The Grumpy Doc

Grumpy opinions about everything.

Cholesterol, Demystified: What the Numbers Mean and What to Do About Them

By

On September 14, 2026

In Medicine

Cholesterol has an odd reputation. It’s usually treated as a villain, but your body can’t function without it. Every cell membrane relies on it, and it’s the raw material for hormones like estrogen and testosterone, as well as for vitamin D. The trouble starts when you have too much of the wrong kind circulating in your blood for too long a time. Excess cholesterol can quietly build up inside your artery walls for many years before you’re aware of it. The consequences of ignoring it can range from an abnormal stress test to a heart attack. Let’s walk through how your doctor diagnoses a cholesterol problem, how you can treat it, and what happens if it goes unaddressed.

How Cholesterol Is Diagnosed

The starting point is a lipid panel.  That is a blood test that’s usually done after you’ve been fasting.  Although newer research has shown non-fasting panels work nearly as well for most purposes. The panel reports several numbers, and each identifies a different type of cholesterol.

LDL cholesterol, low-density lipoprotein, is the one most people mean when they say “bad cholesterol.”  It’s the particle that tends to stick to artery walls and starts the buildup of plaque, the main component of blockages.

HDL, high-density lipoprotein, works in the opposite direction. It helps carry cholesterol back to the liver for disposal, which is why it’s nicknamed “good cholesterol.”

Triglycerides, a different type of fat entirely, round out the standard panel and, when elevated, add their own risk on top of LDL.

There isn’t one universal LDL number that applies to everyone. Instead, doctors weigh your LDL alongside your overall cardiovascular risk that also considers age, blood pressure, diabetes status, smoking history, and family history. If you’ve already had a heart attack, stroke, or other diagnosed artery disease you have increased risk.

The 2026 guideline from the American College of Cardiology and American Heart Association, sets LDL goals that correspond with risk: under 100 mg/dL for people at borderline or intermediate risk, under 70 mg/dL for those at high risk, and under 55 mg/dL for people who already have known artery disease and are considered very high risk. Additionally, initial lipid panels are now recommended starting at age 19, rather than waiting until later adulthood.

Two additional tests are being used more often now. Apolipoprotein B, or apoB, counts the actual number of cholesterol-carrying particles in your blood rather than just the cholesterol mass inside them. The newest guideline lists it as a more accurate risk predictor, even though it sometimes disagrees with the standard LDL number.

 Lipoprotein(a), or Lp(a), is a genetically determined particle that raises artery-disease risk independent of LDL.  An elevated Lp(a), even in the absence of an elevated LDL, is considered an increased risk. The update also recommends adults be screened for it once, since it isn’t affected by diet or exercise. When it’s high, your doctor may be more aggressive in treating your other numbers.

There are two tests that are not strictly cholesterol but are related to the risk associated with elevated cholesterol. They may be ordered for patients considered to be at risk or to evaluate their risk if it is unknown or uncertain.

Coronary artery calcium (CAC) scoring is a noninvasive, low-radiation CT scan that measures calcified atherosclerotic plaque in the coronary arteries and reports a calcium score. A score of zero indicates no detectable coronary calcium, while progressively higher scores indicate a greater level of coronary atherosclerosis and generally greater future cardiovascular risk. CAC is particularly useful when a person’s need for preventive treatment, such as a statin, is uncertain.

The new American Heart Association PREVENT (Predicting Risk of Cardiovascular Disease EVENTs) calculator, is recommended in the 2026 dyslipidemia guideline in place of older methods.  It estimates the 10- and 30-year risk of atherosclerotic cardiovascular disease, heart failure, and total cardiovascular disease in adults ages 30–79 who do not have established cardiovascular disease. It incorporates age, sex, blood pressure, cholesterol, smoking, diabetes, body mass index, kidney function and medication use. PREVENT and CAC complement one another. PREVENT provides an initial estimate based primarily on clinical risk factors, while CAC can selectively provide direct evidence of coronary atherosclerosis.

Lifestyle Modifications

For most people with mild to moderately elevated cholesterol, lifestyle change is the first line of treatment. It isn’t just a box to check before starting medication. It can meaningfully move the numbers on its own.

Diet has the most consistent evidence behind it. Cutting back on saturated fat (found in fatty cuts of meat, butter, and full-fat dairy) and replacing it with unsaturated fats from sources like olive oil, nuts, and fatty fish can lower LDL. Soluble fiber, the kind found in oats, beans, and fruits like apples and pears, binds cholesterol in the digestive tract and carries it out of the body before it can be absorbed.

Exercise helps too, primarily by raising HDL and improving how your body handles triglycerides.  Most clinical guidelines recommend at least 150 minutes a week of moderate activity, like brisk walking. More vigorous exercise appears to help more. Even a modest weight loss tends to improve the whole lipid panel.

Quitting smoking doesn’t lower LDL by much, but it dramatically improves HDL function. It also reduces the inflammation that turns cholesterol deposits into unstable, rupture-prone plaque.  

Alcohol is not as clear cut. Heavy drinking clearly raises triglycerides and worsens overall risk but claims that moderate drinking meaningfully protects the heart have not held up well. It’s clearly not a reason to start drinking for health purposes.

Treatments

Doctors generally fall into one of two categories when dealing with our own health issues. Some tend to obsess about their health and check their labs and other tests repeatedly and sometimes undertake unnecessary or only marginally beneficial treatments.  Others ignore their own health in ways they would never accept from their patients.  I tend to fall into the latter category, and I ignored my marginally elevated cholesterol for several years until my cardiologist, who is also a friend, told me to quit being “stupid” and start treating it.  

When lifestyle change isn’t enough on its own (mine wasn’t), or when your risk is high enough or your doctor doesn’t want to wait and see, medication is an option. Statins remain the default first step for most patients. They work by blocking an enzyme your liver uses to make cholesterol, which prompts the liver to pull more LDL out of the bloodstream. Decades of large trials tie this to real reductions in heart attacks and strokes.

If you don’t reach their goal on a statin alone, or you can’t tolerate one, several add-on options exist. Ezetimibe, a daily pill, blocks cholesterol absorption in the gut and is usually the first addition tried because it’s inexpensive and well tolerated. PCSK9 inhibitors, injectable medications like evolocumab and alirocumab, block a liver protein that normally limits how much LDL the liver can clear. They can lower LDL by roughly 50 to 65 percent on top of a statin. Inclisiran works on the same PCSK9 pathway but through a different mechanism, silencing the gene that produces LDL. It only needs to be injected twice a year rather than biweekly. Its long-term effect on heart attacks and strokes is still being evaluated in ongoing trials.  Bempedoic acid, a newer oral option, works further upstream in the same cholesterol-production pathway as statins and has shown to reduce cardiovascular events in people who can’t take statins. It’s a more modest LDL reducer than the injectable options and carries a higher risk of gout and gallstones.

Specialists disagree about how aggressively to treat cholesterol, and what the target should be.  Guidance has shifted more than once in the last decade. The 2026 multi-society guideline leans toward “lower for longer” as the general philosophy. Some professional groups have pushed back, arguing the most aggressive targets are better supported only for people who have already had a cardiac event.  For what it’s worth, my own philosophy is “lower is better.”  It’s worth discussing with your own physician.

What Happens If It Goes Untreated

This is the part that makes cholesterol worth taking seriously even though it produces no symptoms of its own for years or decades. Excess LDL particles work their way into the walls of arteries, where they trigger an inflammatory response. Immune cells arrive to clean up the cholesterol, become engorged with it, and form the fatty streaks that eventually mature into plaque. This process, called atherosclerosis, narrows and stiffens arteries throughout the body. It’s essentially silent until it isn’t.

Plaque in the arteries feeding the heart, can cause angina, chest discomfort during exertion when narrowed vessels can’t deliver enough blood.  Later it can cause a heart attack if a plaque ruptures and a clot suddenly completely blocks the vessel.

The same rupture-and-clot process occurs in the arteries feeding the brain when a piece of plaque breaks loose and travels downstream causing an ischemic stroke. In the legs, arms, or abdomen, narrowed arteries produce peripheral artery disease, which shows up as cramping or pain with walking and, in advanced untreated cases, can progress to gangrene and amputation.

Chronic kidney disease and, less commonly, vascular dementia are also linked to long-term uncontrolled atherosclerosis, since the same narrowing process affects the small vessels feeding the kidneys and brain. This link is not as well documented as the coronary and peripheral vascular effects.

People with familial hypercholesterolemia, a genetic condition that causes very high LDL from birth, have an accelerated risk. Without treatment, clinically apparent artery disease can show up as early as someone’s thirties or forties instead of the more typical sixth or seventh decade of life.

It’s a useful reminder that the danger of high cholesterol isn’t only about the number itself. It’s also about the cumulative years of exposure.  Starting treatment earlier, even modestly, tends to pay off more than starting aggressively later on.

Medical Disclaimer

The information provided in this article is intended for general educational and informational purposes only and does not constitute medical advice. It should not be used as a substitute for professional medical advice, diagnosis, or treatment.

Always seek the guidance of a qualified healthcare provider with any questions you may have regarding a medical condition or treatment. Never disregard professional medical advice or delay seeking it because of something you have read here. 

If you are experiencing a medical emergency, call 911 or your local emergency number immediately.

The author of this article is a licensed physician, but the views expressed here are solely those of the author and do not represent the official position of any hospital, health system, or medical organization with which the author may be affiliated.

Illustration generated by the author using ChatGPT.

Sources

1. National Lipid Association, summary of the 2026 ACC/AHA/Multisociety Dyslipidemia Guideline — https://www.lipid.org/nla/2026-accahamultisociety-dyslipidemia-guideline-released

2. American College of Cardiology, news release on the 2026 ACC/AHA dyslipidemia guideline — https://www.acc.org/latest-in-cardiology/journal-scans/2026/03/13/15/20/acc-aha-release-new-clinical-guideline-for-managing-dyslipidemia

3. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia, Circulation — https://www.ahajournals.org/doi/10.1161/CIR.0000000000001423

4. JACC, Maturation of Lipid Management in the 2025 ACC/AHA Acute Coronary Syndrome Guideline — https://www.jacc.org/doi/10.1016/j.jacc.2025.04.024

5. PMC, Current and emerging PCSK9-directed therapies to reduce LDL-C and ASCVD risk — https://pmc.ncbi.nlm.nih.gov/articles/PMC11755694/

6. Harvard Health, The changing landscape of LDL lowering drugs — https://www.health.harvard.edu/heart-health/the-changing-landscape-of-ldl-lowering-drugs

7. ScienceDirect, Advances in targeting LDL cholesterol: PCSK9 inhibitors and beyond — https://www.sciencedirect.com/science/article/pii/S2666667724000692

8. Cleveland Clinic, Hypercholesterolemia: Causes, Symptoms & Treatment — https://my.clevelandclinic.org/health/diseases/23921-hypercholesterolemia

9. Medical News Today, Complications of high cholesterol and tips to prevent them — https://www.medicalnewstoday.com/articles/high-cholesterol-complications

10. StatPearls (NCBI Bookshelf), Atherosclerosis — https://www.ncbi.nlm.nih.gov/books/NBK507799/

11. PMC, Familial Hypercholesterolemia Patients with COVID-19 — effective cholesterol-lowering therapy is urgent — https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11270387/

12. PMC, A 72-Year-Old Patient with Longstanding, Untreated Familial Hypercholesterolemia but no Coronary Artery Calcification: A Case Report — https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5991918/

The Venerable Bede: England’s First Historian

By

On September 11, 2026

In History

Not long ago I was reading a history of early English kings. It struck me how the work of a single person may represent all that we know about a period of history. Such a person was The Venerable Bede.

Imagine a world without a reliable calendar, without a coherent narrative of your own people’s past, and without any agreed-upon system for numbering the years. Now imagine a single monk, living out his entire life within the walls of a remote Northumbrian monastery, quietly fixing all three problems while also rewriting the intellectual map of early medieval Europe. That was Bede — a man whose influence was so vast and enduring that the Catholic Church eventually declared him a saint and a Doctor of the Church, and scholars still call him the Father of English History nearly thirteen centuries after his death.

Origins and Family

Bede was born around 672 or 673 AD in the Kingdom of Northumbria, most likely near the mouth of the River Wear in what is now Tyne and Wear in northeast England. While the precise location is disputed, Monkton in Durham is the traditional candidate. But what is clear is that he came into the world on or very near the land that would later become the twin monastery of Wearmouth-Jarrow. His family appears to have been Saxon and, by the modest standards of the day, reasonably prosperous. Beyond that, we know almost nothing about them. Bede himself provided the only substantive autobiographical sketch in the closing pages of his masterwork, the Ecclesiastical History of the English People, and he said nothing at all about his parents or siblings. They are, for history, invisible.

What we do know is that at the age of seven, an age that strikes us as astonishingly young, Bede was entrusted by his family to the care of Abbot Benedict Biscop at the newly founded monastery of St. Peter at Wearmouth. Whether this was driven by economic necessity, genuine piety, or both is impossible to say. In the early medieval world, placing a child in a monastic school was both a religious act and a pragmatic one. It offered the child the best available education and freed the family from one mouth to feed. Whatever the motive, the decision launched one of the most consequential scholarly careers in Western history.

Entering the Church

A year or two after his arrival at Wearmouth, around 681 or 682, the young Bede was transferred to the newly founded companion monastery of St. Paul at Jarrow, under Abbot Ceolfrith. He would remain there for the rest of his life. In 686, not long after his arrival, a devastating plague swept through Jarrow and killed most of the community. According to Ceolfrith’s anonymous biographer, only two monks survived with the full capacity to sing the liturgical offices, Ceolfrith himself and a young boy. That boy was almost certainly Bede, then about fourteen years old. The two of them maintained the full round of daily worship until the monastery could be rebuilt around them.

Bede was ordained a deacon around 691 or 692, in his nineteenth year, and was ordained a priest around 702 or 703, at the age of thirty, both times by Bishop John of Beverley. He later recalled that following his admission to the priesthood, he devoted every year to scriptural study and commentary. His own words, written near the end of his life, are striking in their simplicity: “It has been ever my delight to learn or teach or write.” For a man of towering intellect, that is a remarkably modest mission statement and he kept it faithfully for over four decades.

