Indiana's Ryan White opened hearts to AIDS fight. Don't abandon his legacy now.
Ryan White was a spirited, bright kid who loved basketball, Nintendo and dreaming big. In 1984, 13-year-old Ryan contracted HIV through a contaminated blood transfusion used to treat his hemophilia.
With widespread misconceptions about HIV/AIDS dominating the headlines, and fear overruling facts, Ryan was barred from attending his school and driven from his hometown of Kokomo. His harrowing story suddenly thrust Ryan onto the national stage, where he transformed the attention into a powerful force for changing perceptions about those living with HIV/AIDS.
He had no idea how far his message would reach. Yet he was determined to use it for the greater good. His courage inspired the creation of the Elton John AIDS Foundation, which continues to help people across America, and around the world, stay safe and well.
At the time of his diagnosis, doctors gave Ryan only six months to live. On April 8, 1990, six precious years later, we sat together at Ryan's bedside and held his hands as he lost his young, heroic life to AIDS. First lady Barbara Bush attended his funeral, and businessman Donald Trump came to the family home to pay his respects.
When Americans needed to take compassionate action, Ryan opened the door and urged everyone to take heart and to help.
Four months later, in his name, Congress nearly unanimously enacted the Ryan White CARE Act – providing essential HIV care and treatment to Americans living with the virus. After years of fearmongering and paralysis, the U.S. government had finally committed to join the fight against our common enemy: AIDS.
Ryan would be grateful for the progress being made. Today, more than 500,000 Americans living with HIV get lifesaving treatment through the Ryan White CARE Act.
In 2019, President Trump proudly launched the End the HIV Epidemic initiative in his State of the Union address − a focused prevention effort to end the HIV epidemic in America by 2030.
This evidence-based strategic initiative has achieved remarkable results, reducing new HIV infections by 21% in targeted communities and connecting people newly diagnosed with HIV to vital care and support services.
This push to end AIDS is in full swing across America, but the work is not done yet – with young people, particularly in the South, now most severely impacted.
We are grateful that the draft budget before Congress continues critically important funding for the Ryan White CARE Act and the End the HIV Epidemic efforts. That is an affirmation of these programs' effectiveness and bipartisan support.
However, the proposal also would end federal funding to states for HIV surveillance, testing and education; for community-based organizations that reach those most at risk; and for substance abuse treatment and mental health programs that are crucial for driving down HIV infections.
Attempts to cut Medicaid are also alarming, as more than 40% of people living with HIV have their care and treatment covered by Medicaid.
Without this essential insurance, scores of people living with HIV won't get the care and medicines they need to keep them healthy. The president has said don't mess with Medicaid. We agree.
Programs that provide treatment, fuel prevention and fight stigma should be expanded, not eliminated, as we work toward eradicating the disease that ended Ryan's life.
The game-changing opportunity of the moment is to scale up prevention medication that keeps people HIV-free. The recent American-led development of PrEP − a pill or shot that prevents the virus from taking hold − is just the tool we need to end AIDS, but only if we make it accessible to those who need it.
The economics are compelling: 14,000 people can receive generic PrEP ($30 annually) for the lifetime cost of treating one person with HIV ($420,285) − keeping Americans healthy, HIV-free and productive.
The moment of truth is here. As the administration and Congress consider their investment priorities for next year, we urge them to continue joining forces in the fight against AIDS in the United States and worldwide.
Together, their investments over time have created this once-in-a-generation opportunity to end AIDS in America by 2030, as called for by President Trump. Together they can seize that opportunity by banking on prevention.
Ryan would expect nothing less.
Hashtags
Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles
Yahoo
an hour ago
- Yahoo
‘Explosive increase' of ticks that cause meat allergy in US due to climate crisis
Blood-sucking ticks that trigger a bizarre allergy to meat in the people they bite are exploding in number and spreading across the US, to the extent that they could cover the entire eastern half of the country and infect millions of people, experts have warned. Lone star ticks have taken advantage of rising temperatures by the human-caused climate crisis to expand from their heartland in the south-east US to areas previously too cold for them, in recent years marching as far north as New York and even Maine, as well as pushing westwards. The ticks are known to be unusually aggressive and can provoke an allergy in bitten people whereby they cannot eat red meat without enduring a severe reaction, such as breaking out in hives and even the risk of heart attacks. The condition, known as alpha-gal syndrome, has proliferated from just a few dozen known cases in 2009 to as many as 450,000 now. 'We thought this thing was relatively rare 10 years ago but it's become more and more common and it's something I expect to continue to grow very rapidly,' said Brandon Hollingsworth, an expert at the University of South Carolina who has researched the tick's expansion. 'We've seen an explosive increase in these ticks, which is a concern. I imagine alpha-gal will soon include the entire range of the tick, which could become the entire eastern half of the US as there's not much to stop them. It seems like an oddity now but we could end up with millions of people with an allergy to meat.' The exact number of alpha-gal cases is unclear due to patchy data collection but it's likely to be a severe undercount as people may not link their allergic reaction to the tick bites. The Centers for Disease Control and Prevention (CDC) has said around 110,000 cases have been documented since 2010 but acknowledges the true number could be as high as 450,000. Cases will rise further as the ticks spread, aided by their adaptability to local conditions, according to Laura Harrington, an entomologist and disease specialist at Cornell University. 'With their adaptive nature and increasing temperatures, I don't see many limits to these ticks over time,' she said. Alpha-gal is a confounding condition because it doesn't cause an immediate allergic reaction, unlike a peanut allergy, with symptoms often appearing several hours after consuming meat. The syndrome is not caused by a pathogen but spurs an allergy to a sugar molecule found in mammals and an array of other things, from toothpaste to medical equipment. Researchers think the condition can wane over time but is also worsened by further tick bites. This leads to a confusing and fraught experience for the growing number of Americans with alpha-gal, who are now girding for another expected hot summer full of ticks. 'The ticks are rampant this year, I've pulled 10 ticks off me this season alone, it feels like they are uncontrollable at the moment,' said Heather O'Bryan, a horticulturist in Roanoke, Virginia, who has alpha-gal. 'They are so disgusting. I'm not afraid of a lot, but I'm afraid of ticks.' In 2019, O'Bryan suffered full body hives and struggled to breathe after eating a pork sausage. 'It was terrifying experience, I didn't know I had an allergy but it almost killed me,' she said. She now avoids products containing mammal-derived elements, such as certain toothpastes and even toilet paper, due to adverse reactions. Dairy, another mammalian product, is also off limits. 'I've learned what I can eat now, but I was so sad when I realized I couldn't have pizza again, I remember crying in front of a frozen pizza in the supermarket aisle,' she said. There is now an 'almost constant' stream of new members to the Facebook alpha-gal support groups that O'Bryan is part of, she said, with her region of Virginia now seemingly saturated by the condition. 'Everyone knows someone who has it, I talk a friend off a ledge once a month when they've been bitten because they are so afraid they have it and are freaking out,' she said. Lone star ticks are aggressive and can speedily follow a human target if they detect them. 'They will hunt you, they are like a cross between a lentil and a velociraptor,' said Sharon Pitcairn Forsyth, a conservationist who lives in the Washington DC area. A particular horror is the prospect of brushing up against vegetation containing a massed ball of juvenile lone star ticks, know as a 'tick bomb', that can deliver thousands of tick bites. 'They are so tiny you can't see them but you have to take it seriously or you'll never get them off you,' said Forsyth, who now carries around a lint roller to remove such clusters. After being diagnosed with alpha-gal, Forsyth set up online resources about the condition to help spread awareness and advocate for better food labeling to include alpha-gal warnings. 'I get calls from doctors asking questions about this because they just don't know about it,' she said. 'I'm not a medical professional, so I just send them the research papers.' As the climate heats up, due to the burning of fossil fuels, ticks are able to shift to areas that are becoming agreeably warm for them. Growing numbers of deer, which host certain ticks, and sprawling housing development into natural habitats is also causing more interactions with ticks. 'Places where houses push up against habitats and parks where nature has regrown are where we are seeing cases,' said Hollingsworth. But much is still unknown, such as why lone star ticks, which have long been native to the US, suddenly started causing these allergic reactions. Symptoms can also be alarmingly varied – Forsyth said she rarely eats out now because of concerns of contamination in the food and even that alpha-gal could be carried to her airborne, via the steam of cooked meat. 'Some people are scared to leave the house, it's hard to avoid,' she said. 'Many people who get it are over 50, so the first symptom some of them have is a heart attack.' So how far can alpha-gal spread? Cases have been found in Europe and Australia, although in low numbers, while in the US it's assumed lone star ticks won't be able to shift west of the Rocky mountains. But other tick species might also be able to spread alpha-gal syndrome – a recent scientific paper found the western black legged tick and the black legged tick, also called the deer tick, could also cause the condition. Hanna Oltean, an epidemiologist at Washington state department of health, said it was 'very surprising' to find a case of alpha-gal in Washington state from a person bitten by a tick locally, suggesting the western black legged tick could be a culprit. 'The range is spreading and emerging in new areas so the risk is increasing over time,' Oltean said. 'Washington state is very far from the range and the risk remains very low here. But we don't know enough about the biology of how ticks spread the syndrome.' The spread of alpha-gal comes amid a barrage of disease threats from different ticks that are fanning out across a rapidly warming US. Powassan virus, which can kill people via an inflammation of the brain, is still rare but is growing, as is Babesia, a parasite that causes severe illnesses. Lyme disease, long a feature of the US north-east, is also burgeoning. 'We are dealing with a lot of serious tick-borne illnesses and discovering new ones all the time,' said Harrington. 'There's a tremendous urgency to confront this with new therapies but the problem is we are going backwards in terms of funding and support in the US. There have been cuts to the CDC and NIH (National Institutes of Health) which means there is decreasing support. It's a major concern.'
