On an October evening, Tom Frost was zooming down a dark state road on the northern edge of Indiana. The father of two had just finished his shift at a small town fiberglass factory. Now, he was doing what he loved, riding a Harley Davidson in his typical getup: black gloves, leather chaps, no helmet.

As Frost revved past the corn fields and thinning birch trees that led to his girlfriend’s house, a green pickup jerked off a side road and into his path.

Frost didn’t have time. He hit the truck and flew backwards, leaving his body and small trails of blood on the asphalt, police photos show.

First responders loaded Frost, now incapacitated, onto a helicopter and flew him to the area’s biggest hospital, Parkview Health’s Regional Medical Center. The sprawling, near-million square foot campus had opened its doors a year earlier, the capital of a rapidly expanding empire of hospitals and doctors offices spreading out from Fort Wayne to the rural counties of the Indiana-Ohio borderlands.

Parkview Health’s doctors operated on Frost’s fractured right leg and face. Eventually, he woke up from his coma. But for weeks afterwards, he suffered from significant brain trauma. He called his mother, who spent days sitting beside his hospital bed, “Number 1”, not “Mom”.

So about a month after the 2013 crash, when a hospital employee pulled aside his mother and asked her to sign an agreement promising to pay for “all” of her son’s charges, the 66-year-old retired bartender signed where she was told.

Frost’s mother didn’t know how much the bill was going to be. All she knew was that her son, who was uninsured, needed care.

After Frost’s discharge, Parkview Health, a not-for-profit system, sent him a letter outlining how much it wanted: $629,386.50.

Frost’s family was willing to pay, according to a subsequent court filing submitted by his attorney. But the bill was bigger than what they thought was reasonable. For example, after his high-level surgeries, Parkview transferred him to a skilled nursing facility, where he worked on his rehab and recovery for 55 days. For that period, the hospital wanted $144,487.73, effectively a daily charge of more than $2,600.

An auditor hired by the family’s attorney identified thousands of dollars in billing errors in the hospital’s itemized statement, some of which the hospital later relented on. More significantly, going off of federal billing guidelines, the auditor concluded the “fair and reasonable value” of the services Frost received actually amounted to $255,903.45 – still a hefty sum, but only about 40% of what the hospital was demanding.

After a two year legal battle that threatened to shed light on Parkview’s closely-guarded billing practices, the hospital had Frost sign a confidentiality agreement and settled the case for an undisclosed sum.

But the enormous hospital bill Parkview sent to Frost was not an aberration.

Over more than a decade, Parkview Health has demanded that the people of north-eastern Indiana and north-western Ohio pay some of the highest prices of any hospital system in the country – despite being headquartered in Fort Wayne, Indiana, which currently ranks as the No 1 most affordable metro area to live in the United States. For 10 of the last 13 years, Parkview hospitals on average have been among the top 10% most expensive in the country, a Guardian US analysis of cost estimates based on data submitted to the Centers for Medicare and Medicaid shows.

Parkview’s steep prices are the product of a more than two decade campaign by hospital executives to establish market dominance in Fort Wayne and to squeeze revenue from a pool of patients and employers who feel they have no better alternatives, according to interviews with more than 40 current and former Parkview employees, patients, local business leaders, lawmakers and competitors, as well as leaked audio recordings of meetings and hundreds of internal billing, patient and policy documents obtained by the Guardian.

During this period, Parkview has taken over six former rival hospitals and built up a network of almost 300 sites for its physicians and providers, forming a ring around its gleaming regional center, which some staff refer to in private as the “Big House” or “Emerald City” for its ritzy amenities and green corporate branding.

This consolidation, former employees say, has allowed Parkview to control referral flows, routing primary care patients to their own costly specialists and facilities, even if those patients could get the same services elsewhere for less. It has also increased Parkview’s leverage in negotiations with health insurance companies, as they bargain over procedure prices on behalf of employers that offer the insurers’ health plans to their workers.

Insurance industry sources say Parkview’s growing web of hospitals makes it hard for any insurer to offer a viable health plan locally without including the chain’s facilities in their network, an advantage that has helped the not-for-profit extract high prices and earn a reputation as one of the toughest negotiators in the state.

Not-for-profit healthcare has been good business for Parkview as it has been for hundreds of other ostensible charities across the US which operate nearly half of the nation’s hospitals. In exchange for generous tax breaks, these institutions are required to provide free and discounted care to poor patients, but many have faced criticism for skimping on charity care, demanding high prices and giving executives exorbitant salaries.

Since 2019, Parkview has raked in more than $2bn in revenue annually, enabling the system to give dozens of its executives and top doctors six and seven figure annual compensation packages. Before his retirement at the end of 2022, Parkview’s longtime CEO, an avowed Christian who publicly styled himself as a “servant” leader, took home nearly $3m from the not-for-profit, according to the system’s last publicly available IRS disclosure.

Parkview declined repeated requests in recent weeks to make its current CEO available for interview and chose not to respond to a series of detailed questions submitted by the Guardian several days ahead of publication. In response to criticism about its high prices, Parkview has previously pointed to its various charitable initiatives, its role as a leader in the region’s economic development, and the quality of its care – which varies by facility according to federal ratings. The system has also claimed that past studies of its prices have been “filled with inaccuracies” and “incomplete analyses”.

Parkview’s expansion in Fort Wayne, a mid-sized, midwestern city surrounded by miles of corn fields and manufacturing plants, reflects a larger trend of consolidation that has transformed America’s once mostly locally run healthcare system and ratcheted up its costs for more than a generation.

Since the 1990s, hospital systems across the US – for and not-for-profit alike – have relentlessly chased after market power, executing nearly 2,000 mergers with little pushback from overwhelmed federal antitrust regulators and indifferent state authorities. Research from the American Medical Association found that by 2013, 97% of healthcare markets in the US had little competition and were highly consolidated under Department of Justice antitrust guidelines. By 2021, that figure had risen to 99%.

With consolidation, academic researchers have consistently found significant increases in prices. A 2012 research survey concluded that when hospitals merge in concentrated markets price hikes were “typically quite large, most exceeding 20 percent”. A 2019 study found that prices at hospitals enjoying local monopoly power were 12% higher than those in markets with at least four competitors. A study released earlier this year identified dozens of hospital mergers that it said regulators could have flagged as likely to diminish competition and raise prices. Those mergers did, in fact, result in average price hikes of 5% or more, the researchers found.

Rising healthcare costs don’t just hurt patients. They also squeeze local employers, who have to choose between wages, headcount and insurance costs – decisions that low-wage workers pay for down the line. A working paper from earlier this summer found that every 1% increase in healthcare prices, driven by hospital mergers, lowered both employment and payroll at companies outside the health sector by approximately 0.4% – trends, which in turn, increased deaths by opioid overdose and suicide.

Zack Cooper, a Yale economist and one of the co-authors of that paper, argues that consolidation has its most pernicious effects in areas like north-eastern Indiana and north-western Ohio, where Parkview has established itself as the dominant player: semi-rural parts of the country which already had comparatively few healthcare providers and are even more vulnerable to consolidation and price hikes.

“That’s where you start to see these 10 to 15% price increases over time,” said Cooper. “Outside of New York, LA, Chicago and Houston, often the hospitals are really the biggest employers in town. They’ve got these beautiful campuses and rolling grass lawns, and you say, ‘Oh gosh, this is good for the economy.’ But what we’re starting to see is that many of our local health systems are boa constrictors just tightening around and squeezing the life of some of these local economies.”

The not-for-profit cut services. Then a young mother died

Parkview Health is now north-eastern Indiana’s largest employer. And as the hospital system has grown, it has refashioned greater Fort Wayne in its own image.

