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This story was originally published in The Highlight, Vox’s member-exclusive magazine. To get early access to member-exclusive stories every month, join the Vox Membership program today. The sharp decline in child mortality rates is one of the great global success stories of the past several decades.  In 1990, nearly 13 million children died before their fifth birthday, primarily from infectious diseases or complications during birth. By 2022, that number had fallen by more than 50 percent, meaning that today, about 8 million fewer children are dying than were some 35 years ago.  Overall development improvements, alongside a handful of targeted public health interventions — ensuring that skilled health care workers are present during childbirth, improving access to clean water, providing postnatal care, and expanding vaccination, to name a few — have helped ensure far more children live to see their fifth birthday and beyond.  Yet despite that progress, around 5 million children younger than 5 years old still die prematurely each year, with about 80 percent of those deaths occurring in sub-Saharan Africa and southern Asia. And progress to reduce child mortality has slowed in recent years. Between 2015 and 2022, child mortality rates fell by only 2 percent, down from about 4 percent between 2000 and 2015. But one surprising intervention — periodically distributing antibiotics prophylactically to young children en masse — could help further reduce child mortality rates in some of the worst-affected countries. A study published in August examined children in Niger, a country in West Africa with one of the highest child mortality rates in the world. Researchers found that twice-yearly mass distributions of an antibiotic to children between the ages of 1 and 5 reduced child mortality by 14 percent.  If this sounds too good to be true — significant reductions in child deaths simply by giving them basic drugs designed to fight bacterial infections — it may be. This intervention around one major health challenge — childhood mortality — is somewhat controversial because it seems to directly run against another major health challenge: the rise of drug-resistant infections. Such infections, which are caused by the overuse of antibiotics, claim an estimated 1 million lives every year, a number that could nearly double by 2050.  “If you increase the amount of antibiotic exposure in the population, you are guaranteed to increase the risk of having drug resistance,” said Gautam Dantas, a professor at Washington University’s School of Medicine who studies the human microbiome and antimicrobial resistance. These drug-resistant pathogens can spread around the world, creating a public health threat for everyone.  And there’s another question: While the positive results show promise, no one is exactly sure why giving antibiotics to children who have no overt sign of infection but still live in high-risk areas reduces overall child mortality in the community. Given the unknowns and potential to contribute to global drug resistance, the World Health Organization in 2020 strongly recommended against mass antibiotic distribution as a universal intervention. Instead, the agency suggested that public health officials pursue the intervention only in places where under 5 mortality is greater than 80 children per 1,000 births. In 2022, only 10 countries recorded under 5 mortality rates higher than this threshold.  The scientists who study and advocate for the mass distribution of antibiotics are well aware of these issues. The essential question: How does one weigh saving children’s lives against fueling another deadly health threat?  A safety net of antibiotics The idea of mass distributing antibiotics to reduce child mortality has its origins in control programs for a specific disease: trachoma. Trachoma is a bacterial eye infection that can lead to visual impairment and irreversible blindness.  Though the disease has plagued humanity for at least 10,000 years, by the early 20th century it had become a serious scourge, infecting anyone from soldiers to boarding school students. But the disease was wiped out in most developed countries in the 1950s and 1960s following the invention and widespread use of antibiotics, especially azithromycin.  But trachoma has persisted in about 50 countries, mostly in poor, rural areas of Africa, Asia, the Middle East, as well as Central and South America. About 2 million people today have blindness or visual impairment caused by trachoma and another 103 million are considered at risk of contracting the disease.   In communities where trachoma is still a problem, the disease prevalence is high, ranging from 60 to 90 percent. Because trachoma became so widespread, the World Health Organization in the early 1990s recommended that health officials treat everyone in an affected community with the antibiotic azithromycin, whether or not they had been diagnosed with the disease. The thinking was that treating the entire community with an antibiotic would reduce the amount of bacteria circulating in the community, thus reducing transmission — much like mass vaccination is used to curtail viral outbreaks.  In the early 2000s, researchers started noticing that mass distribution of azithromycin not only reduced trachoma, but also seemed to reduce overall child mortality. Scientists running a trachoma control study in Ethiopia hypothesized that because azithromycin was effective against other infectious diseases, including respiratory and diarrheal diseases and malaria — all leading causes of childhood death in the country — mass distribution of the drug might help save children’s lives.  Other public health scientists probed this idea further by conducting mass antibiotic distribution trials in places where trachoma wasn’t found.  In one 2018 study known as the MORDOR trial (MORDOR stands for Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance, French for “Oral Macrolides to Reduce Deaths with an Eye on Resistance”), researchers randomly selected more than 1,000 villages across Malawi, Niger, and Tanzania to either receive the mass distribution of azithromycin or a placebo intervention. Children who were between one month and five years in the intervention villages received a small dose of azithromycin twice a year for two years.  