Atlantic
an hour ago
- Atlantic
American Insomnia
I like to tell people that the night before I stopped sleeping, I slept. Not only that: I slept well. Years ago, a boyfriend of mine, even-keeled during the day but restless at night, told me how hard it was to toss and turn while I instantly sank into the crude, Neanderthal slumber of the dead. When I found a magazine job that allowed me to keep night-owl hours, my rhythms had the precision of an atomic clock. I fell asleep at 1 a.m. I woke up at 9 a.m. One to nine, one to nine, one to nine, night after night, day after day. As most researchers can tell you, this click track is essential to health outcomes: One needs consistent bedtimes and wake-up times. And I had them, naturally; when I lost my alarm clock, I didn't bother getting another until I had an early-morning flight to catch. Then, one night maybe two months before I turned 29, that vaguening sense that normal sleepers have when they're lying in bed—their thoughts pixelating into surreal images, their mind listing toward unconsciousness—completely deserted me. How bizarre, I thought. I fell asleep at 5 a.m. This started to happen pretty frequently. I had no clue why. The circumstances of my life, both personally and professionally, were no different from the week, month, or two months before—and my life was good. Yet I'd somehow transformed into an appliance without an off switch. I saw an acupuncturist. I took Tylenol PM. I sampled a variety of supplements, including melatonin (not really appropriate, I'd later learn, especially in the megawatt doses Americans take—its real value is in resetting your circadian clock, not as a sedative). I ran four miles every day, did breathing exercises, listened to a meditation tape a friend gave me. Useless. I finally caved and saw my general practitioner, who prescribed Ambien, telling me to feel no shame if I needed it every now and then. But I did feel shame, lots of shame, and I'd always been phobic about drugs, including recreational ones. And now … a sedative? (Two words for you: Judy Garland.) It was only when I started enduring semiregular involuntary all-nighters—which I knew were all-nighters, because I got out of bed and sat upright through them, trying to read or watch TV—that I capitulated. I couldn't continue to stumble brokenly through the world after nights of virtually no sleep. I hated Ambien. One of the dangers with this strange drug is that you may do freaky things at 4 a.m. without remembering, like making a stack of peanut-butter sandwiches and eating them. That didn't happen to me (I don't think?), but the drug made me squirrelly and tearful. I stopped taking it. My sleep went back to its usual syncopated disaster. In Sleepless: A Memoir of Insomnia, Marie Darrieussecq lists the thinkers and artists who have pondered the brutality of sleeplessness, and they're distinguished company: Duras, Gide, Pavese, Sontag, Plath, Dostoyevsky, Murakami, Borges, Kafka. (Especially Kafka, whom she calls literature's 'patron saint' of insomniacs. 'Dread of night,' he wrote. 'Dread of not-night.') Not to mention F. Scott Fitzgerald, whose sleeplessness was triggered by a single night of warfare with a mosquito. But there was sadly no way to interpret my sleeplessness as a nocturnal manifestation of tortured genius or artistic brilliance. It felt as though I'd been poisoned. It was that arbitrary, that abrupt. When my insomnia started, the experience wasn't just context-free; it was content-free. People would ask what I was thinking while lying wide awake at 4 a.m., and my answer was: nothing. My mind whistled like a conch shell. But over time I did start thinking—or worrying, I should say, and then perseverating, and then outright panicking. At first, songs would whip through my head, and I couldn't get the orchestra to pack up and go home. Then I started to fear the evening, going to bed too early in order to give myself extra runway to zonk out. (This, I now know, is a typical amateur's move and a horrible idea, because the bed transforms from a zone of security into a zone of torment, and anyway, that's not how the circadian clock works.) Now I would have conscious thoughts when I couldn't fall asleep, which can basically be summarized as insomnia math: Why am I not falling asleep Dear God let me fall asleep Oh my God I only have four hours left to fall asleep oh my God now I only have three oh my God now two oh my God now just one. 'The insomniac is not so much in dialogue with sleep,' Darrieussecq writes, 'as with the apocalypse.' I would shortly discover that this cycle was textbook insomnia perdition: a fear of sleep loss that itself causes sleep loss that in turn generates an even greater fear of sleep loss that in turn generates even more sleep loss … until the next thing you know, you're in an insomnia galaxy spiral, with a dark behavioral and psychological (and sometimes neurobiological) life of its own. I couldn't recapture my nights. Something that once came so naturally now seemed as impossible as flying. How on earth could this have happened? To this day, whenever I think about it, I still can't believe it did. In light of my tortured history with the subject, you can perhaps see why I generally loathe stories about sleep. What they're usually about is the dangers of sleep loss, not sleep itself, and as a now-inveterate insomniac, I've already got a multivolume fright compendium in my head of all the terrible things that can happen when sleep eludes you or you elude it. You will die of a heart attack or a stroke. You will become cognitively compromised and possibly dement. Your weight will climb, your mood will collapse, the ramparts of your immune system will crumble. If you rely on medication for relief, you're doing your disorder all wrong—you're getting the wrong kind of sleep, an unnatural sleep, and addiction surely awaits; heaven help you and that horse of Xanax you rode in on. It should go without saying that for some of us, knowledge is not power. It's just more kindling. The cultural discussions around sleep would be a lot easier if the tone weren't quite so hectoring—or so smug. A case in point: In 2019, the neuroscientist Matthew Walker, the author of Why We Sleep, gave a TED Talk that began with a cheerful disquisition about testicles. They are, apparently, 'significantly smaller' in men who sleep five hours a night rather than seven or more, and that two-hour difference means lower testosterone levels too, equivalent to those of someone 10 years their senior. The consequences of short sleep for women's reproductive systems are similarly dire. 'This,' Walker says just 54 seconds in, 'is the best news that I have for you today.' He makes good on his promise. What follows is the old medley of familiars, with added verses about inflammation, suicide, cancer. Walker's sole recommendation at the end of his sermon is the catechism that so many insomniacs—or casual media consumers, for that matter—can recite: Sleep in a cool room, keep your bedtimes and wake-up times regular, avoid alcohol and caffeine. Also, don't nap. I will now say about Walker: 1. His book is in many ways quite wonderful—erudite and wide-ranging and written with a flaring energy when it isn't excessively pleased with itself. 2. Both Why We Sleep and Walker's TED Talk focus on sleep deprivation, not insomnia, with the implicit and sometimes explicit assumption that too many people choose to blow off sleep in favor of work or life's various seductions. If public awareness is Walker's goal (certainly a virtuous one), he and his fellow researchers have done a very good job in recent years, with the enthusiastic assistance of my media colleagues, who clearly find stories about the hazards of sleep deprivation irresistible. (In the wine-dark sea of internet content, they're click sirens.) Walker's TED Talk has been viewed nearly 24 million times. 'For years, we were fighting against 'I'll sleep when I'm dead,' ' Aric Prather, the director of the behavioral-sleep-medicine research program at UC San Francisco, told me. 'Now the messaging that sleep is a fundamental pillar of human health has really sunk in.' Yet greater awareness of sleep deprivation's consequences hasn't translated into a better-rested populace. Data from the CDC show that the proportion of Americans reporting insufficient sleep held constant from 2013 through 2022, at roughly 35 percent. (From 2020 to 2022, as anxiety about the pandemic eased, the percentage actually climbed.) So here's the first question I have: In 2025, exactly how much of our 'sleep opportunity,' as the experts call it, is under our control? According to the most recent government data, 16.4 percent of American employees work nonstandard hours. (Their health suffers in every category—the World Health Organization now describes night-shift work as ' probably carcinogenic.') Adolescents live in a perpetual smog of sleep deprivation because they're forced to rise far too early for school (researchers call their plight 'social jet lag'); young mothers and fathers live in a smog of sleep deprivation because they're forced to rise far too early (or erratically) for their kids; adults caring for aging parents lose sleep too. The chronically ill frequently can't sleep. Same with some who suffer from mental illness, and many veterans, and many active-duty military members, and menopausal women, and perimenopausal women, and the elderly, the precariat, the poor. 