Primary care is the foundation of American medicine — and it’s withering.
Soon after Dr. Gerard Weigel moved his family to Somerset, Kentucky, in the mid-1960s, he found himself not only the town’s only primary care doctor but the only doctor of any kind — the cardiologist, endocrinologist, and pulmonologist for each patient at his practice.
In a 1967 Mercury Monterey — ”It looked just like Steve McGarrett’s car on Hawaii Five-O,” his son, Dr. Joseph Weigel, recalls — his father would drive around the town of 10,000 to see patients at their homes.
“My father was an old-school general internist,” Joseph Weigel told me. “He was literally ‘the man’ here for all of those years.”
Four of the eight Weigel children went into medicine, and Joseph, the oldest, decided to become a generalist like his dad, who is now 96. After graduating from medical school, Joseph Weigel started practicing in Somerset in the 1980s.
At first, his career was based on relationships with patients, just like his dad’s. He felt he knew everything about them: their medical history, whether they had lost a job recently, if they had gone through a divorce. Early in his career, if one of his patients was admitted to the hospital, Weigel would follow them there. He would work in the critical care unit and sometimes even do surgical procedures, such as placing temporary pacemakers, because there was no other clinician around who could do it. Once his patients had been discharged, they would come back to his office. He would see the person through every step of their care.
But those patient-doctor relationships Weigel remembers have become a relic in the modern American health care system.
Sam, Weigel’s son, remembers going out in public as a kid with his dad and they would often run into one of his dad’s patients. The respect they would show was one of the reasons Sam wanted to go into medicine. He, too, is now a doctor, the third generation in the family. But he works at the local hospital, where he sometimes treats a patient for a few days for an acute illness and then never sees them again.
“He has a completely different lifestyle, a completely different way of practicing medicine than either my father or I ever did,” Joseph Weigel said.
Sam doesn’t envy the early mornings and late nights that Joseph would have to work back in those days to maintain his practice; his dad would come home from work and pop dinner in the microwave at 8 pm because he missed the family meal. But Sam recognizes he has missed out on something. “I haven’t had that same experience,” he said.
Today, primary care is being squeezed from all sides. Long-standing patient-doctor relationships, once the foundation of medical treatment, are becoming less common: The number of Americans who say their source of medical care is a personal physician has been steadily declining. That is especially true for younger patients: As of 2018, nearly half of adults under 30 said they did not have a primary care doctor.
Many opt instead for the convenience offered by urgent care clinics, clinics in retail stores, and even their local emergency room.
The once-dominant model of an independent practitioner who ran their own practice, an entrepreneur as much as a physician, is less and less feasible. The overhead is prohibitive. Hospital systems and other corporate entities have absorbed the majority of America’s primary care workforce. The field is becoming less attractive to aspiring doctors, who can make more money in another specialty.
Patients are paying the price for America’s failure to invest in primary care. Clinical evidence indicates that when patients have a steady primary care relationship, they tend to be healthier and live longer. But it is too hard for too many Americans to find and keep a primary care doc. By one recent estimate, 100 million Americans face some kind of barrier (physical or financial) to accessing primary care. One in four Americans doesn’t have a regular source of health care, a share that has been steadily growing since 2000.
In the face of those headwinds, some primary care practices are trying to recapture what has been lost, to re-engage their patients and communities so that they might enjoy the benefits of having a long-term relationship with one physician. Some of these experiments rely on new technologies (such as for virtual visits) and on new business models (such as direct primary care practices and concierge-style clinics).
In one sense, primary care is trying to find a modern version of the kind of more personal medicine the elder Drs. Weigel practiced. Doctors say they are doing more home visits, holding later office hours, and setting up clinics in schools and workplaces. They are trying anything to meet their patients where they are, to salvage that core tenet of medical care Weigel and others fear is disappearing.
Why fewer and fewer Americans have a primary care doctor
Primary care doctors are intended to be patients’ first contact point with the health care system, the practice where people receive regular physicals, basic medical tests and treatment for mild illnesses, and are referred out to other doctors if their problems are serious.