Parkview has built its own police force with dozens of armed officers stationed across the region. It has stuck its green and gray colors on the jerseys of Fort Wayne’s minor league baseball team, and paid millions to call their downtown stadium, “Parkview Field”. Today, even the local hockey rink, “SportOne Parkview Icehouse”, and a local YMCA, “Parkview Family YMCA”, pay homage to the not-for-profit.

In Fort Wayne and its surrounding deep-red counties, business leaders and Republican state lawmakers have grumbled for years about Parkview’s high prices – including several who spoke on the condition of anonymity for this story. But no major establishment figure has been willing to cross the hospital.

Last summer, the biggest ever local challenge to the not-for-profit’s carefully cultivated reputation came not from elected officials, but a spontaneous coalition of suburban and rural mothers from DeKalb county. The women, calling themselves “Moms Against Parkview”, were upset that the healthcare system had decided to shut down the labor and delivery unit at their local formerly independent hospital, which the system had absorbed and rechristened as “Parkview DeKalb” in 2019.

In a statement to the media, the prosperous not-for-profit likened itself to the hundreds of struggling rural hospitals nationwide that have cut maternal care services: “Across the country, rural hospitals have experienced ongoing challenges in ensuring sustainable access to high-quality obstetrics services.”

The protesters didn’t buy this explanation, which they assumed was a convenient excuse for Parkview to slash a money-losing service line. Standing at an intersection near the gargantuan Regional Medical Center last September, several women and their children held handmade signs, declaring in scrawled marker: “Save DeKalbs OB Unit” and “Parkview puts $$$ over mothers!”

That month, Michelle Dunn, one of the protesters, submitted an anonymous letter to a local newspaper, which she told the Guardian she had received from a nurse working at Parkview Dekalb. “Shutting our unit down would be detrimental to women and their children especially when they cannot make it to Parkview Regional,” the letter stated.

Parkview executives largely ignored the women. A few weeks later, the anonymous writer’s warning proved prescient.

Late in the day on 10 October 2023, a 26-year-old named Taysha Wilkinson-Sobieski showed up at Parkview DeKalb looking pale, according to one current and one former hospital source.

Parkview hadn’t approved 24/7 onsite ultrasound coverage – a basic medical imaging tool – at the outlying hospital, according to two former Parkview employees with knowledge of the incident. But because of her vitals, the two former employees said, staff suspected she was bleeding internally due to an ectopic pregnancy, a potentially life-threatening condition in which an egg grows outside of the uterus.

Even after the closure of the labor and delivery unit, Parkview Dekalb still had OB-GYNs who did pre-scheduled procedures and an on-call general surgeon who had the technical skills to try and help Wilkinson-Sobieski, two current and two former Parkview employees told the Guardian.

But alongside the publicly-announced unit closure, hospital executives had also quietly slashed on-call OB-GYN emergency coverage at Parkview DeKalb, so the de facto practice became for staff to transfer pregnancy-related emergencies to Parkview Regional Medical Center, a 20-minute drive away, one current employee and one former high-ranking Parkview employee with knowledge of the matter said.

The transfer cost Wilkinson-Sobieski time she could not afford.

When the young woman arrived at the regional hub, she was still conscious and doctors were waiting for her, according to a source familiar with her post-transfer care. Staff ran an ultrasound, put her to sleep with anesthesia, and began an operation to put a clamp across one of her fallopian tubes, which by this point had ruptured, the source said.

They got to her too late. She had already lost too much blood. She never woke up again, the source said.

Wilkinson-Sobieski was pronounced dead two days later. She left behind her husband Clayton and their one-year-old son, Reid.

Afterwards, her family received a bill from Parkview, according to her husband and another person familiar with the matter.

Parkview did not respond to numerous detailed questions from the Guardian about the sources’ claims regarding the case, and declined to comment for a previous story about the case in the Indianapolis Star.

In a previous statement to local press about its OB-GYN service cuts, Parkview said its “unwavering commitment to healthy moms and babies” was at “the heart” of its new approach, which it claimed would create “new opportunities to optimize prenatal care, labor and delivery, and postnatal care”.

But current and former Parkview employees told the Guardian the case points to the dangers of treating medicine like a business.

“What do you do about the ectopic? What do you do about the mom that comes in with a foot hanging out?” said one current longtime medical provider at Parkview, who spoke on the condition of anonymity. “At the end of the day, that’s why the practitioners routinely say, ‘This cannot be quantified.’ Medicine does not fit neatly into an excel spreadsheet.”

The duo that built ‘Emerald City’

With a price tag of over $600m, Parkview’s Regional Medical Center – a campus of brick walls and glass panes – is one of the most expensive developments in north-eastern Indiana.

When patients walk through the sliding doors of its main entrance, they enter a bright atrium. Light floods through the front windows, revealing its immaculate floors and a grayscale glass mural that includes engravings of surgery staff and a motto in cursive: “Generosity Heals.”

This is the house that Parkview built – and that the patients and employers of greater Fort Wayne paid for with some of the highest prices across the land.

The ever-expanding campus was a crowning achievement for Parkview’s longtime CEO, Michael Packnett, who retired two years ago, having turned the system from a small community chain into a regional powerhouse.

During his 16-year tenure, Packnett, a doughy-faced Oklahoman with a soft voice and a graying widow’s peak, won near universal acclaim for his carefully-cultivated brand of “servant leadership”.

Former employees, from nurses to executive team leaders, reminisce about how Packnett would walk the halls and shake the hands of subordinates, whom he called “co-workers” in public pronouncements.

Even today, local critics of the hospital find it hard to believe Packnett could have been in the know about the hospital’s more controversial charging and acquisition tactics. What they don’t like, they sometimes ascribe to Rick Henvey, Packnett’s longtime deputy and eventual successor. Henvey, a balding Texas native with a taut face, does not project Packnett’s “care bear” image, as one Republican lawmaker put it.

But sources who dealt with both over their 23-year partnership say that, in their business practices, the two were closely aligned.

Henvey followed Packnett to Fort Wayne. What they built there, one of the wealthiest hospital systems in Indiana, they built together – a trajectory that was not inevitable.

When the duo took over Parkview in 2006, Fort Wayne – then a city of around 250,000 – had a relatively competitive hospital market. Parkview had a slightly smaller regional market share than a for-profit competitor, and struggled with wobbly revenues, tough dealings with insurers, and a lack of bed capacity – causing it to sometimes lose patient referrals to its rival.

With the arrival of Packnett and Henvey, the hospitals’ operating revenues exploded, rising from around $700m at the close of 2006 to $1bn by the end of 2011 – a 40%-plus increase, though patient admissions only grew 11% during that period, according to Moody’s Ratings reports from the time.

Hospital industry rivals and insurance sources attribute a large part of Packnett’s success in those early days to his team’s aggressive acquisition of dozens of freestanding medical facilities, including doctors’ offices, imaging sites and surgery centers.

Like many hospital leaders across the country, Parkview administrators sometimes reclassified these acquisitions as “hospital-based” outpatient departments, according to one former Parkview employee and two healthcare industry sources familiar with the matter.

The reclassifications didn’t fundamentally change the services offered and the facilities were not necessarily on Parkview hospital campuses, sources asserted, but thanks to lax Medicare and commercial insurance reimbursement practices, administrators could insert the hospital’s tax identification number, a hospital address, and higher charges onto bills from these sites.

“So Packnett shows up here from Oklahoma and he realizes he has unlimited dollars,” recalled one rival hospital executive, who was operating in Fort Wayne at the time.

