Editor’s note, October 4, 8 am ET: We’re bringing you some of our best-loved Your Mileage May Vary columns while Sigal Samuel is on parental leave. The one below was originally published last year.

This unconventional advice column offers you a unique framework for thinking through moral dilemmas. It’s based on value pluralism: the idea that each of us has multiple values that are equally valid but that often conflict with each other. Submit your own question here.

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My partner and I did IVF recently and luckily we ended up with several embryos. One of those will be implanted in me so I hopefully get pregnant. But which one?

My fertility clinic is encouraging me to do PGT-A testing, which would screen for things like Down syndrome and would also let me see the sex of each embryo so I could potentially choose whichever I want. (And to be honest, I really want a girl!) I’m also hearing about these new companies that can test embryos for all kinds of things — like how smart the kid might be, how tall they’ll get, and whether they’ll have a lower chance of getting breast cancer, diabetes, mental illness, stuff like that.

I don’t know how to feel about any of this. On the one hand, it feels weirdly eugenics-y to do so much tinkering with embryos, and I can’t help feeling a little pressured into overmedicalizing everything with these expensive tests. But then again, if I could do something to make my baby healthier and happier, don’t I kind of have to do everything in my power? What does a parent owe their child?

Dear Expecting,

This is such an exciting — and also confusing — time. You’re about to have your first kid, and that comes with all sorts of fears and insecurities and hopes and dreams. You want to do the right thing — no, the best thing! — for your child. It’s a beautiful impulse. Unfortunately, it makes it easy for companies to prey on you.

So let me walk you through what these companies can and can’t really provide. After we talk about the science, we can talk about the ethics. 

The simpler test you mentioned, PGT-A, has been around since the 1990s. It can indeed screen for conditions like Down syndrome and let you see the sex of each embryo. Mind you, that doesn’t predict what gender your child will ultimately end up identifying with — more on that soon.

The newer testing you mentioned is called polygenic testing. The conditions it screens for are complex ones, influenced by thousands of genes. We’re talking about everything from breast cancer to depression. Some companies even offer screenings not for disease prevention, but for genetic enhancement — so you can select for a taller kid or a kid with higher IQ.

Polygenic testing companies claim to predict each embryo’s risk for each condition, and the potential reduction of risk you’ll get if you choose one embryo over another. As the statistical geneticist Sasha Gusev explains, it’s very, very easy to be misled by this claim. If the company claims to lower absolute risk of Type 2 diabetes by 12 percent, you might think this means, “The chance of my kid ever developing diabetes just went down by 12 percent — great!” But really what it means is that, all else equal, a kid who would’ve developed diabetes is likely now at the high end of pre-diabetes instead, or just develops diabetes a few years later. The same holds true for other conditions, like breast cancer. Sure, if your kid is going to develop diabetes or breast cancer, you’d rather they develop it later — but it’s not the bill of perfect health customers might imagine.  

“Typical risk reduction estimates tend to exploit statistical assumptions to overstate their benefits and lead to confusion,” Gusev writes.

It’s also important to note that there’s a difference between a physical disease like cancer, which is straightforwardly and universally negative, and a complex mental health condition like depression. For one thing, polygenic scores don’t perform as well in psychiatry, as the psychologist Eric Turkheimer notes. Plus, most mental health conditions come in mild to moderate to severe forms, and it’s not clear that we should want to get rid of mild or moderate manifestations. 

“Sure, it would be nice if no one ever got depressed, but what would that actually mean?” Turkheimer writes. “People are going to be sad, and the most modern models of psychiatric disorders view most of them as extremes on continuous dimensions of normal behavior. I don’t think we want some kind of genetic version of Soma.”

To give a personal example: I have generalized anxiety with some obsessive tendencies. Is that a major pain in the butt sometimes? You bet. But if I could wave a magic wand and get rid of it, would I? No. In my experience, this trait is linked to another trait I deeply value: my creativity. The same thing that propels me down rabbit holes of worry also propels me down rabbit holes of getting super curious about some topic, researching it into the wee hours of the morning, and then writing a novel or children’s book about it.

That brings me to one other scientific issue: pleiotropy. It’s a fancy term for a simple truth, which is that genes can have an effect on more than one trait. When it comes to behavioral polygenic testing, we actually know very little about which genes cause what — a gene that’s correlated with depression or anxiety may also be correlated with a bunch of other things. So, if everyone were to start selecting embryos to try to protect their kids from depression or anxiety, what would happen? We don’t know! 

Pleiotropy is a scientific issue, but it’s also a moral issue, because in trying to protect your kid from a negative outcome, you could also be accidentally barring them from a positive one.

And that’s just the tip of the moral iceberg.

Another issue is the potential psychological harm that can result from commodifying our kids — treating them like consumer objects with selectable parts. Let’s say you use polygenic testing to try to select for high IQ. Even if the company’s predictor is right 80 percent of the time, that means it’s wrong 20 percent of the time. What happens if it’s wrong about your kid, and they end up with a low IQ instead of a high one? How will your kid feel? Unless you hide the truth from them, they’ll know that they are not what you wanted, that they failed to live up to the vision you went out of your way to chase.

The same goes for sex selection via good old PGT-A. I know you really want a girl. But what would happen if you select for a girl, and then your child grows up and turns out to be trans? They may feel an extra sense that they’re letting you down by not conforming to the gender expectations you had for them.

Then there are the ethical questions around unequal access. Polygenic testing isn’t cheap. (One company, Orchid, charges $2,500 per screened embryo. Test 10 embryos and that’ll cost you $25,000.) So, at least in the short term, that raises the specter of entrenching a caste system, where the gap between rich and poor expands dramatically as the rich get smarter and stronger.

Technologies tend to get cheaper over time, so maybe everyone will ultimately be able to afford polygenic testing. But that raises another problem: implicit coercion. If more and more of us make ourselves smarter and stronger, we may create a society in which everyone feels pressure to alter their child’s biology — even if they don’t want to. To refuse embryo selection would mean to put a child at a huge professional disadvantage, or to face moral condemnation for making “suboptimal” kids when optimization is possible. Society may no longer offer health insurance benefits or accommodations for kids with disabilities (or even non-enhanced IQ), reasoning that “it was the parents’ choice.” 

Some philosophers, like Julian Savalescu, already argue that parents have a “moral obligation to create children with the best chance of the best life.” Polygenic testing companies love that argument; Orchid founder Noor Siddiqui tells parents that “the responsible decision” is to “protect their children” from disease, using language like, “What if you could have stopped it…but chose not to?” And we generally live in a culture that’s obsessed with optimization. 

So it’s no wonder that you find yourself asking, “If I could do something to make my baby healthier and happier, don’t I kind of have to do everything in my power?” 

It’s a view that will be very appealing to utilitarians, who believe the right action is the action that maximizes well-being or happiness. But maximizing principles can be dangerous. If we’re laser-focused on maximizing one value, however noble it may be, that can lead us to overlook a host of other important values. Think about diversity, for example; polygenic testing could lead to a less diverse world. 

And it’s not even clear how to maximize well-being given that each embryo will have some downsides: How would you choose between one embryo with a slightly elevated risk for schizophrenia, another with a moderately elevated risk for cancer, and a third with a high risk for Alzheimer’s? You’d have to decide how to rank the importance of each condition, which would require a dizzying bit of moral math: How much weight do you put on the longevity associated with each condition, how much on patient-reported quality of life for each condition, and how much on your own ability to cope with each — and society’s ability (which will change over the years)? Plus, even if the screening does end up optimizing life for your individual child, it could have negative effects on the population level, for the reasons we covered above.

As the Nobel laureate Herbert Simon pointed out, many problems contain way more variables and way too much uncertainty for maximizing along a single axis to be feasible or even desirable. So it often makes sense to just go with an option that’s “good enough.” He coined the term “satisficing” — a portmanteau of “satisfying” and “sufficing” — to describe opting for this good enough choice.

What would satisficing look like in the context of embryos? If there’s a very serious condition that runs in your family — like Tay-Sachs or the BRCA mutation that markedly increases cancer risk — then I do think there’s a strong case for screening for that. These conditions are debilitating and can lead to early death. Nobody wants them. Genetic testing that lets us prevent them is an awesome gift. 

Then there are conditions that can include suffering, like autism, but can also be very compatible with a happy life. Mental health conditions in particular are heavily socially constructed — a lot of the associated suffering comes about because society constructs a certain biological reality as a problem and doesn’t support the people who have it. In these cases, if you want to give your child a “good enough” or even “optimized” life, remember that you don’t have to achieve that by biological means; working to change the social environment can be just as important, and it doesn’t carry the societal risks associated with polygenic testing. 

Ultimately, when considering what counts as a “good enough” life, each parent will draw the line in a slightly different place. And there’s a part of that that can’t be boiled down to objective facts about disease, because this is also about how well-resourced the parent feels — emotionally, socially, and financially — to deal with a certain condition. What feels manageable to one parent may feel crushingly hard to another. 

So, I can’t tell you exactly which screenings to do and which to forgo. What I do want to tell you is to resist being bullied or shamed by others, especially those with a profit incentive to push you in a certain direction.

As the epidemiologist Abby Lippman has noted, genetic testing is supposed to offer parents more choice, but it too often has the opposite effect. When someone like Orchid’s Siddiqui says about a disease, “What if you could have stopped it…but chose not to?” — well, that language preys on parents’ worst fears and insecurities. It holds parents hostage while pretending to be giving them more autonomy. 

You are nobody’s hostage. You are a moral agent free to look at the many different relevant factors, weigh them all in the balance, and then make the choice that works well enough for your family.   

Bonus: What I’m reading

• Silicon Valley is obsessed with IQ, so it’s no surprise that tech execs there are using polygenic testing in hopes of creating supersmart babies. This article shows the kind of mental pretzels customers get into when trying to figure out whether to select the embryo with the highest predicted IQ or that with the lowest risk of disorders. One couple asks: “How much additional risk of ADHD cancels out against 10 extra IQ points?”

• Rereading “The Last Children of Down Syndrome,” Sarah Zhang’s 2020 Atlantic feature on prenatal testing, it struck me that when people think “prenatal testing,” Down syndrome is often the first condition that comes to mind, even though it’s not the most severe or straightforwardly negative (it’s compatible with a happy life). It’s just that Down syndrome was easy to test for, so we started testing for it early. I wonder if that built up the condition as a bogeyman in the expectant parent’s imagination — if the fact that we could screen for it shaped the public’s perception of Down syndrome as something that should be screened for and potentially screened out.

• One trait that many people assume we should select for is a great memory. But I highly recommend the short story “Funes the Memorious” by Jorge Luis Borges. It’s a reminder that having too good a memory is not always a benefit.  

Vox Members got to read this story first. Support independent journalism and get exclusive access to stories like this by becoming a Vox Member today.

In the moody alcoves of a lobby bar in Chicago in 2021 over French 75s, Dr. Louise King, a gynecologic surgeon, and Katie L. Watson, a bioethics professor, found themselves in conversation about a topic that had long frustrated them both: Female surgeons are consistently underpaid compared to male surgeons, even after accounting for specialty, rank, age, and other factors. 

What troubled them even more was how the pay gap compounded in King’s own field. Surgeons who perform procedures that are specifically for women, like gynecological surgeries, are paid less for their services than surgeons who perform comparable surgeries for the male anatomy. Gynecologic surgeons are also predominantly women. Over the course of the conversation, Watson termed this situation “double discrimination,” a phrase that captures the overlapping dilemma of lower pay for surgeries in a specialty that is overwhelmingly female and also serves a primarily female patient population.

That term, which has since entered the medical literature, stuck because the problem it describes has been well documented for decades. In 1997, a group of gynecologic surgeons published a paper in the journal Gynecologic Oncology with a title that gets straight to it — “Is Adam worth more than Eve?” Dr. Barbara A. Goff, now chair of Obstetrics and Gynecology at University of Washington Medicine, and colleagues found that doctors are paid around 44 percent more for performing male-specific procedures than analogous female-specific ones. 

In the three decades since, the problem hasn’t been fixed. To the contrary, it has been effectively institutionalized, built into the systems and codes that determine how surgeons bill for procedures of all kinds. Today, gynecologic or female-specific procedures are in large parts still reimbursed at lower rates than male-specific procedures even when they take similar time and skill.

Those disparities have consequences that extend beyond the compensation of individual doctors. When gynecological procedures don’t bring in as much money to hospitals, those same hospitals are disincentivised to offer women’s health services. That can lead to worse care for women and, crucially, fewer training opportunities for the surgeons who do that work. 

But this historically persistent inequality is not a foregone conclusion.

How healthcare services are billed changes all the time as procedures get reevaluated, new ones get added, and medical societies and experts push for revisions. In fact, one of the biggest changes in how maternity care is billed and reimbursed is set to take effect early next year, splitting up services for prenatal care, delivery, postpartum care, and more. While this is a long-overdue fix for obstetrics, gynecologic surgery — which covers most of a woman’s life outside of childbearing years — continues to be left out of the conversation. 

And although real change will require concerted efforts, King and Watson — and other advocates who have spent years documenting this disparity — have a fairly clear sense of how to start fixing it.  

How surgical procedures are valued

The work of deciding how much a medical procedure is worth starts well above the head of any given doctor, medical practice, or hospital. In the United States, the Centers for Medicare and Medicaid Services, a federal agency that administers healthcare and health insurance policies, sets rates for different procedures based on a metric called relative value units (RVUs). An RVU is supposed to take into account how long a procedure takes, the skill it requires, and the intensity of work it demands. Both Medicare and private insurers consider these figures when they’re settling on reimbursement levels. If a procedure has a higher RVU, it is valued more highly, and makes more money.

In a recent study, cheekily titled “Price and Prejudice,” researchers from the Mount Sinai Health System found that out of 55 pairs of sex-specific procedures that they evaluated in 2023, 75 percent had lower RVUs for procedures on female patients. On average, RVUs for male-specific procedures were 30 percent higher, and when those procedures were performed in a hospital or surgical center, surgeons were paid around 26 percent more.

For example, doctors will often perform biopsies — taking a small sample of tissues, cells, or fluids — on both male and female genitalia to diagnose problems. In 2023, researchers found that Medicare’s standard national rate for reimbursing surgeons was $121.32 for a penile biopsy but only $65.74 for a vaginal biopsy. 

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King, the director of reproductive bioethics at Harvard Medical School Center for Bioethics and a contributor on the study, believes that when the RVU system was created back in the 1990s, gynecological services were largely ignored, leaving the specialty undervalued from the start. While Medicare and Medicaid Services has undertaken some efforts to make RVUs more equitable across specialties over the years, that undervaluation has persisted. 

That problem may come down to how those values are determined in the first place — and who determines them. RVUs are set by a committee of doctors convened by the American Medical Association (AMA), with most of the seats allocated to members of major medical societies. The committee surveys different doctors on the time and skill required for procedures in their specialties. Based on these responses, the committee recommends values for each service to the federal government, which has historically accepted nearly 90 percent of them.

While the data quality of the underlying surveys has improved over the years, it is still not very high, said Dr. Miriam Laugesen, a tenured associate professor of health policy and management at Columbia University Mailman School of Public Health. Because the committee’s process isn’t transparent, it is often unclear what evidence its valuations rest on. This leads to distortions of all kinds, she said.

“It’s not a government process; It’s not a federal advisory committee,” Laugesen said. “It’s just a committee that was put together by the [AMA]. It’s pretty unusual in terms of how policy is made.”

In particular, King said that the surveys have a very low response rate from some specialties and are only sent to a small subset of doctors. She has never received a committee survey in the 17 years that she has practiced. 

The American College of Obstetricians and Gynecologists (ACOG) has a core seat on the committee that determines RVUs. But most ACOG members are general OB-GYNs, who split their time between obstetrics and gynecology and typically operate relatively rarely. The surgeons who perform the bulk of gynecologic operations are subspecialists – gynecologic oncologists, urogynecologists, and minimally invasive gynecologic surgeons — who complete an additional fellowship after residency. They mainly belong to their own societies and don’t have a seat at the table when RVUs are being determined. 

“From a purely cynical or economic standpoint, [ACOG] has no reason to advance billing for gynecology. It doesn’t represent a large portion of the practices of their members,” said King, adding that ACOG has been heroic in its efforts to obtain reimbursement equity for its own members. (One unintended possible result of that advocacy is that pushing for a smaller pay gap for services related to pregnancy, has in turn sent the message that women’s bodies are literally worth less, and are less deserving of care when they’re not engaged in the god-given duty of reproduction.)

The result is that doctors in specialties like OB-GYN who operate infrequently are answering the surveys about complicated surgical procedures that gynecologic surgeons perform more frequently. King said that her surgical schedule aligned more closely with those of general surgeons. For example, she operates two to three times a week whereas, according to her, an average OB-GYN will likely operate once a month. 

“So they’re not the right people to be answering these surveys. They [the survey committee and ACOG] don’t target the surveys to people who operate a lot,” she said. 

Part of the problem with using surveys to determine a key foundation of medical reimbursements is that the data is self-reported by doctors. This is especially relevant when more objective avenues may be available. One of those avenues is the American College of Surgeons’ National Surgical Quality Improvement Program, which is an initiative that collects and manages key surgical data to track quality and improvement in surgical fields, including the actual time spent performing surgical procedures, making it a more definitive measure than self-reported surveys.

Dr. Shitanshu Uppal, a gynecologic oncologist and division chief for gynecology oncology service at the University of Michigan, and his colleagues analyzed 901,917 surgeries using both the National Surgical Quality Improvement Program as well as the self-reported surveys used to determine RVUs. They found that median RVUs per hour vary widely between specialties. Gynecology had the third-lowest median RVUs per hour of all the specialties studied. In effect, that means that gynecological surgeons are paid less for every hour that they work. 

The researchers also found that compared to the operating times logged for real surgeries in the Surgical Quality Improvement Program, surgeons in certain specialties tended to report longer procedure times in the self-reported surveys sent out by the RVUs committee. Specialties that reported longer operating times were more likely to be awarded higher RVUs, leading to greater hourly rates of reimbursement.

According to Uppal’s analysis, urologists — a profession most often associated with procedures on men because their work routinely concerns the prostate and the testicles — reported times that exceeded the baseline data by a median of 20 minutes. By contrast, estimates from gynecologists only exceeded the actual time by a median of five minutes, meaning that urologists tended to overestimate their time spent in surgery by four times as many minutes. Generally, urologists earn much more than general OB-GYNs, who in turn earn more than other subspecialties like gynecologic surgery. Despite having access to reliable electronic records of operating time, Uppal and his colleagues note, the AMA committee still continues to use self-reported operating times, which influences their RVU recommendations, ultimately cementing disparities in female-specific procedures. 

“The system that they have now developed over time,” King said, “now creates discrimination because of its complexity.” She added that this is how systemic discrimination is perpetuated, even if systems or rules appear seemingly neutral.

How low reimbursement rates make women’s lives worse

The US healthcare system has never been especially good at putting its money where its mouth is when it comes to women’s health. Experts have been sounding the alarm on sex-based disparities in medical billing for a long time — long enough that governing authorities like the committee responsible for RVUs and ACOG have had time to respond to the concerns. 

Over the years, the gap between male-specific procedure reimbursements and female-specific reimbursements has decreased slightly. But researchers of the Price and Prejudice study showed that between 2003 and 2023, there were no statistically significant improvements to the pay disparities. Comparing a smaller set of procedures across 1997, 2015 and 2023, they found that the gap had narrowed only minimally.

One common justification that ACOG provides for the pay gap is that obstetrics and gynecologic services see a higher-than-average share of patients on Medicaid, which pays doctors less than other insurers. King agreed this is a real factor, but it doesn’t explain why Medicare itself values procedures on women lower in the first place. And as her account of double discrimination makes clear, undervaluing gynecology ultimately affects women everywhere for the worse.

“I have patients who are waiting for surgery with me for a year at a time. I mean, that’s crazy.”