These long-term relationships of mutual trust between doctors and patients are part of the foundation of American medicine. In the 1800s, the profession was in competition with home-based care and unscientific healers. It distinguished itself over time through professionalization, but also because doctors established their authority by settling down in a community, caring for patients’ medical needs for years. Paul Starr, in his acclaimed history The Social Transformation of American Medicine, quoted contemporary reports of patients in the 1840s and 1850s who would wait for hours at their doctor’s home until he returned from another call.
That image of the do-it-all primary care physician persisted for generations, well into living memory. Dr. Dominic Mack, a doctor for more than 30 years and the director of the National Center for Primary Care at the Morehouse School of Medicine, described growing up in Augusta, Georgia, where a handful of primary care doctors cared for most of the Black population. They admitted patients to the hospital and called in prescriptions. They would even deliver babies and perform general surgery.
“That one doctor retained the knowledge of your health throughout the system,” Mack told me.
In the early 1980s, three-quarters of US doctors still owned their own practice. But over the ensuing decades, that share would steadily drop. The push to control costs in the ’80s and ’90s led hospitals to start buying up more independent practices. Managed care — the idea that a single patient’s needs across the health system should be overseen in a more comprehensive way — made integrating physicians into a larger health system the logical move. Even as the craze for HMOs faded, doctors found it increasingly difficult to operate their own practices in competition with the growing hospital systems. Joining a larger system became more attractive, and hospitals were willing to put a lot of money down to get their foot in the primary care field.
Today, for the first time, fewer than half of doctors own their own practices. Doctors under 40 are much more likely to work for somebody else than their older counterparts.
It’s not just the business side of primary care that is changing. Patients’ expectations are evolving, too. Even in the 1990s, Americans would often face much longer wait times than they do now. But today’s patients no longer have the patience to wait for the doctor to see them.
A survey of physician staffing firms observed that wait times for primary care have actually dropped from a high of more than four weeks in 2017 to about three weeks in 2022. But that improvement was not really a sign that it was easier for patients to get an appointment. Instead, analysts at Merritt Hawkins wrote that “a growing number of patients are accessing primary care through urgent care centers, retail clinics, and telemedicine.”
“What is unique about current times is the changes in patients’ expectations with immediacy of access to doctors. I don’t want to be on hold for 10 to 15 minutes. I don’t want to wait months for an appointment,” Ishani Ganguli, assistant professor of medicine at Harvard Medical School and Brigham and Women’s Hospital, said. “It makes sense we as consumers and patients want that from our primary care.”
So patients have sought out alternative options, prioritizing their convenience over the continuity that is increasingly hard to find.
Urgent care clinics have been around since the 1970s, but they have enjoyed a boom in the past decade. In 2014, there were about 6,400 urgent care clinics in the US; that number had grown to more than 11,000 as of early 2023. CVS and Walgreens have established in-store clinics built on a similar premise: You may not see the same doctor every time, but you can see a doctor quickly. Walmart began to adopt the same model in 2019, and the company plans to double its health care footprint by the end of 2024. Dollar General, which recently hired a chief medical officer, appears to be on the same path.
“We’re living in an era when people don’t have a relationship with a bank teller or hardware store,” said Dr. Yul Ejnes, who practices in Rhode Island and is the former chair of the American Board of Internal Medicine’s board of directors. Consumers expect service “24/7/365 … Health care has evolved in that way. People want what they want when they want it.”
But something may be lost under the new model. Research has consistently found that a long-term relationship with a doctor leads to better health results. One recent analysis, published in April of this year, found that when patients lose their longtime primary care doctor, the number of emergency department visits and hospital admissions increases, as does their mortality rate.
“These effects were magnified if that relationship was longer in the first place. That really does align well with prior studies and clinical experience,” Ganguli told me. “A patient you meet for the first time may not believe you for good reason: They don’t know you. But over time, you build that relationship, that same advice carries a lot more weight.”
How primary care doctors are trying to reinvigorate their practices
In some ways, the problems facing primary care are not new. Ejnes remembers being at a policy meeting in the mid-1990s when one of the agenda items was about a troublesome demographic: young adult men who had health insurance but who were not establishing relationships with primary care docs. The Washington Post reported on the same trend earlier this year.