'Sleep opportunity is not evenly distributed across the population,' Prather noted, and he suspects that this contributes to health disparities by class. In 2020, the National Center for Health Statistics found that the poorer Americans were, the greater their likelihood of reporting difficulty falling asleep. If you look at the CDC map of the United States' most sleep-deprived communities, you'll see that they loop straight through the Southeast and Appalachia. Black and Hispanic Americans also consistently report sleeping less, especially Black women. Even for people who aren't contending with certain immutables, the cadences of modern life have proved inimical to sleep. Widespread electrification laid waste to our circadian rhythms 100 years ago, when they lost any basic correspondence with the sun; now, compounding matters, we're contending with the currents of a wired world. For white-collar professionals, it's hard to imagine a job without the woodpecker incursions of email or weekend and late-night work. It's hard to imagine news consumption, or even ordinary communication, without the overstimulating use of phones and computers. It's hard to imagine children eschewing social media when it's how so many of them socialize, often into the night, which means blue-light exposure, which means the suppression of melatonin. (Melatonin suppression obviously applies to adults too—it's hardly like we're avatars of discipline when it comes to screen time in bed.) Most of us can certainly do more to improve or reclaim our sleep. But behavioral change is difficult, as anyone who's vowed to lose weight can attest. And when the conversation around sleep shifts the onus to the individual—which, let's face it, is the American way (we shift the burden of child care to the individual, we shift the burden of health care to the individual)—we sidestep the fact that the public and private sectors alike are barely doing a thing to address what is essentially a national health emergency. Given that we've decided that an adequate night's rest is a matter of individual will, I now have a second question: How are we to discuss those who are suffering not just from inadequate sleep, but from something far more severe? Are we to lecture them in the same menacing, moralizing way? If the burden of getting enough sleep is on us, should we consider chronic insomniacs—for whom sleep is a nightly gladiatorial struggle—the biggest failures in the armies of the underslept? Those who can't sleep suffer a great deal more than those gifted with sleep will ever know. Yet insomniacs frequently feel shame about the solutions they've sought for relief—namely, medication—likely because they can detect a subtle, judgmental undertone about this decision, even from their loved ones. Resorting to drugs means they are lazy, refusing to do simple things that might ease their passage into unconsciousness. It means they are neurotic, requiring pills to transport them into a natural state that every other animal on Earth finds without aid. Might I suggest that these views are unenlightened? 'In some respects, chronic insomnia is similar to where depression was in the past. We'd say, 'Major depression' and people would say, 'Everybody gets down now and then,' ' John Winkelman, a psychiatrist in the sleep-medicine division at Harvard Medical School, said at a panel I attended last summer. Darrieussecq, the author of Sleepless, puts it more bluntly: ' 'I didn't sleep all night,' sleepers say to insomniacs, who feel like replying that they haven't slept all their life.' The fact is, at least 12 percent of the U.S. population suffers from insomnia as an obdurate condition. Among Millennials, the number pops up to 15 percent. And 30 to 35 percent of Americans suffer from some of insomnia's various symptoms—trouble falling asleep, trouble staying asleep, or waking too early—at least temporarily. In 2024, there were more than 2,500 sleep-disorder centers in the U.S. accredited by the American Academy of Sleep Medicine. Prather told me the wait time to get into his sleep clinic at UCSF is currently a year. 'That's better than it used to be,' he added. 'Until a few months ago, our waitlist was closed. We couldn't fathom giving someone a date.' So what I'm hoping to do here is not write yet another reproachful story about sleep, plump with misunderstandings and myths. Fixing sleep— obtaining sleep—is a tricky business. The work it involves and painful choices it entails deserve nuanced examination. Contrary to what you might have read, our dreams are seldom in black and white. Whenever I interviewed a clinician, psychiatrist, neuroscientist, or any other kind of expert for this story, I almost always opened with the same question: What dogma about sleep do you think most deserves to be questioned? The most frequent answer, by a long chalk, is that we need eight hours of it. A fair number of studies, it turns out, show that mortality rates are lowest if a person gets roughly seven hours. Daniel F. Kripke, a psychiatrist at UC San Diego, published the most famous of these analyses in 2002, parsing a sample of 1.1 million individuals and concluding that those who reported more than eight hours of sleep a night experienced significantly increased mortality rates. According to Kripke's work, the optimal sleep range was a mere 6.5 to 7.4 hours. These numbers shouldn't be taken as gospel. The relationship between sleep duration and health outcomes is a devil's knot, though Kripke did his best to control for the usual confounds—age, sex, body-mass index. But he could not control for the factors he did not know. Perhaps many of the individuals who slept eight hours or more were doing so because they had an undetected illness, or an illness of greater severity than they'd realized, or other conditions Kripke hadn't accounted for. The study was also observational, not randomized. But even if they don't buy Kripke's data, sleep experts don't necessarily believe that eight hours of sleep has some kind of mystical significance. Methodologically speaking, it's hard to determine how much sleep, on average, best suits us, and let's not forget the obvious: Sleep needs—and abilities—vary over the course of a lifetime, and from individual to individual. (There's even an extremely rare species of people, known as 'natural short sleepers,' associated with a handful of genes, who require only four to six hours a night. They tear through the world as if fired from a cannon.) Yet eight hours of sleep or else remains one of our culture's most stubborn shibboleths, and an utter tyranny for many adults, particularly older ones. 'We have people coming into our insomnia clinic saying 'I'm not sleeping eight hours' when they're 70 years of age,' Michael R. Irwin, a psychoneurologist at UCLA, told me. 'And the average sleep in that population is less than seven hours. They attribute all kinds of things to an absence of sleep—decrements in cognitive performance and vitality, higher levels of fatigue—when often that's not the case. I mean, people get older, and the drive to sleep decreases as people age.' Another declaration I was delighted to hear: The tips one commonly reads to get better sleep are as insipid as they sound. 'Making sure that your bedroom is cool and comfortable, your bed is soft, you have a new mattress and a nice pillow—it's unusual that those things are really the culprit,' Eric Nofzinger, the former director of the sleep neuroimaging program at the University of Pittsburgh's medical school, told me. 'Most people self-regulate anyway. If they're cold, they put on an extra blanket. If they're too warm, they throw off the blanket.' 'Truthfully, there's not a lot of data supporting those tips,' Suzanne Bertisch, a behavioral-sleep-medicine expert at Brigham and Women's Hospital, in Boston, told me. That includes the proscription on naps, she added, quite commonly issued in her world. (In general, the research on naps suggests that short ones have beneficial outcomes and long ones have negative outcomes, but as always, cause and effect are difficult to disentangle: An underlying health condition could be driving those long naps.) Even when they weren't deliberately debunking the conventional wisdom about sleep, many of the scholars I spoke with mentioned—sometimes practically as an aside—facts that surprised or calmed. For instance: Many of us night owls have heard that the weather forecast for our old age is … well, cloudy, to be honest, with a late-afternoon chance of keeling over. According to one large analysis, we have a 10 percent increase in all-cause mortality over morning larks. But Jeanne Duffy, a neuroscientist distinguished for her expertise in human circadian rhythms at Brigham and Women's, told me she suspected that this was mainly because most night owls, like most people, are obliged to rise early for their job. So wait, I said. Was she implying that if night owls could contrive work-arounds to suit their biological inclination to go to bed late, the news probably wouldn't be as grim? 