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When Women Initiate Estrogen Therapy Matters | The Menopause Society

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New large-scale analysis shows potential long-term benefits of initiating hormones during perimenopause

CLEVELAND, Ohio (Oct 21, 2025)—Menopause may take a toll on women physically and emotionally due to declining estrogen levels. For some, the use of hormone therapy has proven valuable in managing bothersome menopause symptoms. A new study suggests that when a woman starts taking hormones makes a major difference in longer term health outcomes. Results of the study will be presented at the 2025 Annual Meeting of The Menopause Society in Orlando October 21-25.

A large percentage of women will experience some type of menopause symptoms, with the most common symptom being hot flashes. Many women will actually start to experience menopause symptoms during perimenopause, the transitional period before the final menstrual period. Perimenopause can last for years, during which time a woman’s estrogen levels fluctuate and decline.

Estrogen therapy has been shown to be one of the most effective and generally safe means for managing bothersome menopause symptoms. However, there is a lack of data regarding the impact of initiating hormone therapy in perimenopause in terms of longer-term health outcomes. A new retrospective cohort analysis based on data from more than 120 million patient records aimed to compare the impact of menopausal estrogen therapy when started during perimenopause or after menopause or not at all. Specifically, the study looked at breast cancer, heart attack and stroke rates associated with estrogen therapy.

The findings revealed that perimenopausal women who had used estrogen within 10 years prior to menopause had no significantly higher associated rates of breast cancer, heart attack and stroke compared to the other two groups. These findings highlight the potential benefit of earlier initiation of estrogen therapy during perimenopause for minimizing risk and optimizing long-term health outcomes. More detailed results will be discussed at the 2025 Annual Meeting of The Menopause Society as part of the poster presentation entitled “The Timing of Estrogen Therapy: Perimenopausal Benefits and Postmenopausal Risks.”

“There has long been a debate about if and when estrogen therapy should begin, so hopefully the use of large-scale electronic health record data will help resolve that question,” says Ify Chidi, lead author from Case Western Reserve University School of Medicine in Cleveland.

Her mentor, Dr. Rachel Pope, Menopause Society Certified Practitioner at University Hospitals Cleveland Medical Center and Ms. Chidi’s public health professor agrees. “We know that the safest time to start hormone therapy is within the first 10 years of menopause, but we wanted to know if it was also safe to start hormones prior to that when many women begin noticing symptoms—that is, during perimenopause. Hopefully, these results start a larger conversation about prevention in women’s health and will incite more prospective research. If we can better understand the effect of hormones throughout menopause, we can improve the quality of life and reduce disease burden,” says Dr. Pope.

Further clinical research is needed to confirm these results and to explore the long-term effects of estrogen therapy during perimenopause.

“The findings of this study suggest lower risk and potentially greater benefit of estrogen-based therapy when started in perimenopause. While the observational study design is subject to known potential biases such as healthy user bias, these results may pave the way for additional research on the risks and benefits of hormone therapy when initiated earlier in the menopause transition,” says Dr. Stephanie Faubion, medical director for The Menopause Society.

Ms. Chidi, Dr. Pope and Dr. Faubion are available for interviews after the presentation.

For more information about menopause and healthy aging, visit <a href="http://menopause.org" rel="nofollow">menopause.org</a>.

The Menopause Society is dedicated to empowering healthcare professionals and providing them with the tools and resources to improve the health of women during the menopause transition and beyond. As the leading authority on menopause since 1989, the nonprofit, multidisciplinary organization serves as the independent, evidence-based resource for healthcare professionals, researchers, the media, and the public and leads the conversation about improving women’s health and healthcare experiences. To learn more, visit <a href="http://menopause.org" rel="nofollow">menopause.org</a>.

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Timing is everything - by Deborah Copaken - Ladyparts

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I was in the middle of researching a different story yesterday when I happened upon a new study that not only stopped me in my tracks, it made me decide that getting this information out there today was more important. It also made me more than a little enraged, both for myself and for every Gen-X and Boomer woman who was either taken off hormone therapy, deterred from starting, or, like me, never even told that she and her body might benefit from it.

Millennial and Gen-Z women, however? Listen up. I know many of you are not necessarily thinking about your body’s dramatic loss of estrogen in the near or far future, but if you’re in your forties right now or younger, you have a unique opportunity, if you start taking estrogen early, not only to outlive us estrogen-deprived oldsters but also to feel like yourself and have fewer symptoms while thriving. As long as your doctors—many of whom received no training in the menopause transition whatsoever—are made aware of this new data: a big caveat, I know, and one we will all have to work hard to overcome.

This new retrospective study out of Case Western Reserve School of Medicine, of 120 million patient records in the TriNetX Research Network, is called “The Timing of Estrogen Therapy: Perimenopausal Benefits and Postmenopausal Risks.” It was just presented by its lead author, Ify Chidi, MPH, at the Menopause Society’s annual meeting in Florida. The study’s dramatic results suggest that a much earlier timing of initiation of estrogen therapy in perimenopause—ideally ten years prior to menopause and continuing on it for that same length of time—is not only helpful in alleviating the many debilitating symptoms of the menopause transition, but that starting HRT (aka MHT) in perimenopause should now be considered standard preventative medicine. Here’s the direct quote from the Menopause Society’s initial announcement: “The findings revealed that perimenopausal women who had used estrogen for at least 10 years prior to menopause had significantly lower odds of developing breast cancer, heart attack and stroke compared to the other two groups—approximately 60% lower.”