Around 2010, Packnett and Henvey saw an opportunity for this kind of billing arbitrage across state lines in Bryan, Ohio. The town of less than 10,000 people had a small community hospital that was fighting to keep its independence as well as an aging doctors group that was looking to cash out.

Packnett and Henvey wanted both, according to the Bryan hospital’s then CEO Phil Ennen. But when the duo couldn’t convince the local hospital to surrender, they settled for the doctors’ practice, which had its own facility doing affordable imaging and lab work right across the street.

Then the Fort Wayne not-for-profit executives jacked up prices, Ennen recalls.

Suddenly, he said, patients in Bryan receiving imaging from the same personnel in the same facility, were on the hook for hundreds of dollars more in charges because of its hospital-based reclassification, a spike that sparked complaints from local employers.

“It’s a powerful aphrodisiac, right?” said Ennen. “We can take ’em over and take their lab and their X-ray and make it ours, and charge our prices.”

Packnett’s physician grabs also softened up hospital targets for poaching down the line, according to one former high-level Parkview employee. With the Bryan doctors’ group now in Parkview’s hands, Ennen noted, the system began siphoning referrals away from the Ohio community hospital – shifting hospital facility fees and future patient visits from Bryan west to Fort Wayne.

Thirteen years later, struggling with finances, the community hospital group that operated the hospital in Bryan and another one in a nearby small town finally gave in and joined Parkview.

“They put Parkview doctors in Ohio and took their volume away,” recalled the former high-ranking Parkview employee. “It was a slow bleed.”

Announcing the affiliation, Tasha Eicher, Parkview’s market president for north-east Indiana and Ohio, said the system looked forward to “seeing the impact” it could have as “both a healthcare provider and a community partner”.

‘The more you code, the higher you code, the more credit you get’

As Parkview took over formerly independent county hospitals and doctors’ offices, more and more patients were referred within its system, exposing them to the not-for-profit’s meticulous revenue strategies.

Within a few years of Parkview’s acquisition of the formerly independent community hospital in DeKalb county, Indiana, in 2019, managers there were ranking doctors by revenue metrics, holding meetings about which practitioners had failed to hit their expected financials, and basing their bonus pay, in large part, on patient volume and new patient encounters, internal documents show.

Five former Parkview employees interviewed for this story asserted that this pay structure incentivized some practitioners to churn through dozens of patients a day and to steer them toward costly procedures and testing.

“The more you code, the higher you code, the more credit you get, which would translate to bonuses,” said one former Parkview office manager, who worked in the system for more than a decade.

“Somebody comes in with knee arthritis and basically they’re having pain, but they haven’t had any other treatment,” recalled a former Parkview doctor, questioning how his colleagues weighed surgeries versus more conservative alternatives. “These guys will jump right to a knee replacement surgery.”

Revenue pressure was even brought down to the level of nurses – some of whom say they have been pushed to charge for the smallest of items from Kleenexes to batteries. One 2022 email, obtained by the Guardian, shows a supervisor at Parkview DeKalb telling nurses that she had reviewed their charts for the week and found they had “missed” $50,000 in charges as a team. The following year, managers told staff to be more stringent about how many linen towels they handed out to patients – an initiative they termed “linen stewardship”.

“It makes me feel disgusting. It makes me feel dirty,” said one current Parkview nurse, describing how staff have been made to charge for supplies and services down to the micro-level. “Why should I be trying to make sure that they’re getting the most money that they can?”

In some cases, these volume and coding protocols resulted in enormous bills and significant additional revenue for the system, according to medical and legal records reviewed by the Guardian.

In 2021, after a young girl went to the ER for an accidental razor cut, a doctor applied an “adhesive skin affix”, a special type of wound glue, on her finger for about 10 seconds, according to her mother. Afterwards, Parkview charged just over $85 for the glue capsule, about four to five times the price listed online. The hospital also tacked another $295 onto the bill for the labor, which it classified as an intermediate surgical procedure, according to paperwork reviewed by the Guardian.

In 2022, Indiana’s attorney general announced a $2.9m overbilling settlement with Parkview, which stemmed from allegations that staff at multiple hospital locations were using improper revenue codes for blood-clotting tests to score more Medicaid dollars.

In a statement to local press, Parkview said it believed it was “using the correct billing code” and denied any wrongdoing.

The system has also previously argued it needs to “maintain a strong, stable financial position” in order to provide millions of dollars in charity care to poor patients, though such charitable figures are themselves based on the system’s high prices.

‘Take my pricing or no deal’

Under Packnett, Parkview’s growing ring of hospitals increased its leverage in contract negotiations with health insurers. Parkview had facilities that insurance companies effectively needed for their network plans in the Fort Wayne region, especially since local employers were afraid of making their workers leave their beloved chain, the one that had put its name on the local minor league baseball field and the local Y, according to two former Parkview employees and two Indiana insurance industry sources.

“The hospital was like, ‘Take my pricing or no deal’,” recalled one former Parkview employee, who spoke on the condition of anonymity because of the confidential nature of hospital-insurance bargaining.

Marty Wood, president of the Insurance Institute of Indiana, a lobbying group, told the Guardian that Parkview has been known to force insurance companies in negotiations to accept “all or nothing” agreements as part of their contracts. “All or nothing” agreements make insurers keep all of a system’s hospitals in their networks, regardless of their quality or costs – an arrangement that the California attorney general’s office and class action attorneys in other parts of the country have investigated as part of antitrust cases.

“That has absolutely got to drive up the overall costs,” Wood said.

Parkview did not respond to questions about whether it used “all or nothing” agreements.

With this growing bargaining power, Parkview secured higher and higher payments from private health insurers throughout the 2010s.

In 2011, commercial insurers were paying an estimated 233% of what the federal government was paying Parkview for the same services through Medicare. By 2019, that number had shot up to 282%. The same year, Packnett took home more in annual compensation than he ever had previously from the not-for-profit: $3.8m.

The escalating costs sparked growing consternation among local employers. That May, the Employers’ Forum of Indiana released a study it had commissioned that found the once obscure regional system had some of the highest hospital prices in the country.

Gloria Sachdev, the employer alliance’s president, said Parkview had not taken her up on her offer to meet before its release, but after the New York Times reported on their findings, Packnett invited her to come in from Indianapolis suburbs and discuss the study.

So one morning that May, Sachdev drove into Fort Wayne, past the corn fields, hospital billboards, and the minor league baseball stadium named after Parkview. Around 11am, she found herself at the head of a conference table inside the hospital’s regional center, where c-suite leaders grilled her with methodological questions and expounded on their civic-minded efforts.

After feeling like they had been going in circles for hours, Sachdev abruptly ended the meeting.

“Your job is not to provide revenue for the baseball field,” she recalls blurting out to the hospital executives. “Your job is not to provide revenue for the community outside of healthcare. Your job is to provide the best healthcare you can at an affordable price.”

Afterwards, Packnett, who had mostly stayed silent, offered to walk her out. As the two stood in the regional center’s airy atrium, Sachdev said, the hospital CEO asked for her advice.

“His concern was not about the prices. It was not about the impact to the community,” Sachdev recalled. “It was about being in the New York Times and how he should manage that.”

Sachdev says she urged Packett to be a local hero by lowering his chain’s prices. The national news cycle, she told him, was short.

Packnett nodded and looked relieved, she said.

The following year, Anthem, the area’s largest commercial health insurer, used Sachdev’s price study to bargain hard with Parkview, and secured temporary reimbursement reductions. In 2021 and 2022, average prices at Parkview hospitals dropped out of the nation’s top 10% most expensive hospitals. But in 2023, the system’s average prices climbed once again into the top 10%.

