ZERO GRACE/ZERO MALICE

Amazon's purchase of One Medical could speed up American healthcare

The U.S. healthcare industry is a 7-ton seal bleeding at sea. Predators are circling. Unearned margin: price increases relative to inflation without quality improvements. Amazon is the 11-foot megalodon with 7-inch teeth. Amazon is no longer circling... but attacking.

In 2020 dollars, per capita U.S. healthcare spending increased from $2,968 in 1980 to $12,531. The result is a massive industry with 13% of the nation's workers and a fifth of GDP.

Doctor No

In 40 years, healthcare has made progress. From 73.7 in 1980 to 78.8 in 2019, life expectancy rose (before Covid knocked it back down a bit). Pharmacological therapies have revolutionized, and genetic research is paying off. The financial return, improvement split by cost increases, is terrible. No country has expense rises like the U.S., and no one spends as much per capita as we do. Developed countries have longer life expectancies, healthier populations, and less economic hardship.

Two-thirds of U.S. personal bankruptcies are due to medical expenses and/or missed work. Mom or Dad getting cancer could bankrupt many middle-class American families. 40% of American adults delayed or skipped needed care due to cost. Every healthcare improvement seems to have a downside. Same pharmacological revolution that helped millions caused opioid epidemic. Our results are poor in many areas: The U.S. has a high infant mortality rate.

Healthcare is the second-worst retail industry in the country. Gas stations are #1. Imagine walking into a Best Buy to buy a TV and a Blue Shirt associate requests you fill out the same 14 pages of paperwork you filled out yesterday. Then you wait in a crowded room until they call you, 20 minutes after the scheduled appointment you were asked to arrive early for, to see the one person in the store who can talk to you about TVs, who has 10 minutes for you. The average emergency room wait time in New York is 6 hours and 10 minutes.

If it's bad for the customer, it's worse for the business. Physicians spend 27% of their time helping patients; 49% on EHRs. Documentation, order entry, billing, and inbox management. Spend a decade getting an M.D., then become a bureaucrat.

No industry better illustrates scale diseconomies. If we got the same return on healthcare spending as other countries, we'd all live to 100. We could spend less, live longer and healthier, and pay off the national debt in 15 years. U.S. healthcare is the worst ever.

What now? Competition is at the heart of capitalism, the worst system of its kind.

Priority Time

Amazon is buying One Medical for $3.9 billion. I think this deal will liberate society. Two years in, I think One Medical is great. When I got Covid, I pressed the One Medical symbol on my phone; a nurse practitioner prescribed Paxlovid and told me which pharmacies had it in stock.

Amazon enables the company's vision. One Medical's stock is down to $10 from $40 at the start of 2021. Last year, it lost $250 million and needs cash (Amazon has $60 billion). ONEM must grow. The service has 736,000 members. Half of U.S. households have Amazon Prime. Finally, delivery. One Medical is a digital health/physical office hybrid, but you must pick up medication at the pharmacy. Upgrade your Paxlovid delivery time after a remote consultation. Amazon's core competency means it'll happen. Healthcare speed and convenience will feel alien.

It's been a long, winding road to disruption. Amazon, JPMorgan, and Berkshire Hathaway formed Haven four years ago to provide better healthcare for their 1.5 million employees. It rocked healthcare stocks the morning of the press release, but folded in 2021.

Amazon Care is an employee-focused service. Home-delivered virtual health services and nurses. It's doing well, expanding nationwide, and providing healthcare for other companies. Hilton is Amazon Care's biggest customer. The acquisition of One Medical will bring 66 million Prime households capital, domain expertise, and billing infrastructure. Imagine:

"Alexa, I'm hot and my back hurts."

"Connecting you to a Prime doctor now."

Want to vs. Have to

I predicted Amazon entering healthcare years ago. Why? For the same reason Apple is getting into auto. Amazon's P/E is 56, double Walmart's. The corporation must add $250 billion in revenue over the next five years to retain its share price. White-label clothes or smart home products won't generate as much revenue. It must enter a huge market without scale, operational competence, and data skills.

Current Situation

Healthcare reform benefits both consumers and investors. In 2015, healthcare services had S&P 500-average multiples. The market is losing faith in public healthcare businesses' growth. Healthcare services have lower EV/EBITDA multiples than the S&P 500.

Amazon isn't the only prey-hunter. Walmart and Alibaba are starting pharmacies. Uber is developing medical transportation. Private markets invested $29 billion in telehealth last year, up 95% from 2020.

The pandemic accelerated telehealth, the immediate unlock. After the first positive Covid case in the U.S., services that had to be delivered in person shifted to Zoom... We lived. We grew. Video house calls continued after in-person visits were allowed. McKinsey estimates telehealth visits are 38 times pre-pandemic levels. Doctors adopted the technology, regulators loosened restrictions, and patients saved time. We're far from remote surgery, but many patient visits are unnecessary. A study of 40 million patients during lockdown found that for chronic disease patients, online visits didn't affect outcomes. This method of care will only improve.

Amazon's disruption will be significant and will inspire a flood of capital, startups, and consumer brands. Mark Cuban launched a pharmacy that eliminates middlemen in January. Outcome? A 90-day supply of acid-reflux medication costs $17. Medicare could have saved $3.6 billion by buying generic drugs from Cuban's pharmacy. Other apex predators will look at different limbs of the carcass for food. Nike could enter healthcare via orthopedics, acupuncture, and chiropractic. LVMH, L'Oréal, and Estée Lauder may launch global plastic surgery brands. Hilton and Four Seasons may open hospitals. Lennar and Pulte could build "Active Living" communities that Nana would leave feet first, avoiding the expense and tragedy of dying among strangers.

Risks

Privacy matters: HIV status is different from credit card and billing address. Most customers (60%) feel fine sharing personal health data via virtual technologies, though. Unavoidable. 85% of doctors believe data-sharing and interoperability will become the norm. Amazon is the most trusted tech company for handling personal data. Not Meta: Amazon.

What about antitrust, then?

Amazon should be required to spin off AWS and/or Amazon Fulfillment and banned from promoting its own products. It should be allowed to acquire hospitals. One Medical's $3.9 billion acquisition is a drop in the bucket compared to UnitedHealth's $498 billion market valuation.