Um, a SIXTY PERCENT reduction in our chances of getting three lethal diseases if only we’d started taking estrogen in perimenopause? I read that line and teared up, wishing I could go back in time. And because I always love a good personal example of what can happen when a female body is deprived of a hormone she needs, allow me to provide my own soap operatic tale of As the Estrogen Turns.

I lost my uterus to a hysterectomy in 2012 due to adenomyosis. I was 46 years old. Right in that key window of perimenopause, but now that I no longer had a uterus shedding its lining, I also had no way of marking the natural end of menses. Nor was I provided any information about perimenopause or what it might do to me. I was simply wheeled out from my hysterectomy with a handful of flowers and instructions for recovery and wound care.

Here’s what happened over that next decade, when—we now know—I should have been treating my body with estrogen both preventatively for my heart, breasts, and circulatory system as well as to treat symptoms such as hot flashes, depression, recurring UTIs, migraines, and brain fog that are essentially the body’s way of saying, “Hey, Deb! WTF? Where’s the estrogen? We can’t operate this way…”:

2013: I was diagnosed with DCIS of the left breast. Before that, I’d already fallen into a funk so deep that I—a normally cheerful and optimistic person—leaned my head out a window and seriously considered throwing myself out of it. Yes, my marriage had just ended, and my financial situation was bleak, but it was much more than situational trauma. It was a full-bodied darkness that left me feeling as if I were drowning. 2014: I essentially stopped sleeping through the night, for years, because I kept being awoken, drenched in hot-flash sweat. 2015: I started fainting, frequently, sometimes injuring myself on the way down. I was also having heart palpitations, so I went to a cardiologist who put me on a Holter monitor for a month and diagnosed a near constant tachycardia, for which I was prescribed metoprolol, a beta blocker which made me tired, even dizzier, and even foggier. 2016: I began getting migraines so intense, I asked my neurologist, “Could this be hormone related?” She rolled her eyes and said, “No.” Not a fan of belittling contempt from those in charge of my medical care, I switched neurologists. The new one said, “Yes, I personally think this could be hormone related, but we haven’t really studied it,” and put me on a CGRP inhibitor, which worked. This was when I also started getting recurring UTIs. As in 12-15 times a year. The constant need for antibiotics wreaked havoc on my body and made it resistant to one of them. 2017: I was diagnosed with pre-cancer of the cervix and had it removed. Two weeks later, I bled out from vaginal cuff dehiscence. Why? Possibly because my vaginal tissue was now so estrogen-starved and thin, the stitches holding it and me together simply broke right through that thinning tissue and came undone, so I nearly died. 2018: I started forgetting common words, like the artichoke I was holding in my hand. 2019: The UTIs continued, unabated, until Dr. Rachel Rubin, who read a story I wrote in The Atlantic, reached out over twitter DM, and told me to get some estrogen in my body, stat. I ignored her because I was erroneously worried about the flawed WHI reporting that had stopped estrogen treatment in its track back in 2002. 2020: diagnosed with post-Covid POTS. It lasted a year. Could it also have been hormone related? Who the hell knows? 2021: Finally, fed up with the recurring UTIs, I listened to Dr. Rubin and started taking estrogen, both vaginal and systemic. But first I had to find a menopause specialist in my area who took my insurance, which took forever and was a massive hurdle to care. 2023: Diagnosed with osteoporosis.

After I started using vaginal estrogen and dabbing a small circle of systemic estrogen gel on my thigh every morning? My body stopped rebelling. Or, better put, both it and I felt as if we’d reverted back to our pre-hysterectomy self, even if my bones were now as brittle as an 80-year-old’s. No more tachycardia. No more night sweats. No more UTIs. No more dizziness, brain fog, sleeplessness, all of which are outward signs of the internal dysregulation of estrogen loss.

Life, I now realize, did not have to be that way. I did not have to lose an entire decade to medical chaos. Hopefully, once the data in this study is published, and we can get gynecologists and primary care providers not only to read it but to act on its findings, this next generation of women entering perimenopause will have it easier. Until then, if you are (or know or love) a woman who is or will soon be entering her forties, consider hopping on the estrogen bandwagon ten years prior to menopause. 120 million patient records is a substantial number of female bodies to have included in a study, even retrospectively. And a 60% reduction in breast cancer, heart attacks, and stroke is a substantial reduction in female morbidity and mortality, especially considering that heart disease is the number one killer of women.

I know we’ve all been feeling a lack of good news these days, but despite the fact that this news cannot help me and my generation personally, I see it as a welcome exception for the next generation of women as well as a boon to our understanding of our own bodies in particular, and women’s health in general.

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Why Are Electricity Prices Rising? - by Michael Thomas

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Few daily necessities have become more expensive recently than electricity. The average American’s bill is likely to be anywhere from 8% to 26% higher this year than it was in 2022.

In New Jersey, electricity prices rose 22% in the last year alone. Rising bills are now seen as a top election issue in the state’s upcoming governors race. “Electricity is the new eggs,” one consumer advocate told the New York Times recently.

Everyone has a take on why electricity bills are rising. Trump’s Energy Secretary Chris Wright argued this summer that solar and wind subsidies were to blame. Fossil fuel lobbyist Alex Epstein recently argued that electrification mandates are the main cause. Some progressive groups, like More Perfect Union, point the finger at data centers.