Impact During His Lifetime

Bede’s monastery at Jarrow was not an intellectual backwater. Northumbria in the late seventh century was a kingdom where Christianization and the consolidation of royal power went hand in hand.  Monastic houses such as Wearmouth–Jarrow were founded and endowed by noble patrons like Benedict Biscop, a Northumbrian aristocrat who had traveled to Rome multiple times and brought back books, relics, and ideas that served as the raw material for a new Christian intellectual culture. Thanks to the energetic collecting of Abbot Biscop, St. Paul’s boasted a library of roughly 700 volumes. It was an extraordinary resource by the standards of 7th- and 8th-century Europe. Bede put this collection to relentless use, producing somewhere around forty works across his lifetime spanning theology, natural science, poetry, biography, and history.

Bede received a broad education for the time, including Latin and some Greek, biblical exegesis, theology, grammar, poetry, computus (the calculation of the date of Easter), and even elements of what would be called natural philosophy (science) and astronomy.

During his lifetime, Bede’s reputation rested more on his scriptural commentaries and didactic treatises than on the historical work for which he is best known today.

His earliest writings were practical aids for students: treatises on spelling, verse composition, and figures of speech. He then turned to chronology, producing De Temporibus (On Times) in 703 and its much more substantial successor, De Temporum Ratione (On the Reckoning of Time), in 725. These works addressed one of the most contentious practical problems in the early medieval church, how to calculate the date of Easter, which changes each year according to a complex lunar formula. The controversy over the correct method of calculation had split the English church for generations, with Celtic Christians and Roman Christians using different systems. Bede’s meticulous analysis helped consolidate the Roman method and contributed to a lasting resolution.

He also pioneered what is now the standard system for numbering years in the Western world. Although the anno Domini (AD) convention had been invented by the monk Dionysius Exiguus in the sixth century, it was through Bede’s Ecclesiastical History that it entered general use across Europe. Before Bede made the system widely accessible, dates were typically reckoned from the regnal years of various kings, a system that was chaotic at best and impenetrable at worst. The AD framework Bede popularized gave Europe a shared chronological language it still uses today.

His most celebrated achievement was the Ecclesiastical History of the English People, completed in 731, just four years before his death. Divided into five books, it traced the history of Britain from Julius Caesar’s raids through to the early eighth century, with special emphasis on the conversion of the Anglo-Saxon kingdoms to Christianity. Bede was a careful historian by the standards of any era: he named his sources, often quoted them directly, sought written testimony from across Britain and even from the papal archives in Rome, and distinguished between what he knew firsthand and what he was reporting at second hand. He was not infallible, he sometimes accepted miraculous accounts uncritically and he misread some historical processes as single events, but his commitment to sourcing and accuracy was genuinely unusual for his age.

During his lifetime, Bede’s scriptural commentaries were even more widely read than his historical work. Copies circulated to monastic libraries across western Europe, spreading his reputation well beyond the British Isles. He corresponded with bishops and abbots, was known to the Archbishop of York, and dedicated his masterwork to King Ceolwulf of Northumbria. He never traveled to Rome or met a pope, but he was, by any measure, one of the most connected intellectuals in early medieval Europe.

Legacy and Lasting Influence

Bede died on May 25, 735, still dictating a translation of the Gospel of John to his scribes. Within a generation, he had acquired the honorific “Venerable”, the same title used later for his tomb’s Latin inscription at Durham Cathedral: Hic sunt in fossa Bedae Venerabilis ossa (“Here are buried the bones of the Venerable Bede”). His bones were brought to Durham in 1022 and eventually moved to the Galilee Chapel of Durham Cathedral, where they remain.

The intellectual debt owed to Bede is difficult to overstate. Alfred the Great, the ninth-century king who did more than anyone to preserve English learning during the Viking Age, had Bede’s Ecclesiastical History translated into Old English so that it could reach readers beyond the monastery walls. The scholars Alcuin and Boniface promoted Bede’s work on the European continent, ensuring that his reputation stretched from Ireland to the court of Charlemagne. The nineteenth-century historian Thomas Carlyle called him “the greatest historical writer since Herodotus”, a comparison that places Bede in remarkably elite company across the full span of Western civilization.

In 1899, Pope Leo XIII officially declared Bede a saint and a Doctor of the Church, one of only 37 individuals in Catholic history to receive that dual distinction, which requires both recognized holiness and a body of teaching that has profoundly enriched the faith. He is the only Englishman ever to hold that title. His feast day is celebrated on May 25 in the Catholic Church and May 26 in the Church of England.

Bede’s influence extends in more practical directions as well. His framework for the AD dating system underpins every secular and religious calendar in use across the Western world today. His Ecclesiastical History remains an indispensable primary source for early Anglo-Saxon history. Without it, enormous stretches of English history from roughly 400 to 730 AD would be lost to near-total darkness. The annual Jarrow Lecture, held at St. Paul’s Church in Jarrow since 1958, continues to honor his legacy, and the Jarrow Hall museum (formerly known as Bede’s World) preserves the site where he lived and worked.

A Life Well Spent

What makes Bede’s story compelling beyond the resume is the character behind it. By all accounts he was modest, genuinely curious, and deeply rooted in the rhythms of monastic life — prayer, study, teaching, writing. He seems to have had no particular ambition beyond doing his work well. He never sought a bishop’s throne or a place at court. He spent his entire adult life within the walls of a single monastery in the northeast of England, and from that narrow geographic perch he somehow managed to reshape how all of Western civilization thinks about time, history, and the English past. There is something almost improbable about that. And yet the bones of the Venerable Bede still rest in Durham Cathedral, and the calendar on your phone still counts the years the way he taught the world to count them.

Illustration generated by the author using ChatGPT.

Sources

Wikipedia – Bede — https://en.wikipedia.org/wiki/Bede

Britannica – Saint Bede the Venerable — https://www.britannica.com/biography/Saint-Bede-the-Venerable

EBSCO Research Starters – Saint Bede the Venerable — https://www.ebsco.com/research-starters/biography/saint-bede-venerable

Historic UK – The Venerable Bede — https://www.historic-uk.com/HistoryUK/HistoryofEngland/The-Venerable-Bede/

History Hit – 10 Facts About the Venerable Bede — https://www.historyhit.com/facts-about-the-venerable-bede/

Catholic Encyclopedia (New Advent) – The Venerable Bede — https://www.newadvent.org/cathen/02384a.htm

Durham World Heritage Site – The Venerable Bede — https://www.durhamworldheritagesite.com/learn/history/bede

Britain Express – The Venerable Bede Biography — https://www.britainexpress.com/History/bio/bede.htm

Pressbooks (Early British Literature) – Bede: From Ecclesiastical History — https://pressbooks.pub/earlybritishlit/chapter/bede-ca-673-735/

Study.com – Venerable Bede: Summary & History — https://study.com/academy/lesson/venerable-bede-summary-history-quiz.html

Ink and Intrigue: John Beckley, Philip Freneau and the Birth of American Political Warfare

By

On September 7, 2026

In History

Most people think of the Founding era as a time of stately deliberation — powdered wigs, quill pens, and gentlemanly debate. Yet beneath that polished surface existed another reality, one filled with political gossip, anonymous attacks, newspaper manipulation, patronage, espionage-like intelligence gathering, and organized partisan warfare.

Many leading Americans hoped the new republic would avoid the factionalism that had plagued European politics. George Washington famously warned against “the baneful effects of the spirit of party.” But from the moment the new federal government took shape in 1789, it became a battleground of competing visions, personal vendettas, and bare-knuckled political maneuvering

Two men who rarely get starring roles in the history books, John Beckley and Philip Freneau, were at the heart of it all. One was a former indentured servant who reinvented himself as America’s first professional campaign manager. The other was a Princeton-educated poet who turned journalism into a weapon. Working with Thomas Jefferson and James Madison, they helped shape the very concept of organized political opposition in the United States.

John Beckley: From Indentured Servant to Political Operative

John James Beckley was born on August 4, 1757, the son of obscure English parents, and was sent to Virginia in 1769 as an indentured servant. It is a remarkable origin story for a man who would go on to become one of the most consequential political operatives of the early republic. His master was John Clayton, clerk of court for Gloucester County. It was in Clayton’s household that Beckley developed his extraordinary clerical skills, the tools that would eventually open every door ahead of him.

Prior to earning a position with Congress, Beckley worked in various clerking jobs, including clerk of the committee of trade of the Virginia House of Delegates, clerk of the Virginia Senate, and clerk of the Virginia House of Delegates. In the 1780s, he was elected mayor of Richmond three times. He failed to win the clerkship of the Constitutional Convention but was successful in gaining the position of secretary of the Virginia ratifying convention. That last role put him in the room where Virginia’s crucial debate over ratification unfolded. It was an experience that shaped his understanding of how political outcomes are manufactured, not argued into existence.

Although Beckley was just a boy when he came to Virginia as an indentured servant, he rose to become a potent force in Virginia politics. Beckley and Jefferson began their political partnership during the American Revolution. Though never close personal friends, Beckley became a key political supporter and adviser to Jefferson. This was the relationship that would define his career. Jefferson provided the vision. Beckley provided the machinery.

Beginning April 1, 1789, Beckley was elected Clerk of the United States House of Representatives to the first four Congresses. As the very first person to hold that office, he was responsible for establishing its procedures from scratch. He prepared the rules for the Office of Clerk, as well as the parliamentary rules for the entire House, and established the procedural system for House operations. It was a position of enormous institutional power, and Beckley exploited every inch of it.

Philip Freneau: Poet, Privateer, and Pamphleteer

Philip Freneau came from a very different world. He was born on January 2, 1752, in New York City, the oldest of five children of Huguenot wine merchant Pierre Freneau and his Scottish wife. He attended the College of New Jersey, later renamed Princeton University, where he studied under John Witherspoon. Princeton in the 1760s and 1770s was a hotbed of pre-revolutionary sentiment, and Freneau absorbed it all.

At Princeton, Freneau was close friends with James Madison, and this relationship led to his co-founding the National Gazette with Madison and Thomas Jefferson. He graduated in 1771 and immediately found himself torn between the literary life and the political turmoil swirling around him. After graduating he tried teaching and briefly pursued theology, neither of which suited his restless temperament.

When the Revolution arrived, Freneau threw himself into it, literally. He eventually became a crew member on a revolutionary privateer and was captured along with the rest of the crew.  

He was held on a British prison ship for about six weeks. This experience, which nearly killed him, was detailed in his work The British Prison Ship.  It prompted many more patriotic and anti-British writings throughout the revolution and after. For this, he was nicknamed “The Poet of the American Revolution.”

After the war, Freneau alternated between seafaring and journalism. By 1790, he had published two collections of poetry. He was celebrated for his verse and respected for his Revolutionary credentials. Soon Jefferson and Madison came calling with a proposition that would redirect his entire career.

The War of the Gazettes

By 1790, the new federal government was riven with ideological conflict. Alexander Hamilton, as Secretary of the Treasury, had pushed through an ambitious financial program that included assumption of state debts, a national bank, and an excise tax.  Jefferson and Madison viewed these proposals as a dangerous consolidation of federal power and a gift to merchant and financial elites. Madison and John Beckley began organizing a party to oppose Hamilton and his allies, whom Jefferson derisively referred to as “stock jobbers.”   This “Anti-Administration” faction became what later was called the Democratic-Republican Party.

The Federalists already had their press organ, the Gazette of the United States. It was edited by John Fenno and backed by Hamilton. Jefferson and Madison needed someone with a sharp pen and a fighting spirit to run a counter-operation.

Freneau was exactly that man. He was strongly anti-Federalist and skilled at using wit, ridicule, and irony in his poetry and prose to attack his opponents. At times he would at times use sheer blunt force in his writing to make a strong point.

In 1791, encouraged by James Madison and others, Jefferson hired Freneau as a translating clerk for the State Department. The salary was a modest $250 a year. The position was largely fiction.  Jefferson was criticized for hiring Freneau as a translator, even though he spoke no foreign languages except French, in which Jefferson was already fluent. Freneau accepted this undemanding position, which left him free time to head the Democratic-Republican newspaper Jefferson and Madison envisioned.

Jefferson leaked information to Freneau by leaving items out in his office, which Freneau was then able to access with his key. Jefferson also provided financial support to the National Gazette by giving Freneau State Department printing contracts and urging others to subscribe to the newspaper. James Madison, then a congressman for Virginia, contributed at least 18 anonymous articles to the paper — a standard practice of the day.

President Washington himself grew deeply frustrated with the increasingly toxic political climate. Although he tried to remain above party conflict, he came to resent the Republican newspaper attacks upon his administration as he believed them to be personal insults. Washington eventually concluded that Jefferson was surreptitiously encouraging these assaults through allies such as Freneau.

John Beckley was busy trying to form a barrier against what Republicans called John Fenno’s “monarchism.” Beckley recruited subscribers, coordinated with Republican allies in multiple states, and used his insider access to Congress to channel information into the opposition press.

The National Gazette was read widely, with leading Republicans such as John Hancock and Samuel Adams promoting it in Massachusetts, while others ensured that copies of the newspaper were delivered to the frontier. Articles from the National Gazette were reproduced in other Republican newspapers around the country.

Washington was irritated, reportedly complaining to friends about “that Rascal Freneau.” Jefferson, for his part, later credited Freneau’s paper with having saved the Constitution from sliding toward monarchy — revealing just how seriously the Republicans took the threat they believed Hamilton represented.

Hamilton Fights Back — and Exposes His Own Scandal

Hamilton was not a man who absorbed attacks quietly. He tried to silence the National Gazette through a letter published on August 4, 1792, in the Gazette of the United States, in which he criticized Freneau for attacking the government while receiving a government salary and called on Jefferson to resign. Jefferson stood by Freneau, though the pressure eventually forced Freneau to surrender his State Department position, dealing a financial blow to the paper.

But the most damaging episode for the Federalists wasn’t the press war, it was the Reynolds affair. In 1791, Hamilton began a romantic affair with Maria Reynolds, a married woman. Her husband, James Reynolds, soon discovered the affair and, rather than try to stop it, decided to profit from the situation by extorting money from Hamilton.

When congressional investigators, including Senator James Monroe, confronted Hamilton with evidence of payments to James Reynolds, Hamilton confessed to the affair to prove the money was hush money, not financial speculation. The investigators agreed to keep the matter private.

What happened next illustrated just how ruthless the early republic’s political culture could be. Monroe made a copy of the incriminating letters and sent them to Thomas Jefferson, Hamilton’s chief adversary. John Beckley, as Republican clerk of the House of Representatives, may also have surreptitiously copied them. It remains unclear whether Jefferson or Beckley was ultimately responsible for leaking the materials to journalist James Callender, who published the story in 1797.