At the end of the study, in communities where children had received the antibiotic, the overall annual mortality rate was lower — by about 3 percent in Tanzania, 6 percent in Malawi, and 18 percent in Niger — compared to the villages that received a placebo. The drop in mortality was even greater, about 25 percent, among the youngest children, those between 1 and 5 months old. While the results are promising, researchers still do not fully understand how mass azithromycin distribution reduces child mortality. One explanation is that the intervention works in a similar way as it does in trachoma-endemic settings, but instead of providing communities a blanket of protection against merely the Chlamydia trachomatis bacterium that causes trachoma, it bestows protection against a wider range of bacteria, including the ones that cause the common respiratory diseases and diarrheal diseases that can kill young children in poor countries.  “It may not be just that you get lucky and you treat a kid that happens to be sick that week,” said Thomas Lietman, a professor at the Proctor Foundation at the University of California, San Francisco who has led studies on trachoma and was the senior author of the 2018 and 2024 child mortality studies.  “We think it’s that we’re reducing the pathogen load in the community. And one of the reasons we think this is because there appears to be an indirect effect. In other words, you receive benefit just by your community being treated.” The cost of saving lives Even during these early trials, researchers were concerned about how giving antibiotics to kids might fuel another massive global challenge: antimicrobial resistance, the process by which bacteria evolve the ability to evade antibiotics. It’s simply a matter of evolution: the more that antimicrobials are used, the more opportunities pathogens have to develop resistance to them. If that process continues long enough, it will eventually render these critical, life-saving medicines ineffective.  At the same time, most major drug developers have turned away from making new antibiotics. That means our stores of effective antibiotics are dwindling. If left unchecked, researchers predict that some 2 million people might die from drug-resistant infections by 2050, making it a leading cause of death. But people won’t just die from drug-resistant infections. Life-saving surgeries and treatments such as chemotherapy, which massively damage the immune system, will become much riskier because it will be harder to prevent infections.. In its antibiotic stewardship guidelines, the Centers for Disease Control and Prevention recommends that health care workers only prescribe antimicrobials if they know what pathogen is causing a patient’s illness. But the idea of mass distributing antibiotics to reduce childhood mortality runs entirely counter to that.  “We’re taught in every health care field not to give antibiotics non-specifically; yet that’s exactly what we’re doing here,” Lietman said. “We’re giving antibiotics to children whether or not they’re sick, whether or not they have a particular pathogen.” However, it is unclear what impact mass distribution interventions have on drug resistance. After the MORDOR trial, researchers conducted follow-up studies where they collected swab samples from the children who received the antibiotic during the study and those who did not. Among children who participated in the study in Tanzania, researchers reported that there was no significant difference in the number of azithromycin-resistant strains of two types of bacteria between the two groups. Yet in Niger, researchers found that children who received the antibiotic harbored more drug-resistant strains.  Other studies, though not all, that have assessed drug resistance in the wake of mass distribution campaigns for trachoma control have documented measurable but short-lived increases in drug-resistant bacterial strains.  Regardless of whether and to what extent mass antibiotic distribution contributes to drug resistance, the intervention uses a small fraction of the total antibiotics consumed worldwide either by humans or livestock animals. In the 2018 MORDOR study, children received about 20 milligrams per kilogram of body weight which equates to about 360 milligrams for a 40-pound child or a total of, at most, 36 kilograms of antibiotics for the roughly 100,000 children that received the intervention across four distributions.  Compare that to, say, the 6.2 million kilograms of medically important antibiotics sold for use in livestock operations in the US in 2022. Perhaps it would be more effective to reduce antibiotic use in agriculture than target relatively miniscule antibiotic use during an intervention that saves children’s lives. But there may be other consequences to mass antibiotic use. A series of studies conducted mostly in the US and Europe have linked antibiotic use in childhood with an increased risk of developing obesity, attention deficit hyperactivity disorder, asthma, and other lifelong disorders.  Still, it is important to note here that these studies are looking at a very different population than children in Niger who face a high risk of dying before they turn 5. Some research suggests the link between antibiotic use and obesity and other disorders may be related to alterations in the gut microbiome, but it remains unclear exactly how antibiotics might cause poor health outcomes and what role other lifestyle factors might play. And those factors could be entirely different in a country like Niger or Tanzania than in the US.  “Right now, the benefit outweighs the harm,” Dantas said. “Yes, you may encode some burden elsewhere, but you’ll save the life of a child.” It’s hard to argue that saving thousands — if not millions — of children’s lives doesn’t outweigh future threats of drug resistance or a possible heightened risk of developing chronic diseases. There are plenty of other ways to address the public health challenges posed by antibiotic resistance and chronic diseases that don’t put the lives of some of the poorest children in the world at risk.  And there is one conclusion that is undeniable: If millions of young children were dying every year in the US, parents would demand that every possible intervention be used — whatever the future consequences. 

