newyorker--2020-10-04--A Scientist’s Reckoning with the Cruelty of Chance

I had always imagined that if I died young , it would be in some empty part of our world .
I figured I ’ d get swept off by katabatic winds , lose my way in a desert , or inch too close to a volcano .
As a planetary-science professor , I have spent my career doing field work in far-off places , trying to understand how life survives on Earth , and , ultimately , whether it might exist on Mars .
I have pulled molecular fossils from the salt-crusted sediments of the Australian outback and sequenced @ @ @ @ @ @ @ I have helicoptered to the shorelines of ancient lakes in the Antarctic Dry Valleys and belly-crawled through the darkness of basaltic-lava tubes .
Out in these extreme environments , there are known risks , and I ’ m always aware that , if I ’ m not careful , I could abruptly run up against some mortal limit of my own .
But I never thought my life might end like this : a Monday morning , a medical accident .
A couple weeks into the summer , I dropped by my obstetrician @ @ @ @ @ @ @ blood work .
I went alone , not expecting an ultrasound , but one of the office ’ s soon-to-be-replaced machines was sitting idly outside the door , so she wheeled it in .
As she traced her wand over my belly , a murky shape appeared , and then , out of nowhere , another .
“ Twins !
” she exclaimed , the sound of double heartbeats filling the small room .
I ’ d had two of these ultrasounds already—one at eight weeks and one at ten—and no one had @ @ @ @ @ @ @ called my husband with the news , he had to duck out of an important meeting .
He was quiet for a second , and then he began to laugh .
More detailed imaging that afternoon revealed that the babies were identical , much to the delight of our young son and daughter .
Two lives , sprung from the very same template .
What were the chances ?
It seemed like a twist on the enigma of creation—unexpected and completely enchanting , like discovering life in an ice-sealed lake or a mile @ @ @ @ @ @ @ I couldn ’ t help but smile as I thought about all the arbitrary miracles of existence , and how this one had happened to me .
I turned down a research opportunity in Mauna Loa , and my husband started coming to the lab to help me lift heavy dewars of liquid nitrogen .
After I passed into the second trimester , I started shopping for tiny matching outfits online .
I lost myself in reviews of all the ingenious contraptions that had been invented : the Twingaroo baby carrier , the @ @ @ @ @ @ @ City bassinet .
As the summer progressed , the pregnancy went from feeling exceptional , almost inexplicable , to reassuringly commonplace .
In some ways , it felt like settling into an expedition at the edge of the Earth .
After a while , every grand adventure begins to feel normal , just part of a life ’ s work .
Like most women pregnant with twins , I was scheduled for frequent checkups .
One morning , right before the start of the fall semester , the babies appeared as usual—waving and @ @ @ @ @ @ @ picked up some anomalous blood flow in the placenta .
A bit worried , our obstetrician sent my husband and me for a follow-up consult at another doctor ’ s office .
We arrived just two hours later , but , when the next ultrasound came into focus , one of our babies was floating deathly still , like a child who had fallen into a swimming pool .
The next few seconds stretched into minutes that stretched into hours , all a taffy of numbness .
A team of doctors quickly mobilized @ @ @ @ @ @ @ our other baby , we needed a fetal blood transfusion .
When , after hours of anxious waiting , it finally arrived—a lavish pint , when all we needed was a few millilitres—a doctor plunged a long , thin needle into my womb .
She nodded encouragingly as she did real-time tests : things were going well .
Then , at the very end of the procedure , the umbilical-cord vessels inexplicably began to coagulate .
The room went quiet .
If the flow of blood was strangled , our baby would asphyxiate @ @ @ @ @ @ @ changed—nothing worsened , but nothing improved .
Eventually , we were told that there was nothing to do but wait .
The next morning , we were back at the hospital , in front of the same screen , desperate for some piece of news .
As soon as we saw our baby moving , I burst into tears .
Our doctor did , too .
She told us that the heartbeat was strong , and all the blood was flowing in the right direction .
She told us that our baby could @ @ @ @ @ @ @ twenty-four sleepless hours , I tried to rest .
I thought about the baby who had already died , who I would carry with me until the end of the pregnancy , who would be mummified into a fetus papyraceus .
Grief was punctuated by consolation , or my attempts at consolation : we had lost a baby , but we still had a baby , and that baby was a carbon copy of the one we ’ d lost .
Sort of , but of course not at all .
Just two @ @ @ @ @ @ @ tighten .
We rushed back to the hospital .
Yet another ultrasound , our anxiety both painfully new and terribly familiar .
We strained to hear the sounds of an unborn heart and searched the doctors ’ faces for the news that they were about to break .
They switched off the display .
I ’ m not sure if they ever even said the words .
Eventually , I stood up , carrying two lifeless bodies with me .
When the surgery to remove the fetuses was scheduled , I looked forward @ @ @ @ @ @ @ at least some of the pain and put an end to the unreality that I had been living .
I would fall asleep and wake up and it would all be over .
Instead , what had seemed like the last chapter of one bad story became the first of another .
I have no memory of the accident : an unseen artery , inadvertently punctured .
What I remember , as the anesthesia wore off in the recovery room , is a rising chorus of beeps , a sense that people were @ @ @ @ @ @ @ to take a deep breath .
By the time they rushed me back to the O.R.
, two litres of blood had escaped the punctured vessel and pooled inside my abdominal cavity .
I spent several days in the I.C.U .
Even after I was removed from the ventilator , I was pierced with tubes , unrecognizable to myself and friends and family .
I was eventually transferred to a hospital ward , and then released .
But the day after I arrived home I was overcome by a rapidly spreading infection at @ @ @ @ @ @ @ the weeks that followed , I shuttled back and forth between home and the emergency room .
Septic thrombophlebitis , deep-vein thrombosis .
Scans for brain bleeds , scans for clots in my lungs .
Our apartment was crowded by then : my husband , my children , my mother , my father , my sister .
Each time we would leave for the E.R.
, my four-year-old daughter clutched my leg and sobbed .
My son , who had just turned seven , stared blankly ahead , sometimes sinking his teeth into @ @ @ @ @ @ @ more I fought to recover , the more the complications came , a riptide I couldn ’ t escape .
I had always thought of life as an expression of resilience .
The kinds of organisms that I study can survive—can thrive—in the most unimaginable conditions .
They can endure breathtaking pressures , boiling-hot and freezing-cold temperatures .
They can make a home out of bare rock .
If life ever took hold on Mars , I reasoned , traces of it were likely still there , for the more we learn about @ @ @ @ @ @ @ impossible it seems that it could ever be wholly extinguished from a planet .
Even my small children had struck me , from the moment they were born , as strong and vital , as irrepressible beings .
But now , in the days and weeks that followed my surgeries , they seemed intent on cataloguing hazards : where was the nearest volcano , they needed to know , the closest asteroid .
I tried to assure them that everything was O.K.
, that the world was no teacup .
I promised them @ @ @ @ @ @ @ One morning at the end of October , we buried the babies in a quiet ravine .
It had taken weeks to make the arrangements .
We ’ d skipped calls from the hospital morgue , then calls from the funeral home , until finally we decided that we were ready .
We covered the graves with flower clippings sent from friends all over the country .
It seemed we had finally reached the bottom of our loss .
The next day , my father collapsed on a bathroom floor .
As he @ @ @ @ @ @ @ nose onto the vinyl tile—the result , we would learn , of a pulmonary embolism .
We rushed the kids to the car and broke highway speed limits getting to the West Virginia hospital where he had been taken .
The next night , I took my mother ’ s place , on an air mattress beside my father ’ s bed .
Trying to sleep , I fought off a panic attack .
I was back in a hospital ward , the fluorescent lights , the anonymous alarm of nurses rushing in @ @ @ @ @ @ @ , my father was diagnosed with advanced metastatic cancer .
The doctors said that he ’ d probably had it for less than six months .
They could slow it down but not cure it .
For the two months that he ’ d been away from home , helping to take care of me and my family , my father had avoided complaining about his pain ; he thought it was just from sleeping on an uncomfortable couch .
On one Zoom appointment , conducted from my kitchen , I learned the @ @ @ @ @ @ @ : I had inherited a blood-clotting disorder .
It was caused by a point mutation .
Of the three billion nucleotide pairs that make up my chromosomes , there was one mistake .
But that one tiny error created a much bigger problem , twisting a protein into the wrong shape , setting off a cascade of other changes in my blood chemistry , and leading to thrombophilia , the propensity to develop clots .
The kind of clot that could lodge inside a placenta , or block the blood flow in the @ @ @ @ @ @ @ I took the news hard , not because the outlook was dire—the condition is easily treated—but because it made the recent catena of misfortune seem so avoidable .
I couldn ’ t stop thinking about the what-ifs , the many small nudges that could have brought about a different , happier ending .
If only there had been a little guanine base where it belonged .
If only I had known about the mutation , and taken some daily low-dose aspirin during the pregnancy .
If only I ’ d sat or slept @ @ @ @ @ @ @ been a day earlier .
If only I ’ d seen my father ’ s aching for what it was , before the first cancerous cell migrated into his bloodstream .
The same kind of thinking was irresistible in the early days of the pandemic , and remains tempting today : if only we ’ d started testing sooner , or wearing masks earlier ; if only that hundred-and-twenty-five-nanometre virus had been carried away by the wind .
I sometimes find comfort in thinking that recent events , in my own life and @ @ @ @ @ @ @ departures from the normal way of things , the result of unfathomably bad luck .
In a way , the thought gives me a sense of hope , as if there is a predestined positive outcome that will come to pass in our lives , so long as we can avoid things going wrong .
But I know that the world doesn ’ t work that way .
A wheel of fortune is deeply embedded in life itself—from a cellular to a planetary level .
My twins were formed when a blastocyst collapsed @ @ @ @ @ @ @ dying , doubled .
The DNA fused in their tiny genes was the result of an almost impossible string of events , beginning with the birth of a star billions of years ago .
Their cells carried echoes of the origins of life , of multicellularity , of consciousness—the fingerprints of mass extinctions and annihilating pandemics , of thousands of generations of opportune human meetings and human pairings .
All of that led to two tiny bodies , unrepeatable , full of boundless potential .
I explained how we now can read every @ @ @ @ @ @ @ ; how we can peer through human bodies to find out why someone is sick , where they are bleeding , what has happened to them ; how we can target the rogue cells in his grandfather ’ s body and leave the healthy ones alone ; how we can limn the crowns of a virus and trace its spread across the world .
I assured my son that these were reasons for hope , and they are .
We are now pulling COVID-19 antibodies from the plasma of survivors , developing new @ @ @ @ @ @ @ , and deploying rapid new tests in hot spots .
And , one day , we will formulate a vaccine .
In our conversation , I emphasized that there is rhyme and reason to the universe , and that our challenge is to understand it .
I didn ’ t mention that , lately , it has been harder for me to face this challenge .
But I know this is a lesson he ’ ll learn in time : that causality exists in a constant , essential tension with randomness—that the universe @ @ @ @ @ @ @ chance .
As my family , like countless others , finds its way forward in these uncertain times , I remember the moment in the I.C.U .
when , after all the emergency procedures , after the intubation , after two CT scans , after a dozen transfusions had been sluiced into my neck , my blood pressure still wouldn ’ t stabilize .
It was too dangerous to open me back up , so my bed was ferried to a lower floor of the hospital , for a radiation-guided angiogram .
I @ @ @ @ @ @ @ On the screen , my veins were a terrifying white , as if they ’ d been filled with snow .
Then a tiny probe designed by brilliant human beings , using a kind of light we can not see , threaded its way into my body .
It found the rupture and stemmed the breach .
An almost impossible procedure , with an almost impossible result .
It might just as easily have gone the other way .