Antitrust enforcement shouldn't assume some people/firms are good/bad. It should recognize that competition is good and focus on making markets more competitive in each deal. The FTC should force asset divestitures in e-commerce, digital marketing, and social media. These companies can also promote competition in a social ill.

U.S. healthcare makes us fat, depressed, and broke. Competition has produced massive value and prosperity across most of our economy.

Dear Amazon … bring it.

or, how I spread monkeypox and got it myself.

This story contains nsfw (not safe for wife) stuff and shouldn't be read if you're under 18 or think I'm a newborn angel. After the opening, it's broken into three sections: a chronological explanation of my disease course, my ideas, and what I plan to do next.

Your journey awaits.

As early as mid-may, I was waltzing around the lab talking about monkeypox, a rare tropical disease with an inaccurate name. Monkeys are not its primary animal reservoir. It caused an outbreak among men who have sex with men across Europe, with unprecedented levels of person-to-person transmission. European health authorities speculated that the virus spread at raves and parties and was easily transferred through intimate, mainly sexual, contact. I had already read the nejm article about the first confirmed monkeypox patient in the u.s. and shared the photos on social media so people knew what to look for. The cdc information page only included 4 photographs of monkeypox lesions that looked like they were captured on a motorola razr.

I warned my ex-boyfriend about monkeypox. Monkeypox? responded.

Mom, I'm afraid about monkeypox. What's monkeypox?

My therapist is scared about monkeypox. What's monkeypox?

Was I alone? A few science gays on Twitter didn't make me feel overreacting.

This information got my gay head turning. The incubation period for the sickness is weeks. Many of my social media contacts are traveling to Europe this summer. What is pride? Travel, parties, and sex. Many people may become infected before attending these activities. Monkeypox will affect the lgbtq+ community.

Being right always stinks. My young scientist brain was right, though. Someone who saw this coming is one of the early victims. I'll talk about my feelings publicly, and trust me, I have many concerning what's occurring.

Part 1 is the specifics.

Wednesday nights are never smart but always entertaining. I didn't wake up until noon on june 23 and saw gay twitter blazing. Without warning, the nyc department of health announced a pop-up monkeypox immunization station in chelsea. Some days would be 11am-7pm. Walk-ins were welcome, however appointments were preferred. I tried to arrange an appointment after rubbing my eyes, but they were all taken. I got out of bed, washed my face, brushed my teeth, and put on short shorts because I wanted to get a walk-in dose and show off my legs. I got a 20-oz. cold brew on the way to the train and texted a chelsea-based acquaintance for help.

Clinic closed at 2pm. No more doses. Hundreds queued up. The government initially gave them only 1,000 dosages. For a city with 500,000 LGBT people, c'mon. What more could I do? I was upset by how things were handled. The evidence speaks for itself.

I decided to seek an appointment when additional doses were available and continued my weekend. I was celebrating nyc pride with pals. Fun! sex! * ‍

On tuesday after that, I felt a little burn. This wasn't surprising because I'd been sexually active throughout the weekend, so I got a sti panel the next day. I expected to get results in a few days, take antibiotics, and move on.

Emerging germs had other intentions. Wednesday night, I felt sore, and thursday morning, I had a blazing temperature and had sweat through my bedding. I had fever, chills, and body-wide aches and pains for three days. I reached 102 degrees. I believed I had covid over pride weekend, but I tested negative for three days straight.

STDs don't induce fevers or other systemic symptoms. If lymphogranuloma venereum advances, it can cause flu-like symptoms and swollen lymph nodes. I was suspicious and desperate for answers, so I researched monkeypox on the cdc website (for healthcare professionals). Much of what I saw on screen about monkeypox prodrome matched my symptoms. Multiple-day fever, headache, muscle aches, chills, tiredness, enlarged lymph nodes. Pox were lacking.

I told my doctor my concerns pre-medically. I'm occasionally annoying.

On saturday night, my fever broke and I felt better. Still burning, I was optimistic till sunday, when I woke up with five red splotches on my arms and fingertips.

As spots formed, burning became pain. I observed as spots developed on my body throughout the day. I had more than a dozen by the end of the day, and the early spots were pustular. I had monkeypox, as feared.

Fourth of July weekend limited my options. I'm well-connected in my school's infectious disease academic community, so I texted a coworker for advice. He agreed it was likely monkeypox and scheduled me for testing on tuesday.

nyc health could only perform 10 monkeypox tests every day. Before doctors could take swabs and send them in, each test had to be approved by the department. Some commercial labs can now perform monkeypox testing, but the backlog is huge. I still don't have a positive orthopoxvirus test five days after my test. *My 12-day-old case may not be included in the official monkeypox tally. This outbreak is far wider than we first thought, therefore I'm attempting to spread the information and help contain it.

*Update, 7/11: I have orthopoxvirus.

I spent all day in the bathtub because of the agony. Warm lavender epsom salts helped me feel better. I can't stand lavender anymore. I brought my laptop into the bathroom and viewed everything everywhere at once (2022). If my ex and I hadn't recently broken up, I wouldn't have monkeypox. All of these things made me cry, and I sat in the bathtub on the 4th of July sobbing. I thought, Is this it? I felt like Bridesmaids' Kristen Wiig (2011). I'm a flop. From here, things can only improve.

Later that night, I wore a mask and went to my roof to see the fireworks. Even though I don't like fireworks, there was something wonderful about them this year: the colors, how they illuminated the black surfaces around me, and their transient beauty. Joyful moments rarely linger long in our life. We must enjoy them now.

Several roofs away, my neighbors gathered. Happy 4th! I heard a woman yell. Why is this godforsaken country so happy? Instead of being rude, I replied. I didn't tell them I had monkeypox. I thought that would kill the mood.

By the time I went to the hospital the next day to get my lesions swabbed, wearing long sleeves, pants, and a mask, they looked like this:

I had 30 lesions on my arms, hands, stomach, back, legs, buttcheeks, face, scalp, and right eyebrow. I had some in my mouth, gums, and throat. Current medical thought is that lesions on mucous membranes cause discomfort in sensitive places. Internal lesions are a new feature of this outbreak of monkeypox. Despite being unattractive, the other sores weren't unpleasant or bothersome.