'Yes,' she replied. A subsequent study showed that the owl-lark mortality differential dwindled to nil when the authors controlled for lifestyle. Apparently owls are more apt to smoke, and to drink more. So if you're an owl who's repelled by Marlboros and Jameson, you're fine. Kelly Glazer Baron, the director of the behavioral-sleep-medicine program at the University of Utah, told me that she'd love it if patients stopped agonizing over the length of their individual sleep phases. I didn't get enough deep sleep, they fret, thrusting their Apple Watch at her. I didn't get enough REM. And yes, she said, insufficiencies in REM or slow-wave sleep can be a problem, especially if they reflect an underlying health issue. But clinics don't look solely at sleep architecture when evaluating their patients. 'I often will show them my own data,' Baron said. 'It always shows I don't have that much deep sleep, which I find so weird, because I'm a healthy middle-aged woman.' In 2017, after observing these anxieties for years, Baron coined a term for sleep neuroticism brought about by wearables: orthosomnia. But most surprising—to me, anyway—was what I heard about insomnia and the black dog. 'There are far more studies indicating that insomnia causes depression than depression causes insomnia,' said Wilfred Pigeon, the director of the Sleep & Neurophysiology Research Laboratory at the University of Rochester. Which is not to say, he added, that depression can't or doesn't cause insomnia. These forces, in the parlance of health professionals, tend to be 'bidirectional.' But I can't tell you how vindicating I found the idea that perhaps my own insomnia came first. A couple of years into my struggles with sleeplessness, a brilliant psychopharmacologist told me that my new condition had to be an episode of depression in disguise. And part of me thought, Sure, why not? A soundtrack of melancholy had been playing at a low hum inside my head from the time I was 10. The thing was: I became outrageously depressed only after my insomnia began. That's when that low hum started to blare at a higher volume. Until I stopped sleeping, I never suffered from any sadness so crippling that it prevented me from experiencing joy. It never impeded my ability to socialize or travel. It never once made me contemplate antidepressants. And it most certainly never got in the way of my sleeping. The precipitating factor in my own brutal insomnia was, and remains, an infuriating mystery. Sleep professionals, I have learned, drink a lot of coffee. That was the first thing I noticed when I attended SLEEP 2024, the annual conference of the American Academy of Sleep Medicine, in Houston: coffee, oceans of it, spilling from silver urns, especially at the industry trade show. Wandering through it was a dizzying experience, a sprawling testament to the scale and skyscraping profit margins of Big Sleep. More than 150 exhibitors showed up. Sheep swag abounded. Drug reps were everywhere, their aggression tautly disguised behind android smiles, the meds they hawked called the usual names that look like high-value Scrabble words. I've never understood this branding strategy, honestly. If you want your customers to believe they're falling into a gentle, natural sleep, you should probably think twice before calling your drug Quviviq. I walked through the cavernous hall in a daze. It was overwhelming, really—the spidery gizmos affixed to armies of mannequins, the Times Square–style digital billboards screaming about the latest in sleep technology. At some point it occurred to me that the noisy, overbusy, fluorescent quality of this product spectacular reminded me of the last place on Earth a person with a sleep disorder should be: a casino. The room was practically sunless. I saw very few clocks. After I spent an afternoon there, my circadian rhythms were shot to hell. But the conference itself …! Extraordinary, covering miles of ground. I went to one symposium about 'sleep deserts,' another about the genetics of sleep disturbance, and yet another about sleep and menopause. I walked into a colloquy about sleep and screens and had to take a seat on the floor because the room was bursting like a suitcase. Of most interest to me, though, were two panels, which I'll shortly discuss: one about how to treat patients with anxiety from new-onset insomnia, and one on whether hypnotics are addictive. My final stop at the trade fair was the alley of beauty products—relevant, I presume, because they address the aesthetic toll of sleep deprivation. Within five minutes, an energetic young salesman made a beeline for me, clearly having noticed that I was a woman of a certain age. He gushed about a $2,500 infrared laser to goose collagen production and a $199 medical-grade peptide serum that ordinarily retails for $1,100. I told him I'd try the serum. 'Cheaper than Botox, and it does the same thing,' he said approvingly, applying it to the crow's-feet around my eyes. I stared in the mirror. Holy shit. The stuff was amazing. 'I'll take it,' I told him. He was delighted. He handed me a box. The serum came in a gold syringe. 'You're a doctor, right?' A beat. 'No,' I finally said. 'A journalist. Can only a dermatologist—' He told me it was fine; it's just that doctors were his main customers. This was the sort of product women like me usually had to get from them. I walked away elated but queasy, feeling like a creep who'd evaded a background check by purchasing a Glock at a gun show. The first line of treatment for chronic, intractable sleeplessness, per the American Academy of Sleep Medicine, is cognitive behavioral therapy for insomnia, or CBT-I. I've tried it, in earnest, at two different points in my life. It generally involves six to eight sessions and includes, at minimum: identifying the patient's sleep-wake patterns (through charts, diaries, wearables); 'stimulus control' (setting consistent bedtimes and wake-up times, resisting the urge to stare at the clock, delinking the bed from anything other than sleep and sex); establishing good sleep habits (the stuff of every listicle); 'sleep restriction' (compressing your sleep schedule, then slowly expanding it over time); and 'cognitive restructuring,' or changing unhealthy thoughts about sleep. The cognitive-restructuring component is the most psychologically paradoxical. It means taking every terrifying thing you've ever learned about the consequences of sleeplessness and pretending you've never heard them. I pointed this out to Wilfred Pigeon. 'For the medically anxious, it's tough,' he agreed. 'We're trying to tell patients two things at the same time: 'You really need to get your sleep on track, or you will have a heart attack five years earlier than you otherwise would.' But also: 'Stop worrying about your sleep so much, because it's contributing to your not being able to sleep.' And they're both true!' Okay, I said. But if an insomniac crawls into your clinic after many years of not sleeping (he says people tend to wait about a decade), wouldn't they immediately see that these two messages live in tension with each other? And dwell only on the heart attack? 'I tell the patient their past insomnia is water under the bridge,' Pigeon said. 