Category: Health

Last week, students returning to campus at Oberlin College in Ohio got a shock: A local news outlet reported that the campus’ student health services would severely limit who could get contraception prescriptions. They would only be given to treat health problems — not for the purpose of preventing pregnancy — and emergency contraception would only be available to victims of sexual assault.

It turned out the college had outsourced its student health services to a Catholic health agency – and like other Catholic health institutions, it follows religious directives that prohibit contraception to prevent pregnancy. They also prohibit gender-affirming care.

“I would characterize the student’s reaction as outrage,” says Remsen Welsh, a fourth-year Oberlin student and co-director of the student-run Sexual Information Center on campus. “A lot of people in my circles were sending [the news story] around like, what is happening?”

Although the college quickly came up with a new plan to offer reproductive health services to students on campus, the incident at Oberlin shows the wide reach of Catholic health care in the U.S., and how the rules these institutions follow can limit access to contraception.

Now that many states – including Ohio – have adopted restrictions or outright bans on abortion, that’s also raised the stakes for contraception access.

Religious restrictions affect many health care settings

Issued by the U.S. Council of Catholic Bishops, the Ethical and Religious Directives that guide Catholic health care systems “prohibit a broad swath of reproductive care,” including birth control pills, IUDs, tubal ligation and vasectomies, says Dr. Debra Stulberg, a professor of family medicine at the University of Chicago who has researched how these directives play out in health care.

Catholic hospitals have long been a mainstay of health care in America. And these days, the directives apply to a wide range of settings where people seek reproductive health care – including urgent care centers, doctors’ offices and outpatient surgery centers that have been bought by or merged with Catholic health systems.

They can also apply when Catholic health agencies are hired to manage health care services for other institutions, which is what happened at Oberlin.

Four of the 10 largest health care systems in the country are Catholic, according to a 2020 report. In some counties, they dominate the market. In 52 communities, the report found, a Catholic hospital is the only one around within a 45-minute drive.

“After all this consolidation, this is where it shakes out, where we’ve got about 40% of reproductive age women living in areas with high or dominant Catholic hospital market share,” says Marian Jarlenski, a health policy researcher at the University of Pittsburgh, who examined the data in 2020.

‘Not transparent at all’

Patients often aren’t aware that these restrictions might affect the care they get, says Lois Uttley, a senior advisor with the health advocacy group Community Catalyst. They may not realize their hospital or doctor’s office has Catholic ties. For instance, Common Spirit Health, one of the nation’s biggest health systems, is Catholic, but you wouldn’t know it from its name. And Uttley says Catholic health institutions typically don’t publicize these policies.

“They are not open and transparent about it at all,” Uttley says. “We think it’s only fair that a patient be warned ahead of time about what she may or may not be able to get at a local doctor’s office or urgent care center or hospital.”

In a campus bulletin posted on Tuesday, Oberlin’s president, Carmen Twillie Ambar, said Oberlin had only recently learned that these restrictions would be enforced by Bon Secours, the large Catholic health system whose subsidiary was hired to run the college’s health services. Bon Secours told the local Chronicle-Telegram that it would only offer birth control prescriptions for medical reasons – an exception allowed under the religious directives.

When workarounds are all you’ve got

In practice, many doctors who work for Catholic-owned or affiliated health providers routinely rely on “medical condition” exceptions as a way to get around religious restrictions on contraception, Stulberg’s research has found.

For example, hormonal IUDs can be used to control heavy menstrual bleedings, so doctors will often say they’re providing the IUD to treat this condition, even if the real goal is contraception.

Or doctors who aren’t allowed to perform a tubal ligation might instead remove the tubes altogether — they’ll just say it’s to lower a patient’s risk of ovarian cancer. Dr. Corinne McLeod, an OB/GYN at Albany Medical Center, says these kinds of workarounds were pretty common when she worked at a Catholic hospital in Albany, N.Y.

