Out of a firestorm of controversy over teen nicotine use, Juul Labs emerged in January with a newly sober and adult marketing identity. Forget the fruit-flavored vaping pods, the former colorful ads populated with young models, the viral Instagram and Facebook posts. What the Silicon-Valley e-cigarette giant is really about, its $10 million television ad campaign declares, is helping cigarette smokers shake their cigarette addictions and get healthy.
The ads feature mature subjects with their ages clearly stated on screen: “Carolyn, 54,” “Patrick, 47,” “Mimi, 37.” They sit against muted domestic backdrops and say that because of Juul, they’ll never touch a cigarette again after decades of dependency. Juuling, they emphasize, is an “alternative” to smoking. Juul’s website underlines that message: “Our mission,” one page reads in bold white text, is to “improve the lives of the world’s one billion adult smokers by eliminating cigarettes.”
In its effort to define its products as a safer alternative to traditional cigarettes, Juul appears to be following a familiar marketing cycle. Throughout the 20th century, as warnings about the health risks of cigarettes arose, tobacco companies repeatedly found new ways to downplay concerns and advertise their products as healthy options. When their claims were refuted by evidence, they traded them out for new claims.
E-cigarettes like Juuls are still a recent invention, and their long-term health effects remain largely unknown. Some evidence shows that vaping can help smokers quit, as Juul’s ads profess, and that it is a safer substitute for people who already smoke. But studies are finding that, like the many tobacco and nicotine products that preceded them, Juuls also come with considerable risks. History seems to be repeating itself.
Tobacco and nicotine use has long been associated with health risks. Certain effects of smoking, like throat irritation and coughing, have been obvious for centuries. Others, like the increased risk of cancers and vascular diseases, began to be reported in the 1890s. Despite that evidence, tobacco companies marketed cigarettes as health products throughout the late 19th and early 20th centuries. A number of brands promoted their products as curatives for respiratory conditions like asthma and hay fever. Camel sold its cigarettes as digestive aids.
Marshall Cigarette COmpany
As concerns about smoking gradually mounted, tobacco companies didn’t stop claiming their products had health benefits. Instead, many adapted, presenting their cigarettes in print and television ads as healthier than competing brands’, if not healthy outright. Athletes, from swimmers to cyclists to track stars, cropped up often in marketing campaigns. Camel, for instance, declared that their cigarettes were a “mild” choice preferred by professional athletes and doctors. “The athletes—to whom ‘wind,’ healthy nerves, ‘condition,’ are vitally important—these men and women insist on mildness,” claimed one ad featuring the Yankees first baseman Lou Gehrig.
Doctors were also frequently cited, if not always shown. “More doctors smoke Camels than any other cigarette,” one Camel ad campaign proclaimed. Camel’s competitors boasted that “throat doctors vote Old Gold best for your throat” and printed ads “based on the opinion of [thousands of] physicians” that reassured prospective buyers they would suffer “no throat irritation” and “no cough” if they smoked Lucky Strikes.
In the 1920s, the Axton-Fisher Tobacco Company introduced cigarettes flavored with menthol, a mint extract that can temporarily relieve the throat irritation caused by smoking. The company used that effect to promote menthol cigarettes as a source of relief for smokers suffering from a cold, a sore or dry throat, or a cough. They were a “superior” alternative to normal cigarettes, one 1940 ad argued, in part because of their “greater safety.” The company’s menthol cigarettes, called Spuds, became the fifth best-selling cigarette brand in the country seven years after they hit the market.
Brown & Williamson Tobacco Corporation
Meanwhile, the evidence against tobacco companies’ promotions of healthier cigarettes only continued to grow. In 1953, a team of New York researchers demonstrated a direct causal relationship between cigarette tar and lung cancer for the first time using lab rats. Then, in a landmark 1964 report, the surgeon general’s office concluded that smoking was correlated with emphysema and heart disease and caused chronic bronchitis and an increased risk of cancer. The media publicized the danger to potential and current smokers around the world. An estimated 30 million quit over the next decade in response.
The surgeon general’s report marked an inflection point, the beginning of a concentrated effort to regulate cigarette advertising and legally bar smoking from public spaces in America. For tobacco companies, this meant the beginning of a long, bitter fight to keep people smoking. Advertisers leaned into the strategy they’d already been employing for decades: convincing the public to trust that their products were special, safe.
Companies promised to reduce smokers’ exposure to dangerous tars and nicotine with the help of filters. Philip Morris inserts from the 1950s promoted “the cigarette that takes the FEAR out of smoking,” while a Kent cigarette ad from 1964 claimed that “no medical evidence or scientific endorsement has proven any other cigarette to be superior.” Bolstered by these claims of protection, filtered cigarettes quickly took over the market amid the influx of new health studies in the 1950s. They remain dominant to this day.
Another marketing strategy was born in 1966, when the Federal Trade Commission began testing nicotine and tar levels in various cigarette brands. Tobacco companies began producing “light,” “low tar,” and “less nicotine” cigarettes that were designed to produce reduced readings of tar and nicotine content, and used the government’s own measurements as implicit evidence that their cigarettes were safer to smoke. The Public Health Service lent credence to those claims by running public-service advertisements encouraging smokers to switch to cigarettes that produced less tar and nicotine.
R.J. Reynolds Tobacco Company
But for the second time in the ongoing back-and-forth of health warnings and marketing reassurances, a wave of research discredited tobacco companies’ claims. Evidence disputes the idea that filtering or flavoring cigarettes can reduce health risks. Studies have shown that “mild” cigarettes flavored with menthol are in fact not healthier than those without it, though they are more addictive. Researchers have also demonstrated that filtered and “light” cigarettes are not, in fact, healthier or safer to smoke than unfiltered ones, and may actually be worse for smokers.
Internal memos have shown that the health risks of filtered cigarettes were understood by tobacco companies, even as they created new products and printed ads to promote their improved safety. Since the 1950s, private and public lawsuits have argued that the tobacco industry undertook decades-long effort to suppress information about smoking’s negative health effects. In a landmark 2006 decision, the United States District Court for the District of Columbia held that their efforts equated to illegally defrauding the American public.
In 2017, after a series of failed appeals, the companies found liable in that case began paying for a new series of court-ordered “corrective statements” to run on television and in newspapers to counter decades of false advertising. Instead of images of doctors, athletes, and smiling young smokers, these ads feature simple white backgrounds overlaid with black text; instead of promises that this cigarette is better, cleaner, healthier, they recite a series of facts about the health effects of smoking. “Smoking kills, on average, 1,200 Americans. Every day,” one statement reads. “All cigarettes cause cancer, lung disease, heart attacks, and premature death—lights, low tar, ultra lights, and naturals. There is no safe cigarette,” reads another.
Now, just as tobacco companies have been forced out of the cycle of concern and reassurance that they’ve maintained for decades, Juul looks like it’s jumping in. Unlike mentholated, filtered, or “light” cigarettes, studies have found that e-cigarettes are at least somewhat healthier to smoke than the traditional model. But as e-cigarettes have gained popularity and researchers have begun studying their long-term effects, they’ve found evidence linking vaping to potential dangers to the heart, respiratory system, and brain—and suggesting that, regardless of Juul’s claimed mission to help adult smokers quit, e-cigarette use can lead younger people to take up smoking.
Juul’s serious new television ads don’t address any of that. Instead, the company’s marketing strategy relies on a now familiar sleight of hand, ignoring this mounting evidence of health complications and pivoting to a narrative of relative safety. The ads bank on Big Tobacco’s villainous reputation, earned through decades of scheming and misrepresentation, to make Juul seem noble in contrast: like an e-cigarette hero, swooping in to save the day.
In an emailed statement, a Juul spokesperson told me that the company’s marketing reflects its mission to help smokers make the switch from traditional cigarettes. “We do not want non-nicotine users to buy JUUL products and that is why our marketing is aimed at adult smokers age 35 and up,” the statement said, adding the disclaimer: “JUUL products are not intended to be used as cessation products, including for the cure or treatment of nicotine addiction, relapse prevention, or relief of nicotine withdrawal symptoms.”
These legal actions recall the anti-smoking fight waged in past decades, too. If Juul wants insight into that history, it won’t have to look far: It can turn to the Marlboro-maker Altria, one of the largest tobacco companies in the world and, as of last December, a major investor and 35-percent stakeholder in Juul Labs.
When Nara Milanich wrote Paternity: The Elusive Quest for the Father—a history of the scientific, legal, and social conceptions of fatherhood in Western civilization—she wasn’t expecting that her publicity tour would be full of interviewers asking her whether she’s done 23andMe. And, truth be told, she’s not that into the question.
Of course people ask. The direct-to-consumer DNA-testing kits are the latest and trendiest technological development relevant to her subject matter. But given the history she’s just written about how sensitive, fraught, and complicated the subject of biological provenance is, Milanich is particularly attuned to how the question of whether someone has done 23andMe could be an intensely invasive one. People are asking whether she’s spent $99 and sent in a swabbed sample of her saliva to find out whether the family she’s always understood to be her family is genetically related to her or not. The next time it happens, Milanich told me as we sat in her office, in the history department of Barnard College, “I’ve decided I’m going to turn it back on them and say, ‘Have you?’”
