences only stands to reason.

Read: Long-haulers are fighting for their future

However, none of these may be what most people think of when long COVID is invoked. Some may even argue that such syndromes are not, in fact, long COVID at all, even if they cause long-term suffering. “Long Covid is not a condition for which there are currently accepted objective diagnostic tests or biomarkers,” wrote Steven Phillips and Michelle Williams in the New England Journal of Medicine. “It is not blood clots, myocarditis, multisystem inflammatory disease, pneumonia, or any number of well-characterized conditions caused by Covid-19.” Instead, for some the term may invoke a chronic illness—a complex of numerous unexplained, potentially debilitating symptoms—even among those who may barely have felt sick with COVID in the acute phase. Symptoms may vary widely, and include severe fatigue, cognitive issues often described as brain fog, shortness of breath, “internal tremors,” gastrointestinal problems, palpitations, dizziness, and many other issues around the body—all typically following a mild acute respiratory infection. If the other forms of long COVID seem more easily explainable, this type is often characterized as a medical mystery.

Teasing apart which kind of long COVID a person has is important, both to advance our understanding of the illness and to best care for people. Yet lumping and splitting varieties of long COVID into categories is not easy. A given patient’s case might have features of more than one of the types that I’ve described here. Some patient advocates and researchers have tended to exclude patients in the first category—that is, survivors of protracted critical illness—from their conception of COVID long-haulers. I would argue that, insofar as we define long COVID as lasting damage and symptoms imposed by SARS-CoV-2, the full variety of severe long-term manifestations should be included in its scope. “Clinical phenotyping” studies now under way may eventually help scientists and doctors better understand the needs of different types of patients, but patients in all categories deserve better care today.

The biological mechanisms by which an acute coronavirus upper respiratory infection might lead to a bewildering range of chronic, burdensome symptoms even in the aftermath of mild infections are debated. Some scientists, for instance, believe that the virus causes an autoimmune disease akin to lupus. Meanwhile, one group of researchers has argued that even a mild respiratory infection from SARS-CoV-2 causes tiny clots to block tiny blood vessels all over the body, depriving tissues of oxygen throughout the body. Still others believe that the coronavirus causes a chronic infection, as such viruses as HIV or hepatitis C do. Meanwhile, some have emphasized the possibility of structural brain damage. While some published studies have provided support for each theory, none has been adequately validated as a central unifying thesis. Each is, however, worth continuing to explore.

A recently published investigation, conducted at the National Institutes of Health, suggests that clinicians and scientists should consider additional possibilities as potential drivers of symptoms for at least some patients. The researchers found far higher levels of physical symptoms and mental distress among subjects who had had COVID (many with long COVID) than among those who had not. Yet symptoms could not be explained by basically any test results: Researchers found effectively no substantive differences in markers of inflammation or immune activation, in objective neurocognitive testing, or in heart, lung, liver, or kidney function. And yet these patients were suffering from such symptoms as fatigue, shortness of breath, concentration and memory problems, chest pain, and more. Notably, researchers did not identify viral persistence in the bodies of patients reporting troublesome symptoms.

What this means in practice is that there are some people suffering from long COVID symptoms without evidence of structural damage to the body, autoimmunity, or chronic infection. Psychosocial strain and suffering, moreover, appears common in this population. Even pointing this out is sensitive territory—it leads some people to wrongly suggest that long COVID is less severe or concerning than those suffering from it describe, or even to question the reality of the illness. And, understandably, the invocation of psychosocial factors as potential contributing factors to suffering for some individuals may make patients feel as though they are being second-guessed. The reality, though, is that psychosocial strain is an important driver of physical symptoms and suffering—one that clinicians should treat with empathy. All suffering, after all, is ultimately produced and perceived in one place: our brain.

Severe depression, for instance, can inflict debilitating and severe physical symptoms of every sort, including crushing fatigue and withering brain fog, and is itself linked to having had COVID-19. And notably, a recent study in JAMA Psychiatry found that pre-infection psychosocial distress—e.g. depression, anxiety, or loneliness—was associated with a 30–50 percent increase in the risk of long COVID among those infected, even after adjustment for various factors. A false separation of brain and body has long plagued medicine, but it does not reflect biological reality: After all, diverse neuropsychiatric processes are associated with numerous “physical” changes, ranging from reduced blood flow to the brain to high (or low) levels of the stress hormone cortisol.