This story was originally published in The Highlight, Vox’s member-exclusive magazine. To get early access to member-exclusive stories every month, join the Vox Membership program today. The pod looked like a tanning bed from another planet: a human-sized chamber, white and sparkly purple with a clear glass door, resting on an inclined platform. Previously, it had been on display in public exhibitions, but now it was in Schaffhausen, in a large park in northern Switzerland, near the border with Germany.  A woman stood in front of it, under a dense canopy of trees. She wore a white fleece jacket, dark pants, and flip-flops. It was late September 2024, and the air in this part of the country had become cool. The woman, a 64-year-old American whose name has not been made public, had come to the Alpine country, to this place of vineyards and rolling meadows and mountain views, to end her life. It was a private decision that, paradoxically, would have global implications for the debate over end-of-life care and whether people have a right to medically assisted suicide. For more than 25 years, Switzerland has been a destination for people who want a medically assisted suicide, thanks to the country’s longstanding and liberal law regarding the practice. Each year, the number of people choosing assisted suicide in the country grows; in 2023, that number reached more than 1,200. Most people who end their lives in Switzerland are elderly or have an incurable illness, though a person can sometimes get approval for an assisted suicide under other circumstances. And though the majority who die this way are citizens, Switzerland is one of the few countries that also allows foreigners to travel there for the purpose, a practice critics have derided as “suicide tourism.”  The country’s largest assisted suicide nonprofit, Exit, takes only citizens and permanent residents. But other prominent organizations, including Dignitas and Pegasos, accept foreigners. People who are interested reach out to the groups online and apply for membership, which provides counseling and guidance around end-of-life care. Those seeking a medically assisted death are required to have consultations with a doctor associated with one of the organizations. After determining that the person is eligible, of sound mind, and, when applicable, has considered their full range of treatment options, the doctor writes a prescription for sodium pentobarbital, the same substance used for pet euthanasia and many lethal injection executions in the US, to be used at a later date chosen by the patient. The doctor is not allowed to administer the medication themselves. That practice is known as euthanasia, which is not legal in the country because it is considered “deliberate killing.” Instead, they provide the medication to the patient, who, in the presence of the doctor or an aide for one of the organizations, either swallows it or takes it with a gastric tube or an intravenous infusion.  The entire process, for foreigners, costs about $11,000 and usually takes a couple of months.  Had the American woman chosen to end her life under the standard Swiss protocol, it probably wouldn’t have been controversial. She reportedly had skull base osteomyelitis, a rare and painful inflammatory condition that is often fatal if untreated. She told the group helping her that her adult children fully supported her decision. But she wasn’t there to end her life the standard way. Instead, she was about to become the first person to try a controversial new method for suicide, using a technology that would roil public debate over assisted suicide in Switzerland and capture attention around the globe.  She would use the Sarco pod, an invention of Philip Nitschke, a strident right-to-die advocate. Nitschke hopes that the 3-D printed pod, with a name that’s short for sarcophagus, will revolutionize the practice of voluntary assisted death by taking doctors out of the picture.  The Sarco, he has said, doesn’t require a lengthy screening process or thousands of dollars. Rather than relying on sodium pentobarbital, a person who wanted to use the pod could buy nitrogen. They would lie down inside the pod, resting their head on a neck travel pillow. Then, they would close the door and push a button. The chamber would fill with nitrogen gas, and oxygen levels would quickly drop below levels humans need to survive.  As a method of execution in the US, nitrogen hypoxia has been highly controversial. Earlier this year, UN experts raised concerns that the execution of Alabama death row inmate Kenneth Eugene Smith using nitrogen gas could constitute “torture,” and the state is currently being sued by another inmate alleging the practice is cruel and unconstitutional. Right-to-die advocates, though, say that when administered properly, it’s a relatively painless death because people exposed to high levels of nitrogen quickly lose consciousness. The American woman entered the chamber just before 4 pm, according to Dutch newspaper de Volkskrant, which had a photographer in the woods of Schaffhausen before and after the death to document the scene. To protect against the possibility that they might be accused of foul play, Nitschke and his colleagues also set up two video cameras to record. Then Nitschke went across the border to Germany, possibly to avoid the risk of arrest. The only person who remained with the woman at the scene the entire time was Florian Willet, a colleague of Nitschke’s who co-founded The Last Resort, an organization to promote the Sarco pod’s use in Switzerland.  Seconds after entering the pod, the woman pressed the button to release the gas. Willet waited with her, monitoring her vital signs on an iPad and relaying them to Nitschke over the phone. After confirming her death, Willet called the police — a standard practice after an assisted suicide in Switzerland.  