On a leaden afternoon at the end of last August, six months before the pandemic took hold of the country, I found myself in an I.C.U. near Washington, D.C., breathing by way of a ventilator. I was fully conscious, having lost too much blood to risk sedation. I remember gripping the button on the morphine drip. When a nurse changed the position of my bed, my neck wrenched to the side, and saliva began to pool in my throat. With my index finger, I spelled “C-H-O-K-I-N-G” over and over again on my husband’s hand, until the nurse returned with a suction bulb. For that terror-filled night and into the next day, the machine drew my breaths in and out.
I had always imagined that if I died young, it would be in some empty part of our world. I figured I’d get swept off by katabatic winds, lose my way in a desert, or inch too close to a volcano. As a planetary-science professor, I have spent my career doing field work in far-off places, trying to understand how life survives on Earth, and, ultimately, whether it might exist on Mars. I have pulled molecular fossils from the salt-crusted sediments of the Australian outback and sequenced the red sands of the Atacama. I have helicoptered to the shorelines of ancient lakes in the Antarctic Dry Valleys and belly-crawled through the darkness of basaltic-lava tubes. Out in these extreme environments, there are known risks, and I’m always aware that, if I’m not careful, I could abruptly run up against some mortal limit of my own. But I never thought my life might end like this: a Monday morning, a medical accident.
If time could be unspooled, I would go back to the beginning—or what I thought was the beginning. Springtime in our apartment in D.C., flowers everywhere, an easy warmth that promised real heat to come. I took a pregnancy test and marvelled as the faintest of pink lines appeared. I was thirty-nine years old. This would be our third child.
A couple weeks into the summer, I dropped by my obstetrician’s office for some quick prenatal blood work. I went alone, not expecting an ultrasound, but one of the office’s soon-to-be-replaced machines was sitting idly outside the door, so she wheeled it in. As she traced her wand over my belly, a murky shape appeared, and then, out of nowhere, another. “Twins!” she exclaimed, the sound of double heartbeats filling the small room. I’d had two of these ultrasounds already—one at eight weeks and one at ten—and no one had noticed a second baby. When I called my husband with the news, he had to duck out of an important meeting. He was quiet for a second, and then he began to laugh.
More detailed imaging that afternoon revealed that the babies were identical, much to the delight of our young son and daughter. Two lives, sprung from the very same template. What were the chances? It seemed like a twist on the enigma of creation—unexpected and completely enchanting, like discovering life in an ice-sealed lake or a mile beneath the surface of the Earth. I couldn’t help but smile as I thought about all the arbitrary miracles of existence, and how this one had happened to me.
I turned down a research opportunity in Mauna Loa, and my husband started coming to the lab to help me lift heavy dewars of liquid nitrogen. After I passed into the second trimester, I started shopping for tiny matching outfits online. I lost myself in reviews of all the ingenious contraptions that had been invented: the Twingaroo baby carrier, the Twin Z nursing pillow, the Twin City bassinet. As the summer progressed, the pregnancy went from feeling exceptional, almost inexplicable, to reassuringly commonplace. In some ways, it felt like settling into an expedition at the edge of the Earth. After a while, every grand adventure begins to feel normal, just part of a life’s work.
Like most women pregnant with twins, I was scheduled for frequent checkups. One morning, right before the start of the fall semester, the babies appeared as usual—waving and dancing. But then the ultrasound technician picked up some anomalous blood flow in the placenta. A bit worried, our obstetrician sent my husband and me for a follow-up consult at another doctor’s office. We arrived just two hours later, but, when the next ultrasound came into focus, one of our babies was floating deathly still, like a child who had fallen into a swimming pool.
The next few seconds stretched into minutes that stretched into hours, all a taffy of numbness. A team of doctors quickly mobilized; if we were going to save our other baby, we needed a fetal blood transfusion. When, after hours of anxious waiting, it finally arrived—a lavish pint, when all we needed was a few millilitres—a doctor plunged a long, thin needle into my womb. She nodded encouragingly as she did real-time tests: things were going well. Then, at the very end of the procedure, the umbilical-cord vessels inexplicably began to coagulate. The room went quiet. If the flow of blood was strangled, our baby would asphyxiate. As the minutes passed, nothing changed—nothing worsened, but nothing improved. Eventually, we were told that there was nothing to do but wait. The next morning, we were back at the hospital, in front of the same screen, desperate for some piece of news. As soon as we saw our baby moving, I burst into tears. Our doctor did, too. She told us that the heartbeat was strong, and all the blood was flowing in the right direction. She told us that our baby could recover.
Back at home, after twenty-four sleepless hours, I tried to rest. I thought about the baby who had already died, who I would carry with me until the end of the pregnancy, who would be mummified into a fetus papyraceus. Grief was punctuated by consolation, or my attempts at consolation: we had lost a baby, but we still had a baby, and that baby was a carbon copy of the one we’d lost. Sort of, but of course not at all.
Just two days later, my belly started to tighten. We rushed back to the hospital. Yet another ultrasound, our anxiety both painfully new and terribly familiar. We strained to hear the sounds of an unborn heart and searched the doctors’ faces for the news that they were about to break. They switched off the display. I’m not sure if they ever even said the words. Eventually, I stood up, carrying two lifeless bodies with me.
When the surgery to remove the fetuses was scheduled, I looked forward to it. It would speed past at least some of the pain and put an end to the unreality that I had been living. I would fall asleep and wake up and it would all be over. Instead, what had seemed like the last chapter of one bad story became the first of another. I have no memory of the accident: an unseen artery, inadvertently punctured. What I remember, as the anesthesia wore off in the recovery room, is a rising chorus of beeps, a sense that people were gathering around me. I told myself to take a deep breath. By the time they rushed me back to the O.R., two litres of blood had escaped the punctured vessel and pooled inside my abdominal cavity.
I spent several days in the I.C.U. Even after I was removed from the ventilator, I was pierced with tubes, unrecognizable to myself and friends and family. I was eventually transferred to a hospital ward, and then released. But the day after I arrived home I was overcome by a rapidly spreading infection at the site of an I.V. In the weeks that followed, I shuttled back and forth between home and the emergency room. Septic thrombophlebitis, deep-vein thrombosis. Scans for brain bleeds, scans for clots in my lungs. Our apartment was crowded by then: my husband, my children, my mother, my father, my sister. Each time we would leave for the E.R., my four-year-old daughter clutched my leg and sobbed. My son, who had just turned seven, stared blankly ahead, sometimes sinking his teeth into his arm. It seemed that the more I fought to recover, the more the complications came, a riptide I couldn’t escape.
When the time came, when I was finally well, I wasn’t really. My body was still covered in scars—numb cables of skin, flanked by eyelet holes where staples had been. Some nights, I didn’t sleep at all, and when I did I had unnerving dreams, in which I suffocated by every means possible: my tongue swelled in my mouth; a tsunami collapsed on top of me. I’d wake up right before I died, my chest like a cage of scared birds.
I had always thought of life as an expression of resilience. The kinds of organisms that I study can survive—can thrive—in the most unimaginable conditions. They can endure breathtaking pressures, boiling-hot and freezing-cold temperatures. They can make a home out of bare rock. If life ever took hold on Mars, I reasoned, traces of it were likely still there, for the more we learn about what life can endure, the more impossible it seems that it could ever be wholly extinguished from a planet. Even my small children had struck me, from the moment they were born, as strong and vital, as irrepressible beings. But now, in the days and weeks that followed my surgeries, they seemed intent on cataloguing hazards: where was the nearest volcano, they needed to know, the closest asteroid. I tried to assure them that everything was O.K., that the world was no teacup. I promised them that there were happy times ahead.
One morning at the end of October, we buried the babies in a quiet ravine. It had taken weeks to make the arrangements. We’d skipped calls from the hospital morgue, then calls from the funeral home, until finally we decided that we were ready. We covered the graves with flower clippings sent from friends all over the country. It seemed we had finally reached the bottom of our loss.