Dr. Louise King

Lower reimbursements in gynecologic surgery disproportionately affect female surgeons because they represent a majority of this specialty. It’s not just the surgeons’ salaries that are affected. Hospitals and facilities work on a revenue-based model — if gynecologic surgeries are not bringing in enough money, institutions tend to allocate fewer resources to those procedures. That, in turn, can limit access to operating rooms, surgical staff, and operating times. 

“I have patients who are waiting for surgery with me for a year at a time. I mean, that’s crazy,” King said. As a minimally invasive gynecologic surgeon, she surgically treats women with endometriosis, fibroids, cysts or other such conditions.

It also affects the training that gynecologic surgeons receive. When there aren’t enough resources to operate regularly, opportunities to train residents are rarer than they should be. The result is that low reimbursement rates have contributed to a workforce of low-volume gynecologic surgeons who are sometimes not as well-trained as other surgeons who operate frequently.

The relationship between volume of surgeries performed and patient outcomes is well-documented in other fields. Research shows that surgeons who operate infrequently have worse outcomes, including more complications before, after, and during surgeries, compared to surgeons who operate regularly. 

Low volume gynecologic surgeons — who perform a particular procedure less than 12 times a year — have significantly higher rates of causing bowel and urinary tract injuries in their patients. Especially in benign gynecological surgery (procedures not related to cancer), having surgeons who operate frequently also increases the amount of minimally invasive procedures performed, which is related to better patient outcomes. 

Payment reform is an uphill battle, but not a lost cause

It takes multiple years and pressure from different entities to update or add new RVUs for procedures — but crucially, it is not impossible. The first few steps to creating a sustainable system might look like submitting gynecology-related procedure codes for reevaluation to the AMA committee or prompting a congressional report on the matter. 

For example, for years there has only been one billing code for endometriosis, regardless of the complexity of surgery or technique used. This disincentivizes surgeons from taking on complicated surgical cases of endometriosis because of the low reimbursement rate. Reevaluating that rate or diversifying the various surgical approaches that different cases require would help affected women get the care they deserve.

Medicare’s payment system also has what’s called a budget neutrality rule, which dictates that significantly increased payments for any given procedure must be offset by cuts elsewhere. The AMA itself believes that reforming this rule would make it easier to work toward reimbursement equity for female-specific procedures.  

Experts have suggested creating gynecology-specific conversion factors to bring parity to a system that naturally undervalues these procedures, while others think that eliminating sex-specific billing codes whenever possible is the right move. For example, the code for genitalia biopsies is different for men and women. This means that those procedures can be reimbursed differently even though they are essentially similar. Adopting one sex-neutral code for any genitalia biopsies would avoid this. While the reform required for this would be substantial, researchers believe that it would narrow the billing gap significantly.     

Authorities often justify lower RVUs for female-specific procedures by pointing to training: Gynecologists spend fewer years learning to operate than urologists and other higher-paid surgical specialists, according to King.

Historically, surgeons who operated on the female pelvis trained in ways that were more closely aligned with general surgeons than OB-GYNs. When obstetrics and gynecology merged into one specialty in the 1900s, the training for gynecologic surgery was truncated. 

“General OB-GYNs will train for four years and of that four years about 18 months is devoted to surgical training in gynecology,” said King, contrasting the new training period to those of general surgeons which is in years. 

She believes that training periods should be increased for gynecologic surgeons. That change would secure better reimbursement for the speciality, while also producing better trained surgeons who would be more attuned to advances in minimally invasive surgery that will ultimately improve the outcomes for their female patients. In some cases, the experience gained during a two-year fellowship in gynecologic surgery was equivalent to 19 years in practice.  

In their initial work on double discrimination, Watson and King argued that failing to implement solutions for parity is tantamount to saying that female patients deserve less well-trained surgeons than male patients.  

As with most women’s health issues, it is unclear if this systemic disparity in medical reimbursement is the result of conscious misogyny or a by-product of ignorance. But that question of origins matters little when its consequences have been enshrined in medical policy, with lasting consequences for the practice of medicine more generally. We have allowed this wage gap to persist, even as many have sounded the alarm for decades. It is long past time to heed their warnings.

After moving to West Virginia last year, Steve Kuo signed up for a new insurance plan that would cost him $500 a month. But there was one upside: He knew he was entitled to a free preventive visit. He wanted to take advantage of it, so he made an appointment at a clinic near his new home.

But then when he got there, they asked about his medical history and he mentioned prior kidney problems. When he received a bill a few weeks later, he had been charged twice for the same appointment: Once as that free preventive visit, once as an “office sick visit” because of the kidney conversation. He was flummoxed — and very annoyed, as he shared on social media. “No copayment means no copayment, exactly as stated in the insurance guidelines,” Kuo told me over email. “What is written and agreed upon should be honored.”

He is far from alone. On Reddit, I easily found more than a dozen examples in just the past year of people getting a surprise bill for what they thought was going to be a free visit. 

One woman posted a nearly $1,000 bill she’d received for what she thought was going to be a preventive gynecology visit. Another woman said that she ended up facing roughly $3,000 bills because she was given an ultrasound (which she said she didn’t request) at a preventive visit, and then her blood draw was sent to an out-of-network lab. Another person lamented that they had been billed $170 for an office visit because they had briefly mentioned back stiffness.

It’s not supposed to be like this. Americans don’t get much when it comes to our healthcare, but most of us are supposed to be entitled to at least one thing: Once every year, no matter your health insurance, you can go to the doctor with the goal of preventing future health problems by discussing important vaccinations, cancer screenings, and cardiovascular health screenings. The Affordable Care Act made that the law in 2010.

But more than 15 years later, people all over the country are walking into their doctor’s office, thinking they’re entitled to that one free visit every year, and walking out being billed for a sick visit, blood labs, and more. Researchers estimate that Americans spend tens of millions, maybe hundreds of millions of dollars every year on services that are supposed to be free under the ACA.

Dr. Yalda Jabbarpour, a family physician in the Washington, DC, area and medical director of the Robert Graham Center for Policy Studies, told me she still deals all the time with people’s confusion about what a preventive visit really means.

“Every single time I’m in the clinic, this issue comes up with a patient. And it’s sad that it comes up,” Jabbarpour told me. “In my mind, the blame is not to be put on the patient. The blame is not to be put on the physician. Really, this points to a bigger system issue that we need to solve.”

How could a seemingly simple promise of one free annual doctor’s visit result in a situation so convoluted that patients and doctors are still struggling with it nearly two decades later? And how might we fix it?

Patients are getting surprise bills from their doctors — and they’re pissed off

The goal of the ACA was to expand coverage and make sure health insurance would be comprehensive to actually help people stay healthy. As part of that project, the authors of the law added a mandate for insurers to cover those services, including an annual wellness exam. The problem is, they did not define what the parameters of that preventive visit actually were, said Alex Hoagland, a healthcare economist at the University of Toronto. 

“It didn’t establish a clear definition of…all the diagnosis codes and procedure codes and how frequently you get that combination within a year,” he said. “They don’t define what actually is preventive care and what’s not.”

That has left each insurer to define a preventive visit on their own — and that’s where the perverse incentives that leave patients in a lurch begin. Preventive visits are supposed to be reserved strictly for screenings and talking about other preventive measures you can take to protect your long-term health, but you may get billed for an “office visit” or a “sick visit” if you talk about any specific symptom you’re experiencing, the same as if you had come in because you had the flu. 

Health insurers have an incentive to keep the definition of preventive care as narrow as possible, so they have to pay fewer claims without any contribution from the patient. At the same time, doctors want to be paid for the actual services that they are providing. If somebody does bring up a bigger health problem during a preventive visit, then the doctor reasonably wants to be paid accordingly. 

“I know, particularly in the healthcare space, it’s really popular to blame one party or another, and here I don’t think it’s a matter of corporate greed or physician incompetence or whatever,” Hoagland said. “It’s just a natural mismatch of incentives.”

So the reality is that “one free doctor’s visit” sounds straightforward, but, in practice, it’s much more complicated. You as the patient might think of it as one visit, but in our fee-for-service healthcare system, where providers bill based on each specific thing they do, it’s not. The conversation about your vaccination may be free — but asking about your back pain is not. If you get blood tests ordered, that’s another line item. The list goes on. “It’s not like you walk into a doctor’s office and it’s just one thing that happens, right?” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “It’s multiple different things that are happening when you go into a doctor’s office.”

Part of the problem may be that it’s one free visit. We Americans are consumers at heart: Tell us we’re going to get something for free and we want to take advantage of it. But having just one free visit may also lead to people bringing a laundry list of questions to that preventive visit, because they think of it as their only chance to ask everything of their doctor. 

That makes it easy for the discussion to tip over into a sick visit — and not only does that lead to a surprise bill, it can also crowd out the conversation about prevention that the visit is supposed to be focused on.

“What ends up happening a lot…is that a patient comes in for their annual visit, and in their mind, that is their time to bring up every single thing that’s been happening during the year, because they see it as the free visit to bring up everything that’s happened during the year. For some patients, that takes up the entire visit,” Jabbarpour told me. “They leave, and it’s like, ‘Oh my god, we forgot to do all the screening things: the vaccinations, the cancer screenings, and the cardiovascular risk screening.’ And then something happens down the line because you never address those screenings.”

A 2021 study by Hoagland and Paul Shafer, both of Boston University at the time, estimated that Americans with employer-sponsored insurance had in 2018 alone paid between $75 million and $219 million in medical bills that should have been free. They were more likely to be charged for things like contraception or cholesterol and diabetes screenings, with individuals sometimes paying hundreds of dollars for those services.

Hoagland told me he had been billed for preventive visits because he has type 1 diabetes and the system automatically categorized his appointment as a diabetic visit. Earlier this year, he co-authored a study that found people with chronic conditions were more likely to be charged for preventive care. Corlette said that she too had recently been charged for what was supposed to be a preventive visit after she mentioned an issue as an aside. And these are folks who study health care for a living.

“It was literally maybe a 10-second conversation where I would ask the doctor a question about something,” she said. “And that triggered it.”

Colonoscopies are another dramatic example of how this issue plays out in real life; Corlette told me the procedure was one of the first services where this fuzzy line between prevention and treatment under the ACA became obvious. People go under for what is supposed to be a preventive colonoscopy. But then their doctor finds a polyp and decides to remove it — good clinical practice, but as a result, their patient could end up being charged thousands of dollars because the colonoscopy was no longer preventive once that polyp was snipped.

“All of a sudden, that would trigger what the patient thought was a preventive service into a cost-sharing obligation,” Corlette said. “Colonoscopies can be thousands of dollars. That was when we were first like, ‘Oh, yeah, this is a more complicated area than I think the lawmakers that drafted this provision originally envisioned.’”

How the US could fix our preventive visit headaches

The ACA’s preventive visit promise was clearly well-intentioned and it’s worth remembering that, if you look in the aggregate, more Americans are getting more free preventive care than they did before the law was passed. The problem, as much as anything, is expectations: People think they’re entitled to a free visit and are understandably frustrated when they get billed for it.

“The difference is before the Affordable Care Act, maybe they anticipated some kind of cost-sharing,” Hoagland said. “But after, they expect it to be free.”

It doesn’t have to be this way. Corlette’s team at Georgetown University recently released a proposal that Americans be entitled to three primary care and two urgent care visits every year with no cost-sharing. This approach has two virtues, she told me: It will help people feel like they are actually getting value from their insurance — the very complaint that Steve Kuo raised — and, because we know primary care helps prevent problems down the road, it should also improve people’s health in the long term. Take the pressure off that one free visit and let people see the doctor a few times a year without worrying about being charged.

“In employer-based insurance, a lot of people feel like, ‘What the hell am I getting for my premium each month?’” Corlette said. “We wanted people to feel like they’re getting good value, and we wanted to get to better population health.”

Hoagland also endorsed the idea of at least one free physician’s visit every year, no matter what’s discussed. In the long term, Jabbarpour said she’d like to see copays eliminated entirely for primary care. 

But any payment reforms are not going to happen immediately. What can we do right now?

For one, doctor offices could make an effort to be as transparent as possible. Jabbarpour’s MedStar system has started calling people a couple of days before their appointment with a brief script that tells the patient that they could be charged if the conversation with their doctor touches on additional medical problems. If your doctor’s office doesn’t proactively bring it up, ask when you schedule your appointment or when they call you to confirm it. Worst-case scenario, ask your provider what they consider preventive care when your visit begins. You might also want to educate yourself on what services are generally considered preventive and should be available for free: Your insurer may make that information available on their website, or KFF has a database you can peruse.

It’s not a perfect solution. “What ends up happening is patients come in, and they say, ‘I know I’m not supposed to talk to you about anything else, so I’m not going to tell you about anything else.’ And you don’t want that to happen,” Jabbarpour said. You should ask your doctor directly: What do you consider to be preventive care? Establish boundaries at the start. That way, you can at least be aware if you are going to get charged because the conversation crossed the line to discussing an active health problem.

And if you want to see the underlying laws change, start organizing. Contact your state and federal reps and ask them what they are doing to ensure this stops happening. Things could be different: Jabbarpour said she hopes to one day work in a health system where the cost of a single primary care visit isn’t so high-stakes, where doctors and their patients can manage their health according to their particular needs, rather than worry about how to bill for one specific conversation that covers the whole range of somebody’s health — like primary care is supposed to do.

“I think some patients can be managed by seeing us once every year, once every two years, and some patients need to see us monthly,” Jabbarpour told me. “To put all patients in the same box and say you can only see your primary care physician once a year if you want it paid for, it makes zero sense.”

Sifting through my pile, I feel the crisp edges of the glossy, technicolor marker that was previously nestled in the dirt of a bonnie green bell sweet pepper plant I bought from the farmers market this summer. I feel a pristine black-and-white receipt for one order of steamed dumplings and one dumpling soup; a thick bundle of political mailers; a Hadestown program that is gently shriveled from the torrential downpour on the night I saw it; a cellophane mailing envelope with Japanese postage. It’s garbage; it’s art supplies; it’s memories; and it’s all mine for the taking for use in my junk journal. 

A junk journal is a collaged scrapbook that you fill with literal scraps, the ephemera of your everyday life: business cards, ticket stubs, fliers, price tags, labels, product packaging, mail, printed photos (you remember those, right?), stickers…anything, really. The basic idea is that these items can be rescued from the garbage or recycling bin and turned into a physical, visual record of a given moment in time. That it’s made from trash is key; the abundant, inexpensive materials mean that junk journaling has a really low barrier to entry, which reduces the pressure and ultimately infuses it with a fun, feral energy that is perfect for 2026.   

So many slow-moving existential threats have accelerated and consolidated this year: climate change, inflation, war, surveillance, the erosion of free speech, oligarchs operating with impunity, the institutional collapse of both the humanities and science. At the same time, we live in an increasingly remote, digitized world, where we constantly have to question our reality thanks to AI, and where most everyone feels like their brain is a little broken. There are a lot of possible solutions to these interconnected crises, but experts agree that most involve being in the physical world. And your little pile of stuff is undeniably concrete. 

Girija Kaimal, a professor and the chair of the Creative Arts Therapies Department at Drexel University, said that junk journaling can help us feel hopeful — which is important when you’re mired in digital malaise and existential dread. “Everything is getting more expensive or more difficult, or AI is going to take away all your jobs, and oh, these are all the diseases coming at you. It can really give you a sense of helplessness,” Kaimal told me. But generative acts, where you make something out of nothing, can help you push through that despair and remind you of your own agency. 

“Even the smallest act of creating is sending a signal to your brain: Hey, I got this…” she said.

“I can bring a little beauty and meaning into this world,” Kaimal said. “I’m not this helpless pawn being tossed around by powerful forces. I mean, in a way I am, but I have something to give to this world.” 

As a longtime diarist, former scrapbooker, and big fan of this new iteration of it, I’m all in favor — and the experts I spoke to all agree that it’s a hobby that is really well suited to this particular moment. So if you need a creative outlet or just want something to do with your hands that’s not scrolling through AI slop, here’s why you should give junk journaling a try. 

The barrier to entry is incredibly low (and incredibly cheap)

Every form of entertainment, novelty, and inspiration right now is so, so expensive: concerts, live theater, movies, sports, travel, dinners out…the list goes on and on. Hobbies have gotten pricey too. Joann’s went under at the same time that tariffs started driving up the cost of yarn, art supplies, and so many other consumer goods. This is a real problem when it comes to both creative stimulation and human connection; a 2025 survey of 688 young people in Scotland found that cost was a significant barrier to engaging with a hobby for nearly half of respondents. That’s not good! 

But even folks who can afford to spend $300 on a beginner ceramics class might still prefer to have the option to do something creatively stimulating for free. That’s why a hobby that anyone can cobble together from the garbage pile is so thrilling. (And many of us are already hanging onto the basic materials for sentimental reasons, hoping to do…something…meaningful with it all…someday. Instead of letting it collect dust in a drawer for years, you can give it a more permanent home!) You don’t even need to buy a journal to get started; you can use whatever notebook you have lying around (including your current daily planner!), or tear half the pages out of an old book (to create more room for everything you’re going to put in it) and use that as your base. 

While some people’s junk journals include supplies they purchased specifically for it (i.e., the $30 “junk journaling kits” that craft retailers have started pushing), I strongly encourage you to resist the urge to shop, as I think this hobby works best when it’s done using stuff you already have or naturally acquire in your everyday life. Buying a bunch of preselected supplies adds pressure — because once you’ve invested money in something, there’s a desire to not just do it, but to do it right. It also turns the junk journal from a creation that’s really authentic and personal, akin to a diary, to something more curated and outward-facing; when you start with materials designed (often with faux-nostalgia undertones!) by someone else, you remove a fundamental bit of yourself from the process. It shifts from being personal, messy, and maybe even a little ugly, a place where you can make “mistakes” and change your mind, and becomes more about having a coherent aesthetic. That’s something to be very wary of in a moment in which every experience feels like fodder for social media. When you have an audience in mind, the blank page starts to feel like a subpoena instead of an invitation, leading to a paralysis that makes it harder to get started and more difficult to enjoy the process. 

So not only is junk journaling a hobby that can be affordable, I’d argue it’s one that should be. The less cash you spend on supplies and the more you rely on a pile of detritus, the better off you’ll be. Speaking of which… 

Junk journaling is a beautiful invitation to turn trash into art 

Back in July, the air in New York City was thick with haze due to wildfires in Canada; it was dangerous to be outside, but I didn’t really want to go out anyway, thanks to the concurrent heat emergency we were dealing with. Meanwhile, more than 2.3 million acres across the state of Oregon burned between mid-July and mid-August, which also happened to be the hottest month ever recorded in the United States. At the same time, Europe was boiling. Nearly 3,000 people died in England’s heat waves in May and June. 

While we need major systemic change to stop the progress of climate change, it’s hard to read all of this news and not feel a moral obligation to do something, or at least not directly contribute to the problem. Knowing that penguins are dying certainly makes me want to reduce my own consumption — and that includes trying to curb the amount of new hobby supplies I’m buying. Junk journaling dovetails perfectly with this. 

And just on a creative level, there’s real value in the whole “turning trash into treasure” thing. Having limited resources is a really helpful starting point for imaginative thinking. Looking at a pile of garbage and being able to see art (or even just something lightly coherent) is really energizing and exciting, especially when you’ve been feeling bored and a little stuck. I’ve found that looking for items for my junk journal has helped me notice color, shape, texture, and artistry more in my everyday life, which ultimately makes me feel more connected and creative. 

The trash element of junk journaling meets the demands of our current moment: “There’s a huge shift, and I kind of love it, towards being sustainable,” Kaimal said. “Everybody is talking about AI, this, that, but the new generation is really thinking about the environmental cost.” 

My friend Ryan Swedenborg recently got her MFA in Studio Art from Maine College of Art & Design, where she focused on sculpture. She wrote her thesis on assemblage (kind of a 3-D version of a junk journal), arguing that it’s not just an art form, but that it’s a way of navigating complex systems — “just trying to stay alive while living with others,” as she put it. She said that instead of trying to master something, assemblage is an iterative way of working with what is already around you — “I mean, that’s how you stay alive,” she said. 