But the problems are going to get worse as fewer doctors in training elect to practice primary care and more family physicians reach retirement age. Right now, according to a report from the Milbank Memorial Fund, 1 in 3 US doctors practices primary care, but among young doctors two years into their career, the share is only one in five. The Association of American Medical Colleges projects the country will be short as many as 48,000 primary care doctors by 2034.
The traditional fee-for-service model for financing medical care — in which doctors are paid based on how many appointments they have and how many tests they order — also contributed to primary care’s deterioration. Doctors have been rewarded for seeing as many patients as possible in a given day, not taking more time to establish closer relationships with them. Insurers and health systems have been slow to adopt so-called “value-based payments,” which could reward primary care’s contribution to patients’ long-term health.
Doctors characterize the new mode of health care as “industrial” or, as Ejnes put it, “transactional.” Thirty years ago, Ejnes told me, “it was just you and the patient in the exam room.” But today, “a dozen other people are there in spirit” — a performance evaluation team monitoring how the patient is faring with managing their diabetes, a billing team that decides how to code every service, an insurer that wants all this documentation in order to cover drugs or tests.
As they feel intimacy with patients slipping away, doctors are turning to technology that promises to provide convenience: telemedicine, widely adopted during and after the pandemic, and new business models, particularly direct primary care and concierge-like clinics, that could eliminate some of the perverse incentives created by volume-based payments.
For both primary and concierge care, patients pay a flat fee — a retainer of sorts — to establish a relationship with a doctor. In direct primary care, the doctor will typically make house calls for both check-ups and sick visits. That model has been growing quickly, with an estimated 1,600 practices across the United States, but still serves a small percentage of the population, about 300,000 patients. With concierge clinics, the best known of which is probably Amazon-owned One Medical (though it sometimes disavows the “concierge” label), patients can not only access their personal doctor on demand, they may also be enrolled in wellness programs and other perks the clinic offers.
Both models mean doctors are no longer dependent entirely on the number of services they provide. They have a steady source of income from patients’ membership fees. Ejnes noted that direct primary care was not as financially affected during the first few months of the pandemic, whereas regular independent practices saw a huge drop in patient visits and some were threatened with closure as a result.
Based on his conversations with colleagues, doctors at a regular clinic might have as many as 1,500 patients on their rolls; those in direct primary care or concierge care may carry only 500. The model gives physicians the leeway to give their patients the more personal touch without jeopardizing their livelihood.
“We have to understand, patients don’t necessarily want what we’ve been selling,” Ejnes said. “We can still offer the same good we would have offered 30 or 40 years ago, but in a contemporary way.”
These ventures aren’t a cure-all. If every primary care doctor suddenly cut their patient roster in half, the shortages already in existence would get worse. And these clinics have often catered to upper-middle-class professionals living in cities, not marginalized communities where medical access is most constrained.
Even at more conventional practices, though, doctors are experimenting. What unites these disparate efforts to reinvigorate the field is, ironically, a return to the basics.
Dr. Oswaldo Bacani and Dr. Jennifer Bacani McKenney, father and daughter, are part of a practice in Fredonia, Kansas, that is taking an all-of-the-above approach to connecting with their patients.
Bacani came to the US from the Philippines and settled down in Fredonia for what was supposed to be a one-year trial after his medical residency. But he and his wife liked the town so they stayed; they’ve now lived there for 45 years. At first, he was one of the do-it-all doctors, performing surgeries at the local hospital in the morning and seeing his primary care patients in the afternoon. But over time, he focused more on the latter. McKenney says she remembers watching cartoons in the back office of his primary care practice, watching the patients come and go.
“The thing I always remembered is watching Dad interact with his patients. You could see it was personal,” she told me. “They would hug. They would laugh.”
He would come home with pies his patients had made him. One time, a patient paid for surgery with a goat. The kids named it Peaches, after its favorite food.
“I’d see the way his patients loved him, the way they came up to him,” McKenney, who works with her father now at the hospital where she was born, said. “I never remember not wanting to be a doctor.”