newyorker--2020-10-04--Sunday Reading: Intrepid Personalities

Sunday Reading: Intrepid Personalities

Climate change threatens the natural world , our world , the only one we have , and yet you would hardly know it from the way it was treated at the first Presidential debate—particularly by the President .
But attention must be paid .
What is more important ?
For nearly sixty years , The New Yorker has published groundbreaking coverage of environmental issues and the growing crisis of climate change .
From Rachel Carson ’ s “ Silent Spring , ” published in 1962 , to Elizabeth Kolbert ’ s “ Climate of Man ” series , from 2005 @ @ @ @ @ @ @ the urgency of global warming and the rise in pollution .
This week , we ’ re releasing “ The Fragile Earth , ” a new anthology filled with some of the best pieces we ’ ve published in the magazine on this crucial subject .
To accompany its publication , we ’ re bringing you a selection of stories from our archive on the environment and the global climate crisis .
In “ The End of Ice , ” Dexter Filkins writes about the scientists who are assessing the rapid melting of @ @ @ @ @ @ @ In “ A Grand Plan to Clean the Great Pacific Garbage Patch , ” Carolyn Kormann explores a young entrepreneur ’ s dream of ridding the oceans of plastic contaminants .
In “ Silent Spring , ” Rachel Carson offers a sweeping investigation into the environmental impact of DDT and other pesticides .
In “ How Extreme Weather Is Shrinking the Planet , ” Bill McKibben examines how wildfires and rising sea levels risk making large regions of our planet uninhabitable .
Finally , in “ Greenland Is Melting , ” Elizabeth Kolbert @ @ @ @ @ @ @ ’ s ice sheet is accelerating the global crisis .
We hope that these pieces offer an illuminating glimpse into the slight progress that we ’ ve made and the enormous obstacles that remain .
If we are living so intimately with chemicals , we had better know something about their power .
Can a controversial young entrepreneur rid the ocean of plastic trash ?
With wildfires , heat waves , and rising sea levels , large tracts of the earth are at risk of becoming uninhabitable .
But the fossil-fuel industry continues @ @ @ @ @ @ @ shrinking of the country ’ s ice sheet is triggering feedback loops that accelerate the global crisis .
The floodgates may already be open .

Climate change threatens the natural world, our world, the only one we have, and yet you would hardly know it from the way it was treated at the first Presidential debate—particularly by the President. But attention must be paid. What is more important? For nearly sixty years, The New Yorker has published groundbreaking coverage of environmental issues and the growing crisis of climate change. From Rachel Carson’s “Silent Spring,” published in 1962, to Elizabeth Kolbert’s “Climate of Man” series, from 2005, the magazine has brought awareness to the urgency of global warming and the rise in pollution. This week, we’re releasing “The Fragile Earth,” a new anthology filled with some of the best pieces we’ve published in the magazine on this crucial subject. To accompany its publication, we’re bringing you a selection of stories from our archive on the environment and the global climate crisis. In “The End of Ice,” Dexter Filkins writes about the scientists who are assessing the rapid melting of a prominent glacier in the Himalayas. In “A Grand Plan to Clean the Great Pacific Garbage Patch,” Carolyn Kormann explores a young entrepreneur’s dream of ridding the oceans of plastic contaminants. In “Silent Spring,” Rachel Carson offers a sweeping investigation into the environmental impact of DDT and other pesticides. In “How Extreme Weather Is Shrinking the Planet,” Bill McKibben examines how wildfires and rising sea levels risk making large regions of our planet uninhabitable. Finally, in “Greenland Is Melting,” Elizabeth Kolbert chronicles how the shrinking of the country’s ice sheet is accelerating the global crisis. We hope that these pieces offer an illuminating glimpse into the slight progress that we’ve made and the enormous obstacles that remain.
— David Remnick
Illustration by Emiliano Ponzi
If we are living so intimately with chemicals, we had better know something about their power.
Exploring a Himalayan glacier.
Illustration by Cristiana Couceiro. Photographs: Michel Porro / Contour by Getty (man); Getty (trash); Roman Sidorenko / Shutterstock (fish); Rich Carey / Shutterstock (seahorse)
Can a controversial young entrepreneur rid the ocean of plastic trash?
With wildfires, heat waves, and rising sea levels, large tracts of the earth are at risk of becoming uninhabitable. But the fossil-fuel industry continues its assault on the facts.
Photograph by Daniel Beltrá
The shrinking of the country’s ice sheet is triggering feedback loops that accelerate the global crisis. The floodgates may already be open.


newyorker--2020-10-04--The Cryptic Crossword: No. 76

The Cryptic Crossword: No. 76

Some clues have been edited for clarity .
Subscribers can find explanations of the original puzzle ’ s answers in @ @ @

Some clues have been edited for clarity. Subscribers can find explanations of the original puzzle’s answers in our archive.


newyorker--2020-10-04--Purdue Pharma and the Sackler Family’s Plan to Keep Its Billions