But look at the data and most of these arguments quickly fall apart.

If solar and wind were to blame for high prices, you’d expect states with the highest renewable energy penetration rates like Iowa and South Dakota to have the highest bills. Instead, they have some of the cheapest. There’s basically no correlation between renewable penetration and electricity prices.

For most Americans, the proliferation of data centers don’t explain their high utility bills either1. Not yet at least.

The state with the highest electricity price increase last year was Maine. There are virtually no data centers in the state—and certainly none of the gigascale projects that have the potential to distort rates significantly.

If big tech and their data centers were to blame, you’d expect states like Nebraska and Iowa—where Google is building its largest cluster of data centers—to have some of the fastest growing rates. But inflation-adjusted rates were negative in both states.

In North Dakota, crypto and AI companies have driven some of the fastest electricity demand growth in the country. You’d expect the state to have seen the fastest growth in utility bills. But again, intuition would fail you. North Dakota is the only state in the US that didn’t see its electricity prices rise between 2019 and 2024. Over that period, rates actually fell in inflation-adjusted terms.

Most of our intuitions and political biases on this topic draw us to the wrong conclusions for a simple reason: electricity ratemaking is complicated. The fact that rates are set by hundreds of different utilities and regulated by 50 different state regulatory commissions doesn’t make things any easier.

This month, researchers at Lawrence Berkeley National Laboratory (LBNL) published a report that attempts to clear up some confusion on the topic.

So what did these researchers find? Surging electricity prices are like Tolstoy’s unhappy families, each unhappy for their own reasons. There isn’t a single cause of high electricity bills. And most of the popular arguments you read about on social media and in the news are misleading or not true.

Here are some takeaways from the report:

  • Extreme weather is driving some of the largest cost increases—especially on America’s coasts.

  • The rising cost of “poles and wires” are behind rate increases in most states.

  • The natural gas price spikes that followed Russia’s invasion of Ukraine are still costing Americans a lot on their utility bills.

  • Rooftop solar programs probably added some costs in some states. (But this claim is likely to be refuted by distributed energy advocates and is a part of a larger long-running debate).

  • Rising demand from electricity (e.g. from data centers) was associated with lower costs, not higher costs as many people might assume. But this relationship isn’t guaranteed to exist in the future.

One of the largest causes of recent price increases comes from extreme weather and natural disasters, which have been made worse by climate change. Utilities across the country are rebuilding their grids due to recent disasters and in anticipation of future ones. And they’re passing the costs on through bills.

In Maine storm recovery costs rose from 0.1 cent per kilowatt hour (kWh) in 2020 to 1.8 cents per kWh in 2024. This year, they’ll be 3.2 cents per kWh. Or to put it another way, Mainers are paying 32 times more for storm damages this year than they were just five years ago.

Utilities across the Southeastern US are passing similar price increases on due to Hurricane Helene, which was one of the most expensive natural disasters in US history.

On the other side of the country, utility bills are rising as result of wildfire mitigation. Over the last decade, downed transmission lines have caused multiple wildfires across the West Coast. In some cases they’ve literally bankrupted utilities, like California’s PG&E. Now utilities are trying to prevent future fires by doing things like sticking their transmission and distribution lines underground where they can’t light trees on fire.

In California this has come at an enormous cost. PG&E customers are paying 7 cents per kWh for wildfire mitigation alone. That’s equivalent to about half the cost of electricity in many states—all going to prevent future wildfire risk.

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Pattern Recognition And Repetition | blarg

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The Great Reckoning: What the West Should Learn from China

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This essay was originally published in The Ideas Letter and is reprinted here with permission.

The world feels unsettled, as if history itself were changing tempo. The familiar landmarks of the modern age are blurring, slipping away, and the stories we once told ourselves about progress and power no longer map cleanly onto the terrain before us. What we are living through seems, with each new day, less like a passing rearrangement of power, less like a momentary realignment of nations. We sense something deeper and more enduring: a transformation whose outlines we are only beginning to discern. History no longer feels like something unfolding behind us but something rushing toward us, urgent and impossible to ignore.

The economic historian Adam Tooze, reflecting on his recent, intense engagement with China, put it to me in July with characteristic directness: “China isn’t just an analytical problem,” he said. It is “the master key to understanding modernity.” Tooze called China “the biggest laboratory of organized modernizations there has ever been or ever will be at this level [of] organization.” It is a place where the industrial histories of the West now read like prefaces to something larger.

His observation cuts to the heart of what makes this moment so difficult to process. We have witnessed not merely the rise of another great power, but a fundamental challenge to assumptions long embedded in Western thought—about development, political systems, and civilizational achievement itself. We simply haven’t yet found the intellectual courage to face it.

This reckoning touches all of humanity, but it falls especially hard on the developed world and hardest on the United States, where assumptions about exceptionalism and hierarchy are most exposed and most fiercely denied. The familiar framing of China as “rising” or “catching up” no longer holds. China is now shaping the trajectory of development, setting the pace economically, technologically, and institutionally. For Americans especially, the deeper psychic shock lies in the recognition that modernity is no longer something they authored and others merely inherit. That story has outlived its usefulness.