Typically, police examine the scene to verify that there are no signs of foul play.  But this wasn’t a typical death. Police arrested Willet, his attorneys, and the de Volkskrant photographer nearby on suspicion of “inducing and aiding and abetting suicide,” according to Reuters.  More than eight weeks later, Willet remained in jail, with police investigating the woman’s death as a possible “intentional killing.”  And Switzerland, a country that has for decades maintained a public consensus in support of assisted suicide, has been confronted with a series of questions that have implications for one of the most significant moments of every person’s life: To what extent should people have the right to determine when and how they die? What are the moral and philosophical implications for a society that sanctions the practice of medically assisted suicide? How does a nation handle the need for the safety of vulnerable people while also protecting their dignity and individual rights?  Switzerland isn’t the only country that allows assisted suicide. Other nations, including the Netherlands, Belgium, Luxembourg, Colombia, Spain, and Canada, also permit the practice, which some advocates call medical aid in dying (MAID) to differentiate it from the usual connotations of the word “suicide.” In late November, the British Parliament took the first step to pass a bill that would legalize assisted dying for some terminally ill patients. In some countries, the law goes further than it does in Switzerland, allowing voluntary euthanasia, where doctors can administer lethal doses for patients who can’t or don’t want to do it themselves. Belgium and the Netherlands, for example, allow physician-assisted euthanasia for mental illnesses if a doctor determines that the condition creates unbearable suffering. What constitutes unbearable suffering, though, is inherently subjective and open to interpretation. The number of deaths via euthanasia in both countries has grown considerably in recent years; the same is true of Canada, which recently passed some of the world’s most liberal euthanasia laws. Critics worry that the easy availability of assisted death creates incentives for people to see it as the only solution to their suffering, even when there might be effective treatments. They also worry about a “slippery slope” where doctor might approve assisted suicide for more and more reasons, ultimately resulting in suicides for non-medical reasons being enabled by law. The United States does not permit euthanasia, but physician-assisted suicide is legal in 10 states, including California, Oregon, and Washington. According to a Gallup survey earlier this year, 71 percent of Americans believed that a doctor should be able to administer a euthanasia drug if requested by a patient or their family member, and nearly the same amount supported physician-assisted suicide for people with terminal illnesses.  Erika Preisig, a family physician and founder of the organization Lifecircle, which helps foreigners come to Switzerland for assisted suicide and advocates for other countries to legalize it, says the issue is going to become more important as more baby boomers reach the end of their lives.  “They will not let others decide how they have to die. They will decide themselves,” says Preisig, who is a member of that generation. “This will raise the percentage of assisted dying all over.”  But even with widespread support, the practice is still controversial in the US and elsewhere. The American public, despite supporting legalization, is more divided on the morality of doctor-assisted suicide. It’s opposed by the Catholic Church and other Christian organizations, which believe the practice goes against God’s will. Some disability rights advocates have argued fiercely against it, saying that it allows medical professionals to offer disabled people death rather than finding ways to improve their lives. The American College of Physicians (ACP) also opposes medically assisted dying on the grounds that the practice is incompatible with a doctor’s duty as a healer who takes the Hippocratic Oath, promising to do no harm.  “[T]he focus at the end of life should be on efforts to prevent or ease suffering,” the ACP’s president said in 2017. Partly as a result of those disagreements, Americans have different rights regarding assisted suicide depending on which state they live in. That’s led some Americans, including the woman who used the Sarco pod, to come to countries like Switzerland to end their lives. The birthplace of Calvinism and an intellectual center of the Protestant Reformation, Switzerland has a long history of bucking the dogma of the Catholic Church and charting its own moral and philosophical path. Famously neutral during the World Wars, and now home to world governing bodies like the United Nations and the World Health Organization, the country can appear to be a tightly regulated place like many other Western European countries.  In reality, it’s a society built on compliance with social and cultural norms moreso than government regulations. Political scientists point to it as among the most libertarian societies on earth, and Switzerland is consistently ranked as the number one country in the Human Freedom Index report put out by the Cato Institute, a libertarian think tank.   Assisted suicide is no exception. The practice has been permitted in Switzerland longer than in any other country. In 1942, the government put into effect a statute outlawing abetting assisted suicide for “selfish purposes,” like gaining access to an inheritance, but otherwise, it wasn’t explicitly banned — which meant that, by omission, assisting suicide for non-selfish purposes was technically legal. To this day, the 1942 statute is the only law explicitly referring to assisted suicide. In an email to Vox, the prosecutor in charge of the case confirmed that Willet was arrested under suspicion of breaking this law. In place of those laws, requirements for obtaining a medically assisted suicide were developed by doctors and codified into guidelines maintained by Switzerland’s medical professional organizations. The regulations are nonbinding, but disobeying them can in theory lead to professional sanctions. In practice, this has meant that the doctors are regulating themselves.  “We have one of the most liberal systems in the world,” Yvonne Gilli, the president of the country’s professional association for doctors, told Vox in an email. For most of the medical community, the desire seems to be to keep it that way. “We would therefore do well to leave doctors in a central role in assisted suicide,” Gilli wrote.     In a small, relatively homogenous nation of just under 10 million people, assisted suicide has never been quite the culture war issue it was in the United States in the 1990s and early 2000s, when Dr. Jack Kevorkian, a right-to-die advocate nicknamed “Dr. Death” by the media, filmed himself performing a voluntary euthanasia and sent the video footage to 60 Minutes, intentionally triggering a trial that would result in his conviction for murder. In 2011, a referendum that proposed a ban on assisted suicide in Zurich, the country’s most populous canton or state, was rejected with 85 percent of the vote. That high level of public support has allowed assisted suicide organizations to operate with relatively little friction and without much public debate, even as demand increases. According to a long-term study of assisted suicides in the country from 1999-2018, the total number of physician-assisted suicides doubled every five years.  “Suicide assistance has been quite calm. The Swiss assisted suicide organizations were under the radar; there wasn’t much discussion about them,” says Bernhard Rütsche, a professor at the University of Lucerne and an expert on assisted suicide in Switzerland. “They care for their reputation. The whole branch of suicide assistance has been shaken up with this new method, and they don’t like that, quite understandably.” The intervention of Nitschke and his Sarco pod threatens to upend the status quo.  In 1996, Nitschke became the first doctor in the world to help a terminally ill patient die legally by assisted suicide in Australia. A decade later, he and his partner Fiona Stewart published The Peaceful Pill Handbook, a guide that provides information about methods of assisted suicide and describes the process of obtaining one in Switzerland.  Nitschke, according to Katie Engelhart’s book The Inevitable: Dispatches on the Right to Die, began his work believing that patients with terminal illnesses should have the right to choose an end to their suffering. But as his advocacy deepened, his thinking evolved. Why should doctors like him be the one to make the decisions? Why should doctors get to determine what counts as extraordinary suffering and what doesn’t?  Over time, Nitschke came to believe that the right to die should be entirely in the hands of individuals and not medical professionals. The deeper his advocacy became, the more he clashed with other members of the medical community. He burned his medical license in 2015 after a protracted battle with Australia’s medical board. He also became more critical of mainstream MAID groups that focus only on the sickest patients.  He takes issue with the Swiss system, which he has said is too deferential to doctors and too expensive. “We are convinced that no money should be charged for an assisted death. Especially when you realize that it is already very expensive for foreigners who wish to die to travel to Switzerland,” Nitschke said of his organization, Exit International, in a recent interview. (Exit International, which is not related to the Swiss group Exit, pointed to statements on their website and declined to be interviewed before deadline.) Nitschke approaches end-of-life issues with the zeal of a libertarian techno-futurist. In interviews, he’s spoken about a future where the Sarco pod’s blueprints are posted online, allowing anyone to 3-D print one anywhere in the world. He has said that AI could replace doctors in assessing whether a person meets the criteria to end their life. “We really want to develop that part of the process so that a person can have their mental capacity assessed by the software, rather than … spending half an hour with a psychiatrist,” Nitschke told Wired. Nitschke’s unapologetic belief that people should be able to choose how and when they die, combined with his confrontational style, has made him a lightning rod for controversy, leading some of the doctors who support assisted dying to think that he does more harm to their cause than good.  “Nitschke wants to give everybody, without thinking, the possibility to die. For me, this is unethical,” says Preisig, the founder of Lifecircle. “This is very bad for Switzerland. It’s a big problem for us.” Leaders of other assisted suicide organizations have also been critical.  The debate over the Sarco pod has even reached the Swiss government. Nina Fehr Düsel, a member of the Swiss National Council (which is similar to the US Congress), has made a motion for the National Council to discuss assisted suicide in the coming months. She’s also asking her colleagues to consider banning the Sarco pod explicitly.  “I don’t want to overregulate this,” Fehr Düsel, a member of the populist right-wing Swiss People’s Party, which controls the most seats in the federal assembly, tells Vox. She has concerns about the use of nitrogen, which is at this point cheap and easy to obtain in the country. In general, she says, the organizations that are already established in the country should be left alone. “We already have these two longstanding organizations and that is enough,” Fehr Düsel says. For others, the Sarco pod case has merely exposed the extent to which assisted suicide is operating without clear legal guidelines. “We need some regulation that ensures that autonomy is safeguarded and capacity is properly assessed, and the means for suicide assistance — the instruments and the medications — are safe and comply with human dignity,” says Rütsche, the professor at the University of Lucerne.  According to Rütsche, the government should codify the existing standards doctors have established, with laws around the assessment of someone’s capacity, obligations to provide information and counseling to make sure the decision is well considered, requirements for how the process takes place (including what drugs and devices are allowed and what aren’t), and oversight for the assisted suicide organizations — with the ability to ban a group for flouting the guidelines.  