Science
What military doctors can teach us about power in the United States
Power is invisible, but its effects can be seen everywhere — especially in the health records of active duty military personnel.
By examining details of 1.5 million emergency room visits at U.S. military hospitals nationwide, researchers found that doctors invested significantly more resources in patients who outranked them than in patients of equal or lesser rank. The additional clinical effort devoted to powerful patients came at the expense of junior patients, who received worse care and were more likely to become seriously ill.
Military rank wasn’t the only form of power that translated into inequitable treatment. The researchers documented that patients fared better when they shared the same race or gender as their doctor, a pattern that tended to favor white men and caused Black patients in particular to be shortchanged by their physicians.
The results were published Thursday in the journal Science.
The findings have implications far beyond the realm of the military, said Manasvini Singh, a health and behavioral economist at Carnegie Mellon University who conducted the research with Stephen D. Schwab, an organizational health economist at the University of Texas at San Antonio.
For instance, they can help explain why Black students do better in school when they are taught by Black teachers, and why Black defendants get more even-handed treatment from Black judges.
“We think our results speak to many settings,” Singh said.
The disparities wrought by power imbalances are easy to spot but difficult to study in real-world scenarios.
“It’s just hard to measure power,” Singh said. “It’s abstract, it’s complicated.”
That’s where the military health records come in.
The Military Health System operates 51 hospitals across the country. The doctors who staff them are active-duty personnel, as are many of the patients they treat. Comparing their ranks gave Singh and Schwab a handy way to gauge the power differential between physicians and the people in their care.
The researchers restricted their analysis to patients who sought treatment in emergency departments, where patients are randomly assigned to doctors. That randomness made it easier to measure how power influenced the treatment patients received.
To further isolate the effects of power, the researchers made comparisons between patients of the same rank. If they happened to outrank their doctor, they were considered a “high-power” patient. If not, they were classified as a “low-power” patient.
The medical records showed that doctors put 3.6% more effort into treating high-power patients than low-power ones. They also utilized significantly more resources such as clinical tests, scans and procedures, according to the study.
Those extra resources translated into better care: High-power patients were 15% less likely to become sick enough to be admitted to the hospital over the next 30 days.
To see if they could replicate their results, Singh and Schwab narrowed their focus to doctors who treated patients within a one-year period before or after the patients were promoted to a higher rank. The researchers found that doctors devoted 1% more effort to patients post-promotion, as well as more medical resources. Those differences may have been small, but they were statistically significant, Schwab said.
Next, the pair considered what happened to low-power patients while high-power patients were getting extra attention. One hypothesis was that ordering additional tests for one patient might prompt doctors to order the same tests for everyone they treated that day. It was also possible that the decisions doctors made for their high-power patients had no bearing on their other patients.
Neither turned out to be the case. Instead, the added effort spent on high-power patients was siphoned away from low-power patients, who got 1.9% less effort from their doctors. On top of that, their risk of needing to return to the ER or be admitted to the hospital over the following 30 days increased by 3.4%, the researchers found.
“The powerful unwittingly ‘steal’ resources from less-powerful individuals,” Schwab and Singh wrote.
Outside the military, doctors and patients can’t use official rank to measure their power relative to each other, but they do contend with the effects of race and gender. That led the researchers to investigate whether the physicians in their study treated patients differently if they shared these attributes.
White doctors devoted more effort to white patients than to Black patients across the board, the researchers found. The gap was the same regardless of whether the doctor had a higher or lower rank than the patient.
However, white doctors increased their effort for high-power patients by the same amount regardless of race. As a result, white doctors treated high-power Black patients the same, on average, as low-power white patients.
The story was different for Black doctors. When they outranked their patients, they gave essentially the same amount of effort to everyone. But on the rare occasions when they encountered a higher-ranked Black patient, the amount by which they dialed up their efforts was more than 17 times greater than it was when they treated a higher-ranked white patient.
It’s not clear what accounted for this “off-the-charts effort,” the researchers wrote. They speculated that since Black service members were underrepresented among the pool of high-power patients, Black doctors were particularly attuned to their status.
The effects of gender were more difficult to ascertain, since biology dictates that men and women require different kinds of care.