I had a bacterial sti with the pox. Who knows if that would've created symptoms (often it doesn't), but different infections can happen at once. My care team remembered that having a sti doesn't exclude out monkeypox. doxycycline rocks!

The coworker who introduced me to testing also offered me his home. We share a restroom, and monkeypox can be spread through surfaces. (Being a dna virus gives it environmental hardiness that rna viruses like sars-cov-2 lack.) I disinfected our bathroom after every usage, but I was apprehensive. My friend's place has a guest room and second bathroom, so no cross-contamination. It was the ideal monkeypox isolation environment, so I accepted his offer and am writing this piece there. I don't know what I would have done without his hospitality and attention.

The next day, I started tecovirimat, or tpoxx, for 14 days. Smallpox has been eradicated worldwide since the 1980s but remains a bioterrorism concern. Tecovirimat has a unique, orthopoxvirus-specific method of action, which reduces side effects to headache and nausea. It hasn't been used in many people, therefore the cdc is encouraging patients who take it for monkeypox to track their disease and symptoms.

Tpoxx's oral absorption requires a fatty meal. The hospital ordered me to take the medication after a 600-calorie, 25-gram-fat meal every 12 hours. The coordinator joked, "Don't diet for the next two weeks." I wanted to get peanut butter delivered, but jif is recalling their supply due to salmonella. Please give pathogens a break. I got almond butter.

Tpoxx study enrollment was documented. After signing consent documents, my lesions were photographed and measured during a complete physical exam. I got bloodwork to assess my health. My medication delivery was precise; every step must be accounted for. I got a two-week supply and started taking it that night. I rewarded myself with McDonald's. I'd been hungry for a week. I was also prescribed ketorolac (aka toradol), a stronger ibuprofen, for my discomfort.

I thought tpoxx was a wonder medicine by day two of treatment. Early lesions looked like this.

however, They vanished. The three largest lesions on my back flattened and practically disappeared into my skin. Some pustular lesions were diminishing. Tpoxx+toradol has helped me sleep, focus, and feel human again. I'm down to twice-daily baths and feeling hungrier than ever in this illness. On day five of tpoxx, some of the lesions look like this:

I have a ways to go. We must believe I'll be contagious until the last of my patches scabs over, falls off, and sprouts new skin. There's no way to tell. After a week and a half of tremendous pain and psychological stress, any news is good news. I'm grateful for my slow but steady development.

Part 2 of the rant.

Being close to yet not in the medical world is interesting. It lets me know a lot about it without being persuaded by my involvement. Doctors identify and treat patients using a tool called differential diagnosis.

A doctor interviews a patient to learn about them and their symptoms. More is better. Doctors may ask, "Have you traveled recently?" sex life? Have pets? preferred streaming service? (No, really. (Hbomax is right.) After the inquisition, the doctor will complete a body exam ranging from looking in your eyes, ears, and throat to a thorough physical.

After collecting data, the doctor makes a mental (or physical) inventory of all the conceivable illnesses that could cause or explain the patient's symptoms. Differential diagnosis list. After establishing the differential, the clinician can eliminate options. The doctor will usually conduct nucleic acid tests on swab samples or bloodwork to learn more. This helps eliminate conditions from the differential or boosts a condition's likelihood. In an ideal circumstance, the doctor can eliminate all but one reason of your symptoms, leaving your formal diagnosis. Once diagnosed, treatment can begin. yay! Love medicine.

My symptoms two weeks ago did not suggest monkeypox. Fever, pains, weariness, and swollen lymph nodes are caused by several things. My scandalous symptoms weren't linked to common ones. My instance shows the importance of diversity and representation in healthcare. My doctor isn't gay, but he provides culturally sensitive care. I'd heard about monkeypox as a gay man in New York. I was hyper-aware of it and had heard of friends of friends who had contracted it the week before, even though the official case count in the US was 40. My physicians weren't concerned, but I was. How would it appear on his mental differential if it wasn't on his radar? Mental differential rhymes! I'll trademark it to prevent theft. differential!

I was in a rare position to recognize my condition and advocate for myself. I study infections. I'd spent months researching monkeypox. I work at a university where I rub shoulders with some of the country's greatest doctors. I'm a gay dude who follows nyc queer social networks online. All of these variables positioned me to think, "Maybe this is monkeypox," and to explain why.

This outbreak is another example of privilege at work. The brokenness of our healthcare system is once again exposed by the inequities produced by the vaccination rollout and the existence of people like myself who can pull strings owing to their line of work. I can't cure this situation on my own, but I can be a strong voice demanding the government do a better job addressing the outbreak and giving resources and advice to everyone I can.

lgbtqia+ community members' support has always impressed me in new york. The queer community has watched out for me and supported me in ways I never dreamed were possible.

Queer individuals are there for each other when societal structures fail. People went to the internet on the first day of the vaccine rollout to share appointment information and the vaccine clinic's message. Twitter timelines were more effective than marketing campaigns. Contrary to widespread anti-vaccine sentiment, the LGBT community was eager to protect themselves. Smallpox vaccination? sure. gimme. whether I'm safe. I credit the community's sex positivity. Many people are used to talking about STDs, so there's a reduced barrier to saying, "I think I have something, you should be on the watch too," and taking steps to protect our health.

Once I got monkeypox, I posted on Twitter and Instagram. Besides fueling my main character syndrome, I felt like I wasn't alone. My dc-based friend had monkeypox within hours. He told me about his experience and gave me ideas for managing the discomfort. I can't imagine life without him.

My buddy and colleague organized my medical care and let me remain in his home. His and his husband's friendliness and attention made a world of difference in my recovery. All of my friends and family who helped me, whether by venmo, doordash, or moral support, made me feel cared about. I don't deserve the amazing people in my life.

Finally, I think of everyone who commented on my social media posts regarding my trip. Friends from all sectors of my life and all sexualities have written me well wishes and complimented me for my vulnerability, but I feel the most gravitas from fellow lgbtq+ persons. They're learning to spot. They're learning where to go ill. They're learning self-advocacy. I'm another link in our network of caretaking. I've been cared for, therefore I want to do the same. Community and knowledge are powerful.