“That was basically a wink, wink, nudge, nudge,” McLeod says, adding, “Everybody knew what was happening. That was just the way they got around [restrictions].” One problem with relying on such loopholes, she says, is that if religious higher-ups at institutions get wind of it, they might crack down.

In other cases, workarounds might include creating a separately funded and run wing within a Catholic hospital or health clinic to provide the full range of reproductive health services.

That’s essentially what happened at Oberlin: The college partnered with a local family planning clinic to offer these services on campus three days a week, and said it would provide students with transportation to the clinic on other days. But the Catholic health provider will continue to offer other health services on campus.

Tiffany Yuen, a fourth-year Oberlin student who runs the Sexual Information Center with Welsh, said the solution was “a start. But it’s not enough.” In the past, about 40% of visits to the student health center were related to sexual health, according to Aimee Holmes, a certified nurse midwife who worked as a women’s health specialist at Oberlin for many years until Bon Secours’ subsidiary took over.

‘In some cases, women truly have no other choices’

Research suggests that even with workarounds, Catholic directives can limit women’s contraception choices. For example, one study found that while it was pretty easy for patients to book an appointment for hormonal birth control at clinics owned by Catholic hospitals, it was rarer to get one if you wanted a copper IUD, which is one of the most effective forms of long-acting reversible contraception.

I personally ran into these limitations eight years ago, when I gave birth to my second child. When I asked my doctor for a tubal ligation once I was on the delivery table, he informed me he couldn’t do the procedure because we were at a Catholic hospital. A recent study suggests this experience is common: It found that women who deliver at a Catholic hospital are half as likely to get tubal ligation or removal as those who deliver at another type of hospital.

Stulberg has conducted surveys that find many people don’t realize their choices will be limited because they don’t know their health provider is governed by these rules. “And of the people that had some kind of a reproductive health refusal, the majority, it wasn’t until either they were there or afterwards that they found out that they couldn’t get what they wanted,” she says.

In some cases, patients may simply be able to go to another health provider to get the contraception they need – but not always. “In some cases, women truly have no other choices,” Stulberg says. “This hospital or this system is the only provider in town.”

She says a patient’s options may also be constrained depending on their health insurance and whether the providers covered under the plan are subject to religious directives.

Several experts said that these restrictions can often impact low-income patients disproportionately. Dr. Karishma Dara, a family medicine doctor in Seattle, says that when she worked as a resident at a Catholic hospital in Washington, D.C., that served many low-income people, patients who came in for IUD appointments were told they had to go to a different, non-Catholic clinic to get the devices inserted.

“Any time that you have to add another step to getting care or contraceptive care, it’s like another point at which an unintended pregnancy can happen,” Dara says.

In fact, Catholic directives can limit access to contraception long after a health care facility stops being Catholic, says Elizabeth Sepper, an expert on religious liberty and health law at the University of Texas at Austin. “There are lots of examples where a Catholic health system has purchased a hospital, just held it for a handful of years and then sold the hospital,” she says. “But the purchase agreement then commits the next owner to continue the Catholic religious restrictions.”

Reproductive rights advocates want to see laws that require hospital systems to be more transparent about what health services they do and don’t offer. Legislators in New York have introduced such a law.

“You know, I’m not against Catholic health care, but I think that patients need to know what kind of services are available to them,” says Jarlenski.

Four days after recovering from a COVID-19 infection, President Joe Biden has tested positive again. When he first got sick, Biden—like more than one-third of the Americans who have tested positive for COVID-19 this summer, according to the U.S. government’s public records—was prescribed Paxlovid, an antiviral pill treatment made by Pfizer. Like many Paxlovid takers, he soon tested negative and resumed his normal activities. And then, like many Paxlovid takers, his infection came right back. (Biden does not currently have symptoms, according to his physician.)

With more than 40,000 prescriptions being handed out a day, we’re taking Paxlovid at about the same rate that we’re taking oxycodone. When Biden got sick last week, he started taking the pills before the day was out. When Anthony Fauci had COVID in June, he took two courses. That enthusiasm is in line with the government’s messaging around the drug.