'We're trying to erase the added risks that ongoing chronic insomnia will have. Just because a person has smoked for 20 years doesn't mean they should keep smoking.' He's absolutely right. But I'm not entirely convinced that these incentives make the cognitive dissonance of CBT-I go away. When Sara Nowakowski, a CBT-I specialist at Baylor College of Medicine, gave her presentation at SLEEP 2024's panel on anxiety and new-onset insomnia, she said that many of her patients start reciting the grim data from their Fitbits and talking about dementia. That's likely because they've read the studies. Rapid-eye-movement (REM) sleep, that vivid-dream stage when our eyes race beneath our eyelids like mice under a blanket, is essential to emotional regulation and problem-solving. Slow-wave sleep, our deepest sleep, is essential for repairing our cells, shoring up our immune systems, and rinsing toxins from our brains, thanks to a watery complex of micro-canals called the glymphatic system. We repair our muscles when we sleep. We restore our hearts. We consolidate memories and process knowledge, embedding important facts and disposing of trivial ones. We actually learn when we're asleep. Many insomniacs know all too well how nonnegotiably vital sleep is, and what the disastrous consequences are if you don't get it. I think of the daredevil experiment that Nathaniel Kleitman, the father of sleep research, informally conducted as a graduate student in 1922, enlisting five classmates to join him in seeing how long they could stay awake. He lasted the longest—a staggering 115 hours—but at a terrible price, temporarily going mad with exhaustion, arguing on the fifth day with an imaginary foe about the need for organized labor. And I think of Allan Rechtschaffen, another pioneer in the field, who in 1989 had the fiendish idea to place rats on a spinning mechanism that forced them to stay awake if they didn't want to drown. They eventually dropped dead. So these are the kinds of facts a person doing CBT-I has to ignore. Still. Whether a patient's terrors concern the present or the future, it is the job of any good CBT-I practitioner to help fact-check or right-size them through Socratic questioning. During her panel at SLEEP 2024, Nowakowski gave very relatable examples: When you're struggling to fall asleep, what are you most worried will happen? I'll lose my job/scream at my kids/detonate my relationship/never be able to sleep again. And what's the probability of your not falling asleep? I don't sleep most nights. And the probability of not functioning at work or yelling at the kids if you don't? Ninety percent. She then tells her patients to go read their own sleep diary, which she's instructed them to keep from the start. The numbers seldom confirm they're right, because humans are monsters of misprediction. Her job is to get her patients to start decatastrophizing, which includes what she calls the 'So what?' method: So what if you have a bad day at work or at home? You've had others. Will it be the end of the world? (When my second CBT-I therapist asked me this, I silently thought, Yes, because when I'm dangling at the end of my rope, I just spin more.) CBT-I addresses anxiety about not sleeping, which tends to be the real force that keeps insomnia airborne, regardless of what lofted it. The pre-sleep freaking out, the compulsive clock-watching, the bargaining, the middle-of-the-night doom-prophesizing, the despairing—CBT-I attempts to snip that loop. The patient actively learns new behaviors and attitudes to put an end to their misery. But the main anchor of CBT-I is sleep-restriction therapy. I tried it back when I was 29, when I dragged my wasted self into a sleep clinic in New York; I've tried it once since. I couldn't stick with it either time. The concept is simple: You severely limit your time in bed, paring away every fretful, superfluous minute you'd otherwise be awake. If you discover from a week's worth of sleep-diary entries (or your wearable) that you spend eight hours buried in your duvet but sleep for only five of them, you consolidate those splintered hours into one bloc of five, setting the same wake-up time every day and going to bed a mere five hours before. Once you've averaged sleeping those five hours for a few days straight, you reward your body by going to bed 15 minutes earlier. If you achieve success for a few days more, you add another 15 minutes. And then another … until you're up to whatever the magic number is for you. No napping. The idea is to build up enough 'sleep pressure' to force your body to collapse in surrender. Sleep restriction can be a wonderful method. But if you have severe insomnia, the idea of reducing your sleep time is petrifying. Technically, I suppose, you're not really reducing your sleep time; you're just consolidating it. But practically speaking, you are reducing your sleep, at least in the beginning, because dysregulated sleep isn't an accordion, obligingly contracting itself into a case. Contracting it takes time, or at least it did for me. The process was murder. 'If you get people to really work their way through it—and sometimes that takes holding people's hands—it ends up being more effective than a pill,' Ronald Kessler, a renowned psychiatric epidemiologist at Harvard, told me when I asked him about CBT-I. The problem is the formidable size of that if. 'CBT-I takes a lot more work than taking a pill. So a lot of people drop out.' They do. One study I perused had an attrition rate of 40 percent. Twenty-six years ago, I, too, joined the legions of the quitters. In hindsight, my error was my insistence on trying this grueling regimen without a benzodiazepine (Valium, Ativan, Xanax), though my doctor had recommended that I start one. But I was still afraid of drugs in those days, and I was still in denial that I'd become hostage to my own brain's terrorism. I was sure that I still had the power to negotiate. Competence had until that moment defined my whole life. I persuaded the doctor to let me try without drugs. As she'd predicted, I failed. The graphs in my sleep diary looked like volatile weeks on the stock exchange. For the first time ever, I did need an antidepressant. The doctor wrote me a prescription for Paxil and a bottle of Xanax to use until I got up to cruising altitude—all SSRIs take a while to kick in. I didn't try sleep restriction again until many years later. Paxil sufficed during that time; it made me almost stupid with drowsiness. I was sleepy at night and vague during the day. I needed Xanax for only a couple of weeks, which was just as well, because I didn't much care for it. The doctor had prescribed too powerful a dose, though it was the smallest one. I was such a rookie with drugs in those days that it never occurred to me I could just snap the pill in half. Have I oversimplified the story of my insomnia? Probably. At the top of the SLEEP 2024 panel about anxiety and new-onset insomnia, Leisha Cuddihy, a director at large for the Society of Behavioral Sleep Medicine, said something that made me wince—namely, that her patients 'have a very vivid perception of pre-insomnia sleep being literally perfect: 'I've never had a bad night of sleep before now.' ' Okay, guilty as charged. While it's true that I'd slept brilliantly (and I stand by this, brilliantly) in the 16 years before I first sought help, I was the last kid to fall asleep at slumber parties when I was little. Cuddihy also said that many of her patients declare they're certain, implacably certain, that they are unfixable. 'They feel like something broke,' she said. Which is what I wrote just a few pages back. Poisoned, broke, same thing. By the time Cuddihy finished speaking, I had to face an uncomfortable truth: I was a standard-issue sleep-clinic zombie. But when patients say they feel like something broke inside their head, they aren't necessarily wrong. An insomniac's brain does change in neurobiological ways. 'There is something in the neurons that's changing during sleep in patients with significant sleep disruptions,' said Eric Nofzinger, who, while at the University of Pittsburgh, had one of the world's largest databases of brain-imaging studies of sleeping human beings. 'If you're laying down a memory, then that circuitry is hardwired for that memory. So one can imagine that if your brain is doing this night after night …' We know that the hypothalamic-pituitary-adrenal axis, our body's first responder to stress, is overactivated in the chronically underslept. If the insomniac suffers from depression, their REM phase tends to be longer and more 'dense,' with the limbic system (the amygdala, the hippocampus—where our primal drives are housed) going wild, roaring its terrible roars and gnashing its terrible teeth. (You can imagine how this would also make depressives subconsciously less motivated to sleep—who wants to face their Gorgon dreams?) Insomniacs suffering from anxiety experience this problem too, though to a lesser degree; it's their deep sleep that's mainly affected, slimming down and shallowing out. And in all insomniacs, throughout the night, the arousal centers of the brain keep clattering away, as does the prefrontal cortex (in charge of planning, decision making), whereas in regular sleepers, these buzzing regions go offline. 'So when someone with insomnia wakes up the next morning and says, 'I don't think I slept at all last night,' in some respects, that's true,' Nofzinger told me. 'Because the parts of the brain that should have been resting did not.' And why didn't they rest? The insomniac can't say. The insomniac feels at once responsible and helpless when it comes to their misery: I must be to blame. But I can't be to blame. The feeling that sleeplessness is happening to you, not something you're doing to yourself, sends you on a quest for nonpsychological explanations: Lots of physiological conditions can cause sleep disturbances, can't they? Obstructive sleep apnea, for instance, which afflicts nearly 30 million Americans. Many autoimmune diseases, too. At one point, I'll confess that I started asking the researchers I spoke with whether insomnia itself could be an autoimmune disorder, because that's what it feels like to me—as if my brain is going after itself with brickbats. 