Paternity traces the long history of how society got here, to a place where biological paternity is a patently knowable fact that’s apparently fair game to ask a stranger about. As Milanich explains in the book, certainty of biological paternity is a relatively new concept in the long arc of human history. Though it’s been known for centuries that every person has one biological father, the notion that this biological father could be determined by science first broke through in the early 20th century. Milanich’s book illustrates in detail how paternity testing became both a useful tool and a powerful weapon, depending on whose hands the technology landed in. As she pointed out when we spoke, the history of paternity testing may provide valuable clues as to the potentially huge consequences of DNA testing’s swift proliferation as a consumer product.
Maternity, Milanich notes early on in the book, tends to be a much less mysterious relationship than paternity, given the visible facts of pregnancy and birth. Paternity, by contrast, is invisible, and until the 20th century and the advent of the earliest paternity testing, claims to fatherhood (and denials of fatherhood) were only as strong as the implicated parties’ insistence, and circumstantial evidence.
As a result, Milanich explains, for most of modern history, neither the public nor the courts made any distinction between legal and biological fatherhood. When someone had a father, it was because a man had claimed fatherhood status and behaved as a father was expected to by providing care and shelter. The husband of a wife was generally understood, by society and by most countries’ laws, to be the father of her children and thus responsible for providing for them—a rule that proved frustrating to some men when suspicions about their wife’s marital fidelity arose. The expectation for a husband to also necessarily be a father is why the notion of “stepchildren” didn’t really break into mainstream consciousness until the 20th century. It’s also why, Milanich points out, children born to unmarried mothers and absent fathers were for generations simply considered “fatherless,” and many ended up in the custody of the Church or the state when their mothers couldn’t adequately provide for them.
The fascination with knowing paternal identity tends to be a strong and propulsive one. The once-murky nature of paternity provides the central tension of countless great works of fiction, for example. Even contemporary works such as Min Jin Lee’s National Book Award–nominated Pachinko and Elena Ferrante’s bestselling Neapolitan novels, as well as blockbuster musicals and TV shows such as Mamma Mia and Game of Thrones, rely on secret or unknown biological paternity as a plot device. So perhaps it should come as no surprise that scientists all over the developed world worked for decades to find a way to test for a biological relationship between father and offspring.
The first widespread scientific practice to be considered a “paternity test” was blood testing. The blood groups A, B, AB, and O were discovered around the turn of the 20th century, and over the next few decades, scientists applied Mendelian genetics logic to establish that there were limits to the blood types that combinations of parental blood types could produce. This sort of testing couldn’t definitively establish a biological link between two people, but it could rule out a biological link between people whose blood types were incompatible. It took a while, however, for biological paternity to supplant “social” paternity in the popular imagination as the standard by which to measure whether someone was a father. For example, in a famous trial in California in the early 1940s, the silent-film star Charlie Chaplin was accused of fathering a baby with a much younger woman, a charge he denied. A blood test found that it was impossible for Chaplin to have fathered the baby in question, and the results were presented in court. But after witnesses testified that they had seen Chaplin enter the mother’s home at night and leave in the morning, the jury came back with the verdict that Chaplin was in fact the baby’s father.
“The press, and especially the scientific community, went nuts. [They wrote,] California has declared black to be white and the Earth to be flat; how can they be so ignorant?” Milanich told me. “But ultimately, his paternity was determined based not on his biological relationship with the baby but on his social relationship with the mother.”
Within half a century, scientists would begin to unlock the codes of the human genome and further understand the so-called DNA fingerprint. By the 1980s, lab scientists could—given some time and considerable compensation—test two people for a genetic match that would positively confirm biological parenthood, to 99.99 percent certainty.
The sudden ability to positively identify a father for countless numbers of people whose fathers might have remained uncertain forever had significant repercussions. DNA testing promised a way to identify fathers and hold them accountable for supporting the children they could no longer dispute were theirs. This essentially “privatized,” as Milanich puts it in the book, the duty of providing for children, taking the responsibility away from the state or the Church and giving it to biological fathers. For example, Milanich posited when we spoke that it is likely not an accident that the United States’ “child support apparatus” was largely established around the same time that courts and private citizens began to routinely request DNA paternity testing.
The thing to remember about paternity testing, Milanich emphasized, is that it’s available to everyone, for uses both benign and less so. Just as governments and courts have sometimes used paternity testing to ensure that children get the support they need, authorities have also historically used paternity testing to exert control over citizens. Blood testing, for example, was used in Nazi Germany to try to establish whether certain citizens came from Jewish or Aryan parentage; whether a person was sent to a concentration camp or not, in other words, could depend on that person’s ability to prove non-relation to known Jews.
Paternity testing was also used to regulate Chinese immigration to America in the early 20th century, when immigrants were allowed by law to help their immediate families gain entry into the country. Before the implementation of blood testing, immigrants needed only to tell authorities that they had children who wanted to join them in the United States. When the country began testing for biological parentage between immigrants and their putative family members, it aimed to curb the practice of “paper kinship,” or the sale of immigration opportunities to people willing to pose as family members of immigrants already in the United States. But the measures also made it so that immigrants’ adopted children—or other nonbiological kids in their care or guardianship—could be detained for long periods or denied entry.
Now that the knowledge of biological paternity is available cheaply and discreetly through services such as 23andMe, Ancestry, and MyHeritage, Milanich has a few worries about what effects that rampantly available knowledge might have on American society and American citizens’ lives. For one thing, she noted, it’s getting harder to keep biological relationships a secret even if you want to, which can seriously undermine people’s perceived right to privacy, not to mention their peace of mind.
“There’s been a long-standing discussion over the past century about whether ‘knowing who the father is’ is always a socially valuable piece of information,” Milanich said. “Might it be a destabilizing piece of information? Yeah.” (As my colleague Sarah Zhang hasreported, it certainly can, as in the case of the fertility doctor Donald Cline, who was found in 2017 to have impregnated many of his unknowing patients with his own sperm.)
The mass commercialization of genetic testing—or as Milanich likes to call it, “Big Paternity”—has made that information more accessible than ever, “and, at least in the U.S., we’ve sidestepped any public conversation about whether people should have access to these things.” For example, Milanich noted that in the age of Big Paternity, the new ease with which people can learn the identities of even “anonymous” sperm donors might deter men from donating. (As I’ve reported before, lawyers who work in assisted reproductive technology and adoption now advise clients that anonymous sperm donation and closed adoption no longer reliably exist.) It’s for reasons like this, she noted, that some countries—such as France—have virtually outlawed direct-to-consumer genetic testing. (“People [in France] do them anyway,” Milanich added. “They just send them to Switzerland and Spain.”)
Milanich also worries about the potential uses of paternity testing as a tool of governmental authority. Already, she noted, U.S. immigration authorities have been using DNA testing at the U.S.-Mexico border to help determine whether migrant families coming into the United States are indeed biological families (as opposed to unrelated individuals posing as families). Testing is also being used to help reunify parents and children who have been detained separately under the Donald Trump administration’s family-separation policy.
Ultimately, adults today are some of the first-ever humans to be able to discreetly and cheaply find out (or verify) their biological parentage without leaving their home. They are also, however, the first generation of adults to be vulnerable to abrupt, destabilizing violations of privacy thanks to the same widely available technology. That most of the advertising and messaging around direct-to-consumer genetic testing focus on the former could prove, down the line, to have been an oversight.
The first time someone commented on what I was eating at work, I was a teenager at my first job, manning the front desk at the local courthouse’s law library. On the way out one day, a regular visitor interrupted my fistful of cashews to tell me he loved watching me eat—I did it with such relish. Before I could think of a response, he left.
At 18, I was already well aware of the frequency with which grown men say bizarre things to teenage girls, but what stuck with me was the fact that someone who wasn’t a parent or close friend noticed when and what I ate. It was like realizing I had been looking into a two-way mirror all along, and the food police were on the other side. What had people seen me do before I knew I was being watched?
The library incident was a startling introduction to an experience that I eventually learned is common in workplaces: being compelled to talk about my body through pointed comments or idle diet chat among co-workers. At my college job, other employees asked why I subjected myself to 280-calorie frozen diet meals, and then raised their eyebrows when people ate “too much” fast food. At my first job after graduation, I shared an office with a guy who always expressed his surprise if I bought lunch several days in a row instead of bringing it myself. After being laid off, I embarked on a 10-year career in fashion, where we talked a lot about juice fasts and an intern once fussed at me for ordering a chicken quesadilla.
My experiences aren’t just a string of bad luck with break-room busybodies. As attitudes about body image creak into the future, the workplace remains a stubborn locus of petty sniping about diet and exercise routines. Many workers have a hard time escaping that one person leaning over people’s shoulders to give them feedback on their lunches. Office diet scolds are more than annoying: In a culture where disordered eating is often rewarded and larger people, especially larger women, get passed over for promotions, workplaces that let food-shamers run rampant can threaten their employees’ careers—and their health.