Even in their small town, where interpersonal relationships may come more naturally, they have noticed some disengagement from patients. Some people in Fredonia became more skeptical of medical experts after the Covid-19 pandemic.
So their practice is reaching out to the community. They have started setting up flu shot clinics on-site at local businesses. They have considered contracting with local companies to act as a direct primary care provider for their employees. The practice has also set up a clinic at a local school so that students and teachers wouldn’t have to leave and come sit in their waiting room if they need care for something minor.
Those attempts to bridge the patient’s desire for convenience while maintaining a long-term relationship with one practice could help arrest primary care’s decline. Ganguli told me she has begun holding office hours until 7 pm at least once a week, so it’s easier for people to come in after work, and she has seen employer-driven efforts to provide primary care up close after one Boston-area hospital set up an on-site clinic for its employees.
Ejnes, whose practice was recently acquired by a larger health system, said he and his colleagues have set up an after-hours co-op of sorts: They take turns being on call after regular business hours. Maybe the patient won’t see their own doctor, but they’ll at least see someone who knows their doctor. (It is a similar concept to the co-ops that are prevalent in the Netherlands, which Vox profiled a few years ago.)
This is what the new MO in primary care looks like. Meet the patients where they are. Lure them back with the kind of convenience that had prompted them to seek other options in the first place.
“We’re not waiting for them to show up,” McKenney said.
The history behind Israel’s democratic crisis, explained.
The Israeli Supreme Court is currently hearing arguments in a landmark case about itself.
At issue is the first law passed in Prime Minister Benjamin Netanyahu’s judicial overhaul package — a new limitation on the court’s ability to overturn decisions made by Netanyahu and his cabinet it finds “extremely unreasonable.” This may sound like a small technocratic dispute, but in fact, the fundamental nature and even survival of Israeli democracy is at stake. There’s a reason Netanyahu’s overhaul has spawned the largest protest in Israeli history: The attack on the court is seen, by millions of Israelis, as an attack on Israeli democracy itself.
“Absolute power corrupts absolutely, and while this government may not abuse its power, when the power is there, it will be used,” Aner Helman, the lawyer representing Israel’s attorney general, said in Tuesday’s hearing while arguing the new law should be overturned. Helman’s argument was notable not only for its seriousness, but also for the fact that he is a government attorney who typically defends its policies in court.
To understand how the judiciary became the policy issue in Israeli politics, one potent enough to turn core state institutions against each other, you need to understand a series of profound and overlapping tensions in Israeli Jewish society — divisions between the religious and the secular, between the right wing and the center left, and between Netanyahu and the country’s traditional political establishment. All of these tensions are connected to perhaps the central philosophical question of Israeli politics: What does Israel’s core legal identity as a “Jewish and democratic” state mean?
For years, it seemed possible that this fundamental issue could be worked out within the confines of the existing political and legal system. But the rise of the Israeli far right in the past two decades, and Netanyahu’s fateful decision to join ranks with them, pushed things well outside “normal” political parameters. The court is the last institutional bulwark standing in the way of a series of far-right initiatives on everything from the Palestinian conflict to the role of religion in public life. The far right wants to smash through this guardrail, and has the votes in the Knesset (Israeli parliament) to do so.
Many specific developments in Israeli politics, ranging from controversial Supreme Court rulings to Netanyahu’s trial on corruption charges, came together to make the attack on the court possible. A democratic “perfect storm” created a unique opportunity for the right to permanently resolve the central dilemma of Israeli politics on their terms — and galvanized those committed to alternative visions of Israel to fight for a court they see as their last best hope.
This week’s case, then, is not just about a specific judicial power. It is part of a bigger fight over whether the right will be allowed to continue redefining the Israeli state along illiberal and anti-democratic lines — and whether the Supreme Court is willing to risk a constitutional crisis to stop them.
The conflicts at the heart of Israeli identity
Israel does not have a formal constitution. Instead, it has what are called “Basic Laws” — laws that create a kind of constitution-lite amendable by a simple majority vote in the Knesset. The current crisis stems from a new Basic Law, passed this June, that eliminates courts’ power to overturn decisions by Israel’s cabinet or its ministers that they find to be “extremely unreasonable” — meaning decisions that the government can’t prove were made according to some basic standards of fair and just policymaking.