The Biden administration has consistently hailed Paxlovid as an effective tool in the fight against SARS-CoV-2. “For the most part, Paxlovid is doing what you’re asking it to do,” Fauci told me recently. Many researchers and physicians agree. Ann Woolley, the associate clinical director of transplant infectious diseases at Brigham and Women’s Hospital, told me that she feels “very fortunate” to be able to offer Paxlovid to her patients, even if it’s not a COVID panacea.

But some providers are prescribing the drug with a bit less enthusiasm, particularly when it comes to vaccinated patients (such as Biden and Fauci). Reshma Ramachandran, a family-medicine doctor and researcher at Yale, told me that she’s feeling a sense of “resignation” about Paxlovid. Though it’s one of the few COVID treatments she can offer, she can’t say with confidence that the pills will help someone who’s been immunized. Bob Wachter, the chair of medicine at UC San Francisco, called assessing the value of Paxlovid for these patients a “massively complicated three-dimensional chess game.” Anyone who might want to take the drug should discuss with their doctor whether and when they’ve been infected before, how many vaccine doses they’ve had (and when they had them), their age, and other risk factors—all in light of the limited clinical data that are now available. Patients will surely struggle to make sense of all these variables. Their doctors might, too. “I can barely decide whether I want it, and I do this for a living,” Wachter said.

A person could have easily forgiven such confusion when Paxlovid was first being rolled out on a large scale, following an emergency authorization last winter. But now, eight months later? More than 3 million people have taken it. Pfizer has announced two sets of results from its clinical trial and submitted data to the FDA for full approval. Dozens of independent studies of the drug have been published or released as preprints. And yet, doctors remain unsure of: who might benefit from Paxlovid and in what ways; who really needs it; why and how often rebound infections such as Biden’s and Fauci’s occur; whether the drug reduces patients’ risk of developing long COVID; and whether the virus will slowly develop resistance to the drug.

Read: Rebound COVID is just the start of Paxlovid’s mysteries

These questions remain unanswered (or incompletely answered) thanks to corporate secrecy, the minutiae of drug testing, and the necessary care with which human trials are conducted. But in a more fundamental way, the persistent fog around Paxlovid comes from the disease that it’s meant to alleviate. The pandemic is simply moving too quickly, the virus is evolving too fast, and our responses to it are changing too often for anyone to find unambiguous answers about one specific drug.

Before we walk into that fog, let’s get some things settled: Paxlovid is effective at keeping unvaccinated, high-risk people—those who are most likely to require hospitalization if they come down with COVID—alive and out of the hospital. The drug has some side effects, such as a strange and unpleasant taste, but its safety profile is stellar. (It does have some known, dangerous interactions with other common medications.) No one died while taking it in Pfizer’s clinical trials. Got it? Good. Now on to the mysteries.

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When I spoke with Fauci, he repeatedly emphasized that the point of Paxlovid is “to keep you out of the hospital and prevent you from progressing to severe disease.” But does the drug really have this benefit for young, vaccinated people, who would seem to represent a significant proportion of those taking it? COVID hospitalization rates for those younger than 60 are currently less than two per 100,000. Given those numbers, Paxlovid—or any other drug, for that matter—isn’t likely to provide much benefit. “If your risk of hospitalization is incredibly low, to make that even lower is somewhat improbable,” David Boulware, an infectious-disease physician and a researcher at the University of Minnesota, told me.

That might explain why Pfizer’s trial found no statistically significant effect on hospitalization among a group of unvaccinated people at low risk from the disease and vaccinated people at high risk. An Israeli study conducted this winter similarly showed that Paxlovid did not significantly affect hospitalization rates in vaccinated, high-risk patients younger than 65. A study from Hong Kong did find that vaccinated Paxlovid takers were only about two-thirds as likely as non-takers to be hospitalized; but these data were not broken down by age, and the most popular vaccine choice among older Hong Kongers, Sinovac, is less effective than the mRNA-based vaccines that have dominated in the United States. A study that Woolley co-authored in Massachusetts found that Paxlovid reduced the risk of hospitalization for vaccinated people of all ages by 28 percent; and if a person’s last shot was more than 20 weeks old, the protection offered by the pills nearly doubled.