Dieting and the workplace aren’t traditionally joined in the American consciousness, but often when people talk about how they’ve encountered ideas about diet and exercise, they talk about their co-workers. Although they happen in every type of workplace, these conversations can be most visible in media circles. Recently, in a New York Times op-ed excoriating the wellness industry’s dire effect on women’s well-being, the author Jessica Knoll related an experience at a Hollywood business lunch in which her companions bonded by talking cruelly about their own bodies. Last week, GQ named its head fact-checker as the magazine’s “fittest” staffer, casually detailing the extreme diet and exercise practices that got him there.
Beyond media and entertainment, Silicon Valley is well on its way to rebranding age-old diet practices into health-enhancing body hacks. Twitter’s CEO, Jack Dorsey, who has talked publicly of fasting for days at a time to achieve focus and productivity, might be America’s most prominent passive-aggressive workplace-wellness practitioner.
At a time when workplace propriety is as touchy an issue as it has ever been, it might seem counterintuitive that a person’s body size and food choices would be such routine fodder for conversation. In reality, the fact that many personal things are strictly off-limits might make dieting an even more tempting topic. Anat Lechner, an organizational-management professor at NYU’s Stern School of Business, says that’s because work is a fundamentally social setting. “To feel real in a workplace and not just like a cog in a wheel, I think we have a need to connect when we can,” Lechner explains. “We may not choose to talk about going through divorce or some big disease we have, so we revert to things that are real, but a little less intimate.” That’s where food, exercise, and bodies come in.
Even though weight can be a touchy subject, the ideas that weight loss is always positive and that being thin is a reliable indicator of overall health can make weight feel like an appropriate topic for workplace bonding. After all, size is public and observable. Even if your co-workers aren’t picking on others, they might be using their own bodies as frequent conversation starters, as Knoll writes about in her Times op-ed. That tends to conscript people into the cycle of diet chat without the red flag of bullying.
“This idea that weight loss is universally lauded and praised really hurts people struggling,” says Claire Mysko, the CEO of the National Eating Disorders Association, or NEDA. Sudden weight loss is often a side effect of serious illnesses such as cancer and thyroid disease, not to mention eating disorders. Mysko notes many people in recovery for restrictive disorders such as anorexia report that their weight loss was widely encouraged at first, which reinforces life-threatening behaviors and often delays treatment until the disorder is worse—and harder to treat.
Disordered eating is both widespread and devastating. Anorexia is the psychiatric disorder most likely to be fatal in Americans, with a mortality rate of about 10 percent. According to NEDA’s numbers, at least 30 million Americans will experience a full-blown eating disorder at some point in their life, but Mysko says the real number is likely far higher because many don’t seek treatment. The number of people struggling with disordered eating behaviors that don’t fit the full diagnostic criteria is even higher: A 2008 study found them among 75 percent of American women.
Lechner and Mysko both point to a relatively recent workplace trend that reinforces these norms, even as diet chat becomes more passé among the socially aware: workplace-wellness programs. These weight-loss and exercise challenges, many of which are subsidized by the Affordable Care Act, have become a typical part of office life in the past decade, pressuring employees to restrict their eating and sometimes overexercise, often to win cash prizes for themselves or their team.
“There’s a huge amount of money being invested in a program that essentially makes it okay for people to shame others,” Mysko says. “There’s an idea that if people feel shamed, they’re going to ‘take better care of themselves,’ and all of these very shaming kinds of messages are validated by these programs.” In reality, the opposite is true: Research has consistentlyshown that shaming fat people harms both their physical and psychological well-being.
Part of the blame also goes to the idea of “wellness,” as Knoll detailed it in her piece. The wellness trend, as shaped by Instagram influencers and nutrition and supplement start-ups, recasts thinness as not a goal in and of itself, but as the primary indicator of corporeal sophistication and spiritual peace. That helps the diet industry evade the hard-fought battles that activists have won to diminish some of dieting’s more extreme components, such as liquid meal replacements, and sell basically the same stuff they’ve always offered. It also makes old opportunities for idle chatter and passive aggression feel novel and righteous.
“Wellness in general is a relatively new phenomenon, so I don’t think there’s deep awareness of how we behave around this issue,” Lechner explains. That can attract the attention of workers who are looking for a way to act out, by either putting themselves down or shaming their colleagues—or often both. “You’re likely to find within the same person the same violation of quite a few different boundaries,” Lechner says. In workplaces where people have been unable to negotiate healthy boundaries for themselves, it’s up to employers to find a way to deal with the instigators. “The stuff they need to manage is just escaping through another door,” Lechner says. “This time, it’s through wellness.”
Every morning for 20 years, Karl-Heinz Martens steered his yellow mail truck through the narrow streets of Eutin, a market town arranged around a little castle in northern Germany, near the Baltic Sea. On his route, Martens would drive through miles of farms and fields before disappearing into a deep, enchanted forest, where he unlocked a gate using a special key and reversed into his parking spot—as all mailmen do—facing outward to ensure a quick exit. As he crunched into the woods carrying his mailbag, his tidy beard and glasses were sometimes flecked with snowflakes or sleet, and every morning, just before the clock struck 12, he arrived beneath a towering oak.
“People used to memorize my route and wait for me to arrive because they couldn’t believe that a postman would deliver letters to a tree,” Martens told the press, who called the now-retired mailman the “messenger of love.” The Bräutigamseiche, or Bridegroom’s Oak, is the only tree in Europe with its own mailing address. Every day the 500-year-old tree receives dozens of lonely-hearts letters, and singletons arrive from near and far to reach into a small knothole in the trunk, hoping to find a match. The tree is believed to possess magical matchmaking powers.
According to legend, the tree and its longest-serving mailman are together responsible for more than a hundred marriages. Despite holding the most romantic job in Europe, Martens was a middle-aged divorcé who did not believe in fate. The scores of relationships he helped create, he said when we spoke last year, were “just lucky coincidences.” But that was before the magical oak changed his life, too, and created a happy ending to rival any fairy tale.
In 1984, when Martens first took up the role, the Berlin Wall still separated West Germany (where the Bridegroom’s Oak grew) from the country’s Communist East. The mailman’s personal life had split down the middle too, when his marriage fizzled out and he found himself alone, with shared custody of his 12-year-old son. “I was fed up with women back then,” he said, and had sworn off dating. Sometimes Martens found his love-letter duties tiresome. People assumed the Bridegroom’s Oak was his only stop, he complained, but the tree was part of a challenging delivery route controlled by Deutsche Bundespost, the mail service that employed him. By noon the tourists would be waiting, he half-joked, to “steal my time.”
The magical tree drew tourists and fans of German folklore, in which forests are overrun with lonely princesses, magical spells, and romance (Disneyland’s castle is based on a Bavarian palace). Martens, who speaks in Low German, the blue-collar dialect of the country’s lowlands, was ordered by his superiors to educate the tourists. His ancient tongue added a certain authenticity to a story that sounds like other tales from the German forests, such as “Snow White” and “Little Red Riding Hood.”
“Once upon a time, there was a son of a prince,” Martens began. “He was left in this forest and no one cared about him until a very beautiful girl rescued him. And because he was so grateful to her, he planted a tree.” That seedling, he said, grew into a mighty, 82-foot-tall oak.
“That’s the short version,” Martens told me as we trudged through the forest late last year, kicking up leaves.
The story of how the tree became known for matchmaking is a little longer, he explained. In 1890, a chocolate maker from nearby Leipzig fell in love with the forester’s daughter, but her father forbade the relationship. Instead, the two lovers left each other notes in the knothole of the oak tree. Eventually, the girl’s father had a change of heart. He threw a wedding ceremony where his daughter’s love had bloomed. There, in the shadow of the branches, the bride and groom kissed, and the tree found its name. It was after that, Martens said, that other love letters started to arrive.
By 1927 the Bridegroom’s Oak was overwhelmed with mail. The post office made the unusual decision to give the tree its own mailing address. Deutsche Bundespost even erected a 10-foot-tall ladder up to the mailbox, to help people reach in to open, read, and respond to love letters at senders’ provided return addresses. The only rule, Martens told me sternly, is that if you open a letter and don’t respond, you must place it back in the tree for someone else to find. He added that young women believe that if they walk around the tree three times under a full moon while thinking of their beloved, they “will be married within the year.”
Over the years, scores of sweethearts who were united by the tree have carved their initials into its branches, and the tree wears these scars as evidence of its powers. This litany of happy couples includes an American girl and the English army officer she met by writing to the oak. They moved to Scotland to be together, according to newspapers. Also engraved in the trunk are the initials of a young lady who was too shy to write to the tree, but found love after her friends wrote on her behalf. She married a German soldier.
Courtesy of Karl-Heinz Martens
When Martens was running late or found himself in no mood to tell a fairy tale, he photocopied the legend and handed it out. But as the tree’s popularity increased, the mailman soon found himself talking to radio and television reporters, whose stories would prompt even more people to write. “I usually came here with a handful of letters, about five each day,” he told me. “When the press was here and did a story on the tree, then you would have about 50 letters a day.” He remembers just a few days when the oak received no letters, he said. “I can count on two hands the days I haven’t been here, except for weekends and holidays.”