“To put it bluntly, I don’t think they were committed and acting in good faith,” Sachdev said of Parkview. “They gave a concession just to pacify people, then they just raised their prices again.”

A Guardian analysis of price transparency data from Parkview’s Regional Medical Center found that prices increased at the flagship hospital in 2024. The Guardian US compared the cost of nearly 500 in-patient medical procedures in 2023 and 2024 and found that private insurance companies with more than 10 covered procedures saw an average price increase of 20% between 2023 and 2024.

The Guardian’s analysis also showed just how much costs could swing at Parkview depending on a patient’s coverage. ​​Parkview negotiates the cost of each procedure with each insurance company and on average, the difference between the maximum and minimum negotiated price varies by $30,000.

Wood, the insurance lobbyist, called the spread “outrageous” and said it suggested that much of what determines hospital rates comes down to negotiating power, rather than real world costs.

“How can that be for the same thing? It makes no sense,” Wood said, referring to the differing procedure costs. “They’re forcing the hand of certain payors to pay this much or not be part of their network. That’s all I can think of.”

Parkview did not respond to the Guardian’s request to explain its price variations.

‘She could have easily died’

The October 2023 death of Taysha Wilkinson-Sobieski – the young mother who had an ectopic pregnancy – did not spur change at Parkview’s outlying hospitals.

In the months that followed, according to one current and one former employee, Parkview hospital administrators did not restore OB-GYN emergency coverage service to two of its smaller hospitals: Parkview LaGrange and Parkview DeKalb, the local hospital Wilkinson-Sobieski had gone to for help.

Nor did they make sure that the facilities had 24/7 ultrasound service – a level of service that is only provided at the regional center, according to internal hospital records from earlier this year obtained by the Guardian.

On New Year’s day, less than three months after Wilkinson-Sobieski’s death, another woman who did not know she had an ectopic pregnancy walked through the doors of the ER at Parkview Dekalb.

For most of that day, Melanie Boterf, 33, had felt nauseous. She was having trouble breathing and felt pain between her hips. Worried about incurring a bill for her family, the stay-at-home mom had tried to sleep it off. But after she went to the bathroom and saw blood in her underwear, she drove to her local ER, leaving her husband, a sanitation truck driver, to watch the kids before his early shift the next morning.

As in Wilkinson-Sobieski’s case, Parkview DeKalb lacked ultrasound capabilities at night and OB-GYN emergency coverage – limiting the staff’s ability to confirm whether Boterf had an ectopic pregnancy and to care for her if that was the case, according to medical records and a current Parkview employee. The ER doctor at DeKalb that night decided to transfer her, telling her it was because they couldn’t run an ultrasound, Boterf recalls.

Boterf says she was shocked. She had come to her local emergency room after all.

“The moment that they told me I’m not getting imaging here and I need to be transferred, I’m like, ‘Ok what’s the point of this being a hospital then?’”

At Parkview’s Regional Medical Center, Boterf, whose vitals had stabilized, waited more than two-and-a-half hours to be operated on. By the time the team ran her ultrasound, the imaging suggested that she had suffered a “moderate to large” hemorrhage within her pelvis, an indication that one of her fallopian tubes might have ruptured, medical records show.

Fortunately for Boterf, afterwards a Parkview surgeon was able to stop her internal bleeding and save her life. But several medical experts interviewed for this story pointed out that the case could have ended differently. It was impossible to know when exactly Boterf’s tube was going to burst, they said. If it had happened during her transfer, the experts said, she may not have survived.

“You can’t predict when it’s going to happen. If it had happened on the truck she could have died,” said a medical source, who used to work at Parkview DeKalb. “It’s like you’re filling a water balloon. It keeps going and just goes ‘pow!’ Then the hose is still going to bleed.”

“She could have easily died in that ambulance going from hospital A to hospital B,” said Dr Larry Melniker, an ultrasound expert and vice chief of quality at New York-Presbyterian Brooklyn Methodist Hospital’s Department of Emergency Medicine.

In an internal meeting ahead of Parkview DeKalb’s OB-GYN service cuts last year, hospital leaders claimed they had tried their best to recruit OB-GYNs, but had been struggling to find enough providers to maintain the same level of services, according to an audio recording obtained by the Guardian.

“Healthcare is just rapidly changing,” one executive told staff, in an apparent nod to the national OB-GYN shortage. “We’re not alone in this.”

Some sources questioned this line. They point out that unlike struggling rural hospitals, Parkview has a deep bench of OB-GYNs at its main regional campus and that the cuts allowed the system to skimp on a low-reimbursement service line.

Despite their resources, higher ups have not been willing to make more of their OB-GYN physicians take call shifts at their semi-rural hospitals while investing enough to attract additional recruits there, according to two former high-ranking Parkview employees.

The same month Wilkinson-Sobieski died, Parkview announced it had absorbed the community hospital in Bryan, Ohio, along with two other medical facilities on that side of the Indiana-Ohio border.

This fiscal year it found roughly $140m to pour into capital projects across greater Fort Wayne – investments that, a Moody’s report from July noted, will help further its goal of regional expansion.

The not-for-profit has enough resources to recruit more OB-GYNs for their outlying hospitals, one of the former high-ranking Parkview employees argued.

“They have the money,” she said. “They just don’t want to spend it.”

Methodology box

The Guardian analyzed Parkview hospital prices using two different data sources. We used a metric called the commercial to Medicare cost ratio to analyze how pricey Parkview hospitals are compared to other hospitals around the country. This metric is an estimate of how much more a hospital charges private health insurance compared with what it charges Medicare and is based on records submitted to the Centers for Medicare and Medicaid. The Guardian identified Parkview hospitals for each year from 2011 to 2023, and took each hospital’s commercial to Medicare ratio from processed data available from the RAND Corporation. The Guardian found the 90th percentile commercial to Medicare estimate by analyzing every general hospital, an approach adapted from this research paper.

The cost of individual inpatient procedures are based on 2023 and 2024 hospital price transparency files from Parkview Regional Medical Center. The Guardian matched every procedure based on the name of the insurer and the Centers for Medicare and Medicaid classification number. We matched 484 different medical procedure codes for 14 insurance companies and found four private insurance companies with more than 10 inpatient procedures in both 2023 and 2024, plus additional Medicare and Medicaid plans. We only compared the cost of one procedure for one insurer in each year to ensure an accurate year-to-year comparison.

Last Sunday night, as I was getting ready for bed, my friend Ali from the South Hebron Hills of Palestine sent me a text which read, “Israel is burning sleeping people alive in the refugee camps.” I clicked on the accompanying video and I could not believe what I saw: an inferno blazing, people running around screaming, and there, amidst the flame, a body writhing, crackling; a raised arm, reaching out for help, still attached to an IV. I waited for the following morning to share the video, until the event had been reported by reputable news outlets, because the images appeared too gruesome to be real – like they were something out of a movie – but they were real: an Israeli airstrike hit near the grounds of al-Aqsa Martyrs’ hospital in the central Gaza city of Deir al-Balah and killed at least four people. The man that we saw burning alive? His name was Sha’ban al-Dalou, a 19-year-old software engineering student.

In the 24 hrs since this attack, my social media feed was filled with videos of and reactions to this attack. The reel posted on Instagram by Palestinian journalist Saleh Aljafarawi has been shared over 455,000 times. The CNN Instagram post has been viewed over 1.2m times. Randa, a Palestinian friend of mine whose grandparents were born in Gaza, shared that this event was clear proof that Israel was waging a war of “annihilation”. Survivors of the attack said the fires were caused by gas cooking canisters. Israel blamed “secondary explosions” in a statement.