With the exception of Pfizer’s clinical trial, these studies are not placebo-controlled experiments, which makes them vulnerable to confounding factors. Woolley acknowledged the limitations of her own research, and told me that the benefit she found was “incremental.” Still, thanks to the paper, “I do feel like I have, now, significant data and experience to be able to have a well-informed discussion with my patients,” she said. “I’m not worried that we are giving placebo.”

Read: Paxlovid mouth is real—and gross

Other experts aren’t yet convinced. “I think we’re still left with a little bit of head-scratching about the utility of the drug in younger people or in people who are fully vaccinated and boosted,” Wachter told me. Boulware said he’s eager to see Pfizer’s results separated by vaccination status, which the company has not released. Those numbers wouldn’t necessarily tell us how Paxlovid fares against BA.5, but at least they come from a placebo-controlled trial. The data that have been made public to this point, he said, “suggest that there’s really minimal to no benefit, most likely, for the vast majority of people.”

If Paxlovid was shown to have benefits beyond keeping people out of the hospital—if we knew that it made symptoms less intense, for example, or go away sooner—then the case for using it in young, vaccinated people might be stronger. But so far, those data have been lacking too. Pfizer’s own trials found that the drug did not reduce the duration of COVID patients’ symptoms or work to prevent infection when taken as a prophylactic.

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According to a CDC advisory, people who take Paxlovid for a COVID-19 bout could experience a resurgence of the infection—a Paxlovid rebound—between 2 and 8 days after their initial recovery. Biden’s four-day boomerang, then, is fairly typical.

How common are these rebounds, and why do they occur? Even now, no one really knows. The Biden administration and researchers have maintained that rebound cases are not severe in general. But no definitive evidence has emerged to indicate how often they occur, who’s most likely to get them, or whether they’re related to Paxlovid at all. “It remains one of the most confusing things I can recall during the pandemic,” Wachter said.

The few studies that have quantitatively assessed the rate of rebound have returned a range of numbers, centered at something less than 10 percent. Pfizer told me this spring that just 2 percent of their unvaccinated, high-risk Paxlovid takers rebounded during clinical trials. In June, a Mayo Clinic study of 483 patients logged a symptom-rebound rate of less than 1 percent, while one from Case Western Reserve University and the National Institutes of Health found that 5.4 percent of Paxlovid patients tested positive again within 30 days, and 5.9 percent had a recurrence of symptoms. (Similar numbers rebounded after taking molnupiravir.)

Yet some clinicians told me that they don’t yet buy these numbers. Wachter said he suspects the real rebound rate is more like 10 or 15 percent. Ramachandran’s experience with her patients, family, and friends makes her think it’s even higher, perhaps 25 or 50 percent. (She stressed that this estimate is purely based on anecdotes.) Woolley didn’t want to pick a number, but said that a rate higher than 2 percent and much lower than 20 seems plausible to her. Even Fauci was willing to entertain the notion that 2 percent simply isn’t right. “I want to be humble and modest enough to say I don’t know,” he said.

Daniel Griffin, an infectious-disease expert, believes that fewer than 10 percent of people who take Paxlovid end up rebounding, but he also thinks those rebounds have nothing to do with the drug. “We’ve always seen this,” he told me. According to Griffin, physicians who have been taking care of COVID patients since 2020 were already seeing a pattern of disease, especially in high-risk patients, that entailed two weeks of worsening symptoms. He suspects Paxlovid suppresses the first half of the illness; when that suppression stops, you get the “rebound.”