'Narcolepsy appears to be an example of a sleep disorder involving the immune system,' Andrew Krystal, a psychiatrist specializing in sleep disorders at UCSF, told me. What? I said. Really? Really, he replied. 'There are few things I know of,' he said, 'that are as complicated as the mammalian immune system.' But insomnia-as-autoimmune-disorder is only a wisp of a theory, a wish of a theory, nothing more. In her memoir, The Shapeless Unease: A Year of Not Sleeping, the novelist Samantha Harvey casts around for a physiological explanation, too. But after she completes a battery of tests, the results come back normal, pointing to 'what I already know,' she writes, 'which is that my sleeplessness is psychological. I must carry on being the archaeologist of myself, digging around, seeing if I can excavate the problem and with it the solution—when in truth I am afraid of myself, not of what I might uncover, but of managing to uncover nothing.' I didn't tolerate my Paxil brain for long. I weaned myself off, returned to normal for a few months, and assumed that my sleeplessness had been a freak event, like one of those earthquakes in a city that never has them. But then my sleep started to slip away again, and by age 31, I couldn't recapture it without chemical assistance. Prozac worked for years on its own, but it blew out whatever circuit in my brain generates metaphors. When I turned to the antidepressants that kept the electricity flowing, I needed sleep medication too—proving, to my mind, that melancholy couldn't have been the mother of my sleep troubles, but the lasting result of them. I've used the lowest dose of Klonopin to complement my SSRIs for years. In times of acute stress, I need a gabapentin or a Unisom too. Unisom is fine. Gabapentin also turns my mind into an empty prairie. Edibles, which I've also tried, turn my brain to porridge the next day. Some evidence suggests that cannabis works as a sleep aid, but more research, evidently, is required. (Sorry.) Which brings me to the subject of drugs. I come neither to praise nor to bury them. But I do come to reframe the discussion around them, inspired by what a number of researcher-clinicians said about hypnotics and addiction during the SLEEP 2024 panel on the subject. They started with a simple question: How do you define addiction? It's true that many of the people who have taken sleep medications for months or years rely on them. Without them, the majority wouldn't sleep, at least in the beginning, and a good many would experience rebound insomnia if they didn't wean properly, which can be even worse. One could argue that this dependence is tantamount to addiction. But: We don't say people are addicted to their hypertension medication or statins, though we know that in certain instances lifestyle changes could obviate the need for either one. We don't say people are addicted to their miracle GLP-1 agonists just because they could theoretically diet and exercise to lose weight. We agree that they need them. They're on Lasix. On Lipitor. On Ozempic. Not addicted to. Yet we still think of sleep medications as 'drugs,' a word that in this case carries a whiff of stigma—partly because mental illness still carries a stigma, but also because sleep medications legitimately do have the potential for recreational use and abuse. But is that what most people who suffer from sleep troubles are doing? Using their Sonata or Ativan for fun? 'If you see a patient who's been taking medication for a long time,' Tom Roth, the founder of the Sleep Disorders and Research Center at Henry Ford Hospital, said during the panel, 'you have to think, 'Are they drug-seeking or therapy-seeking ?' ' The overwhelming majority, he and other panelists noted, are taking their prescription drugs for relief, not kicks. They may depend on them, but they're not abusing them—by taking them during the day, say, or for purposes other than sleep. Still, let's posit that many long-term users of sleep medication do become dependent. Now let's consider another phenomenon commonly associated with reliance on sleep meds: You enter Garland and Hendrix territory in a hurry. First you need one pill, then you need two; eventually you need a fistful with a fifth of gin. Yet a 2024 cohort study, which involved nearly 1 million Danes who used benzodiazepines long-term, found that of those who used them for three years or more—67,398 people, to be exact—only 7 percent exceeded their recommended dose. Not a trivial number, certainly, if you're staring across an entire population. But if you're evaluating the risk of taking a hypnotic as an individual, you'd be correct to assume that your odds of dose escalation are pretty low. That there's a difference between abuse and dependence, that dependence doesn't mean a mad chase for more milligrams, that people depend on drugs for a variety of other naturally reversible conditions and don't suffer any stigma—these nuances matter. 'Using something where the benefits outweigh the side effects certainly is not addiction,' Winkelman, the Harvard psychiatrist and chair of the panel, told me when we spoke a few months later. 'I call that treatment.' The problem, he told me, is when the benefits stop outweighing the downsides. 'Let's say the medication loses efficacy over time.' Right. That 7 percent. And over-the-counter sleep meds, whose active component is usually diphenhydramine (more commonly known as Benadryl), are potentially even more likely to lose their efficacy—the American Academy of Sleep Medicine advises against them. 'And let's say you did stop your medication,' Winkelman continued. 'Your sleep could be worse than it was before you started it,' at least for a while. 'People should know about that risk.' A small but even more hazardous risk: a seizure, for those who abruptly stop taking high doses of benzodiazepines after they've been on them for a long period of time. The likelihood is low—the exact percentage is almost impossible to ascertain—but any risk of a seizure is worth knowing about. 'And are you comfortable with the idea that the drug could irrevocably be changing your brain?' Winkelman asked. 'The brain is a machine, and you're exposing it to the repetitive stimulus of the drug.' Then again, he pointed out, you know what else is a repetitive stimulus? Insomnia. 'So should these things even be considered a part of an addiction?' he asked. 'At what point does a treatment become an addiction? I don't know.' Calvinist about sleep meds, blasé about sleep meds—whatever you are, the fact remains: We're a nation that likes them. According to a 2020 report from the National Center for Health Statistics, 8.4 percent of Americans take sleep medications most nights or every night, and an additional 10 percent take them on some. Part of the reason medication remains so popular is that it's easy for doctors to prescribe a pill and give a patient immediate relief, which is often what patients are looking for, especially if they're in extremis or need some assistance through a rough stretch. CBT‑I, as Ronald Kessler noted, takes time to work. Pills don't. But another reason, as Suzanne Bertisch pointed out during the addiction-and-insomnia-meds panel, is that 'primary-care physicians don't even know what CBT-I is. This is a failure of our field.' Even if general practitioners did know about CBT-I, too few therapists are trained in it, and those who are tend to have fully saturated schedules. The military, unsurprisingly, has tried to work around this problem (sleep being crucial to soldiers, sedatives being contraindicated in warfare) with CBT-I via video as well as an online program, both shown to be efficacious. But most of us are not in the Army. And while some hospitals, private companies, and the military have developed apps for CBT-I too, most people don't know about them. For years, medication has worked for me. I've stopped beating myself up about it. If the only side effect I'm experiencing from taking 0.5 milligrams of Klonopin is being dependent on 0.5 milligrams of Klonopin, is that really such a problem? There's been a lot of confusing noise about sleep medication over the years. 'Weak science, alarming FDA black-box warnings, and media reporting have fueled an anti-benzodiazepine movement,' says an editorial in the March 2024 issue of The American Journal of Psychiatry. 'This has created an atmosphere of fear and stigma among patients, many of whom can benefit from such medications.' A case in point: For a long time, the public believed that benzodiazepines dramatically increased the risk of Alzheimer's disease, thanks to a 2014 study in the British Medical Journal that got the usual five-alarm-fire treatment by the media. Then, two years later, another study came along, also in the British Medical Journal, saying, Never mind, nothing to see here, folks; there appears to be no causal relationship we can discern. That study may one day prove problematic, too. But the point is: More work needs to be done. A different paper, however—again by Daniel Kripke, the fellow who argued that seven hours of sleep a night predicted the best health outcomes—may provide more reason for concern. In a study published in 2012, he looked at more than 10,000 people on a variety of sleep medications and found that they were several times more likely to die within 2.5 years than a matched cohort, even when controlling for a range of culprits: age, sex, alcohol use, smoking status, body-mass index, prior cancer. Those who took as few as 18 pills a year had a 3.6-fold increase. (Those who took more than 132 had a 5.3-fold one.) John Winkelman doesn't buy it. 