Though public speaking was difficult at first, with daily practice Martens started to relish sharing the story of the tree. “I have always regarded this task as a great honor,” Martens said. “I was picked for the job because I had a talent for chattering. I have a French mother,” he added, by way of explanation. And so begins a story of an unbelievable coincidence, and the first time Martens’s life was turned upside down by a letter out of the blue.
Martens’s mother, Yvette, was a teenager during the Second World War. She spent her days hanging around her parents’ laundromat in France, where they cleaned and starched the uniforms of the German army. One day, she caught the eye of a sergeant major. “Three beautiful young girls were running around and he picked the youngest and said, ‘That’s the one,’” Martens said. “And that’s my mother.” She was just 17 when he was born, Martens told me, and she named him after his parachutist father. By the end of the war, Karl-Heinz Sr. was missing, presumed dead.
Miraculously, his father resurfaced some months later in a military hospital in Italy. He was transferred to his hometown, Flensburg, where he recovered from his injuries. Yvette brought Martens to Germany as an infant to reunite him with his father, but she was so homesick that she yearned to return to France. Martens’s grandparents insisted that the baby remain in Germany. He had a cold and was too sick to make the journey by train, they said. Yvette, just a child herself, agreed, and left Martens to be raised by his father. Growing up with a stepmother, he only found out about his real mother in France when he was 12 or 13, and had no way of finding her.
“My stepmother used to work at the telecommunications office and my father worked at the post office,” Martens recalled. In 1961 he followed his father into the mail industry, taking a job at the post office, where he sorted mail and returned lost letters to their sender. One day, when Martens was about 25, a letter came across his desk addressed to him at his grandparents’ old house. They had long since moved out, and when he saw the sender’s name, Martens said he was “baff”—the German word for dumbstruck. He rushed the letter to his boss. “This letter,” he said, “is from my mother.” He needed to open it, he begged, knowing that to do so was a mortal sin for a postal worker. “Alright,” his supervisor said, “you can open the letter with me as a witness.”
With shaking hands, Martens read the note. His real mother was alive and well. he French army was searching for him as a deserter, she wrote, and urged him to meet her in France. It was a lot to take in. When Martens told his father, he turned cold. “Well, you know what you have here,” his father warned. “You don’t know what it will be like down there.” But Martens fired up his Volkswagen Beetle. I asked how he felt as he drove to the French border. It was summer, he said, and the Beetle’s engine is in the back, so the cabin felt like a sauna. No, I asked, how did you feel about the meeting?
“Excuse me,” he said. “What would you feel like if you were meeting your mother for the first time?”
When he met his mother at the border, she was with her husband and her brother. During the few days they spent together, Martens said he felt like they had never parted. His mother’s husband was a French cook and his meals were “top-class,” Martens said. It all started to make sense: He had always enjoyed French food and culture, and soon he identified in his nature a quirky sense of humor that was entirely French. Slowly, Martens and his mother rebuilt their relationship. He visited her up to five times a year, or whenever he could take time off work. And he never forgot that it was all thanks to a lucky letter.
During the 1960s, Deutsche Bundespost underwent a major modernization. A new program for the sorting of letters reduced the service’s number of letter centers from 3,600 to just 350, and in 1967 Martens was relocated from his job in Kappeln to another in Kiel. Then, in 1972, when his son, Olaf, was born, he moved to his girlfriend’s birthplace, Eutin. They married, but their relationship began to crumble, he said. Their divorce was straightforward and drama-free. After they signed the papers they enjoyed a meal with their son, as if to say, We will always be your parents. Martens took custody of Maica, the family’s jet-black mutt, whom they’d lovingly named after a brand of sausage. When I asked whether Maica ever joined Martens on his rounds, the former mailman was appalled. That would be verboten, he said.
Martens was 38 when he started delivering mail to the Bridegroom’s Oak. The delivery route was not desirable. Previous mailmen, mostly bachelors, complained about the mile-long detour. Ernst Pries, who was the messenger of love in the 1950s and ’60s, told The Boston Globe: “I wasn’t very thrilled at first about having to go out of my way to deposit what I thought were stupid letters.”
Martens had no time for affairs of the heart either. He grew up in Flensburg, the no-nonsense town near Denmark where his father was born, home to the German Department of Motor Vehicles and its point system for punishing unruly motorists. Martens always felt destined for a job in the public sector, and believed that delivering love letters was his civic duty. You could set your watch by Martens’s arrival at the Bridegroom’s Oak.
Germany’s present-day mail service is a testament to the country’s efficiency. The service is famously fast, and 94 percent of letters reach their recipient the next working day. By the time Martens started delivering letters to the Bridegroom’s Oak in 1984, he was one of 543,200 Deutsche Bundespost employees; the West German post office had more manpower than the national army and was just as regimented. One dedicated mailman in Munich once discovered a quicker route between postal depots, but was hauled before a judge and faced criminal charges for not following protocol.
Deutsche Post, the mail service on the other side of the Berlin Wall, was quite the opposite. The East German secret service, the Stasi, regularly ransacked packages for cash and valuables, while economic problems made for a sketchy service starved of raw materials. Still, letters from people in East Germany hoping to make contact with the West found their way to the Bridegroom’s Oak. “I wanted to write back,” Martens said, “but my boss recommended me not to.”
“I can’t answer every question. If they were asking what cars were driven here, I can’t write back, ‘BMW.’” He said women asked about nylon tights. “I didn’t have any idea about that. Who am I?” Martens scoffed. “I would just send them a pre-written letter back,” he said curtly. The photocopied page he sent comprised a biography of the tree and some interesting facts.
In 1988, Martens delivered a letter to the tree bearing the postmark of Bad Salzungen, one of East Germany’s oldest saltwater spa towns. The letter was mailed by a lonely 19-year-old nurse named Claudia. She spent her evenings alone, clandestinely tuned in to West German television stations, looking for entertainment. When she saw a news item about the Bridegroom’s Oak, her heart filled with excitement. “At the end, the address of the tree faded in,” she told me. Claudia picked up her pen and scribbled down: “Dodau 99 Dodau Forsthaus, 23701 Eutin, Germany.”
Shortly after Martens delivered her letter, it was discovered by a 36-year-old farmer’s son. Friedrich Christiansen was an agricultural-machine technician who lived in Malente in West Germany, just a short drive from the forest. Tired of striking out with local girls at farmers’ dances, he was intrigued when his mother spoke of the tree of love. One day he wandered into the forest and peered into the knothole. When he read Claudia’s hopeful letter, he thought she sounded like a perfect match. “I liked her handwriting,” he told me.
Their letters grew in passion and promise, but politics prevented Friedrich and Claudia from forging a relationship from opposite sides of the border. Like the chocolatier’s son and the forester’s daughter who first discovered the Bridegroom’s Oak, they exchanged love letters and prayed that their circumstances might change. One day, after much frustration, the farmer purchased a map to find out where Claudia lived—he had to see her in the flesh. Information was scant about the other side, and some German maps were printed with large blank sections. He nervously headed for the border.
At the checkpoint, he lied to the guards. He told them he was visiting a cousin. But he was secretly headed to a rendezvous about 100 miles northeast of Frankfurt, where he and Claudia finally embraced. “She had a moped!” Friedrich said. Despite having only one brief meeting, by the summer of 1989 they were engaged.
Left: Martens visits the tree today (Jeff Maysh); Right: A younger Martens poses for an undated photo at the oak during his rounds (Courtesy of Karl-Heinz Martens)
Witnessing romances like this one blossom started to thaw Martens’s cold heart. He tried to date, he admitted, but the dating pool in a town of 20,000 was so small that it made romance awkward. No one ever seemed to be “the one,” he told me. His life revolved around delivering the mail on time, taking Maica on long walks, and social events at the local sports club. Martens was proudly self-reliant and didn’t need a wife. Visitors to his spotless apartment couldn’t believe a woman didn’t live there, he said.
Like Martens, Karin Grüttemeier did not believe in fate. Karin lived in Hörstel near the Dutch border and had heard about the Bridegroom’s Oak years ago, but never thought she’d write to it. Then one Christmas her husband died. For the first time in years, she felt so alone. “I wasn’t feeling very well back then,” Karin told me. She tried to enjoy her summer holidays in the Bavarian Forest, and while she was there she was reminded of the matchmaking tree. Could the Bridegroom’s Oak help her find love again? “I’m gonna send a letter there,” she decided one day in the late 1980s.
Around that time, Hans Peter Gerörde was visiting Germany’s Baltic coast to tell his aunt some difficult news. His marriage was over, and a divorce loomed. When the aunt suggested he visit the Bridegroom’s Oak, Hans Peter also thought the magical tree was worth a try. One afternoon, after Martens had delivered the morning’s letters, Hans Peter pulled from the knothole the note from Karin, the widower from Hörstel. He wrote a reply the same day. Just weeks later, they were in each other’s arms. The tree had struck again. It was, Karin said, “love at first sight.”