Hamilton was forced to issue a lengthy public pamphlet admitting to the affair in order to disprove the financial speculation charges. It was a devastating personal and political blow that permanently ended any realistic hope he had of reaching the presidency.

The 1796 Campaign: America’s First Professional Political Operation

Beckley’s most audacious performance came in the presidential election of 1796, when Jefferson ran against John Adams. Beckley operated as the nation’s first political party manager, organizing the Pennsylvania campaign effort to elect Thomas Jefferson president of the United States.

In the 1796 presidential election there were no pre-printed ballots. Voters were expected to arrive at the polls with a slip of paper, or “ticket”, on which they had written the name of their preferred candidate. Printed tickets were not allowed. Beckley blanketed the state with agents who passed out 30,000 hand-written tickets for Jefferson electors.

Historians consider Beckley to be one of the first American professional campaign managers, and his techniques were quickly adopted in other states. He also invented or popularized other modern campaign methods such as mass distribution of pamphlets, coordinated messaging across multiple newspapers, and systematic grassroots voter outreach.

Jefferson lost narrowly to Adams, and the Federalists made Beckley pay for his open partisanship. He lost his job as clerk of the House of Representatives following the Federalist victories in the elections of 1796. It was a stark reminder that the clerkship, which Beckley had treated as a partisan instrument, was not yet insulated from electoral politics.

Aftermath and Legacy

The National Gazette collapsed in late 1793. Freneau’s loss of his State Department salary, combined with unpaid subscriptions and the economic devastation caused by a yellow fever epidemic in Philadelphia, proved to be more than the paper’s stretched finances could handle. Freneau returned to New Jersey and spent his remaining decades alternating between seafaring, farming, and sporadic literary work. He died in 1832, frozen to death in a blizzard near his home in Monmouth County — a fitting, if grim, end for a man who had spent his whole life in storms.

Beckley fared better, at least temporarily. When Jefferson won the presidency in 1800, Beckley was reelected as clerk of the House of Representatives and also secured the newly created title of Librarian of Congress. It was a fitting reward for the man who had done as much as anyone to put Jefferson in office. He died in Washington in 1807.

What Beckley and Freneau built together — with Jefferson and Madison providing the strategic direction — was genuinely new. The combination of a dedicated partisan press, a professional ground-level campaign organization, coordinated messaging, and the willingness to weaponize personal scandals established patterns that American politics has never really abandoned. Neither man is a household name today, but the infrastructure they pioneered is very much with us.*

*Though few current residents recognize it, Beckley, West Virginia was named for John Beckley.

Image generated by author using ChatGPT.

Sources

  1. West Virginia Encyclopedia — John Beckley. Encyclopedia of West Virginia History and Culture. https://www.wvencyclopedia.org/entries/390
  2. Quill Project — John Beckley Biography. https://www.quillproject.net/person/4606
  3. Library of Congress Information Bulletin — “First Librarian Featured in New Book” (1996). https://www.loc.gov/loc/lcib/9610/beckley.html
  4. Dictionary of Virginia Biography — John James Beckley. Library of Virginia. https://old.lva.virginia.gov/public/dvb/bio.asp?b=Beckley_John_James
  5. U.S. House of Representatives History, Art & Archives — BECKLEY, John. https://history.house.gov/People/Detail/38343
  6. Wikipedia — John J. Beckley. https://en.wikipedia.org/wiki/John_J._Beckley
  7. Library of Congress — John James Beckley (1757–1807). https://www.loc.gov/item/n84136150/john-james-beckley-1757-1807/
  8. Wikipedia — Philip Freneau. https://en.wikipedia.org/wiki/Philip_Freneau
  9. Poetry Foundation — Philip Freneau. https://www.poetryfoundation.org/poets/philip-freneau
  10. Britannica — Philip Freneau. https://www.britannica.com/biography/Philip-Freneau
  11. Founders Online, National Archives — Philip Freneau to Thomas Jefferson, 8 April 1809 (with editorial note). https://founders.archives.gov/documents/Jefferson/03-01-02-0104
  12. Newspapers.com — National Gazette archive and history. https://www.newspapers.com/paper/national-gazette/32593/
  13. Library of Congress — National Gazette (Philadelphia), 1791–1793. https://www.loc.gov/item/sn83025887/
  14. Founders Online, National Archives — Origins of Freneau’s National Gazette, 25 July 1791 (editorial note). https://founders.archives.gov/documents/Madison/01-14-02-0046
  15. Founders Online, National Archives — Jefferson, Freneau, and the Founding of the National Gazette (editorial note). https://founders.archives.gov/documents/Jefferson/01-20-02-0374-0001
  16. Wikipedia — Jeffersonian Democracy. https://en.wikipedia.org/wiki/Jeffersonian_democracy
  17. Wikipedia — First Party System. https://en.wikipedia.org/wiki/First_Party_System
  18. Wikipedia — Federalist Party. https://en.wikipedia.org/wiki/Federalist_Party
  19. Smithsonian Magazine — “Alexander Hamilton’s Adultery and Apology.” https://www.smithsonianmag.com/history/alexander-hamiltons-adultery-and-apology-18021947/
  20. New-York Historical Society — The Reynolds Pamphlet. https://www.nyhistory.org/exhibitions/reynolds-pamphlet
  21. Georgia Tech Historical Annotation Project — Reynolds Pamphlet Analysis. https://sites.gatech.edu/1102hamilton/2018/06/09/document-transcription-reynolds-pamphlet/

When the Bladder Won’t Cooperate: A Plain-Language Look at Urinary Incontinence

By

On September 4, 2026

In Medicine

If you’ve ever laughed a little too hard, sprinted across the street, or simply gotten older, you may have noticed your bladder has developed opinions of its own. You’re suddenly chagrined to discover that you’ve developed more than a passing acquaintance with urinary incontinence. Since my own prostate surgery, a little over 10 years ago, I’ve become all too familiar with the inconvenience and the embarrassment of urinary incontinence.

It’s one of those conditions that’s extraordinarily common and yet still gets talked about in whispers, if it gets talked about at all. That’s a shame, because it’s rarely something people simply have to live with. Roughly six in ten women and about one in seven men will deal with some form of it at some point. The reasons range from childbirth to prostate surgery to the ordinary business of getting older.

The bladder is essentially a muscular storage reservoir. As urine enters the bladder, the bladder muscle—the detrusor—normally remains relaxed while the urinary sphincter and pelvic floor help keep the outlet closed. When we decide to urinate, a coordinated neurologic process causes the bladder to contract and the sphincter to relax.

Incontinence is a disruption, either structural or physiological, of this process.

Let’s walk through the main types, how the picture differs for men and women, what surgery can do to bladder control, and why aging tilts the odds toward leakage without making it inevitable.

The Main Types, and Why the Distinction Matters

Doctors sort urinary incontinence into a handful of categories, and getting the category right matters because the treatments diverge from one type to the next.

Stress incontinence is the leakage that shows up during a cough, a sneeze, a laugh, or a heavy lift. It can occur at any moment when pressure inside the abdomen spikes and overwhelms a weakened sphincter or a poorly supported urethra.

Urge incontinence is a different animal entirely.  It’s the sudden, hard-to-ignore need to go, often followed by leakage before you can get to a bathroom.  It traces back to a bladder muscle that contracts on its own schedule rather than yours.

Plenty of people have some of both, which is fittingly called mixed incontinence and is in fact the most common pattern among women with bladder symptoms.

Then there’s overflow incontinence, a steady dribble that happens when the bladder never quite empties and eventually overflows. Frequently something, often an enlarged prostate in men, is partially blocking the outlet.

Functional incontinence isn’t really a bladder problem at all  It happens when the bladder and urethra work fine but a physical or cognitive barrier, arthritis, dementia, an unfamiliar building, keeps you from reaching a toilet in time.

Reflex incontinence, less commonly discussed, involves the bladder contracting without any warning sensation at all, usually the result of nerve damage from conditions like multiple sclerosis or spinal cord injury.

How the Picture Differs Between Women and Men

Sex matters quite a bit here, both in how common incontinence is and in which type shows up. In women, stress incontinence is the single most common variety, and pregnancy and vaginal childbirth are the biggest reasons why. They stretch and sometimes injure the pelvic floor muscles and connective tissue that ordinarily keep the urethra snugly closed.

Menopause adds another layer, since declining estrogen thins the urethral lining and can weaken sphincter function further. Cleveland Clinic data estimate roughly 62 percent of women age twenty and older experience some form of incontinence, a striking number that reflects just how common, and how underreported, this condition is.

Men have a lower overall rate, on the order of 14 percent, but their pattern looks different. Because men don’t have the childbirth-related stresses on the pelvic floor, stress incontinence in men is less common on its own and shows up mainly after prostate surgery, which we’ll get to shortly.

Overflow incontinence is proportionally more of a male problem, since an enlarging prostate gland can squeeze the urethra and prevent the bladder from emptying completely.

Urge incontinence and overactive bladder symptoms affect both sexes and become more common with age regardless of gender.

What Hysterectomy Does to Bladder Control

Hysterectomy is one of the most common major surgeries performed on women, and extensive research has looked at what it does to the bladder over the years following surgery. The short version: removing the uterus appears to modestly raise the long-term risk of stress incontinence, likely because the surgery can disturb the nerves, ligaments, and connective tissue that support the bladder neck and urethra. These structures sit close to the uterus and cervix.

A large systematic review found that during the first decade after hysterectomy, women faced a higher likelihood of urinary incontinence of any type, and stress incontinence specifically, compared with women who hadn’t had the surgery. Beyond ten years out, the gap widens further for stress incontinence.  

A nationwide Finnish cohort that followed five thousand women for over a decade found that about one in fifty ultimately needed a surgical procedure to correct stress incontinence, with the risk running somewhat higher after vaginal or laparoscopic hysterectomy than after the abdominal approach.

It’s worth remembering that most women who have a hysterectomy never develop significant incontinence. Surgery is often the right choice for the underlying problem being treated, whether that’s fibroids, heavy bleeding, or cancer. But the association is real enough that it belongs in the conversation that women have with their surgeons beforehand. Particularly if they have already had vaginal deliveries, since that appears to carry extra risk.

What Prostatectomy Does to Bladder Control

For men, radical prostatectomy, the surgical removal of the prostate gland, most often performed for prostate cancer, is by a wide margin the leading cause of urinary incontinence. Nearly every man leaks to some degree immediately after the catheter comes out, which sounds alarming but reflects basic anatomy.  The prostate normally works alongside the external sphincter to hold urine back, and removing it shifts the entire job onto that external sphincter, which needs time to adapt to the extra workload.

Continence rates climb steadily over the following year, with studies reporting roughly a quarter to half of men fully continent by three months, somewhere around two-thirds to three-quarters by six months, and the large majority continent by twelve months.

The American Urological Association’s guidelines note that incontinence is expected in the short term and generally improves toward baseline by a year after surgery, though for a minority, often cited as around a third of patients, some degree of leakage persists longer and occasionally requires further treatment such as pelvic floor therapy or, less often, a surgical procedure. Surgical technique matters too: preserving the nerve bundles that run alongside the prostate and maintaining a longer stretch of urethra during the operation are both associated with faster, more complete recovery of continence.

Late onset urinary incontinence effects approximately 10 to 15 percent of men who regained continence after a radical prostatectomy. It can begin anywhere from 5 to 15 years after surgery. This is frequently believed to be exacerbated by age-related changes.

The Effects of Ordinary Aging

Even without surgery in the picture, the bladder changes as we get older, and those changes tilt the odds toward incontinence for both sexes. Bladder capacity tends to shrink somewhat, meaning it fills to an uncomfortable point sooner.

The detrusor muscle, the smooth muscle that squeezes urine out, becomes more prone to firing off contractions on its own rather than only when you decide it’s time to go. This is a big part of what drives urge incontinence in later life.

The bladder also tends to leave more urine behind after each trip to the bathroom, called increased residual volume, raising the risk of both overflow symptoms and urinary tract infections that can trigger or worsen leakage.

The details diverge a bit by sex. In women, the drop in estrogen after menopause thins and shortens the urethral lining, loosening the seal the sphincter can form and compounding whatever pelvic floor weakening already occurred from childbirth.

In men, incontinence related to aging alone tends to show up later, generally after the seventh decade of life, and often travels alongside prostate enlargement. This is a nearly universal feature of male aging that can produce overflow-type symptoms even without prior surgery.

Incontinence prevalence rises sharply after age 65, and some nursing-home studies put rates as high as two-thirds among residents in their late eighties. Women’s rates consistently outpace men’s at every stage of later life.

None of this means incontinence is simply the toll of aging and that nothing can be done about it. While the physiological changes make leakage more likely, they don’t make it unavoidable. The same toolkit used with younger patients, pelvic floor exercises, bladder training, medications, and in some cases surgery, works for older adults too.

The bigger obstacle tends to be that people, especially older adults, often wait years before mentioning symptoms to a doctor, quietly reorganizing their lives around bathroom access instead of asking for help that’s readily available.

The Bottom Line

Urinary incontinence is sometimes dismissed as an embarrassing inconvenience, but its consequences can be substantial. People may stop exercising, traveling, attending social events, or even leaving home because they are worried about finding a bathroom. Older adults rushing to the toilet at night may also increase their risk of falling.

While urinary incontinence is common, it’s rarely discussed as openly as it deserves to be, and it is seldom explained to patients in plain language.

The consistent message across the research is that this is a treatable condition rather than a life sentence, and the first step toward treatment is usually just being willing to bring it up.

Illustration generated by author using ChatGPT

Medical Disclaimer

The information provided in this article is intended for general educational and informational purposes only and does not constitute medical advice. It should not be used as a substitute for professional medical advice, diagnosis, or treatment.

Always seek the guidance of a qualified healthcare provider with any questions you may have regarding a medical condition or treatment. Never disregard professional medical advice or delay seeking it because of something you have read here. 

If you are experiencing a medical emergency, call 911 or your local emergency number immediately.

The author of this article is a licensed physician, but the views expressed here are solely those of the author and do not represent the official position of any hospital, health system, or medical organization with which the author may be affiliated.