Practice Fusion agreed to pay a hundred and forty-five million dollars in fines and forfeiture .
The settlement seemed to represent the first half of a two-act drama : if the company was now coöperating with authorities , then the Justice Department would surely turn next to Pharma Co. X—a prospect that became all the more intriguing when Reuters reported , the next day , that the drugmaker ’ s identity was Purdue Pharma , the maker of the blockbuster opioid OxyContin .
Many pharmaceutical companies had a hand in creating the opioid crisis , an ongoing public-health emergency in @ @ @ @ @ @ @ Americans have lost their lives .
But Purdue , which is owned by the Sackler family , played a special role because it was the first to set out , in the nineteen-nineties , to persuade the American medical establishment that strong opioids should be much more widely prescribed—and that physicians ’ longstanding fears about the addictive nature of such drugs were overblown .
With the launch of OxyContin , in 1995 , Purdue unleashed an unprecedented marketing blitz , pushing the use of powerful opioids for a huge range of ailments and @ @ @ @ @ @ @ in “ fewer than one percent ” of patients .
This strategy was a spectacular commercial success : according to Purdue , OxyContin has since generated approximately thirty billion dollars in revenue , making the Sacklers ( whom I wrote about for the magazine , in 2017 , and about whom I will publish a book next year ) one of America ’ s richest families .
But OxyContin ’ s success also sparked a deadly crisis of addiction .
Other pharmaceutical companies followed Purdue ’ s lead , introducing competing products ; @ @ @ @ @ @ @ with opioid-use disorders .
Many people who were addicted but couldn ’ t afford or access prescription drugs transitioned to heroin and black-market fentanyl .
According to a recent analysis by the Wall Street Journal , the disruptions associated with the coronavirus have only intensified the opioid epidemic , and overdose deaths are accelerating .
For all the complexity of this public-health crisis , there is now widespread agreement that its origins are relatively straightforward .
New York ’ s attorney general , Letitia James , has described OxyContin as the “ taproot @ @ @ @ @ @ @ study , by a team of economists from the Wharton School , Notre Dame , and RAND , reviewed overdose statistics in five states where Purdue opted , because of local regulations , to concentrate fewer resources in promoting its drug .
The scholars found that , in those states , overdose rates—even from heroin and fentanyl—are markedly lower than in states where Purdue did the full marketing push .
The study concludes that “ the introduction and marketing of OxyContin explain a substantial share of overdose deaths over the last two decades.
@ @ @ @ @ @ @ Fusion investigation seemed like it might be a prelude to a definitive showdown between federal prosecutors and Purdue .
But the company has a talent for evading meaningful retribution .
It pleaded guilty to federal charges once before , in 2007 , when prosecutors in Virginia alleged that the company had deceived doctors about the dangers of OxyContin .
At the time , prosecutors wanted to indict three Purdue executives on numerous felonies .
But the company hired influential lawyers who appealed to the political leadership in the Justice Department of President George @ @ @ @ @ @ @ guilty to felony “ misbranding ” and got off with a fine of six hundred million dollars—at the time , the equivalent of about six months ’ worth of OxyContin revenue .
Separately , the three Purdue executives pleaded guilty to misdemeanors , and the Sacklers kept their name out of the case altogether .
Arlen Specter , then a Republican senator from Pennsylvania , was unhappy with the deal .
When the government fines a corporation instead of sending its executives to jail , he declared , it is essentially granting “ @ @ @ @ @ @ @ the settlement , Purdue kept marketing OxyContin aggressively and playing down its risks .
( The company denies doing so . )
Sales of the drug grew , eventually reaching more than two billion dollars annually .
The fact that , thirteen years after the 2007 settlement , Purdue is alleged to have orchestrated another criminally overzealous campaign to push its opioids suggests that Specter was right : when the profits generated by crossing the line are enormous , fines aren ’ t much of a deterrent .
In fact , Purdue is @ @ @ @ @ @ @ misconduct extending well beyond the scheme with Practice Fusion .
In a little-noticed court filing by the Department of Justice this summer , federal prosecutors indicated that they had several other ongoing investigations into alleged misconduct by Purdue .
The filing states that , between 2010 and 2018 , Purdue sent sales representatives to call on prescribers who the company knew “ were facilitating medically unnecessary prescriptions.
” The company also purportedly paid kickbacks to prescribers , motivating them to write yet more opioid prescriptions , and “ paid kickbacks to specialty pharmacies @ @ @ @ @ @ @ other pharmacies refused to fill.
” Purdue ’ s alleged conduct , Justice Department officials maintain , “ gives rise to criminal liability.
” The company faces other challenges .
Last September , Purdue filed for Chapter 11 bankruptcy , and for the past year a judge in White Plains , New York , has been overseeing a process to satisfy the company ’ s many creditors .
Purdue is also a defendant in some three thousand lawsuits , brought by both public and private litigants .
Forty-seven states have sued the drugmaker @ @ @ @ @ @ @ ; twenty-nine of those have specifically named members of the Sackler family as defendants .
Both the family and the company have vigorously disputed the many allegations against them , maintaining that their conduct was always appropriate and blaming their woes on greedy lawyers and hysterical press coverage .
In an interview with Vanity Fair last year , David Sackler , a former board member and a son of the company ’ s one-time president , Richard Sackler , expressed acute grievance over the “ endless castigation ” of his family .
The @ @ @ @ @ @ @ have hardly given up the fight .
And a bankruptcy court in White Plains , it turns out , is a surprisingly congenial venue for the family to stage its endgame .
Behind the scenes , lawyers for Purdue and its owners have been quietly negotiating with Donald Trump ’ s Justice Department to resolve all the various federal investigations in an overarching settlement , which would likely involve a fine but no charges against individual executives .
In other words , the deal will be a reprise of the way that the @ @ @ @ @ @ @ Multiple lawyers familiar with the matter told me that members of the Trump Administration have been pushing hard to finalize the deal before Election Day .
The Administration will likely present such a settlement as a major victory against Big Pharma—and as another “ promise kept ” to Trump ’ s base .
If the deal goes forward , it would mark a stunning turn in the decades-long saga of trying to hold Purdue and the Sacklers responsible for their role in the opioid crisis .
But even more stunning is the projected @ @ @ @ @ @ @ Plains .
At a recent hearing , the judge , Robert Drain , became defensive when a lawyer representing creditors suggested that the Sacklers might “ get away with it.
” But , if the Sacklers achieve the result that the family ’ s legal team is quietly engineering , they seem poised to do just that .
The 2007 case was not supposed to end the way it did .
For four years , prosecutors in the Western District of Virginia gathered evidence on Purdue , subpoenaing millions of documents .
They @ @ @ @ @ @ @ in which Purdue systematically misled doctors ( and the general public ) about the risks associated with OxyContin .
In September , 2006 , the prosecutors detailed their damning evidence in a hundred-and-twenty-page memo , suggesting that the wrongdoing at Purdue was so pervasive , and so consistent , that it could have been authorized only by the company ’ s leaders .
This memo , an internal government document , was not made public until August , 2019 , when the Times published excerpts of it showing that the prosecutors had intended @ @ @ @ @ @ @ Purdue executives : Michael Friedman , Howard Udell , and Paul Goldenheim .
The full memo , which I have reviewed , describes the Sacklers as “ The Family ” and notes that the company was owned and controlled by the brothers Mortimer and Raymond Sackler and their heirs .
( The heirs of a third Sackler brother , Arthur , sold their interest in the company prior to the introduction of OxyContin . )
The company “ trained its sales representatives ” to use “ false and fraudulent ” claims about OxyContin @ @ @ @ @ @ @ noted that the three executives they intended to charge “ reported directly to The Family.
” ( An attorney for Paul Goldenheim said that Goldenheim pleaded guilty to an “ unjust misdemeanor , ” and that there was no evidence he had “ participated in or approved off-label marketing ” ; Michael Friedman could not be reached for comment ; Howard Udell died in 2013 . )
The Sacklers have long maintained that they and their company are blameless when it comes to the opioid crisis because OxyContin was fully approved by the @ @ @ @ @ @ @ of the more shocking passages in the prosecution memo involve previously unreported details about the F.D.A .
official in charge of issuing that approval , Dr. Curtis Wright .
Prosecutors discovered significant impropriety in the way that Wright shepherded the OxyContin application through the F.D.A.
, describing his relationship with the company as conspicuously “ informal in nature.
” Not long after Wright approved the drug for sale , he stepped down from his position .
A year later , he took a job at Purdue .
According to the prosecution memo , @ @ @ @ @ @ @ three hundred and seventy-nine thousand dollars—roughly three times his previous salary .
( Wright declined to comment . )
Before the prosecutors in Virginia could secure indictments in such an ambitious case , they needed approval from Washington .
A Department of Justice official , Kirk Ogrosky , studied the evidence in the memo and concluded that the case was not just righteous but urgent .
In an internal review of the charges , Ogrosky wrote , “ Perhaps no case in our history rivals the burden placed on public health and safety @ @ @ @ @ @ @ in the Western District of Virginia .
OxyContin abuse has significantly impacted the lives of millions of Americans.
” He urged the department to proceed with indictments as soon as possible , noting that Purdue had a “ direct financial incentive ” to slow the case down , because any further delay “ will merely allow the continued fraudulent sales and marketing of OxyContin and substantial additional revenue to the Defendants.
” Purdue had assembled a team of high-powered attorneys , including Mary Jo White , the former U.S. Attorney for the Southern @ @ @ @ @ @ @ , the former New York City mayor ; and Howard Shapiro , the former general counsel of the F.B.I .
According to former officials involved in the case , Purdue ’ s lawyers persuaded the political leadership in the Bush Justice Department to scuttle the prosecution .
When the U.S. Attorney for the Western District of Virginia , John Brownlee , announced , in May , 2007 , that Purdue had pleaded guilty to felony misbranding and had agreed to pay more than half a billion dollars in fines , he framed the @ @ @ @ @ @ @ .
But it wasn ’ t .
“ This is the reason we have the Department of Justice , to prosecute these kinds of cases , ” Paul Pelletier , a senior department official at the time , told me .
“ When I saw the evidence , there was no doubt in my mind that if we had indicted these people—if these guys had gone to jail—it would have changed the way that people did business.
” Purdue has long maintained that it did alter its behavior after the guilty plea , @ @ @ @ @ @ @ plan for its sales reps , while also suggesting there really wasn ’ t much that needed changing .
Members of the Sackler family and company lawyers have said that there was no systemic problem in the company ; rather , it was a case of a few bad apples ( or a “ number of sales reps , ” as David Sackler told Vanity Fair ) .
One indication of how seriously the company regarded its punishments came to light in a 2015 deposition of Richard Sackler .
During Purdue ’ s @ @ @ @ @ @ @ prosecutors and company lawyers had negotiated a so-called Agreed Statement of Facts : a list of transgressions to which Purdue was ready to concede .
It was considerably more modest than the extravagant catalogue of misdeeds contained in the Department of Justice ’ s prosecution memo ; even so , an Agreed Statement of Facts can serve as a useful corrective for a company that has erred , offering a road map to better corporate responsibility .
In the deposition , Richard Sackler was asked whether , as a longtime executive and board @ @ @ @ @ @ @ was anything in the document that had surprised him .
“ As we sit here today , have you ever read the entire document ?
” he was asked .
In August , 2019 , David Sackler flew to Cleveland , where he presented a proposal to a coalition of public and private attorneys who were suing the company .
Purdue was facing nearly three thousand lawsuits from states , cities , counties , Native American tribes , school districts , hospitals , and a host of other plaintiffs .
The company had @ @ @ @ @ @ @ with the state of Oklahoma , for two hundred and seventy million dollars .
But , at the time , Purdue was being sued by forty-five other states , and David Sackler offered to resolve all the cases against the company and the family in a single grand gesture .
A wave of headlines reported the news : “ PURDUE PHARMA OFFERS $ 10-12 BILLION TO SETTLE OPIOID CLAIMS.
” This seemed like a significant figure , but the headlines were misleading .
According to a term sheet in which attorneys for the @ @ @ @ @ @ @ of this proposed “ comprehensive settlement , ” the Sacklers were prepared to make a guaranteed contribution of only three billion dollars .
Further funds could be secured , the family suggested , by selling its international businesses and by converting Purdue Pharma into a “ public benefit corporation ” that would continue to yield revenue—by selling OxyContin and other opioids—but would no longer profit the Sacklers personally .
This was a discomfiting , and somewhat brazen , suggestion : the Sacklers were proposing to remediate the damage of the opioid crisis with @ @ @ @ @ @ @ drug that had initiated the crisis .
At the same time , the term sheet suggested , Purdue would supply new drugs to treat opioid addiction and counteract overdoses—though the practicalities of realizing this initiative , and the Sacklers ’ estimate that it would represent four billion dollars in value , remained distinctly speculative .
( A family representative told me that the Sacklers want “ to set aside divisive litigation based on misleading allegations to collaborate in working together to find real solutions that save lives.
” ) Roughly half of the @ @ @ @ @ @ @ a great deal of money , and many states are reeling from the costs of the opioid crisis .
But other attorneys general balked , complaining that the Sacklers were not contributing enough out of pocket .
When they pushed the family to make a guaranteed contribution of four and a half billion dollars , the Sacklers refused to budge .
According to Josh Stein , the attorney general of North Carolina , who negotiated directly with the family , their position was “ take it or leave it.
” It might seem @ @ @ @ @ @ @ legal exposure to issue such a stark ultimatum , but the Sacklers had an important piece of leverage .
Even as David Sackler was making his offer in Cleveland , Purdue Pharma was preparing to file for bankruptcy .
If the company declared bankruptcy , it would leave virtually every state—and thousands of other claimants—with no choice but to fight over Purdue ’ s remaining assets in bankruptcy court .
Mary Jo White , who still represents the Sacklers , announced , “ Purdue and the Sackler family members , given this litigation @ @ @ @ @ @ @ the plaintiffs in a constructive way to get the monies to the communities that need them.
” Take the money now , she warned , or the alternative would be to “ pay attorneys ’ fees for years and years and years to come .
”