'Really,' he told me, 'what makes a lot more sense is to ask, 'Why did people take these medications in the first place?' ' And for what it's worth, a 2023 study funded by the National Institute on Drug Abuse and published in the Journal of the American Medical Association found that people on stable, long-term doses of a benzodiazepine who go off their medication have worse mortality rates in the following 12 months than those who stay on it. So maybe you're damned if you do, damned if you don't. Still, I take Kripke's study seriously. Because … well, Christ, I don't know. Emotional reasons? Because other esteemed thinkers still think there's something to it? In my own case, the most compelling reasons to get off medication are the more mundane ones: the scratchy little cognitive impairments it can cause during the day, the risk of falls as you get older. (I should correct myself here: Falling when you're older has the potential to be not mundane, but very bad.) Medications can also cause problems with memory as one ages, even if they don't cause Alzheimer's, and the garden-variety brain termites of middle and old age are bummer enough. And maybe most generally: Why have a drug in your system if you can learn to live without it? My suspicion is that most people who rely on sleep drugs would prefer natural sleep. So yes: I'd love to one day make a third run at CBT-I, with the hope of weaning off my medication, even if it means going through a hell spell of double exhaustion. CBT-I is a skill, something I could hopefully deploy for the rest of my life. Something I can't accidentally leave on my bedside table. Some part of me, the one that's made of pessimism, is convinced that it won't work no matter how long I stick with it. But Michael Irwin, at UCLA, told me something reassuring: His research suggests that if you have trouble with insomnia or difficulty maintaining your sleep, mindfulness meditation while lying in bed can be just as effective as climbing out of bed, sitting in a chair, and waiting until you're tired enough to crawl back in—a pillar of CBT‑I, and one that I absolutely despise. I do it sometimes, because I know I should, but it's lonely and freezing, a form of banishment. And if CBT-I doesn't work, Michael Grandner, the director of the sleep-and-health-research program at the University of Arizona, laid out an alternative at SLEEP 2024: acceptance and commitment therapy, or ACT. The basic idea is exactly what the name suggests. You accept your lot. You change exactly nothing. If you can't sleep, or you can't sleep enough, or you can sleep only in a broken line, you say, This is one of those things I can't control. (One could see how such a mantra might help a person sleep, paradoxically.) You then isolate what matters to you. Being functional the next day? Being a good parent? A good friend? If sleep is the metaphorical wall you keep ramming your head against, 'is your problem the wall?' Grandner asked. 'Or is your problem that you can't get beyond the wall, and is there another way?' Because there often is another way. To be a good friend, to be a good parent, to be who and whatever it is you most value—you can live out a lot of those values without adequate sleep. 'When you look at some of these things,' Grandner said, 'what you find is that the pain'—of not sleeping—'is actually only a small part of what is getting in the way of your life. It's really less about the pain itself and more about the suffering around the pain, and that's what we can fix.' Even as I type, I'm skeptical of this method too. My insomnia was so extreme at 29, and still can be to this day, that I'm not sure I am tough enough—or can summon enough of my inner Buddha (barely locatable on the best of days)—to transcend its pain, at once towering and a bore. But if ACT doesn't work, and if CBT-I doesn't work, and if mindfully meditating and acupuncture and neurofeedback and the zillions of other things I've tried in the past don't work on their own … well … I'll go back on medication. Some people will judge me, I'm sure. What can I say? It's my life, not theirs. I'll wrap up by talking about an extraordinary man named Thomas Wehr, once the chief of clinical psychobiology at the National Institute of Mental Health, now 83, still doing research. He was by far the most philosophical expert I spoke with, quick to find (and mull) the underlayer of whatever he was exploring. I really liked what he had to say about sleep. You've probably read the theory somewhere —it's a media chestnut—that human beings aren't necessarily meant to sleep in one long stretch but rather in two shorter ones, with a dreamy, middle-of-the-night entr'acte. In a famous 2001 paper, the historian A. Roger Ekirch showed that people in the pre-electrified British Isles used that interregnum to read, chat, poke the fire, pray, have sex. But it was Wehr who, nearly 10 years earlier, found a biological basis for these rhythms of social life, discovering segmented sleep patterns in an experiment that exposed its participants to 14 hours of darkness each night. Their sleep split in two. Wehr now knows firsthand what it is to sleep a divided sleep. 'I think what happens as you get older,' he told me last summer, 'is that this natural pattern of human sleep starts intruding back into the world in which it's not welcome—the world we've created with artificial light.' There's a melancholy quality to this observation, I know. But also a beauty: Consciously or not, Wehr is reframing old age as a time of reintegration, not disintegration, a time when our natural bias for segmented sleep reasserts itself as our lives are winding down. His findings should actually be reassuring to everyone. People of all ages pop awake in the middle of the night and have trouble going back to sleep. One associates this phenomenon with anxiety if it happens in younger people, and no doubt that's frequently the cause. But it also rhymes with what may be a natural pattern. Perhaps we're meant to wake up. Perhaps broken sleep doesn't mean our sleep is broken, because another sleep awaits. And if we think of those middle-of-the-night awakenings as meant to be, Wehr told me, perhaps we should use them differently, as some of our forebears did when they'd wake up in the night bathed in prolactin, a hormone that kept them relaxed and serene. 'They were kind of in an altered state, maybe a third state of consciousness you usually don't experience in modern life, unless you're a meditator. And they would contemplate their dreams.' Night awakenings, he went on to explain, tend to happen as we're exiting a REM cycle, when our dreams are most intense. 'We're not having an experience that a lot of our ancestors had of waking up and maybe processing, or musing, or let's even say 'being informed' by dreams.' We should reclaim those moments at 3 or 4 a.m., was his view. Why not luxuriate in our dreams? 'If you know you're going to fall back asleep,' he said, 'and if you just relax and maybe think about your dreams, that helps a lot.' This assumes one has pleasant or emotionally neutral dreams, of course. But I take his point. He was possibly explaining, unwittingly, something about his own associative habits of mind—that maybe his daytime thinking is informed by the meandering stories he tells himself while he sleeps. The problem, unfortunately, is that the world isn't structured to accommodate a second sleep or a day informed by dreams. We live unnatural, anxious lives. Every morning, we turn on our lights, switch on our computers, grab our phones; the whir begins. For now, this strange way of being is exclusively on us to adapt to. Sleep doesn't much curve to it, nor it to sleep. For those who struggle each night (or day), praying for what should be their biologically given reprieve from the chaos, the world has proved an even harsher place. But there are ways to improve it. Through policy, by refraining from judgment—of others, but also of ourselves. Meanwhile, I take comfort in the two hunter-gatherer tribes Wehr told me about, ones he modestly noted did not confirm his hypothesis of biphasic sleep. He couldn't remember their names, but I later looked them up: the San in Namibia and the Tsimané in Bolivia. They average less than 6.5 hours of sleep a night. And neither has a word for insomnia. This article appears in the August 2025 print edition with the headline 'American Insomnia.'