Sources

1. Urinary Incontinence, StatPearls, National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK559095/

2. Definition & Facts for Bladder Control Problems (Urinary Incontinence), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems/definition-facts

3. Urinary Incontinence: Causes, Leakage, Types & Treatment, Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/17596-urinary-incontinence

4. Types of urinary incontinence, Harvard Health Publishing. https://www.health.harvard.edu/bladder-and-bowel/types-of-urinary-incontinence

5. Urinary Incontinence in Women, Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/urinary-incontinence/urinary-incontinence-in-women

6. Associations between hysterectomy and pelvic floor disorders: a systematic review and meta-analysis, American Journal of Obstetrics & Gynecology. https://www.ajog.org/article/S0002-9378(25)00164-4/abstract

7. Stress urinary incontinence after hysterectomy: a 10-year national follow-up study, Archives of Gynecology and Obstetrics (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8967811/

8. Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study, The Lancet (PubMed). https://pubmed.ncbi.nlm.nih.gov/17964350/

9. Incontinence after Prostate Treatment: AUA/GURS/SUFU Guideline, American Urological Association. https://www.auanet.org/guidelines-and-quality/guidelines/incontinence-after-prostate-treatment

10. The location of the bladder neck in postoperative cystography predicts continence convalescence after radical prostatectomy, BMC Urology (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977542/

11. Duration and Influencing Factors of Postoperative Urinary Incontinence after Robot-Assisted Radical Prostatectomy in a Japanese Community Hospital, PMC. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10001515/

12. Effects of Aging on the Urinary Tract, Merck Manual Consumer Version. https://www.merckmanuals.com/home/kidney-and-urinary-tract-disorders/biology-of-the-kidneys-and-urinary-tract/effects-of-aging-on-the-urinary-tract

13. Incontinence in the elderly, ‘normal’ ageing, or unaddressed pathology?, Nature Reviews Urology. https://www.nature.com/articles/nrurol.2017.53

14. Neurogenic mechanisms in bladder and bowel ageing, PMC. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4361768/

15. Prevalence of Incontinence Among Older Americans, National Center for Health Statistics, Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/data/series/sr_03/sr03_036.pdf

Jim Justice and the Price of Delay

By

On August 31, 2026

In Uncategorized

When Powerful Debtors Play by Different Rules

Jim Justice is one of West Virginia’s most recognizable public figures. He built his political identity on the language of business success, hometown loyalty, and plain common sense. As a coal operator, the longtime owner of the historic Greenbrier Resort, a two-term governor, and now a United States senator, he has cultivated a reputation as a successful entrepreneur and a folksy political leader.

For more than a decade, though, his business empire has also generated a striking number of lawsuits, tax liens, collection actions, environmental penalties, and disputes over unpaid bills. In August 2026, that long financial story reached what may be its most consequential chapter yet. Facing the threat of a court-ordered takeover, the Justice family agreed to hand majority ownership of The Greenbrier to an outside investment firm as part of a refinancing deal reported at figures ranging from roughly $380 million to $500 million, depending on which court filing or press account you read.

None of this is really in dispute anymore. The debts, the liens, and the lawsuits are documented in court records and government filings, not rumor. The more interesting question is why Jim Justice and his companies have so often been given additional time to make things right, while many ordinary citizens facing comparable debts experience much faster and harsher consequences.

It is worth saying up front that Justice’s financial troubles are one single debt. He and his family control dozens of separately incorporated businesses, so what looks from a distance like “Jim Justice’s debt” is really a long list of obligations owed by different companies to different creditors. Over the years these have included unpaid federal and state taxes, mine safety penalties, environmental fines, delinquent property taxes, unpaid vendor bills, employee health benefit contributions, workers’ compensation premiums, and very large commercial loans. Justice has typically responded by disputing how serious the debts really are, suggesting political motives behind the collection efforts, or arguing that the trouble was temporary and would eventually work itself out. Court filings and lien records, however, show a consistent pattern: creditors sue or file liens, and the amounts owed grow because of interest, penalties, and delay.

A Personal Tax Bill

One of the more personal episodes involved Justice and his wife directly. In late 2025, the U.S. Department of Justice sued the couple for roughly $5.2 million in unpaid federal income taxes, penalties, and interest tracing back to their 2009 return. The government’s complaint said that despite notice and demand, the Justices had not paid in full. On the very day the suit was filed, their attorney signed a consent judgment agreeing to pay the amount, and Chief U.S. District Judge Frank Volk approved it.

Justice has linked the dispute to an IRS audit that began under the Obama administration, describing it as politically motivated and tying it back to the complicated 2009 sale of Bluestone Coal to the Russian firm Mechel for roughly $436 million. Whatever the origin of the disagreement, it ended not with a courtroom fight over whether the money was owed, but with a signed agreement to pay it.

The Greenbrier’s Reckoning

By 2026, the biggest financial fight by far involved The Greenbrier itself. The Justice family bought the historic resort in 2009 and, for years, told the story of its rescue as one of the family’s signature achievements. That story came under real strain in 2026, when the resort became the focus of a legal and financial battle involving hundreds of millions of dollars.

The trouble came to public attention when White Sulphur Springs Holdings, an affiliate of Omni Hotels & Resorts’ parent company, TRT Holdings, acquired roughly $300 million in Greenbrier-related loan debt previously held by Carter Bank & Trust. That debt was secured by The Greenbrier and related properties. When the Justice family fell behind, the Omni affiliate went to federal court seeking a receiver — essentially, court-appointed control of the resort — arguing that the Justice companies had defaulted and had already failed to meet the terms of earlier forbearance agreements. The Justice family sharply disputed that characterization, accusing the Omni-linked company of trying to seize The Greenbrier outright rather than simply collect what it was owed.

The stakes could hardly have been higher. A receivership could have effectively ended the family’s control of the resort altogether. Once again, though, the Justices were given more time. Judge Volk paused the case for nearly two months in the spring of 2026 while the family worked to arrange new financing, and he later extended that deadline more than once as negotiations dragged on.

The proposed deal was with Kennedy Lewis Investment Management, a New York-based private credit firm founded in 2017 that manages more than $30 billion in assets and specializes in lending to companies working through financial disruption. The transaction, reported to be as high as $500 million, was meant to pay off the Greenbrier’s secured debt, address other liens, and fund capital improvements at the aging resort.

The closing date slipped repeatedly. An initial mid-July deadline came and went, with attorneys for the Omni-affiliated creditor telling the court they remained skeptical a deal would ever close. Judge Volk then granted the family until August 7 to finish the job, warning that the underlying takeover litigation would resume in full if they missed it again. As that deadline approached, the situation looked precarious enough that the family told the court it might have to temporarily shut down the resort’s casino (more on that below).

Then, on August 14, the deal finally closed.

Majority Control Changes Hands

What closed was not a simple refinancing. Under the structure described to West Virginia gaming regulators, Kennedy Lewis formed a new company that holds 51 percent ownership of The Greenbrier and controls three of five board seats. In practical terms, Kennedy Lewis becomes the majority controlling owner of the resort, while the Justice family keeps a meaningful minority stake and a voice on the board, but not the final word.

That distinction matters. The Justice family did not lose The Greenbrier to foreclosure or a court-appointed receiver, but it also did not emerge from the crisis with the same control it had exercised since buying the resort in 2009. Kennedy Lewis named veteran gaming and hospitality executive Lloyd Nathan as chairman of the new board, and the firm has said it plans long-term investment in the property.

Jill Justice, who previously ran day-to-day operations at the resort, publicly framed the arrangement as bringing in financial strength and expertise to protect the property’s future.  Governor Patrick Morrisey — a Republican and a political rival of Justice’s — was quick to note on social media that Kennedy Lewis now holds majority ownership and controlling interest.

The closing also ended the receivership lawsuit brought by White Sulphur Springs Holdings, which was dismissed once the transaction went through. The Greenbrier stayed open throughout the transition, and existing reservations, conferences, weddings, and other events continued as scheduled.

More Tax Liens Piled Up Along the Way

The refinancing saga unfolded against a backdrop of still more tax trouble. In June 2026, the West Virginia State Tax Division disclosed roughly $4.4 million in state tax liens against Greenbrier Hotel Corporation, made up of about $3.9 million in consumer sales and use taxes and roughly $455,000 in state payroll-related taxes.

Federal liens followed close behind. In July, the IRS filed liens totaling about $3.5 million against Greenbrier-related properties, roughly $3.3 million tied to the hotel itself and another $290,000 tied to the Greenbrier Clinic. Attorneys for the Justice businesses said at the time that these liabilities would be resolved through the anticipated financing deal.

Then, on August 10, just days before the deal closed, the IRS recorded additional liens of more than $8 million against Greenbrier Hotel Corporation, plus roughly $827,000 against the Greenbrier Clinic. These were payroll tax liens — covering federal income tax withholding along with Social Security and Medicare taxes tied to employee paychecks. They are worth pausing on, because payroll taxes are not an ordinary corporate debt. This is money withheld from workers’ paychecks and owed to the government on their behalf. The hotel-related liens broke down to roughly $4.92 million for the tax period ending December 31, 2025, and another $3.08 million for the period ending March 31, 2026.

The Justice organization said the new Kennedy Lewis financing would provide the money to clear these obligations. As of the most recent public reporting available for this article, however, the closing of the deal should not be read, by itself, as proof that every one of these federal and state liens has actually been released. That will require separate confirmation from the taxing authorities once the paperwork catches up. This is a distinction that matters for anyone trying to track whether the debts are truly resolved or simply announced as satisfied.

The Casino That Almost Closed

The refinancing produced one more, oddly dramatic subplot, a last-minute fight over The Greenbrier’s casino. Because Kennedy Lewis was taking a controlling interest in the resort, West Virginia gaming regulators had to review the change in ownership before it could take effect. As the August 7 deadline bore down, attorneys for the Greenbrier told the court the family was prepared to temporarily close the casino rather than delay the total transaction any further. They cited daily carrying costs they put at roughly $145,000. Court filings indicated that a shutdown could have meant layoffs for around 90 casino employees.

That outcome was ultimately avoided. The West Virginia Lottery Commission determined the casino could keep operating while its review continued, so long as safeguards kept incoming board members walled off from casino operations. The casino stayed open, and the anticipated layoffs did not happen. Still, the episode is a useful reminder of how close The Greenbrier’s financial troubles came to producing real, immediate consequences for ordinary employees who had nothing to do with the underlying debts.

Debts Tied to Workers’ Benefits

Some of the more consequential unpaid bills across the entire Justice business empire have involved insurance meant to protect workers and retirees, rather than conventional taxes and government fines. Back in 2017, an insurer won an $850,000 default judgment in New York against Justice’s Southern Coal Corporation over unpaid workers’ compensation and liability premiums.

When federal marshals later went looking for company assets in West Virginia to satisfy the judgement, they reportedly found bank accounts that were empty or had been closed. A separate ProPublica investigation documented retired coal miners who said health coverage promised by Justice-linked companies lapsed after premiums went unpaid, with some retirees describing delayed medical care as a result.

More recently, an insurer sued in 2021 over roughly $166,000 in unpaid deductibles under a workers’ compensation policy, and in January 2026 a federal judge ordered Justice-controlled coal and coke companies to pay just over $1 million to a Liberty Mutual affiliate for unpaid workers’ compensation and employers’ liability premiums covering 2020 through 2022.

Greenbrier-related employee benefits have had their own troubles, too. In 2024, union officials reported that Greenbrier-related companies were roughly $2.4 million behind on payments to an employee health insurance fund. Because the Justice business empire is spread across so many separate corporations, there is no single public accounting that confirms every one of these employment-related obligations is now fully current.

A Long Mine Safety Record

The mine safety side of the story follows a similar arc. Between 2014 and 2019, federal inspectors issued thousands of citations to Justice-controlled coal operations, and a 2019 Department of Justice lawsuit followed after reporting showed the companies carried some of the largest delinquent mine-safety penalty balances in the country. A federal court approved a roughly $5 million settlement in 2020, to be paid through an initial installment followed by monthly payments. Court records then showed repeated missed deadlines, prompting government notices and further enforcement action. In August 2024, federal attorneys asked a court to hold the Justice coal companies in contempt for continuing to owe money under that settlement, and a 2025 agreement set new payment deadlines with the threat of daily contempt penalties if they were missed again.

This history matters because it shows the Greenbrier dispute is not an isolated event. It fits a pattern already visible across other parts of the Justice business empire.

Payment, Eventually — Usually Under Pressure

To be fair, it would be wrong to say Jim Justice or his companies simply never pay what they owe. They do, mostly. Tax liens have been satisfied. Creditors have been paid. Settlements have been reached. Regulatory penalties have eventually been resolved. It’s important to note that many of these debts have been negotiated to a much lower amount than the Justice companies initially owed.

Perhaps the fairer criticism is not that Justice never pays, but that his business history shows a recurring cycle: large obligations build up, litigation follows, deadlines get extended, new agreements get negotiated, those deadlines sometimes get missed too, and actual payment or restructuring tends to happen only after real legal pressure. The Greenbrier saga fits that pattern about as neatly as one could imagine.

Why Do Courts Keep Granting More Time?

This is the question that has trailed Justice’s financial disputes for years. Why do judges keep giving him and his companies additional chances? The answer has less to do with Justice personally than with how American civil litigation generally works. Judges tend to prefer repayment over economically destructive liquidation. When a debtor owns an operating business that employs hundreds of people, seizing or shutting it down immediately can destroy jobs, reduce the value of the underlying assets, and ultimately leave creditors with less money than they would get through an orderly refinancing or restructuring. Courts routinely give parties time to negotiate, refinance, and restructure when there is a realistic chance of being paid.

That principle played out clearly in the Greenbrier case. Judge Volk allowed the family additional time in part because the proposed Kennedy Lewis transaction looked concrete enough to justify waiting before reaching for the drastic remedy of receivership. The eventual closing arguably validated that call. The main creditor was satisfied without ever forcing The Greenbrier into court-ordered receivership. These legal principles, in theory, apply to everyone regardless of wealth or political standing. Whether access to them works out equally in practice is a separate question.

The Advantage That Wealth and Influence Buy

The sheer frequency with which Justice and his companies have secured additional opportunities has understandably generated public skepticism. Ordinary taxpayers who fall behind can quickly face tax liens, wage garnishment, bank levies, and foreclosure.  Small businesses that miss tax or benefit payments often run into aggressive collection efforts. Homeowners who miss mortgage payments do not typically have access to teams of lawyers capable of negotiating a half-billion-dollar restructuring on their behalf.