The denial, the deflection, and the anxious overreaction so often seen in Western discourse are symptoms of that dislocation. Yet the reluctance to acknowledge this shift extends beyond governments, media narratives, or expert consensus. It includes people who’ve spent years thinking about these issues. I have been as susceptible as anyone—tempering big claims, second-guessing implications, staying in safer territory even when the evidence has been pointing in this direction for some time. There’s always a “but” when it comes to recognizing China’s accomplishments, a reflex to tick off the costs and enumerate the failings, to pull back just when the scale of transformation becomes clear.

The greater risk, I now believe, lies in saying too little.

This essay doesn’t rehearse the familiar bill of particulars on China—constraints on political pluralism and independent media; expansive security powers and preemptive detention; pressure on religious and ethnic expression; and episodes of extraterritorial coercion—not because those concerns are trivial, but because the task here is different. We’ve all learned to recite that litany, as a way of protecting ourselves from what real comparison might imply. The aim here is to confront, with intellectual honesty, what China’s achievements oblige us to reconsider about modernity, state capacity, forms of political legitimacy, and our own complacencies. Recognizing real costs can coexist with taking the magnitude of transformation seriously. This argument asks us to face squarely what has been accomplished and then measure ourselves against it.

And let me be clear: This reckoning is not a surrender. It is not an argument for abandoning liberal values, declaring authoritarian systems superior, or slavishly imitating features of China’s governance. It is instead a call for the kind of frank, sober assessment that genuine confidence requires—the willingness to acknowledge challenges directly, to learn from others’ successes even when they unsettle our assumptions, and to strengthen our own institutions through clear-eyed recognition of their shortcomings rather than defensive denial of their failures. Liberal democracy is indeed undergoing a profound crisis, but that crisis need not be terminal. The question is whether we will meet it with the rigorous self-examination that has historically enabled democratic renewal, or retreat once more into the comforting myths that have blinded us to both our weaknesses and our rivals’ strengths.

If we are to speak honestly, we must take stock of what China has achieved in human terms. The numbers are staggering, but numbers alone cannot capture their significance. Since the early 1980s, according to the World Bank, China has lifted nearly 800 million people out of extreme poverty, accounting for roughly three-quarters of the global reduction in poverty during that time. Life expectancy in China, which stood at only 33 in 1960, reached 78 in 2023; life expectancy at birth in the United States in 2023 was 78.4. Nearly every household in China has had access to electricity for about a decade. Secondary school enrollment is now nearly universal. Per capita income has risen from just a few hundred dollars at the start of reform in the late 1970s to over $13,000 today.

But perhaps most revealing of the struggle to process the scale is what has happened in the energy sector. China now accounts for more than half of the world’s installed solar and wind capacity combined. Roughly three-quarters of all renewable energy projects currently underway worldwide are either in China or being driven by Chinese contractors. About 30% of global emissions come from China, but so too does much of the growth in decarbonization technology. China has transformed the global energy transition by demonstrating that massive and rapid deployment could make renewable energy cost-competitive worldwide.

Whatever one thinks of China’s political system, these are the hallmarks not of a failing state, but of a society whose people are, in many respects, flourishing as never before.

The scale of China’s transformation poses what might be called the intellectual challenge of acknowledgment. Even those of us who have followed China closely, who pride ourselves on seeing past Western prejudices, have found it difficult to fully absorb what we are witnessing. The familiar frameworks—middle-income traps, authoritarian brittleness, inevitable convergence with liberal norms—offer cognitive comfort even as they fail to explain what is actually happening.

The intellectual historian Joseph Levenson, in his magnum opus Confucian China and Its Modern Fate (1958–65), argued that China’s quest was to find a path that could deliver wealth and power in a way both authentically Chinese and objectively effective. For over a century, Chinese intellectuals grappled with this challenge: how to achieve modernity without losing cultural identity, how to become powerful without abandoning what made China distinctive.

That historical chapter may now be closing. China appears to have found that path. The system powering its success is an extraordinarily intricate alloy of Confucianism, Leninism, technocratic authoritarianism, state capitalism, and market mechanisms. Yet based on the many conversations I’ve had with Chinese intellectuals, they now recognize that China has attained wealth and power in a distinctly Chinese way. If Levenson’s framework is correct, we are witnessing not merely China’s rise but its graduation from the central quest that defined its modern history.

Even within China, though, this transition—from the pursuit of modernity to its realization—remains difficult to accept in full. Many Chinese intellectuals I’ve talked to or have read, however patriotic and confident in their country’s accomplishments, still seem unprepared to reckon with what those accomplishments mean. The idea that China has moved beyond catching up to redefining development itself challenges habits of mind formed over generations. For intellectuals conditioned to see the West as a permanent reference point—even if they view it critically—the prospect that China might now be setting terms rather than responding to them demands a fundamental reorientation that has not yet fully occurred.

China’s apparent resolution of its modern quest has profound implications. If China is no longer seeking its path to modernity but has become one of modernity’s principal architects, then the questions that have long organized our thinking about China—Will it democratize? Will it converge with Western norms? When will the contradictions catch up with it?—may be the wrong questions entirely.

But if China has indeed moved beyond its central quest, new questions must take their place. Chinese intellectuals are grappling with challenges that have no modern precedent: What kind of global power should China become? How should a civilization that has regained confidence in its own path engage with a world still organized around Western institutions and assumptions? China’s leaders speak of building a “community of common destiny for mankind,” but the practical meaning of such concepts remains deliberately vague. The deeper questions are harder still: Can a civilization that has never fit comfortably within a Westphalian order find a way to work inside it, or will it seek to reshape the norms themselves? How does a country that has achieved prosperity through state-led development share that model without appearing to compromise others’ sovereignty? These are the questions that preoccupy Chinese strategists today—questions not of catching up but of leading responsibly.