You're probably wondering where the diatribe is. You may believe he's gushing about his loved ones, and you'd be right. I say that just because the queer community can take care of itself doesn't mean we should.

Even when caused by the same pathogen, comparing health crises is risky. Aids is unlike covid-19 or monkeypox, yet all were caused by poorly understood viruses. The lgbtq+ community has a history of self-medicating. Queer people (and their supporters) have led the charge to protect themselves throughout history when the government refused. Surreal to experience this in real time.

First, vaccination access is a government failure. The strategic national stockpile contains tens of thousands of doses of jynneos, the newest fda-approved smallpox vaccine, and millions of doses of acam2000, an older vaccine for immunocompetent populations. Despite being a monkeypox hotspot and international crossroads, new york has only received 7,000 doses of the jynneos vaccine. Vaccine appointments are booked within minutes. It's showing Hunger Games, which bothers me.

Second, I think the government failed to recognize the severity of the european monkeypox outbreak. We saw abroad reports in may, but the first vaccines weren't available until june. Why was I a 26-year-old pharmacology grad student, able to see a monkeypox problem in europe but not the u.s. public health agency? Or was there too much bureaucracy and politicking, delaying action?

Lack of testing infrastructure for a known virus with vaccinations and therapies is appalling. More testing would have helped understand the problem's breadth. Many homosexual guys, including myself, didn't behave like monkeypox was a significant threat because there were only a dozen instances across the country. Our underestimating of the issue, spurred by a story of few infections, was huge.

Public health officials' response to infectious diseases frustrates me. A wait-and-see approach to infectious diseases is unsatisfactory. Before a sick person is recognized, they've exposed and maybe contaminated numerous others. Vaccinating susceptible populations before a disease becomes entrenched prevents disease. CDC might operate this way. When it was easier, they didn't control or prevent monkeypox. We'll learn when. Sometimes I fear never. Emerging viral infections are a menace in the era of climate change and globalization, and I fear our government will repeat the same mistakes. I don't work at the cdc, thus I have no idea what they do. As a scientist, a homosexual guy, and a citizen of this country, I feel confident declaring that the cdc has not done enough about monkeypox. Will they do enough about monkeypox? The strategic national stockpile can respond to a bioterrorism disaster in 12 hours. I'm skeptical following this outbreak.

It's simple to criticize the cdc, but they're not to blame. Underfunding public health services, especially the cdc, is another way our government fails to safeguard its citizens. I may gripe about the vaccination rollout all I want, but local health departments are doing their best with limited resources. They may not have enough workers to keep up with demand and run a contact-tracing program. Since my orthopoxvirus test is still negative, the doh hasn't asked about my close contacts. By then, my illness will be two weeks old, too long to do anything productive. Not their fault. They're functioning in a broken system that's underfunded for the work it does.

*Update, 7/11: I have orthopoxvirus.

Monkeypox is slow, so i've had time to contemplate. Now that I'm better, I'm angry. furious and sad I want to help. I wish to spare others my pain. This was preventable and solvable, I hope. HOW?

Third, the duty.

Family, especially selected family, helps each other. So many people have helped me throughout this difficult time. How can I give back? I have ideas.

1. Education. I've already started doing this by writing incredibly detailed posts on Instagram about my physical sickness and my thoughts on the entire scandal. via tweets. by producing this essay. I'll keep doing it even if people start to resent me! It's crucial! On my Instagram profile (@kyleplanckton), you may discover a story highlight with links to all of my bizarre yet educational posts.

2. Resources. I've forwarded the contact information for my institution's infectious diseases clinic to several folks who will hopefully be able to get tpoxx under the expanded use policy. Through my social networks, I've learned of similar institutions. I've also shared crowdsourced resources about symptom relief and vaccine appointment availability on social media. DM me or see my Instagram highlight for more.

3. Community action. During my illness, my friends' willingness to aid me has meant the most. It was nice to know I had folks on my side. One of my pals (thanks, kenny) snagged me a mcgriddle this morning when seamless canceled my order. This scenario has me thinking about methods to help people with monkeypox isolation. A two-week isolation period is financially damaging for many hourly workers. Certain governments required paid sick leave for covid-19 to allow employees to recover and prevent spread. No comparable program exists for monkeypox, and none seems to be planned shortly.

I want to aid monkeypox patients in severe financial conditions. I'm willing to pick up and bring groceries or fund meals/expenses for sick neighbors. I've seen several GoFundMe accounts, but I wish there was a centralized mechanism to link those in need with those who can help. Please contact me if you have expertise with mutual aid organizations. I hope we can start this shortly.

4. lobbying. Personal narratives are powerful. My narrative is only one, but I think it's compelling. Over the next day or so, i'll write to local, state, and federal officials about monkeypox. I wanted a vaccine but couldn't acquire one, and I feel tpoxx helped my disease. As a pharmacologist-in-training, I believe collecting data on a novel medicine is important, and there are ethical problems when making a drug with limited patient data broadly available. Many folks I know can't receive tpoxx due of red tape and a lack of contacts. People shouldn't have to go to an ivy league hospital to obtain the greatest care. Based on my experience and other people's tales, I believe tpoxx can drastically lessen monkeypox patients' pain and potentially curb transmission chains if administered early enough. This outbreak is manageable. It's not too late if we use all the instruments we have (diagnostic, vaccine, treatment).

*UPDATE 7/15: I submitted the following letter to Chuck Schumer and Kirsten Gillibrand. I've addressed identical letters to local, state, and federal officials, including the CDC and HHS.

I hope to join RESPND-MI, an LGBTQ+ community-led assessment of monkeypox symptoms and networks in NYC. Visit their website to learn more and give to this community-based charity.

How I got monkeypox is a mystery. I received it through a pride physical interaction, but i'm not sure which one. This outbreak will expand unless leaders act quickly. Until then, I'll keep educating and connecting people to care in my neighborhood.

Despite my misgivings, I see some optimism. Health department social media efforts are underway. During the outbreak, the CDC provided nonjudgmental suggestions for safer social and sexual activity. There's additional information regarding the disease course online, including how to request tpoxx for sufferers. These materials can help people advocate for themselves if they're sick. Importantly, homosexual guys are listening when they discuss about monkeypox online and irl. Learners They're serious.