Large corporations and wealthy individuals simply have options that most debtors do not: specialized attorneys, accountants, investment bankers, tax advisers, and restructuring experts who can challenge assessments, negotiate forbearance agreements, refinance assets, appeal judgments, and line up financing. The Greenbrier transaction clearly illustrates the point.

Facing the possibility of losing the resort to a receiver, the Justice family negotiated a deal approaching half a billion dollars with a major private investment firm — a deal that preserved a piece of the family’s ownership, kept the resort operating, protected hundreds of jobs, and apparently satisfied its principal secured creditor. That is a legitimate business solution. It is also one that would be entirely out of reach for most Americans facing unpaid debts of their own.

Is This Unequal Justice?

It is worth being careful here. There is no public evidence that judges improperly favored Jim Justice because of his wealth or political standing. Each extension can generally be explained under ordinary principles of civil procedure and commercial law, and the Greenbrier refinancing arguably shows why judges grant such extensions in the first place. Had the court moved immediately to receivership, the financing deal that ultimately kept the resort operating as a going concern might never have happened.

Even so, the cumulative pattern remains. When a debtor repeatedly misses deadlines and yet keeps getting fresh chances to refinance, restructure, settle, or renegotiate, it is reasonable for citizens to wonder whether the legal system functions differently for people with enormous financial and political resources than it does for the rest of us. The difference may not lie in the law itself so much as in who has the practical ability to use it. For the average West Virginian watching this play out, that may be the more important distinction. A sitting senator who represents ordinary taxpayers, while his businesses repeatedly face tax liens, unpaid employee-related obligations, regulatory penalties, and collection lawsuits, is bound to raise questions about fairness and accountability.  Questions that a single successful refinancing does not resolve.

The August 2026 Greenbrier transaction does not erase that longer history. If anything, it offers an unusually revealing conclusion to one chapter of it. After months of litigation, a threatened receivership, millions of dollars in fresh tax liens, repeated court extensions, missed financing deadlines, and even the brief prospect of a shuttered casino, the Justice family avoided the forced loss of The Greenbrier. But keeping the resort required giving up something significant in return: majority control of perhaps the most prominent business asset carrying the Justice name.

Whether that outcome represents another example of a wealthy debtor enjoying opportunities unavailable to ordinary citizens, or simply the commercial legal system working as it is designed to, is a matter of interpretation, and reasonable people can land in different places. What is not really open to interpretation is the documented sequence of events. Debts accumulated, creditors went to court, deadlines were extended again and again, new liens kept appearing even as the refinancing was being negotiated, and a major restructuring eventually became unavoidable.

For many West Virginians, the lasting question about Jim Justice may be less about whether any particular debt eventually got paid, and more about whether a legal system that supposedly treats everyone alike hands out very different practical options to those with extraordinary wealth, valuable assets, political prominence, and access to sophisticated advisers. The Greenbrier survived its latest financial crisis, and the Justice family kept a stake in it — but for the first time since the family rescued the resort in 2009, someone else is now the one in control.

Illustration generated by author using ChatGPT.

References

Mike Tony, West Virginia GazetteMail. The articles by Mike Tony concerning Jim Justice’s multiple tax and financial difficulties are too numerous to individually list. His work has been both a source and an inspiration for this article.

Associated Press. “U.S. Sen. Jim Justice of West Virginia agrees to pay nearly $5.2 million in overdue personal taxes.” November 25, 2025. (AP News)

Associated Press. “Debt problems that dogged Sen. Jim Justice as West Virginia’s governor continue to nip at his heels.” 2025. (AP News)

West Virginia Public Broadcasting. “U.S. Sen. Jim Justice Agrees To Pay Nearly $5.2M In Overdue Personal Taxes.” November 25, 2025. (West Virginia Public Broadcasting)

West Virginia MetroNews. “IRS files $3.5 million in liens on Greenbrier properties.” July 3, 2026. (WV MetroNews)

West Virginia Press Association. “Greenbrier Hotel and Clinic struggles mount with IRS filing.” July 7, 2026. (West Virginia Press Association)

West Virginia Watch. “Late and unpaid bills are nothing new for Justice and his family businesses.” August 27, 2024. (West Virginia Watch)

Is Russell Vought the Most Destructive Person in the Trump Administration?

By

On August 28, 2026

In Politics

Of all the figures who populate Donald Trump’s second administration, few operate with less name recognition and more raw institutional power than Russell Vought. He does not command troops like the Secretary of Defense, he does not prosecute cases like the Attorney General, nor does he dominate health news like RFK Jr. Yet as director of the Office of Management and Budget (OMB), Vought sits astride the single path through which every dollar appropriated by Congress must pass before it reaches an agency, a court, a hospital, or a family. That chokepoint, combined with Vought’s explicit authorship of the government-dismantling blueprint known as Project 2025, has led critics to call him the “shadow president” and, more provocatively, the most destructive force in the administration. Whether you accept that label depends on what you take “destructive” to mean — destructive of the liberal vision of the administrative state, or destructive of the state’s basic capacity to function at all. Let’s look at Vought’s role, his authorship of Project 2025, and the specific programs and institutions he has targeted as OMB director, then weighs the case for and against the “most destructive” designation.

Who Is Russell Vought, and What Does He Control?

Vought is currently the Director of the OMB, the West Wing-adjacent agency that, on paper, sounds simply bureaucratic.  It reviews agency budgets, writes regulations, and controls the timing of federal spending but in practice it functions as one of the most powerful levers in the executive branch. He held the same job at the end of Trump’s first term, from mid-2020 to January 2021, after serving as deputy director starting in 2018.

What’s unusual this time is how many hats he’s worn, most at the same time. Since being confirmed in February 2025, Vought has also served as acting director of the Consumer Financial Protection Bureau and, for several months in mid-to-late 2025, he was acting administrator of USAID while that agency was being dismantled. In practice, that means one person has simultaneously controlled the government’s checkbook, the main federal consumer-finance watchdog, and the country’s foreign aid apparatus.

Vought and Project 2025

Before returning to government, Vought ran a think tank called the Center for Renewing America, and in that role, he became one of the central figures behind Project 2025, the Heritage Foundation’s 900-plus-page transition blueprint for a second Trump term. He personally wrote the chapter on the Executive Office of the President, and by most accounts he was also deeply involved in a separate, less public “180-Day Playbook” designed to help the new administration move fast before opposition could organize.

Vought’s own language, captured on hidden camera by researchers with the Centre for Climate Reporting in 2024, is probably the most-quoted material about him. He described spending roughly 80 percent of his time on “destroying” the sense of independence exhibited by some executive branch agencies.  He said he wanted federal employees to be “traumatically affected” by the changes he had planned.  He referred to Trump’s public distancing from Project 2025 during the campaign as “graduate-level politics,” implying it wasn’t sincere. He has also spoken about reviving “Schedule F,” a first-term proposal that would strip job protections from a large swath of career civil servants and make it easier to them fire for political reasons.

None of that is speculation on my part; it’s drawn directly from his own recorded remarks and from the Project 2025 chapter he authored. Whether you read it as candid strategic planning or as something more alarming is a judgment call.

What He’s Cutting or Eliminating

This is the part of the story with the most concrete paper trail, because OMB’s decisions show up in court dockets, congressional hearings, and the government’s own funding apportionment documents.

Days before Vought’s confirmation, an OMB memo closely tied to him ordered a sweeping freeze on federal grants, loans, and cooperative agreements, citing a need to root out spending on “wokeness” and “Green New Deal social engineering.” The freeze briefly disrupted payment portals for Medicaid, Head Start, Meals on Wheels, and community health centers before a federal judge intervened and the memo was rescinded.

USAID and Foreign Aid

As acting USAID administrator, Vought oversaw the agency’s near-total shutdown, including a freeze on foreign assistance that a federal judge blocked in part in February 2025. House Democrats published a report attributing roughly 600,000 preventable deaths worldwide to the cuts, a figure Vought has disputed without offering his own count. In June 2026 Senate Democrats separately objected to OMB withholding another $3.2 billion in already-appropriated humanitarian and development aid.

The Education Department

Through 2026, OMB left roughly three dozen Education Department programs marked “unallocated” in official apportionment documents. This means the department technically wasn’t authorized to spend congressionally appropriated funds on them. That produced a lawsuit in June 2026 from Protect Democracy and several education groups, and a separate revolt from ten Republican senators over a summer-program funding freeze they said contradicted the president’s own stated goals.

The Consumer Financial Protection Bureau

As acting director, Vought moved almost immediately to halt CFPB operations, close its headquarters, and pursue mass layoffs. He targeted roughly 90 percent of the workforce, later scaled back to about two-thirds under court pressure. A federal judge blocked the initial plan, and litigation (National Treasury Employees Union v. Vought) was still working through the D.C. Circuit as of mid-2026. The bureau’s union president put it bluntly: “Everyone knows Vought doesn’t want CFPB to exist at all.” Vought has said the cuts follow directly from a roughly 50 percent reduction Congress made to the bureau’s funding cap in 2025’s reconciliation bill.

Climate, Environmental-justice, and Infrastructure Funding

Vought also announced the cancellation of nearly $8 billion in climate-related grants across 16 Democratic-leaning states, describing them on social media as “Green New Scam funding,” and placed a hold on roughly $18 billion in New York City infrastructure funding due to his objections to “unconstitutional DEI principles”.

Broader impoundment and “pocket rescissions”

The most structurally significant fight is over whether OMB can simply decline to spend money Congress has appropriated, a practice called impoundment that is prohibited by a 1974 law. Vought has argued publicly that many of these actions are “programmatic delays,” not impoundments, and that the Impoundment Control Act’s restrictions are unconstitutional. Critics, including House Appropriations Committee Democrats and two dozen state attorneys general, say OMB has used the apportionment process to delay the routine paperwork that releases funds to agencies creating a chokepoint to freeze billions in spending without following the law’s formal rescission procedure. A related, roughly $9 billion “pocket rescission” package targeting foreign aid and public broadcasting (including PBS and NPR funding) passed the Senate in 2026 after Vice President Vance broke a tie.

The Federal Workforce

Beyond any single agency, Vought’s OMB has pushed reductions in force across the government, including a September 2025 memo instructing agencies to use that fall’s government shutdown as an “opportunity” to eliminate programs. House Democrats on the Judiciary and the Appropriations committees called that a misuse of shutdown authority, and a court issued a temporary restraining order blocking some of the resulting layoffs.

The Case for the Defense

It’s worth noting that Vought and his allies don’t dispute most of these facts — they dispute the framing. Their argument is that OMB is doing what it’s statutorily supposed to do: enforce fiscal discipline, cut waste and duplication, and give the president control over an executive branch that Vought and others believe has become too autonomous. Senator John Cornyn, backing Vought’s 2025 confirmation, praised his first-term record of regulatory rollback and called him “the right choice” to get federal agencies “back on track.” Vought himself has repeatedly said these are the first of several planned rounds of cuts, framing the approach as accountability to taxpayers rather than sabotage of government functions.

A Closing Thought

History will ultimately judge which interpretation proves more accurate. What seems increasingly clear is that Russell Vought has become one of the defining figures of the second Trump administration. His influence extends well beyond annual budgets. Through Project 2025 and his leadership of the Office of Management and Budget, he has sought to redefine how the federal government operates, who exercises power within it, and what authority the federal government should exert over American society.

Image generated by the author using ChatGPT.

Sources

1. Ballotpedia — confirmation background and career timeline. https://ballotpedia.org/Confirmation_process_for_Russell_Vought_for_director_of_the_Office_of_Management_and_Budget

2. Wikipedia — Russell Vought, overview of concurrent roles (OMB, CFPB, USAID). https://en.wikipedia.org/wiki/Russell_Vought

3. ABC News — on Vought’s Project 2025 authorship and vetting. https://abcnews.com/US/trump-vetting-project-2025-architect-top-administration-post/story?id=115993180

4. Forbes — Vought’s Senate confirmation and Project 2025 ties. https://www.forbes.com/sites/alisondurkee/2025/02/06/project-2025-author-russell-vought-confirmed-by-senate-here-are-all-the-trump-officials-with-ties-to-policy-agenda/

5. Critical Resistance (Substack) — hidden-camera remarks and “radical constitutionalism.” https://criticalresistance.substack.com/p/russ-vought-and-the-paperwork-revolution

6. The Hill — House hearing on USAID cuts and preventable-deaths estimate. https://thehill.com/homenews/house/5947905-vought-clashes-democrats-spending-cuts/

7. The Hill — USAID close-out funds and withheld humanitarian aid. https://thehill.com/policy/international/5870587-usaid-funds-19b-closeout/

8. Education Week — frozen Education Department apportionments. https://www.edweek.org/policy-politics/white-house-blocks-2-billion-for-education-see-all-the-affected-programs/2026/05

9. Protect Democracy — lawsuit over withheld education funding. https://protectdemocracy.org/work/congressionally-mandated-education-programs/

10. Federal News Network — CFPB staffing-cut plan and union response. https://federalnewsnetwork.com/management/2026/04/white-house-scales-back-plan-to-dismantle-the-cfpb-but-still-wants-to-slash-staff-by-two-thirds/

11. HousingWire — CFPB layoffs update and Vought’s stated intent to eliminate the bureau. https://www.housingwire.com/articles/cfpb-vought-new-nomination/

12. House Appropriations Committee (Democrats) — background on impoundment and apportionment tactics. https://democrats-appropriations.house.gov/news/fact-sheets/background-unlawful-impoundment-president-trumps-executive-orders

13. The Conference Board — legal analysis of the Impoundment Control Act dispute. https://www.conference-board.org/research/ced-policy-backgrounders/adiministration-view-on-impoundment

14. House Judiciary Committee (Democrats) — letter on shutdown-era RIF memo. https://democrats-judiciary.house.gov/media-center/press-releases/litigation-task-force-leaders-raskin-neguse-delauro-and-garcia-slam-russell-vought-for-exploiting-republican-shutdown-to-implement-unlawful-purge-of-federal-workforce

15. Office of Rep. Kamlager-Dove — articles of impeachment and funding-freeze allegations. https://kamlager-dove.house.gov/media/press-releases/kamlager-dove-introduces-articles-impeachment-against-omb-director-russell

16. Office of Sen. Cornyn — statement supporting Vought’s confirmation. https://www.cornyn.senate.gov/news/cornyn-votes-to-confirm-russ-vought-for-omb-director

Schizophrenia: A Serious Illness That Is Often Misunderstood

By

On August 24, 2026

In Medicine

Few psychiatric illnesses carry as much misunderstanding and stigma as schizophrenia. The word itself sometimes conjures images of unpredictable or dangerous behavior, and it is still occasionally confused with having a “split personality.” Neither picture accurately describes the disease.