Creative practices like assemblage and collage tend to flourish in times of instability, Ryan said; the irreverent and absurdist Dada movement was a direct response to World War I, machine culture, and mass media. The neo-Dada movement immediately followed World War II, and, like the earlier version, heavily featured collage. After 9/11, assemblage surged again, often as a direct response to the attacks. “I feel like, especially in New York…people [were] just literally taking these objects that live within the streets and building something new,” Ryan said. 

Consciously or not, people want to feel a sense of control when it feels like the world is falling apart, and junk journaling is a very literal way of picking up the pieces. 

Junk journaling is something creative to do with your hands

If you want to be on your phone less (and who among us doesn’t want that?), it’s important to find something else to fill your time. And a low-stakes project that’s both creative and tactile is a great alternative. (It’s also something that a lot of people are gathering to do together in person — Google your city plus “junk journaling events” to see what’s going on near you — which is a really fun bonus if you’re looking to get out and meet people.)

First, creativity is really, really good for your physical and mental health. According to a review of various scholarly studies of the topic published in the Journal of Creativity in 2024, art and other creative acts help with emotional regulation, reduce stress, and build self-esteem; they can also help you build community and cope with grief, chronic illness, pain, and loneliness. Journaling, too, is great for your mental health; a 2022 meta-analysis showed it helps with anxiety and PTSD, and another study found it “reduces intrusive and avoidant thoughts about negative events and improves working memory.”

The way you use your fingers to sort through, arrange, cut, layer, and paste the materials can also serve as a balm for your weary brain, said Mark Paterson, a sociologist at the University of Pittsburgh who studies touch (and all five senses) in history and philosophy, as well as material culture and consumption. “We are manipulating machines. That is what we do. Everything from picking fruit, grabbing a branch of a tree and swinging in our early history, and so on. But also the feel of a typewriter, the tactile feel of a typewriter — all these things were part of the absolute background buzz of everyday life,” Paterson told me. “And it’s so strange in such a short time that it’s just become absent really, really quickly. And so things like scrapbooks, notebooks, that type of thing, are bringing us back to something which is a little bit more considered.” 

Since talking to Paterson — and after reading my colleague Sara Herschander’s deep dive on how humans are losing our sense of touch — I’ve been focused on finding ways to consciously engage with my sense of touch every single day. And in combining this with other creative acts, I’ve found a really satisfying alternative to scrolling that I genuinely look forward to every day. 

Kaimal, the creative arts therapies professor, said that having these tactile, creative experiences is good for our brains and our sense of self. “To me, doing things with your hands, using your hand-eye coordination, the sensory aspects…the choices you are making, all those reinforce a sense of confidence and a sense of valuing yourself like, ‘Hey, my vision really matters. I have something to say and do in this world that nobody else is saying or doing.’ And to me, having that space is a big part of creating a sort of mental respite.”

A junk journal is proof of something real

I’ve always been drawn to keeping diaries and scrapbooks, for reasons I can’t fully articulate. 

But this deep, often-inexplicable desire isn’t unique; it spans cultures and millennia. “I think there’s a very human, timeless urge to just be like, ‘I was here.’ You think of archeologists digging up graffiti in Pompeii or other locations around the world where someone just wants to say, ‘I am a person, I existed, I am in this context, and I’m going to anchor myself to the physical,’” Mallory Furnier, a special collections and archives librarian at California State University Northridge, told me. “I think there’s a need to feel remembered.” 

In more recent history, this desire took the form of things like commonplace books, yearbooks, and slam books. But in the past decade, we’ve taken this urge to social media, which feels the same, but just isn’t; Furnier said posting online is often more about status, about performance — I went to this event, I hung out with these friends. We all kind of agree that the things we see on social media aren’t real.

A junk journal, on the other hand, offers you literal, tangible proof that your experiences were real, along with an authenticity you simply don’t get when you’re posting for an audience. Technically, you could still lie or obfuscate reality in your junk journal, as 58-year-old Jane Hemmer did in The Onion’s “Local Woman’s Life Looks Bearable In Scrapbook,” but you probably won’t! So collecting and arranging your ephemera in this way serves as a nice antidote to the cozenage of both Instagram and AI slop, and the way that we now all have to constantly question our very reality. 

Paterson, the sociologist, told me that humans have long seen a connection between our sense of touch and the idea of deeper truth and understanding; he pointed to noli me tangere, which comes from a scene in the New Testament in which Christ’s followers reach out to try and touch his wounds following his resurrection to confirm that he’s real. Shuffling through your pile of ephemera isn’t quite the same as rooting around in your buddy’s stitches, but it’s an instinctive, almost unconscious way that we validate what’s true nonetheless. 

A junk journal is a way to make meaning out of your life, whether you use it to record things that are positive, negative, or neutral. “To track your life every day and to document it is to be more intentional about your personal narrative,” Furnier said. “Otherwise, you’re just going through life as a robot and not really making sense and making meaning and celebrating your little wins every day, processing what didn’t go well.” Furnier added that collaging takes this to an even deeper level because you’re deciding what to keep and how to position it. She told me that when scrapbooks are too old and fragile to handle, archivists sometimes have to disassemble them to preserve the individual elements, but they always take photos and scans before they do to keep a record of the original arrangement: “There is this meaning-making of juxtaposing different objects from different places together. There’s an authorship and a reimagining of these disparate, seemingly unconnected items that happen in a scrapbook when they’re brought together like that.”

My friend Ryan said that the ability to create a document that feels somewhat permanent in a moment of upheaval is a big part of what makes this such an appealing medium. “It is like an archival process,” she said. “You are putting a time and a place when you’re making these pieces, because you’re using objects that exist today. So it’s putting a timestamp on it. … Things that are seen as mundane in the moment really get to become part of the record. And I think that’s really exciting, especially as we look back at the lineage of assemblage and we can see how that played out.” 

While you might get into junk journaling with future history in mind, you could also come at it from the opposite perspective, and try it precisely because things feel so unstable. “Today, with so much uncertainty in the world, I’m not sure that people — young people especially — imagine a scenario in which their story and their labor survives intact, unsullied for generations,” Danille Christensen, a professor at Virginia Tech who studies scrapbooks, folklore, and material culture, told me in an email. “Maybe an ethic of noticing and reusing or incorporating small incidents and things — ‘making beauty from ashes’ (to modify a phrase from Isaiah) — is the kind of hope that people can muster right now.” 

A junk journal is a way of creating something that is yours and yours alone

Americans are awash in mass-produced crap: Influencers are constantly peddling fast fashion; gadgets and products we don’t need and that are destined to end up in landfills; furniture and other home decor that is both cheaply made and weirdly expensive. While pushing back on this can be hard, my junk journal has served as a really nice reminder that it’s possible to resist the commodification of everything and just make whatever we want, using whatever we have, simply because it feels good. In that sense, it can be another version of craftivism, which has been popular for generations and is currently having a renaissance.

Paterson drew a connection between junk journaling and bricolage, a French term that generally is used to mean “DIY project,” but has come to be associated with mixed media and using whatever materials you have on hand. “It’s this idea of an everyday art, of making do, of coping. So it’s not simply about the arts, but it’s actually about coping with everyday life and so on…” he said. “Maybe commenting on mass consumption and trying to do something about that.” He said that remixing widely available items, turning them into something new and personally meaningful isn’t a trend; in fact, it’s something that tends to cycle in and out of the culture as people discover it — and perhaps remember their need for it — anew. You see this in things like ripped jeans, punk, or, more recently, appliquéd or embroidered Trader Joe’s bags (another current project of mine). “Consumption is not just passive, but it can be a very creative act,” he said. The junk journal, then, is “an artistic statement. It’s very much ours. And maybe it means nothing to anybody else. Maybe it actually just looks just like a little junk, clearly. But of course it’s deeply meaningful for the person who puts it together.” 

Furnier, the archivist, pointed out that as our lives have become more digital, they’ve also been commodified and sold back to us — you post a picture from the theater and then start getting Broadway-related ads. A nice memory that’s related to your identity and your relationships has been turned into a marketing opportunity. “It’s almost like we’re reclaiming our data by making it physical,” Furnier said. “And there’s something that feels almost radical and liberating with the idea that you can create something and you can share it in person or you can keep it for yourself, and you’re not going to get a targeted ad.” 

When ownership writ large feels very out of reach and every moment in our lives is a new opportunity for both consumption and for performance, you can still have agency in this very small way. The fact that it doesn’t require you to enrich a billionaire in the process makes it even more appealing. “It’s no great mystery in many ways, especially with the acceleration and the frictionlessness of everyday life and the goal-orientedness…we need these speed bumps, these forms of friction to slow us down,” Paterson said. “And so I can see junk journaling as one of the most accessible ways of slowing the world down and making it slightly more one’s own.” 

My favorite restaurant, here in Madison, Wisconsin, closed this week. 

It was not my favorite because it had the greatest food I’d ever had, nor the most memorable ambiance. But I loved the Mad Rabbit Cafe because it had become my anchor in the neighborhood — it felt like home to me and a core group of friends as surely as the century-old houses lining the surrounding city blocks. Most importantly, it was entirely vegan — a rarity in this city, which, despite its ultra-progressive politics, embraces Wisconsin’s identity as “America’s Dairyland.” It was a refuge where my most closely held values found expression.

That closure is part of a national trend. US plant-based restaurants appear to be going through a contraction, amid the tumultuous aftermath of the Covid-19 pandemic and, perhaps, an anti-plant-based cultural vibe shift.

VegNews magazine reported that data from HappyCow, an app that lists vegan and vegetarian restaurants, finds the number of vegan restaurants in three of the country’s top destinations for vegan dining — New York City, Los Angeles, and Portland, Oregon — decreased by between 21 and 25 percent from 2022 to late 2024. Those cities alone make up a significant share of America’s vegan restaurants. Then, in 2025 and 2026, some of the country’s most renowned, long-running plant-based restaurants also announced that they’d shut down: Modern Love and Candle in New York City, the Vegan Joint in LA, Millennium in Oakland, a more than three-decade-old institution (though it later reopened as a leaner operation), among many others. 

According to a Vegan Society report, in October 2025, HappyCow (which is like Yelp but for plant-based dining) listed 1,717 all-vegan restaurants in the US. As of this writing, HappyCow lists 1,509.

Madison has never had anything like the vegan riches of New York or San Francisco, but even we are having our own vegan recession. When Mad Rabbit opened in early 2024, the city had four fully vegan restaurants; now, depending on how you count, one or two remain (and even the one that’s unambiguously vegan is a food-court-style stall). I visited Mad Rabbit at its last Sunday brunch, where it served what many people have described as the best tofu scramble they’ve ever had, and a crowd-pleasing rotation of crepe specials (this month, it was mango lassi). It’s a culinary niche that, once gone, is hard to replace in a mid-tier city like this one. 

Mad Rabbit’s owner, Nate Anger, told me the business hadn’t been in particularly bad financial shape; it was profitable for each of the three years in which it operated, but not profitable enough to justify the punishing time commitment required to run it. Managing it had taken over his life, as it’s wont to do for many people in the food service industry. “I live here. I spend far more time here than anywhere else,” he told me in a recent interview at the restaurant. “I’ve missed my kids’ baseball game and tournaments and school band recitals.” I looked around at the oddball, DIY space he’d conjured — walls covered in houndstooth print, an Alice in Wonderland-like vortex, and art of rabbits in mischievous-looking moods, one brandishing a pair of large knives (the sort of room you wouldn’t want to encounter while stoned). 

The animal rights movement has two very different emotional registers: the grief and terror of looking squarely at factory farming, and the joy of discovering how much creativity, abundance, and pleasure can exist outside it. All-vegan restaurants represent perhaps the fullest embodiment of that second feeling — like “a little heaven,” as Krupa Panchal, co-owner of Bombay Food Junkies, a vegan Indian spot in suburban St. Louis, put it to me. 

Even as vegan businesses struggle to survive, plant-based options at non-vegan restaurants have become far more mainstream than they were a decade or two ago. Set against the stagnating (if not declining) share of Americans who identify as vegan or vegetarian, that raises difficult and even paradoxical questions for the animal movement.

For that reason, the mass die-off of plant-based restaurants has been much dissected and lamented in the vegan community. As I faced losing my own — a possibility I’d always feared and tried to forestall by supporting it as much as possible — the problem became much more visceral for me. I found myself thinking about why it mattered to me so much: What is lost when these places disappear, and what does that tell us about whether the plant-based movement can grow and endure?

What vegan restaurants are for

The vegan restaurant predates the word “vegan” itself — and so, apparently, do questions about whether they can be financially viable. More than a century ago, French anarchist Georges Butaud co-founded the Foyer Végétalien in Paris, writing in a 1923 letter that he was unsure whether it would attract a sufficient “clientèle végétalienne” to sustain itself. Why start such a business at all, when the audience for plant-based food is so vanishingly small? “I already have some positive results. A few people have become vegan since we opened,” Butaud wrote. The restaurant “is a school where we reciprocally teach one another…I have believed in the usefulness of creating it, and I will be happy if, over the months to come, the number of vegans increases.” 

Many vegan restaurant proprietors today still share that ambition — to be good enough to help the movement grow. 

Long before it became routine to find plant-based options on normie restaurant menus (iceberg lettuce leaves don’t count), plant-based restaurants compensated for vegans’ exclusion from mainstream cuisine. But they have also aimed to provide proof of concept of the diverse, surprising possibilities of plant-based food for a larger audience, showing that plant-based food need not be confined to marginalia. 

Today, of course, restaurants are far more central to our daily lives than they were in Butaud’s time. Americans consume about a third of their calories and the majority of their food budgets outside the home, and food-serving businesses are perhaps our most important third spaces. Meanwhile, the problems associated with animal agriculture and overconsumption of animal products grow unabated in America and around the world. The US alone slaughters 10 billion land animals for meat every year, the overwhelming share of them raised in appalling conditions, and those farmed for milk and eggs endure no better. Reciting these grim facts tends not to be a very fruitful path toward making friends or convincing people that veganism can be a positive and enjoyable lifestyle. Plant-based restaurants, on the other hand, make veganism feel less like a prohibition than an invitation; hospitality rather than horror. 

Anyone who has ever gone vegan knows what it’s like to incessantly be asked the well-meaning but bewildering question: “What do you eat?” (And, I get it! It’s confusing for those of us who grew up viewing food free of animal products as side salad or overcooked green beans.) Plant-based businesses have long been laboratories for answering it, developing techniques that draw richness and variety from ingredients not often treated as the main event in Western cuisines.

The more than 50-year-old Moosewood Restaurant (although mostly vegetarian, not fully vegan) was an early conduit between restaurant experimentation and home cooking, its recipes spreading far beyond Ithaca, New York, through its enormously popular cookbooks. Soul Vegetarian in Atlanta, opened in 1979, developed a plant-based soul food repertoire that helped cut a path for dozens of other vegan soul restaurants across the US; the Chicago Diner, in the city long identified with stockyards and slaughterhouses, helped popularize plant-based versions of American diner and deli staples. And chef Miyoko Schinner, at her erstwhile San Francisco restaurant Now & Zen, experimented with plant-based cheeses long before launching Miyoko’s Creamery, one of the most acclaimed and influential vegan dairy companies of the past decade. 

The 21st century in particular has seen a flowering of vegan restaurants serving every palate and national cuisine, in every possible aesthetic — punk, hippie, psychedelic, fussy and upscale. They still expand my mind today, showing that a lifetime wouldn’t be enough to discover all the ways we can eat without the exploitation of animals.

The longtime Grasshopper restaurant in Boston, whose pan-Asian fare draws partly from Vietnamese Buddhist temple cuisine, makes mock meats that are worlds away from the rubbery substitutes that many Americans associate with the category (it closed its beloved, homey restaurant space in 2024, later reopening a stall inside a food court). Mad Rabbit changed even this longtime vegan’s idea of what tofu could be. Chicago-based Penelope’s Vegan Taqueria makes, as far as I’m concerned, the most exceptional Mexican food — vegan or not — this side of the Rio Grande. V-Grits, a Southern comfort spot in Louisville, Kentucky (RIP, 2024), provided evidence that some of America’s most exciting plant-based food could be found far from the big coastal cities best known for it. 

So why are so many of these places shuttering now? 

The vegan restaurant death spiral? 

Theories abound about the great dying of vegan restaurants.

Some of the casualties, it must be said, just weren’t very good in the first place. The raw vegan boom of the 2000s and 2010s, for example, produced numerous establishments built around that especially unforgiving constraint — no cooking. The result was often less-than-thrilling food (which isn’t to say it’s never good!), all in service of a restriction with scant evidence of health benefits to support it. Lots of these restaurants have closed in the 2020s, reflecting diminishing demand for that particular variant of vegan food. 

But the 2010s weren’t merely a golden age for zucchini noodles and date-walnut brownies — vegan restaurants of all stripes were multiplying, as was interest in the new generation of plant-based meats (Beyond and Impossible). It really did appear, for a minute there, that the future might be plant-based, vindicating decades of animal advocates’ work to push veganism into the mainstream. 

“I felt like veganism had really hit a big stride” in that period, Anger, the Mad Rabbit founder, said. Everyone was streaming documentaries advocating for plant-based diets — Forks Over Knives, Cowspiracy, What the Health, among others. Some polls suggested the share of Americans who called themselves vegan was growing. Anger said his market research led him to believe that the overall trend line for veganism would continue going up, even a little. Instead, “it just rolled right back over.” His restaurant had a core customer base of committed vegans, but its heavy reliance on regulars also showed how limited its reach was; stagnating interest in veganism may have been putting a ceiling on its growth. Keith Uruski, owner of Nooch, a vegan restaurant in Windsor, Ontario, open since 2018, told me that the business had thrived in its first few years, but has since slowed considerably, and he hasn’t paid himself in three years.  

In the years leading up to the pandemic, the assumption that the audience for vegan food would keep growing shaped much bigger bets than Mad Rabbit. Vegan chain restaurants including Veggie Grill, Native Foods, and Planta had pursued aggressive growth plans in the 2010s and early 2020s but eventually retrenched, closing locations and abandoning the scale they’d once envisioned. (Again, some of this may be merit-based rather than evidence of a broad rejection of veganism — YMMV, but I found Veggie Grill, at least last time I had it pre-Covid, to be mid.) “Most dedicated vegan chains are now in kind of a managed decline,” Lizzy Bartlett, senior director of menu research and insights at Technomic, a food service industry research firm, told me.  

The cultural winds have certainly shifted. The Make America Healthy Again (MAHA) movement has probably contributed to a thermostatic swing away from “unnatural”-seeming diets and simulacra of traditional foods, like plant-based meat and milk. I also think society has deep carnist antibodies that activate whenever meat-eating faces heightened moral scrutiny. In the last few years, that’s taken the form of a protein obsession that has hijacked the minds of otherwise rational people, convincing them tofu and beans lack sufficient protein to build muscle.

But perhaps my favorite explanation was articulated by Financial Times journalist Henry Mance last year: “The decline in idealism,” reflected in the reelection of Donald Trump — the triumph of our collective id.  

There’s a risk of reading too much into all this, however. Many restaurants, vegan or not, suffered during Covid and from prolonged inflation in food and energy prices. This year, consumers are spending less at restaurants because of elevated fuel prices due to the war in Iran. Panchal, of Bombay Food Junkies, said that her sales have been down in 2025 and 2026 compared to the years prior, but she doesn’t believe vegan restaurants have been faring worse than non-vegan ones. Some vegan businesses have recently closed in St. Louis for personal reasons rather than failing in the market, she told me.

This is part of the natural life cycle of independent restaurants — many disappear within a few years, and even highly successful ones eventually run their course. US cities had many vegan restaurants open in the 2000s and 2010s, so we might now be seeing a wave of closures that reflects the aging of that cohort. 

Preliminary results shared with Vox from a 2026 survey of the global vegan restaurant industry, by the nonprofit Vegan Hospitality, also complicate the idea that plant-based restaurants are being killed off because of waning demand for vegan food. In responses from about 59 vegan restaurants (a self-selected group, to be sure), mostly in the US and Mexico, roughly four in five said they’d still choose to be fully vegan if they were opening today. Of 13 businesses that were closing or had been sold, six said that being vegan actually helped them, and four said it made no meaningful difference.