The questions the West now faces are equally challenging, if not harder: What does modernity look like when it is no longer exclusively Western in conception? How to understand development when the most successful model does not conform to liberal democratic assumptions? What happens when the world’s second-largest economy operates according to principles that upend core Western beliefs about how prosperity is achieved and sustained?

Levenson’s framework offers a lens for understanding the United States’ current predicament as well. A civilization, in his formulation, is stable when what is mine (meum) and what is true (verum) remain in harmony—when a society’s inherited assumptions about how the world works align with observable reality. Instability emerges when these fall out of alignment, when what tradition insists must be true no longer accords with what one can plainly see. This was China’s crisis after the Opium Wars: The painful recognition that Confucian certainties about China’s centrality and civilizational superiority could not explain Western gunboats in the Pearl River. It took nearly two centuries of intellectual upheaval, political experimentation, and often violent transformation for China to resolve that tension.

The question now is whether the shocks more recently delivered by China’s rise—less violent but no less disruptive to foundational assumptions—are pushing the United States toward a similar reckoning. When a nation that was supposed to remain forever behind suddenly leaps ahead in renewable energy, artificial intelligence, and infrastructure; when authoritarian capitalism proves more adaptive than was predicted; when “the end of history” reveals itself as premature triumphalism—the gap between meum and verum widens. The choice, as China learned over its long modern ordeal, lies between the painful work of intellectual reconstruction and the increasingly desperate defense of comfortable illusions.

The Chinese crisis of the mid-to-late 19th century and the American crisis of the early 21st are not, of course, identical, but there are some historical rhymes worth noting. In the 1860s and 1870s, Chinese reformers of the Self-Strengthening Movement grappled with a civilizational challenge through the formulation of yong and ti—the idea that China could adopt Western techniques and technologies (yong) and harness them in the preservation of its essential Chinese character (ti).

Today, something remarkably similar is playing out in reverse across the American political spectrum From industrial policy to direct government stakes in strategic companies like Intel, U.S. policymakers increasingly embrace methods that look suspiciously like Chinese state capitalism, all while insisting that they are defending rather than abandoning free-market principles. Under both the Biden administration and now in Trump’s second term, coordinated government-industry partnerships have emerged that represent a quiet but decisive shift. There may not have been a national conversation about it, but the United States has unmistakably entered the domain of industrial policy it once disdained.

To be sure, the United States has long practiced forms of industrial policy—from the construction of transcontinental railroads to the Manhattan Project and the space race—but it has generally done so while insisting that it was something else. For decades, American economic orthodoxy treated state planning as both inefficient and un-American, deriding other nations’ developmental models—whether Japan’s rise through its Ministry of International Trade and Industry; the coordination of chaebol, or conglomerates, in South Korea; or China’s state capitalism—as violations of free-market faith. Yet with the CHIPS and Science Act of 2022, the Inflation Reduction Act of 2022, and now Trump’s explicitly protectionist revival of state-driven economics, the United States has abandoned that pretense. What once marked the ideological boundary between “us” and “them” has quietly dissolved. Just as Chinese reformers once argued they could selectively borrow Western methods without compromising Chinese civilization, U.S. leaders now claim they can adopt Chinese-style state intervention without betraying U.S. values. History suggests that such experiments in selective borrowing are rarely as tidy as their architects imagine.

Just as historians of modern China have in recent decades wisely revised the old impact-response paradigm that once dominated narratives of “China’s encounter with the West”—moving beyond simply registering an external shock to centering the domestic Chinese factors that shaped the country’s transformation—so too should Americans, and other Westerners, resist the temptation to attribute America’s current malaise primarily to Chinese provocation. The seeds of self-doubt were sown long before: the quagmires of the wars in Afghanistan and Iraq, the 2008 financial crisis, Washington’s polarization and paralysis, the shameful spectacle of the attack on the Capitol in January 6, 2021, and the visible fraying of civic cohesion.

But China has magnified that doubt, and it has done so in unsettling ways. Seeing a rival building, educating, and innovating at the scale that China has done casts U.S. dysfunction into sharper relief. Every infrastructure breakdown, every squabble over basic funding, every government shutdown feels more noticeable in contrast to China’s rapid and extensive transformation.

What might have been another season of U.S. introspection has morphed into something more acute: the painful recognition that another system, however flawed, has delivered results on a scale that the United States has not. This is to me, as an American, a source of not inconsiderable anguish. I take no pleasure in witnessing what my country has become—a nation I love, torn apart by political tribalism so intense and so toxic that I fear it may be beyond repair, at least in the coming, and critical, decade.

But confronting this crisis requires looking squarely at what seems so unsettling about China’s success. As Chas W. Freeman, a retired senior U.S. diplomat, has observed, “Americans now exhibit an odd combination of self-doubt, complacency, and hubris”— a mix that has prevented the kind of clear-eyed assessment the moment requires.

Part of what sticks in the United States’ craw is, uncomfortably, racial. It would be surprising if it weren’t. The twilight of white privilege in an increasingly diverse country maps onto the twilight of American hegemony in an increasingly multipolar world. Just as white ethnonationalism represents an irrational response to the perceived erosion of white privilege domestically, so too does the lurch toward a new Cold War represent an irrational response to the perceived erosion of U.S. privilege globally.