Schizophrenia is a serious mental illness that affects the way a person thinks, perceives reality, expresses emotions and relates to other people. It can be profoundly disabling, but it is also treatable. With appropriate medication and social support, some people with schizophrenia attend school, work, maintain relationships and live independently.

A Disease That Usually Begins in Youth

Schizophrenia rarely arrives out of nowhere. Most people who develop it pass through a prodromal phase, a stretch of weeks, months, or even a couple of years before the first clear psychotic episode. During this phase, subtle changes in thinking, mood, and social behavior begin to show up. Someone might withdraw from friends, lose interest in things they used to enjoy, struggle to concentrate, or seem “off” in a way that is hard to pin down and easy to mistake for depression, anxiety, or ordinary teenage moodiness.

The disorder most often declares itself in late adolescence and early adulthood, though the timing differs somewhat between men and women. Men typically experience their first symptoms in their late teens to mid-twenties, while women tend to develop symptoms somewhat later, often in their late twenties to mid-thirties, with a second, smaller peak of onset around menopause. The leading explanation for this gap involves estrogen, which appears to have a protective effect on dopamine signaling in the brain, an effect that fades after menopause, explaining why some women may see this second, later window of vulnerability.  Onset in childhood or after age 40 is uncommon and, when it does occur, doctors generally look harder for other explanations before settling on a schizophrenia diagnosis.

The first obvious event may be an episode of psychosis, an impairment of the   ability to distinguish what is real from what is not. But the illness most likely was developing quietly for months or even years.

A young adult who had previously been doing well may gradually withdraw from friends, lose interest in school or work, neglect personal hygiene or become unusually suspicious. Concentration may deteriorate and conversation may become increasingly difficult to follow. Families frequently recognize that something is wrong long before they recognize it as mental illness and denial is frequent.

Eventually, more recognizable symptoms emerge. A person may begin hearing voices that nobody else hears. These hallucinations can seem every bit as real to the patient as an actual conversation. Others develop delusions, firmly held beliefs that are inconsistent with reality. Someone might become convinced that neighbors are spying on him, that television personalities are communicating directly with her, or that another person is secretly controlling his thoughts. Thinking itself can become disorganized, making conversation difficult to follow.

But these dramatic symptoms are only part of schizophrenia. Some of its most disabling features are less obvious. A person may lose motivation, withdraw socially, speak very little or show little outward emotion. Psychiatrists call these “negative symptoms” because normal abilities have diminished rather than something unusual being added.

There may also be problems with memory, concentration, planning and decision-making. These cognitive symptoms can make holding a job or living independently difficult even after hallucinations and delusions have improved.

What Causes Schizophrenia?

We don’t know exactly.

There is clearly a genetic component. Schizophrenia occurs more frequently in some families, but there is no single schizophrenia gene. Instead, many genetic variations probably contribute to vulnerability.

Researchers have also found differences in brain development, brain circuitry and chemical signaling. Dopamine has an important role, but the once-popular explanation that schizophrenia simply results from “too much dopamine” is far too simplistic.

The best current explanation is that schizophrenia develops through an interaction among genetic susceptibility, brain development and environmental influences.

Certain environmental exposures may increase risk in susceptible individuals. Prenatal complications such as infections, severe stress and maternal substance use, including alcohol and tobacco, have all been investigated. Cannabis deserves particular attention because frequent use, especially of high-potency products, has been associated with an increased risk of psychosis. The presence of one or more of these factors does not necessarily mean that an individual will develop schizophrenia.

How Do Doctors Diagnose It?

There is no blood test or brain scan that says, “This patient has schizophrenia.”  Diagnosis depends upon the patient’s history, symptoms, behavior and psychiatric examination, often supplemented by observations from family members.

Just as important is determining what the illness is not. Bipolar disorder, severe depression, medication side effects, recreational drugs and neurological or medical diseases can all produce psychotic symptoms. Laboratory studies, drug screening or brain imaging may be necessary, not to prove schizophrenia, but to exclude other causes. This becomes especially important later in life.

Treatment Has Improved

The cornerstone of treatment remains antipsychotic medication. These drugs are particularly useful for reducing hallucinations, delusions and severe thought disturbance. Newer, “atypical” antipsychotics, including risperidone, olanzapine, quetiapine, aripiprazole, and clozapine, are not dramatically more effective than older drugs, but they do offer a sometimes significantly different side effect protocol.   Individual response varies enough that psychiatrists often try more than one medication before finding the right fit. These newer medications carry their own tradeoffs, most notably a higher risk of metabolic side effects such as weight gain, diabetes, and unfavorable cholesterol changes, which is why patients on these drugs need regular medical monitoring. Long-acting injectable medications are available for patients who have difficulty taking pills consistently.

Medication alone is rarely the entire answer.  Psychotherapy, family education, rehabilitation, social-skills training, assistance with employment and stable housing can make enormous differences. Programs for people experiencing their first episode of psychosis increasingly combine these approaches through coordinated specialty care. Early treatment is important because a prolonged period of untreated psychosis is associated with poorer outcomes.

What Is the Prognosis?

There is no simple answer.  Schizophrenia is considered a chronic illness and its course varies remarkably from one person to another.

Some people experience one or several episodes followed by substantial recovery. Others have repeated periods of psychosis separated by relatively normal functioning. Still others develop persistent symptoms requiring lifelong treatment and assistance.

The World Health Organization notes that at least one in three people with schizophrenia can fully recover. Modern treatment emphasizes recovery and function, rather than simply eliminating hallucinations. The goal is to return the patient to as normal a life as is possible.

Without treatment, the outlook is considerably worse. Persistent psychosis can destroy educational and employment opportunities, relationships and the ability to maintain stable housing. Substance-use disorders can complicate the disease. Untreated schizophrenia is associated with a higher risk of suicidal thinking, progressive decline in cognitive functioning, and increased risk of cardiovascular disease, driven partly by lifestyle factors and partly by the physiological toll of chronic untreated illness.  One widely cited estimate suggests that roughly two out of three people experiencing psychosis worldwide never receive adequate care, whether due to stigma, lack of insight into their own illness (a symptom in itself for some patients), cost, or limited access to services. This is why early identification and consistent care, imperfect as current treatments may be, make such a measurable difference in how the illness unfolds over a lifetime.

Schizophrenia in Older Adults

Schizophrenia presents an interesting problem as the patient ages. Many people who developed schizophrenia at 20 or 25 are now living into their seventies and eighties. Their psychiatric illness must be treated alongside the problems of aging, including cardiovascular disease, diabetes, cognitive decline and multiple medications.

Antipsychotic drugs also require particular caution in elderly patients because they may contribute to sedation, falls, orthostatic hypotension (blood pressure drop), abnormal movements and medication interactions.

But there is an even more important rule when dealing with an older person. New psychosis should not automatically be called schizophrenia, particularly in a hospitalized patient. Delirium associated with hospitalization, formerly called hospital psychosis, is not a psychiatric disorder. It will frequently resolve after treating underlying medical issues and discharging the patient from the hospital.

Imagine a previously mentally healthy 78-year-old who suddenly becomes convinced that strangers are entering his house or begins seeing people who aren’t there. Schizophrenia is possible, but it would not be the first assumption.

Delirium, dementia, Parkinson’s disease, stroke, infection, metabolic abnormalities, medications, alcohol and other drugs can all produce hallucinations, paranoia or confusion. Alzheimer’s disease and related dementias can also produce psychosis. An acute urinary track infection should always be high on the differential diagnosis of any older patient with a new mental status change.

A new onset of hallucinations or delusions in an elderly patient deserves a careful medical, neurological and medication evaluation.

True late-onset schizophrenia does occur, but is rare and schizophrenia beginning in young adulthood is much more typical.

A Disease, Not a Character Flaw

Perhaps the most important change in our understanding of schizophrenia is recognizing what it is not. It is not a failure of willpower. It is not caused by bad parenting. It does not mean someone has multiple personalities. A diagnosis of schizophrenia does not automatically make a person dangerous. It is a complex disorder of brain function whose ultimate cause remains incompletely understood.

We cannot yet cure schizophrenia in the conventional sense, nor can we predict with certainty which young person experiencing a first psychotic episode will eventually develop the disease. But we can treat it far more effectively than was possible just several years ago.

That makes early recognition particularly important.

When a young person gradually withdraws from the world, begins thinking or speaking strangely, or starts hearing voices or developing bizarre beliefs, the appropriate response is neither ridicule nor fear. It is medical evaluation.

For an elderly person who suddenly develops the same symptoms, the message is slightly different but equally important: don’t assume schizophrenia. Look carefully for the cause.

In both situations, psychosis is a symptom that deserves immediate attention and schizophrenia is an illness that deserves treatment rather than stigma.

Medical Disclaimer

The information provided in this article is intended for general educational and informational purposes only and does not constitute medical advice. It should not be used as a substitute for professional medical advice, diagnosis, or treatment.

Always seek the guidance of a qualified healthcare provider with any questions you may have regarding a medical condition or treatment. Never disregard professional medical advice or delay seeking it because of something you have read here. 

If you are experiencing a medical emergency, call 911 or your local emergency number immediately.

The author of this article is a licensed physician, but the views expressed here are solely those of the author and do not represent the official position of any hospital, health system, or medical organization with which the author may be affiliated.

Image generated by author using ChatGPT

Sources

National Institute of Mental Health — Schizophrenia

National Institute of Mental Health — Understanding Psychosis

World Health Organization — Schizophrenia

Why Is Everyone Talking About Socialism Again?

By

On August 22, 2026

In Commentary, Politics

For much of the late twentieth century, “socialism” was almost a forbidden word in American politics. Republicans used it as an accusation, Democrats generally avoided it, and politicians who actually described themselves as socialists occupied a small place on the political fringe.

Things have changed dramatically. Today, politicians on both the right and the left talk about socialism—although they usually mean entirely different things.

On the right, “socialism” has become a broad warning label applied to proposals ranging from universal health insurance to government regulation and higher taxes. On the left, a growing number of politicians and activists have reclaimed the word, associating it with economic equality, stronger labor rights, universal public services, and restraints on corporate power.

The interesting question may be less whether America is becoming socialist than why Americans are suddenly arguing about the meaning of socialism.

Socialism Originally Meant Something Specific

Historically, socialism was not simply another word for government spending. It developed during the nineteenth century largely in response to industrial capitalism. Although socialist thinkers disagreed considerably among themselves, they generally believed that the production resources of society—factories, mines, transportation systems, land, and eventually large corporations—should be owned collectively or controlled by workers rather than by private investors.

Karl Marx advocated a transformation by revolution. Other socialists eventually pursued democratic and parliamentary approaches.

That distinction matters because many policies routinely described as “socialist” in American political debate do not meet the traditional definition at all. A government can tax corporations, regulate banks, provide health insurance, and maintain a generous welfare system while leaving most businesses privately owned. Economists would normally describe such a country as a mixed capitalist economy or social democracy, rather than a socialist economy.

What the American Right Means by Socialism

For many conservatives, socialism has acquired a much broader meaning. The term is frequently applied to policies that increase government involvement in the economy such as progressive taxation, environmental regulation, student-debt relief, subsidized health care, expanded welfare benefits, government-supported child care, or other programs that redistribute income or provide services collectively.

In this usage, socialism is less a precise economic system than a direction of travel. Conservatives argue that as government assumes greater responsibility for allocating resources and providing benefits, individual choice and private markets become less important.

There is a legitimate philosophical argument here. There has always been a debate over where the boundary should lie between private markets and collective responsibility.

But calling every government economic intervention “socialism” stretches the word almost beyond recognition. By that definition, nearly every modern industrial democracy—including the United States—has been partly socialist for generations.

The political usefulness of the word helps explain its persistence. For Americans who remember the Cold War, “socialism” may evoke the Soviet Union, communist Eastern Europe, Cuba, or more recently Venezuela. Calling an opponent socialist therefore does more than criticize a particular tax or health-care proposal. It associates that proposal with an entire political system many Americans regard as oppressive and economically unsuccessful.

Polling illustrates how powerful that association remains. Pew Research Center found in 2022 that only 14 percent of Republicans and Republican-leaning independents had a positive impression of socialism. Republicans were also much more likely than Democrats to associate socialism with restrictions on individual freedom.

What the American Left Means by Socialism

The situation on the left is considerably more complicated because there is no single left-wing definition of socialism.

Many Americans who describe themselves favorably toward “socialism” appear to mean something closer to social democracy: a basically capitalist economy combined with universal health care, stronger unions, affordable higher education, progressive taxation, extensive social insurance, and stronger regulation of corporations.

Their preferred models are often Scandinavian countries such as Denmark and Finland. Yet those countries retain private businesses, private property, financial markets, entrepreneurship, and international corporations. They are heavily regulated capitalist welfare states, not classical socialist economies.

Pew’s research demonstrates this ambiguity. When Americans favorable toward socialism were asked what they liked about it, many emphasized fairness, meeting basic needs, and combining elements of capitalism and socialism rather than eliminating capitalism altogether.

Other people on the American left mean something more substantial when they use the term. The Democratic Socialists of America, for example, explicitly says democratic socialism should go beyond merely regulating capitalism. The organization advocates greater democratic control of workplaces and collective ownership of important parts of the economy, including areas such as energy and transportation. That position is much closer to the traditional meaning of socialism.

Consequently, it is misleading to assume that a liberal Democrat supporting Medicare expansion and a democratic socialist advocating worker control of corporations necessarily have the same economic philosophy.

They may support some of the same immediate policies while disagreeing profoundly about the ultimate economic system they want.

Why Has Socialism Suddenly Returned?

First was the financial crisis of 2008. Younger Americans watched banks and financial institutions receive extraordinary government assistance while millions of ordinary Americans lost jobs, savings, and homes. That experience weakened the assumption that an essentially unregulated market produces fair outcomes.

Then came decades of concern about wage stagnation, college debt, housing affordability, medical expenses, and growing concentrations of wealth. For some younger Americans, “capitalism” increasingly came to mean not neighborhood businesses and entrepreneurship but enormous corporations, billionaires and now trillionaires, expensive housing, and economic insecurity.