Illnesses of any cause that result in protracted time off one’s feet can also instigate (likely in conjunction with other factors) reversible cardiovascular deconditioning, wherein the blood volume contracts and the amount of blood ejected by the heart with each squeeze falls—changes that can lead to a racing heart rate or faintness when standing, as decades of studies have shown. Diverse neurological symptoms can also be produced by a glitch in the function rather than the structure of the brain—or what has been described as problems of brain “software” rather than “hardware”—resulting in conditions known as functional neurological disorders. Similar glitches, known as functional respiratory disorders, can disturb our breathing patterns or cause shortness of breath, even when our lungs are structurally normal. My point is not to speculate on some overarching hypothesis to explain all symptoms among all patients with long COVID. The whole point is that there’s unlikely to be just one. And there is still much to learn.

Research is underway to better understand this spectrum of illnesses, and their causes. But whichever diverse factors might be contributing to patients’ symptoms, we can take steps—both among clinicians and as a society—to improve lives now. Social supports can be as important as medical interventions: For those unable to work, qualification for disability assistance should not depend on a particular lab or lung-function test result. All patients with long-COVID symptoms deserve and require high-quality medical care without onerous cost barriers that may bankrupt them, which further compounds suffering. Universal healthcare is, that is to say, desperately needed to respond to this pandemic and its aftermath.

Additionally, while no specific long-COVID medications have emerged, some treatments may be helpful for improving certain symptoms regardless of the specific type of illness, such as physical rehabilitative treatments for those with shortness of breath or reduced exercise tolerance. Ensuring universal access to such specialized rehabilitative care is essential as we enter the next stage of this pandemic. So is helping patients avoid the emerging cottage industry of dodgy providers hawking unproven long-COVID therapies. Health-care professionals also need more education about the broad spectrum of COVID-19-related issues, both to improve care and reduce stigmatization of patients with all types of this illness.

Read: The pandemic after the pandemic

Doctors and scientists still have much to learn about symptoms that continue—or first turn up—months or weeks after an initial COVID infection. What’s clear today is that long COVID can be many different things. That may confound our efforts to categorize it and discuss its implications, but the sheer variety should not get in the way of care for all who are suffering.

This fall, unlike the one before it, and the one before that, America looks almost like its old self. Schools and universities are in session; malls, airports, and gyms are bustling with the pre-holiday rush; handwashing is passé, handshakes are back, and strangers are packed together on public transport, nary a mask to be seen. On its surface, the country seems ready to enjoy what some might say is our first post-pandemic winter.

Americans are certainly acting as if the crisis has abated, and so in that way, at least, you could argue that it has. “If you notice, no one’s wearing masks,” President Joe Biden told 60 Minutes in September, after proclaiming the pandemic “over.” Almost no emergency protections against the virus are left standing; we’re dismantling the few that are. At the same time, COVID is undeniably, as Biden says, “a problem.” Each passing day still brings hundreds of deaths and thousands of hospitalizations; untold numbers of people continue to deal with long COVID, as more join them. In several parts of the country, health-care systems are struggling to stay afloat. Local public-health departments, underfunded and understaffed, are hanging by a thread. And a double surge of COVID and flu may finally be brewing.

So we can call this winter “post-pandemic” if we want. But given the policy failures and institutional dysfunctions that have accumulated over the past three years, it won’t be anything like a pre-pandemic winter, either. The more we resist that reality, the worse it will become. If we treat this winter as normal, it will be anything but.

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By now, we’ve grown acquainted with the variables that dictate how a season with SARS-CoV-2 will go. In our first COVID winter, the vaccines had only just begun their trickle out into the public, while most Americans hadn’t yet been infected by the virus. In our second COVID winter, the country’s collective immunity was higher, but Omicron sneaked past some of those defenses. On the cusp of our third COVID winter, it may seem that SARS-CoV-2 has few plot twists left to toss us.

But the way in which we respond to COVID could still sprinkle in some chaos. During those first two winters, at least a few virus-mitigating policies and precautions remained in place—nearly all of which have since come down, lowering the hurdles the virus must clear, at a time when America’s health infrastructure is facing new and serious threats.