But race is only one current in a larger riptide. To understand why China sticks in the craw, one needs to appreciate the deeper psychological challenge it poses to U.S. identity. For generations, Americans inhabited a national story that assured them they would always be first in the domains that matter most—innovation, technology, military might, economic dynamism, cultural magnetism. China’s achievements have systematically undermined pillar after pillar of American exceptionalism. Deep-rooted and often unconscious hierarchies still position the West as normative and other states as derivative. The moment of recognition and readjustment requires confronting those reflexes.

It was once axiomatic that a dynamic market economy required liberal democracy; China has showcased an authoritarian capitalism that works anyway. It was believed that social media would inevitably liberate the subjects of autocracies; then the Arab Spring fizzled, Edward Snowden reframed surveillance debates, and platform politics went sideways at home. It was assumed that genuine innovation required political freedom; then Chinese firms and labs began producing world-class results while operating within a very different information ecosystem. Each inversion chips away at the catechism. Each surprise compounds the shock.

Western discourse consistently attributes China’s achievements to its regime type rather than its substantive capabilities. Breakthroughs by Tencent, BYD, Huawei, or Shenzhen’s hardware ecosystem are often explained away as resulting from state diktat rather than design brilliance or the unrivaled speed of co-located manufacturing. That flattening of context feeds the sense that China’s ascent is somehow an affront to how the world should work, rather than evidence that the world works differently than was assumed.

No global problem mirrors this Great Reckoning more starkly than climate change. A fundamental pattern emerges: evidence accumulating faster than our willingness to absorb it, narratives designed to soothe rather than illuminate, and a collective refusal to revise assumptions that no longer fit the world we inhabit.

The parallels run deep. With climate, we watch wildfire smoke choke our cities, once-in-a-century floods arrive every few years, oceans warm and acidify at alarming rates—and still we avert our eyes, hunting for reasons to delay, deflect, or offload responsibility. In China, infrastructure is growing on a continental scale, technological breakthroughs accumulate, renewable-energy capacity doubles and redoubles—and yet still we find ways to explain that away, minimize it, deride it as overcapacity, and predict its imminent unraveling. Some even dismiss these advances as a hoax. In both cases, we prefer the comfort of familiar stories to the discomfort of genuine reckoning.

The symmetry goes deeper still. Climate change has forced all of us to confront the limits of human mastery over nature—the Enlightenment conceit that humans could harness natural forces without consequence. China’s rise forces us to confront the limits of Western mastery over modernity: the potent conceit that only liberal democratic capitalism could deliver sustained prosperity and innovation. Both developments demand that we abandon wishful thinking and face the world as it is. Both reveal how brittle our inherited certainties have become, and how dangerous denial can be.

Climate also illuminates something else: the shift in what constitutes political legitimacy in the 21st century. If legitimacy once rested primarily on procedures and forms—constitutions, elections, parliaments—it now rests increasingly (though by no means exclusively) on performance. What could matter more than the ability to safeguard the very habitability of the planet?

Here, the China paradox becomes instructive. China is simultaneously the world’s largest emitter of carbon and the largest builder of renewable energy capacity; it installs more solar and wind power each year than the rest of the world. That contradiction contains a lesson: Legitimacy in this century will not flow from ideological purity but from the messy, uneven, urgent capacity to deliver. Systems will be judged not by the elegance of their theories but by their ability to meet existential challenges.

For Americans, the contrast cuts deep. While they quarrel endlessly over pipelines and transmission lines, China wires continent-spanning grids. While Americans have retreated from global climate leadership—the second Trump administration pulled out again from the Paris Agreement and recently slammed renewable energy at the UN General Assembly—China has become the indispensable actor in the energy transition. The country that was supposed to be the problem has become essential to the solution, not through moral transformation but through sheer manufacturing and deployment capacity.

This points to another dimension of performance legitimacy that must now be acknowledged: resilience under pressure. For decades, the United States leveraged its dominance over financial systems, technological chokepoints, and global supply chains to coerce adversaries—and occasionally even allies. That leverage is no longer one-sided. China has demonstrated it can withstand such pressure and respond in kind, from its mining of rare earths to its advanced manufacturing inputs. Its response to technological containment—accelerating domestic innovation in semiconductors, artificial intelligence, and other strategic sectors—reveals a system with remarkable adaptive capacity.

Performance legitimacy in the 21st century, then, encompasses multiple dimensions: the ability to deliver prosperity and stability, yes, but also to build at scale, to innovate under pressure, to absorb economic coercion without buckling, and to mobilize resources for global challenges like the energy transition. On each dimension, the contrast between U.S. dysfunction and Chinese capacity becomes harder to ignore.

These achievements come at a moment when not just the United States but many democracies in the West are themselves in crisis. This simultaneity forces an uncomfortable question: Is political legitimacy purely about procedural democracy? Or must it also encompass performance, delivery, competence, and resilience? Can the virtues of technocratic governance—its efficiency, its ability to plan and build and manufacture at scale—be adopted without succumbing to authoritarian temptation?

The answer is no longer self-evident. And that uncertainty is itself part of the reckoning the West faces.