Both male and female doctors invested the most effort in female patients who outranked them. But male doctors upgraded their care for high-power patients of both genders to a much greater extent than female doctors. And unlike female doctors, male doctors devoted more effort to female patients across the board.
Finally, the researchers wondered whether doctors gave preferential treatment to high-power patients because of their elevated status or because those patients had the authority to make trouble if they were unsatisfied with their care. To make inferences about this, they compared the treatment of retirees (who retained their status but had given up their authority) to the treatment of active-duty patients (who still had both).
Schwab and Singh found that high-power patients continued to elicit extra effort from doctors for up to five years after they retired, suggesting that status was an important factor.
“I think it’s really, really cool that even after retirement, you still have these effects,” said Joe C. Magee, a professor of management and organization at the NYU Stern School of Business who studies the role of hierarchy. He sees that as a strong sign that status was driving doctors’ decisions all along.
“What these folks are able to show is that it has real health consequences,” Magee said.
Eric Anicich, a professor of management and organization at the USC Marshall School of Business, called the study “impressive” and the findings “important.”
Although a 3.5% increase or a 1.9% decrease in physician effort may seem small, their cumulative impact is meaningful, especially when it comes to something as critically important as healthcare, he said.
The inequities documented in the study aren’t unique to doctors or to the armed forces, Schwab and Singh said. The mathematical model they developed to describe the behavior in military emergency rooms also helps explain why people in all kinds of situations give preferential treatment to people who look like them: It may help minimize the effects of societal disparities.
In a commentary that accompanies the study, Laura Nimmon of the University of British Columbia’s Centre for Health Education Scholarship wrote that “the ephemeral and unobservable nature of power has made it profoundly difficult to study.” But she said it’s worth the effort to make sure doctors wield their power more fairly.
The disparities reported by Schwab and Singh are “of serious concern to society at large,” she wrote.
Science
Pediatricians urge Americans to stick with previous vaccine schedule despite CDC’s changes
For decades, the American Academy of Pediatrics and the U.S. Centers for Disease Control and Prevention spoke with a single voice when advising the nation’s families on when to vaccinate their children.
Since 1995, the two organizations worked together to publish a single vaccine schedule for parents and healthcare providers that clearly laid out which vaccines children should get and exactly when they should get them.
Today, that united front has fractured. This month, the Department of Health and Human Services announced drastic changes to the CDC’s vaccine schedule, slashing the number of diseases that it recommends U.S. children be routinely vaccinated against to 11 from 17. That follows the CDC’s decision last year to reverse its recommendation that all kids get the COVID-19 vaccine.
On Monday, the AAP released its own immunization guidelines, which now look very different from the federal government’s. The organization, which represents most of the nation’s primary care and specialty doctors for children, recommends that children continue to be routinely vaccinated against 18 diseases, just as the CDC did before Robert F. Kennedy Jr. took over the nation’s health agencies.
Endorsed by a dozen medical groups, the AAP schedule is far and away the preferred version for most healthcare practitioners. California’s public health department recommends that families and physicians follow the AAP schedule.
“As there is a lot of confusion going on with the constant new recommendations coming out of the federal government, it is important that we have a stable, trusted, evidence-based immunization schedule to follow and that’s the AAP schedule,” said Dr. Pia Pannaraj, a member of AAP’s infectious disease committee and professor of pediatrics at UC San Diego.
Both schedules recommend that all children be vaccinated against measles, mumps, rubella, polio, pertussis, tetanus, diphtheria, Haemophilus influenzae type B (Hib), pneumococcal disease, human papillomavirus (HPV) and varicella (better known as chickenpox).
AAP urges families to also routinely vaccinate their kids against hepatitis A and B, COVID-19, rotavirus, flu, meningococcal disease and respiratory syncytial virus (RSV).
The CDC, on the other hand, now says these shots are optional for most kids, though it still recommends them for those in certain high-risk groups.
The schedules also vary in the recommended timing of certain shots. AAP advises that children get two doses of HPV vaccine starting at ages 9 to12, while the CDC recommends one dose at age 11 or 12. The AAP advocates starting the vaccine sooner, as younger immune systems produce more antibodies. While several recent studies found that a single dose of the vaccine confers as much protection as two, there is no single-dose HPV vaccine licensed in the U.S. yet.