The government has a terrible track record with lgtbq+ health issues, and they're not off to a good start this time. I hope this time will be better. If I can aid even one individual, I'll do so.

Thanks for reading, supporting me, and spreading awareness about the 2022 monkeypox outbreak. My dms are accessible if you want info, resources, queries, or to chat.

y'all well

kyle

My colleague Ilana Ovental and I examined pandemic media coverage of education at the end of last year. That analysis examined coverage changes. We tracked K-12 topic attention over the previous two decades using Lexis Nexis. See the results here.

I was struck by how cleanly the past two decades can be divided up into three (or three and a half) eras of school reform—a framing that can help us comprehend where we are and how we got here. In a time when epidemic, political unrest, frenetic news cycles, and culture war can make six months seem like a lifetime, it's worth pausing for context.

If you look at the peaks in the above graph, the 21st century looks to be divided into periods. The decade-long rise and fall of No Child Left Behind began during the Bush administration. In a few years, NCLB became the dominant K-12 framework. Advocates and financiers discussed achievement gaps and measured success with AYP.

NCLB collapsed under the weight of rigorous testing, high-stakes accountability, and a race to the bottom by the Obama years. Obama's Race to the Top garnered attention, but its most controversial component, the Common Core State Standards, rose quickly.

Academic standards replaced assessment and accountability. New math, fiction, and standards were hotly debated. Reformers and funders chanted worldwide benchmarking and systems interoperability.

We went from federally driven testing and accountability to government encouraged/subsidized/mandated (pick your verb) reading and math standardization. Last year, Checker Finn and I wrote The End of School Reform? The 2010s populist wave thwarted these objectives. The Tea Party, Occupy Wall Street, Black Lives Matter, and Trump/MAGA all attacked established institutions.

Consequently, once the Common Core fell, no alternative program emerged. Instead, school choice—the policy most aligned with populist suspicion of institutional power—reached a half-peak. This was less a case of choice erupting to prominence than of continuous growth in a vacuum. Even with Betsy DeVos' determined, controversial efforts, school choice received only half the media attention that NCLB and Common Core did at their heights.

Recently, culture clash-fueled attention to race-based curriculum and pedagogy has exploded (all playing out under the banner of critical race theory). This third, culture war-driven wave may not last as long as the other waves.

Even though I don't understand it, the move from slow-building policy debate to fast cultural confrontation over two decades is notable. I don't know if it's cyclical or permanent, or if it's about schooling, media, public discourse, or all three.

One final thought: After doing this work for decades, I've noticed how smoothly advocacy groups, associations, and other activists adapt to the zeitgeist. In 2007, mission statements focused on accomplishment disparities. Five years later, they promoted standardization. Language has changed again.

Part of this is unavoidable and healthy. Chasing currents can also make companies look unprincipled, promote scepticism, and keep them spinning the wheel. Bearing in mind that these tides ebb and flow may give educators, leaders, and activists more confidence to hold onto their values and pause when they feel compelled to follow the crowd.

Canonicalization and canonical URLs are essential for SEO, and improper implementation can negatively impact your site's performance.

Canonical tags were introduced in 2009 to help webmasters with duplicate or similar content on multiple URLs.

To use canonical tags properly, you must understand their purpose, operation, and implementation.

Canonical URLs and Tags

Canonical tags tell search engines that a certain URL is a page's master copy. They specify a page's canonical URL. Webmasters can avoid duplicate content by linking to the "canonical" or "preferred" version of a page.

How are canonical tags and URLs different? Can these be specified differently?

Tags

Canonical tags are found in an HTML page's head></head> section.

<link rel="canonical" href="https://www.website.com/page/" />

These can be self-referencing or reference another page's URL to consolidate signals.

Canonical tags and URLs are often used interchangeably, which is incorrect.

The rel="canonical" tag is the most common way to set canonical URLs, but it's not the only way.

Canonical URLs

What's a canonical link? Canonical link is the'master' URL for duplicate pages.

In Google's own words:

A canonical URL is the page Google thinks is most representative of duplicate pages on your site.

— Google Search Console Help

You can indicate your preferred canonical URL. For various reasons, Google may choose a different page than you.

When set correctly, the canonical URL is usually your specified URL.

Canonical URLs determine which page will be shown in search results (unless a duplicate is explicitly better for a user, like a mobile version).

Canonical URLs can be on different domains.

Other ways to specify canonical URLs

Canonical tags are the most common way to specify a canonical URL.

You can also set canonicals by:

• Setting the HTTP header rel=canonical.

• All pages listed in a sitemap are suggested as canonicals, but Google decides which pages are duplicates.

• Redirects 301.

Google recommends these methods, but they aren't all appropriate for every situation, as we'll see below. Each has its own recommended uses.

Setting canonical URLs isn't required; if you don't, Google will use other signals to determine the best page version.

To control how your site appears in search engines and to avoid duplicate content issues, you should use canonicalization effectively.

Why Duplicate Content Exists

Before we discuss why you should use canonical URLs and how to specify them in popular CMSs, we must first explain why duplicate content exists. Nobody intentionally duplicates website content.

Content management systems create multiple URLs when you launch a page, have indexable versions of your site, or use dynamic URLs.

Assume the following URLs display the same content to a user:

1. https://www.website.com/category/product-a/

2. https://www.website.com/product-a/

3. https://website.com/product-a/

4. http://www.website.com/product-a/

5. http://website.com/product-a/

6. https://m.website.com/product-a/

7. https://www.website.com/product-a

8. https://www.website.com/product-A/

A search engine sees eight duplicate pages, not one.

• URLs #1 and #2: the CMS saves product URLs with and without the category name.

• #3, #4, and #5 result from the site being accessible via HTTP, HTTPS, www, and non-www.

• #6 is a subdomain mobile-friendly URL.

• URL #7 lacks URL #2's trailing slash.

• URL #8 uses a capital "A" instead of a lowercase one.

Duplicate content may also exist in URLs like:

https://www.website.com
https://www.website.com/index.php

Duplicate content is easy to create.