Bernie Sanders accelerated the transformation during his presidential campaigns in 2016 and 2020. By openly calling himself a democratic socialist while attracting millions of votes, Sanders helped remove some of the Cold War stigma surrounding the word.

Generational change matters as well. Younger Americans did not experience the Cold War in the same way their parents and grandparents did. Pew found striking age differences in its 2022 survey. Americans under 30 were roughly as likely to have an exclusively positive view of socialism as an exclusively positive view of capitalism. Older Americans remained considerably more favorable toward capitalism.

The political right has responded by emphasizing the word even more strongly. That makes strategic sense. If progressive Democrats increasingly accept the socialist label—or propose policies Republicans can associate with it—Republicans have an incentive to connect those policies with a word that remains deeply unpopular among conservative and many older voters.

The result is a feedback loop: the left talks more about socialism because the word has become less frightening to some voters, while the right talks more about socialism precisely because it hopes to make the word frightening again.

Is America Already Partly Socialist?

The answer depends almost entirely upon our definition.

Under the traditional definition—collective ownership of the means of production—the United States is overwhelmingly capitalist. Most farms, factories, banks, hospitals, restaurants, stores, technology companies, media companies, and other productive enterprises are privately owned.

But America has never operated as a completely laissez-faire capitalist economy either.

The federal government operates Social Security, for example, which the Social Security Administration itself describes as a social insurance program. Workers and employers contribute through payroll taxes, and benefits provide partial income replacement after retirement, disability, or death. About 96 percent of American jobs are covered.

Medicare and Medicaid place government deeply into health-care financing while most hospitals, physician practices, pharmaceutical manufacturers, and medical suppliers remain private.

The government also insures private bank deposits through the FDIC. Deposits at insured banks are generally protected up to $250,000 per depositor, per bank, per ownership category, backed by the federal government.

Public schools, public universities, highways, libraries, police departments, fire departments, water systems, parks, and numerous municipal utilities provide goods and services collectively rather than through ordinary private markets.

The United States even owns or operates certain enterprises directly. The Postal Service, for example, is an independent establishment within the executive branch that provides a nationwide public service while simultaneously operating in a competitive marketplace.

These arrangements contain elements of collective provision, social insurance, public ownership, or economic regulation, but calling all of them “socialism” creates more confusion than clarity.

A public fire department is not evidence that America has adopted a socialist economic system any more than a privately owned grocery store proves that government has no role in the economy.

America Has a Mixed Economy—and Always Has

Perhaps the greatest problem with the current socialism debate is the assumption that capitalism and socialism exist as two completely separate boxes and that a country must choose one or the other. Modern economies rarely work that way.

The United States relies primarily on private ownership, competition, investment, and markets to produce goods and services. At the same time, Americans have repeatedly decided that certain risks and services should be handled collectively.

Even organized labor introduces an element of collective economic power into a capitalist system, although union membership has declined substantially. In 2025, 10 percent of American wage and salary workers belonged to unions, compared with 20.1 percent in 1983.

The real political disagreement is rarely capitalism versus socialism in their pure theoretical forms. It is about where to draw the line between the market and the community.

Should health insurance operate primarily as a commercial product or a public service? Should housing be left largely to market forces or should government intervene to make it more affordable? Should corporations answer primarily to shareholders, or should workers have greater influence over corporate decisions? How progressive should taxation be? Which industries, if any, should be publicly owned? How much inequality should society tolerate in exchange for the incentives created by private enterprise?

A surprising twist is that some of the loudest recent “socialism” accusations are coming from conservatives — aimed at their own president. Since returning to office, the Trump administration has taken direct equity stakes in Intel, secured a “golden share” in U.S. Steel, arranged profit-sharing with Nvidia and AMD on chip sales to China, imposed sweeping tariffs, and directed the Pentagon to prioritize coal — an unprecedented degree of direct federal involvement in private enterprise for a Republican administration. Commentators across the spectrum — from the Council on Foreign Relations to the Wall Street Journal — have reached for terms like “state capitalism” or “state capitalism with American characteristics,” an explicit echo of the Chinese Communist Party’s own “socialism with Chinese characteristics”. One economist with more than three decades of market-watching called it plainly “the most economically interventionist government of my lifetime”.

Those are legitimate political questions. Calling one side “capitalist” and the other “socialist” obscures more than it explains.

The Word May Matter Less Than the Argument

There is one particularly revealing finding in the polling. Americans do not necessarily treat capitalism and socialism as opposites. Pew found people who expressed favorable opinions of both, suggesting that many Americans interpret capitalism as representing markets and opportunity while interpreting socialism as representing economic security and fairness.

That may tell us something important about the current debate. It appears that Americans want the vitality of capitalism tempered by the compassion of socialism.

The renewed interest in socialism doesn’t indicate that millions of Americans suddenly want the government to seize factories and abolish private enterprise. Instead, it reflects dissatisfaction with how the existing economic system distributes opportunity, security, wealth, and political power.

Conservative warnings about socialism often reflect a genuine concern that expanding government responsibility can gradually reduce economic freedom, increase taxation, and shift decisions from individuals and markets toward political institutions.

Those are fundamentally different concerns—and both become difficult to discuss when the same word means entirely different things to the people using it.

The question is not whether America should become “socialist,” it is what kind of capitalism we want.

That argument has been with us throughout American history. Only the vocabulary has changed.

For an additional discussion of the elements of socialism, see my post Three Shades of Left, published on November 10th 2025.

Image generated by author using ChatGPT.

Sources

  1. NY1 State of Politics, “Understanding democratic socialism amid its rise in 2026 elections,” July 7, 2026. https://nystateofpolitics.com/state-of-politics/new-york/politics/2026/07/07/understanding-democratic-socialism-amid-its-rise-in-2026-elections
  2. CNN, “Americans — including many Republicans — are losing faith in capitalism, polling shows,” July 23, 2026. https://www.cnn.com/2026/07/23/politics/republicans-capitalism-socialism-poll
  3. HotAir, “Is Socialism Really Gaining Steam, or Are Socialists Just Gaming the System Better?,” July 28, 2026. https://hotair.com/david-strom/2026/07/28/is-socialism-really-gaining-steam-or-are-socialists-just-gaming-the-system-better-n3817374
  4. USA Today, “Mamdani wins NYC mayor’s race in generational shift for Democrats,” November 2025. https://www.yahoo.com/news/articles/mamdani-faces-cuomo-become-nyc-132437910.html
  5. AOL/NBC News republish, “In generational shift, Zohran Mamdani wins NYC mayor’s race,” November 2025. https://www.aol.com/articles/generational-shift-zohran-mamdani-wins-024145015.html
  6. Charisma Magazine, Dinesh D’Souza, “The Specter of Socialism,” August 6, 2026. https://mycharisma.com/news/the-specter-of-socialism/
  7. Wikipedia, “Socialism for the rich and capitalism for the poor” (Bernie Sanders quote on the 2008 bailout). https://en.wikipedia.org/wiki/Socialism_for_the_rich_and_capitalism_for_the_poor
  8. Yahoo/The Hill, “Jeffries accuses Trump of tanking the economy to create opportunities for the rich,” 2026. https://www.yahoo.com/news/jeffries-accuses-trump-tanking-economy-220454230.html
  9. Goodreads (reprint), Robert Reich, “The populist left and right are on the same side.” https://www.goodreads.com/author_blog_posts/10288117-robert-reich-the-populist-left-and-right-are-on-the-same-side
  10. A Versus B, “Capitalism vs Socialism 2026: Key Differences Explained.” https://www.aversusb.net/blog/capitalism-vs-socialism-2026-key-differences-explained

Our Shared Story Can Still Bring Us Together

By

On August 18, 2026

In Commentary

I’ve been a member of the Sons of the American Revolution for quite some time now. At the beginning of April, I started looking around for a Memorial Day event that we could join. I had assumed that my hometown of Charleston WV, being the state capital, would surely have an event since it is the 250th anniversary of the Declaration of Independence. I was surprised to find that none was planned.

I believed that it was especially important that a Memorial Day service be held here because West Virginia has, since World War II, one of the highest per capita rates of military service and combat casualties in the country.  So, another SAR member and I got together, and we planned our own event and arranged for it to be held on the state capitol grounds. At the end of our service, I looked out at the group that was gathered: there was no right or left, there was no red or blue, there was no conservative or liberal.  There were only proud Americans who had come together to honor our country, its veterans and its history.

Americans disagree about almost everything these days. Politics, religion, education, history, and even the meaning of patriotism have all become subjects of bitter debate. Too often, we define ourselves more by the groups we oppose than by the country we share.

Yet there are still opportunities to remember that before we were Republicans or Democrats, conservatives or progressives, we were Americans. The ongoing 250th Anniversary of the Revolutionary Era offers one of those rare opportunities to express what we share, not how we differ.

The semiquincentennial should be far more than fireworks, parades, and historical reenactments. It should be an invitation to rediscover the remarkable story we all inherited. The American Revolution was not perfect. The nation it created was imperfect from the beginning, carrying the stain of slavery, denying women equal rights, and often failing to live up to its own ideals. Those shortcomings do not erase the extraordinary achievement of creating a republic founded on the revolutionary belief that legitimate government derives its authority from the consent of the governed.

The founders left us more than a nation. They left us a challenge. Every generation has been asked to move the country a little closer to the principles expressed in the Declaration of Independence—that all people are created equal and possess inherent rights that no government should take away. Those words have inspired abolitionists, suffragists, civil rights leaders, immigrants seeking freedom, and millions of ordinary citizens who believed America could become better than it was.

That is a heritage worth celebrating together.

Organizations devoted to civic life have an important role to play in that celebration. Groups such as the Sons of the American Revolution, the Daughters of the American Revolution, the American Legion, Rotary clubs, Civitan clubs, veterans’ organizations, scouting groups, historical societies, libraries, museums, churches, and countless other local groups have spent decades preserving history, encouraging volunteerism, supporting education, and strengthening their communities. While each has its own mission and traditions, they all remind us that citizenship is more than voting every few years. It is an ongoing commitment to serving neighbors and improving the places where we live.

These organizations also offer something increasingly rare in modern America: opportunities for people with different political views to work side by side on practical goals. A community service project, a scholarship program, a veterans’ memorial, a food drive, or a history program rarely asks participants how they voted. It asks only if they are willing to help.

That is a lesson our country desperately needs. Social media and cable television often reward outrage. Algorithms profit by convincing us that our fellow Americans are enemies rather than neighbors. It becomes easy to believe that our differences outweigh everything we have in common.

History tells a different story. Americans have survived fierce political battles before. We have argued over the Constitution, endured civil war, struggled through economic depression and assassinations, fought world wars, and confronted profound disagreements about civil rights and social change. Our history has never been one of perfect unity. Instead, it has been a continuing effort to find common purpose despite deep disagreements.

The Revolution itself offers an example. The thirteen colonies differed enormously in religion, economy, geography, and culture. New England merchants, Virginia planters, Pennsylvania farmers, and South Carolina traders often had conflicting interests. Yet they discovered that some principles were more important than their differences. Their unity was never complete, but it was sufficient to build a nation. We face no less important a challenge today.

The 250th anniversary should encourage every community to host public readings of the Declaration of Independence, historical lectures, concerts, service projects, naturalization ceremonies, veterans’ recognitions, student essay contests, and volunteer events that welcome everyone. These occasions should not become platforms for partisan speeches. They should remind us that our history belongs to all Americans.

Celebrating our shared heritage does not require us to ignore the darker chapters of our past. Mature patriotism is honest enough to acknowledge failures while remaining grateful for the ideals that allowed those failures to be challenged and corrected. A confident nation can tell its whole story without either whitewashing its mistakes or denying its accomplishments.

Perhaps that is the greatest gift the 250th anniversary can offer is reminding us that America has always been a work in progress. Each generation inherits both the nation’s achievements and its unfinished work. If we can gather to honor the courage, sacrifice, and aspirations of those who came before us, perhaps we can rediscover something that has become increasingly scarce — the ability to see one another first as fellow citizens.

Our common heritage cannot solve every political disagreement. It will not erase ideological differences or end heated debates about the country’s future. Nor should it. Democracy depends upon vigorous debate. But it also depends upon something deeper — a shared commitment to our republic and our active participation as citizens. We need to become informed participants in our society and we need to vote and encourage others to vote.

As we celebrate America’s 250th birthday, the greatest act of patriotism is not winning another political argument. It is remembering that despite our many differences, we remain participants in the same remarkable American experiment. If civic organizations, veterans’ groups, historical societies, schools, churches, and local communities can help us rediscover that simple truth, they will have performed one of the greatest public services imaginable.

The founders gave us a republic, and they challenged each generation to preserve it and to improve it. Two hundred and fifty years later, that responsibility belongs to all of us.  We must not fail.

Image generated br author using ChatGPT.

Refusing the Needle: A History of Vaccine Resistance in America

By

On August 17, 2026

In Medicine, Uncategorized

Every vaccine the United States has ever rolled out has arrived with a shadow twin: a countermovement insisting the shot poses more danger than the disease it prevents, or that no government has the right to demand it. That pattern predates the country itself, and it has recurred with almost eerie consistency across three centuries — from the smallpox pustules of colonial Boston to the mRNA vials of 2021.

Colonial Boston and Smallpox

The story usually begins in Boston in 1721, during the sixth smallpox epidemic to strike the city since its founding. A ship called the Seahorse arrived from the Caribbean that April carrying a sailor with active smallpox, and within weeks the disease was moving through a city of roughly 11,000 people. By the time the epidemic burned out the following year, more than 6,000 Bostonians had been infected and about 850 had died.

The remedy that split the town in two was not vaccination in the modern sense but variolation, or inoculation — deliberately introducing live smallpox matter into a small cut in the skin, on the theory that a controlled, minor case would produce immunity without the risk of the full-blown disease. The technique had circulated for generations across West Africa, the Ottoman Empire, and Asia, and it reached Boston through the  injustice of slavery. The Puritan minister Cotton Mather learned of it from Onesimus, a man he held in bondage, who described having undergone the procedure himself in Africa. Mather corroborated the account with other enslaved Africans in Boston and read reports out of Constantinople before becoming inoculation’s loudest champion.