And there’s some tension between the “death of veganism” hypothesis and what may be one of the biggest forces now disadvantaging dedicated vegan restaurants: the widespread adoption of plant-based options on omnivorous restaurant menus. That it’s now easier to be vegan at mainstream establishments is “unquestionable,” Anger said. He viewed Mad Rabbit’s competitors as not just fully plant-based businesses, but any restaurant that offers “more than two or three” vegan options; it was located just a block away from one of Madison’s best-regarded restaurants, a Laotian place with several very good plant-based offerings.

Likewise, Michael Fifelski, general manager of Red Sushi in downtown Madison, which has a solid list of vegan options, told me, “Our vegetarian and vegan rolls actually are quite popular” — a foundational part of the menu. There can be a real advantage to simply letting vegan food blend in — Amanda Byrd, the manager of Everly, an eclectic, globally inspired restaurant in Madison, told me that its top dish, a butternut squash and forbidden rice curry, is incidentally plant-based. In many cases, “if you de-emphasize the vegan statement, but the dish happens to be vegan,” it will sell better, Claire Conaghan of the food industry research firm Datassential said.

Though nothing compares, for me, to the feeling of total alignment that comes with dining at an all-vegan restaurant, there is also something affirming about seeing plant-based food finally taken seriously by the wider culture — and vegan dishes surviving on their own merits alongside everything else on the menu.

Do vegan restaurants still matter?

In a world where you can find a satisfying vegan entrée at Chipotle or Taco Bell or your local brewpub, are fully vegan restaurants still needed? What purpose do they serve?

The most fundamental problem beneath the downturn in vegan businesses is simply that the vegan population does not seem to be growing much at all. Polling on the question is messy and often inconsistent, but according to Gallup’s 2026 survey, 2 percent of Americans call themselves vegan, the same figure as in 2012, when the firm first started asking the question. If expanding the number of people who abstain from animal products remains an important goal (a point debated within the animal movement, though I think dietary change still matters a great deal), then which is more likely to move that objective forward: vegan restaurants, or an abundance of vegan options at omnivorous ones? Which does more to increase the number of plant-based meals consumed rather than animal-based ones and generate excitement about vegan food?  

I put those questions to Seth Ariel Green, a research scientist at Stanford’s Humane and Sustainable Food Lab, who writes the Substack “Regression to the Meat.” He’s one of the most intellectually honest researchers anywhere on meat reduction. His answer, via email, is that we don’t really know: “I have no idea how to weigh the pros and cons of, when I’m choosing between meals, 1) signaling to the world that vegan businesses are viable or 2) signaling to a particular business that their vegan options are viable. That’s a hard problem!” (It might be “a microeconomic structural equation modeling paper waiting to be written,” he added.)

Reducing prevailing levels of meat consumption even a tiny bit, much less convincing people to become vegan, is really, maddeningly hard, as Green has written. One frequently cited obstacle to growing the animal rights movement — its “central unsolved problem,” as one movement leader recently put it — is that it lacks much in the way of an in-person social world and sense of community. Vegan restaurants alone can’t fix that, of course, but they are among the few physical institutions the movement has. At their best, they provide a space where a private dietary choice can be reinforced by a shared sense of identity — a place to run into someone you already know or meet someone new, at a speaker event or social mixer. These spontaneous, embodied connections made Mad Rabbit such a warm presence in my life, and its final days all the more melancholy.

That function may be especially useful when plant-based restaurants are rooted in traditions people already belong to — cultural, religious, or otherwise — and help them view veganism as continuous with an identity they already have rather than as something alien to it. As Green has suggested, “let’s tap into pre-existing identities, explain how plant-based diets are consistent with them, and then take folks somewhere to enjoy convenient, delicious plant-based food together.” 

On the other hand, plant-based options at omnivorous establishments matter for almost the opposite reason. People often struggle to stay vegan because eating differently isolates them from non-vegan friends and family; restaurants that can accommodate mixed-diet social groups help remove that social penalty. These options also need a customer base — if no one orders them, they’re unlikely to remain on menus. 

I’m enough of a weirdo that I try to almost exclusively support plant-based restaurants whenever I eat out. I desperately want them to survive, and at the end of the day, no one is more invested in advancing the craft of plant-based cooking than vegan restaurants themselves.

Not everyone needs to be like me — in a world where almost all people still eat animal products, a healthy ecosystem needs both places built entirely around veganism and those where plant-based food is woven into broader food culture. It needs, most of all, excellent vegan food, wherever it might be found. And now that veganism has made at least a small breach into mainstream dining, vegan restaurants still offer something their meat-serving counterparts cannot. They’re like miniature utopias where the normal order of things is inverted and, for the length of a meal, we can see what a future without animal exploitation would look like. 

Vegan and vegetarian dining options might be more common than ever, but around the country, vegan restaurants are closing at a quicker rate than their non-vegan peers. In this month’s Highlight cover story, Marina Bolotnikova investigates what’s happening to those restaurants as her own favorite vegan establishment closes its doors. And she tries to answer the bigger questions about the closures: What’s lost for the vegan community as restaurants disappear, and what does it tell us about the future of the plant-based movement? Also in this issue: falling in love with friends. 20th-century affordable housing is staging a comeback. A free, lightly feral hobby to escape your phone. And why are doctors paid less to treat women?

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America’s empty bedrooms are up for grabs

By Rachel Cohen Booth

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What should you do if your friend is in love with you?

By Shayla Love

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Where did all the vegan restaurants go?

By Marina Bolotnikova

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The free, lightly feral hobby that will help you stop doomscrolling

By Rachel Wilkerson Miller

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The preventative visit scam

By Dylan Scott

Coming October 1

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The insidious, fascinating, and utterly infuriating reason that women’s health care is worse than men’s

By Anusha Subramanian

Coming October 2

Todd Waller wasn’t expecting to spend the latter half of his 30s living with roommates. But in late 2022, following a breakup with his girlfriend, he needed to find a new place to live, quickly. 

A social worker based in the Atlanta metro, Waller started googling “efficiency apartments” and stumbled onto an ad for PadSplit, a company founded in 2017 that lets property owners rent out individual furnished bedrooms in single-family homes by the week. “It said I could get approved right away and move in tomorrow,” he recalled. There was no security deposit required.

All of a sudden, Waller found himself living with six other people and able to save a lot of money. His rent was just $180 per week, or less than $800 per month. Though he earned a decent salary, he never really had anything left over after all his bills were paid, and the new financial breathing room made the tradeoff of housemates feel worth it.

After a while, Waller decided he would be willing to upgrade to a nicer PadSplit unit, one with more amenities but still with roommates. Now he pays $1,250 a month to live on one side of a 2,000-square-foot home, with access to his own private bathroom, a private entrance, and a renovated kitchen. Three other people live on the other side of the house, and he rarely interacts with them.

“My house is awesome; I pay $500 less a month than I would if I were renting [a place of my own] without roommates, and I just was able to buy a new car,” he told me. He knows one day he’ll move somewhere else and perhaps even buy his own home, but he likes that he feels he can make that decision comfortably at his own pace.

With rents outpacing wages in most of the country, legislators are increasingly looking at co-living — sometimes called house-sharing or adult dorm rooms — as an overlooked piece of America’s housing stock. Zillow counts roughly 21 million “empty nest households” — or homes where older residents living with no children have at least two extra bedrooms. Some lawmakers want to make it easier for those homeowners to rent them out, which could put workers closer to their jobs and help seniors stay in houses they can no longer afford alone. Others are eyeing a different kind of vacancy: Post-pandemic remote work has left about a fifth of American office space empty, and there’s growing interest in turning some of it into apartments. 

Many advocates for people experiencing homelessness also argue that co-living is a needed solution, something that could help people going through emergencies avoid the scary slide into shelter living, especially models where you can move in almost immediately and without a deposit. PadSplit surveyed its renters in December and found a population that mostly works (83 percent were employed) and mostly hadn’t been to college. The median income was $32,500.

That co-living needs advocates at all is a legacy of the last century. Renting a single room in a boarding house or residential hotel was once an ordinary way to live in an American city, but in the decades after World War II those rooms became shorthand for poverty and vice, and cities responded by banning new ones and paying landlords to get rid of the old. Half a century later, many people still see sharing space with strangers as a last resort, or feel embarrassed about having roommates past a certain age. And discriminatory zoning codes written in that era are still on the books in most communities, enforcing traditional nuclear family arrangements when it comes to single-family housing, by defining “family” as people related by blood, marriage, or adoption. Those rules can be wielded against home-sharing, and against specific renters neighbors want to keep out.

But these longstanding barriers are starting to finally give. Doubling up with people you aren’t related to is less unusual than it used to be. Between 2017 and 2022, the number of households sharing space with nonrelatives grew by more than 500,000. Lawmakers desperate for anything that adds more housing supply also seem less picky about where it comes from. Companies like PadSplit are putting private capital behind the model, and a wave of new laws and litigation — much of it led by conservative legal groups arguing on property-rights grounds — is making it harder for cities to tell homeowners who can and cannot sleep in their spare rooms. 

For the first time since cities banned cheap rooms, the people trying to bring them back have the momentum, and the next couple of years will go a long way toward deciding whether co-living stays a niche workaround for people like Waller or becomes something a lot more people are able to consider.

The return of SROs

At the turn of the 20th century, as American cities swelled, immigrants, day laborers, and factory workers crowded into downtowns looking for somewhere cheap and temporary to sleep. A small room could be rented by the day, the week, or however long someone needed it. Some “boarded” in private homes while others took beds in bottom-rung hotels known as flophouses. These arrangements varied widely, but became broadly known as single-room occupancies (SROs).

The turn against them came after World War II, as middle-class white families decamped for roomy new houses in the suburbs, and SROs grew more closely associated with shoddy housing for the poor and the deviant. New York and other cities started banning SRO construction in the 1950s. By the 1970s, SROs were a regular media villain, even as they still housed hundreds of thousands of people, including the mentally ill who had been turned out by the closing of state asylums. Cities started to offer landlords incentives to convert their SROs into luxury rentals. Between the mid-1970s and the 1990s, roughly a million of these affordable market-rate units disappeared from the market across the country.

The idea that perhaps cities made a mistake in banning these lower-cost housing options has been simmering in urbanist policy circles for the last 15 years, particularly as the homelessness crisis has gotten worse. The Furman Center at NYU argued in 2018 that reintroducing SROs could help address the housing shortage. The architecture critic Karrie Jacobs argued in 2021 that cities had blamed a kind of housing for problems that belonged to the people living in it. “The notion took hold that if you eliminated the housing, the marginal people would simply vanish,” she wrote in Curbed.

Still, lawmakers have dragged their feet on actually making it easier to rent these kinds of units again, and until recently the people pushing for it had little to show beyond op-eds and white papers. What’s different now is that the fight has moved out of the world of policy papers and into places where it can produce actual results, including a lawsuit that could reach the Supreme Court.

Suing over who counts as family

In early 2022, a home-sharing startup called HomeRoom was renting out two houses in Shawnee, Kansas, a suburb of Kansas City. The company rented rooms one at a time to unrelated adults who wanted cheaper housing, and at a local city council meeting that year, Shawnee’s community development director asked whether the city should support such arrangements in single-family neighborhoods at all. Two months later, the council passed an ordinance banning “co-living groups,” which it defined as four or more unrelated adults sharing a home. 

Under the ordinance, if even one adult in a house wasn’t related to the others by blood, marriage, or adoption, the whole household counted as unrelated.

While the new law forced HomeRoom to evict its tenants, it also put Val French, a Shawnee homeowner, in a bad situation. She lived with her husband, their two adult sons, and one son’s girlfriend. Because the girlfriend was related to no one, the house was now deemed in violation of the city’s occupancy rules. Her son and his girlfriend had to move out, and French couldn’t rent the empty room to anyone else.

French and HomeRoom sued in federal court in May 2023, with assistance from the libertarian Pacific Legal Foundation. They argued that their right to choose who they live with is protected under the 14th Amendment, but they ran into legal precedent from a 1974 Supreme Court case, Village of Belle Terre v. Boraas, which upheld a Long Island village’s nearly identical rule against six college students sharing a house.

The decision came down in the same years cities were clearing out their SROs, and it has given local governments cover to decide who counts as a family ever since.

A federal judge dismissed the Shawnee suit in September 2023, citing Belle Terre, and this past April the US Court of Appeals for the 10th Circuit upheld the dismissal. A few months later, the Pacific Legal Foundation (PLF) petitioned the US Supreme Court to hear the case and reconsider Belle Terre once and for all. The precedent has already frayed in places — state courts in California, Michigan, New Jersey, and New York have struck down local “unrelated occupants” limits under their own laws — but it still governs everywhere else. 

There is “a fundamental liberty right to choose household living companions — whether as an articulation of the right of intimate association or independently — that is deeply rooted in American history and tradition,” PLF’s lead attorney on the case, David Deerson, told me. 

The Supreme Court hears only about 1 percent of the cases it’s asked to take, and even if it took this one, the plaintiffs would be asking a conservative majority to recognize a new constitutional right, which that majority has spent the past few years insisting courts should almost never do. 

Deerson’s argument is aimed at that skepticism, though. When the Supreme Court overturned Roe v. Wade in 2022, it held that an unwritten right counts only if it is “deeply rooted in history and tradition.” Deerson and his allies are arguing that living with people you aren’t related to qualifies as such because, for most of American history, boarding houses and lodgers were typical staples of family life. Belle Terre is also a short opinion written by William O. Douglas, a liberal justice whose legacy has little connection to today’s conservative justices. 

The legislative front

A Supreme Court reversal would be the cleanest fix for co-living, but advocates aren’t waiting on it. State legislatures have already shown they’ll act: Iowa barred cities from enforcing relationship-based occupancy limits in 2017, Oregon and Washington followed in 2021, and in 2024, Colorado lawmakers passed a law prohibiting cities from restricting how many unrelated roommates can live under one roof absent a clear health or safety reason. 

The Pacific Legal Foundation worked on that last bill too, and has since turned it into model legislation for other states. They colloquially call it the “Golden Girls bill” since occupancy caps like these would have prevented the four unrelated women of the hit 1980s sitcom from sharing a house. 

This year Pennsylvania lawmakers introduced their own version, with supporters citing not private property rights but the potential to ease the state’s affordable housing shortage. As legislators considered the proposal, Pacific Legal Foundation published research showing that nine of the 10 most populous cities in Pennsylvania capped the number of unrelated adults who could live together. The state House passed the Golden Girls bill this summer, though the Pennsylvania Senate version has not yet received a vote. 

The objection lawmakers hear most is the same one that animated Belle Terre — that lifting occupancy caps could turn quiet, orderly, neighborhood homes into de facto frat houses. That college partying concern killed Connecticut’s proposed Golden Girls bill this year. While the bill cleared the state Senate, it never got a vote in the House, amid reported concerns from the speaker about college students moving into wealthy neighborhoods. “What if a neighbor is unhappy about four unrelated people who are 19 years old or 22 years old living in the house?” state House Speaker Matt Ritter asked in an interview with the Connecticut Mirror. 

Pennsylvania’s sponsors tried to head off those fears by amending the bill to exclude protections where someone is enrolled at a college or university. In other words, the law would have covered Blanche, Dorothy, Rose, and Sophia from Golden Girls unless one of them signed up for a class at their community college.

Nevertheless, advocates are expanding their push. Jim Manley, state policy director for the Pacific Legal Foundation, told me he expects Texas, Florida, Pennsylvania, North Carolina, Rhode Island and Utah to take up new versions of the legislation in 2027.

And occupancy caps aren’t the only co-living target. Sam Hooper, a lawyer who has been lobbying state legislatures to re-legalize SROs, and his former colleagues at the Institute for Justice are now focused on the ROOM Act, model legislation that would bar cities from restricting SROs and other co-living arrangements, including rules that make it hard to convert offices into apartments. A version was first introduced in Rhode Island earlier this year. 

For Meagan Forbes, Institute for Justice’s director of legislation, the goal is for co-living to be treated like any other form of housing. “Other local laws can regulate things like noise and fire safety, but current regulations just go way too overboard in preventing this kind of housing,” she told me. 

Hooper, who drafted the ROOM Act, says he wanted to “take a massive sledgehammer” to existing restrictions. The resistance he runs into isn’t only the frat-house worry, but older cultural fears that SROs would recreate the poor tenement conditions of the early 20th century. “I think there’s this real problem of letting the perfect be the enemy of the good in housing policy,” he told me. “People accuse us of wanting people to live in undignified housing, but they just struggle to understand that it can be a perfectly fine option for many people at different points in their life.” Hooper credits his own London co-living experience in his 20s with introducing him to some of his best friends and his wife. 

Even so, he cited a broad political coalition backing him up, from property rights champions in conservative states to Democrats and progressive YIMBYs drawn to the housing justice and homelessness angles. There are business leaders interested in workforce housing, he said, and he noted that the AARP testified for the ROOM Act in Rhode Island. “I’m hopeful we’ll be able to keep this bipartisan coalition that hasn’t succumbed to the culture wars,” Hooper added.

Not every co-living proposal is about removing rules. DC’s Senior Co-Living Program Establishment Act, also nicknamed the Golden Girls bill, would pay senior homeowners $300 a month to rent a room to another senior, plus up to $2,500 for home modifications. 

The 21st Century ROAD to Housing Act, the federal housing package that became law in July, doesn’t touch occupancy rules. But it does fund a pilot program for converting vacant commercial buildings into housing, which could make adult dorm office conversions easier.

The demand question

While momentum for co-living is real, demand is also complicated. Americans are doubling up more than they were before the pandemic — about 8.2 million households in 2024, up 4.3 percent since 2019, according to analysis shared by Zillow. Yet the share made up of unrelated adults living together actually fell slightly, by roughly 50,000 households, while homes shared with couples or families grew by nearly 400,000. In other words, when Americans need to save on rent, they still mostly turn to people they already know.

PadSplit is betting that changes. Atticus LeBlanc recently announced his company is expanding into New York, Chicago, and San Francisco, three of the most expensive rental markets in the country.

“Does that mean things have gotten more desperate, that it’s forcing this cultural acceptance?” he asked me in an interview. “I think there’s certainly an argument to be made there. But you could just as easily make the argument that, holy cow, we are really, really wasteful with space.”

Hi readers! Shayla Love here, science journalist and longtime fan of Your Mileage May Vary. I’m honored to be subbing for Sigal Samuel while she’s out on parental leave. I’m diving into your questions as a way to help understand human nature and our choices through multiple lenses: philosophical, psychological, and beyond. Please send in any emotional, body/brain, sociological, perceptual, or other kind of life quandaries you might have.

My best friend confessed his love for me one year ago and I rejected him because I was unhappily in love with another man, and I was never really physically attracted to my best friend. He was devastated. I am happy our friendship survived.

Over a year later, I find myself thinking about how it would be like to be in a relationship with my best friend. He is the only man who ever showed me genuine love and support, and I wonder what if I try…maybe I will fall in love with him. However, I am concerned about hurting his feelings again. Is it selfish of me wanting to try this love out because it promises security and appreciation?

Dear Fanning the Flame,

I can’t blame you for being curious about the common “friends to lovers” storyline. It’s often portrayed as the best kind of pairing: Two people have the foundation of their friendship plus a newfound love; the romantic relationship is like a soaring addition to an existing sturdy house. 

But real life is not always like the movies, and it sounds to me like you haven’t actually had an awakening of desire for your friend. In fact, it’s the opposite: He once expressed feelings for you, and you confronted a lack of physical attraction for this person. Now you’re wondering if it would be possible for you to fall in love if you tried. I think you’d agree that your timing is suspect. After a breakup, it’s common and understandable to seek out comfort and intimacy. Still, I detect a philosophical streak in your question beyond the issue of whether or not this would simply be a rebound. 

If your friend has always appreciated you, made you feel safe, and loves you — could that be a form of love that’s better than what you had in your last relationship? Maybe that is what love is.