The pediatricians’ group also continues to recommend the long-standing practice of a single shot combining the measles, mumps and rubella (MMR) and varicella vaccines in order to limit the number of jabs children get. In September, a key CDC advisory panel stocked with hand-picked Kennedy appointees recommended that the MMR and varicella vaccines be given as separate shots, a move that confounded public health experts for its seeming lack of scientific basis.
The AAP is one of several medical groups suing HHS. The AAP’s suit describes as “arbitrary and capricious” Kennedy’s alterations to the nation’s vaccine policy, most of which have been made without the thorough scientific review that previously preceded changes.
Days before AAP released its new guidelines, it was hit with a lawsuit from Children’s Health Defense, the anti-vaccine group Kennedy founded and previously led, alleging that its vaccine guidance over the years amounted to a form of racketeering.
The CDC’s efforts to collect the data that typically inform public health policy have noticeably slowed under Kennedy’s leadership at HHS. A review published Monday found that of 82 CDC databases previously updated at least once a month, 38 had unexplained interruptions, with most of those pauses lasting six months or longer. Nearly 90% of the paused databases included vaccination information.
“The evidence is damning: The administration’s anti-vaccine stance has interrupted the reliable flow of the data we need to keep Americans safe from preventable infections,” Dr. Jeanne Marrazzo wrote in an editorial for Annals of Internal Medicine, a scientific journal. Marrazzo, an infectious disease specialist, was fired last year as head of the National Institute of Allergy and Infectious Diseases after speaking out against the administration’s public health policies.
Science
‘We’re not going away’: Rob Caughlan, fierce defender of the coastline and Surfrider leader, dies at the age of 82
Known by friends and colleagues as a “planetary patriot,” a “happy warrior” and the “Golden State Eco-Warrior,” Rob Caughlan, a political operative, savvy public relations specialist and one of the early leaders of the Surfrider Foundation, died at his home in San Mateo, on Jan. 17. He was 82.
His wife of nearly 62 years, Diana, died four days earlier, from lung cancer.
Environmentalists, political operatives and friends responded to his death with grief but also joy as they recalled his passion, talent and sense of humor — and his drive not only to make the world a better place, but to have fun doing it.
“He’d always say that the real winner in a surfing contest was the guy who had the most fun,” said Lennie Roberts, a conservationist in San Mateo County and longtime friend of Caughlan’s. “He was true to that. It’s the way he lived.”
“When he walked into a room, he’d have a big smile on his face. He was a great — a gifted — people person,” said Dan Young, one of the original five founders of the Surfrider Foundation. The organization was cobbled together in the early 1980s by a group of Southern California surfers who felt called to protect the coastline — and their waves.
They also wanted to dispel the stereotype that surfers are lackadaisical stoners — and show the world that surfers could get organized and fight for just causes, said Roberts, citing Caughlan’s 2020 memoir, “The Surfer in the White House and Other Salty Yarns.”
Before joining Surfrider in 1986, Caughlan was a political operative who worked as an environmental adviser in the Carter administration. According to Warner Chabot, an old friend and recently retired executive director of the an Francisco Estuary Institute, Caughlan got his start during the early 1970s when he and his friend, David Oke, formed the Sam Ervin Fan Club, which supported the Southern senator’s efforts to lead the Watergate investigation of President Nixon.
According to Chabot, Caughlan organized the printing of T-shirts with Ervin’s face on them, underneath the text “I Trust Uncle Sam.”
“He was an early social influencer — par extraordinaire,” he said.
Glenn Hening, a surfer, former Jet Propulsion Laboratory space software engineer and another original founder of the Surfrider Foundation, said one of the group’s initial fights was against the city of Malibu, which in the early 1980s was periodically digging up sand in the lagoon right offshore and destroying the waves at one of their favorite surf spots.
According to Hening, it was Caughlin’s unique ability to persuade and charm politicians and donors that put Surfrider’s efforts on the map.
Caughlan served as the foundation’s president from 1986 to 1992.
