The overwhelming majority of young Americans worry about the climate crisis, and more than half say their concerns about the environment will affect where they decide to live and whether to have children, new research finds.

The study comes just weeks after back-to-back hurricanes, Helene and Milton, pummeled the south-eastern US. Flooding from Helene caused more than 600 miles of destruction, from Florida’s west coast to the mountains of North Carolina, while Milton raked across the Florida peninsula less than two weeks later.

“One of the most striking findings of the survey was that this was across the political spectrum,” said the lead author, Eric Lewandowski, a clinical psychologist and associate professor at the NYU Grossman School of Medicine. “There was no state sample where the endorsement of climate anxiety came in less than 75%.”

The study was published in the Lancet Planetary Health, and follows a 2021 study covering 10 countries. Both the previous and current study were paid for by Avaaz, an advocacy group.

The new study was conducted by researchers from NYU School of Medicine, Stanford University, Utah State University, the University of Washington and George Washington University, among others.

In an online survey, researchers asked young people aged 16-25 from all 50 US states to rate their concerns, thoughts and emotions regarding the climate crisis; about their political affiliation and about who has responsibility for causing climate change. Researchers conducted the survey online from July to November 2023.

An overwhelming majority of young people said they were worried about the climate crisis – 85% said they were at least moderately worried, and more than half (57%) said they were “very or extremely” worried. Nearly two-thirds endorsed the statement: “Humanity is doomed,” and more than half of the sample (52%) endorsed: “I’m hesitant to have children.”

“I often hear adults say that our generation, gen Z, will fix what they have broken. What they may not understand is the pressure this puts on all of us,” said Zion Walker, a student and member of the Climate Mental Health Network’s Gen Z Advisory Board, in a statement. “Yes, we are taking steps and fighting for the future, but many of us are overwhelmed by the daily reality of climate disasters – waking up to news of wildfires engulfing homes and hurricanes taking lives.”

Large majorities of both main political parties – 92% of Democrats and 73% of Republicans – said they worried about the climate. Respondents also said they had negative thoughts about the climate and had planned action to respond to their concerns, including voting for political candidates who would pledge to support “aggressive” action.

Using a statistical technique called a regression model, researchers also found that young people who reported more exposure to more climate-related disasters were more likely to want a plan for action.

“One of the findings we talk about in the text was the proportion of people who want this to be talked about,” said Lewandowski. He added that more than 70% of young people want the climate to be a subject of discussion, “and for older generations to try to understand how they feel.”

The new research represents an emerging topic in mental health stressors. The relationship between mental health impacts and natural disasters – such as Helene, Milton and even Covid-19 – is well established. Researchers have even found a dose-response relationship, with more reported depression symptoms associated with greater exposure to disaster. Climate anxiety, such as worry about the future of the planet, is an area of emerging research.

“Stressors like divorce, unemployment, having your kids do poorly in school, having a hard time looking after your ageing parents are all associated with worse mental health,” said Dr Sandro Galea, dean of the Boston University School of Public Health, who was not involved in the research.

Although less studied, Galea said, “having stressors around climate, worsening of the planet, fear of things like conflict – those are all very plausibly associated with poor mental health.”

In the end, after a year-long, multi-agency manhunt involving the latest technology, Israel’s best special forces and American assistance, Yahya Sinwar appears to have been killed by regular soldiers who had stumbled into him and had no idea whom they had killed.

According to the initial reports, they were not there on an assassination operation and had no prior intelligence that they could be in the vicinity of the elusive Hamas leader, architect of the 7 October attacks, the man Israel most wanted to kill. It was only after they took a closer look at his face and found identity documents on him that the troops realised they had got Sinwar.

Along the way, Israel Defense Forces (IDF) have smashed much of Gaza and are estimated to have killed more than 42,000 Palestinians, driving two million from their homes, a humanitarian disaster Sinwar set in motion with the sheer brutality of the initial surprise assault a year ago, killing 1,200 Israelis and taking 250 hostage.

Sinwar’s last reported sighting had been just a few days after the 7 October attack, when he appeared out of the subterranean gloom in a Gaza tunnel when a group of hostages were been held.

In fluent Hebrew, perfected over more than 22 years in an Israeli prison, Sinwar reassured them that they were safe and would soon be exchanged for Palestinian prisoners. One of the hostages, Yocheved Lifshitz, an 85-year-old veteran peace campaigner from the Nir Oz kibbutz, had no time for his show of concern for their welfare and challenged the Hamas leader to his face.

“I asked him how he wasn’t ashamed to do something like this to people who had supported peace all these years?” Lifshitz told the Davar newspaper after her release following 16 days in captivity. “He didn’t answer. He was quiet.”