The Israeli social change organization Looking the Occupation in the Eye, with whom I’ve volunteered in the West Bank, shared Aljafarawi’s video, commenting that “the burning of men, women, and children alive is not a policy of extermination, but the loss of humanity”. It seemed clear to me that, after over a year of war livestreamed to the world, the images of this particular horror had broken through the noise on social media and was crystallizing as something larger, something different, something that would symbolize both the sheer brutality of the Israeli government and military’s assault as well as the nightmarish nature of Palestinian suffering in Gaza. Will Sha’ban al-Dalou become for Israelis and Palestinians the kind of symbol Emmitt Till has been for Americans?

When 14-year-old Emmitt Till was abducted, beaten and murdered by two white men in Mississippi in August 1955, the lynching of Black Americans was hardly a new phenomenon. In the late 19th and early 20th centuries, an estimated two or three Black people were lynched each week in the south. Before Till, more than 500 people were lynched in Mississippi alone. But the sight of Till’s mutilated face, viewed by tens of thousands of mourners at Till’s funeral in Chicago, and which millions more would see in print in newspapers and magazines around the country, provoked a different reaction in the US.

Till’s cousin Simeon Wright, who was with him the night he was murdered, has spoken about the significance of the decision by Emmitt’s mother Mamie Till-Mobley to have an open casket. “She said it herself, she wanted the world to see what those men had done to her son because no one would have believed it if they didn’t [see] the picture or didn’t see the casket. No one would have believed it. And when they saw what happened, this motivated a lot of people that were … ‘on the fence’, against racism. It encouraged them to get in the fight and do something about it. That’s why many say that that was the beginning of the civil rights era … [N]ow we had the whole nation behind us.”

Indeed, four months later, in December 1955, Black activists, including Martin Luther King, Jr and Rosa Parks, organized the Montgomery bus boycott. For more than a year, between 30,000 and 40,000 Black residents – that’s four-fifths of the city’s entire Black population – participated in sustained socio-political action, which eventually resulted in a US supreme court ruling that segregated buses were unconstitutional.

A shocking image won’t, on its own, lead to change, as Till’s story makes clear. Change comes when particular events – what social movement theorists often call “moments of the whirlwind” whip people up, usually in moments of crisis, to envision and then enact new political realities.

This is what we need now for Gaza: we need to see and to believe; to let ourselves be completely disgusted and filled with rage; and to get up off the fence and take decisive collective action. Israeli human rights groups B’Tselem, Yesh Din, Physicians for Human Rights, and Gisha are warning us that the Israeli military may have already begun the forcible transfer of Palestinian civilians from northern Gaza through tightening the siege and starving the population.

The war between Israel and Lebanon is escalating, with over 2,000 Lebanese now killed at the hands of Israeli forces, and, just two days ago, four Israeli soldiers were killed and some 60 others injured in a Hezbollah drone attack on a military base inside Israel. And regional violence can easily escalate: an Israeli retaliation against Iran for its recent missile barrage appears imminent; the US has sent 100 American soldiers to Israel to operate a new missile defense system, potentially drawing the US personnel directly into a devastating hot war with Iran.

In Jewish and Muslim traditions, we believe that every life is a universe. To kill one person is the equivalent of destroying an entire world. But in our mass media culture, certain lives take on greater symbolic significance while others remain virtually anonymous. Emmitt Till came to represent not only thousands of Black people lynched, but also the millions of innocent people still living, whose precious lives we still have time to defend against the scourge of racism. In this sense, a single life lost can lead to the salvation of an entire nation – a spiritual galaxy – if we choose to make it so.

In the video that Ali sent me, the cries of the onlookers were too loud to hear what Sha’ban al-Dalou, engulfed in flame, reaching out from his hospital bed, might have been saying – if he had enough air in his lungs to utter anything at all. But to me, a thousand miles away, seeing this video alongside all the other news, I hear one clear message: stop the killing, stop the war, let Palestinian people live. Because every life, whether it burns out in a blaze on social media, or flickers out in silence, is an entire universe.

So in the memory of those lost worlds, and for the protection of the living, we must make this moment a watershed that quenches the hellfire that threatens to envelop Israel, Palestine, Lebanon and the entire region. Let the memory of Sha’ban al-Dalou be the memory that brings us back to our common humanity and ends this war – the war that started on 7 October and the war that has raged for 100 years between the River and the Sea.

Meta, the owner of Facebook and Instagram, has reportedly fired about 24 staff at its Los Angeles offices for using their $25 (£19) meal credits to buy items such as toothpaste, laundry detergent and wine glasses.

The tech firm, which is worth £1.2tn and also owns the messaging platform WhatsApp, is said to have dismissed workers last week after an investigation discovered staff had been abusing the system, including sending food home when they were not in the office.

That included one unnamed worker on a $400,000 salary, who said they had used their meal credits to buy household goods and groceries such as toothpaste and tea.

On the anonymous messaging platform Blind, they wrote: “On days where I would not be eating at the office, like if my husband was cooking or if I was grabbing dinner with friends, I figured I ought not to waste the dinner credit.”

The worker admitted the breach when approached as part of a human resources investigation into the practice and was later fired. “It was almost surreal that this was happening,” the person wrote, according to the Financial Times, which first reported the story.

Some employees were also found to have spent the credits on other household items, such as acne pads. Employees who had only occasionally broken the rules were reprimanded, but were able to keep their jobs, the newspaper reported.

Free food has long been one of the perks of working for large tech companies.

Meta, which was founded by Mark Zuckerberg, usually feeds staff for free from canteens at its larger offices, including its sprawling Silicon Valley headquarters.

But those at smaller sites are given daily credits to order food though delivery services such as UberEats and Grubhub. Daily allowances include $20 for breakfast, $25 for lunch and $25 for dinner.

In 2022, the company caused a staff uproar after it decided to delay its daily free dinner service at its Silicon Valley campus by half an hour to 6.30pm, as part of wider cuts. It meant fewer employees would eat on campus if they managed to catch the last shuttle leaving the site at 6pm. It also made it more difficult for employees to stock up on free food to bring home as leftovers.

Other big tech companies have also been cracking down on employee perks. Google started to cut back on fitness classes and the frequency of laptop replacements last year. The company had also reportedly become more stringent on office supplies including staplers and tape, with staff having to borrow items from their reception desks instead.

Meta’s decision to fire staff it accuses of abusing their perks last week came as its bosses launched a fresh restructuring plan that meant laying off and relocating staff from its WhatsApp and Instagram divisions and its augmented reality arm, Reality Labs.

The company has just emerged from large-scale job cuts, with Zuckerberg having ordered 21,000 redundancies in 2022 and 2023. Meta had about 70,799 staff at the end of June this year.

Meta has been contacted for comment.

Tesco has struck a deal to buy enough solar power to run 144 of its large supermarkets, buying almost two-thirds of the entire electricity output from the Cleve Hill solar park in Kent.

The £450m solar park is being built on farmland near Faversham by Quinbrook Infrastructure Partners, a London-based firm that invests in renewable and low-carbon energy in the US, UK and Australia.

The site will provide Tesco with up to 10% of its UK electricity demand over 15 years. Tesco said the amount of clean energy generated would be enough to power 144 of its large stores for a year.

Cleve Hill, on the north Kent coast, is a solar and battery storage project that will have a capacity of 373 megawatts. Construction began early last year and it is expected to be up and running by the start of next year. Tesco said it was the UK’s largest corporate power purchase deal for a solar farm.

Ken Murphy, Tesco’s chief executive, hailed the deal as a “significant step” in its journey towards carbon neutrality across its business by 2035.

