Science
Opinion: Fentanyl could fuel another cycle of loss in L.A.'s Black communities. It doesn't have to
The death of a parent is typically a gutting and disorienting experience for adults. For a child, it’s even worse, stoking feelings of frustration and abandonment and sometimes self-destructive behaviors such as drug use that can continue well into adulthood. This has particularly serious implications when the child is Black and therefore more likely to end up in the child welfare system.
A recent report by federal researchers provides the fullest picture yet of the sprawling impact of overdose deaths on Black children in Los Angeles and other cities — and what we can do about it.
From 2011 to 2021, the report found, more than 321,000 American children lost a parent to a drug overdose. Black children experienced the highest increases in the rate of such losses during those years, compounding a long-standing public health crisis across Black America. Like much of the United States, Los Angeles has seen drug overdoses soar in recent years, with disproportionate losses among the city’s Black adults.
Black people are significantly more likely to experience drug-related deaths due to limited access to treatment and resources such as naloxone, which can reverse overdoses. When they’re parents, the toll on their children is both rapid and deep. Parental drug use is highly associated with use among children.
Although Black children make up just 7.4% of the Los Angeles County population, they represented 24% of those who entered the child welfare system in one recent year. One study found that about 47% of Black children in California were the subject of a maltreatment investigation before the age of 18, with substance use accounting for 41% of the state’s child maltreatment cases.
The disproportionate number of Black children in Los Angeles’ child welfare system has been scrutinized since the late 1980s, the height of Los Angeles’ heroin and crack epidemics. The drugs, then largely addressed as a criminal issue through heavy-handed policing and prosecution, consigned a generation of young and middle-aged Black Angelenos, both users and dealers, to premature death and incarceration. Many of their children wound up in the city’s fragmented child welfare system and, all too often, on a similar path toward addiction and entanglement with the legal system.
When a child’s parent dies, other family members — the child’s other parent, grandparents, aunts or uncles — are the first resort to assume responsibility for their care. But Black children, especially those from low-income communities, often end up in the child welfare system instead.
Why? The child’s surviving family members may lack the resources to fill the breach. But racial biases also predispose child welfare workers to remove Black children from their families and impede reunification efforts.
Research has consistently shown that child welfare workers more readily define Black parents’ behavior as abusive or neglectful even when it’s comparable to the conduct of parents of other races. Child welfare workers are also more likely to regard Black families as less loving of their children and less redeemable.
Children who enter the child welfare system due to parental death already spend twice as much time in the system. Black children tend to remain in the system even longer because of bias.
The twin depredations of Los Angeles’ opioid epidemic and its child welfare system are daunting but not beyond repair. The first necessity is to revamp the city’s racially biased child removal process. Los Angeles officials have been piloting a “blind removal” approach in which investigations are followed by a decision-making process that excludes demographic details such as the child’s race. This is a step in the right direction.
However, a UCLA study of the pilot program revealed that racial disproportionality persists, demonstrating how deep-seated child welfare biases are. For blind removal to be effective in eliminating racial disparities, it must be supplemented by greater transparency, expanded civilian review boards and training in implicit bias.
Second, we need a better understanding of the consequences of placing Black children in the child welfare system. In general, Black children in the system are highly stigmatized, especially when they come from families with histories of drug abuse. That contributes to making them less likely to be adopted. The trauma of losing a parent also means they’re more likely to experience depression and anxiety.
These experiences frequently devolve into social isolation, poor academic outcomes, limited employment prospects and incarceration. Officials must work to identify these patterns early and provide resources such as mental health care to disrupt this harmful cascade.
Lastly, policymakers must continue to explore the benefits of guaranteed basic income to provide a cushion for personal and professional growth. Another California pilot program would provide guaranteed basic income to those who age out of foster care at 21 or older. The state should lower the eligibility age to 18 to account for the steep challenges in housing and employment Black youths face as soon as they become adults. Researchers at Stanford and other institutions have found that such policies support better health, housing security and employment prospects.
Addressing the deepening overdose epidemic in Los Angeles’ Black communities requires attention not just to the immediate risks to drug users but also to the childhood experiences that often drive them to use. One of our most powerful tools for preventing future overdoses is to take better care of the children most directly affected by today’s losses.
Jerel Ezell is an assistant professor of community health sciences at UC Berkeley who studies the racial politics of substance use.
The sun had barely risen over the Pacific Ocean when a small motorboat carrying a team of Indigenous artisans and Mexican biologists dropped anchor in a rocky cove near Bahías de Huatulco.
Mauro Habacuc Avendaño Luis, one of the craftsmen, was the first to wade to shore. With an agility belying his age, he struck out over the boulders exposed by low tide. Crouching on a slippery ledge pounded by surf, he reached inside a crevice between two rocks. There, lodged among the urchins, was a snail with a knobby gray shell the size of a walnut. The sight might not dazzle tourists who travel here to see humpback whales, but for Mr. Avendaño, 85, these drab little mollusks represent a way of life.
Marine snails in the genus Plicopurpura are sacred to the Mixtec people of Pinotepa de Don Luis, a small town in southwestern Oaxaca. Men like Mr. Avendaño have been sustainably “milking” them for radiant purple dye for at least 1,500 years. The color suffuses Mixtec textiles and spiritual beliefs. Called tixinda, it symbolizes fertility and death, as well as mythic ties between lunar cycles, women and the sea.
The future of these traditions — and the fate of the snails — are uncertain. The mollusks are subject to intense poaching pressure despite federal protections intended to protect them. Fishermen break them (and the other mollusks they eat) open and sell the meat to local restaurants. Tourists who comb the beaches pluck snails off the rocks and toss them aside.