Such a standard for judicial review might seem overbroad in the United States. But it’s actually relatively common internationally, and Israel in particular has a need for it given that it has no constitution, no federal system, and no separation of executive and legislative powers. The courts are basically the only check on decisions made by the elected government — and the current government, a far-right coalition led by Prime Minister Benjamin Netanyahu, is trying to weaken the judiciary’s powers and pack the courts with ideologically friendly jurists.
At issue in this week’s case, in part, is whether the court can do something it’s never done before: overturn a new Basic Law on grounds that it conflicts with other Basic Laws. The issue is not just whether this one change to the law is defensible. It’s an existential question of how the basic contours of the Israeli political system are to work.
To understand just why the stakes have gotten so high, it’s necessary to dwell on the definition of the state as both “Jewish and democratic” — which is not only a guiding vision for the state but also an identity legally inscribed in the Basic Laws.
The idea, at least in theory, is that Israel is supposed to be at once a distinctly Jewish state and a democratic state founded on liberal ideas of equality and human rights.
“Compatibility between the democratic and Jewish-Zionist character of the state is a cornerstone in the ideology of all Zionist political parties in Israel and the opinion of the overwhelming majority of the Jews,” the Israeli sociologist Sammy Smooha argued in the late 1990s (while noting that “from this Jewish consensus, ultra-nationalists dissent.”)
In practice, Smooha argues, there are obvious tensions between these two prongs of its self-identity — ones inherent to the “Jewish and democratic” concept itself and thus evident since the state’s creation.
One of Israel’s foundational aims is to serve as a homeland for Jews around the world and a refuge for those facing persecution. As such, Israeli immigration policy allows for Jews anywhere to move to Israel and become a citizen. But the same immigration rights are not extended to anyone who isn’t Jewish. Ethnoreligious discrimination is, by design, a central part of Israeli immigration law.
It gets thornier. The question of what it means to be a “Jewish” state is contested, to put it mildly. Religious extremists believe the government should be based on halakah (Jewish law), while staunch secularists believe the Israeli state should play no role at all at in strictly religious matters. Most Israeli Jews fall somewhere along that spectrum, leading to bitter fights on a series of specific policy questions (like whether public transportation should be open on Shabbat).
There’s also the critical question of non-Jewish citizens.
After the Israeli War of Independence, the Arab Palestinian population that remained inside its borders were granted citizenship but put under martial law — a not-very-democratic legal arrangement that remained in place until 1966. Today, Arab citizens make up around 20 percent of the population, and are subject to frequent discrimination in areas like housing and policing. And that’s to say nothing of the authoritarian military occupation that noncitizen Palestinians live under in the West Bank.
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Mostafa Alkharouf/Anadolu Agency/Getty Images
For this reason, Smooha argues that Israel is a very particular kind of democracy: an “ethnic democracy” that “combines the extension of civil and political rights to individuals and some collective rights to minorities with institutionalization of majority control over the state.” Such a state is split between the “democratic principle,” which prioritizes “equal rights and equal treatment of all,” and the “ethnic principle,” which prioritizes “fashioning a homogenous nation-state and privileging the ethnic majority.”
Managing this tension is difficult both philosophically and legally. There will always be specific cases that push the limits of what the laws, Basic or otherwise, have set as legal standards for managing Israel’s dual identity.
This means Israel’s courts are, by necessity, regularly called upon to make judgments about the most fundamental issues surrounding the nature of Israeli state and society. While courts in every country make controversial decisions, few face the kind of existential questions about the country’s survival and purpose that Israel’s do.
As a result, the court’s judgments were bound to attract anger from the losing side in major cases — ones that might lead them to attack the institution itself. In fact, that’s been happening since the state’s earliest days.
The long history of struggle over the courts
In a 2021 paper on the history of political conflict over the court system, Israeli scholar Dahlia Scheindlin finds an almost immediate post-independence conflict between secular and ultra-Orthodox Israelis about the proper role of the judiciary — to the point where Israel’s leading rabbis actually boycotted the opening ceremonies for the Supreme Court in 1948.