“I can’t say,” he replied.
“As we sit here today, have you ever read the entire document?” he was asked.
“No,” Sackler said.
In the past few years, it has become significantly more difficult for the Sacklers to display such willful disregard for the conduct of the family company. In January, 2019, the attorney general of Massachusetts, Maura Healey, unveiled a blistering two-hundred-and-seventy-four-page complaint against Purdue, in which she took the unprecedented step of naming not just the company but eight members of the Sackler family as defendants in a civil case. Her filing was studded with damning internal company e-mails revealing that, even in the face of a skyrocketing death toll from the opioid crisis, members of the Sackler family pushed Purdue staff to find aggressive new ways to market OxyContin and other opioids, and to persuade doctors to prescribe stronger doses for longer periods of time. Letitia James, the New York attorney general, soon followed with her own complaint, which also named the Sacklers and presented further evidence of the family’s complicity. (The Sacklers and Purdue have strenuously denied the charges in both complaints.) Museums and universities, which had previously been happy to receive donations from the Sacklers and name buildings and wings after them, have distanced themselves, announcing that they will no longer accept contributions from the family. Tufts University and the Louvre Museum have gone so far as to take down all signs bearing the Sackler name.
In August, 2019, David Sackler flew to Cleveland, where he presented a proposal to a coalition of public and private attorneys who were suing the company. Purdue was facing nearly three thousand lawsuits from states, cities, counties, Native American tribes, school districts, hospitals, and a host of other plaintiffs. The company had just narrowly avoided a trial by settling with the state of Oklahoma, for two hundred and seventy million dollars. But, at the time, Purdue was being sued by forty-five other states, and David Sackler offered to resolve all the cases against the company and the family in a single grand gesture. A wave of headlines reported the news: “PURDUE PHARMA OFFERS $10-12 BILLION TO SETTLE OPIOID CLAIMS.”
This seemed like a significant figure, but the headlines were misleading. According to a term sheet in which attorneys for the Sacklers and Purdue laid out the particulars of this proposed “comprehensive settlement,” the Sacklers were prepared to make a guaranteed contribution of only three billion dollars. Further funds could be secured, the family suggested, by selling its international businesses and by converting Purdue Pharma into a “public benefit corporation” that would continue to yield revenue—by selling OxyContin and other opioids—but would no longer profit the Sacklers personally. This was a discomfiting, and somewhat brazen, suggestion: the Sacklers were proposing to remediate the damage of the opioid crisis with funds generated by continuing to sell the drug that had initiated the crisis. At the same time, the term sheet suggested, Purdue would supply new drugs to treat opioid addiction and counteract overdoses—though the practicalities of realizing this initiative, and the Sacklers’ estimate that it would represent four billion dollars in value, remained distinctly speculative. (A family representative told me that the Sacklers want “to set aside divisive litigation based on misleading allegations to collaborate in working together to find real solutions that save lives.”)
Roughly half of the states embraced the proposal. It was a great deal of money, and many states are reeling from the costs of the opioid crisis. But other attorneys general balked, complaining that the Sacklers were not contributing enough out of pocket. When they pushed the family to make a guaranteed contribution of four and a half billion dollars, the Sacklers refused to budge. According to Josh Stein, the attorney general of North Carolina, who negotiated directly with the family, their position was “take it or leave it.”
It might seem reckless for a family facing potentially ruinous legal exposure to issue such a stark ultimatum, but the Sacklers had an important piece of leverage. Even as David Sackler was making his offer in Cleveland, Purdue Pharma was preparing to file for bankruptcy. If the company declared bankruptcy, it would leave virtually every state—and thousands of other claimants—with no choice but to fight over Purdue’s remaining assets in bankruptcy court. Mary Jo White, who still represents the Sacklers, announced, “Purdue and the Sackler family members, given this litigation landscape, would like to resolve with the plaintiffs in a constructive way to get the monies to the communities that need them.” Take the money now, she warned, or the alternative would be to “pay attorneys’ fees for years and years and years to come.”
When the attorneys general refused to consent to the deal, the Sacklers followed through on their threat, and Purdue declared bankruptcy. But, significantly, the Sacklers did not declare bankruptcy themselves. According to the case filed by James, the family had known as early as 2014 that the company could one day face the prospect of damaging judgments. To protect themselves on this day of reckoning, the lawsuit maintains, the Sacklers assiduously siphoned money out of Purdue and transferred it offshore, beyond the reach of U.S. authorities. A representative for Purdue told me that the drugmaker, when it declared bankruptcy, had cash and assets of roughly a billion dollars. In a deposition, one of the company’s own experts testified that the Sacklers had removed as much as thirteen billion dollars from Purdue. When the company announced that it was filing for Chapter 11, Stein derided the move as a sham. The Sacklers had “extracted nearly all the money out of Purdue and pushed the carcass of the company into bankruptcy,” he said. “Multi-billionaires are the opposite of bankrupt.”
One curiosity of corporate-bankruptcy law is that a company can effectively pick the judge who will preside over its case. On March 1, 2019—just weeks after the first lawsuit that named the Sacklers as defendants, and six months before the company actually filed for bankruptcy—Purdue paid a thirty-dollar fee to change its address for litigation documents to an anonymous office building in White Plains, New York. There is a federal courthouse in White Plains, and only one bankruptcy judge presides there: Robert Drain. A former corporate lawyer, he was appointed to the bench during the George W. Bush Administration. When Purdue declared bankruptcy, Drain issued an injunction pausing all the state and federal lawsuits against the company until the bankruptcy could be resolved—a standard feature of bankruptcy proceedings. But then Drain did something more surprising. Attorneys for the Sacklers requested that he also issue a stay halting any litigation that was directed at members of the family. This was a bold gambit. James complained that the Sacklers were asking for “the benefits of bankruptcy protection without filing for bankruptcy themselves.” Nevertheless, Drain granted the motion. This may be one of the reasons that Purdue selected him in the first place: in the past, he had shown a willingness to enjoin litigation even against so-called third parties who had not declared bankruptcy themselves. The decision was upheld on appeal.
A declaration of bankruptcy conjures images of failure and shame, but, for the Sacklers, Drain’s court has been a safe harbor. As a bankruptcy judge, Drain seems to regard himself as a creative technocrat, a dealmaker whose chief concern is efficiency. In the Purdue case, he has frequently invoked the great expense of the bankruptcy process—with scores of attorneys billing by the hour—and has sought to streamline the proceedings, citing the needs of those who have suffered from the opioid crisis and suggesting, as Mary Jo White did, that whatever limited funds remain should go toward helping people struggling with addictions, rather than toward enriching lawyers. Given Drain’s deliberately narrow conception of his own assignment, it is perhaps understandable that he has exhibited little interest in larger questions of justice and accountability, which may seem abstract or extraneous to the negotiation at hand. Indeed, at some proceedings in the past year, he has evinced frustration with state attorneys general and lawyers representing victims who have lost loved ones to the crisis. The Sacklers’ offer to settle all claims for a guaranteed payment of three billion dollars is still on the table. In a hearing in March, Drain suggested that the continued refusal by some state attorneys general to agree to the proposal was, in effect, political grandstanding; the notion that any of the parties would “hold up something that is good for all” was, in his view, “almost repulsive.”