Whether Switzerland moves forward with a new law remains to be seen. But the Sarco pod’s future seems more certain.  Police confiscated the pod at the scene of the woman’s death. In November, Schaffhausen prosecutor Peter Sticher confirmed to Vox in an email that one person remained in police custody regarding the investigation. Willet, according to The Last Resort’s website, has been held in jail for two months.  Holding someone that long on suspicion of abetting a suicide for selfish purposes is highly unusual. But in late October, de Volkskrant, the Dutch paper, reported another reason that may explain Willet’s long detention: According to court records, a forensic doctor told investigators the woman was found with injuries to her neck, raising the possibility that Willet was the subject of an “intentional killing” investigation. “The allegation of a [killing] is simply not true, and I’d guess everyone involved knows this,” says Andrea Taormina, the lawyer for the photographer who was detained after the woman’s death. “There are no facts that would indicate differently. This is mainly an allegation brought forward simply to raise the stakes in this procedure.” De Volkskrant, which had access to and reviewed the camera footage, said in their report that nothing on the recording showed Willet opening the pod or doing anything to disturb the woman.  Ultimately, after 70 days in detention, Willet was released in early December. Exit International and The Last Resort, Nitschke’s organizations, celebrated Willet’s release. “The allegation of intentional homicide was, and remains, absurd,” it said in a statement.  But in response to an email, Sticher told Vox that both investigations remained open. “All persons are still under investigations, for aiding and abetting a suicide for selfish purposes and for intentional homicide,” Sticher wrote. “But we had no more reasons to keep this last person in custody.” While the drama brought by the Sarco pod’s use is exceptional, the broader debate shouldn’t be.   According to a UN report from 2023, the world population of people over 65 is expected to double, from 761 million in 2021 to 1.6 billion in 2050. In 25 years, people over 65 will make up 1 in 6 people on Earth — part of a global trend toward aging. Thanks to legalization in several countries, many of these people now know that physician-assisted suicide is an option. Assisted suicide remains rare, both globally and in the US. But as more attention is paid to it, the moral, philosophical, and political questions that the case prompted will only become more urgent.  In Switzerland, where assisted suicides are still a relatively small percentage of overall deaths, supporters say it’s important to maintain that right. “Modern medicine is keeping people alive longer and longer. This is why there are more and more very old people, and therefore more and more medical problems towards the end of life,” Marion Schafroth, the president of Exit, said in an email. “Human support for suicide is certainly not morally wrong. It serves the dignity and self-determination and safety of those who wish to die.” Even if they don’t ultimately choose assisted suicide, says Preisig, the founder of Lifecircle, it’s important for people who are seriously ill to know they have the option. “People are not afraid of death, they’re afraid of unbearable suffering,” she says. “When they know they could [die] if they wanted to, then they lose this fear of unbearable suffering. This is the most important point for me.” Still, other countries, like Canada, are grappling with serious concerns about whether the criteria for approval is expanding too quickly, enabling or even encouraging people who aren’t suffering to end their lives.  Canada’s Medical Assistance in Dying (MAID) program is a primary example for critics of what can go wrong. When MAID was first legalized in 2016, Canada had strict criteria: It was only to be used to end unbearable suffering in patients whose conditions were advanced and whose impending death was reasonably foreseeable. In 2021, following a court ruling, the government removed the criteria that a death be reasonably foreseeable. Stories emerged of people who had been approved for euthanasia who didn’t have terminal illnesses. Health care workers have said they’re struggling with the ethical implications arising from people requesting euthanasia not for incurable illnesses but because they’re on government subsidies, were recently widowed, or are dealing with chronic but nonfatal conditions like obesity. And in October, a Canadian committee found that people had received approval for euthanasia for reasons such as social isolation.  Some disability rights groups in Canada are challenging the country’s expanded MAID laws in court. “We are witnessing an alarming trend where people with disabilities are seeking assisted suicide due to social deprivation, poverty, and lack of essential supports,” a leader of the group, Inclusion Canada, said in a statement in September. “This law also sends a devastating message that life with a disability is a fate worse than death, undermining decades of work toward equity and inclusion.”  The controversies around these cases, like the Sarco case, are raising uncomfortable questions for which there might not be easy answers. A legalized assisted suicide program without strong guardrails runs the risk of creating opportunities for abuse. Among those who decide to die via assisted suicide will likely be complicated people with complicated motivations, some of which might not seem reasonable to others. On the other hand, in countries where assisted suicide is illegal, people often find other ways to end their lives. (The leading cause of suicide deaths in the United States is not a new technology like the Sarco pod but a much older one: guns.)  How governments balance the need to protect their citizens’ rights while also safeguarding the most vulnerable among them is a real conundrum. Switzerland found a balance, but the Sarco pod threatened to upset it. Restoring the balance is more than just a major imperative. It’s a matter of great moral significance — and of life and death. 