Signs of recognition are beginning to emerge across the U.S. political spectrum. The most vital force in the Democratic Party may be the “abundance” movement sparked by writers like Derek Thompson and Ezra Klein. While they don’t explicitly center China in their analysis, their focus on state capacity, industrial policy, and the need to build more and faster clearly reflects a dawning recognition that the United States’ approach to development has been inadequate.

That recognition found its fullest expression in the technology analyst and writer Dan Wang’s Breakneck: China’s Quest to Engineer the Future, arguably the most talked-about, if not the most important, book of 2025 for anyone who thinks seriously about China’s trajectory. Wang’s argument that technocracy and engineering governance have driven China’s success has found an eager audience among Americans finally ready to confront what they had ignored or dismissed.

Even more surprising is the response from parts of the U.S. right. While much of the MAGA movement’s interest in China stems from troubling sources—admiration for its ethnic homogeneity, its surveillance capabilities, its authoritarian toolkit—it represents a grudging acknowledgment that China’s system delivers results in ways that the United States’ increasingly does not. Meanwhile, Silicon Valley accelerationists and tech entrepreneurs, many of whom are now aligned with Trump, openly express what might be called “China envy”—recognition that China’s coordination between state and private sectors has produced breakthroughs that fragmentation in the United States has not.

Perhaps most tellingly, recent polling shows a shift among younger Americans in their attitudes toward China. Born long after Tiananmen and constantly exposed on social media to what one friend calls “Chinese infrastructure porn,” they see a country that increasingly looks like the future rather than the past. This generational change may prove more consequential than elite opinion in reshaping how the United States ultimately responds to China’s emergence.

In conversations I’ve had over the last few months in Beijing with professionals spanning various industries, from biotech to automotive, from renewable energy to humanoid robotics, I’ve heard variations of the same observation: The transformation that has swept through their sectors in China over the past two decades—or even just the past five years—would be utterly unfathomable to anyone who hasn’t witnessed it firsthand. They describe returning from conferences in the United States or Europe struck by a disconnect: The tsunami of transformation coming from China just isn’t felt with an urgency remotely commensurate with the scale of the disruption in store.

In China, this moment feels different. Among the intellectuals and cultural figures I encounter during my extended stays there, there’s a palpable confidence that wasn’t present when I first arrived decades ago. They’re not asking whether China can catch up anymore. They’ve grown up in a country that is already technologically advanced, globally consequential, and proud of its achievements. They see China’s ability to weather trade wars, leap ahead in artificial intelligence, and build infrastructure on a continental scale, and they take it as a given that China belongs in the front rank of nations.

That confidence, though it can shade into arrogance, is healthier than the insecurity that once gnawed at the national psyche. It also suggests that China’s leaders and citizens alike are beginning to grapple with what it means to be not a rising power but a risen one—with all the responsibilities and expectations that entails and all the anxieties it may yet provoke abroad.

What should follow from this recognition is not despair but humility before the sheer unpredictability of what comes next. If China has unsettled the West’s inherited assumptions about development and governance, so too will the currents rising across the Global South, which are already beginning to reorder expectations in ways that can barely be anticipated.

Technological ingenuity, demographic weight, and political experimentation will emerge from quarters long dismissed as peripheral. The real challenge is not to anchor oneself too firmly to any present arrangement, but to cultivate the intellectual flexibility to adapt when the world changes faster than one’s theories can keep up with.

The Great Reckoning may be about China right now, but in the larger arc of history, it is about far more: about a world no longer revolving around familiar centers, about the need to find steadiness without the comfort of inherited myths, about recognizing that the stories some of us told ourselves about modernity may have been too narrow, too self-serving, too small for the world we’re actually living in.

Consider what China’s trajectory means for countries across the Global South that were told for decades there was only one path to prosperity: the Washington Consensus path of privatization, deregulation, and democratic governance. China offers proof that another model can work: state-led development, long-term planning, massive infrastructure investment, and selective integration with global markets, all while maintaining political autonomy. Whether one admires this model or not, its success cannot be denied, and its implications ripple far beyond East Asia.

This forces all of us to acknowledge that modernity itself—the entire project of human development, technological progress, and social organization that has defined the last several centuries—is no longer the exclusive property of the West. The future is being written in multiple places, according to multiple logics, with results that confound easy categorization.

For Americans especially, that recognition requires abandoning the assumption that they are uniquely qualified to lead, uniquely positioned to judge, uniquely capable of innovation and adaptation. It means accepting that their way of organizing society, however precious to them, is one among several viable approaches to human flourishing.

Yet the United States retains profound sources of strength, chief among them its universities, which remain powerful magnets for global talent even amid mounting political attacks. There are also the vast Chinese diasporic communities whose creativity, mobility, and cultural fluency form connective tissue between worlds. They are not instruments of any single state but participants in a shared global project of knowledge, invention, and exchange. To the extent that a more plural modernity is emerging, it may be these communities, rather than governments, that embody it.

Coming to terms with China doesn’t require abandoning one’s own values or surrendering one’s aspirations. But it does require that the rest of us hold them more lightly, argue for them more persuasively, and demonstrate their worth through performance rather than proclamation. If liberal democracy and market capitalism are indeed superior forms of organization, they should be able to prove that through results, not rhetoric.

Above all, some of us need to stop framing our approach to China in terms of why it can’t last, what must go wrong, or when the contradictions will finally catch up with it. The system has worked. It has delivered. Waiting for its collapse is not a strategy; it’s a coping mechanism.