The site will feature more than 560,000 solar panels – some as tall as buses – and energy storage infrastructure. The French state-owned utility EDF will provide power balancing services.

Over the past five years, Tesco has announced several energy projects, helping the retailer source green electricity directly from windfarms and solar parks across the UK. With the addition of Cleve Hill, these power purchase agreements will cover 45% of Tesco UK’s – or 36% of the group’s – expected electricity demand in 2030.

Keith Gains, managing director and UK regional lead at Quinbrook said Cleve Hill was a “blueprint for the next generation of energy transition infrastructure in the UK”.

Renewable energy is seen as a crucial element in the UK’s plans to end its contribution to the climate crisis by building a carbon neutral economy by 2050.

Other major companies have moved to buy nuclear energy in recent weeks.

Tesco’s move comes a day after Google signed a deal to buy energy from a fleet of mini nuclear reactors to generate the power needed for the rise in use of artificial intelligence. The US tech corporation has ordered six or seven small nuclear reactors from California’s Kairos Power, with the first due to be completed by 2030 and the remainder by 2035.

Google hopes the move will provide a low-carbon solution to power datacentres, which require huge volumes of electricity. The company, owned by Alphabet, said nuclear provided “a clean, round-the-clock power source that can help us reliably meet electricity demands”.

Last month, Microsoft struck a deal for a nuclear reactor to power its expanding AI operations. However, the Three Mile Island site in Pennsylvania was the location of the most serious nuclear meltdown and radiation leak in US history in March 1979 and has been in a decommissioning phase.

The reactor will be reactivated after its owners, Constellation Energy, signed a 20-year power purchase agreement to supply Microsoft’s energy-hungry datacentres.

“The sea does not belong to despots,” Jules Verne wrote in 1869 in Twenty Thousand Leagues Under the Sea. “Upon its surface men can still exercise unjust laws, fight, tear one another to pieces, and be carried away with terrestrial horrors. But at 30 feet below its level, their reign ceases, their influence is quenched, and their power disappears.”

Now, more than 150 years later, geopolitics experts are warning that Verne’s final sentiment, expressed as it was through the character of Captain Nemo, was wrong. From seabeds and sea caves to sea canyons, underwater ridges, seamounts, sea knolls and reefs, academics say countries around the world are using the politics of nationalism to permanently stamp their mark on the topography of the ocean.

Klaus Dodds, professor of geopolitics at Royal Holloway, University of London, says that countries today are engaged in a “scramble for the oceans”. “There’s more and more ocean grabbing going on in the world, because countries have been given legal permission to do that.”

Dr Sergei Basik, a geographer at Conestoga College in Ontario, Canada, says a relatively recent process of 3D mapping the ocean floor has allowed nations to assert their sovereignty over newfound undersea features, known as “bathyonyms”.

Just as in 1492, when it was a new map of the ocean that inspired and emboldened Christopher Columbus to set sail across the world to find a new trade route to Asia, leading to the colonisation of America, the once murky abyss of the ocean has now resolved into clearly defined topographical features on a 3D map. All of these require a name – and nation states hungry for valuable natural resources and national territory are staking symbolic claims on their “discoveries”.

“When we give a name to an object, we claim it. And we claim not only the surface. We claim the territory and all of its resources,” says Basik. “From an economic perspective nations are thinking about the potential [of the features]: how can we use this?”

Basik, who first outlined his thesis in the geography journal Area, fears that countries will one day mine these features for minerals or other economic assets whose power or value is not yet known. “The first step is the symbolic claim, and after that, we’re talking about commodification of the ocean and resources in the ocean.”

Countries must petition the International Hydrographic Organization (IHO), an intergovernmental body based in Monaco with 100 member states, for the right to name the features in internationally recognised nautical charts and documents.

During the 20th century, just 17 names for bathyonyms were proposed on average each year, Basik’s research shows. But since 2000, countries have proposed 95 names on average a year – and recently this trend has strengthened, with more than 1,000 names put forward since 2016.

Basik’s research reveals that Japan is the most zealous proposer of names for seabed objects in the world: it is responsible for naming 615 bathyonyms, followed by the US (560), France (346), Russia (313), New Zealand (308) and China (261).

Dodds says that, in part, this rush to name areas of the seabed has been stimulated by coastal states trying to extend their sovereign rights, which really revolve around potential mineral resources in the sea. “There’s been a lot of enthusiasm for mapping, surveying and carrying out geological investigations.”

Some countries are seeking to demonstrate that a nearby seabed is part of their continental shelf and therefore belongs to them. This then enables that country – under the rules and procedures of international sea laws – to potentially extend its underwater sovereignty by as much as 350 nautical miles from its coastline, Dodds says. “These are really huge areas we’re talking about.”

Naming a feature reinforces the point about exclusive ownership. “It’s saying: this is my space.” You name to begin the process of developing a more refined sense of ownership and sovereign authority, he says. For this reason, “the politics of naming is always tied to expressions of national identity”.

For example, the Alamang Reefs in the Makassar Strait were discovered by the Indonesian navy in 2022 and named by Indonesia after a traditional Indonesian sword. Similarly, the O’Higgins Guyot and Seamount, which were discovered in the south Pacific by a Chilean vessel, were named by Chile after the 19th-century Chilean independence leader Bernardo O’Higgins Riquelme last year.

Countries do not always restrict themselves to proposing names for geographical features near their own coastlines. “A lot of this attention around naming is now being increasingly developed to ever remoter parts of the seabed,” says Dodds.

For example, Bulgaria, which has a very modest presence in the Antarctic, has been one of the most enthusiastic exponents of Antarctic place naming. “This is probably a bit counterintuitive, because there are other countries that have done far more in Antarctica and have actually named far fewer features,” says Dodds. “But Bulgaria has conducted research in the Antarctic. And the whole point about Antarctica and the oceans, at that sort of depth, is that no country is close.”

He adds: “What’s happening is we’ve got an international legal system that is encouraging mapping and surveying and claiming. And one of the things that historically has driven a lot of this work is an interest in mining the deep seabed.”

For Basik too, the naming – and claiming – of ocean features is not merely a territorial issue. “This is not only about possible geopolitical conflicts and potential wars,” he says. “This is about the future and future development. This is about the potential for using the oceans in an absolutely unacceptable manner from an environmental point of view.”

Breakthroughs sometimes turn up in unexpected places. The researchers working on the international push to bring back the thylacine say they found theirs in a long-ignored bucket in the back of a cupboard at a Melbourne museum.

It contained an astonishingly well-preserved head of the extinct marsupial, also known as the Tasmanian tiger.

“It was literally a head in a bucket of ethanol in the back of a cupboard that had just been dumped there with all the skin removed, and been sitting there for about 110 years,” Prof Andrew Pask, the head of the thylacine integrated genetic restoration research (with the perfect acronym Tigrr) lab at the University of Melbourne, says.

“It was pretty putrid, a completely gruesome sight. People had chopped large chunks off it.”

Aesthetics aside, the specimen had a lot going for it. It contained material the scientists thought would be impossible to find – including long RNA molecules crucial to reconstructing an extinct animal’s genome. “This was the miracle that happened with this specimen,” he says. “It blew my mind.”

A year on, Pask says it has advanced the work of the team of Australian and US scientists who are trying to resurrect the species more than he expected at this stage. “We are further along than I thought we would be and we have completed a lot of things that we thought would be very challenging, and others said would be impossible,” he says.

The plan to ‘de-extinct’ the thylacine

The project to bring back the thylacine is being driven by Colossal, a Texas-based biotechnology “de-extinction and species preservation” company that is also aiming to recreate the woolly mammoth and the dodo using genetic engineering techniques.