Some experts have hypothesized that the way we’re using Paxlovid may be causing rebound. Wachter raised the possibility that taking Paxlovid too early in your course of illness could be one factor. The idea is plausible, Woolley told me, but “it goes against what we know also to be the case: The earlier you treat with an antiviral, the more effective it is.” (The FDA has only authorized Paxlovid to be distributed within the first five days of a patient’s having COVID symptoms.)

Do rebound cases suggest that the virus can evolve, within a patient, to make itself Paxlovid-proof? Again, the research seems to point in two directions. A group of researchers at UC San Diego studied one rebound case very carefully, and ruled out antiviral resistance as the cause. But even if resistance isn’t driving rebound, subsequent research has shown that SARS-CoV-2 is capable of developing resistance to Paxlovid, at least in a lab setting. “Any time you’re treating a disease caused by an RNA virus with a single drug, it’s not optimal, just because their capacity for change is great,” Timothy Sheahan, a virologist at the University of North Carolina at Chapel Hill, told me. He described the way he studies antiviral resistance in the lab. Step one: Grow a virus. Step two: Add some antiviral medicine, but not enough to completely suppress viral replication. Step three: Introduce that virus to a new host. Repeat. It sure sounds a lot like a COVID patient taking Paxlovid, rebounding, not realizing that they’re contagious again, and giving the virus to somebody else.

To ward off the possibility of resistance, Sheahan said, we need other drugs. “My hope, taking a page from the HIV-therapy playbook, is that there will and should be a multidrug cocktail to treat this disease, at the very minimum containing a few direct-acting antivirals,” he said. He’s also keen to find out whether such a cocktail would eliminate rebound.

Other researchers, including the ones from UC San Diego, suspect that prescribing a longer Paxlovid course might do the trick. Pfizer is planning to test whether a 10- or 15-day course of the drug might lead to better results, including lower rebound rates, among immunocompromised patients.

“I think it’s really important to determine what the real duration of treatment should be,” Fauci told me. Maybe, he said, it’s “going to have an impact not only on rebound, but also on whether a person gets long COVID or not.” But Ramachandran and Wachter both said they fear that hypothetical connection could go both ways: Perhaps rebound could raise a person’s chances of getting long COVID. To be clear, there is no empirical evidence as yet that supports this possibility—just physicians’ feelings of uncertainty around Paxlovid, plus some anecdotes. A few months ago, Wachter’s wife had COVID, took Paxlovid, and rebounded. Now, he said, she gets tired much more easily than she did before.

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Don’t expect this fog to lift anytime soon. For one thing, Pfizer has not yet made full data on the use of Paxlovid by vaccinated people available to researchers or anyone else. The Biden administration has not made any public efforts to pressure the company into doing so.

More research groups are, of course, working to find answers. Several experts told me they’re eagerly awaiting the results of the RECOVERY trial in the U.K., which will rigorously test Paxlovid in hospitalized patients. Woolley and her colleagues plan to study the risk profiles of patients who request a second course of Paxlovid because they experience a rebound. At UNC, Sheahan is part of a group working on a rebound-related study. Fauci said, “We are making steps and planning studies and doing concept sheets for studies” regarding rebound rates and the appropriate duration of treatment.

All of that research is going to take time. A spokesperson for the RECOVERY trial told me that fewer than 100 participants had been recruited as of July 25, and that the researchers need “at least several thousand” to draw conclusions. “It is likely to be many months yet before the trial can generate a result for Paxlovid,” they wrote in an email. Pfizer’s trial in immunocompromised patients, which will specifically investigate rebound and treatment duration, is listed as “not yet recruiting” on clinicaltrials.gov. Sheahan and his colleagues began planning their study around the turn of the new year, and only received approval from their institutional research board this month. They haven’t yet begun enrolling participants. When I asked Sheahan when he expected results, he said, “Hopefully several months.”

By the time this work gets peer-reviewed and published, it will be a little out of date. Months from now, America’s immune landscape will be different thanks to new infections, waning immunity, and newly formulated vaccines. We might be facing a new variant or subvariant that causes more or less severe disease, or replicates differently in the body, or simply responds differently to antivirals. The pandemic has been in an accelerating state of all-over-the-place since last year; research on Paxlovid can only lag behind.