The foundation grabbed the national spotlight in 1989 when it went after two large paper mills in Humboldt Bay that were discharging toxic wastewater into an excellent surfspot in Northern California. The foundation took aim and in 1991 filed suit alongside the U.S. Environmental Protection Agency; the paper mills settled for $5.8 million.
Hening said the victory would never have happened without Caughlan.
The mills had tried to brush off the suit by offering a donation to the foundation, Hening said. But Caughlan and Mark Massara — an environmental lawyer with the organization — rebuffed the gesture.
“The paper mill guys said, ‘Well, what can we do here? How can we make this go away?’” said Hening, recalling the conversation. “And Rob said, ‘It’s not going to go away. We’re not going away. We’re surfers.”
Roberts said Caughlan’s legacy can be felt by anyone who has ever spent time on the San Mateo County coastline. In the 1980s, the two spearheaded a successful ballot measure still protects the coast from non-agricultural development and ensured access to the beaches and bluffs. It also prohibits onshore oil facilities for off-shore facilities.
The two also worked on a county measure that led to the development of the Devil’s Slide tunnels on Highway 1 between Pacifica and Montara, designed to make that formerly treacherous path safer for travelers.
The state had wanted to build a six-lane highway over the steep hills in the area. “It would have been dangerous because of the steep slopes, and it would be going up into the fog bank and then back down out of the fog. So it was inherently dangerous,” Roberts said.
Chad Nelsen, the current president of the Surfrider Foundation, said he was first drawn into Caughlan’s orbit in 2010 when Surfrider got involved with a lawsuit pertaining to a beach in San Mateo County. Silicon Valley venture capitalist Vinod Khosla purchased 53 acres of Northern California coastline for $32.5 million and closed off access to the public — including a popular stretch known as Martin’s Beach — so Surfrider sued.
Nelsen said that although Caughlan had left the organization about 20 years before, he reappeared with a “sort of unbridled enthusiasm and commitment to the cause,” and the organization ultimately prevailed — the public can once again access the beach “thanks to ‘Birdlegs.’”
Birdlegs was Caughlan’s nickname, and according to Nelsen, it was probably coined in the 1970s by his fellow surfers.
“He had notoriously spindly legs, I guess,” Nelsen said.
Robert Willis Caughlan was born in Alliance, Ohio, on Feb. 27, 1943. His father, who was a parachute instructor with the U.S. Army, died when Caughlan was 4. In 1950, Caughlan moved with his mother and younger brother to San Mateo, where he saw the ocean for the first time.
He rode his his first wave in 1959, at the age of 16, from the breakwater at Half Moon Bay.
Science
LAUSD says Pali High is safe for students to return to after fire. Some parents and experts have concerns
The Los Angeles Unified School District released a litany of test results for the fire-damaged Palisades Charter High School ahead of the planned return of students next week, showing the district’s remediation efforts have removed much of the post-fire contamination.
However, some parents remain concerned with a perceived rush to repopulate the campus. And while experts commended the efforts as one of the most comprehensive post-fire school remediations in modern history, they warned the district failed to test for a key family of air contaminants that can increase cancer risk and cause illness.
“I think they jumped the gun,” said a parent of one Pali High sophomore, who asked not to be named because she feared backlash for her child. “I’m quite angry, and I’m very scared. My kid wants to go back. … I don’t want to give him too much information because he has a lot of anxiety around all of these changes.”
Nevertheless, she still plans to send her child back to school on Tuesday, because she doesn’t want to create yet another disruption to the student’s life. “These are kids that also lived through COVID,” she said.
The 2025 Palisades fire destroyed multiple buildings on Pali High’s campus and deposited soot and ash in others. Following the fire, the school operated virtually for several months and, in mid-April of 2025, moved into a former Sears department store in Santa Monica.
Meanwhile, on campus, the U.S. Environmental Protection Agency and the U.S. Army Corps of Engineers cleared debris from the destroyed structures, and LAUSD hired certified environmental remediation and testing companies to restore the still-standing buildings to a safe condition.
LAUSD serves as the charter school’s landlord and took on post-fire remediation and testing for the school. The decision to move back to the campus was ultimately up to the charter school’s independent leadership.