Physician Zabdiel Boylston put the idea into practice, inoculating his own son and two enslaved members of his household first, then expanding the program despite fierce opposition. The city’s medical establishment largely revolted. Dr. William Douglass, one of the few Bostonians who actually held a medical degree, led the case against inoculation on grounds that ranged from the religious objection, that deliberately spreading disease usurped divine providence, to a reasonable-for-the-time scientific worry that the practice itself was seeding new outbreaks. The argument did not stay academic. Someone threw a lit grenade through Mather’s window that November, with a note attached reading, in essence, that he could inoculate himself with the bomb. It failed to detonate.

The case against inoculation was never purely religious or clinical; it was tangled up with its origin. Opposition writers repeatedly invoked its African and Ottoman source as grounds for distrust, treating its foreign, non-Christian lineage as evidence of danger apart from any medical argument. One Boston pamphleteer asked why residents should “cherish the cruel Blood of Africa or Asia” in their bodies, and a London critic writing a decade later dismissed inoculation as a “barbarous and dangerous Invention” imported from Turkey that had wrought “Havock and Slaughter” once it took hold. Because the technique reached Boston through Onesimus, the racial dimension of the debate was impossible to separate from the medical one — critics were rejecting a treatment in part because of who had brought it, not because of what it did.

What makes 1721 more than a historical curiosity is that Boylston and his allies did something close to a clinical study. They tallied outcomes among the inoculated against outcomes among those who caught smallpox naturally, and the inoculated group fared markedly better. That comparison helped slowly tip opinion in inoculation’s favor over the following decades.  By the time George Washington ordered mandatory inoculation of the Continental Army in 1777, the practice — though still controversial — had become an accepted tool of public health.

The Gilded Age Leagues: Liberty, Quackery, and the Courts

Edward Jenner’s cowpox vaccine, introduced in 1796, eventually replaced variolation as the standard smallpox prevention. As vaccination spread across the Atlantic world through the nineteenth century, so did organized resistance. Britain passed an 1853 law making infant vaccination compulsory, and an 1867 act extended the mandate to age fourteen with real penalties attached for refusal. Britons who objected on religious, medical, or libertarian grounds organized the Anti-Vaccination League and, in 1867, the Anti-Compulsory Vaccination League, and within a few years it claimed over a hundred branches and roughly 10,000 members.

The British campaigner William Tebb carried that movement across the Atlantic. Following Tebb’s visit, Americans opposed to compulsory vaccination founded the Anti-Vaccination Society of America in 1879, and the New England Anti-Compulsory Vaccination League followed in 1882. These organizations drew on a mix of motives that will sound familiar to a modern reader: a libertarian objection to state intrusion into personal and parental decisions, religious conviction that disease and its prevention were matters for providence, and — more cynically — the financial interests of the era’s patent-medicine sellers and homeopaths, whose loosely regulated business model was directly threatened by a state-endorsed, evidence-based alternative.

The movement’s grievances were not entirely invented. In 1901, contaminated diphtheria antitoxin killed thirteen children in St. Louis, and contaminated smallpox vaccine killed several more in Camden, New Jersey, in the same year. Congress responded with the Biologics Control Act of 1902, the first federal law requiring licensure and safety standards for vaccine manufacturers — an early ancestor of the FDA’s modern oversight role. Those tragedies, however, did not settle the legal question of whether a state could force the issue. That came in 1905, when the Supreme Court decided Jacobson v. Massachusetts, upholding a Cambridge ordinance that fined residents who refused smallpox vaccination during an outbreak. The Court held that individual liberty was not absolute and could yield to a state’s power to protect public health — the first Supreme Court ruling on the subject, and one still cited today in disputes over compulsory vaccination and other public health mandates.

The ruling galvanized rather than pacified the opposition. Three years later, in 1908, opponents founded the Anti-Vaccination League of America in Philadelphia, built on the principle — in the League’s own words — that health was nature’s greatest safeguard against disease and that no state had the right to demand its impairment. It had the stated goal of abolishing what it called oppressive medical laws. Charles Higgins, one of the League’s most prolific pamphleteers, published tracts like his 1912 broadside “Open Your Eyes Wide!” arguing that vaccination was both dangerous and a violation of fundamental freedom. When Texas tried to require vaccination for public school attendance, the League’s arguments resurfaced in Zucht v. King, a 1922 case in which the Supreme Court again sided with the state.

Polio and The Vaccine Disasters of the 20th Century

By the mid-twentieth century, American vaccine skepticism had a new source of fuel, manufacturing failures serious enough to validate the movement’s oldest fear, that the shot itself might cause the disease. On April 12, 1955, officials announced that Jonas Salk’s inactivated polio vaccine, tested in a trial of 1.8 million children, was safe and effective, and the federal government licensed five manufacturers within days to begin mass production. One of them, Cutter Laboratories of Berkeley, California, shipped batches in which the virus-inactivation process had failed, leaving live, virulent polio virus in vaccine given to roughly 200,000 children across five states. An estimated 40,000 developed abortive polio, 200 were left with some degree of paralysis, and at least ten died. The program was suspended within weeks, federal oversight of vaccine manufacturing was overhauled, and vaccination resumed that fall under tighter controls.

The Cutter Incident became a formative episode in the history of American vaccine regulation and it had a lasting effect: a generation of parents who had watched the worst-case scenario for the trustworthiness of vaccines play out on the evening news, and that memory did not fade quickly.

Two decades later, a different kind of failure struck the flu vaccine. In early 1976, an Army recruit at Fort Dix, New Jersey, died of an influenza strain resembling the one responsible for the catastrophic 1918 pandemic. Fearing a repeat, the Ford administration pushed Congress to fund a crash national vaccination campaign, and nearly 43 million Americans were vaccinated within about ten weeks — an extraordinary logistical feat. The anticipated pandemic never arrived. Worse, as vaccinations proceeded, epidemiologists began detecting a modest but real increase in Guillain-Barré syndrome, a rare autoimmune paralytic condition, among recipients — roughly one additional case per 100,000 doses by later estimates. The program was suspended in December 1976, the CDC director was fired on live television, and the New York Times dubbed the whole affair a “fiasco,” a label that stuck for decades.

The Flu Shot’s Persistent Image Problem

Unlike smallpox or polio vaccination, the annual flu shot has never fully shaken a reputation for being optional, unpleasant, and only modestly effective in any given year. This is largely because the vaccine’s composition is re-engineered annually against strains predicted months in advance. That combination of a recurring injections, a variable and sometimes underwhelming efficacy rate, and the folk memory of 1976 has kept flu vaccination rates well below public health targets in most seasons, hovering in recent years around half of American adults, with substantial swings by age, region, and political affiliation. There is still the belief among some groups that the vaccine itself can cause flu even though flu vaccines do not contain live virus and cannot cause the disease.

COVID-19: An Old Argument at Unprecedented Speed

The COVID-19 pandemic compressed a century of vaccine controversy into about eighteen months. The mRNA vaccines developed by Pfizer-BioNTech and Moderna, along with a viral-vector vaccine from Johnson & Johnson, received emergency authorization by early 2021 after a development timeline that was, by historical standards, astonishingly fast. It was a point public health officials framed as a triumph of scientific investment and one that vaccine skeptics framed as a reason for caution. By September 2021, about 62 percent of Americans age twelve and older had received at least one dose, but demand had already begun slowing well before the country approached anything like universal coverage.

What followed diverged from earlier vaccine controversies in one important respect, hesitancy did not fade as more safety data accumulated, and in some respects it hardened. One national longitudinal study found that COVID-19 vaccine refusal actually rose from about 41 percent of adults in 2021 to nearly 45 percent in 2022. Even as overall vaccination coverage climbed, belief in the vaccine’s broader social benefit fell sharply, from roughly 48 percent to 25 percent. Parental hesitancy about vaccinating children against COVID-19 rose by nearly 16 percentage points in just nine months of 2021 and 2022, notably concentrated among white and rural parents, a pattern that cut against the demographic profile of vaccine resistance in earlier eras of American history. By the 2025–26 respiratory virus season, CDC surveillance found that only about 16 percent of American adults had received that season’s COVID-19 vaccine, with somewhat higher uptake — about 31 percent — among adults sixty-five and older, who face the greatest risk from the disease.

COVID-19 did not create vaccine skepticism, but it sharply politicized and enlarged the anti-vaccine movement by tying vaccination to partisan identity, distrust of government and public-health institutions, and debates over mandates, individual liberty, and pandemic restrictions. Political leaders, partisan media, and online networks often framed vaccination less as a medical decision grounded in evidence than as a symbol of cultural allegiance or resistance to perceived government overreach. Anti-vaccine activists used that environment to spread misinformation and reach audiences far beyond earlier disputes over childhood immunizations. The result was a more organized “health freedom” politics in which skepticism about COVID-19 vaccines could spill over into opposition to other routine vaccines, making public health a continuing front in America’s broader political polarization.

The pandemic-era pattern echoes several of its historical predecessors at once: distrust of a fast-moving federal program (echoing 1976), suspicion of a technology many found unfamiliar and difficult to evaluate (echoing the original inoculation debates of 1721), and a fusion of libertarian and religious objection to government mandates (echoing the Anti-Vaccination League of America a century earlier).

A Recurring American Argument

Over the last 50 years, advocacy groups have questioned the growing number of childhood vaccines and raised concerns about vaccine ingredients, scheduling, and possible long-term effects. The movement gained momentum after publication in 1998 of a now-retracted paper by Andrew Wakefield that falsely suggested a link between the measles-mumps-rubella (MMR) vaccine and autism. Numerous large studies subsequently found no evidence supporting such a connection, and investigations revealed ethical violations and scientific misconduct in Wakefield’s work, but the damage was done and the foundation was laid for the modern anti vaccination movement.

Read across three centuries, American vaccine resistance is not one continuous movement so much as the same underlying argument recurring in new costumes. It is a tension between collective protection and individual or parental autonomy, sharpened at each turn by episodes — some tragic and real, like Cutter and the 1976 swine flu campaign, some largely fabricated, like William Tebb’s invented nineteenth-century casualty statistics — that gave skeptics evidence, or the appearance of it, to point to. The debate has never been resolved so much as relitigated, generation after generation, against whatever the era’s most feared disease happens to be.

Disclaimer: The author writes independently. The views expressed here are his own and are not made on behalf of, and should not be attributed to, any hospital, university, or other institution with which he is affiliated. This article is a work of historical journalism, not medical advice.

Image generated by the author using ChatGPT.

Sources

1. The Fight Over Inoculation During the 1721 Boston Smallpox Epidemic, Harvard SITN. https://sites.harvard.edu/sitn/2014/12/31/the-fight-over-inoculation-during-the-1721-boston-smallpox-epidemic

2. Benjamin Franklin’s fight against a deadly virus, The Conversation. https://theconversation.com/benjamin-franklins-fight-against-a-deadly-virus-colonial-america-was-divided-over-smallpox-inoculation-but-he-championed-science-to-skeptics-161569

3. A “Doubtful and Dangerous Practice”: The 1721 Boston Inoculation Controversy, Readex Report. https://www.readex.com/readex-report/issues/volume-10-issue-1/doubtful-and-dangerous-practice-1721-boston-inoculation

4. The 200-year history of the anti-vaxxer movement, Newsweek. https://www.newsweek.com/history-anti-vaxxers-vaccination-1358403

5. National Anti-Vaccination League, Wikipedia. https://en.wikipedia.org/wiki/National_Anti-Vaccination_League

6. History of Anti-Vaccination Movements, History of Vaccines (College of Physicians of Philadelphia). https://historyofvaccines.org/vaccines-101/misconceptions-about-vaccines/history-anti-vaccination-movements/

7. Anti-Vaccination Society of America, Wikipedia. https://en.wikipedia.org/wiki/Anti-Vaccination_Society_of_America

8. Anti-vaccination in America, National Museum of American History (Smithsonian). https://americanhistory.si.edu/explore/stories/anti-vaccination-america

9. Anti-vaccination in America, National Museum of American History (Smithsonian). https://americanhistory.si.edu/explore/stories/anti-vaccination-america

10. On this day, the Supreme Court rules on vaccines and public health, National Constitution Center. https://constitutioncenter.org/blog/on-this-day-the-supreme-court-rules-on-vaccines-and-public-health

11. Freedom, Rights, and Vaccine Refusal: The History of an Idea, PubMed / American Journal of Public Health. https://pubmed.ncbi.nlm.nih.gov/35080944/

12. Historical Vaccine Concerns, CDC. https://www.cdc.gov/vaccine-safety/historical-concerns/index.html

13. The Cutter Incident, Polio Network (citing CDC). https://polionetwork.org/archive/adig3shiiagcds4x1igpvp9u3istoo

14. The Cutter Incident, 50 Years Later, New England Journal of Medicine. https://www.nejm.org/doi/abs/10.1056/nejmp048180

15. 1976 Swine Flu Vaccination Program, David J. Sencer CDC Museum. https://www.cdc.gov/museum/online/story-of-cdc/h1n1/index.html

16. Reflections on the 1976 Swine Flu Vaccination Program, Emerging Infectious Diseases (CDC). https://wwwnc.cdc.gov/eid/article/12/1/05-1007_article

17. Biology:1976 swine flu outbreak, HandWiki (summarizing CDC and contemporary reporting). https://handwiki.org/wiki/Biology:1976_swine_flu_outbreak

18. The Long Shadow of the 1976 Swine Flu Vaccine ‘Fiasco,’ Smithsonian Magazine. https://www.smithsonianmag.com/smart-news/long-shadow-1976-swine-flu-vaccine-fiasco-180961994/

19. Swine Flu Immunization Program of 1976, Gerald R. Ford Presidential Library. https://www.fordlibrarymuseum.gov/digital-research-room/topic-guides/swine-flu-immunization-program-1976

20. Determinants and trends of COVID-19 vaccine hesitancy and vaccine uptake in a national cohort of U.S. adults, medRxiv. https://www.medrxiv.org/content/10.1101/2021.05.12.21257116.full.pdf

21. Changes in general and COVID-19 vaccine hesitancy among U.S. adults from 2021 to 2022, PMC. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11141308/

22. Sociodemographic Trends and Correlation between Parental Hesitancy towards Pediatric COVID-19 Vaccines and Routine Childhood Immunizations, PMC. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11126092/

23. Vaccination Uptake, Intent, and Confidence, RespVaxView, CDC. https://www.cdc.gov/respvaxview/dashboards/vaccination-behavioral-social-drivers.html

Page 1 of 31

Next

Powered by WordPress & Theme by Anders Norén