“For certain groups in society, there has never even been full agreement over the role and authority of civil law versus religious law. In turn, the institutions of justice have been flashpoints of tension from the earliest years of statehood — and none more than the Supreme Court,” Scheindlin finds.
After Israel seized the West Bank and Gaza Strip in the 1967 Six-Day War, the country was faced with a whole new set of legal questions surroundings its military occupation of those lands. These, too, implicated fundamental questions of Israeli identity. What lands, exactly, should constitute its final borders? Should biblical descriptions of ancient Jewish land have any authority over present-day policy? And how could Israel be a democracy of any kind when it ruled over a Palestinian population who would never be permitted the rights of citizens?
The settlement enterprise — a campaign by religious nationalist Israelis to establish towns designed to cement control over Palestinian land, aided and abetted by the government — forced the court to weigh in on these weighty disputes. Typically, the court deferred to the the settlers, especially when the government claimed that establishing settlements in a particular area was a matter of national security.
But in 1979, the court ruled that a new settlement called Elon Moreh could not be justified on any legal grounds, security or otherwise. It ordered that the settlement be moved. The settlers were furious, with their spokespeople almost immediately calling for political war on the legal system.
“We must create a team of jurists for whom the matter of settlements is close to their hearts, in order to solve legal problems and prevent mishaps,” one said. “If democracy begins to interfere with the building of a Jewish state, we must give up democracy,” said another.
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Chanania Herman/GPO/Getty Images
The political resentment of both groups, the ultra-Orthodox and the settlers, became supercharged in the 1990s — the decade where it seemed most likely that the Israeli state might settle on a more liberal answer to the Jewish/democratic tension.
In 1992, the Knesset enacted two new Basic Laws that significantly expanded the scope of Israeli protections of individual rights. Protections for “human dignity” and “liberty,” specifically included “to embed the values of the State of Israel as a Jewish and democratic state in a basic law,” created significant grounds for courts to declare legislation at odds with the Basic Law.
Supreme Court Justice Aharon Barak declared this to be a “constitutional revolution.” In the following years, the court would rule that the the new Basic Laws included a fundamental right to equality for all Israelis, an idea that struck at the heart of both the ultra-Orthodox and settler visions for the state. A state that protects equality cannot privilege one ethnoreligious group in the institutionalized way these groups believed it should.
Not coincidentally, this constitutional revolution happened at the same time as the Oslo peace process with the Palestinians. The agreements, which set up the Palestinian Authority as a temporary self-rule mechanism until a final peace agreement could be reached, threatened to destroy the settlement enterprise altogether.
It hasn’t played out that way: The occupation of Palestinian land is now so entrenched that leading human rights groups have described the situation as a form of apartheid. But at the time, the Israeli state seemed on the verge of moving its “ethnic democracy” in a more liberal direction: one in which the power of religion over private life was minimized, and Jewish supremacy from the river to the sea foreclosed.
The court, being a central agent of this overall change, was obviously a major target of its enemies’ anger at this development. The question is not why they wanted to weaken the court, but whether they’d ever be strong enough to do it.
The court’s perfect storm
The 21st century has, broadly speaking, marked the decline of the Israeli left and the rise of its far right.
The Oslo peace process failed, devolving into the bloodshed of the second intifada in the early 2000s. When Israel withdrew from Gaza in 2005, dismantling and evacuating Jewish settlements, the result was the Strip’s conquest by the militant Hamas faction. Israelis soured on the feasibility of a negotiated settlement with the Palestinians — and the political left that had long championed peace accords. Through it all, Israel expanded West Bank settlements and deepened the occupation, in ways that necessarily degraded the quality of its democracy inside its legally recognized borders.
As the left lost influence, Israeli politics lurched to the right. Netanyahu, the leader of the historically center-right Likud party, ruled the country between 2009 and 2021 — at the helm of coalition governments that, over time, became increasingly dependent on settler and ultra-Orthodox parties. This manifested in an increasingly hostile policy approach toward the courts.