Led by the tech and software entrepreneur Ben Lamm, Colossal has raised US$235m, employs 155 people directly and is funding research at 13 laboratories across the globe. They include the Tigrr lab, which operates at the University of Melbourne School of Biosciences.

The thylacine was Australia’s only marsupial apex predator. It once lived across the continent, but was restricted to Tasmania about 3,000 years ago. Dog-like in appearance and with stripes across its back, it was extensively hunted after European colonisation. The last known survivor died in captivity in 1936 and it was officially declared extinct in the 1980s.

Colossal says researchers have made several breakthroughs in its work on the species, putting the company much closer to its goal of returning the species to the wild in Tasmania. They include what they say is the highest quality ancient genome ever produced, with just 45 gaps in a genetic blueprint that contains about 3bn pieces of information.

Lamm says it is an “incredible scientific leap” putting the program “on track to de-extinct the thylacine”, while other recent breakthroughs will be immediately useful in protecting critically endangered species. “We are pushing as fast as possible to create the science necessary to make extinction a thing of the past,” he says.

The soft tissue of the Museums Victoria specimen that researchers dubbed “head in a bucket” contained preserved long sequences of DNA – genetic material that is the same in almost every cell nucleus in a body – but also long RNA molecules. Pask says the latter were crucial, and unexpected.

RNA is much less stable than DNA. It varies in different types of tissue within a specimen and contains what is effectively a readout of the active genes needed for a particular tissue to function. It meant researchers were able to get information related to the animal’s nose, eyes, tongue and other facial material, giving a picture of what a thylacine could taste, what it could smell, what kind of vision it had and how its brain functioned.

Pask says the result is the first annotated extinct animal genome, what he calls “an incredible blueprint”. “It helps us prove that what we are bringing back is genuinely a thylacine and not some hybrid animal,” he says.

The thylacine researchers aim to take stem cells from a living species with similar DNA to a thylacine, the fat-tailed dunnart, and turn them into the closest approximation of thylacine cells possible using gene editing expertise developed by George Church, a professor of genetics at Harvard Medical School and Colossal’s co-founder.

A thylacine-looking thing – but what comes next?

The announcement about the genetic breakthrough came ahead of an event at the SXSW festival in Sydney on Friday, where Lamm and Pask will talk about their work with the actor Luke Hemsworth. The Hemsworths have been vocal and financial backers of the project.

Colossal claims several other breakthroughs in their recent work, including the development of the first artificial reproductive technology to induce ovulation in marsupials, a step that could lead to captive breeding programs for threatened species.

They say they have fertilised single-cell embryos and culture them to over halfway through pregnancy in an artificial uterus, and refined work engineering resistance to cane toad toxin in the cells of another marsupial, the northern quoll.

On when a thylacine might be created, Pask says he expects the first “thylacine-looking thing” could be born within three to five years, but that he “wouldn’t call that a thylacine”.

He says the researchers are confident in creating a thylacine’s skull, legs and even stripes, but there are “still other things we still don’t know how to do”.

Other scientists are watching on with varying degrees of caution and scepticism. Some ask why so much funding and effort is going into bring back species when thousands that are still alive are on the brink of extinction. Euan Ritchie, a professor of wildlife ecology and conservation at Deakin University, says it is an ambitious project and likely to lead to breakthroughs that could help with conservation. But he says there will be other challenges “if-and-when we bring back thylacine-like animals”.

“I think we will probably get some thylacine-like animal, but they won’t actually be thylacines. The question is: what comes next?” he says.

“How will they behave in the wild and what effects might they have in the ecosystems? We have no idea how they are going to behave because there are no living thylacines left, and when you can bring back a thylacine-like animal it has got no other thylacine-like animals to learn from.

“That’s at least as big a challenge, if not a bigger challenge, than the genetic challenge. As an ecologist, that’s the big unknown.”

Kamala Harris faced a grilling on Fox News, with host Brett Baier pressing the vice-president on immigration, the economy and the Biden administration in a 30-minute interview on Wednesday night.

The Democratic candidate’s first appearance on the conservative network formed part of a direct appeal to right-leaning voters, after she was joined by more than 100 Republicans at a campaign event in Pennsylvania earlier in the day.

The interview was combative, with Harris, towards the end, speaking over Baier as she asked him to interview her “grounded in full assessment of the facts”, while calling him out for playing clips that she said were not relevant to what they were discussing.

Here are the key takeaways:

More than half the world’s food production will be at risk of failure within the next 25 years as a rapidly accelerating water crisis grips the planet, unless urgent action is taken to conserve water resources and end the destruction of the ecosystems on which our fresh water depends, experts have warned in a landmark review.

Half the world’s population already faces water scarcity, and that number is set to rise as the climate crisis worsens, according to a report from the Global Commission on the Economics of Water published on Thursday.

Demand for fresh water will outstrip supply by 40% by the end of the decade, because the world’s water systems are being put under “unprecedented stress”, the report found.

The commission found that governments and experts have vastly underestimated the amount of water needed for people to have decent lives. While 50 to 100 litres a day are required for each person’s health and hygiene, in fact people require about 4,000 litres a day in order to have adequate nutrition and a dignified life. For most regions, that volume cannot be achieved locally, so people are dependent on trade – in food, clothing and consumer goods – to meet their needs.

Some countries benefit more than others from “green water”, which is soil moisture that is necessary for food production, as opposed to “blue water” from rivers and lakes. The report found that water moves around the world in “atmospheric rivers” which transport moisture from one region to another.

About half the world’s rainfall over land comes from healthy vegetation in ecosystems that transpires water back into the atmosphere and generates clouds that then move downwind. China and Russia are the main beneficiaries of these “atmospheric river” systems, while India and Brazil are the major exporters, as their landmass supports the flow of green water to other regions. Between 40% and 60% of the source of fresh water rainfall is generated from neighbouring land use.

“The Chinese economy depends on sustainable forest management in Ukraine, Kazakhstan and the Baltic region,” said Prof Johan Rockström, the director of the Potsdam Institute for Climate Impact Research and one of the co-chairs of the commission. “You can make the same case for Brazil supplying fresh water to Argentina. This interconnectedness just shows that we have to place fresh water in the global economy as a global common good.”

Tharman Shanmugaratnam, the president of Singapore and a co-chair of the commission, said countries must start cooperating on the management of water resources before it was too late.

“We have to think radically about how we are going to preserve the sources of fresh water, how we are going to use it far more efficiently, and how we are going to be able to have access to fresh water available to every community, including the vulnerable – in other words, how we preserve equity [between rich and poor],” Shanmugaratnam said.

The Global Commission on the Economics of Water was set up by the Netherlands in 2022, drawing on the work of dozens of leading scientists and economists, to form a comprehensive view of the state of global hydrological systems and how they are managed. Its 194-page report is the biggest global study to examine all aspects of the water crisis and suggest remedies for policymakers.

The findings were surprisingly stark, said Rockström. “Water is victim number one of the [climate crisis], the environmental changes we see now aggregating at the global level, putting the entire stability of earth’s systems at risk,” he told the Guardian. “[The climate crisis] manifests itself first and foremost in droughts and floods. When you think of heatwaves and fires, the really hard impacts are via moisture – in the case of fires, [global heating] first dries out landscapes so that they burn.”

Every 1C increase in global temperatures adds another 7% of moisture to the atmosphere, which has the effect of “powering up” the hydrological cycle far more than would happen under normal variations. The destruction of nature is also further fuelling the crisis, because cutting down forests and draining wetlands disrupts the hydrological cycle that depends on transpiration from trees and the storage of water in soils.