Is it? Over a long night of drinking some 2,400 years ago, one group of thinkers allegedly debated the true nature of love, as Greek philosopher Plato describes in The Symposium. 

Aristophanes, a playwright, tells a story that most closely aligns with the love we see in the rom-coms of today. He said that humans used to be larger creatures with four arms and four legs. After annoying the gods, Zeus cuts all the humans in half, creating the two-limbed bodies we have today. The result is that people wander the world looking for the one person who used to literally complete them. If you followed Aristophanes’s fable, you shouldn’t try to be with your friend unless you felt that deep longing that one has when meeting their other half. 

The rest of the dinner party companions have more circumspect ideas. Phaedrus, a Greek aristocrat, thought that true love inspired people to become the best possible version of themselves. Pausanias, a military man, thought that love driven only by attraction to someone’s body was “vulgar love”, and that “noble love” was the love of someone’s values. Eryximachus, a doctor, asserts that love is also about moderation, and it needs order, much in the way the natural world does. Finally, Socrates says that even if you start out with physical infatuation, you can eventually transcend that and end up loving wisdom itself, the highest form of love. As I read it, the men are grappling with how to make love make sense, while acknowledging that it can make us lustful and impulsive. Shouldn’t its best manifestations instead be practical and virtuous?   

You could easily justify trying to date your friend with these theories that try to wrangle and tame love. For example, if your friend inspires you to be the best version of yourself, you could decide that’s enough to go for it. You could also decide that because you admire your friend’s character, and not his body, that’s a noble love, and better than the vulgar love of attraction. 

German philosopher Arthur Schopenhauer wrote in his 19th-century essay “The Metaphysics of Sexual Love” that he distrusted the feeling of being desperately in love. He considered romantic love to be a biological drive disguised as a real emotion — one whose goal is to trick us into procreating. You could even see your lack of attraction as an indication that you’re able to act more rationally, and not be deceived by that cunning trickster, passion. 

I know you’ve recently gone through a breakup, but I hope you can feel how bleak these views can become: to see love only as the window dressing for the propagation of a species, or as just a bridge to the love of wisdom. 

This cynicism has other consequences. Wondering if you could redefine love in a relationship with your friend isn’t like a wine-fueled dinner party bouncing around thought experiments. It involves your best friend and his own feelings too, and could risk not only hurting him, but also robbing him of a better romantic partner. 

For Simone de Beauvoir, the 20th-century existential philosopher, the most important aspect of life was freedom: We are technically free to do whatever we want, and it’s the choices we make with that freedom that determine our authenticity, or lack of it. De Beauvoir worried about forms of love that stole freedom from other people. In narcissistic love, she wrote in The Second Sex, a partner doesn’t love the other person, but loves the fact that the other loves them. It’s a relationship built on the self-interest of one of its members. 

I want to gently point out that it sounds like there may be aspects of the narcissistic relationship in your dilemma. While it may be intriguing to consider what it’s like to date a friend, you don’t seem to be as romantically interested so much as you are interested in his interest in and support of you. Actually involving yourself in such a dynamic could take his freedom, as well as your own capacity to learn from your break-up, then find a partner you’re genuinely drawn to for their own merits.  

I’m not saying friendship isn’t an important ingredient in love. Many of the most successful, very long-term partners I know have developed a deep friendship with one another. This friendship helps them stay kind to each other and have fun over many years when work, health, or stress can interrupt more passionate times of connection. But those same couples also had the undeniable spark of attraction at the start of their relationships too. They didn’t have to try. Sometimes they tried not to feel as strongly as they did, and still weren’t able to stop. 

Even in cases when a relationship first launches platonically, if something more is there, the undeniable, reciprocal pull tends to emerge soon thereafter. In H.G. Wells’ 1911 novel, The New Machiavelli, which was largely based on a real-life affair Wells had, he writes about a college graduate called Richard who meets a young woman, Isabel. The two become friends and are entranced with each other’s minds. But they quickly start to notice more between them, despite trying to push such thoughts away.

They fail at this attempt. Richard has a moment of realization, when he turns to look at Isabel’s face one day. “And something — an infinite tenderness, stabbed me,” Wells wrote. “It was a keen physical feeling, like nothing I had ever felt before. …From that time forth I knew I loved Isabel beyond measure.” I think you owe it to yourself, and your friend, to pursue connections that have this quality, especially at the start. 

You should also make room for and appreciate your friendship. If it never becomes romantic, that doesn’t make it a lesser relationship. The couples therapist, Esther Perel, calls friendships their own kind of love story. She once described a simple exercise to help appreciate that bond. Take a few minutes and think about a friend who isn’t a family member or romantic partner. “Recall a time when that friend reflected you back to yourself, created space for joy, or helped you remember who you are,” Perel suggests. Then, send a message to that friend about that moment, and thank them. 

Having a good friend by your side in the aftermath of a breakup is a gift. Work on maintaining and nurturing that friendship, and make sure you spend some time helping him with his life too. Don’t fixate on whether you should attempt to fall in love. The truth is, for better or for worse, if you love him, you won’t have to try.

Bonus: What I’m reading

• I’ve always been interested in the history of love, by which I mean the differences over time in how love has been expressed and discussed. William Reddy, a historian of emotion, has an excellent book called The Making of Romantic Love; you can also check out a syllabus for a class at Duke University he taught on the subject. 
• For a deeper dive (and refresher!) on Plato’s Symposium, I found that there was no better person to turn to than Melvyn Bragg and his guests on the BBC In Our Time episode on the philosophy of love. 
• Arranged marriages are an interesting window into understanding the growth of love. Mansi Choksi’s nonfiction book, The Newlyweds, follows three couples in India who attempt to marry for love; here’s an excerpt that was published in Harper’s Magazine. 

Hier ist das diesmalige Heftblättern – unter erschwerten Umständen (Messelärm…), aber mit großem Enthusiasmus aufgenommen von unserem Autoren Stephan Freundorfer und Jörg Langer. Dass wir ein, zwei “Regieanweisungen” aus dem laufenden Interview heraus drin gelassen haben, ist kein Versehen, sondern Teil der Atmosphäre…

Wie üblich bei diesem Format, besprechen wir das aktuelle Heft (hier erhältlich) und lassen auch die eine oder andere Anekdote unserem Gehirnarchiv entspringen. Viel Spaß!

Editor’s note, September 6, 8 am ET: We’re bringing you some of our best-loved Your Mileage May Vary columns while Sigal Samuel is on parental leave. The one below was originally published last year.

This unconventional advice column offers you a unique framework for thinking through moral dilemmas. It’s based on value pluralism: the idea that each of us has multiple values that are equally valid but that often conflict with each other. Submit your own question here.

I am a university teaching assistant, leading discussion sections for large humanities lecture classes. This also means I grade a lot of student writing — and, inevitably, see a lot of AI writing too. 

Of course, many of us are working on developing assignments and pedagogies to make that less tempting. But as a TA, I only have limited ability to implement these policies. And in the meantime, AI-generated writing is so ubiquitous that to take course policy on it seriously, or even to escalate every suspected instance to the professor who runs the course, would be to make dozens of accusations, some of them false positives, for basically every assignment.

I believe in the numinous, ineffable value of a humanities education, but I’m also not going to convince stressed 19-year-olds of that value by cracking down hard on something everyone does. How do I think about the ethics of enforcing the rules of an institution that they don’t take seriously, or letting things slide in the name of building a classroom that feels less like an obstacle to circumvent?

Dear Troubled Teacher,   

I know you said you believe in the “ineffable value of a humanities education,” but if we want to actually get clear on your dilemma, that ineffable value must be effed! 

So: What is the real value of a humanities education? 

Looking at the modern university, one might think the humanities aren’t so different from the STEM fields. Just as the engineering department or the math department justifies its existence by pointing to the products it creates — bridge designs, weather forecasts — humanities departments nowadays justify their existence by noting that their students create products, too: literary interpretations, cultural criticism, short films. 

But let’s be real: It’s the neoliberalization of the university that has forced the humanities into that weird contortion. That’s never what they were supposed to be. Their real aim, as the philosopher Megan Fritts writes, is “the formation of human persons.” 

In other words, while the purpose of other departments is ultimately to create a product, a humanities education is meant to be different, because the student herself is the product. She is what’s getting created and recreated by the learning process. 

This vision of education — as a pursuit that’s supposed to be personally transformative — is what Aristotle proposed back in ancient Greece. He believed the real goal was not to impart knowledge, but to cultivate the virtues: honesty, justice, courage, and all the other character traits that make for a flourishing life. 

But because flourishing is devalued in our hypercapitalist society, you find yourself caught between that original vision and today’s product-based, utilitarian vision. And students sense — rightly! — that generative AI proves the utilitarian vision for the humanities is a sham. 

As one student said to his professor at New York University, in an effort to justify using AI to do his work for him, “You’re asking me to go from point A to point B, why wouldn’t I use a car to get there?” It’s a completely logical argument — as long as you accept the utilitarian vision. 

The real solution, then, is to be honest about what the humanities are for: You’re in the business of helping students with the cultivation of their character. 

I know, I know: Lots of students will say, “I don’t have time to work on cultivating my character! I just need to be able to get a job!”

It’s totally fair for them to be focusing on their job prospects. But your job is to focus on something else — something that will help them flourish in the long run, even if they don’t fully see the value in it now. 

Your job is to be their Aristotle. 

For the ancient Greek philosopher, the mother of all virtues was phronesis, or practical wisdom. And I’d argue there’s nothing more useful you can do for your students than help them cultivate this virtue, which is made more, not less, relevant by the advent of AI.

Practical wisdom goes beyond just knowing general rules — “don’t lie,” for example — and applying them mechanically like some sort of moral robot. It’s about knowing how to make good judgments when faced with the complex, dynamic situations life throws at you. Sometimes that’ll actually mean violating a classic rule (in certain cases, you should lie!). If you’ve honed your practical wisdom, you’ll be able to discern the morally salient features of a particular situation and come up with a response that’s well-attuned to that context. 

This is exactly the sort of deliberation that students will need to be good at as they step into the wider world. The breakneck pace of technological innovation means they’re going to have to choose, again and again and again, how to make use of emerging technologies — and how not to. The best training they can get now is training in how to wisely make this type of choice. 

Unfortunately, that’s exactly what using generative AI in the classroom threatens to short-circuit, because it removes something incredibly valuable: friction. 

AI is removing cognitive friction from education. We need to add it back in.

Encountering friction is how we give our cognitive muscles a workout. Taking it out of the picture makes things easier in the short term, but in the long term, it can lead to intellectual deskilling, where our cognitive muscles gradually become weaker for lack of use. 

“Practical wisdom is built up by practice just like all the other virtues, so if you don’t have the opportunity to reason and don’t have practice in deliberating about certain things, you won’t be able to deliberate well later,” philosopher of technology Shannon Vallor told me last year. “We need a lot of cognitive exercise in order to develop practical wisdom and retain it. And there is reason to worry about cognitive automation depriving us of the opportunity to build and retain those cognitive muscles.” 

So, how do you help your students retain and build their phronesis? You add friction back in, by giving them as many opportunities as possible to practice deliberating and choosing. 

If I were designing the curriculum, I wouldn’t do that by adopting a strict “no AI” policy. Instead, I’d be honest with students about the real benefit of the humanities and about why mindless AI cheating would be cheating themselves out of that benefit. Then, I’d offer them two choices when it comes time to write an essay: They can either write it with help from AI, or without. Both are totally fine. 

But if they do get help from AI, they have to also write an in-class reflection piece, explaining why they chose to use a chatbot and how they think it changed their thinking and learning process. I’d make it shorter than the original assignment but longer than a paragraph, so it forces them to develop the very reasoning skills they were trying to avoid using.

As a TA, you could suggest this to professors, but they may not go for it. Unfortunately, you’ve got limited agency here (unless you’re willing to risk your job or walk away from it). All you can do in such a situation is exercise the agency you do have. So use every bit of it.

Since you lead discussion sections, you’re well-placed to prompt your students to work their cognitive muscles in conversation. You could even stage a debate about AI: Assign half of them to argue the case for using chatbots to write papers and half of them to argue the opposite.

If a professor insists on a strict “no AI” policy, and you encounter essays that seem clearly AI-written, you may have little choice but to report them. But if there’s room for doubt about a given essay, you might err on the side of leniency if the student has engaged very thoughtfully in the discussion. At least then you know they’ve achieved the most important aim.

None of this is easy. I feel for you and all other educators who are struggling in this confusing environment. In fact, I wouldn’t be surprised if some educators are suffering from moral injury, a psychological condition that arises when you feel you’ve been forced to violate your own values.

But maybe it can comfort you to remember that this is much bigger than you. Generative AI is an existential threat to a humanities education as currently constituted. Over the next few years, humanities departments will have to paradigm-shift or perish. If they want to survive, they’ll need to get brutally honest about their true mission. For now, from your pre-paradigm-shift perch, all you can do is make the choices that are left for you to make. 

Bonus: What I’m reading

• I went back to Shannon Vallor’s first book, Technology and the Virtues: A Philosophical Guide to a Future Worth Wanting. If there’s one book I could get everyone in the AI world to read, it would be this one. And I think it can be useful to everyone else, too, because we all need to cultivate what Vallor calls the “technomoral virtues” — the traits that will allow us to adapt well to emerging technologies. 

• A New Yorker piece about AI and cognitive atrophy led me to a 2024 psychology paper titled “The Unpleasantness of Thinking: A Meta-Analytic Review of the Association Between Mental Effort and Negative Affect.” The authors’ conclusion: “We suggest that mental effort is inherently aversive.” Come again? Yes, sometimes I just want to turn off my brain and watch Netflix, but sometimes thinking about a challenging topic is so pleasurable! To me, it feels like running or weightlifting: Too much is exhausting, but the right amount is exhilarating. And what feels like “the right amount” can go up or down depending on how much I practice.

• Astrobiologist Sara Imari Walker published an essay in Noema provocatively titled “AI Is Life.” She reminds us that evolution produced us and we produced AI. “It is therefore part of the same ancient lineage of information that emerged with the origin of life,” she writes. “Technology is not artificially replacing life — it is life.” To be clear, she’s not arguing that tech is alive; she’s saying it’s an outgrowth of human life, an extension of our own species.

This story was originally published in The Highlight, Vox’s member-exclusive magazine. To get early access to member-exclusive stories every month, join the Vox Membership program today.

This story was originally published in The Highlight. To get access to member-exclusive stories like this every month, become a Vox Member today.

Every day it seems scientists are making breakthroughs in Alzheimer’s disease. 

New treatments that actually slow the disease’s progression — lecanemab and donanemab — have finally appeared on pharmacy shelves in the past few years, delivering real-world results for patients and their families. New blood tests promise to identify at-risk patients earlier in their lives, giving them the chance to make lifestyle changes and potentially start treatment to stave off symptoms. 

The media and wellness influencers are always reporting on new diets, workouts, or hobbies that can combat dementia. Just last month, there was even a report out of China about an experimental brain surgery that allegedly reverses the symptoms of Alzheimer’s disease — the Holy Grail that researchers have been pursuing for generations.

But hype has outpaced the science of treating Alzheimer’s disease before. Promising treatments have gotten a lot of attention before only to fizzle out a short time later. Less than a decade ago, many scientists were wondering whether we had the theory of Alzheimer’s disease completely wrong. 

For those of us who don’t work in the field, that confusing history can make it hard to make sense of these recent developments. It sounds like we are entering a new age for Alzheimer’s prevention and treatment — but are we actually? And, if we are, how can people benefit from it?

I called a couple of leading experts to find out.

Here’s the good news: They say scientists are genuinely shifting the paradigm for treating, detecting, and ultimately preventing Alzheimer’s disease. The two drugs on the market can actually slow down cognitive decline for many patients, something that had been out of reach for decades. And more treatments are coming.

“Diagnosis and treatment of Alzheimer’s has changed in a way that is revolutionary compared to, say, four or five years ago,” said Dr. Jason Karlawish, co-director of the Penn Memory Center.

At the clinic where he sees patients, “people are feeling a sense of hope and promise,” he said.

For a long time, the science on Alzheimer’s disease felt stuck. Now it’s moving. There’s only one thing that could stop it, according to experts: the Trump administration’s anti-science agenda.

Scientists are getting closer to game-changing Alzheimer’s treatments

In 2023, the approval of two drugs transformed the landscape of Alzheimer’s care: lecanemab (sold as Leqembi) and donanemab (sold as Kisunla), two IV treatments that target amyloid plaque in the brain of a person with Alzheimer’s. Before these two drugs — and the approval of aducanemab, a similar but less effective and riskier treatment — it had been decades since the last new Alzheimer’s treatment had come onto the market.

They are not perfect treatments. They are effective only for people with mild cognitive impairment, not more advanced stages of the disease. They can only slow the progression of Alzheimer’s for those people, not stop or reverse it. And they do come with the risk of serious side effects, particularly brain bleeds.

“The good news is, we have these two drugs that can help people,” said Tara Spires-Jones, professor of neurodegeneration at the University of Edinburgh and author of the forthcoming book, Fighting for our Minds: The Neuroscience of Defeating Dementia. “The bad news is, you don’t get any better. You’re still getting worse — you just get worse more slowly.”

These drugs are a start, not the endpoint. Researchers are already working on the next generation of treatments. The drug pipeline is becoming more robust because scientists are finally coalescing around a theory of the disease that’s more complex — and, crucially, opens more potential targets for new drugs. 

For a long time, Alzheimer’s research was dominated by the amyloid hypothesis. The theory posited that the buildup of plaque made from amyloid proteins was responsible for disrupting brain signals and creating the telltale loss of memory and identity associated with Alzheimer’s. Scientists are still confident that amyloid plays a role in Alzheimer’s — and the success of these amyloid-targeting drugs supports that interpretation. But there is also a stronger consensus that other mechanisms must be at work. Some people who have evidence of amyloid plaque building up in their brain nonetheless never develop Alzheimer’s disease. 

Another type of protein called tau seems to be associated with the disease. Scientists also increasingly believe that inflammation may play a role. Part of the breakthrough of the past few years is that scientists are no longer arguing about whether they even understand this disease at all. Instead, the mission is to pursue different drug targets and increase the chances of delivering new treatments.

“I don’t think people in the field are fighting over, ‘Your mechanism is wrong and mine is right,’” Karlawish said. “I think there’s a kind of general democratization. There are multiple promising mechanisms.”

New tau-targeting treatments are moving through clinical trials. Biogen has a drug called diranersen that aims to stop the production of the tau proteins moving through clinical trials. Preliminary results showed that the drug did appear to reduce tau and improve cognitive symptoms — although, curiously, the most effective response was at the lowest dose. Further research is needed before the drug could receive FDA approval. Another tau-targeting drug from Eisai has also entered clinical trials and is in the earlier safety-check phases. And new amyloid-targeting treatments aim to better penetrate the brain-blood barrier and deliver more effective relief for patients.

In the short term, scientists hope these drugs can slow or even stop cognitive decline better than the currently approved medications. In the longer term, these new approaches — and potentially a combination of different drugs with different targets — could eventually allow scientists to reverse Alzheimer’s. (As for that experimental surgery in China, as Nature reported, scientists say its results will need to be replicated in other clinical trials before we’re confident that it really works.)

“The brain is amazing. You can make new synapses,” Spires-Jones said. “If we could stop the insult, it’s theoretically possible in the future that we could have treatments that not only slow the progression but actually let you get better. But I think we’re pretty far from those. What I think is much closer is really, really meaningful treatments that will slow or even stop disease progression. We’re probably going to see something coming out in the next couple of years.”

How patients can get the most out of these new treatments

But even a “cure” in the long term will be conditional. Because Alzheimer’s eventually causes the brain to die (thus its 100 percent fatality rate), there may still be a point of no return once the disease is too entrenched. “A cure for people in the late stages is practically impossible because too much of the brain has died,” Spires-Jones said.

And that reality makes early detection all the more important. That’s the way patients can get the most out of the current medications and their eventual successors.