Canonical URLs help search engines identify different page variations as a single URL on many sites.

SEO Canonical URLs

Canonical URLs help you manage duplicate content that could affect site performance.

Canonical URLs are a technical SEO focus area for many reasons.

Specify URL for search results

When you set a canonical URL, you tell Google which page version to display.

Which would you click?

https://www.domain.com/page-1/

https://www.domain.com/index.php?id=2

First, probably.

Canonicals tell search engines which URL to rank.

Consolidate link signals on similar pages

When you have duplicate or nearly identical pages on your site, the URLs may get external links.

Canonical URLs consolidate multiple pages' link signals into a single URL.

This helps your site rank because signals from multiple URLs are consolidated into one.

Syndication management

Content is often syndicated to reach new audiences.

Canonical URLs consolidate ranking signals to prevent duplicate pages from ranking and ensure the original content ranks.

Avoid Googlebot duplicate page crawling

Canonical URLs ensure that Googlebot crawls your new pages rather than duplicated versions of the same one across mobile and desktop versions, for example.

Crawl budgets aren't an issue for most sites unless they have 100,000+ pages.

How to Correctly Implement the rel=canonical Tag

Using the header tag rel="canonical" is the most common way to specify canonical URLs.

Adding tags and HTML code may seem daunting if you're not a developer, but most CMS platforms allow canonicals out-of-the-box.

These URLs each have one product.

How to Correctly Implement a rel="canonical" HTTP Header

A rel="canonical" HTTP header can replace canonical tags.

This is how to implement a canonical URL for PDFs or non-HTML documents.

You can specify a canonical URL in your site's.htaccess file using the code below.

<Files "file-to-canonicalize.pdf"> Header add Link "< http://www.website.com/canonical-page/>; rel=\"canonical\"" </Files>

301 redirects for canonical URLs

Google says 301 redirects can specify canonical URLs.

Only the canonical URL will exist if you use 301 redirects. This will redirect duplicates.

This is the best way to fix duplicate content across:

• HTTPS and HTTP

• Non-WWW and WWW

• Trailing-Slash and Non-Trailing Slash URLs

On a single page, you should use canonical tags unless you can confidently delete and redirect the page.

Sitemaps' canonical URLs

Google assumes sitemap URLs are canonical, so don't include non-canonical URLs.

This does not guarantee canonical URLs, but is a best practice for sitemaps.

Best-practice Canonical Tag

Once you understand a few simple best practices for canonical tags, spotting and cleaning up duplicate content becomes much easier.

Always include:

One canonical URL per page

If you specify multiple canonical URLs per page, they will likely be ignored.

Correct Domain Protocol

If your site uses HTTPS, use this as the canonical URL. It's easy to reference the wrong protocol, so check for it to catch it early.

Trailing slash or non-trailing slash URLs

Be sure to include trailing slashes in your canonical URL if your site uses them.

Specify URLs other than WWW

Search engines see non-WWW and WWW URLs as duplicate pages, so use the correct one.

Absolute URLs

To ensure proper interpretation, canonical tags should use absolute URLs.

So use:

<link rel="canonical" href="https://www.website.com/page-a/" />

And not:

<link rel="canonical" href="/page-a/" />

If not canonicalizing, use self-referential canonical URLs.

When a page isn't canonicalizing to another URL, use self-referencing canonical URLs.

Canonical tags refer to themselves here.

Common Canonical Tags Mistakes

Here are some common canonical tag mistakes.

301 Canonicalization

Set the canonical URL as the redirect target, not a redirected URL.

Incorrect Domain Canonicalization

If your site uses HTTPS, don't set canonical URLs to HTTP.

Irrelevant Canonicalization

Canonicalize URLs to duplicate or near-identical content only.

SEOs sometimes try to pass link signals via canonical tags from unrelated content to increase rank. This isn't how canonicalization should be used and should be avoided.

Multiple Canonical URLs

Only use one canonical tag or URL per page; otherwise, they may all be ignored.

When overriding defaults in some CMSs, you may accidentally include two canonical tags in your page's <head>.

Pagination vs. Canonicalization

Incorrect pagination can cause duplicate content. Canonicalizing URLs to the first page isn't always the best solution.

Canonicalize to a 'view all' page.

How to Audit Canonical Tags (and Fix Issues)

Audit your site's canonical tags to find canonicalization issues.

SEMrush Site Audit can help. You'll find canonical tag checks in your website's site audit report.

Let's examine these issues and their solutions.

No Canonical Tag on AMP

Site Audit will flag AMP pages without canonical tags.

Canonicalization between AMP and non-AMP pages is important.

Add a rel="canonical" tag to each AMP page's head>.

No HTTPS redirect or canonical from HTTP homepage

Duplicate content issues will be flagged in the Site Audit if your site is accessible via HTTPS and HTTP.

You can fix this by 301 redirecting or adding a canonical tag to HTTP pages that references HTTPS.

Broken canonical links

Broken canonical links won't be considered canonical URLs.

This error could mean your canonical links point to non-existent pages, complicating crawling and indexing.

Update broken canonical links to the correct URLs.

Multiple canonical URLs

This error occurs when a page has multiple canonical URLs.

Remove duplicate tags and leave one.

Canonicalization is a key SEO concept, and using it incorrectly can hurt your site's performance.

Once you understand how it works, what it does, and how to find and fix issues, you can use it effectively to remove duplicate content from your site.

Canonicalization SEO Myths

Research on preventing disease, extending life, and caring for your body from the inside out

Grapefruit and pomegranates aren't on the list, so ignore that. Mostly, I enjoyed the visual, but those fruits are healthful, too.

15 (or 17 if you consider the photo) different foods a day sounds like a lot. If you're not used to it  — it is.

These lists don't aim for perfection. Instead, use this article and the science below to eat more of these foods. If you can eat 5 foods one day and 5 the next, you're doing well. This list should be customized to your requirements and preferences.

“Every time you eat or drink, you are either feeding disease or fighting it” -Heather Morgan.

The 15 Foods That You Should Consume Daily and Why:

1. Dark/Red Berries

(blueberries, blackberries, acai, goji, cherries, strawberries, raspberries)

The 2010 Global Burden of Disease Study is the greatest definitive analysis of death and disease risk factors in history. They found the primary cause of both death, disability, and disease inside the United States was diet.