The notion that the Sacklers might “get away with it” was raised this past July in a Times Op-Ed written by Gerald Posner, a journalist, and Ralph Brubaker, a bankruptcy scholar at the University of Illinois College of Law. They suggested that Drain could “help them hold on to their wealth by releasing them from liability for the ravages caused by OxyContin.” When one of the lawyers in the case subsequently invoked the Op-Ed in a hearing, the judge exploded. “It doesn’t matter what some numbskull Op-Ed writer puts in,” he said, maintaining that press coverage of the case had been “totally irresponsible” and “utterly misguided.” He urged the lawyers in attendance not to “buy or click on” publications like the Times, and said, “I don’t want to hear some idiot reporter or some bloggist quoted to me again in this case.”
Yet the Op-Ed writers were not wrong to question whether Drain will ultimately release the family from future liability, because that is precisely the scenario that the Sacklers have said they are pursuing. In fact, it is one of the conditions attached to their proposed settlement. In the term sheet, the family suggests that it will supply the three billion dollars and other inducements only in the event that it is released from “all potential federal liability arising from or related to opioid-related activities.” All potential liability—meaning not just civil but criminal, too.
You might think that this would leave open the possibility of future suits brought by states, but Drain has signalled a desire to foreclose those as well, maintaining that a blanket dispensation is a necessary component of the bankruptcy resolution. In February, he remarked that the “only way to get true peace, if the parties are prepared to support it and not fight it in a meaningful way, is to have a third-party release” that grants the Sacklers freedom from any future liability. This is a controversial issue, and Drain indicated that he was raising it early because in some parts of the country it’s illegal for a federal bankruptcy judge to grant a third-party release barring state authorities from bringing their own lawsuits. The case law is evolving, Drain said.
A Purdue lawyer, Marshall Huebner, assured the judge that his firm, Davis Polk, was tracking the case law “with an electron microscope.”
“You may need to do more than track,” Drain said, slipping into a register that sounded strangely like legal advice. “You may need to file an amicus”—a friend-of-the-court brief—“to counteract some of the . . .” He trailed off. “Well, I’m just leaving it at that.”
Huebner, displaying a self-awareness that Drain seemed to lack, said, “I don’t know if the world wants a Purdue Pharma amicus.” He added, “But we’ll have to take that one under advisement.”
In a filing to the court, in March, the states opposing the Sacklers’ settlement terms argued that such treatment at the hands of the legal system appears to be an exclusive prerogative of the wealthy. They wrote, “Allowing the Sacklers the special protection of a nationwide injunction against the law-enforcement actions brought against them, through a bankruptcy in which they are not the debtors, sends the wrong message to the public about the fairness of our courts and system of justice.”
In June, Drain announced that any parties with a potential claim against Purdue in the bankruptcy proceeding had to file with the court by July 30th. It was in this context that the Department of Justice revealed its multiple ongoing investigations of Purdue. Initially, it seemed that the “true peace” that Drain envisaged for the Sacklers might be in jeopardy. But, in fact, attorneys for the Sacklers and Purdue have been aware of these investigations for years, and have been negotiating with attorneys at the Justice Department to resolve them. Purdue legal bills that have been submitted to the bankruptcy court show thousands of hours of lawyer time devoted to “DOJ resolution issues.” A Purdue representative acknowledged to me that the company is engaged in “ongoing discussions” with the department regarding “a potential resolution of these investigations.” According to multiple attorneys—both inside and outside the government—who are familiar with these cases, there is tremendous pressure inside the Justice Department to resolve the investigations before Election Day.
The Trump Administration has paid lip service to the importance of addressing the opioid crisis. Bill Barr, Trump’s Attorney General, has said that his “highest priority is dealing with the plague of drugs.” In practice, however, this has meant rhetoric about heroin coming from Mexico and fentanyl coming from China, rather than a sustained effort to hold the well-heeled malefactors of the American pharmaceutical industry to account. Richard Sackler once boasted, “We can get virtually every senator and congressman we want to talk to on the phone in the next seventy-two hours.” Although the Sacklers may now be social pariahs, the family’s money—and army of white-shoe fixers—means that they still exert political influence.
According to three attorneys familiar with the dynamics inside the Justice Department, career line prosecutors have pushed to sanction Purdue in a serious way, and have been alarmed by efforts by the department’s political leadership to soften the blow. Should that happen, it will mark a grim instance of Purdue’s history repeating itself: a robust federal investigation of the company being defanged, behind closed doors, by a coalition of Purdue lawyers and political appointees. And it seems likely, as was also the case in 2007, that this failure will be dressed up as a success: a guilty plea from the company, another fine.
If such a deal is struck, it is probable that no Purdue executives will face felony charges. This week, two Democratic U.S. senators—Maggie Hassan, of New Hampshire, and Sheldon Whitehouse, of Rhode Island—sent a letter to Barr citing “DOJ’s history of leniency with Purdue” and expressing concern that the department “will once again let connected lawyers obtain a settlement that does not adequately address the harms caused by the company.” In an added irony, if the Trump Administration does seek a fine, the funds could come not from the Sacklers but from the limited pool of money available from the bankruptcy proceeding. More than a hundred thousand individuals—victims of the opioid crisis, people who have lost loved ones or struggled with addiction themselves—have filed claims as “creditors” of Purdue. In the zero-sum calculus of a bankruptcy proceeding, the bigger the financial penalty extracted by federal prosecutors, the less money there will be left over for these and other creditors.
The company is apparently feeling emboldened: it recently sought permission from the bankruptcy court to pay millions of dollars in bonuses to company leaders—some of whom presided over Purdue during the period of alleged criminal activity outlined in the Justice Department’s July 30th filing—including a three-and-a-half-million-dollar “incentive payment” to its C.E.O. In a separate letter to Drain last week, five U.S. senators argued that “no business should seek to reward any employee that has engaged in criminal practices.”
In a statement to The New Yorker, a representative for the families of Raymond and Mortimer Sackler denied all wrongdoing, maintaining that family members on Purdue’s board “were consistently assured by management that all marketing of OxyContin was done in compliance with law.” The statement continued, “Our hearts go out to those affected by drug abuse and addiction,” adding that “the rise in opioid-related deaths is driven overwhelmingly by heroin and illicit fentanyl smuggled by drug traffickers into the U.S. from China and Mexico.” At “the conclusion of this process,” the statement suggested, “all of Purdue’s documents” will be publicly disclosed, “making clear that the Sackler family acted ethically and responsibly at all times.”
The states have asserted in legal filings that the total cost of the opioid crisis exceeds two trillion dollars. Relative to that number, the three billion dollars that the Sacklers are guaranteeing in their offer is minuscule. It is also a small number relative to the fortune that the Sacklers appear likely to retain, which could be three or four times that amount. As the March filing by the states opposed to the deal argued, “When your illegal marketing campaign causes a national crisis, you should not get to keep most of the money.” What the Sacklers are offering simply “does not match what they owe.”
Nevertheless, in absolute terms, three billion dollars is still a significant sum—and the Sacklers have made it clear that they are prepared to pay it only in the event that they are granted a release from future liability. It may be that the magnitude of the dollars at stake will persuade Drain, the Justice Department officials on the case, and even the state attorneys general who initially rejected the Sacklers’ proposal to sign off. The problem, one attorney familiar with the case said, is that “criminal liability is not something that should be sold,” adding, “It should not depend on how rich they are. It’s not right.”