Martens heard that phrase a lot over the years. He told me about another gentleman who arrived in Eutin for treatment at a health resort. When the weather turned too cold to enjoy the Baltic coastline, he took a trip inland instead. He found himself at the Bridegroom’s Oak, with his hand in the knothole. The letter he found, Martens said, was from a woman who lived just a few miles from his home, hundreds of miles away in Ruhr, near Dortmund. Naturally, they met, fell in love, and married, Martens said.
Martens was never invited to the weddings, but that didn’t bother him. He watched the oak’s leaves turn brown, then green, and brown again. His dark beard became gray. Tensions between East and West Germany thawed. And the footsteps of the lonely young women who traced a path around the tree wore away at the forest floor, already compressed from decades of tourist traffic. To preserve the tree, foresters erected a fence around it, and only Martens’s mail truck was allowed to drive up to the ladder. Letter seekers had to arrive on foot.
Then one day, as Martens climbed the wooden steps for maybe the thousandth time, he reached into his mailbag and noticed an unusual letter.
It was addressed to him.
The sender was Renate Heinz, a wine merchant in her late 50s. Renate was divorced, with an adult son from her marriage to a policeman. She was career-focused and liked to spend her free time in front of the television. It was there that she saw a news item on the Bridegroom’s Oak, and an interview with the mailman, Karl-Heinz Martens. “I sat in front of the TV and immediately felt a connection with him,” she told me. Renate recalled that when Martens announced he was single, she turned to her son and said: “I’ll change that!”
Though she had never done anything like it, Renate felt the urge to scribble a note on the back of her business card and mail it off to the Bridegroom’s Oak. When Martens read it, he was captivated by the straight-talking message, which simply read: “I want to get to know you!” When he noticed that the sender was from Saarbrücken, which he knew to be near the French border, it all started to make sense.
That fits, Martens thought: She was practically French. “That’s the reason I got in touch,” he said. “I called her. I’m too lazy to write.” Soon they were talking on the telephone for hours at a time.
“I had quite the phone bill,” he said.
“One day he sent me a photo of his dog,” Renate said. When she saw Maica staring out of the photograph, she was smitten. Before long, she and Martens were talking about a meeting.
“I didn’t know Saarbrücken, but France was close,” Martens said. He was due to visit his mother, and he thought he could visit Renate on the way. The meeting was, he told himself, “nonbinding.” If I don’t like her, he thought, I’ll just get back in the car.
When Martens told a friend at the sports club about his blind date, she was surprised. “Well, you have to know what you’re doing,” she said. Martens wasn’t nervous. He explained that in telling the legend of the tree to strangers every day, he’d gained a unique confidence. And anyway, he had done this before. A strange letter had arrived out of the blue, and he’d driven to France to meet a woman, not knowing what to expect. So one Saturday morning, he opened his car door and let Maica hop in. Then he sat behind the wheel and started the engine.
Saarbrücken is a large baroque town split in half by the Saar river and sutured together by a dozen brick and stone bridges. When Martens arrived that afternoon, he worried about how he would find Renate. “I didn’t know the city,” he said. “So she had to guide me somewhere; we didn’t have smartphones back then.” Renate had given him directions to a parking lot, and there he saw a woman standing alone. She wore a summer dress and had short, dark-blond hair. It had to be her. She was so friendly and charming that any awkwardness melted away.
“We liked each other!” Martens recalled. “Maica of course also had a great connection” with Renate, he added. And Renate later admitted to a newspaper: “I fell in love with Maica straight away too.” The date went so well that Martens spent “a couple of days” in her apartment, he told me. “The first date lasted two days?” I asked. “We had been calling each other for weeks before that. We weren’t strangers anymore,” Martens explained. But that wasn’t the end of it. He still had to see his mother. And he didn’t want to leave Renate.
Martens and Renate embrace after marrying in 1990 (Courtesy of Karl-Heinz Martens)
“I had to warn my mother that I wasn’t coming alone,” Martens said. Soon, Renate and Maica were in the car, and they were speeding out of Saarbrücken to meet his mother in France. On their first date.
At the time, other unexpected developments rocked Germany. In 1989, following the surprise downfall of the German Democratic Republic, the Berlin Wall tumbled and Germany reunified. Friedrich and Claudia, the couple who had exchanged letters for nearly two years across the border, were now able to marry, and tied the knot in May of 1990. Around then, after a short romance, Renate agreed to move in with Martens in Eutin. This didn’t seem crazy, she said. “If you got to know each other via the Bridegroom’s Oak, it’s different than with someone you meet in a disco.”
Renate and Martens shared a love for fine dining. Renate worked as a verkosterin—a taster—and she sold fine wine, especially reds. In the evenings, Renate would bring home a special bottle from work and treat Martens to a robust red from Argentina or South Africa. He liked everything about her, he told me. They called each other schatz—“sweetheart.”
One day, they were drinking beer at his favorite restaurant, Tönnchen, when out of the blue Martens said: “Actually, we could get married.” He said it so casually, as if the idea had just come to him. Renate was thrilled. They ordered another round of beer to celebrate.
In 1994, they exchanged rings in Eutin’s town hall. “We didn’t marry in a church; we aren’t religious,” Martens said. He decided to marry her after five years, he said, because she was “the one.” After the ceremony they were “ordered” to the tree by friends who had prepared a surprise buffet under the branches. Later, they partied at Tönnchen, where postal workers packed the dance floor.
The local newspaper called it the hochzeit des jahres—the “wedding of the year.”
About 65 million years ago, shortly after the time of the dinosaurs, a new critter popped up on the evolutionary scene. This “scampering animal,” as researchers described it, was likely small, ate bugs, and had a furry tail. It looked, according to artistic renderings, like an especially aggressive New York City rat. And it had a placenta, an organ that grows deep into the maternal body in order to nourish the fetus during pregnancy.
The rodentlike thing would become the common ancestor of the world’s placental mammals, with descendants that include whales, bats, dogs, and humans, among many other species. And today, the placenta might hold the key to one of the most enduring mysteries in human medicine: Why do women suffer much higher rates of autoimmune disease than men do?
Autoimmune diseases turn people’s own immune systems against their bodies. In the United States alone, women represent 80 percent of all cases of autoimmune disease. Women are 16 times more likely than men to get Sjogren’s syndrome, in which the immune system goes after the glands that make tears and saliva, and nine times more likely to have Hashimoto’s thyroiditis, in which it sets it sights on the thyroid. Sjogren’s forced Venus Williams to drop out of the U.S. Open in 2011. The singer Selena Gomez underwent a kidney transplant after suffering complications from lupus, which is eight times more common in women.
Some scientists now think the placenta itself might be the reason why women are so disproportionately affected. In a paper published last week in the journal Trends in Genetics, Melissa Wilson, an evolutionary biologist, along with her colleagues from Arizona State University, put forward an explanation called the “pregnancy-compensation hypothesis.” It suggests that women’s immune systems are engaged in a fierce tug of war with placentas, even when the organs aren’t actually present.
Here’s how the theory goes: Women—and all other placental mammals—evolved such that they would be pregnant for many of their adult years. Before the advent of birth control, that was pretty much the fate of the female sex. In modern hunter-gatherer populations, Wilson told me, it’s not uncommon for women to have eight to 12 children each.
Though bearing so many babies might sound grueling, women’s bodies evolved to cope. When the placenta grows during pregnancy, the organ sends signals to the mother’s immune system to change its activity so that the mother’s body doesn’t eject the placenta and the fetus. This might even mean turning down the immune system in some ways, or for some periods of time. If the immune system gets turned down too much, though, it risks leaving women sensitive to pathogens, which would also be bad for the fetus. So instead, the mother’s immune system ramps up in other ways throughout adulthood, Wilson and her colleagues think, so as to remain vigilant against germs even when some of its parts become dormant during pregnancies.
Things get complicated, however, when those pregnancies don’t actually occur. Women today tend to have far fewer children—less than two on average in the United States, according to the CDC. Wilson reasons that without a more or less constant pushback from placentas during pregnancies—the pushback that women’s immune systems have evolved to anticipate—the immune system can get too aggressive, too ramped up. It starts looking for things to attack that aren’t dangerous, which is how autoimmune diseases set in.
For millions of years, minus the past hundred, “the immune system was expecting to have exposure to a placenta,” Wilson says. Imagine if you’re pulling on something heavy, and then the rope snaps. “If you suddenly don’t have that heavy thing anymore,” she says, “you’re gonna go off the moon.”
This is certainly not the first theory for why women suffer from more autoimmune disease than men do. One has to do with a protein called BAFF; another has to do with the fact that women have two X chromosomes instead of one. The way Wilson sees it, the pregnancy-compensation hypothesis synthesizes many of the previous theories into one and provides the evolutionary explanation behind them. “They were all right,” she says. “But everyone was looking under their own streetlight, and we just waited for it to be daytime.”
Wilson says that so far, no one has come forward to attack her for being wrong, despite the seeming boldness of this theory. Several experts I spoke with—even those who have competing theories for the sex difference in autoimmune disease—say Wilson’s theory might fit with what we already know. “I would say there’s not one theory that explains all [autoimmune diseases],” says Nikolaos Patsopoulos, an assistant professor of neurology at Brigham and Women’s Hospital. “This isn’t Lord of the Rings.” Still, he says, “This theory puts together a lot of things we know that are true and some that we’re still trying to understand.”