In the meantime, patients and providers are muddling through. All of the doctors I spoke with said that they’re still erring on the side of prescribing Paxlovid, thanks to its lack of debilitating side effects. Sheahan, though not a medical doctor, was recently a Paxlovid patient when he came down with COVID after traveling. “I ended up on the medication within 48 hours after the onset of symptoms and was antigen negative in nine days. And it never came back,” he said when we spoke last week. Five days later, he emailed me to say that he had tested positive again.

On the list of perfect pet parents, Mikel Delgado, a professional feline-behavior consultant, probably ranks high. The Ph.D. expert in animal cognition spends half an hour each evening playing with her three torbie cats, Ruby, Coriander, and Professor Scribbles. She’s trained them to take pills in gelatin capsules, just in case they eventually need meds. She even commissioned a screened-in backyard catio so that the girls can safely venture outside. Delgado would do anything for her cats—well, almost anything. “Guilty as charged,” Delgado told me. “I do not brush my cats’ teeth.”

To be fair, most cat owners don’t—probably because they’re well aware that it’s weird, if not downright terrifying, to stick one’s fingers inside an ornery cat’s mouth. Reliable stats are scarce, but informal surveys suggest that less than 5 percent of owners give their cats the dental scrub-a-dub-dub—an estimate that the vets I spoke with endorse. “I’m always very shocked if someone says they brush their cat’s teeth,” says Anson Tsugawa, a veterinary dentist in California. When Steve Valeika, a vet in North Carolina, suggests the practice to his clients, many of them “look at me like I’ve totally lost it,” he told me. (This is where I out myself as one of the loons: My cats, Calvin and Hobbes, get their teeth brushed thrice weekly.)

There certainly is an element of absurdity to all of this. Lions, after all, aren’t skulking the savannas for Oral-Bs. But our pets don’t share the diets and lifestyles of their wild counterparts, and their teeth are quite susceptible to the buildup of bacteria that can eventually invade the gums to trigger prolonged, painful disease. Studies suggest that most domestic cats older than four end up developing some sort of gum affliction; several experts told me that the rates of periodontal disease in household felines can exceed 80 percent. Left untreated, these ailments can cost a cat one or more teeth, or even spread their effects throughout the body, potentially compromising organs such as the kidneys, liver, and heart.

To stave off kitty gum disease, veterinary guidelines and professionals generally recommend that owners clean their cat’s chompers daily, ideally for at least a minute, hitting every tooth. “That’s the gold standard,” says Santiago Peralta, a veterinary dentist at Cornell University. Even a gap of two or three days can leave enough time for tartar to cement, Jeanne Perrone, a veterinary-dentistry trainer in Florida, told me. But brushing feline teeth is also really, really, really hard. Most cats aren’t keen on having things shoved into their mouth, especially not bristly, sludge-covered sticks. (Dogs don’t always love cleanings either, but they’re at least used to engaging their owners with their mouths.) My old cat, Luna, was once so desperate to escape a brushing that she shrieked in my face, then peed all over the floor.

Read: Why we think cats are psychopaths

A niche industry has sprouted to ease the ordeal for hygiene-conscious humans: poultry-flavored toothpastes, cat-size toothbrushes, silicone scrubbers that fit on fingers. Sometimes the gear helps; when Chin-Sun Lee, a New Orleans–based writer, purchased malt-flavored toothpaste for her cat, Tuesday, he went bonkers for the stuff. Every morning, he comes trotting over just so he can lick the brush. Krissy Lyon, a neuroscientist at the Salk Institute, told me that one of her cats, Cocchi, is so crazy for his toothpaste that she and her partner have to “restrain him or lock him in a different room” while they’re brushing the teeth of their other cat, Noma.