Vox
an hour ago
- Vox
Obsessive step counts are ruining walking
According to my phone, I've been averaging about 6,600 steps a day so far this year. My meager effort pales in comparison to the 15,000, 20,000, or even 30,000 steps I see influencers on my feed bragging about regularly. To be clear: There is nothing wrong with walking — it's a free and low-impact exercise that, compared to running, has greater mass appeal. Americans are overwhelmingly sedentary, spending an average of 9.5 hours a day seated, and anything that inspires people to move more is good news. But quantifying your every step, tracking every ounce of protein ingested, or hours slept can border on obsessive. The current cultural fixation on nutrition and fitness also speaks to a shift toward beauty standards that once again idealize thinness. Mix that with American hustle culture, and you have a recipe for turning a low-key activity into a compulsion. 'This all comes down to how much our culture values productivity above everything else,' says Keith Diaz, an associate professor of behavioral medicine at Columbia University Medical Center. 'It's just another metric that we measure ourselves by.' From leisure to optimization Walking is perhaps one of the most functional and accessible forms of movement: It gets you where you want to go, and you don't need any special equipment to do it. The vast majority of people walk at some point during their day without having to think too much about it. It makes sense, then, that walking has come in and out of fashion as a form of exercise throughout history. In the late 1800s, leisure walking became a popular sport. A century later, at the height of the fitness boom in the 1980s, walking got a rebrand and a refresh, thanks to a book called Heavyhands touting the benefits of walking with weights. 'That became,' says Danielle Friedman, the author of Let's Get Physical: How Women Discovered Exercise and Reshaped The World, 'a way to make walking not seem weak.' To achieve a textbook hot girl walk, you must walk four miles while expressing gratitude and envisioning your goals. The pandemic was a major boon for walking. With gyms and fitness studios closed and cabin fever setting in, many took to strolling as a way to get moving out of the house. Walking was gentler and less punishing than the high-intensity fitness trends of the early 2000s, Friedman says. 'The pendulum swung a little bit more toward just appreciating movement for movement's sake,' she says. But as social media caught on — the original 'hot girl walk' clip was posted on TikTok in January 2021 — walks became more performative. Walking now had a purpose. To achieve a textbook hot girl walk, for instance, you must walk four miles while expressing gratitude and envisioning your goals. Over time, the step counts ballooned. Keeping careful track of your mileage also has a long history. The first modern pedometer was designed in 1965 in Japan. Called the manpo-kei, or 10,000 steps meter, this simple act of marketing helped cement the 10,000-step threshold as a benchmark that one should strive to hit for good health and well-being. The science doesn't quite back up the marketing. Recent research has found that among women in their 70s, as few as 4,400 steps a day is related to lower mortality, compared to 2,700 steps or less. Those who walked more had even less risk for early mortality, but those benefits tapered off at more than about 7,500 steps. Another study of middle-aged adults found that those who took 8,000 steps were less likely to die early from heart disease and cancer compared to those who only took 4,000 steps. Again, the benefits plateaued after 8,000 steps. Similar findings suggest that 7,000 steps was the magic number (the studies, it should be noted, were observational and could not prove causation.) If you're walking for health, 7,000 to 8,000 steps, however, seems like a pretty good bet. These days, everyone's got a step counter in their pocket or on their wrist. Health tracking apps on phones and wearables like the Apple Watch, Oura, Fitbit, and Whoop have made it much easier to account for every single step. Health-related tracking can be extremely motivating when it comes to behavior change. When you have specific health or fitness goals, tracking is a good way to measure success. 'You have a target and you have a means to measure it,' Diaz says, 'which is great.' At the same time, you should want to engage in that activity because you like it and not because your watch or an influencer is telling you to move. Unless you're intrinsically motivated to achieve that goal — I walk because I like the way it feels — tracking can veer into compulsion. Once you've hit a benchmark of 10,000 or 15,000 or 20,000 steps, you may feel compelled to meet, or exceed, it every day or else fall into a shame and anxiety spiral. 'When the Fitbit first came out,' Diaz says, 'I used it for a couple weeks, and I just had to put it away because I couldn't do it anymore. If I didn't hit 10,000 steps in a day, it'd be nine o'clock at night and…I'd be circling my little, tiny living room for 20 minutes just to get my steps to where I need them to be. I'm sitting there, like how is this healthy in any way, shape, or form that I'm obsessing over a number?' Although quantifying an activity increases how often you do it, you start to enjoy it less. Soon, something that previously brought you enjoyment can start to feel like work. Although quantifying an activity (like counting steps or the number of pages read) increases how often you do it, you start to enjoy it less, a 2016 study found. This change can happen within a few days of tracking, the study's author Jordan Etkin, a professor of marketing at Duke University, says. When participants were able to see their results, they would continue the activity. But when they weren't shown their data, they lost the motivation to continue. 'The reasons for doing the activity shift from being because you like it or find some other value in it,' Etkin says, 'to being because it gives you this sense of accomplishment and productivity. When you don't get that anymore, because you're not tracking how many of these things you're doing, it's less valuable to you.' Instead of just moving for movement's sake, perpetual tracking assigns status and morality to basic bodily functions. Hitting a certain step count is 'good' and having a low readiness score is 'bad.' The number acts as a marker of wellness. These days, the ideal embodiment of that wellness has pivoted back toward thinness. No longer is a step just a step or a gram of protein a bit of nourishment — it's all in service of optimization of a skinnier, healthier self. People who track their health want every step to count, to matter, Etkin says. If it isn't being documented, it may as well not have happened. 'That introduces new dynamics into how people decide what and whether and when to do things,' she says, 'based on whether it's going to be recorded.' A healthy balance By no means should you stop walking if it improves your mental and physical health. But if the pressure of hitting a specific target every day causes anxiety or you're unable to forgo walking for a day, you may need to reconsider your relationship with your goals. This is 'because you're obsessing over this outward signal, and it becomes this unhealthy striving for perfectionism,' Diaz says. People can start to ignore their body's cues for rest and push themselves to injury. Related Take off your Oura Ring In order to maintain a more flexible outlook on your goals, Diaz suggests setting a range target — maybe 8,000 to 12,000 steps a day — or weekly benchmarks. If you know you're going to be moving a lot on the weekend, you won't be so fixated on a weekday where your step count is lower.