The nation is still fighting to contain a months-long monkeypox outbreak; polio continues to plague unvaccinated sectors of New York. A riot of respiratory viruses, too, may spread as temperatures cool and people flock indoors. Rates of RSV are rising; flu returned early in the season from a nearly three-year sabbatical to clobber Australia, boding poorly for us in the north. Should flu show up here ahead of schedule, Americans, too, could be pummeled as we were around the start of 2018, “one of the worst seasons in the recent past,” says Srinivasan Venkatramanan, an infectious-disease modeler at the University of Virginia and a member of the COVID-19 Scenario Modeling Hub.

Read: Fauci addresses ‘The pandemic is over’

The consequences of this infectious churn are already starting to play out. In Jackson, Mississippi, health workers are watching SARS-CoV-2 and other respiratory viruses tear through children “like nothing we’ve ever seen before,” says Charlotte Hobbs, a pediatric-infectious-disease specialist at the University of Mississippi Medical Center. Flu season has yet to go into full swing, and Hobbs is already experiencing one of the roughest stretches she’s had in her nearly two decades of practicing. Some kids are being slammed with one virus after the other, their sicknesses separated by just a couple of weeks—an especially dangerous prospect for the very youngest among them, few of whom have received COVID shots.

The toll of doctor visits missed during the pandemic has ballooned as well. Left untreated, many people’s chronic conditions have worsened, and some specialists’ schedules remain booked out for months. Add to this the cases of long COVID that pile on with each passing surge of infections, and there are “more sick people than there used to be, period,” says Emily Landon, an infectious-disease physician at the University of Chicago. That’s with COVID case counts at a relative low, amid a massive undercount. Even if a new, antibody-dodging variant doesn’t come banging on the nation’s door, “the models predict an increase in infections,” Venkatramanan told me. (In parts of Europe, hospitalizations are already making a foreboding climb.)

And where the demand for care increases, supply does not always follow suit. Health workers continue to evacuate their posts. Some have taken early retirement, worried that COVID could exacerbate their chronic conditions, or vice versa; others have sought employment with better hours and pay, or left the profession entirely to salvage their mental health. A wave of illness this winter will pare down forces further, especially as the CDC backs off its recommendations for health-care workers to mask. At UAB Hospital, in Birmingham, Alabama, “we’ve struggled to have enough people to work,” says Sarah Nafziger, an emergency physician and the medical director for employee health. “And once we get them here, we have a hard time getting them to stay.”

Read: The strongest sign that Americans should worry about flu this winter

Clinical-laboratory staff at Deaconess Hospital, in Indiana, who are responsible for testing patient samples, are feeling similar strain, says April Abbott, the institution’s microbiology director. Abbott’s team has spent most of the past month below usual minimum-staffing levels, and has had to cut some duties and services to compensate, even after calling in reinforcements from other, already shorthanded parts of the lab. “We’re already at this threshold of barely making it,” Abbott told me. Symptoms of burnout have surged as well, while health workers continue to clock long hours, sometimes amid verbal abuse, physical attacks, and death threats. Infrastructure is especially fragile in America’s rural regions, which have suffered hospital closures and an especially large exodus of health workers. In Madison County, Montana, where real-estate values have risen, “the average nurse cannot afford a house,” says Margaret Bortko, a nurse practitioner and the region’s health officer and medical director. When help and facilities aren’t available, the outcome is straightforward, says Janice Probst, a rural-health researcher at the University of South Carolina: “You will have more deaths.”

In health departments, too, the workforce is threadbare. As local leaders tackle multiple infectious diseases at once, “it’s becoming a zero-sum game,” says Maria Sundaram, an epidemiologist at the Marshfield Clinic Research Institute. “With limited resources, do they go to monkeypox? To polio? To COVID-19? To influenza? We have to choose.” Mati Hlatshwayo Davis, the director of health in St. Louis, told me that her department has shrunk to a quarter of the size it was five years ago. “I have staff doing the jobs of three to five people,” she said. “We are in absolute crisis.” Staff have left to take positions as Amazon drivers, who “make so much more per hour.” Looking across her state, Hlatshwayo Davis keeps watching health directors “resign, resign, resign.” Despite all that she has poured into her job, or perhaps because of it, “I can’t guarantee I won’t be one of those losses too.”