But tasty toothpaste isn’t a sufficient lure for all. Valeika, who extols the virtues of feline oral health, admitted that even his own cat, Boocat, doesn’t reap the benefits of his brushing expertise. He “tried hard-core for a couple weeks” when he adopted her seven years ago. But Boocat was too feisty to stand for such a thing. “She can be a real terror,” Valeika told me. “We once saw her chase a bear out of our yard.”

Maybe Boocat is picking up on how odd the whole toothbrushing ritual can be. Even most American people weren’t regularly scrubbing their dentition until around the time of World War II. Vet dentistry, which borrowed principles from its human analogue, “is a relatively new discipline,” Peralta told me. “Thirty years ago, nobody was even thinking about dog or cat teeth.” Nor was it all that long ago that people across the country routinely let their pets sleep outside, eat only table scraps, and run hog wild through the streets. Now pets have become overly pampered, their accessories Gooped. Experts told me that they’ve seen all kinds of snake-oil hacks that purport to functionally replace feline toothbrushing—sprays, gels, toys, water additives, even calls to rub cat teeth with coconut oil. A lot of these products end up just cosmetically whitening teeth, temporarily freshening breath, or accomplishing nothing at all. If a super-simple, once-a-month magic bullet for dental hygiene existed, Tsugawa told me, “we’d be doing it for our own teeth.”

There are probably a lot of un-toothbrushed cats out there who could be s-l-o-w-l-y taught to accept the process and maybe even enjoy it. Mary Berg, the president of Beyond the Crown Veterinary Education, told me that one of her colleagues trained her pet to relish the process so much that “she could just say ‘Brusha brusha brusha’ and the cat would come running.” But getting to that point can require weeks or months of conditioning. Berg recommends taking it day by day, introducing cats first to the toothpaste, then to getting one or two teeth touched, and on and on until they’re comfy with the whole set—always “with lots of praise and reward afterward,” she said. And that’s all before “you introduce that scary plastic thing.”

Read: An offbeat approach to bonding with cats

That’s a big ask for many owners, especially those who went the cat route because of the creatures’ rep for being low-maintenance. The consequences of skipping toothbrushing are also subtle because they don’t directly affect humans, Delgado told me. Miss a nail trimming, and the couch might pay the price. But cat teeth aren’t often glimpsed.

The potential downsides of brushing, meanwhile, can be screamingly clear. On cat forums and Twitter, the cat-toothbrushing-phobic joke about losing their fingers. But what a lot of people are really afraid of sacrificing is their cat’s love. Broken trust can mar the relationship between owner and pet, Perrone said; people simply can’t communicate to skittish animals that this act of apparent torture is for their own good. Some cats never learn to deal. Even among veterinary experts, toothbrushing rituals are rare. Peralta and his wife just try to clear the bar of “at least once a week” with their own cat, Kit Kat; Berg and Perrone don’t brush their felines’ teeth at all. (Tsugawa does not currently own a cat, but he wasn’t a brusher when he did.)

I’m no pro, but I feel a bit torn too. I never took the time to teach Calvin and Hobbes to see toothbrushing as a treat, and they can get pretty grumpy during the ritual itself. Valeika, the North Carolina vet, told me that seeing Boocat’s horrified reactions was the main thing that prompted him to quit the brush. “She would hate it if we were always doing that to her,” he said. “She really would just not be our pet anymore.”

Feline-health experts know they’re losing this fight. “A lot of us are not even talking about toothbrushing anymore, because nobody’s doing it,” Berg said. Luckily, a few well-vetted alternatives to toothbrushing do exist. Berg and Delgado use specialty kibble that can cut down on plaque, and Perrone’s cat, Noriko, is into Greenies dental treats—both options that many pets may be more receptive to. Scientifically, nothing beats bona fide brushing. But realistically, this young art may already be obsolete. The best interventions, Delgado told me, will be the ones that people actually use. “If someone in my profession doesn’t brush their pet’s teeth,” Berg said, “I can’t blame anybody else.”

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.

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