A severe earthquake in 2020 thrust formerly submerged parts of their habitat above sea level, fatally tossing other mollusks in the snail’s food web to the air, and making once inaccessible places more available to poachers.
Decades ago, dense clusters of snails the size of doorknobs were easy to find, according to Mr. Avendaño. “Full of snails,” he said, sweeping a calloused, violet-stained hand across the coves. Now, most of the snails he finds are small, just over an inch, and yield only a few milliliters of dye.
new video loaded: This Parrot Has No Beak, But Is at the Top of the Pecking Order
By Meg Felling and Carl Zimmer
April 20, 2026
For months now, menopausal women across the U.S. have been unable to fill prescriptions for the estradiol patch, a long-established and safe hormone treatment. The news media has whipped up a frenzy over this scarcity, warning of a long-lasting nationwide shortage. The problem is real — but the explanations in the media coverage miss the mark. Real solutions depend on an accurate understanding of the causes.
Reporters, pharmaceutical companies and even some doctors have blamed women for causing the shortage, saying they were inspired by a “menopause moment” that has driven unprecedented demand. Such framing does a dangerous disservice to essential health advocacy.
In this narrative, there has been unprecedented demand, and it is explained in part by the Food and Drug Administration’s recent removal of the “black-box warning” from estradiol patches’ packaging. That inaccurate (and, quite frankly, terrifying) label had been required since a 2002 announcement overstated the link between certain menopause hormone treatments and breast cancer. Right-sizing and rewording the warning was long overdue. But the trouble with this narrative is that even after the black-box warning was removed, there has not been unprecedented demand.
Around 40% of menopausal women were prescribed hormone treatments in some form before the 2002 announcement. Use plummeted in its aftermath, dipping to less than 5% in 2020 and just 1.8% in 2024. According to the most recent data, the number has now settled back at the 5% mark. Unprecedented? Hardly. Modest at best.
Nor is estradiol a new or complex drug; the patch formulation has existed for decades, and generic versions are widely manufactured. There is no exotic ingredient, no rare supply chain dependency, no fluke that explains why women are suddenly being told their pharmacy is out of stock month after month.
The story is far more an indictment of the broken insurance industry: market concentration, perverse incentives and the consequences of allowing insurance companies to own the pharmacy benefit managers that effectively control drug access for the majority of users. Three companies — CVS Caremark, Express Scripts and OptumRx — manage 79% of all prescription drug claims in the United States. Those companies are wholly owned subsidiaries of three insurance behemoths: CVS Health, Cigna and UnitedHealth Group, respectively. This means that the same corporation that sells you your insurance plan also decides which drugs get covered, at what price, and whether your pharmacy can stock them. This is called vertical integration. In another era, we might have called it a cartel. The resulting problems are not unique to hormone treatments; they have affected widely used medications including blood thinners, inhalers and antibiotics. When a low-cost generic such as estradiol — a medication with no blockbuster profit margins and no patent protection — runs into friction in this system, the friction is not random. It is structural. Every decision in that chain is filtered through the same corporate profit motive. And when the drug in question is an off-patent estradiol patch that has negligible profit margins because of generic competition but requires logistical investment to keep consistently in stock? The math on “how much does this company care about ensuring access” is not complicated.
Unfortunately, there is little financial incentive to ensure smooth, consistent access. There is, however, significant financial incentive to steer patients toward branded alternatives, or simply to let supply tighten — because the companies aren’t losing much profit if sales of that product dwindle. This is not a conspiracy theory: The Federal Trade Commission noted this dynamic in a report that documented how pharmacy benefit managers’ practices inflate costs, reduce competition and harm patient access, particularly for independent pharmacies and for generic drugs.
Any claim that the estradiol patch shortage is meaningfully caused by more women now demanding hormone treatments is a distraction. It is also misogyny, pure and simple, to imply that the solution to the shortage is for women’s health advocates to dial it down and for women to temper their expectations. The scarcity of estradiol patches is the outcome of a broken system refusing to provide adequate supply.
Meanwhile, there are a few strategies to cope.
- Ask your prescriber about alternatives. Estradiol is available in multiple formulations, including gel, spray, cream, oral tablet, vaginal ring and weekly transdermal patch, which is a different product from the twice-weekly patch and may be more consistently available depending on manufacturer and region.
- Consider an online pharmacy. Many are doing a good job locating and filling these prescriptions from outside the pharmacy benefit manager system.
- Call ahead. Patch shortages are inconsistent across regions and distributors. A call to pharmacies in your area, or a broader geographic radius if you’re able, can locate stock that your regular pharmacy doesn’t have.
- Consider a compounding pharmacy. These sources can sometimes meet needs when commercially manufactured products are inaccessible. The hormones used are the same FDA-regulated bulk ingredients.
Beyond those Band-Aid solutions, more Americans need to fight for systemic change. The FTC report exists because Congress asked for it and committed to legislation that will address at least some of the problems. The FDA took action to change the labeling on estrogen in the face of citizen and medical experts’ pressure; it should do more now to demand transparency from patch manufacturers.
Most importantly, it is on all of us to call out the cracks in the current system. Instead of repeating “there’s a patch shortage” or a “surge in demand,” say that a shockingly small minority of menopausal women still even get hormonal treatments prescribed at all, and three drug companies control the vast majority of claims in this country. Those are the real problems that need real solutions.
Jennifer Weiss-Wolf, the executive director of the Birnbaum Women’s Leadership Center at New York University School of Law, is the author of the forthcoming book “When in Menopause: A User’s Manual & Citizen’s Guide.” Suzanne Gilberg, an obstetrician and gynecologist in Los Angeles, is the author of “Menopause Bootcamp.”
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