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Gil Cohen-Magen/AFP/Getty Images
From 2015 to 2019, Netayahu’s justice minister — a Knesset member named Ayelet Shaked from a far-right settler party — made a series of efforts to try to bring the courts to heel. She worked hard to politicize Israel’s nonpartisan process for appointing judges, bragging about getting a record number of conservatives on the bench. She stripped the high court of its jurisdiction over West Bank land issues, handing it to a Jerusalem circuit more friendly to the interests of settlers.
By the time she left the Justice Ministry, she claimed to have “broken” the vision of the judiciary championed by Aharon Barak.
But this wasn’t enough for the settler radicals Shaked represented. Their aim was not merely to weaken the court, but to eliminate it as a potential threat to their enterprise and ethnonationalist vision of what a “Jewish and democratic” state means. In particular, the settler parties viewed the court’s remaining power to block the seizure of private Palestinian land as a significant barrier to building up settlements in places that would make the foundation of a Palestinian state maximally difficult. For the settlers to accomplish their dream of Jewish supremacy from the river to the sea, the judiciary needs to be fully brought to heel.
In this campaign, both the ultra-Orthodox and Netanyahu became willing allies — for their own reasons.
In the past decade, the courts have issued a series of rulings on issues like same-sex parenting, non-Orthodox Jewish conversion, and (most importantly) mandatory military service that have infuriated the ultra-Orthodox. Reining in the court, in their mind, is necessary not only to preserve their particular vision of a religious Jewish state but also to protect their community from outside secular influence.
Netanyahu’s interest is less ideological and more practical: He is currently being tried on charges related to alleged corrupt and anti-democratic behavior. The more the prime minister and his allies control the judiciary, the easier it will be for him to use his position to stay in power and out of jail. He aimed, in short, to weaken the democratic character of the Israeli state in order to protect himself from legal accountability.
These three factions — the pro-settlement parties, Netanyahu’s Likud, and the ultra-Orthodox — do not always agree on everything. But they each have every reason to put an assault on the powers of the judiciary first. And when they won the November 2022 election, returning Netanyahu to the top post after a mere year in opposition, that’s exactly what happened. The new government’s first big act was to introduce an omnibus bill containing a series of reforms designed to bring the court system to heel.
In theory, there was nothing the opposition could do to stop them. The coalition had a Knesset majority, which was all they needed to amend Basic Laws. But the public reaction to their proposed power grab was astonishingly negative, going merely beyond bad poll numbers. The proposals so spooked Israelis on the center and the left, who had counted on the courts to check Netanyahu’s extreme-right government, that they turned out to protest in record numbers.
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Throughout 2023, Israeli cities have seen weekly mass protests against the judicial overhaul — the largest social movement in the country’s history. These protests were disruptive enough to scare the government into backing down from first version of the judicial overhaul, which would have imposed a series of major curbs on court power all at once. But the court overhaul was too important for the government to abandon; it was, after all, the glue binding together its three major factions.
So instead, the government chose to enact its overhaul piecemeal: doing one component at a time, a tactic for deliberately eroding a democracy that political scientists call “salami slicing.” The reasonableness bill was the first cut of the meat log; everyone expects there to be more coming soon.
This showdown over the courts, then, is really a showdown between fundamentally incompatible visions of what it means to be Jewish and democratic — a crystallized struggle over the kind of country that Israel is to be. No wonder it’s dividing Israelis starkly: It could very well decide their collective future.
However bad you think lead poisoning is for the world, it’s worse.
Everyone knows lead is bad for you. We’ve known this for a very long time: in the first century BCE, the Roman architect Vitruvius warned against using lead in pipes, observing the “pallid color” of plumbers forced to work with it. We know leaded gasoline leads to premature death in the elderly, that high lead exposure can substantially reduce IQ, and that there is likely a relationship between lead exposure in children and high rates of crime later on.
Yet lead is still everywhere — especially in poorer countries. Pure Earth, the largest nonprofit working on lead contamination internationally, recently conducted a massive survey of products in 25 low and middle-income countries, from Peru to Nigeria to India to the Philippines, to test for lead levels in household goods. In their sample they found high levels of lead in 52 percent of metal and 45 percent of ceramic foodware (a category including dishes, utensils, pots and pans), as well as 41 percent of house paints and 13 percent of toys.