A video recorded on Hamas security cameras at about the same time, on 10 October, and found by the Israeli military some months later, shows Sinwar following his wife and three children through a narrow tunnel and disappearing into the murk.

The ferocious manhunt that ensued involved a mix of advanced technology and brute force, as his pursuers have shown themselves prepared to go to any lengths, including causing extremely high civilian casualties, to kill the Hamas leader and destroy the tight circle around him.

The hunters were a taskforce of intelligence officers, special operation units from the IDF, military engineers and surveillance experts under the umbrella of the Israeli Security Agency, more widely known by its Hebrew initials, or by the acronyms Shabak or Shin Bet.

Personally and institutionally, this team was seeking redemption for the security failures that allowed the 7 October assault to happen. But despite their motivation, they faced more than a year of frustration.

“If you’d told me when the war began he would still be alive [a year later], I would have found it amazing,” said Michael Milshtein, a former head of the Palestinian affairs section in Israeli Military Intelligence (Aman). “But remember, Sinwar prepared for a decade for this offensive and IDF intelligence was very surprised by the size and length of the tunnels under Gaza and how sophisticated they were.”

Some in the Israeli defence establishment believed that Sinwar would be surrounded by hostages as human shields, though others maintained that would slow him down and make his entourage a bigger target. Certainly the risk of killing hostages did not stop the IDF dropping 2,000lb bombs on suspected Hamas leadership targets. In the end, the Israelis reported finding no sign of hostages in the vicinity of Sinwar when he was killed, who seems to have been in the company of just two other men.

There was no shortage of expertise among Sinwar’s pursuers. Targeted killings have been a core tactic of Israel’s military since the founding of the state. Since the second world war, Israel has assassinated more people than any other country in the western world.

Yahalom, a special section within the Combat Engineering Corps, has more experience in tunnel warfare than any of its counterparts in western armies, and has access to state-of-the-art US-made ground-penetrating radar. The clandestine signals intelligence unit 8200 is a global leader in electronic warfare and has been eavesdropping on Hamas communications for decades.

The Shin Bet lost many of its sources in Gaza after Israel pulled out of the territory in 2005, but worked hard to rebuild its network of informants after Israel launched its ground invasion last October, recruiting from among the desperate flows of Palestinians fleeing the onslaught.

Despite the capabilities of this formidable taskforce, it came close to catching Sinwar just once before Thursday’s fatal encounter, in a bunker beneath his home town of Khan Younis in late January. The fugitive warlord had left behind clothing and more than 1m shekels (over £200,000) in wads of banknotes. This was seen by some as a sign of panic, though the Hamas leader was ultimately estimated to have left a few days before Israeli forces raided the bunker.

The assumption made by Sinwar’s trackers was that he had abandoned using electronic communication, well aware of the skills and technology possessed by his hunters. It was not only Hebrew that Sinwar studied in Israeli jail but also the habits and culture of his enemy.

“He really understands the basic instincts and the deepest feelings of Israeli society,” said Milshtein, now at the Moshe Dayan Center for Middle Eastern and African Studies at Tel Aviv University. “I’m quite sure every move he makes is based on his understanding of Israel.”

Throughout his year in hiding, Sinwar continued to communicate with the outside world, albeit with apparent difficulty. The long, fruitless negotiations over a ceasefire in Cairo and Doha were frequently paused while messages were sent to and from the subterranean commander. The dominant theory was that Sinwar uses couriers to remain in command, drawn from a small and shrinking coterie of aides he trusts, starting with his brother Mohammed, a senior military commander in Gaza.

The team hunting Sinwar hoped that his need for contact with couriers, to issue orders and control the hostage negotiations, would ultimately prove his undoing, just as a courier led American trackers over several years to Osama bin Laden’s hideout in Abbottabad, Pakistan.

It is believed that it was a courier who led the Israeli hunters to their biggest scalp of the war before Sinwar. At 10.30am on 13 July, Mohammed Deif, Hamas’s veteran commander who had topped Israel’s most wanted list since 1995, emerged from a hiding place near a camp for displaced people at al-Mawasi to take in some air with a close lieutenant, Rafa’a Salameh. Within an instant, both men were killed by bombs dropped by Israeli jet fighters – at least, according to IDF accounts – along with scores of Palestinians. Hamas insists that Deif is still alive but he has not been seen since.

Many in the Israeli security establishment rued what they saw as a missed historic opportunity in September 2003 when they had planes ready to bomb a house where the entire Hamas leadership was holding a meeting. After furious argument in the military chain of command, the air force used a precision missile fired into the presumed meeting room rather than flattening the whole building with a hail of bombs, out of concern for civilian casualties. They picked the wrong room and the Hamas leaders survived.