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This winter is unlikely to be an encore of the pandemic’s worst days. Thanks to the growing roster of tools we now have to combat the coronavirus—among them, effective vaccines and antivirals—infected people are less often getting seriously sick; even long COVID seems to be at least a bit scarcer among people who are up-to-date on their shots. But considering how well our shots and treatments work, the plateau of suffering at which we’ve arrived is bizarrely, unacceptably high. More than a year has passed since the daily COVID death toll was around 200; nearly twice that number—roughly three times the daily toll during a moderate flu season—now seems to be a norm.

Part of the problem remains the nation’s failed approach to vaccines, says Avnika Amin, a vaccine epidemiologist at Emory University: The government has repeatedly championed shots as a “be-all and end-all” strategy, while failing to rally sufficient uptake. Boosting is one of the few anti-COVID measures still promoted, yet the U.S. remains among the least-vaccinated high-income countries; interest in every dose that’s followed the primary series has been paltry at best. Even with the allure of the newly reformulated COVID shot, “I’m not really getting a good sense that people are busting down the doors,” says Michael Dulitz, a health worker in Grand Forks, North Dakota. Nor can vaccines hold the line against the virus alone. Even if everyone got every shot they were eligible for, Amin told me, “it wouldn’t make COVID go away.”

Read: America created its own booster problems

The ongoing dry-up of emergency funds has also made the many tools of disease prevention and monitoring more difficult to access. Free at-home tests are no longer being shipped out en masse; asymptomatic testing is becoming less available; and vaccines and treatments are shifting to the private sector, putting them out of reach for many who live in poor regions or who are uninsured and can least afford to fall ill.

It doesn’t help, either, that the country’s level of preparedness lays out as a patchwork. People who vaccinate and mask tend to cluster, Amin told me, which means that not all American experiences of winter will be the same. Less prominent, less privileged parts of the country will quietly bear the brunt of outbreaks. “The biggest worry is the burden becoming unnoticed,” Venkatramanan told me. Without data, policies can’t change; the nation can’t react. “It’s like flying without altitude or speed sensors. You’re looking out the window and trying to guess.”

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There’s an alternative winter the country might envision—one unencumbered by the policy backslides the U.S. has made in recent months, and one in which Americans acknowledge that COVID remains not just “a problem” but a crisis worth responding to.

In that version of reality, far more people would be up-to-date on their vaccines. The most vulnerable in society would be the most protected. Ventilation systems would hum in buildings across the country. Workers would have access to ample sick leave. Health-care systems would have excesses of protective gear, and local health departments wouldn’t want for funds. Masks would come out in times of high transmission, especially in schools, pharmacies, government buildings, and essential businesses; free tests, boosters, and treatments would be available to all. No one would be asked to return to work while sick—not just with COVID but with any transmissible disease. SARS-CoV-2 infections would not disappear, but they would remain at more manageable levels; cases of flu and other cold-weather sicknesses that travel through the air would follow suit. Surveillance systems would whir in every state and territory, ready to detect the next threat. Leaders might even set policies that choreograph, rather than simply capitulate to, how Americans behave.

We won’t be getting that winter this year, or likely any year soon. Many policies have already reverted to their 2019 status quo; by other metrics, the nation’s well-being even seems to have regressed. Life expectancy in the U.S. has fallen, especially among Native Americans and Alaskan Natives. Institutions of health are beleaguered; community-outreach efforts have been pruned.

The pandemic has also prompted a deterioration of trust in several mainstays of public health. In many parts of the country, there’s worry that the vaccine hesitancy around COVID has “spread its tentacles into other diseases,” Hobbs told me, keeping parents from bringing their kids in for flu shots and other routine vaccines. Mississippi, once known for its stellar rate of immunizing children, now consistently ranks among those with the fewest young people vaccinated against COVID. “The one thing we do well is vaccinate children,” Hobbs said. That the coronavirus has reversed the trend “has astounded me.” In Montana, sweeping political changes, including legislation that bans employers from requiring vaccines of any kind, have made health-care settings less safe. Fewer than half of Madison County’s residents have received even their primary series of COVID shots, and “now a nurse can turn down the Hepatitis B series,” Bortko told me. Health workers, too, feel more imperiled than before. Since the start of the pandemic, Bortko’s own patients of 30 years, “who trusted me with their lives,” have pivoted to “yelling at us about vaccination concerns and mask mandates and quarantining and their freedoms,” she told me. “We have become public enemy No. 1.”