Harmful subsidies are also distorting the world’s water systems, and must be addressed as a priority, the experts found. More than $700bn (£540bn) of subsidies each year go to agriculture, and a high proportion of these are misdirected, encouraging farmers to use more water than they need for irrigation or in wasteful practices.

Industry also benefits – about 80% of the wastewater used by industries around the world is not recycled.

Ngozi Okonjo-Iweala, the director general of the World Trade Organization, also a co-chair of the commission, said countries must redirect the subsidies, axing harmful ones while ensuring poor people were not disadvantaged. “We must have a basket of policy tools working together if we are to get the three Es – efficiency, equity and environmental sustainability and justice. Therefore we have to couple the pricing of water with appropriate subsidies,” she said.

At present, subsidies mainly benefit those who are better off, Okonjo-Iweala added. “Industry is getting a lot of the subsidy, and richer people. So what we need are better targeted subsidies. We need to identify the poor people who really need this,” she said.

Developing countries must also be given access to the finance they need to overhaul their water systems, provide safe water and sanitation, and halt the destruction of the natural environment, the report found.

Mariana Mazzucato, professor of economics at University College London, and a co-chair of the commission, said loans made by public sector banks to developing countries should be made conditional on water reforms. “These could be improving water conservation and the efficiency of water use, or direct investment for water-intensive industries,” she said. “[We must ensure] profits are reinvested in productive activity such as research and development around water issues.”

Water problems also had an outsized impact on women and girls, Mazzucato added. “One of our commissioners is Yvonne Aki-Sawyerr, the mayor of Freetown in Sierra Leone. She says most of the rapes and abuse of women actually happen when they’re going to fetch water,” Mazzucato said. “Child mortality, gender parity, the water collection burden, the food security burden – they’re all connected.”

Five main takeaways from the report

The world has a water crisis

More than 2 billion people lack access to safe drinking water, and 3.6 billion people – 44% of the population – lack access to safe sanitation. Every day, 1,000 children die from lack of access to safe water. Demand for fresh water is expected to outstrip its supply by 40% by the end of this decade. This crisis is worsening – without action, by 2050 water problems will shave about 8% off global GDP, with poor countries facing a 15% loss. Over half of the world’s food production comes from areas experiencing unstable trends in water availability.

There is no coordinated global effort to address this crisis

Despite the interconnectedness of global water systems there are no global governance structures for water. The UN has held only one water conference in the past 50 years, and only last month appointed a special envoy for water.

Climate breakdown is intensifying water scarcity

The impacts of the climate crisis are felt first on the world’s hydrological systems, and in some regions those systems are facing severe disruption or even collapse. Drought in the Amazon, floods across Europe and Asia, and glacier melt in mountains, which causes both flooding and droughts downstream, are all examples of the impacts of extreme weather that are likely to get worse in the near future. People’s overuse of water is also worsening the climate crisis – for instance, by draining carbon-rich peatlands and wetlands that then release carbon dioxide into the atmosphere.

Water is artificially cheap for some and too expensive for others

Subsidies to agriculture around the world often have unintended consequences for water, providing perverse incentives for farmers to over-irrigate their crops or use water wastefully. Industries also have their water use subsidised, or their pollution ignored, in many countries. Meanwhile, poor people in developing countries frequently pay a high price for water, or can only access dirty sources. Realistic pricing for water that removes harmful subsidies but protects the poor must be a priority for governments.

Water is a common good

All of human life depends on water, but it is not recognised for the indispensable resource it is. The authors of the report urge a rethink of how water is regarded – not as an endlessly renewable resource, but as a global common good, with a global water pact by governments to ensure they protect water sources and create a “circular economy” for water in which it is reused and pollution cleaned up. Developing nations must be given access to finance to help them end the destruction of natural ecosystems that are a key part of the hydrological cycle.

The US supreme court declined on Wednesday to put on hold a new federal rule targeting carbon pollution from coal- and gas-fired power plants at the request of numerous states and industry groups in another major challenge to Joe Biden’s efforts to combat the climate crisis.

The justices denied emergency requests by West Virginia, Indiana and 25 other states – most of them Republican-led – as well as power companies and industry associations, to halt the Environmental Protection Agency (EPA) rule while litigation continues in a lower court. The regulation, aimed at cutting greenhouse gas emissions that drive the climate crisis, took effect on 8 July.

The rule would require existing coal- and new natural gas-fired plants eventually to reduce emissions including by capturing and storing carbon dioxide.

The EPA’s new rule, issued under the landmark Clean Air Act anti-pollution law, was issued two years after a major ruling by the supreme court in 2022 undercutting the agency’s power to issue sweeping regulations to force an electric-generation shift from coal to cleaner energy sources.

The EPA has said efforts to address the climate crisis and its impacts such as extreme weather and rising sea levels must include the power sector because fossil fuel-fired plants make up 25% of overall domestic greenhouse gas emissions.

Notably, the rule mandates that coal plants operating past 2038 and certain new gas plants reduce emissions by 90% by 2032 including by using carbon capture and storage systems that extract carbon dioxide from plant exhaust and sequester it underground.

The EPA has called the technology proven and technically feasible. The rule’s challengers have said it has not been shown effective at the scale predicted by the EPA.

The rule’s requirements are “really a backdoor avenue to forcing coal plants out of existence”, West Virginia, a major coal producer, and other state challengers said in a written filing.

The supreme court’s 2022 ruling was based on what is called the “major questions” legal doctrine embraced by its conservative justices that requires explicit congressional authorization for action on issues of broad importance and societal impact.

The states and certain other challengers contend that the EPA’s new rule likewise implicates a major question and exceeds the agency’s authority.

Numerous states and industry players filed multiple lawsuits challenging the rule in the US court of appeals for the District of Columbia circuit, which on 19 July denied requests to pause the regulation pending its review.

The case did not implicate a major question because the EPA’s actions setting plant limits were “well within” its statutory authority, the DC circuit stated.

Paul Watson, the anti-whaling activist detained in Greenland and awaiting possible extradition to Japan, has appealed to Emmanuel Macron for political asylum in France.

Watson was detained in July after a Japanese request to Interpol over his confrontational tactics aimed at disrupting whaling operations in the Antarctic, and could face up to 15 years in prison if he is extradited and convicted.

His request to the French president was made in a letter several days ago, said Lamya Essemlali, the head of Sea Shepherd France, at a press conference in Paris. Macron has previously expressed his support for Watson and emphasised the importance of the case for environmental advocacy and human rights. There was no immediate comment from Macron’s office on Wednesday.

Essemlali said: “Paul is very attached to France, and it is also the second largest marine territory in the world, which means a lot for ocean conservation. Paul is currently living in France with his family.” She said Watson was “down” and “isolated” but “resilient”.

Jean Tamalet, a lawyer associated with Sea Shepherd France, part of the US-based non-profit conservation activist organisation, emphasised that the call for political asylum was largely symbolic and aimed at securing Watson’s release.

Critics of Watson’s arrest in Greenland have asserted that it stemmed from longstanding political motivations tied to Japan’s whaling practices, which are banned internationally under a 1986 treaty. Japan considers the practices part of its cultural heritage.

For decades, Watson has led high-profile confrontations with whaling ships in the Southern Ocean. The Greenland arrest occurred when Watson’s ship docked in Nuuk for refuelling on its way to intercept a Japanese whaling ship. Danish authorities are reviewing Japan’s request for his extradition.

More than a decade ago, Japan issued a red notice through Interpol. This is not an international arrest warrant but a request for cooperation between member states to locate and detain individuals pending extradition.

In the past, international authorities had paid little attention to the red notice, allowing Watson to travel freely, according to Tamalet, who said: “That has obviously changed.”