It used to be that doctors couldn’t confirm whether somebody had Alzheimer’s disease until the person died and they could perform an autopsy. But the new treatments can give people more time with their loved ones before the disease’s worst symptoms kick in. 

That means waiting is not an option. Patients are demanding better methods of detection.

“Treatment attracts patients, for good reason, and treatment demands diagnosis,” Karlawish said. “Treatment really does drive the business model for a disease.”

So, scientists are designing new blood tests that can detect the presence of tau proteins and predict the later onset of Alzheimer’s disease with impressive accuracy. And they are learning more about pivotal periods in a person’s life where their risk of Alzheimer’s might start to grow — and when interventions might therefore be more effective. New research has suggested that menopause may be an accelerant for Alzheimer’s progression, and therefore may represent an important point in someone’s life. 

These developments are shaping what the near-term future of Alzheimer’s care will look like. As a person ages, they will be able to take one of these blood tests to see if there are signals they are at a higher risk of the disease. If they are, they will have a growing number of medications that they could take to delay or potentially prevent dementia from setting in. For a woman at risk, for example, hormone replacement therapy has been associated with a reduced risk of dementia. Clinical trials are also underway to test whether existing drugs like donanemab and lecanemab can delay the onset of symptoms for somebody who is at higher risk but has not yet started to experience cognitive decline.

“We couldn’t get the right people at the right time early on — and now we can,” Spires-Jones said. “That’s a problem that’s almost solved now.”

Prevention may also be where GLP-1 drugs ultimately prove most useful. As scientists come to better understand the intimate relationship between vascular health and brain health, there is growing reason to think these medicines could help reduce dementia risk decades before symptoms appear.

That would make GLP-1s a complement to drugs such as lecanemab and donanemab, rather than a competitor. Those treatments are designed for people who already have early-stage Alzheimer’s. GLP-1s, by contrast, have so far shown little ability to slow the disease once cognitive decline has begun. In a disappointing clinical trial involving people with mild cognitive impairment or early Alzheimer’s, researchers found that the drugs had a negligible effect on the progression of the disease.

But that result doesn’t mean there isn’t a role for Ozempic and the next generation of GLP-1 drugs in the fight against Alzheimer’s. 

Scientists increasingly believe that chronic inflammation, obesity, and poor vascular health can all accelerate cognitive aging. GLP-1 drugs reduce inflammation, while their effects on weight and metabolic health can substantially lower cardiovascular risk. If US obesity rates continue to fall as these medicines become more widely used, their most consequential effect on Alzheimer’s may therefore be indirect: improving the health of millions of people long before the disease takes hold.

“I think where we’re going in the future is those semaglutide-type drugs will probably be very good for prevention,” Spires-Jones said. “If we can keep people’s obesity in check, that will probably more likely be a preventative treatment. That trial pretty conclusively told us that once you have symptoms, at least, that drug is not going to help.”

This summer, the Alzheimer’s Association announced a $100 million research project to examine whether lifestyle changes plus a GLP-1 medication could reduce the risk of dementia in at-risk older adults.

If you’re worried about your own cognitive health or that of a loved one, you have options, and those options are only going to grow. Talk to your doctor. There are FDA-approved blood tests you can already take. Ask about lecanemab and donanemab. You may also be a good candidate to help scientists in the most active areas of development. Researchers need people to participate in their clinical trials. The Alzheimer’s Association and the federal government have online tools to help people find clinical trials that you or someone you love could be a candidate for. 

Science funding cuts could slow down this progress

All the optimism about the future of Alzheimer’s treatment is based on research and clinical trials. When I asked Karlawish and Spires-Jones about where the story goes from here, they shared one concern: that science becomes so politicized that it would be difficult to get grant funding for research projects that could lead to additional breakthroughs.

“In some sense, the biggest threat is outside the science,” Karlawish said. “There’s deep concern that this politicization of the grant process will essentially wreck American science. We can’t sustain that kind of environment and still demand the results that we’ve come to expect.”

President Donald Trump and US Health Secretary Robert F. Kennedy Jr. like to present their crusade to reform American science as being targeted at frivolous DEI projects. But there are already examples of serious dementia studies being affected: Last month, the Trump administration canceled $15 million in grants for studies to evaluate how discrimination affects long-term brain health.

This is another place where we have more agency to impact what happens next: the ballot box. Use your individual political power to support lawmakers who defend the scientists and researchers doing critical work. 

“You can vote for people who will fund and support science as an endeavor,” Spires-Jones said. “Advances in science don’t happen on their own. We need all of society to get involved.”

I haven’t been on a three-way call this emotionally taxing since junior high school. James is explaining the situation — so many dynamics, so much time urgency — to Rachel, and asking if she thinks it would be workable, while I just nervously try to follow the conversation, crossing my fingers and toes. There’s inevitably going to be heartbreak, but is it possible there could also be a silver lining?

So what is this all about? Well, I’m trying to figure out how to donate my 78-year-old dad’s brain. He has advanced dementia and is living in a memory care community. James Watkins is the research and study coordinator of the UCLA brain donation program. Rachel is someone who works at a crematorium, which, as it turns out, cannot make it work. 

Certainly, the demand is there for my dad’s brain. The World Health Organization describes dementia as “one of the greatest health challenges of our generation” and reports that 78 million people will have dementia by the close of this decade (a 188 percent increase since 2000), for an annual global cost of over $2.8 trillion. And yet, research into what causes it and how to cure it remains stymied by a lack of funding, high-quality data, and — this is where me and my family come in — poor coordination with people suffering from dementia and their caregivers.

My dad hasn’t been a part of any research studies, which I have come to understand is how most people who donate their brains get introduced to the process. Instead, I’m free soloing and it’s not going well. I do some research, make some calls, then lose track of it for months on end. I’ve got two kids — 10 and 12 years old — and there are constantly changing camp pick-up and drop-off times to coordinate with my husband, my mom’s post-op knee replacement appointments to make, and lest you think I’m Mother Teresa, a lot of television to binge and dive-bar beer to drink. Meanwhile my dad is getting worse and worse. 

Will I get the administration on this donation done before my dad dies? They don’t call dementia “the long goodbye” for nothin’, but still, the end is near — and a mind is a terrible thing to waste. 

How does one go about donating a brain?

First things first: Where does one donate a brain? 

Not at the DMV, where you are likely familiar with being asked if you would like to be an organ donor. Brains, unlike livers and lungs and the like, can’t be transplanted, so they are handled differently. 

Brains are donated to brain banks dotted all over the country, which have historically been territorial about their recruitment strategies and cache of post-mortem brain tissue. That began to change in 2013 when the National Institutes of Health created the NeuroBioBank, a consortium of sorts between brain banks that wanted to collaborate, rather than compete. The NeuroBioBank now includes Harvard, Mount Sinai in New York, the University of Maryland, the University of Miami in Florida, and UCLA in Southern California, and together, they share the tissue of 18,000 brains.

The NeuroBioBank has partnered with the Brain Donor Project to help potential donors register. Founded in 2016 by Tish Hevel, daughter of a brain donor, the Brain Donor Project has an online form where people like me can register interest and then they do their best to match you with a geographically proximate brain bank that can coordinate what they call “retrieval” (i.e., cutting your person’s brain out before you proceed with burial or cremation rituals). Over the last decade, they’ve pre-registered 30,000 people with all kinds of brains to help advance cutting-edge research. 

That’s how I ended up on that three-way call. We live in the Bay Area. Last fall, after a bunch of internet research, emails, and phone calls, I learned that neither UCSF nor Stanford would take my dad’s brain, because he hasn’t been a part of any of their studies. I lost steam and a few months went by.

New year, new me. Get your shit together, Courtney. In January of this year, I landed on the Brain Donor Project website and filled out their standard form. Within hours, I was chatting with Watkins — who has a bit of a Southern lilt to his voice and a can-do attitude. 

When I told him that my dad wished to be cremated, he explained that I would need to call them as soon as he died at his facility, get him transported to the crematorium, and then the crematorium would need to hold on to him until a “brain retrieval specialist” could come and get the brain. Some crematoriums weren’t willing to do that, so we would need to call them to find one that would, and hopefully wouldn’t charge anyone extra money for it. 

It is in this way that I have so often found myself taking a sharp turn into logistics and finances while doing what is actually pretty existential elder care these last few years. One minute, I’m wondering about my dad’s quality of life (Does he know me? Is he content? What still gives him pleasure?) and the next, I’m discussing whether he requires one or two people to transfer out of his wheelchair (which affects the monthly charges at his memory care community). One minute, I’m hoping my dad’s imminent death can benefit someone else’s expanded knowledge, and then I’m side-barring with Watkins about whether this crematorium is trying to rip me off. It’s jarring, to say the least.   

Watkins and I call seven crematoriums together. All of them claim to not have the right facilities to accommodate a brain retrieval. It’s feeling grim, but Watkins stays positive. “I won’t be doing my job until we’ve done absolutely everything we can think of to try to make this happen,” he reassures me. 

Hevel says that people like Watkins make all the difference: “It takes a special person because you are helping someone during what may be one of their darkest times. And you’re dealing with logistics…it takes sensitivity and smarts.”

The other “middle man,” as it were, is what they call a “brain retrieval specialist,” who must get to the body within 24 hours of death in order to extract the brain and ship it off to the brain bank. Believe it or not, Hevel reports that this role is often performed by freelancers these days. (Studs Terkel might come back from the dead for that interview!) 

But even if we find one, everything needs to align just right, with multiple specialists and institutions all working together, for us to have any chance to pull this off. 

What are the brains for? 

Looking at real brain tissue under a microscope is a vastly different experience for scientists than using imaging (MRI and PET scans) or blood tests. Dr. Melissa Murray, a professor of neuroscience at Mayo Clinic, compares it to “almost like looking into outer space.” 

The stars, in this case, are our cells, and being able to look so closely at them creates an opportunity to identify them more accurately and understand the most vulnerable among them — which, down the line, can lead to gene or cell-based targeting. “We are getting closer and closer to understanding the genetic underpinnings of everything,” Hevel tells me. “As weird as this sounds, it’s kind of thrilling.” 

It doesn’t sound weird to me. Part of why I want to donate my own dad’s brain is so I can get an accurate diagnosis of what kind of dementia he actually has. My dad’s gerontologist has said he likely has frontotemporal dementia with Lewy body dimensions, but this was her best guess based on examining him once he was pretty far along in his disease, and with no MRI (my mom and dad didn’t opt to get one). 

For many neurological diseases, the only way to know with certainty what someone had is to examine their brain after death. One of the benefits of donating a brain is that you get a neuropathology report that does just that; many people find out that their loved one had diseases that weren’t even on their radar. 

That’s what happened to Cathy Butler, whose husband died in 2024 of what she thought at the time was frontotemporal dementia (FTD). What she learned after donating his brain and getting the pathology report was that “if he hadn’t succumbed to FTD, there were plenty of other pathologies warming up in the bullpen.” 

His brain showed evidence of arteriosclerosis, Lewy body dementia, Alzheimer’s, Parkinson’s, and FTD. All these years later — how does she feel about the choice? 

“With benefit of hindsight, I’m glad I did this,” she said. “It’s the only meaningful opportunity we get to smack back at that miserable bitch FTD.”

Other top reasons that people register with the Brain Donor Project are serious mental illness, Parkinson’s, and traumatic brain injuries caused by — and this made me so sad to learn — intimate partner violence. But scientists desperately need healthy brain donations as well; after all, every experiment needs controls. It’s thrilling that the Brain Donor Project has gotten 30,000 people in the system, but also so inadequate when you consider the scale of these illnesses and their impact on all of us. 

The barriers to brain donation

So why don’t more people do it?  

Well, there are surely some who are religiously opposed to it or feel strongly about leaving their loved ones’ bodies intact. Others have very obvious reasons to distrust the medical and scientific communities (see: Henrietta Lacks). 

But I think more people don’t do it for a very obvious reason that has nothing to do with these oft-cited sacred values: sheer exhaustion. Those most likely to be dealing with the administration of getting a brain donated are burned out and overwhelmed. 

I asked my friend Tricia Boyle, whose mom died of dementia, if she considered donating her brain and she said: “I’m actually frustrated that no one in my family thought to talk about this, but there was so much I was dealing with. I’m giving myself grace for not being on top of it, but I am super sad, as my family likely would have easily said yes to it had someone asked!”

No one did. Not Tricia’s mom’s doctors, social workers, hospice workers, anyone at her assisted living community, etc. And this is true in the vast majority of cases. There just isn’t a centralized system or culture of making sure the people most in touch with those who can donate know it’s an option. 

And by the way, mentioning brain donation in your medical directives or your will isn’t the way to go either. Often those documents are not consulted until it’s too late and a brain bank needs to retrieve a brain immediately. 

Hevel is trying to raise awareness through a variety of creative strategies, including doing partnerships with “death influencers” like @HospiceNurseJulie, who wrote the book Nothing to Fear: Demystifying Death to Live More Fully and has almost 2 million followers on TikTok.

But even if Hevel succeeds in creating the will, there still isn’t much of a way. Take my situation as a case in point. Who wants my dad’s brain to be donated? Me and my family, my friend Watkins and the UCLA brain bank, neuroscientists all over the country, and the leadership at my dad’s memory care community. Who benefits from it happening? The whole society, which knows far too little about one of the most common, demoralizing, and expensive diseases. 

Who can make it happen? Despite the heroic efforts of the Brain Donor Project, the infrastructure needed to coordinate all these moving parts just isn’t there to meet the scale of the challenge. Someone needs to be the brains of the operation, so to speak. Without, that the individual family is responsible for duct taping a system together while we’re facing the imminent death of someone we love. 

My family brain plan

After six months of research, awkward phone calls, and holding my dad’s hand every week, we had a decent plan. When he died, I was to call Sunset View Cemetery, who would transport his body on ice to their facility. I would also call Watkins, who would rustle up a freelance brain retrieval specialist who could get my dad’s brain out and get it on a plane to LA as fast as possible. The cemetery would charge us a $500 fee for the room where the extraction would take place (the brain bank would pay for $200 of that and we’d have to spring for the other $300). For all this effort we’d get a “football-size” amount of ashes and a pathology report potentially unlocking important genetic information, not to mention the cathartic knowledge that our grand loss had furthered science just a little bit. 

Except, like so many best laid plans, it didn’t go that way.

At about 4:45 pm on Thursday, August 13, I noticed my dad’s breathing had significantly changed. I played “Blackbird” by The Beatles off my iPhone for him and then whispered in his ear, “Goodbye dad. I love you forever and ever.” 

He took one last gulping breath and was gone. 

After crying my eyes out, I called Watkins. He said, “We’re not going to be able to do it.” 

Sunset View Cemetery only allows for brain extractions from 9 to 5. Death, as it turns out, doesn’t abide by standard business hours. There was no way to get it to LA within the 16-hour window.  

When I spoke to Hevel when I was first trying to figure all this out, she assured me: “It’s a lot of work, but you will find some comfort in knowing that it wasn’t all for naught. It sounds so corny. I told myself, ‘I’m not going to say that to people when it happens to them,’ but everyone who donates actually says that to us. It’s just true. It restores my faith in humanity on the daily.”

If only it didn’t require so much luck and administrative stamina to do the altruistic thing. 

Sometimes the best way to make friends is to lie. Around the world, people are gathering together to try to figure out if the person next to them is on their side — or is trying to double-cross them. By the end of the process, trickery or no, they’re deeply bonded.

Social deduction games (and the related sister category social deception games) have been around for decades and come in a myriad of formats, including Mafia, Werewolf, and the newer entry, Blood on the Clocktower. Their defining trait is that some players have hidden roles, and the rest of the players have to work out who those people are through social interactions: hinting, lying, interrogating, deducing, obfuscating. If you’ve seen The Traitors, you get the gist. 

Right now, this whole category is trending up. The most recent season premiere of The Traitors in the US drew 638 million viewing minutes in January on Peacock. Meanwhile, Blood on the Clocktower has sold 100,000 games worldwide, is listed as BoardGameGeek’s No. 1 party game, and recently announced that it will be publishing tie-in novels with popular science fiction and fantasy publisher Tor. 

Like all nerd trends, social deduction games are big online. But perhaps more importantly, they’re also big in person.

“I’ve been running game conventions for almost 20 years now,” says Jeff Anderson, the owner of the event planning company Qwyx Events. Anderson says that when Werewolf was at its peak in 2019, his cons would usually fill two rooms with Werewolf players. Now, he says, “I think we’re up to three or four dedicated setups to run Blood on the Clocktower,” and he still has a room full of Werewolf enthusiasts looking to play, too. 

It’s easy to see why playing a game in person is appealing during a time of intense social isolation. But this is also a time when Americans are lonely in part because we disagree on so much and find it difficult to trust one another. Within that context, the prospect of sitting in a room with a bunch of people and having full license to lie to them seems to be paradoxically irresistible.

Playing anti-social games in an anti-social age

Descended from the murder mystery games of the 1920s, social deduction games first took their modern format in the Soviet Union in the 1980s, when a psychology student invented Mafia as a research game. Soviet ex-pats took their new hobby abroad, where it sprouted variants. In the 2000s, Werewolf took the tech world by storm.

Around the same time that Werewolf was heating up, tabletop games in general became more complex and interesting, says Asher McClennahan, Kickstarter’s head of games. During the Monopoly era of millennial childhoods, games were mostly what McClennahan calls “technical manuals for fun,” but the 2000s saw the debut of more flexible, spontaneous games like Ticket to Ride. Tabletop games became increasingly popular in the years that followed, and social deduction games benefited from this renaissance. In 2016, Secret Hitler ascended at the same time as Donald Trump. The video game Among Us became one of the early hits of the pandemic in 2020. Blood on the Clocktower was published in May 2022, and a mere six months later, The Traitors had its triumphant premiere in the UK.

It’s no accident that this category has taken off during a time of radical change in the ways humans relate to each other. We interact through our screens now, exposing more of ourselves to more people than we could have imagined 30 years ago. The algorithm rewards outrageous corruption and vice, as do American politics and the economy of American fame. The idea of getting away with a little (controlled and consensual) anti-social behavior at a time when anti-social people are getting away with a lot is fun. 

Gray Atherton, a UK-based psychologist who specializes in the way that games shape our behavior and cognition, says that it’s this subversion of cultural norms that’s most appealing about social deduction games. To win, you have to double-cross and break trust with ruthless commitment. Breaking that taboo as part of a group creates prosocial bonds.

“You’re able to have that safe space — we call it in gaming this magic circle,” Atherton says. “A lot of the social rules and mores in real life dissolve, and you have permission to be a darker, more insidious character.” Playing a dark character within the game creates dramatic, memorable conflict, but because it all occurs within the magic circle of gameplay, the conflict resolves with no hard feelings. 

Not everyone loves creating this sort of dramatic conflict. The first and only time I found myself on Blood on the Clocktower’s Evil team, I was unable to come up with convincing lies on the spot, a personal weakness I found so stressful that I swore off the whole game. But for those drawn to the idea of consequence-free conflict, game space allows free rein to indulge.

That’s especially valuable for people who are almost certainly going to butt heads in real life eventually, like co-workers. Dana Buxbaum owns a board game café in Illinois that’s had an ongoing weekly Blood on the Clocktower game for the past few years. She frequently brings social deduction games to offices as a company bonding activity.

For Buxbaum, the magic starts with team allegiance. “If you’re on the good team, you are bonded with your good players to sus out evil,” she explains. “If you’re on the evil team, you’re trying to be sneaky. You’re with your evil team and you’re like, ‘Yeah, let’s get those goody two shoes.’”

But the game isn’t just about bonding with some players at the expense of the rest. Once active play is over, most social deduction games will have a master of ceremonies explain exactly what happened to those who weren’t in on all the secrets. “So whichever team you were on, you were all part of the story,” Buxbaum says. “That’s one of my favorite aspects. It brings the whole group together.”  

“I think that’s an important aspect of the hobby of social deduction: to recognize that we sometimes need to take a step back.”