Read: The pandemic’s soft closing

At the same time, many people with chronic and debilitating conditions are more vulnerable than they were before the pandemic began. The policies that protected them during the pandemic’s height are gone—and yet SARS-CoV-2 is still here, adding to the dangers they face. The losses have been written off, Bortko told me: Cases of long COVID in Madison County have been dismissed as products of “risk factors” that don’t apply to others; deaths, too, have been met with a shrug of “Oh, they were old; they were unhealthy.” If, this winter, COVID sickens or kills more people who are older, more people who are immunocompromised, more people of color, more essential and low-income workers, more people in rural communities, “there will be no press coverage,” Hlatshwayo Davis said. Americans already expect that members of these groups will die.

It’s not too late to change course. The winter’s path has not been set: Many Americans are still signing up for fall flu and COVID shots; we may luck out on the viral evolution front, too, and still be dealing largely with members of the Omicron clan for the next few months. But neither immunity nor a slowdown in variant emergence is a guarantee. What we can count on is the malleability of human behavior—what will help set the trajectory of this winter, and others to come. The U.S. botched the pandemic’s beginning, and its middle. That doesn’t mean we have to bungle its end, whenever that truly, finally arrives.

When Sara Laub’s period was late, the New York City resident shrugged it off. She’d used an intrauterine device, or IUD, for three years and knew her odds of getting pregnant were extremely slim. But after 10 days had passed, Laub, 28, took a home test in early July and got unwelcome news: She was pregnant.

Laub went to a Planned Parenthood clinic because she knew someone could see her immediately there. An ultrasound found no sign of a developing embryo in her uterus. That pointed to the possibility that Laub might have an ectopic pregnancy, in which a fertilized egg implants somewhere outside the uterus, usually in a fallopian tube.

Such pregnancies are rare, occurring roughly 2% of the time, but they are extremely dangerous because a growing embryo might rupture the tiny tube, causing massive and potentially life-threatening internal bleeding. Laub was experiencing no pain, bleeding, or other obvious symptoms of trouble. Still, a Planned Parenthood staffer recommended that she go to a hospital emergency department right away.

Laub didn’t realize it, but she was embarking on a lengthy — and very expensive — treatment to end the pregnancy. Even in a state that strongly supports a person’s right to make her own choices regarding pregnancy — New York legalized abortion in 1970, three years before Roe v. Wade made it legal nationwide — Laub’s experience shows the process can be arduous.

An ectopic pregnancy in the fallopian tube is never viable. But following the June reversal of Roe by the Supreme Court, reproductive health experts say treatment may be dangerously delayed as some states move to limit abortion services.

Some of those consequences are already being noted in Texas, where strict abortion limits were instituted last fall before the Supreme Court’s decision. Since abortion is now allowed in Texas only in medical emergencies, doctors might wait to perform abortions until pregnant patients are facing life-threatening complications in order to comply with the law.

“In Texas, we saw people not treating ectopic pregnancies until they ruptured,” said Dr. Kristyn Brandi, an obstetrician-gynecologist in Montclair, New Jersey, who is board chair of Physicians for Reproductive Health, which supports abortion rights.

The 2021 Texas law banned most abortions at about six weeks of pregnancy. University of Texas-Austin researchers interviewed doctors about the impact of the law on maternal and fetal care. A specialist at one unnamed hospital said the facility no longer offers treatment for certain ectopic pregnancies.

About half of states have enacted restrictions on abortion or are trying to do so.

Laub, who is being identified by her middle and last name because of her concerns about privacy, said she couldn’t help thinking about the recent Supreme Court decision as she went through diagnosis and treatment.

“As scary as my ordeal felt at the time, I was acutely aware that I was fortunate to have easy access to treatment, and elsewhere women with my condition face much worse experiences,” Laub said.

At Lenox Hill Hospital’s emergency department on New York’s Upper East Side, doctors ran more tests and gave Laub two options: an injection of methotrexate, a cancer drug that destroys rapidly dividing cells and is often used to end an ectopic pregnancy, or surgery to remove her fallopian tube, where the fertilized egg was lodged.