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The media does not give you an accurate picture of the world. This isn’t to say that we’re not reporting the truth or that we’re making facts up. Rather, our profession has a natural tendency to accentuate the negative because the negative is usually what we mean when we think of the news.  Reports of a strange new “disease X” in the Democratic Republic of the Congo is “news”; the fact that about 2.2 billion cases and 12.7 million deaths from malaria have been averted since 2000 isn’t. Estimates that 2024 will be the warmest year on record get a lot of attention; the chart-busting increase in renewable energy, less so. One-off violent crimes make the news; longer-term trends showing declines in violent crime overall, not so much.   2024 was far from perfect. There was continued war in Gaza and Sudan, new war in Lebanon, just more war, period. Donald Trump’s return to the Oval Office brings with it uncertainty and real danger, not least to public health through his nominated health secretary Robert F. Kennedy Jr. and his vaccine-questioning beliefs — just in time for a possible bird flu pandemic. And it may just be possible that humanity is knocking on the door of artificial general intelligence — which could be very good or very, very bad.  But there was genuine progress throughout the year, often beneath the headlines, in everything from animal welfare to technology to climate policy to geopolitics. Here are nine optimistic stories from 2024 that we hope will lay the groundwork for a better 2025. 1) The first new schizophrenia drug in decades was approved Our World in Data’s Saloni Dattani is one of my favorite writers — which is why we put her on the Future Perfect 50 list in 2022. Few experts are better able to use data to help readers understand when progress in medicine and public health is actually being made, over both the long term and the short.  For an end-of-year post on her Substack, Dattani picked five notable medical breakthroughs in 2024. The one that stood out to me was the approval of Xanomeline-trospium, or Cobenfy, the first new schizophrenia drug to hit the market in decades. Schizophrenia is a horrifying mental disease that afflicts more than 3.5 million Americans. While drugs do exist and the condition can be managed with treatment and support, disproportionate rates of people with schizophrenia experience homelessness and fall victim to suicide. They die 15 to 20 years earlier on average than the rest of the population. And despite decades of research, we’ve largely failed to find better, more effective treatments.  Cobenfy offers hope, however. It targets different receptors in the brain than existing treatments, and it seems to effectively attack symptoms while reducing debilitating side effects. That can make the difference between life and death. 2) New York City is finally going to get congestion pricing (probably) It’s been nearly two decades since then-New York Mayor Michael Bloomberg suggested that drivers going into Manhattan — home to some of the most congested streets in all of America — should pay a charge. That plan was finally set to go into action this summer, when New York Gov. Kathy Hochul pulled a sudden about-face. The stated reason was that the $15 charge for most cars would hurt Manhattan’s economic recovery and put an undue burden on suburban and outer-borough drivers. The real reason was that Democrats feared that suburban voters would punish them in November. Well … that still did kind of happen. But a little more than a week after the election, Hochul announced that she would bring back congestion pricing, albeit with a 40 percent cut in the toll, charging most passenger cars $9 to cross into the most crowded parts of Manhattan.  That was disappointing to many transit and environmental advocates, and the money won’t be enough to fix the New York subway’s massive fiscal deficit. So why am I counting this as a good thing for 2024? Because despite all the political shenanigans, congestion charging, a crucial policy for the climate, is (almost certainly) finally here, for the first time in the US. That was not an easy political lift, and my hope is that when we all realize the benefits of congestion pricing, maybe it will open the door to do it elsewhere.  3) US dietary guidelines might finally recognize the value of the humble bean Americans eat a lot of protein, considerably more than they need (for most people) and often more than dietary guidelines recommend. That’s largely because we eat a lot of animal meat. All that chicken and beef and turkey and pork has real health consequences, but it also contributes to America’s environmentally destructive and inhumane factory farming system.      Of course, protein is very important, especially for those actively building strength and for the elderly. If only there were a way to get protein without consuming animals. Hmm … Oh right, there is. It’s called beans and legumes. As former Future Perfect fellow Julieta Cardenas wrote last year, “[B]eans are high in protein, efficient to grow, and can even improve soil health.” They’re cheap and they’re tasty if you know how to cook them, and if you’re the kind of person worried about processed foods, they’re largely unprocessed. How can we get protein without breaking the bank or hurting the environment or animals? Beans is how. So I’m counting the news that beans and legumes got a starring role in the report of the 2025 US Dietary Advisory Committee, which advises the creation of the federal dietary guidelines, as a major piece of good news. Eat more beans. Please. 