Johann E. Gudjonsson, a professor of skin molecular immunology at the University of Michigan, found that women have more of a molecular switch called VGLL3 in their skin than men do, and that all this VGLL3 might be what causes a heightened immune response in women. In this case, then, the VGLL3 might be how the body ramps up the immune system, but the pregnancy-compensation hypothesis might be why it does so.
Similarly, Hal Scofield, a professor of pathology and medicine at the University of Oklahoma, says that it appears there are lots of genes involved in the immune response on the X chromosome, and since women have two X chromosomes while men have only one, women have more of those immune genes. The placental theory that Wilson’s team devised could be the reason this happens. Because women have to have strong immune systems that buck against the placenta, they evolved to produce more genes involved in the immune response. “I don’t think there’s any way out of thinking that placental pregnancy has to have influenced the evolutionary immune system,” Scofield told me.
Not everyone I reached was impressed by the paper. David Hafler, a professor of neurology at the Yale School of Medicine, told me, “ideas are cheap. It’s data which is hard to get.” In other words, sure, the pregnancy-compensation hypothesis is an interesting idea, but it still has to be tested first.
Wilson says there are opportunities to do just that. Scientists could try to determine whether the number of pregnancies a woman has is predictive of her risk of autoimmune disease. If Wilson’s theory holds, women who have more pregnancies should have a lower risk. Or scientists could study the differences between mammals in the wild and zoo animals, which are sometimes on birth control, to determine whether they have differences in their autoimmune function.
Some people might take Wilson’s findings to mean that women should simply be pregnant all the time, but that’s far from the takeaway here. Pregnancy, after all, also carries major health risks, and not all women want to have 12 kids. And Wilson’s findings suggest that women’s extra-strong immune systems might protect them in some cases. Women are less likely than men to get certain kinds of nonreproductive cancers, for example.
Wilson says that the hope is to eventually learn what it is in the immune system that’s trying to respond to the placenta, and to target that thing with vaccines or treatments. More research could mean major improvements in the way women’s autoimmune diseases are treated. “I’ve never been more excited about an idea than I am about this,” Wilson told me. “This is the first time that I can see my work having a direct impact in the next 10 years on human health.”
Paul and Hava met at a performing-arts social event for people with intellectual disabilities. With the assistance of their parents, they went on a few successful dates. The connection was immediate. After some time, they decided to make their strong, loving bond official. The couple made each other so happy that their parents saw no good reason to deny the proposal.
The group homes where Paul and Hava lived, however, stood in the way of the couple’s union. “They want us not to get married—not to live together,” says Paul in a new short documentary. Prohibited from cohabiting, Paul and Hava struggled to maintain their marriage while living apart. They decide to file a lawsuit against their respective group homes.
In the film, Consuelo Senior, a sex educator at the YAI National Institute for People With Disabilities, says group homes are hesitant to address the issue of sexuality because of the liability associated with matters of consent. New York, where Paul and Hava live, has one of the most restrictive and conservative legal standards for sexual-consent capacity. These standards have been developed, refined, and codified through court decisions; there is no consensus among professionals.
Can Paul and Hava legally prove they can consent to their sexual relationship, thereby earning the right to live together?
One morning in 1934, panicked passengers jumped from the deck of the SS Morro Castle as it sank just off the coast of New Jersey. The ocean liner had caught fire, and the passengers had rushed to grab personal flotation devices. But some improperly wrapped the life preservers around their necks. As they fell and hit the water, the torque snapped some some of their spines.
Personal flotation devices save exponentially more lives than they cost. Of the catastrophic boating accidents that occur daily, 84 percent of people who drown were not wearing one. But etch the details of this horrific wreck scene into one’s mind, and a person might become a life-preserver skeptic. Our basic tendency toward short-term thinking means we judge risk based on whatever is in front of us. We draw anxiety disproportionately from wherever we happen to be focusing our attention.
The same psychology applies throughout public health. At the moment, much attention in the U.S. is being paid to vaccines—rather than the diseases they prevent. This week, the actor Jessica Biel drew fiery eyes for lobbying legislators in California to kill a bill that would standardize the process of exempting children from required vaccinations. Biel, perhaps best known for her leading role in 2006’s The Illusionist, expressed concern for the well-being of a friend’s child. She has responded to accusations of being “anti-vax” by contending in an Instagram post that she “believes in vaccinations,” but wants to protect personal freedom: “I believe in giving doctors and the families they treat the ability to decide what’s best for their patients.”
Like life preservers and everything else, vaccines do come with some fleeting risk of unintended adverse outcomes: mostly rashes or fevers, and in extremely rare cases, seizures. But these risks pale in comparison with those of the diseases vaccines prevent. Before the advent of vaccination, measles alone killed some 6,000 children in the United States every year.
This year has already seen more measles cases than any other since the disease was declared eliminated two decades ago. The trend stems from low rates of vaccination, which are making exemptions from vaccine requirements a flash point. California has triggered a reckoning with why exemptions exist at all—and why belief came to factor so heavily into a question of science. When is a health issue a matter of belief, and when is it simply wrong? When is it so wrong that it’s neglect?
No federal law requires vaccination. But every state mandates that in order to send a child to public school—to have that child sit in close quarters with other children all day, every day—parents must take preventive measures to ensure the child does not carry certain dangerous infections. Requirements are implicit in the legal precedent that withholding vaccination constitutes “medical neglect” of a child. Legally, for example, it’s considered neglect to let a cut on a child’s arm get infected and then refuse antibiotics. If that infection had been airborne, as with measles, declining treatment as a child gasps for air would also be textbook neglect. It has been deemed neglect in cases where infectious diseases could have been easily prevented, but weren’t.
Researchers at Ohio State recently reviewed cases across the country from 1905 to 2016 and found that a majority of the time, refusing vaccination was found to be neglect. There was a curious caveat, though. In states with “religious exemptions,” parents did not have to follow public-health mandates to vaccinate their children against measles and other diseases if the parents cited “genuine and sincere religious beliefs.” The Ohio State researchers found that in these states, vaccine refusal did not constitute neglect—or it was considered neglect only if someone’s belief was deemed insufficiently “sincere.”
Religious exemptions have slowly expanded in the United States, to the point that now, in almost every state, parents can opt out of school requirements—and leave a child open to catching and spreading lethal disease to other children—if doing so is guided by what the state considers a sincere belief. In such cases, the same behavior is not neglect.
Exemptions have expanded to include “personal or philosophical belief” exemptions, as well, which are currently offered in 17 states. When the standard is sincerity of belief, the thinking goes, it shouldn’t have to be drawn from a major religion (or even a minor one).
Accordingly, the number of people taking up belief-based exemptions has been steadily increasing, and rates of vaccination declining. The constitutionality of vaccine requirements is well established, and courts have found states are not obligated to grant religious exemptions. Nevertheless, the overall effect of such respect for the concept of personal belief has been that, gradually, vaccine requirements have become requirements in name only.
The return of measles, though, is forcing a breaking point. In 2015, a measles outbreak was traced back to a single child at Disneyland. California state health officials saw that the outbreak happened not simply because of one unvaccinated child, but because only 90 percent of kindergarteners in the state were fully immunized. To establish herd immunity for measles, a community needs 94 percent of people on board.
This led the state to pass a law that eliminated personal-belief exemptions, making California the first state in recent history to do so, and only the third state in total. (Mississippi did so 35 years ago, and West Virginia never had such exemptions.) The crackdown seemed to work. By last year, kindergarten vaccination rates for the 10 required diseases were up to 95 percent.
California is serving as a model of what could play out across the country—and a microcosm of other debates about science and belief. Several states now have bills in place to repeal non-medical exemptions. Last month, Maine repealed the personal-belief loophole and is currently considering a ban on religious exemptions, as is Connecticut. In New York, in the wake of hundreds of people contracting measles, Democratic lawmakers proposed a bill in May to make their state the fourth to ban religious exemptions. Republican Representative Anne Dauphinais told the AP in response that the religious exemption “is one thing you just don’t mess with.” But the move polled at an overwhelming 84-percent support, across religious lines. The bill passed on Thursday.
Such moves stand to create a novel problem, though, and a test for the medical profession. There is still one way to get an exemption from required vaccinations: from a doctor. Indeed, there are some immune disorders and other rare scenarios where a child cannot is not medically able to receive a vaccination, and so has no choice but to rely on herd immunity to be protected. But in the last two years, California has recently seen such medical exemptions triple. This has been accompanied by some doctors being identified as purveyors of exemptions, sometimes specifically marketing the service.
Public-health officials have taken this to mean there is need for standardization of the process. The new bill, which Biel is protesting, would help the state identify practitioners who were writing dubious exemptions by having schools notify state health officials in suspicious cases. Patterns of invalid exemptions could be traced to certain providers, who could be penalized or educated as necessary to keep the state’s herd immunity strong.