Laub opted for the injection. After getting the shot, patients need follow-up hormone blood tests to confirm that the pregnancy is ending. Laub returned to the emergency department for bloodwork and an ultrasound three days after the shot. She returned again three days later and was given a second shot of methotrexate since the pregnancy hadn’t terminated. The following week, she repeated the treatment in two follow-up visits. On July 20, after 12 days and five emergency department visits, Laub was scheduled for laparoscopic surgery to remove her fallopian tube.

The total charges to date for the medical treatment: an eye-popping $80,000. Because her health plan had negotiated discounted rates with the hospital and the other providers, all of whom were in her provider network, Laub’s out-of-pocket cost will be only a fraction of that total. It now appears Laub will owe a little more than $4,000.

That still seems like a lot, she said.

“On the one hand, I feel grateful that I was able to get treated when I was not in an acute state,” Laub said. “But it’s an awful feeling to know that the decision I made as to the best path forward for care comes at such a high cost.”

The hospital pointed out, however, that its charges were reduced by Laub’s insurer discount. “Charges are based on the specific services provided in the treatment of the patient,” said Barbara Osborn, vice president of public relations at Northwell Health, a system that includes Lenox Hill Hospital. “Any amount due from the patient is based upon the benefit design and cost sharing provisions of the patient’s insurance plan.” 

Understanding hospital charges can be a head-scratcher since they often don’t appear to align with the actual cost of providing care. That’s true in this case. According to a breakdown by WellRithms, a company that analyzes medical bills for self-funded companies and others, on average Lenox Hill Hospital charges $12,541 for the surgery that Laub underwent, based on publicly available data that hospitals submit to the federal Centers for Medicare & Medicaid Services. But the hospital charged Laub’s health plan $45,020.

“Hospitals will charge whatever they can,” said Jordan Weintraub, vice president of claims at the Portland, Oregon, company. “They put it on the payer to deny items rather than billing appropriately.”

Even more revealing is how much it actually costs the hospital to perform the surgery. According to WellRithms’ analysis of the federal data, Lenox Hill’s cost to perform the laparoscopic procedure is $3,750. The average cost statewide is $2,747.

Nationally, the average outpatient charge for the surgical procedure Laub received is $13,670, according to data from Fair Health, a nonprofit that manages a large database of health insurance claims. The average total amount paid by the health plan and patient is $6,541.

Surgical charges for managing an ectopic pregnancy vary widely depending on location. But the charges don’t necessarily correlate with the ease of access to medical care to end a pregnancy. In the New York City metropolitan area, the average charge is $9,587, for example, while in San Francisco, the average charge is $20,963, according to Fair Health. Both New York and California have generous abortion access laws. Meanwhile, locations with more restrictive abortion standards don’t necessarily charge more for ectopic pregnancy surgery. For example, in the Dallas area, the average charge is $14,223, while in Kansas City, Missouri, it’s $16,320, both lower than the average charges in Chicago ($18,989) or Philadelphia ($17,407).

Many women opt for methotrexate over surgery to treat ectopic pregnancy. The drug is successful between 70% and 95% of the time without requiring surgery.

The drug is often administered at a hospital because OB-GYNs are unlikely to keep the cancer drug in their offices, experts say. After the injection, patients must be followed closely until the pregnancy ends, because the risk of a life-threatening rupture remains. In addition, patients must get bloodwork at intervals after an injection to confirm that their pregnancy hormone levels are falling.

After receiving her first injection at the emergency department, Laub was told she needed to return for follow-up bloodwork after each injection. Charges for those emergency department visits were likely significantly higher than the charges would have been had Laub received follow-up care from an OB-GYN in an outpatient setting. The hospital charged between $4,700 and $5,400 for each of those follow-up visits. Laub’s share of the cost was about $500 each time.

“She had a long course of treatment, and if it was all done through the emergency room that would be unfortunate,” said Dr. Deborah Bartz, an OB-GYN at Brigham and Women’s Hospital in Boston. “It would be really nice if instead she could have been worked into the outpatient setting with a protocol for managing surveillance.”

In a statement, Osborn defended the hospital’s approach.

“Ectopic pregnancies, which can be life-threatening conditions, require close surveillance and management to ensure a successful resolution,” Osborn said. “The emergency setting allows for immediate availability of critical surgical services, as was ultimately necessary in this patient’s case.”

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