4) A Nobel Prize for actually good AI As my colleague Kelsey Piper wrote recently, it’s been a wild year for AI. From corporate shenanigans to models that can reason to ongoing copyright disputes, 2024 felt like the year when AI got real. Which, given how transformative and disruptive AI is proving to be, is enough to make me more than a little worried. Will AI steal our jobs? Our votes? Our lives? It’s all potentially on the table. Amid the existential fear, we shouldn’t lose sight of the tremendous good that AI, properly harnessed, can bring about. This year, the Nobel Prize for Chemistry went in part to Google DeepMind founder Demis Hassabis and his colleague John Jumper for their work in creating AlphaFold 2, a machine-learning protein-structure predictor.  Proteins are the literal building blocks of nature, and being able to predict their three-dimensional structure is incredibly important to using them to design drugs or other materials. Before AlphaFold came around, it could take months or even years of lab experiments to identify the structure of a protein from its string of amino acids. AlphaFold 2 cut that time considerably, which promises to speed up the process of developing new medicines. As I once wrote, AlphaFold might be the best example of AI for good. We can only hope we’ll see more such examples in the future. 5) The AI election deepfakes that weren’t The first piece I wrote this year was about how 2024 would be a record-breaking year of global elections. More than 60 countries representing roughly half the world’s population were set to go to the polls in 2024, more than any year in the past. India, Indonesia, the UK, Taiwan, and, of course, the US all held major elections. As many people put it, democracy was on the ballot in 2024.    Beyond concerns about how the elections themselves would play out and whether the forces of far-right populism would continue to seize power, there were more existential questions about the elections themselves. Above all else: At a moment when AI increasingly had the ability to turbocharge deepfakes and other forms of trust-eroding propaganda, could these elections actually be fought fairly?  For the most part, the answer was yes. While there were examples of mis- and disinformation, some of it aided by AI, on the whole elections avoided the worst fears of AI deepfakes. As one piece put it, it was the “apocalypse that wasn’t.” How you feel about 2024’s elections will largely depend on how you feel about the results. But for the most part, even with the growth of AI tools, those results could be trusted. Which might be the best we can hope for now. 6) Vaccines roll out against one of humanity’s oldest killers Malaria has been killing human beings for thousands of years, if not far longer. Its most famous victims are believed to include figures like Alexander the Great, Oliver Cromwell, and the poet Dante Alighieri. Today, though, we know the names of very few malaria victims. That’s not because the disease has been eradicated — nearly 600,000 people died of the disease in 2023 alone — but because its victims are now almost entirely very poor people living in some of the very poorest countries in sub-Saharan Africa.  But 2024 brought us several steps closer to doing in those poor countries what the rich world has already managed: ending malaria’s death toll. In January, Cameroon became the first country to start routine vaccinations against malaria, the first fruits of a multi-decade effort to create effective vaccines against the mass killer. In May, the Central African Republic became the first country to receive doses of an even more effective vaccine called R21. Altogether, vaccines reached children in 17 countries where the disease is endemic in 2024, with more to come. This might be the single best piece of news all year. And if you’d like to play a part, you can even volunteer in a challenge trial for new malaria vaccines and treatments. If Future Perfect’s Dylan Matthews can do it, you can too.  7) The deaf can hear It sounds like an honest-to-goodness miracle: children born with hereditary deafness, given the ability to hear. But that’s what happened to five children this year. Part of a study at Mass Eye and Ear, a specialty hospital in Boston, the children were born deaf because of mutations in the OTOF gene, which fails to produce a protein necessary for the transmission of sound signals from the ear to the brain. Fix the mutation, and perhaps hearing could be restored. That’s precisely what researchers at the hospital did. In a study, a restored version of the OTOF gene was introduced to the children via an inactive virus, a process known as gene therapy. For five out of the six children in the study, hearing was restored to the point where they were able to engage in oral conversation. It was the first such example of using gene therapy to treat this form of deafness, but it almost certainly won’t be the last. 8) Poverty in Indonesia hit a record low Indonesia often gets overlooked, but it shouldn’t. With 277 million people, it’s the fourth most populous country, and its islands, forests, and coral reefs make it one of the most important biodiversity hot spots in the world. It is also, quietly, one of the brightest stories in global development. Thirty years ago, it was in the grip of the dictator Suharto, and 25 years ago, it was struggling under the toll of the Asian financial crisis. Twenty years ago, 170,000 Indonesians died in the 2004 tsunami. Yet today it is vibrant and democratic — for the most part. This summer marked another step forward for what is also the world’s largest Muslim country. Poverty fell to a record low of 9.5 percent. It’s the kind of fact that goes largely unreported in the global news — I had to search to find it. But for the people in Indonesia who experienced this change, very little could be more important.        9) The experience of watching Philadelphia Eagles running back Saquon Barkley  Now, I’ll admit, this might only appear to be a “good thing” for a very specific part of the country that happens to root for a very specific team, so I suppose this qualifies more as an actually good thing for me. What can I say? Editorial prerogative and all that. But unless you’re a New York Giants fan, there can only be joy found in watching Barkley do things like this while aiming to set the single-season rushing record: When your running back appears to operate according to the physics of the Matrix movies, you know it’s a good year. Here’s to a happy 2025.