The Los Angeles Department of Water and Power tested the drinking water for a slew of contaminants, and environmental consultants tested the soil, HVAC systems, indoor air and surfaces including floors, desks and lockers.
They tested for asbestos, toxic metals such as lead and potentially hazardous organic compounds often unleashed through combustion, called volatile organic compounds, or VOCs.
“The school is ready to occupy,” said Carlos Torres, director of LAUSD’s office of environmental health and safety. “This is really the most thorough testing that’s ever been done that I can recall — definitely after a fire.”
Construction workers rebuild the Palisades Charter High School swimming pool.
(Allen J. Schaben / Los Angeles Times)
A handful of soil samples had metal concentrations slightly above typical post-fire cleanup standards, which are designed to protect at-risk individuals over many years of direct exposure to the soil — such as through yard work or playing sports. An analysis by the environmental consultants found the metals did not pose a health risk to students or staff.
On indoor surfaces, the consultants found two areas with lead and one with arsenic, spaces they recleaned and retested to make sure those metals were no longer present.
The testing for contamination in the air, however, has become a matter of debate.
Some experts cautioned that LAUSD’s consultants tested the air for only a handful of mostly non-hazardous VOCs that are typically used to detect smoke from a wildfire that primarily burned plants. While those tests found no contamination, the consultants did not test for a more comprehensive panel of VOCs, including many hazardous contaminants commonly found in the smoke of urban fires that consume homes, cars, paints, detergents and plastics.
The most notorious of the group is benzene, a known carcinogen.
At a Wednesday webinar for parents and students, LAUSD’s consultants defended the decision, arguing their goal was only to determine whether smoke lingered in the air after remediation, not to complete more open-ended testing of hazardous chemicals that may or may not have come from the fire.
Andrew Whelton, a Purdue University professor who researches environmental disasters, didn’t find the explanation sufficient.
“Benzene is known to be released from fire. It is known to be present in air. It is known to be released from ceilings and furniture and other things over time, after the fire is out,” Whelton said. “So, I do not understand why testing for benzene and some of the other fire-related chemicals was not done.”
For Whelton, it’s representative of a larger problem in the burn areas: With no decisive guidance on how to remediate indoor spaces after wildland-urban fires, different consultants are making significantly different decisions about what to test for.
LAUSD released the testing results and remediation reports in lengthy PDFs less than two weeks before students plan to return to campus, while the charter school’s leadership decided on a Jan. 27 return date before testing was completed.
At the webinar, school officials said two buildings near the outdoor pool have not yet been cleared through environmental testing and will remain closed. Four water fixtures are also awaiting final clearance from the Los Angeles Department of Water and Power, and the school’s food services are still awaiting certification from the L.A. County Department of Public Health.
For some parents — even those who are eager to ditch the department store campus — it amounts to a flurried rush to repopulate Pali High’s campus that is straining their decisions about how to keep their kids safe.
Torres stressed that his team acted cautiously in the decision to authorize the school for occupancy, and that promising preliminary testing helped school administrators plan ahead. He also noted that the slow, cautious approach was a point of contention for other parents who hoped their students could return to the campus as quickly as possible.
Experts largely praised LAUSD’s efforts as thorough and comprehensive — with the exception of the VOC air testing.
Remediation personnel power washed the exterior of buildings, wiped down all surfaces and completed thorough vacuuming with filters to remove dangerous substances. Any soft objects such as carpet or clothing that could absorb and hold onto contamination were discarded. The school’s labyrinth of ducts and pipes making up the HVAC system was also thoroughly cleaned.
Crews tested throughout the process to confirm their remediation work was successful and isolated sections of buildings once the work was complete. They then completed another full round of testing to ensure isolated areas were not recontaminated by other work.
Environmental consultants even determined a few smaller buildings could not be effectively decontaminated and consequently had them demolished.
Torres said LAUSD plans to conduct periodic testing to monitor air in the school, and that the district is open to parents’ suggestions.
For Whelton, the good news is that the school could easily complete comprehensive VOC testing within a week, if it wanted to.
“They are very close at giving the school a clean bill of health,” he said. “Going back and conducting this thorough VOC testing … would be the last action that they would need to take to determine whether or not health risks remain for the students, faculty and visitors.”
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