Overseeing standards of practice for doctors is not a novel concept. In the wake of the opioid epidemic and overuse of antibiotics, many health advocates believe oversight should happen more readily—if only to identify serious outliers. This could at least help ensure that no doctor is running an exemption mill, a phenomenon that does tend to happen whenever doctors in a private health-care system become the sole gatekeepers for various allowances or services. This has been an issue in cases like the psychiatric diagnoses that grant kids extra time on standardized tests, or the prescriptions that allow people legal access to marijuana or opioids. (In 2012, I got a medical-marijuana card on Venice Beach by paying $100 in cash to spend five minutes with a doctor. On the wall was a poster with a list of things I could say were bothering me that would warrant marijuana access. This was clearly not the spirit of the law.)
Biel’s lobbying is against this sort of oversight that would prevent similar suspicious practices by doctors. The actor is stepping in to influence policy that could worsen outbreaks like measles because, as best she has publicly stated, it is what she believes. (Biel did not immediately respond to request for further comment.)
In communal undertakings like eradicating infectious disease, the role of personal belief is limited—but not zero. It is exercised through a democratic process where elected officials (and their appointees) implement policies that keep communities safe and well. If public-health officials steer communities wrong, people rally and vote accordingly. The system falls apart, though, when individuals simply declare themselves exempt.
Are you a code sensei? A customer-service rock star? Do you have a passion for sales? Will you devote your life to conference calls, leaving your family and friends behind while you camp out under your desk, ready to dial in at any time?
If the answer to all of those questions is “no”—or even a nervous, hesitant smile—then hopefully you don’t need to look for a new job anytime soon. If you do, get ready to convince prospective employers that you are a success-obsessed results ninja, whatever that means.
A generation ago, American job seekers might have opened a newspaper to find want ads with perfunctory explanations of desired skills, like carpentry or customer service. Classifieds, after all, contain little room for florid prose. But in the last two decades, a changing labor market, combined with the internet’s ability to make things functionally more efficient but existentially far worse, has dramatically transformed how American companies recruit prospective employees. The result is the obnoxious state of the modern job listing, which is often short on details and long on silly demands.
Although this trend has some roots in start-up culture, it has spread to virtually all American industries and far beyond the bounds of urban office work. Alley, a co-working space in New York, seeks a social-media and marketing manager at the co-working company who is “one part visionary, one part online warrior, one part pop-culture guru, a dash of precocious energy, mixed with a little lyrical whimsey, and served with a shot of espresso.” A listing for an Atlanta-based “customer support hero” at the software company Autodesk wants to hear from you if you’re “a ninja with your keyboard” who has “a passion for incredible customer service.”
For some employers, even elite warrior skills aren’t enough. “If a sense of humor isn’t your sixth sense, then even certified marketing ninjas need not apply,” asserts the description for a marketing director at an upstate New York paper company.
These listings weren’t hard to find. A short scroll through a popular job board returned thousands of results with similar keywords. More than ever, it seems, hiring managers are looking for extremists: You can’t just be willing to do the job. You must evince an all-consuming horniness for menial corporate tasks. In an American labor market where wages are stagnant and many workers feel their jobs seeping into their personal time, such demands only create even more anxiety and dread for Americans looking for a new gig.
According to Peter Cappelli, the director of the Wharton School’s Center for Human Resources at the University of Pennsylvania, modern job listings tend to perpetuate the myth that only slavishly devoted employees are valuable. But this notion often makes workplaces worse, he says: “[Hiring managers] are not thinking much about the culture of organizations. Folks are stuck in this idea of just wanting a bunch of ‘A’ players or the really great individual performers.”
Dauntingly vague language can actually fail to net the ultra-dedicated candidates employers are trying to attract, Cappelli notes. Asking someone if they’re obsessed or passionate is unlikely to extract any useful information to evaluate an applicant. “It’s not as if someone is going to say, ‘No, I’m sorry, I really don’t care about this at all,’” he says.
Companies that use these job descriptors sometimes realize they might sound odd. But some companies contend that the language is crucial for team culture, not ignorant of it. “The ‘Customer Service Hero’ job title isn’t to standout from other companies, it’s not clickbait for talent,” Shaya Fidel, who works in human resources at Autodesk, told me over email. “When we first created the ‘Hero’ position, we wanted the job title to reinforce that customer support is the lifeblood of everything we do.”
Samantha Intagliata, Alley’s director of marketing, told me the old way just wouldn’t be appropriate: “We believe if we went the traditional route of just listing out skills and experience, it wouldn’t represent who we are as a company or the individuals who work for us.”
If creative language is in fact a window into a company’s culture, the tireless-ninja mindset still might hurt some workers more than others, though. “You wind up with a combination of a gender skew and an age skew when you use these fanciful terms,” says Ian Siegel, the CEO of the online job marketplace ZipRecruiter. Older, more experienced professionals are generally turned off by employers looking for extremists, as are parents. “You’re going to get mostly young men,” Siegel says.
At the farthest end, building a team made up exclusively of wild-eyed work fanatics isn’t exactly a sound managerial practice, either. “What research shows is that many things at the extreme are actually not good for performance,” says Connie Wanberg, an industrial and organizational psychologist at the at the University of Minnesota’s Carlson School of Management. Extreme personalities can be difficult to manage or integrate into the varied elements of workplace culture. Applicants usually need to be good collaborators or team players in addition to skilled ninjas, Wanberg says.
Siegel points out that the hypercharged language is also poorly suited to the digital nature of most modern job searching, where 70 percent of résumés submitted via online job listings or uploaded to job boards are going to be screened by algorithms looking for keywords. “When you say ‘coding ninja,’ you’re not going to match against ‘java developer.’ If you say ‘spreadsheet guru,’ you’re going to miss the people with ‘Excel expertise.’”
These mismatches have frustrated Wanberg in her research with job seekers. “They’ll apply for jobs and go to the interview, and it has nothing to do with what the job ad was about, so they waste their time on pursuing an opportunity that’s not really right,” she explains. “That’s a waste of time for the company as well.”
To explain how job hunting got so bad for all involved, Cappelli identifies a trend that started long before the internet took over the process of looking for work: the gutting of corporate human-resources departments, which he says has been underway for about a generation. “After the Great Recession, a chimpanzee could have hired well,” he explains. “You just hinted you had a job and there was a queue of overqualified people begging you to hire them.” Now that labor supplies are more constrained, employers have to work harder to find potential employees, but the process is often run by hiring managers with little HR training. The listings hang around a little bit longer and sound a little bit more desperate.
Overall, the nature of the American career has changed significantly in the last generation, Cappelli says: “In the days of the Great Corporation, about 10 percent of vacancies were filled externally, and those were mostly entry-level jobs from college recruiting. Everything after that was promotion from within. Now, we fill about two-thirds of vacancies from the outside.” Hiring managers are competing in what Siegel called a “war” for the best talent, and they’re hiring for more types of positions within their institutions than any of their predecessors ever had to.
Siegel says he understands that employers are trying to stand out by being cutesy. He advises employers to go instead with more technically precise language in their job descriptions and focus their creativity on describing the workplace itself. “It’s an opportunity to say, ‘We’re a family-oriented business, walking distance to many restaurants, a pet-friendly office,’” he says.
Of course, to brag about being a great employer, it helps to be one. Siegel sees plenty of resistance to offering things applicants might actually want—namely, money and flexibility. In a survey ZipRecruiter conducted last year, he says, most employers said they were focusing all their recruiting efforts on job listings themselves. “Instead of doing things like lowering the skills required or improving the pay, it was all about how much they were spending on more job boards or more recruiting solutions,” Siegel says. “There was a real resistance to responding to the market that was telling you that if you want to get good talent, you have to improve your offer.”
In other words, few people seem to want to do the duties of a rock star if they’re not going to get paid like one.
I was standing two feet away when my 74-year-old father slugged an emergency-room doctor who was trying to get a blood-pressure cuff around his arm. I wasn’t totally surprised: An accomplished scientist who was sharp as a tack right to the end, my father had nothing but disdain for the entire U.S. health-care system, which he believed piled on tests and treatments intended to benefit its bottom line rather than his health. He typically limited himself to berating or rolling his eyes at the unlucky clinicians tasked with ministering to him, but more than once I could tell he was itching to escalate.
My father was what the medical literature traditionally labeled a “hateful patient,” a term since softened to “difficult patient.” Such patients are a small minority, but they consume a grossly disproportionate share of clinician attention. Nevertheless, most doctors and nurses learn to put up with them. The doctor my dad struck later apologized to me for not having shown more sensitivity in his cuff placement.
When he wasn’t in the hospital, my dad blew off checkups and ignored signs of sickness, only to reenter the health-care system via the emergency department. Once home again, he enthusiastically undermined whatever his doctors had tried to do for him, practically using the list of prohibited foods as a menu. He chain-smoked cigars (for good measure, he inhaled rather than puffed). He took his pills if and when he felt like it. By his late 60s, he’d been rewarded with an impressive rack of life-threatening ailments, including failing kidneys, emphysema, severe arrhythmia, and a series of chronic infections. Various high-tech feats by some of Boston’s best hospitals nevertheless kept him alive to the age of 76.