newyorker--2020-10-04--How to Understand Trump’s Evolving Condition

A seemingly straightforward answer .
And yet , later , it emerged that Trump ’ s oxygen levels had already dipped low enough to warrant supplementary oxygen .
Was the President not short of breath when that happened ?
No one who wasn ’ t there can say for sure , because the Administration hasn ’ t been communicating clearly and in a detailed way about Trump ’ s illness .
If the President had a fever , then what was his temperature ?
Has he sustained any lung damage ?
When did he last test negative for the virus @ @ @ @ @ @ @ , having been roundly criticized for his evasiveness after his first briefing , would be more forthright at his second , on Sunday .
Instead , he dodged again .
When asked if Trump had received a second round of supplementary oxygen , he pleaded ignorance : “ I ’ d have to check with the nursing staff , ” he said .
The vagueness of the communications we ’ ve received so far may be intentional : in particular , the question of when and how the President was first diagnosed has @ @ @ @ @ @ @ and ethical implications .
Most reports have placed his first positive test sometime between Wednesday morning and Thursday evening .
Clinically , knowing the precise time line would tell us how far into the illness Trump has progressed , and when he will enter the window , usually beginning about a week after the onset of symptoms , in which he ’ s at greatest risk for deterioration .
Epidemiologically , the timing matters for the many people Trump may have exposed to the virus : the President held campaign events throughout the @ @ @ @ @ @ @ Jersey on Thursday where he met with dozens of donors—an event that featured a buffet .
And , ethically , it affects our judgment of his actions .
It ’ s possible that Trump knew that he had been exposed to the virus , or had even received a diagnosis himself , and yet continued to meet with staff and donors , consciously placing their health at risk .
These possibilities may be adding to the Administration ’ s caginess .
In any event , the coronavirus is already confusing .
In the @ @ @ @ @ @ @ ’ ve cared for scores of patients with COVID-19 , many of whom , like Trump , have been advanced in age .
Doctors speak of the “ course ” of a disease ; my patients ’ disease courses have been unpredictable , with long plateaus interrupted by sudden reversals .
Now that Trump himself has COVID-19 , the country as a whole faces the diagnostic challenge with which doctors like me have grown familiar .
We must figure out where Trump is in the landscape of clinical possibility , and try to @ @ @ @ @ @ @ In a sense , our task is harder : we must do it without an organized , comprehensive overview of what ’ s happening , piecing together the scattered information as it emerges .
Doctors now recognize two broad and somewhat overlapping phases of COVID-19 .
In the first phase , it ’ s replication of the virus that causes problems , such as shortness of breath ; especially in the lungs , the virus has hijacked the body ’ s cells to multiply exponentially , and the immune system is fighting to @ @ @ @ @ @ @ during this phase that antiviral drugs are thought to have their greatest effect ; they are like reinforcements for the immune system , and they help to slow the replication of the virus .
In the second phase , it ’ s the immune system itself that starts to become a problem .
The virus provokes an immunological storm that wreaks havoc on many different organs ; the lungs are still at the center of the disease , but other systems get damaged , too .
The body must now fight the virus @ @ @ @ @ @ @ patients never enter this second , more dangerous phase , but those who do can grow seriously ill. To evaluate patients with COVID-19 , therefore , one must start by determining where in the process they find themselves : are they in the first phase , the second , or the transition between ?
It ’ s not unusual for people to be admitted to the hospital during the first phase .
Because their lungs are under attack , they often have trouble breathing and need some supportive oxygen ; in many cases @ @ @ @ @ @ @ primary rationale for hospitalization .
( This seems likely to have been true in Trump ’ s case . )
Such patients are monitored closely for changes in oxygen levels and also for other problems that can arise , such as blood clots , heart-muscle damage , bacterial pneumonia , and worsening kidney function .
They are likely to receive remdesivir , an antiviral drug , and perhaps the steroid dexamethasone , if their oxygen levels dip low enough .
( According to the RECOVERY Trial , a large biostatistical effort in the @ @ @ @ @ @ @ need supplemental oxygen . )
We now know that the President has received both remdesivir and dexamethasone ; in general , the administration of steroids suggests that a patient is approaching , or has already entered , the second , immune-focussed phase of the disease .
Still , at this level of illness , a patient might spend a few days on and off small doses of oxygen , delivered through a nasal cannula—a hose with prongs for the nostrils .
All this is nerve-racking for patients and their doctors and families , @ @ @ @ @ @ @ and then recover enough to be discharged home .
In some cases , however , oxygen levels continue to fall .
The immune system hasn ’ t been able to subdue the virus , and has started to overreact , causing collateral damage to blood vessels or organs .
Once this happens , the second phase has fully arrived .
Doctors monitoring a patient in this situation would be especially concerned if lab tests showed that inflammation was surging within the body , or if a CT scan uncovered a blood clot in @ @ @ @ @ @ @ lung tissue .
If a steroid had not already been started , it would be administered now .
Doctors might also prescribe a blood-thinning medication to treat or prevent a clot , or antibiotics to kill bacteria that are adding insult to viral injury .
They could also introduce more sophisticated oxygen-delivery devices—powerful high-flow nasal cannulas , or “ non-rebreather ” masks—that can provide much higher doses of oxygen to the lungs .
The air we breathe normally is about twenty-one per cent oxygen , and a regular nasal cannula might increase this @ @ @ @ @ @ @ high-flow nasal cannula can shoot nearly a hundred per cent oxygen up your nose , at sixty litres a minute .
If these maneuvers aren ’ t enough to maintain blood-oxygen levels above ninety per cent , then doctors turn to mechanical ventilators .
A tube is snaked down a patient ’ s throat and into the lungs .
All intubated patients are transferred to an I.C.U .
The ventilator takes over the work of breathing ; doctors treat what they can and hope for the best .
Precise estimates of the likelihood @ @ @ @ @ @ @ to hospitalization to I.C.U .
to death are hard to come by , and vary widely .
But a recent meta-analysis suggests that about a third of patients with severe COVID-19 end up in the I.C.U.
, and about a third of those in the I.C.U .
go on to die .
Although mortality rates for patients requiring I.C.U.-level care have declined since the start of the pandemic , they remain distressingly high .
From a medical perspective , many questions remain about Trump ’ s illness ; some may be answered in @ @ @ @ @ @ @ questions concerns diagnostic tests that could give us a clearer understanding of the seriousness of the President ’ s condition and the possibility of decline .
Disclosure of a CT scan , for example , could offer meaningful information about whether the coronavirus has injured his lungs .
( Conley indicated that the President ’ s scans have shown “ expected findings , ” but it wasn ’ t clear what this meant ; notably , he did not say the imaging was normal . )
Blood tests that analyze inflammatory molecules could @ @ @ @ @ @ @ ’ s body , and offer clues about whether the President has crossed from the first phase of illness to the second .
Much of the incomplete diagnostic information provided so far has just raised more questions .
Conley has said , for instance , that Trump is getting daily ultrasounds , which is not standard medical practice .
Ultrasounds of what , and why ?
If one of them reveals a blood clot in the legs , or damage to the heart—both relatively common complications of COVID-19—that would portend a more serious @ @ @ @ @ @ @ case , he might be facing a systemic illness , rather than one confined to the lungs ; his immune system may have failed to contain the virus and now be contributing to damage of the blood vessels and other organs .
A second set of questions revolves around the treatments Trump is receiving .
In the absence of clear communication from his medical team , we can try to work backward , using new steps in his treatment to guess at developments in his illness .
For now , we know that @ @ @ @ @ @ @ , Regeneron ’ s experimental antibody drug , on Friday .
The drug has not completed Phase III clinical trials , and hasn ’ t been approved by the F.D.A .
or authorized for emergency use ; instead , Trump received the medication under a “ compassionate use ” request .
Last week , Regeneron issued a press release indicating that REGN-COV2 has shown promise for reducing the amount of circulating virus in the body and for alleviating symptoms in non-hospitalized patients .
Preliminary results suggest that it is relatively safe , and @ @ @ @ @ @ @ , who haven ’ t yet mounted their own immune responses , are more likely to benefit from it .
( The average age of trial patients , however , was forty-four—thirty years younger than the President . )
The company is still testing to find out whether REGN-COV2 helps hospitalized patients , and whether it can prevent infection in those exposed to the virus .
The fact that Trump ’ s team decided to use an unproven drug suggests something about the perceived seriousness of his disease as early as Friday morning @