Jeff Anderson, owner of Qwyx Events

All competitive games consist of people working at cross purposes to create something bigger than they are. But within social deduction games, it’s almost impossible to see what the game looks like while you’re playing. It takes the final reveal to see the shape of what you and the rest of your group made. When the final revelation occurs, it makes you all teammates, because you all built something strange and confusing and fascinating together.

Anderson, who runs gaming cons, says that in addition to allowing players to bond with like-minded friends, social deduction games also allow us to rehearse the skills we need to interact with people we disagree with. A key part of this type of game is not just trying to see through others’ trickery to build a mental map of the game world, but also convincing others that your worldview is correct, so that you can all agree together on whom to target. Essentially, you’re practicing arguing about radically different ideas about the world without taking it personally. 

Anderson cites the rules of Blood on the Clocktower, which include the instruction to “play nice.” 

“This is a game about deception and trickery,” the rules warn, “so please treat others with respect and consideration. Kill with grace, and die with dignity.”

“I think that’s an important aspect of the hobby of social deduction: to recognize that we sometimes need to take a step back,” Anderson says. “I use that as a model for this world we live in right now, because we’re around people who believe differently than we do.”

Making friends through lying

The intimacy that can form in the magic circle of gameplay seems especially appealing during our increasingly traumatic and isolated times. Many of the Clocktower players I spoke with say they began hosting a running game night because they wanted to spend time with other people in the wake of a larger destabilizing event.

Daniel Pyle began his Clocktower website, Pyles of Blood, in the midst of the pandemic, before Blood on the Clocktower had even been officially published. 

“I’m at home social distancing like everyone, and I wanted a way to be able to connect with people,” Pyle said. After he saw a tabletop game review YouTube channel give Clocktower a rave, he launched his website in April 2021, using an online version of the game. As soon as it was safe to meet in person, he turned his running internet game into an in-person meeting in Bloomington, Indiana, and he’s kept it going for the past five years. 

“Clock’s given me a lot, actually,” he says. “I’ve made a lot of friends through it.” 

I experimented with playing Clocktower because I had moved to a new city and wanted to make friends, and I thought that the kind of nerds who all showed up to play a board game together were likely to be the kind of people I could jive with. But this kind of game can also be a way to reinforce existing social connections, not just build new ones from scratch. 

Akshith Yellapragada started his running Clocktower game in Brooklyn, New York, after the 2024 election. “I was just very unenthusiastic about the general population, but felt very very enthusiastic about the people that I lived near and were friends with locally in the New York area,” he told Vox. “A huge goal that I had was to bring people together more and more, and to have people hang out offline without phone screens. I wanted to be able to do that in a way that I would be able to continue maintaining week after week after week and not burn out or get tired of.” 

Yellapragada decided Clocktower fit the bill. Now he hosts two game nights a month: a private game for his friends, and another that’s open to the public. The fact that you need at least five people to play — but can include as many as 20 players — makes it feel like even more of an event, and it also means he doesn’t have to cancel if a few people bail at the last minute.

Buxbaum has seen Clocktower meetups at her game store lead to several deep relationships. “We’ve had people meet at the cafe playing Blood on the Clocktower, and they’re engaged now,” she says. “It’s really great seeing friendships get made and roommates form.”

Recently, her group had an auxiliary meeting at the home of two of the players. As the game began, the players closed their eyes so they could go about the secret work of murder, sabotage, and spying unobserved. But when they opened their eyes again, the couple hosting were standing up at the front of the room like a bride and groom.

“It was a surprise wedding,” says Buxbaum — a real one, not a wedding within the game. The guests of honor were the heart of the group’s weekly Clocktower game. 

After all weeks of lying sweetly to each other’s faces and killing each other with grace, the social deduction players had become what all of us want: the kind of friend you invite to your wedding. 

This story was originally published in The Highlight. To get access to member-exclusive stories like this every month, become a Vox Member today.

PALAU, Micronesia — On a bright, sunny day last May, I stood on a boat surrounded by the turquoise waters of the island nation of Palau. I was there in the western Pacific watching scuba divers as they prepared to bring up evidence of a mysterious aquatic world. 

Palau is famous for its spectacular and rich coral reefs. But these divers were planning to descend past those sun-lit marine communities and down into a lesser-known twilight zone known as the “mesophotic coral ecosystems.” 

Mesophotic essentially means “middle” and “light,” which is where these ecosystems are — not quite in the bright daylight, not quite in the profound darkness, but somewhere in between. For simplicity’s sake, we’ll call these communities, which range from some 30 meters to 150 meters below the surface, the “deep reefs.” 

One of the divers on the boat with me was a zoologist and curator at the California Academy of Sciences named Luiz Rocha, who has spent decades studying these deep reefs and their secrets. 

“Anything between 30 meters and 150 meters is really, really unknown,” he told me.

Because these deep reefs are so unknown, researchers like Rocha are left with big questions. They want to get a baseline picture of what is going on in these ecosystems — even just who lives there! — so that they can better understand how they function.  They’ve also tried to work out whether (or not) these deep reefs might provide a refuge for species living in shallower coral reefs.

I was in Palau for Vox’s Unexplainable podcast because, in an effort to gather more information about these mysterious places, Rocha left some scientific structures down in these twilight depths back in 2016. Those structures then spent almost a decade becoming encrusted with all kinds of marine life. And now, Rocha was back to retrieve them, hoping that he — along with many other scientists — would be able to open them up, like a box of scientific puzzle pieces, full of clues about this under-understood marine world.

So what is a mesophotic “deep reef”? 

One thing that’s often acknowledged in papers about and descriptions of the “mesophotic coral ecosystems” is that scientists don’t know as much as they’d like to. A National Oceanic and Atmospheric Administration article about them from 2019 is full of “may’s” as in: they may “serve as essential fish habitat for economically and ecologically important species.”

Researchers do know some things, of course. They know that these deep reefs can be found in many of the same locations as shallower coral reefs — so mainly the tropical and subtropical parts of the world, like Micronesia, the Caribbean, and even the Gulf of Mexico. They’ve found that there are many species that seem to be unique to these places, and recent research points to their potential susceptibility to climate change.

Researchers have also gotten a sense of some of the key differences between these deep reefs and their shallower coral neighbors. In shallow reefs, hard corals team up with photosynthesizing algaes. The algaes provide the corals with nutrients, and the corals secrete a calcium-carbonate matrix that helps create the architecture of the reef. 

As you go deeper, though, the light begins to fade, and the opportunities for photosynthesis start to fade with it. The temperature also drops. So the animals living down in the deep reefs are the ones that can survive in a dimmer, cooler world.

Why are these places so mysterious? 

Scientists can dive into the deep reefs to try to learn more about these understudied places — as Rocha has — but exploring down at 100 meters requires more difficult, riskier technical diving than exploring at shallower depths. The deeper you dive, for example, the faster gasses get pushed into your tissues, which imposes limits on these really deep dives.

“We have a very, very short time,” Rocha says, “And by short time, I mean five minutes. Six, seven minutes.” 

Scientists might take some pictures in that time, or make some measurements, or collect a few samples, but then they have to move back upwards, a process which can take hours because they have to rise slowly to avoid decompression sickness.

It is, obviously, not particularly efficient to study an ecosystem in five- to seven-minute bursts. People have also used remote operated vehicles and submersibles to explore the deep reefs, but those have their own issues, and cameras can’t always capture all the detail you might want, or photograph more secretive, cryptic animals. So huge gaps remain in scientific knowledge about these ecosystems. 

“Whenever we go somewhere,” Rocha says, “the first thing we find is new species. … It’s the most basic thing in science you can do.” But this effort goes beyond just cataloguing new species of fish or sponges or sea slugs. 

Rocha wants to answer seemingly fundamental questions like: What is the main energy source for everything down here in the dimmer light? What does the food chain look like? How have things evolved to live down at these depths? How similar are they to the shallow ecosystems, and how different? How are they affected by climate change — and what’s the most efficient way to protect them? 

But, “in some ways we don’t even know what questions to ask,” Rocha says. “We really only know what questions to ask after we have a baseline understanding of what the ecosystem is. And for deep reefs, we don’t know that yet.” 

A new way to understand the deep reefs using “prefab housing”

Rocha is not deterred by the enormous number of question marks that surround these deep reefs. For years now, he has been gathering bits of basic information about them, often via those very short dives. 

About a decade ago, though, Rocha got interested in another method for sampling the biodiversity of this sort of marine ecosystem — a technique involving “autonomous reef monitoring structures” (ARMS).

Basically, each ARMS is a stack of several PVC plates, separated at uniform intervals and attached to a base plate. They look like little grey, featureless hotels. You take them to a place that you want to study, bring them down, secure them, and then leave them alone for a while to let them collect…life.

“As soon as you drop any kind of clean structure on a reef,” Rocha says, “it starts getting colonized by larvae of everything around it — of sponges, gorgonians, corals. And then, because there’s all a lot of hiding spots between the plates — so between the floors of the hotel — they start getting colonized by shrimp, by mollusks, by ascidians, by anything you can imagine in the ocean. … And it becomes this stable, diverse mini reef, if you will, packed with a lot of biodiversity that would be very hard to collect all at once in any given reef.”

A few years after that initial drop, you come back, collect the ARMS, and then study the mini reef that has grown on them. You can sample and touch and analyze things to your heart’s content. 

It’s not only a very effective way to collect lots of creatures, all at once, but also a great way to do so in a standardized way. If you went down — or sent a robot down — to collect an encrusted rock from a reef, you could learn a lot about the life on it, but it would be hard to compare the life on that rock to life on other rocks from other reefs, or even the same reef, because each rock would have its own unique characteristics. Not so for ARMS.

“ Every one’s the same,” Chris Meyer, director of the Smithsonian Global ARMS program, told me, “It’s prefab housing, and then you just look to see who moves in.” 

To Rocha, this seemed like a great way to get a really good, long look at the deep reefs instead of the brief glimpses he was getting from diving. It was also, he told me, fairly cheap to deploy them. So from 2016 to 2018, with some private funding, he and his colleagues left ARMS in some of the deep reefs around Palau — as well as in Guam, the Marshall Islands, and French Polynesia. They installed some around 50 meters, and some around 100, and then some around 10 meters, so he could compare the deep reefs to their shallower neighbors. 

After that, he waited. 

In fact, he waited a little longer than he would have liked, because the retrieval of ARMS is more expensive than deploying them, so he had to work out more funding. 

Eventually, private funders agreed to underwrite the retrieval of the ARMS that Rocha had left. Which is how he and his fellow divers finally found themselves on a boat in Palau again, ready to pull up these structures for the deep.

Opening the scientific puzzle box

Over the course of a few days, I watched a whole team of people pull several ARMS out of the deep reefs of Palau. Some of the ARMS were relatively sparse, but others were almost fuzzy with organisms — vibrant with red and orange and green and pink and white. One had a massive sponge attached to it, another had several delicate fronds dangling from it like coralline ferns. The ARMS collected each day traveled to the Palau International Coral Reef Center in bins full of seawater, where the scientists quickly got to work — seeing and touching (and smelling) this mysterious ecosystem right up close.

The process was, as it turned out, equal parts magical excitement and well-oiled, Cheez-It fueled disassembly line. After the plates were taken apart, Meyer took photographs of the plates — what he called a “time capsule of the place.” Others in the lab picked carefully through trays of debris, hunting for tiny crabs and worms and mollusks, or scraped samples off the plates and deposited them in tubes.

They collected sea squirts, said to be our closest invertebrate relatives. They collected sponges — flat ones that felt dry underwater, thick ones with bristles like tiny, unmoving caterpillars, one as thin as a flake of skin and shot through with silver filaments. They collected strange, soft corals known as “octocorals,” and they collected colonies of animals called bryozoans, which created what looked like swirling, two-dimensional honeycombs.

“We’re looking for every unique thing, which we call a morphospecies,” a Smithsonian research biologist named Sarah Tweedt explained. “And we’re trying to get some representative tissue samples from all of these things so that we can sequence the DNA — and match the DNA to the organism.”

That is, of course, assuming there is already a known genetic match in our existing DNA libraries. 

On the first day that I spent with the team, a Cal Academy curator named Terry Goslinger identified several potential new species. He is an expert on colorful, delightful sea slugs known as nudibranchs, and so, because of his deep knowledge (and because nudibranchs’ bright hues and patterns make them somewhat easier to tell apart than some other underwater creatures), he was able to make some on-the-spot calls about whether or not certain species were likely to be new to science, pending genetic testing to confirm.

Many of the animals were trickier to pin down, though. The researchers did their best to identify the creatures they were finding, but even now, several months out, there’s still a lot of work to be done. Of the close to 3,000 specimens, only a small fraction were identified at a species level. The numbers are a little bit inexact because researchers are still processing the data, but when I checked in with a Cal Academy postdoc working on the project, Susanne Bähr, in July, she told me that only 3 percent of samples had been ID’d by species, and a little less than 20 had a genus designation. Many, many more were only identified at higher, broader taxonomic levels. Genetic testing of the samples, paired with photographs and descriptions of the samples, will help people work out more specific species, and also help them identify whether certain species are new to science.

Beyond discovering new species…and toward solving the big puzzle

The most important parts of this work will involve more than just identifying species. In fact, the more time I spent with these researchers in the lab, (including one evening spent with them as they worked past midnight), the more I got the sense that, while they seemed excited about seeing new species, they seemed equally excited to witness relationships between animals.

When I walked into the lab one day, for example, several people urged me to go over and look through a microscope at a creature known as a pompom crab — a tiny yellow crustacean holding purple anemones in its modified front claws. Tweedt was extremely jazzed when she found something referred to as a “skeleton shrimp,” which looked to me like the marine equivalent of a stick insect, blending in on something called a hydroid. She pulled me aside another time, around one in the morning, to show me “the frosting on the cake” of the day, which turned out to be some bright red sea snails and the bright red octocorals they seemed to live on

As she put it in a later conversation, these relationships are, in many ways, the key takeaway from this ARMS project, and what distinguishes it from efforts to bring up a few individual samples at a time. Studying them, or even just looking at the fuller picture ARMS provide, is what will let researchers tackle some of the outstanding questions about these ecosystems. Bähr, for example, is already working with the data from ARMS retrieved in Guam, trying to analyze how much overlap (or lack thereof) there is between species at different depths in the deep reefs.

Really, though, this is all just the beginning. In one of our conversations, Rocha compared the work they are doing now to ecology work done in the mid-20th century to understand how species’ vertical distribution changes as you go up a mountain. This drove home for me how far behind researchers working on the mesophotic deep reefs are compared to their colleagues working on, say, shallower coral reefs. I asked him what kept him working on such a difficult puzzle.

“It’s the reward at the end of it,” he said, “If it’s a hard puzzle, at the end of it, the reward is always bigger.” 

“But…in our lifetimes, will we assemble the deep reef puzzle?” I asked.

“No, we will not assemble the puzzle, no,” Rocha said, “but we’ll generate some good pieces for the next generation to assemble.”

A fledgling “loneliness economy” is booming on the back of warnings about just how bad loneliness can be for us — “comparable to smoking up to 15 cigarettes a day,” as one often-cited comparison puts it. But can we really spend our way out of loneliness? In this month’s Highlight cover story, Allie Volpe breaks down the false promise of startups promising to banish loneliness (for a price), the real symptom they may be concealing, and a better way to bring people together. Also in this issue: How to know your true self. The ocean’s under-explored “twilight zone.” Making friends by lying to them. And why is it so hard to donate a brain?

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You’re a people pleaser? Here’s how to not lose yourself.

By Shayla Love

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Can you spend your way out of loneliness?

By Allie Volpe

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Inside a quest to learn about the ocean’s mysterious “deep reefs”

By Byrd Pinkerton

Coming September 1

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Why is it so hard to give away my dad’s brain?

By Courtney E. Matin

Coming September 2

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How to make friends by lying to them

By Constance Grady

Coming September 2

Hi readers! Shayla Love here, science journalist and longtime fan of Your Mileage May Vary. I’m honored to be subbing for Sigal Samuel while she’s out on parental leave. I’m diving into your questions as a way to help understand human nature and our choices through multiple lenses: philosophical, psychological, and beyond. Please send in any emotional, body/brain, sociological, perceptual, or other kind of life quandaries you might have.

My wife says I’m a people pleaser. I want to turn over a new leaf (maybe to please her?!) so I’m making a resolution to be less of a weathervane and stand up for myself more. But it’s hard — I love to fit in. I’m a joiner and a collaborator. It’s not that I’m passive, it’s more that I find other people’s “ways of being” contagious. Sometimes I catch myself slipping into imitation of the friends or colleagues I’m talking to.

What’s a chameleon to do? Or, more scarily, who am I when I’m alone? How do I find out who I really am?

Dear Identity Crisis,

At first glance, it’s a bit funny to be accused of being a people pleaser as if it’s entirely a bad thing. It sounds like you have others’ interests genuinely in mind, and that seems like a nice way to build connection.

But I find the term people pleaser to also be a sneaky euphemism. Do you want to know how this sort of behavior is often discussed in the psychological literature? In studies, it’s not always called people pleasing; it’s called lying. 

In fact, wanting to please other people is an incredibly prevalent motivation for lying; it’s more common than lying for personal gain or pleasure. When psychologists evaluated the top reasons that people lied in their everyday life, many wanted to seem more agreeable. Their lies support seemingly magnanimous goals, like complimenting a friend or making sure a social interaction went well. But they were lies all the same, defined by the researchers as a “message that one gives to another in which they are deliberately deceiving them.” 

I find this shift in perspective helpful, if a little harsh, if you’re looking to break a people-pleasing habit. It’s one thing to think about yourself as dedicated to keeping other people pleased. But when you consider that actually, all of your interactions are suffused with lies, the approach becomes a bit more unsavory. 

Imagine the situation in reverse: What if you found out that all the time you had spent with a close friend, they were keeping their real thoughts and feelings from you? You might feel differently about the time you’d spent together. I can bet it certainly wouldn’t feel as authentic. 

I used to be a bartender, and I would be nice and mildly obsequious to frequent customers. Several of them I genuinely liked. But I’ll never forget the uncomfortable moments of running into a regular elsewhere — and their figuring out that we weren’t actually friends. There’s a distance between two people when one’s main role is to please the other. You are creating that distance, even if you may not realize it, and not even getting tipped for it. 

So for starters, try trusting that the people around you are able to handle your real thoughts and feelings. But what are your real thoughts or feelings? This points to the bigger conundrum you face: Who is your true self? 

You’re in good company worrying about this. Religious figures, philosophers, and scientists alike have been trying to figure out if there even is a continuous self, and if there is, what is it made up of? 

Scientifically speaking, there’s not a part of your brain that’s “truer” than others, or where the true self resides. But your ideas about your true self matter, according to research by Rebecca Schlegel, a social scientist at Texas A&M University. She has found that people have greater well-being and find their lives to be more meaningful if they think that they’ve made choices that align with who they “really” are. 

When people make a decision that they think aligns with their own true self, it regularly leads to feeling more satisfaction with that decision — more so than choices steered by considering what other people want, by religious belief, or by advice from others. 

Doing this yourself can be remarkably simple. In one experiment, Schlegel asked participants to make an arbitrary decision and told some to “use your true self” to make up their minds, and others to “use rational thinking.” Those who framed their choices as being guided by their true self were much happier with their selection. For you, it could be that just introducing the question — what would my true self do? — can start making your life feel more like it belongs to you. 

If it feels odd to ask your true self what to do, defining your truest self as what’s moral about you isn’t a bad place to start. Researchers have found again and again that when they ask people which of their traits feel the “truest,” it’s usually the parts that are morally good. When I call my mother on her birthday, that’s my true self. When I say something hurtful to my friend, that’s a deviation from my true self, who knows better. I wasn’t myself this morning, I might say as an apology. So you could make a list of your best qualities, like your generosity or your creativity. Then, when you ask what your core self would do, you’ll have even more specific guideposts to follow. 