This has major consequences. A new paper in Lancet Planetary Health, authored by economist Bjorn Larsen and Ernesto Sánchez-Triana, World Bank’s global lead for pollution management, tries to quantify the scale of the lead problem globally.
The authors estimate that some 5.5 million people die prematurely due to lead exposure every year, and that the problem as a whole imposes a social cost of $6 trillion a year. That equals 6.9 percent of total world GDP.
These are massive numbers, and it’s worth putting them into context: 5.5 million deaths from lead in 2019 exceeds the number of people who died that year from car accidents (1.2 million), tuberculosis (1.18 million), HIV/AIDS (863,837), suicide (759,028), and malaria (643,381) combined. If accurate, the figure means that a little under one in 10 deaths globally can be traced to lead. Meanwhile, a social cost of 6.9 percent of global GDP exceeds a recent World Bank estimate of the social cost of air pollution, which added up to 6.1 percent of GDP.
Digging into the cost of lead
These massive numbers may seem more plausible when you consider just how prevalent serious lead exposure is in developing countries.
A 2021 evidence review led by environmental scientist Bret Ericson reviewed blood lead surveys in 34 nations, which together account for over two-thirds of the world’s population. Overall, those studies estimated that 48.5 percent of children had high lead levels (defined as above 5 micrograms per deciliter, or µg/dL). Levels of exposure varied greatly, with surveys in a few countries (like Tanzania) not finding any children with blood lead levels above 5 µg/dL, and other countries (like Pakistan) showing huge majorities with levels that high. (Of course, it’s possible that limitations in these surveys underestimate lead exposure in some countries.)
We can identify a number of possible sources of these high lead levels. Historically, the major driver was lead in gasoline, but in 2021 the last country on Earth still using lead for that purpose (Algeria) phased it out. Lead is widely used in car batteries, plane fuel, and the consumer goods that Pure Earth surveyed in its report, but which source is most important in contributing to poisoning in children is still unclear.
For one thing, we know surprisingly little about how lead in, say, a plate translates into lead in the system of a human eating off that plate. The Pure Earth study included a test of some aluminum cookware, wherein it boiled acetic acid (the main ingredient in vinegar) in them for two hours, and then tested the liquid for lead. Fifty-two percent of the pots had leached an amount of lead above the World Health Organization guideline level for drinking water. That suggests that food cooked in such pots would contain lead, which would then poison children who drink it. But much more research is needed.
Indeed, “more research is needed” is a decent summary for the whole state of lead research. The Lancet Planetary Health study finding that lead kills 5.5 million people a year relied on lead poisoning estimates from the Global Burden of Disease study, which sometimes produces its numbers not based on surveys of actual people, but on other data (like the share of population in urban areas, and the year that leaded gasoline was phased out) that is in turn predictive of lead exposure.
Further, the Lancet study estimates deaths caused by lead-induced cardiovascular disease based on studies of the US, estimating the effect of lead on cardiovascular disease rates. Air pollution expert Roy Harrison told the news agency AFP that applying such findings to the whole world is “a huge jump of faith.”
That said, any errors could go in both directions. The actual surveys that Ericson and coauthors compiled of blood lead levels showed that the problem was worse than the Global Burden of Disease data suggested. It might be that lead is a greater risk factor for cardiovascular disease in poor countries than in the US, because there are more medical resources to counter the negative effects of lead in the US. All of that could mean the new study actually underestimates the damage lead is doing.
The only way to have a stronger sense of the scale of the problem is to invest more in understanding it. A 2021 report found that nonprofits spend, at most, $10 million a year addressing lead exposure in developing countries, with much of that money coming from governments. For comparison, global efforts to fight HIV/AIDS, which, if this new report is to be believed, kills about one-fifth as many people globally as lead does, got $8.2 billion in government funding in 2022 alone.
The point here is not that we’re spending too much on HIV/AIDS — we may still be spending too little there too. But we’re spending far too little on understanding and tackling lead exposure, when it could be a problem of similar or greater magnitude. It’s among the most neglected problems in global health, and one where a substantial investment could go a long way.