The days since Donald Trump tested positive for the coronavirus have been more confusing than usual. Consider this exchange from Saturday’s news conference with Sean Conley, the White House physician:
REPORTER: Has he also experienced difficulty breathing?
CONLEY: No, no, he has not. Never did. He had a little cough. He had the fever. More than anything he’s felt run-down.
A seemingly straightforward answer. And yet later it emerged that Trump’s oxygen levels had already dipped low enough to warrant supplementary oxygen. Was the President not short of breath when that happened? No one who wasn’t there can say for sure, because the Administration hasn’t been communicating clearly and in a detailed way about Trump’s illness. If the President had a fever, then what was his temperature? Has he sustained any lung damage? When did he last test negative for the virus? One might have hoped that Conley, having been roundly criticized for his evasiveness after his first briefing, would be more forthright at his second, on Sunday. Instead, he dodged again. When asked if Trump had received a second round of supplementary oxygen, he pleaded ignorance: “I’d have to check with the nursing staff,” he said.
The vagueness of the communications we’ve received so far may be intentional: in particular, the question of when and how the President was first diagnosed has become freighted with clinical, epidemiological, and ethical implications. Most reports have placed his first positive test sometime between Wednesday morning and Thursday evening. Clinically, knowing the precise time line would tell us how far into the illness Trump has progressed, and when he will enter the window, usually beginning about a week after the onset of symptoms, in which he’s at the greatest risk for deterioration. Epidemiologically, the timing matters for the many people Trump may have exposed to the virus: the President held campaign events throughout the week, including a fund-raiser in New Jersey on Thursday where he met with dozens of donors—an event that featured a buffet. And, ethically, it affects our judgment of his actions. It’s possible that Trump knew that he had been exposed to the virus, or had even received a diagnosis himself, and yet continued to meet with staff and donors, consciously placing their health at risk.
These possibilities may be adding to the Administration’s caginess. In any event, the coronavirus is already confusing. In the months since the pandemic started, I’ve cared for scores of patients with COVID-19, many of whom, like Trump, have been advanced in age. Doctors speak of the “course” of a disease; my patients’ disease courses have been unpredictable, with long plateaus interrupted by sudden reversals. Now that Trump himself has COVID-19, the country as a whole faces the diagnostic challenge with which doctors like me have grown familiar. We must figure out where Trump is in the landscape of clinical possibility and try to guess where he’s headed. In a sense, our task is harder: we must do it without an organized, comprehensive overview of what’s happening, piecing together the scattered information as it emerges.
Doctors now recognize two broad and somewhat overlapping phases of COVID-19. In the first phase, it’s the replication of the virus that causes problems, such as shortness of breath; especially in the lungs, the virus has hijacked the body’s cells to multiply exponentially, and the immune system is fighting to tamp it down. It’s during this phase that antiviral drugs are thought to have their greatest effect; they are like reinforcements for the immune system, and they help to slow the replication of the virus. In the second phase, it’s the immune system itself that starts to become a problem. The virus provokes an immunological storm that wreaks havoc on many organs; the lungs are still at the center of the disease, but other systems get damaged, too. The body must now fight the virus while weathering its own overreaction. Most patients never enter this second, more dangerous phase, but those who do can grow seriously ill.
To evaluate patients with COVID-19, therefore, one must start by determining where in the process they find themselves: are they in the first phase, the second, or the transition between? It’s not unusual for people to be admitted to the hospital during the first phase. Because their lungs are under attack, they often have trouble breathing and need some supportive oxygen; in many cases, an insufficient blood-oxygen level is the primary rationale for hospitalization. (This seems likely to have been true in Trump’s case.) Such patients are monitored closely for changes in oxygen levels and also for other problems that can arise, such as blood clots, heart-muscle damage, bacterial pneumonia, and worsening kidney function. They are likely to receive remdesivir, an antiviral drug, and perhaps the steroid dexamethasone, if their oxygen levels dip low enough. (According to the RECOVERY Trial, a large biostatistical effort in the U.K., dexamethasone may help people who need supplemental oxygen.) We now know that the President has received both remdesivir and dexamethasone; in general, the administration of steroids suggests that a patient is approaching, or has already entered, the second, immune-focussed phase of the disease. Still, at this level of illness, a patient might spend a few days on and off small doses of oxygen, delivered through a nasal cannula—a hose with prongs for the nostrils. All this is nerve-racking for patients and their doctors and families, but many people go through this experience and then recover enough to be discharged home.
In some cases, however, oxygen levels continue to fall. The immune system hasn’t been able to subdue the virus, and has started to overreact, causing collateral damage to blood vessels or organs. Once this happens, the second phase has fully arrived. Doctors monitoring a patient in this situation would be especially concerned if lab tests showed that inflammation was surging within the body, or if a CT scan uncovered a blood clot in the lungs or widespread injury to delicate lung tissue. If a steroid had not already been started, it would be administered now. Doctors might also prescribe a blood-thinning medication to treat or prevent a clot, or antibiotics to kill bacteria that are adding insult to viral injury. They could also introduce more sophisticated oxygen-delivery devices—powerful high-flow nasal cannulas, or “non-rebreather” masks—that can provide much higher doses of oxygen to the lungs. The air we breathe normally is about twenty-one per cent oxygen, and a regular nasal cannula might increase this proportion by a few percentage points—but a high-flow nasal cannula can shoot nearly a hundred per cent oxygen up your nose, at sixty litres a minute.


newyorker--2020-10-05--“Daffodils,” by Henri Cole

“Daffodils,” by Henri Cole

Sometimes I arrive with my buds closed , and I am mistaken for scallions , but if you cut a @ @ @ @ @ and put me in water , I open up and release yellow dust from my @ @ @ @ @ sprinkled on her shoulders after she bathes and swallows her third tranquillizer to erase herself @ @ @ @ @ through her like a small bunch of flowers grasped by a hand that connects the @ @ @ @ @ urging Trust me , as the blackbirds at dawn trust the aurora that conquers night @

Audio: Read by the author.
Sometimes I arrive with my buds closed,
and I am mistaken for scallions,
but if you cut a half inch from my stems
and put me in water, I open up and release
yellow dust from my petal cups,
like talcum sprinkled on her shoulders
after she bathes and swallows her
third tranquillizer to erase herself,
the sedative piercing right through her
like a small bunch of flowers grasped
by a hand that connects the melancholy
to something in nature urging Trust me,
as the blackbirds at dawn trust
the aurora that conquers night.