Of course, if having a true self still doesn’t feel relatable, you can turn to an approach I’ve found helpful in my own life from Eastern traditions, like Buddhism and Taoism. They endorse the idea that there is no rigid self at all. In Buddhism, this is called anatman, which translates roughly to “no self.” This teaching emerged in response to an earlier Hindu belief: a concept called “atman,” which asserted that all people had an eternal and unchanging core, similar to a soul. Anatman was a rebuttal to that idea.

I’ve found that anatman relieves some of the pressure around all of this. We feel as if there should be an essence to us, some permanent quality that persists over time that you can point to. But anatman reminds us that there’s no aspect of the self that doesn’t change.  

Life is long, and we transform throughout it. As we grow, we learn new physical skills like playing soccer and the piano, and eventually acquire back problems and wrinkles. Our minds evolve too. We read novels, maybe we can do calculus, and we develop political convictions. Hopefully, we gain the skills of being kind and patient. In all of these developments, change is the only constant. This is why the Buddha thought that you couldn’t find the singular, stable self in any of these places — not the mind, the physical form, our habits, or our perceptions. “What is impermanent, subject to change…cannot be taken to be ‘me,’ ‘mine,’ or a ‘self,’” the Buddha taught. 

You asked what you, as a chameleon, should do? You could frame everything you do as being in service to your deeper self. Or you could try halting the search for a strictly defined, enduring version of you, and start making decisions based on who you want that person to become.   

Bonus: What I’m reading

• My book club just read Love, Always, a novel by Ann Beattie, about a group of people who start a magazine in rural Vermont. It’s a summery tale, though somewhat frustrating, about what happens when people don’t change themselves, and only follow their worst instincts. 
• This is a fascinating story of multiple selves in Popular Mechanics by Michael Natale. It documented what happened when seven men confessed to being the culprit of a plane hijacking in 1973 in the Pacific Northwest.
• Over the course of several nights recently, I watched the 1926 silent movie, Faust, directed by F.W. Murnau. It’s a haunting tragedy about the consequences of wanting to hold onto a quality of yourself indefinitely — in this case, staying young forever. I was amazed by the special effects they pulled off for that era! An evergreen reminder that if someone promises you something that’s too good to be true (especially if he looks like the devil), it probably is. 

This story was originally published in The Highlight. To get access to member-exclusive stories like this every month, become a Vox Member today.

Over the years, Julianne Holt-Lunstad has fielded many requests from startups looking for her help. These entrepreneurs came to the Brigham Young University professor with the well-meaning goal of “solving” loneliness; they believed their app or company could help consumers build genuine connections, and wanted Holt-Lunstad’s opinion on this feature or that business tactic. 

Across the pond, University College London professor Noreena Hertz was getting the same calls. They wanted her to join their boards, to advise them, to give their proof of concept a stamp of approval. 

“Of the many startups who’ve approached me, and it’s probably about 50 or 60 in the space,” Hertz told Vox, “there hasn’t been one where I felt convinced by their business model.”

That CEOs and founders were clamoring to pick the brains of these two women is entirely predictable — their work may have been the basis on which these startups were founded. Holt-Lunstad is among the most cited academics who study loneliness and social connection. The commonly repeated stat that loneliness is equivalent to smoking 15 cigarettes a day? That came from her research. She was the lead science editor on the Surgeon General’s 2023 advisory on loneliness and isolation. As for Hertz, in her 2020 book The Lonely Century: How to Restore Human Connection in a World That’s Pulling Apart, she coined the phrase “loneliness economy,” at the time, a fledgling market of niche services, like friends for rent and professional cuddling.

In the years since Hertz gave it a name, the loneliness economy has only ballooned. As public attention to loneliness has mounted — despite the fact that research doesn’t consistently show whether a loneliness epidemic exists in the first place — the market stepped in to offer solutions. No longer are the lonely limited to joining a running club, they can now rent friends and cuddlers. They can hire a coach to help vanquish loneliness and build a community. (One charges $3,000 for a three-month program.) They can attend a $1,000 weekend-long summer camp to make friends (with the option to pay in installments via Klarna). They can buy a $250 pendant that listens to their every word and can communicate back via voice or text. They can join a coworking space meant to quell loneliness with a nearly $300 a month price tag. They can enroll in a bootcamp for how to be less shy, hop in a group travel excursion with other solo venturers, download an app where AI pairs you with other strangers for activities. Loneliness is no longer a societal issue with mental and physical costs and structural solutions but one businesses hope consumers can buy their way out of.

But is it possible to disrupt the slow burn that is making a friend? To outsource the intimacies of friendship to AI? To put a price tag on human connection? 

“I would caution developers to really critically evaluate their business model and the barriers to who they’re actually reaching,” Holt-Lunstad told Vox. “Think about ways that [connection] can occur organically without monetizing it.”

The cottage industry of loneliness services is just another example of capitalism wrapping its tentacles around human desire. But in most cases, the cost of the app, or product, or experience is going to be much higher than the possibility of eliminating loneliness.

One person’s loneliness is another’s business opportunity

Since the early 2000s when Harvard political scientist Robert Putnam warned of the decline of civic and social spaces in his seminal work Bowling Alone, we have witnessed the “privatization of community,” according to Sam Pressler, a fellow at the Harvard Human Flourishing Program who studies community, connection, and class. Gathering spaces shifted away from places of worship and union halls to boutique fitness centers and private, members-only clubs. “There was already this dynamic in place where you could, at a premium level, sell people on community,” Pressler said.

The pandemic pushed the loneliness economy into overdrive. Widespread social isolation enabled researchers to study perceived levels of loneliness during lockdowns. Media coverage of loneliness outlined its harms. Although Vivek Murthy, the US surgeon general during the Obama and Biden administrations, first referred to loneliness as a “health epidemic” in 2017, his 2023 report opened the door for other iterations: the male loneliness epidemic, the Gen Z well-being slump, a worsening midlife crisis. Over the past five years, search interest in the loneliness epidemic grew over 600 percent.

Naturally, the startup world began to see a business opportunity, Pressler said. WeWork founder Adam Neumann launched a new residential real estate company with a goal of “solving loneliness” and $350 million in funding from Andreessen Horowitz. The app 222, which uses AI to pair strangers for group activities based on personality-based questions, raised $10 million in funding. “You then get this anchor within startup land that really has an approach of solve customers’ problems and pain points, in that loneliness is a customer problem or pain point to be solved, through productized market solutions,” Pressler said.

Brian Choi had heard of the male loneliness epidemic, but luckily didn’t feel like he fell into that category. He grew up in the Los Angeles area, where he still lives, and has plenty of friends, but he signed up for 222 several years ago as a way to supplement his social life and meet people who might be interested in activities his existing friends aren’t.

“Dance, for me, means a lot,” the 34-year-old video game character artist, told Vox. “For my best friends, hard to sell them on that. So 222 is a good angle on sharing that experience with other people who are presumably also open to dance.”

But most of the platform’s events, Choi found, were centered around dinner and drinks, which didn’t appeal to him. If there was a meetup with an interactive element, like brunch and a pottery class, he was more likely to engage. But despite attending about a dozen 222 events over the years, Choi hasn’t fostered any serious friendships. “It’s dependent on individuals to be proactive about inviting folks into their lives after the 222 event,” Choi said. “And that can be scary for a lot of people.” 

Once a market emerged for loneliness-adjacent services and products, influencers started promoting them. Over the last few years, the content creator Zaid Khan observed his peers hosting “community” events that seemed well-meaning enough until a few common themes emerged: The events seemed to be furthering the creators’ brands, they often came with a ticket price, and they were attended mostly by young, white people. This widespread commodification of community is what Hertz refers to as “WeWashing” — like greenwashing — because an occasional knitting club with a $50 fee does not a community make. 

Charging any sort of premium for a social event or service runs the risk of exacerbating inequities. According to Holt-Lunstad’s research, people with only a high school education or less or those who made less than $75,000 a year were less socially connected than those with higher education and incomes. People who stand to benefit the most from interventions to build relationships often can’t afford a $200 a month gym, or lack the time to swipe for friends. These spaces can then become, like Khan observed, homogenized by race, class, and ability. “I’m sorry, but young, attractive, white, straight, 20-somethings living in New York will have no issue. … You can walk into any West Village bar and meet those people,” Khan said. “It’s excluding the people who, I think, genuinely could need it.”

“Masking” a symptom

There is a contradiction at the heart of the loneliness economy: the need for human connection in the modern world is difficult to solve, let alone value and commodify. In order to make money, companies either have to charge top dollar for their social club or camp, or, they need their product to be used by as many people as possible, as often as possible, which inherently flies in the face of how relationships are fostered. 

“The ethical problem begins when a company intentionally exploits a consumer’s loneliness, insecure attachment, or fear of missing out to pressure that person into purchasing.”

Cindy Rippé, Terry College of Business at the University of Georgia

Relationships are projects of patience. They unfold after repeated interactions in a physical space, after slow revelations and disclosures and laughs. The loneliness economy isn’t built on unhurried bonding. Instead of consistently showing up to a community event and slowly building connections, some apps are effective at connecting users with strangers for one-time events, but are less focused on encouraging users to exchange numbers and hang out again. “We know from the research that relationships take time to develop, and that there needs to be consistency also over time. When you get to know someone, it takes time,” Holt-Lunstad said. “If you’re only doing it sporadically or once, that’s going to be less likely. If it’s all virtual, that’s going to be less likely.”

Just like hunger and thirst cue you to eat and drink, loneliness is a sign to interact. Swiping for friends may feel productive and occupy time, but without actually hanging out, it may just be a distraction, Holt-Lunstad said. “What I worry is that [apps] may be effective in masking that symptom without actually fulfilling any social needs,” she said. “It would be like no longer feeling thirsty, but we’re not actually drinking any water.”

The loneliness economy also fails to take into account the barriers preventing people from making friends in the first place. In recent surveys, the results of which have not been published, Holt-Lunstad has found both internal and external obstacles to connection, including anxiety, a fear of rejection, physical and mental health limitations, the economic cost of participation, and the time investment required with joining a club. “It might be, that’s a great program, but it’s too far away, or that’s a great program, but it costs too much,” Holt-Lunstad said. “And then, of course, there’s the internal barriers where there’s so much shame and stigma associated with this that many people don’t want to feel like I have to have an app or a program to make friends.”

These potentially lonely consumers may be more vulnerable to companies’ marketing efforts, even though the products are unlikely to solve the underlying issue. According to research, when people feel like they are lacking close, intimate relationships, they are more likely to buy themselves things. “One of the things, for instance, could be spending money to go on group activities rather than individual activities,” Aulona Ulqinaku, an associate professor of marketing at Università Carlo Cattaneo LIUC in Italy, told Vox. People could spend money to join a club you aren’t particularly interested in just to feel a part of something. 

Shopping can also serve as a social experience in itself, Cindy Rippé, a senior lecturer in the Department of Marketing at the Terry College of Business at the University of Georgia, told Vox in an email. Employees and other patrons can become familiar and friendly faces, effectively turning a retail space into a third place. A paid social experience, such as a club, could theoretically achieve the same fulfilling effects as shopping, Rippé said. But spending money isn’t what makes people feel better; it’s repeated social interaction, familiarity, belonging.

Because companies can track your activity online, users who search for local clubs or interact with these groups on social media may be repeatedly served ads for other community-centric businesses and thus spend more money on services that may not be effective.

“I hope that we are looking at a world where marketing can be looked at as an instrument for helping people rather than exploiting people,” Ulqinaku said. “The aim should not be, ‘I make money [off] of you.’ The aim should be, ‘I want to make you feel better. I don’t want to exploit you.’”

Putting a price tag on relationships

The pairing of lonely consumers who might be willing to spend money and businesses that definitely want to make it may be good for the bottom line in the short-term, but perhaps not for social health or for revenue in the long-term. (After all, if these products don’t work, people will stop paying for them, and if they do work as promised, people will also stop paying for them.) Friendship isn’t a product you can advertise or put a dollar amount to, Pressler said, and we shouldn’t apply market solutions to non-market goods.

“You can approach it with a consumptive mindset where it’s like, ‘Well, I just need to consume more relationships, and if I consume more relationships, ergo, I will not be lonely or disconnected,’” he said — but that’s not how real-world interactions work. The power imbalance between the companies earning money and the consumer spending it to fulfill a core human need may veer on exploitative, too, Rippé said: “The ethical problem begins when a company intentionally exploits a consumer’s loneliness, insecure attachment, or fear of missing out to pressure that person into purchasing.”

Which isn’t to say communal gatherings with a price tag are inherently exploitative. Live music and events, like concerts, successfully bring people together for shared experiences, according to Hertz, the professor and author. (Of course, tickets have become so expensive that seeing your favorite act perform is becoming a luxury.) Groups centered around an activity have the potential to connect people, too. But buying your own yarn and needles to bring to a weekly craft night at your local knitting shop is different from paying $50 to join a one-off “knitting club” organized by a VC-backed friendship app.

Because social health touches so many aspects of life — the physical spaces we inhabit, the technology that both facilitates and inhibits socialization, the costs of interacting — the path toward connection is more complex than marketable products or individual purchases. It involves government investment in public spaces and low- or no-cost community events; policies that allow everyone to lead a dignified life, which includes the space for leisure activities; and a societal shift that prioritizes slow, intentional relationship building instead of instant connection. 

“The need is real,” Hertz said. “The purported solutions are many. Some of them I think can be part of the solution. Some of them may well end up making us lonelier as a society.”

This story was originally published in The Highlight. To get access to member-exclusive stories like this every month, become a Vox Member today.

Update 1.7.26: Die erforderliche Unterstützung von mindestens 2.000 Vorbestellungen wurde zum 30.6.26 erreicht – wir werden in Kürze die Planung zum Spieletest-Sonderheft “Die 80er Jahre” beginnen. Das Erscheinen ist für Ende November/Anfang Dezember geplant. Alle Crowdfunder können im Juli den ersten Newsletter erwarten. Wer noch upgraden will, kann das direkt in seinem Konto (die Sonderheft-Bestellung anklicken) machen.

Und wer bislang noch zögert: Wir lassen das Crowdfunding noch eine Weile offen, aber irgendwann in der mittleren Zukunft wird es die höheren Stufen nicht mehr geben, und der Preisvorteil durch die reduzierten Versandkosten fällt weg.

Dieser Link führt euch direkt zum Crowdfunding.

Vielen Dank, dass ihr uns die Verzögerung des Crowdfundings um zwei Wochen (ursprünglich war der Start am 16. Mai geplant) nicht übel genommen habt! Heute früh ist nun das Crowdfunding zum Spieletest-Sonderheft Die 80er Jahre gestartet. Der Hauptgrund für die Verzögerung war die Erweiterung auf fünf Stufen und das Abtesten mehrerer physischer Beilagen. Am Ende haben wir uns nun aber dafür entschieden, den “Firelefanz-Faktor” sehr gering zu halten und nur das Poster zu machen ab Stufe 3, das wir dafür aber von DIN/A3 auf DIN/A2 vergrößert haben. Die Hauptunterschiede liegen nun beim Heft selbst (es gibt drei Varianten: normales Cover, anders layoutetes Cover mit Prägedruck, und das feste “Buch”-Cover für Stufe V) und etwaige “besondere Würdigungen”.

Sicher fragt ihr euch, was es mit der Abstimmungsteilnahme ab Stufe IV auf sich hat: Wird das Spieletest-Sonderheft Die 80er Jahre nun etwa durch Schwarmintelligenz erstellt? Das natürlich nicht. Aber es ist beim vorherigen Sonderheft in seltenen Fällen zu knappen Entscheidungen gekommen (etwa, welches von zwei wichtigen Spielen noch in ein Genre aufgenommen wird), bei denen wir auch eine Münze hätten werfen können. In solchen Fällen werden wir dieses Mal die Vorbesteller der Stufen IV und V abstimmen lassen und uns an das Ergebnis halten.

Und jetzt zur Beschreibung des Hefts – die einzelnen Stufen und ihre Unterschiede findet ihr beim Crowdfunding.

Das Sonderheft 80er Jahre

Unser 2. Sonderheft liefert etwas, das ihr im normalen Retro Gamer nicht findet: Retro-Spieletests. Und zwar gleich 100 davon – mit jeweils mindestens einer Seite Umfang, und von erfahrenen Spieleveteranen-Autoren wie Anatol Locker, Heinrich Lenhardt, Michael Hengst, Hardy Heßdörfer, Roland Austinat und vielen anderen. Gebündelt ergibt das den perfekten Überblick über das wichtigste Spielejahrzehnt überhaupt, denn in den 80ern legten 8- und 16-Bit-Spiele den Grundstein für alles, was danach kam!

Beim 80er-Jahre-Sonderheft steht weniger die Kaufberatung im Vordergrund als vielmehr die Zeitberatung – sind die Klassiker von damals heute wirklich noch eure Freizeit wert? Aber natürlich geht es auch um Einordnung und Würdigung, ihr erhaltet einen guten Überblick über das komplette Spiele-Jahrzehnt. Bei den Tests nutzen wir das altbewährte “objektive” 100er-System und bewerten aus heutiger Retrofan-Sicht: weder durch die rosarote Brille, noch als pingelige Erbsenzähler. Wir erwarten für eine hohe Wertung einfach, dass das Spiel heute noch Spaß macht. Zur Abrundung gibt’s auch noch unsere streng subjektiven Wertungsgesichter zu den Tests – subjektiv kann auch ein mit 71% bewerteter Klassiker noch “Super!” sein.

Wieso der Fokus auf Spieletests statt unserem normalen Mix aus einer Vielfalt von Interviews, Making ofs und Co.? Weil wir euch eben nicht nur „mehr vom Gleichen“ verkaufen wollen. Und weil wir in der RG-Redaktion wehmütig an Magazine wie die Happy Computer Spiele-Sonderhefte zurückdenken, die gekonnt Bekanntes und Unbekanntes zusammenfassten, Marktüberblick und Lesespaß vereinten. Das Sonderheft stammt vom bekannten, leicht erweiterten deutschen Retro-Gamer-Team.

Wieso “Crowdfunding”?

Aktuell ist das Sonderheft ein zwar konkreter Plan, aber noch keine Realität – erst mit euren Crowdfunding-Vorbestellungen stellt ihr sicher, dass wir wirklich loslegen können und uns über den (Früh-) Sommer und Herbst hinweg mit viel Liebe um die 80er Jahre und ihre Klassiker kümmern. Wir werden Ende Juni 2026 Bilanz ziehen, ob wir bereits genügend Geld einnehmen konnten, um als kleiner Verlag bei diesem Projekt finanziell halbwegs abgesichert zu sein. Und da wir das Interesse an den 80er Jahren für etwas geringer einschätzen als an den 90er Jahren, sind die zusätzlichen Crowdfunding-Stufen noch wichtiger als beim ersten Sonderheft. Sollte das Projekt je nicht finanziert werden, erhaltet ihr euer Geld natürlich zurück.

Apropos Geld: “Wieso verlangt ihr so viel Geld?”, fragt sich vielleicht der eine oder andere von euch, gerade in wirtschaftlich schwierigen Zeiten wie diesen. Doch wir haben beim Sonderheft höhere redaktionelle Kosten als beim normalen Retro Gamer, wo etwa die Hälfte der Artikel Lokalisierungen sind (die uns günstiger kommen als neu geschriebene Beiträge). Zudem ist die Seitenzahl höher, und wir haben (vermutlich) keine einzige Anzeigenseite im Sonderheft. Vor allem die deutlich geringere Druckauflage (im Vergleich zu den etwa 18.000 beim Hauptmagazin) erhöht die Kosten pro Heft deutlich, weil es viele Fixkosten gibt. Die bessere Papierqualität kostet zusätzlich.

Dieses Sonderheft gibt es nur hier im Shop, nicht am Kiosk – die Entscheidung, ob wir wie beim 90er-Jahre-Heft wieder in den deutschen Bahnhofsbuchhandel gehen, steht noch aus.

Passend zur Titelstory in Retro Gamer 3/26 zu Shadow of the Colossus (PS2) spielt Hagen Gehritz für euch das auch dort gelobte Remake von Bluepoint Games von 2018, das dieses faszinierende Werk gekonnt auf PS4 gebracht hat. Viel Spaß!