It was in his self-neglect, rather than his hostility, that my father found common cause with the tens of millions of American patients who collectively hobble our health-care system.
But lost in these discussions is, well, us. We ought to consider the possibility that if we exported Americans to those other countries, their systems might end up with our costs and outcomes. That although Americans (rightly, in my opinion) love the idea of Medicare for All, they would rebel at its reality. In other words, we need to ask: Could the problem with the American health-care system lie not only with the American system but with American patients?
One hint that patient behavior matters a lot is the tremendous variation in health outcomes among American states and even counties, despite the fact that they are all part of the same health-care system. A 2017 study published in JAMA Internal Medicine reported that 74 percent of the variation in life expectancy across counties is explained by health-related lifestyle factors such as inactivity and smoking, and by conditions associated with them, such as obesity and diabetes—which is to say, by patients themselves. If this is true across counties, it should be true across countries too. And indeed, many experts estimate that what providers do accounts for only 10 to 25 percent of life-expectancy improvements in a given country. What patients do seems to matter much more.
Somava Saha, a Boston-area physician who for more than 15 years practiced primary-care medicine and is now a vice president at the nonprofit Institute for Healthcare Improvement, told me that several unhealthy behaviors common among Americans (for example, a sedentary lifestyle) are partly rooted in cultural norms. Having worked on health-care projects around the world, she has concluded that a key motivator for healthy behavior is feeling integrated in a community where that behavior is commonplace. And sure enough, healthy community norms are particularly evident in certain places with strong outcome-to-cost ratios, like Sweden. Americans, with our relatively weak sense of community, are harder to influence. “We tend to see health as something that policy making or health-care systems ought to do for us,” she explained. To address the problem, Saha fostered health-boosting relationships within patient communities. She notes that patients in groups like these have been shown to have significantly better outcomes for an array of conditions, including diabetes and depression, than similar patients not in groups.
The absence of healthy community norms goes a long way toward explaining poor health outcomes, but it doesn’t fully account for the extent of American spending. To understand that, we must consider Americans’ fairly unusual belief that, when it comes to medical care, money is no object. A recent survey of 10,000 patients found that only 31 percent consider cost very important when making a health-care decision—versus 85 percent who feel this way about a doctor’s “compassion.” That’s one big reason the push for “value-based care,” which rewards providers who keep costs down while achieving good outcomes, is not going well: Attempts to cut back on expensive treatments are met with patient indignation.
For example, one cost-reduction measure used around the world is to exclude an expensive treatment from health coverage if it hasn’t been solidly proved effective, or is only slightly more effective than cheaper alternatives. But when American insurance companies try this approach, they invariably run into a buzz saw of public outrage. “Any patient here would object to not getting the best possible treatment, even if the benefit is measured not in extra years of life but in months,” says Gilberto Lopes, the associate director for global oncology at the University of Miami’s cancer center. Lopes has also practiced in Singapore, where his very first patient shocked him by refusing the moderately expensive but effective treatment he prescribed for her cancer—a choice that turns out to be common among patients in Singapore, who like to pass the money in their government-mandated health-care savings accounts on to their children.
Most experts agree that American patients are frequently overtreated, especially with regard to expensive tests that aren’t strictly needed. The standard explanation for this is that doctors and hospitals promote these tests to keep their income high. This notion likely contains some truth. But another big factor is patient preference. A study out of Johns Hopkins’s medical school found doctors’ two most common explanations for overtreatment to be patient demand and fear of malpractice suits—another particularly American concern.
In countless situations, such as blood tests that are mildly out of the normal range, the standard of care is “watchful waiting.” But compared with patients elsewhere, American patients are more likely to push their doctors to treat rather than watch and wait. A study published in the Journal of the American Board of Family Medicine suggested that American men with low-risk prostate cancer—the sort that usually doesn’t cause much trouble if left alone—tend to push for treatments that may have serious side effects while failing to improve outcomes. In most other countries, leaving such cancers alone is not the exception but the rule.
American patients similarly don’t like to be told that unexplained symptoms aren’t ominous enough to merit tests. Robert Joseph, a longtime ob‑gyn at three Boston-area hospital systems who last year became a medical director at a firm that runs clinical trials, says some of his patients used to come in demanding laparoscopic surgery to investigate abdominal pain that would almost certainly have gone away on its own. “I told them about the risks of the surgery, but I couldn’t talk them out of it, and if I refused, my liability was huge,” he says. Hospitals might question non-indicated and expensive surgeries, he adds, but saying the patient insisted is sometimes enough to close the case. Joseph, like many American doctors, also worried about getting a bad review from a patient who didn’t want to hear “no.” Such frustrations were a big reason he stopped practicing, he says.
In most of the world, what the doctor says still goes. “Doctors are more deified in other countries; patients follow orders,” says Josef Woodman, the CEO of Patients Beyond Borders, a consulting firm that researches international health care. He contrasts this with the attitude of his grown children in the U.S.: “They don’t trust doctors as far as they can throw them.” (For what it’s worth, patients in China may be even worse than American patients in this regard. According to one report, they spend an average of eight hours a week finding and sharing information online about their medical conditions and health-care experiences. Various observers have told me that Chinese patients wield that information like a club, bullying doctors into providing as many prescriptions as possible.)
American patients’ flagrant disregard for routine care is another problem. Take the failure to stick to prescribed drugs, one more bad behavior in which American patients lead the world. The estimated per capita cost of drug noncompliance is up to three times as high in the U.S. as in the European Union. And when Americans go to the doctor, they are more likely than people in other countries to head to expensive specialists. A British Medical Journal study found that U.S. patients end up with specialty referrals at more than twice the rate of U.K. patients. They also end up in the ER more often, at enormous cost. According to another study, this one of chronic migraine sufferers, 42 percent of U.S. respondents had visited an emergency department for their headaches, versus 14 percent of U.K. respondents.
Finally, the U.S. stands out as a place where death, even for the very aged, tends to be fought tooth and nail, and not cheaply. “In the U.K., Canada, and many other countries, death is seen as inevitable,” Somava Saha said. “In the U.S., death is seen as optional. When [people] become sick near the end of their lives, they have faith in what a heroic health-care system will accomplish for them.”
It makes sense that a wealthy nation with unhealthy lifestyles, little interest in preventive medicine, and expectations of limitless, top-notch specialist care would empower its health-care system to accommodate these preferences. It also makes sense that a health-care system that has thrived by throwing over-the-top care at patients has little incentive to push those same patients to embrace care that’s less flashy but may do more good. Medicare for All could provide that incentive by refusing to pay for unnecessarily expensive care, as Medicare does now—but can it prepare patients to start hearing “no” from their physicians?
Marveling at what other systems around the world do differently, without considering who they’re doing it for, is madness. The American health-care system has problems, yes, but those problems don’t merely harm Americans—they are caused by Americans.
This article appears in the July 2019 print edition with the headline “The Worst Patients in the World.”
After Maryam Henderson-Uloho was convicted of obstruction of justice, she was sentenced to 25 years in a Louisiana prison. Ultimately, she served 13 years—spending more than half of that time in solitary confinement. When she was released, she felt dehumanized.
“You see, in prison, you’re broken—mentally, emotionally, and physically,” Henderson-Uloho says in the short documentary Sister Hearts. “I didn’t know what to do. I was alone. I was scared. I had no one.” An ex-felon, Henderson-Uloho was unable to open a bank account or a credit card. She couldn’t rent an apartment. Nobody would employ her. “I had to go inside myself and find something good about me,” she says. “I felt like trash … I needed help.”
On a street corner, Henderson-Uloho began selling discarded clothing items out of a suitcase. The first day, she made $40. “I just kept doing that,” she says in the film. “Three years later, I have a 15,000-square-foot thrift store and transition-housing facility for other female ex-offenders.”
Mohammad Gorjestani’s film, funded by Square, is the story of how Henderson-Uloho turned her life around and used her success as a springboard to help others. Her New Orleans thrift store, Sister Hearts, is owned and operated by formerly incarcerated women, who have the opportunity to live on the premises while they work to regain economic independence. (The similarities between Henderson-Uloho’s work and the narratives of other ex-offenders are not lost on her. “We’re both getting second chances,” she says in the film.) Henderson-Uloho also leads group-therapy sessions for female inmates, in which she helps the women rebuild their self-esteem and empowers them to create positive change.
In the film, Henderson-Uloho describes how many ex-offenders adapt well to entrepreneurial work. “We know how to come up from the trenches,” she says. “We know how to make something out of nothing. We know how to take a dime and make it a dollar.”
Gorjestani told me that hearing Henderson-Uloho speak about her work was inspiring, but that witnessing the impact of her work was a truly profound experience. “She’s a true advocate for them,” he said. “In the prison, we watched Maryam sit down in front of a group of disinterested women with their arms folded, and within an hour she had transformed the room, giving them all a newfound hope and a sense of a bond based on their shared struggle. By the end, she had these women hugging in a circle and smiling. It was one of the most moving experiences I have been a part of.”
“I want all ex-offenders to know they matter,” Henderson-Uloho says. “I want them to know that just because they’ve committed a crime, they’re no less of a human being.”