Not eating enough fruit, and specifically berries, was one of the best predictors of disease (1).

What's special about berries? It's their color! Berries have the most antioxidants of any fruit, second only to spices. The American Cancer Society found that those who ate the most berries were less likely to die of cardiovascular disease.

2. Beans

Soybeans, black beans, kidney beans, lentils, split peas, chickpeas.

Beans are one of the most important predictors of survival in older people, according to global research (2).

For every 20 grams (2 tablespoons) of beans consumed daily, the risk of death is reduced by 8%.

Soybeans and soy foods are high in phytoestrogen, which reduces breast and prostate cancer risks. Phytoestrogen blocks the receptors' access to true estrogen, mitigating the effects of weight gain, dairy (high in estrogen), and hormonal fluctuations (3).

3. Nuts

(almonds, walnuts, pecans, pistachios, Brazil nuts, cashews, hazelnuts, macadamia nuts)

Eating a handful of nuts every day reduces the risk of chronic diseases like heart disease and diabetes. Nuts also reduce oxidation, blood sugar, and LDL (bad) cholesterol, improving arterial function (4).

Despite their high-fat content, studies have linked daily nut consumption to a slimmer waistline and a lower risk of obesity (5).

4. Flaxseed

(milled flaxseed)

2013 research found that ground flaxseed had one of the strongest anti-hypertensive effects of any food. A few tablespoons (added to a smoothie or baked goods) lowered blood pressure and stroke risk 23 times more than daily aerobic exercise (6).

Flax shouldn't replace exercise, but its nutritional punch is worth adding to your diet.

5. Other seeds

(chia seeds, hemp seeds, pumpkin seeds, sesame seeds, fennel seeds)

Seeds are high in fiber and omega-3 fats and can be added to most dishes without being noticed.

When eaten with or after a meal, chia seeds moderate blood sugar and reduce inflammatory chemicals in the blood (7). Overall, a great daily addition.

6. Dates

Dates are one of the world's highest sugar foods, with 80% sugar by weight. Pure cake frosting is 60%, maple syrup is 66%, and cotton-candy jelly beans are 70%.

Despite their high sugar content, dates have a low glycemic index, meaning they don't affect blood sugar levels dramatically. They also improve triglyceride and antioxidant stress levels (8).

Dates are a great source of energy and contain high levels of dietary fiber and polyphenols, making 3-10 dates a great way to fight disease, support gut health with prebiotics, and satisfy a sweet tooth (9).

7. Cruciferous Veggies

(broccoli, Brussel sprouts, horseradish, kale, cauliflower, cabbage, boy choy, arugula, radishes, turnip greens)

Cruciferous vegetables contain an active ingredient that makes them disease-fighting powerhouses. Sulforaphane protects our brain, eyesight, against free radicals and environmental hazards, and treats and prevents cancer (10).

Unless you eat raw cruciferous vegetables daily, you won't get enough sulforaphane (and thus, its protective nutritional benefits). Cooking destroys the enzyme needed to create this super-compound.

If you chop broccoli, cauliflower, or turnip greens and let them sit for 45 minutes before cooking them, the enzyme will have had enough time to work its sulforaphane magic, allowing the vegetables to retain the same nutritional value as if eaten raw. Crazy, right? For more on this, see What Chopping Your Vegetables Has to Do with Fighting Cancer.

8. Whole grains

(barley, brown rice, quinoa, oats, millet, popcorn, whole-wheat pasta, wild rice)

Whole-grains are one of the healthiest ways to consume your daily carbs and help maintain healthy gut flora.

This happens when fibre is broken down in the colon and starts a chain reaction, releasing beneficial substances into the bloodstream and reducing the risk of Type 2 Diabetes and inflammation (11).

9. Spices

(turmeric, cumin, cinnamon, ginger, saffron, cloves, cardamom, chili powder, nutmeg, coriander)

7% of a person's cells will have DNA damage. This damage is caused by tiny breaks in our DNA caused by factors like free-radical exposure.

Free radicals cause mutations that damage lipids, proteins, and DNA, increasing the risk of disease and cancer. Free radicals are unavoidable because they result from cellular metabolism, but they can be avoided by consuming anti-oxidant and detoxifying foods.

Including spices and herbs like rosemary or ginger in our diet may cut DNA damage by 25%. Yes, this damage can be improved through diet. Turmeric worked better at a lower dose (just a pinch, daily). For maximum free-radical fighting (and anti-inflammatory) effectiveness, use 1.5 tablespoons of similar spices (12).

10. Leafy greens

(spinach, collard greens, lettuce, other salad greens, swiss chard)

Studies show that people who eat more leafy greens perform better on cognitive tests and slow brain aging by a year or two (13).

As we age, blood flow to the brain drops due to a decrease in nitric oxide, which prevents blood vessels from dilatation. Daily consumption of nitrate-rich vegetables like spinach and swiss chard may prevent dementia and Alzheimer's.

11. Fermented foods

(sauerkraut, tempeh, kombucha, plant-based kefir)

Miso, kimchi, and sauerkraut contain probiotics that support gut microbiome.

Probiotics balance the good and bad bacteria in our bodies and offer other benefits. Fermenting fruits and vegetables increases their antioxidant and vitamin content, preventing disease in multiple ways (14).

12. Sea vegetables

(seaweed, nori, dulse flakes)

A population study found that eating one sheet of nori seaweed per day may cut breast cancer risk by more than half (15).

Seaweed and sea vegetables may help moderate estrogen levels in the metabolism, reducing cancer and disease risk.

Sea vegetables make up 30% of the world's edible plants and contain unique phytonutrients. A teaspoon of these super sea-foods on your dinner will help fight disease from the inside out.

13. Water

I'm less concerned about whether you consider water food than whether you drink enough. If this list were ranked by what single item led to the best health outcomes, water would be first.

Research shows that people who drink 5 or more glasses of water per day have a 50% lower risk of dying from heart disease than those who drink 2 or less (16).

Drinking enough water boosts energy, improves skin, mental health, and digestion, and reduces the risk of various health issues, including obesity.