The Great Reckoning is ultimately about intellectual honesty: the willingness to see the world as it is rather than as we wish it were, acknowledge achievement wherever it occurs, and learn from success even when it emerges from sources we find uncomfortable. To reckon is to resist denial, accept the evidence of our eyes, and choose candor over illusion.

That is where any genuine reckoning must begin: not with policy prescriptions nor strategic frameworks, but with the simple recognition that the world has changed in ways we’re only beginning to understand. What policies should follow? I don’t pretend to know. The policy work can only begin after we stop lying to ourselves. The reckoning I’m calling for is perceptual and psychological, not programmatic. We need to see China’s achievements clearly, without the reflexive “yes, but” that immediately minimizes them, before we can think clearly about what they mean for us. The cope itself is the problem I’m trying to solve.

The world has fundamentally changed. The choice, for the West, is not between resistance and surrender, but between thoughtful adaptation and stubborn denial, between strengthening our institutions through honest self-examination or watching them weaken through willful blindness to new realities.

Kaiser Kuo is the host and co-founder of the Sinica Podcast and a professor-at-large at NYU Shanghai.

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sarcozona
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“Chinese intellectuals are grappling with challenges that have no modern precedent: What kind of global power should China become? How should a civilization that has regained confidence in its own path engage with a world still organized around Western institutions and assumptions? China’s leaders speak of building a “community of common destiny for mankind,” but the practical meaning of such concepts remains deliberately vague. The deeper questions are harder still: Can a civilization that has never fit comfortably within a Westphalian order find a way to work inside it, or will it seek to reshape the norms themselves? How does a country that has achieved prosperity through state-led development share that model without appearing to compromise others’ sovereignty?”
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Addiction advocates win landmark ADA victory in N.C. settlement

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Two skilled nursing facilities in North Carolina reached a settlement this month that bars them from discriminating against people with a history of substance use — potentially setting a precedent for how long-term care facilities nationwide treat people with addiction. 

Under the settlement, the facilities are to adopt new antidiscrimination admission policies and apply reasonable judgment to individual applicants, instead of automatically denying them based on past substance use. 

The policies apply to people taking addiction medications like methadone and buprenorphine, as well as those who currently use illegal drugs; facilities are not required to bend their own rules regarding admitted patients’ substance use. It is believed to be the first case in the U.S. to successfully challenge long-term care facilities’ systemic denials of admission to people with substance use disorders. 

“The Americans with Disabilities Act prohibits the denial of health services to people on the basis of current drug use,” said Rebekah Joab, an attorney with the New York-based Legal Action Center. “So somebody with the disability of substance use disorder has to be treated the same as anyone else.” 

The lawsuit was brought jointly by the Legal Action Center, which advocates on behalf of people with addiction or who are incarcerated, and another nonprofit, Disability Rights North Carolina. 

It was filed on behalf of an anonymous “John Doe” client who was denied admission to two facilities in Raleigh and Durham, N.C., respectively: Sunnybrook Rehabilitation Center and Treyburn Rehabilitation Center. 

In an interview, Sara Harrington, an attorney with Disability Rights North Carolina, stressed that the settlement doesn’t require facilities to admit potentially disruptive patients. Instead, she said, it requires them to treat all applicants equally and not automatically reject those with a history of substance use. 

“We’re not saying that they need to condone [drug use] or let people break their rules,” Harrington said. “We’re just saying that people need a chance. If our client had been interviewed, if he had been assessed using nondiscrimination policies, he would have been admitted, most likely. He’s in a facility now, and has been there for over a year, and any concerns the other facilities had came to nothing, because he’s a great resident.” 

The rehabilitation facilities did not immediately return STAT’s request for comment. 

The settlement is the latest in a string of legal developments that, in recent years, have expanded applications of the Americans with Disabilities Act, or ADA, to apply more broadly to people in recovery, people taking medications for opioid use disorder, and increasingly, people who currently use illicit drugs. 

While the ADA views addiction as a disability, it does not protect Americans from repercussions for their drug use — for instance, being dismissed from a job. Increasingly, however, attorneys have used the landmark 1990 law to protect people with opioid addiction from discrimination in various health care and carceral settings. 

Under former President Biden, the Department of Justice issued a string of guidance warning that the denial of medications like methadone or buprenorphine to people with opioid use disorder would violate the ADA. Recently, a federal judge certified a class-action lawsuit against a branch of the Salvation Army for denying admission to people taking either medication based on its religious views. 

Under Biden, the DOJ reached similar settlements with a trial court in Massachusetts, the Indiana Board of Nursing, a Colorado-based social services program, and Pennsylvania’s court system, all for discriminating against people with opioid use disorder, either broadly or specifically with regard to their use of addiction medications. 

While the North Carolina settlement doesn’t create new doctrine for skilled nursing facilities elsewhere across the state or country, it does lay groundwork for similar lawsuits in the future. It is unclear, however, whether the Department of Justice under President Trump will continue efforts from the previous administration to roll back discrimination against people with addiction. 

“The implication should be understood by nursing homes in every state and territory that they have to have antidiscrimination policies and they cannot exclude individuals who have substance use disorder or who are in active use,” said Holly Stiles, the assistant legal director for litigation at Disability Rights North Carolina. “That’s what federal law requires, is that it be interpreted uniformly across the country, so we would encourage other facilities to understand that this is their obligation, too.”

STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.

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sarcozona
15 hours ago
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Epiphyte City
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