14. Tea

All tea consumption is linked to a lower risk of stroke, heart disease, and early death, with green tea leading for antioxidant content and immediate health benefits.

Green tea leaves may also be able to interfere with each stage of cancer formation, from the growth of the first mutated cell to the spread and progression of cancer in the body. Green tea is a quick and easy way to support your long-term and short-term health (17).

15. Supplemental B12 vitamin

B12, or cobalamin, is a vitamin responsible for cell metabolism. Not getting enough B12 can have serious consequences.

Historically, eating vegetables from untreated soil helped humans maintain their vitamin B12 levels. Due to modern sanitization, our farming soil lacks B12.

B12 is often cited as a problem only for vegetarians and vegans (as animals we eat are given B12 supplements before slaughter), but recent studies have found that plant-based eaters have lower B12 deficiency rates than any other diet (18).

Article Sources:

1. The Global Burden of Disease Study 2010 (GBD 2010)

2. I. Darmadi-Blackberry, M. Wahlqvist, A. Kouris-Blazos, et al. Legumes: the most important dietary predictor of survival in older people of different ethnicities. Asia Pac J Clin Nutr. 2004;13(2):217–20.

3. Guha N, Kwan ML, Quesenberry CP Jr, Weltzien EK, Castillo AL, Caan BJ. Soy isoflavones and risk of cancer recurrence in a cohort of breast cancer survivors: the Life After Cancer Epidemiology study. Breast Cancer Res Treat. 2009 Nov;118(2):395–405.

4. Y. Bao, J. Han, F. B. Hu, E. L. Giovannucci, M. J. Stampfer, W. C. Willett, C. S. Fuchs. Association of nut consumption with total and cause-specific mortality. N. Engl. J. Med. 2013 369(21):2001–2011.

5. V. Vadivel, C. N. Kunyanga, H. K. Biesalski. Health benefits of nut consumption with special reference to body weight control. Nutrition 2012 28(11–12):1089–1097.

6. D Rodriguez-Leyva, W Weighell, A L Edel,R LaVallee, E Dibrov,R Pinneker, T G Maddaford, B Ramjiawan, M Aliani, R Guzman R, G N Pierce. Potent antihypertensive action of dietary flaxseed in hypertensive patients. Hypertension. 2013 Dec;62(6):1081–9. doi: 10.1161/HYPERTENSIONAHA.113.02094.

7. Vuksan V, Jenkins AL, Dias AG, Lee AS, Jovanovski E, Rogovik AL, Hanna A. Reduction in postprandial glucose excursion and prolongation of satiety: possible explanation of the long-term effects of whole grain Salba (Salvia Hispanica L.). Eur J Clin Nutr. 2010 Apr;64(4):436–8. doi: 10.1038/ejcn.2009.159. Epub 2010 Jan 20. PMID: 20087375.

8. W. Rock, M. Rosenblat, H. Borochov-Neori, N. Volkova, S. Judeinstein, M. Elias, and M. Aviram. Effects of date (Phoenix dactylifera L., Medjool or Hallawi Variety) consumption by healthy subjects on serum glucose and lipid levels and on serum oxidative status: a pilot study. J. Agric. Food. Chem., 57(17):8010{8017, 2009.

9. Eid N, Enani S, Walton G, et al. The impact of date palm fruits and their component polyphenols, on gut microbial ecology, bacterial metabolites and colon cancer cell proliferation. J Nutr Sci. 2014;3:e46.

10. Li Y, Zhang T, Korkaya H, Liu S, Lee HF, Newman B, Yu Y, Clouthier SG, Schwartz SJ, Wicha MS, Sun D. Sulforaphane, a Dietary Component of Broccoli/Broccoli Sprouts, Inhibits Breast Cancer Stem Cells. Clin Cancer Res. 2010 May 1;16(9):2580–90.

11. Lappi J, Kolehmainen M, Mykkänen H, Poutanen K. Do large intestinal events explain the protective effects of whole grain foods against type 2 diabetes? Crit Rev Food Sci Nutr. 2013;53(6):631–40.

12. S. S. Percival, J. P. V. Heuvel, C. J. Nieves, C. Montero, A. J. Migliaccio, J. Meadors. Bioavailability of Herbs and Spices in Humans as Determined by ex vivo Inflammatory Suppression and DNA Strand Breaks. J Am Coll Nutr. 2012 31(4):288–294.

13. Nurk E, Refsum H, Drevon CA, et al. Cognitive performance among the elderly in relation to the intake of plant foods. The Hordaland Health Study. Br J Nutr. 2010;104(8):1190–201.

14. Melini, F.; Melini, V.; Luziatelli, F.; Ficca, A.G.; Ruzzi, M. Health-Promoting Components in Fermented Foods: An Up-to-Date Systematic Review. Nutrients2019, 11, 1189.

15. H. Funahashi, T. Imai, T. Mase, M. Sekiya, K. Yokoi, H. Hayashi, A. Shibata, T. Hayashi, M. Nishikawa, N. Suda, Y. Hibi, Y. Mizuno, K. Tsukamura, A. Hayakawa, S. Tanuma. Seaweed prevents breast cancer? Jpn. J. Cancer Res. 2001 92(5):483–487.

16. Chan J, Knutsen SF, Blix GG, Lee JW, Fraser GE. Water, other fluids, and fatal coronary heart disease: the Adventist Health Study. Am J Epidemiol. 2002 May 1;155(9):827–33. doi: 10.1093/aje/155.9.827. PMID: 11978586.

17. Fujiki H, Imai K, Nakachi K, Shimizu M, Moriwaki H, Suganuma M. Challenging the effectiveness of green tea in primary and tertiary cancer prevention. J Cancer Res Clin Oncol. 2012 Aug;138(8):1259–70.

18. Damayanti, D., Jaceldo-Siegl, K., Beeson, W. L., Fraser, G., Oda, K., & Haddad, E. H. (2018). Foods and Supplements Associated with Vitamin B12Biomarkers among Vegetarian and Non-Vegetarian Participants of the Adventist Health Study-2 (AHS-2) Calibration Study. Nutrients, 10(6), 722. doi:10.3390/nu10060722