By July this year, the likelihood of killing large numbers of civilians was no longer an obstacle. In targeting Deif, the air force used 2,000lb bombs, the very weapons the Biden administration had stopped sending in May because of their indiscriminate destructive force. Israel reportedly dropped eight of them on 13 July. Ninety Palestinians in the vicinity were killed and nearly 300 injured.

Yossi Melman, a co-author of Spies Against Armageddon and author of other books on Israeli intelligence, said Deif may have made a mistake that Sinwar had avoided.

“Deif was maybe more arrogant or maybe he told himself they tried to kill me so many times, and I lost an eye and an arm but I still survived, so maybe God is with me,” Melman said. “The Shabak and the army were waiting just for this opportunity. All these targeted killings are about waiting for the one minor mistake by the other side.”

There was some talk over the negotiating tables in Cairo and Doha of the past year of cutting a deal in which Sinwar went into exile, and some suggested that he could have crossed the border, hiding in a tunnel on the Egyptian side of the town Rafah. Such theories underestimated the ideological zeal of a man who rose through Hamas ranks as the executioner of suspected informers.

Milshtein, whose job in the Aman military intelligence service was to study Sinwar and other Hamas leaders, predicted months before his eventual death: “It is in his basic DNA to stay in Gaza and to fight until death. He will prefer to die in his bunker.”

In that case, Sinwar got his wish. His death was perhaps preordained by the sheer determination of both sides. He would never leave or surrender, and if the hi-tech intelligence-led hunt for him failed, Israel preferred to flatten Gaza until he was finally killed.

Whether his death will stop the war is another question.

Ram Ben-Barak, a former deputy director of the Mossad, had predicted that after Sinwar’s fall “someone else will come”.

“It is an ideological war, not a war about Sinwar,” Ben-Barak said.

Milshtein said: “After almost 50 years of assassinations, we understand this is a basic part of the game. Sometimes it is necessary to assassinate a very prominent leader. But when you start to think it will be a gamechanger and that an ideological organisation will collapse because you kill one of its leaders, that is a total mistake.

“You cannot create a fantasy. It will not end the war.”

The death of Yahya Sinwar, the head of Hamas and mastermind of the 7 October attacks, has huge implications for the conflict in Gaza, for Israel’s other campaigns in Lebanon and the occupied West Bank, and for Israel’s domestic politics.

There will be the war – or wars – before the killing of the 62-year-old veteran militant and the war(s) after it.

One of the biggest immediate impacts will obviously be on Hamas, which has now lost much of its top leadership. Already the head of its military wing in Gaza, Sinwar took charge of the organisation after Ismail Haniyeh, his predecessor, died in a bomb explosion in a government guesthouse in Tehran in July that was blamed on Israel. Other senior officials were killed in Beirut and in Gaza, where Israeli airstrikes successfully targeted military Hamas commanders such as Marwan Issa and Mohammed Deif.

Hamas will portray Sinwar as a martyr and look to frame his death in a way that will inspire new volunteers. That he appears to have died fighting on a frontline, with a weapon in his hand, will help this. But whatever the propaganda, the elimination of such a respected leader is unlikely to boost recruitment, and Hamas sorely needs new manpower in Gaza where it has taken heavy casualties.

Command in Gaza is likely to pass to Sinwar’s younger brother, Mohammed, 49, who will probably continue the strategy of low-level insurgent resistance to Israel, with a focus on retaining some kind of shadow administrative control in the territory and exploiting international outrage over civilian casualties to put pressure on Israel.

But more broadly Hamas will be thrown into disarray. It will now have to find a new overall leader. Sinwar, despite all the authority he had gathered over decades, was a controversial choice and though the succession of his brother would send a powerful message, Mohammed Sinwar would struggle to unify and rally the organisation. Major strategic choices postponed by the appointment of Yahya Sinwar will now have to be made, under great pressure and in the full knowledge that the Israeli security services are capable of tracking and killing even the most senior officials.

In Israel, where Benjamin Netanyahu is still blamed by many for the security failures that led to the death of 1,200 people, mostly civilians, and the abduction of 250 in the 7 October attacks, Sinwar’s killing will greatly reinforce the prime minister’s political position and rally his hardline rightwing support base. Netanyahu’s poll ratings were already improving after a series of tactical successes in Lebanon, including the assassination of Hezbollah’s leader Hassan Nasrallah, and quickly there were reports of celebrations in Jerusalem on Thursday.

The death of Sinwar will undoubtedly be seen by some Israelis, including many in senior posts in the military, intelligence services and government, as a moment to declare victory in Gaza and end what is widely seen as a draining, if necessary, campaign. But how much real difference this could make on the ground is unclear.

One possibility is that ceasefire negotiations will receive a boost now that one of the two individuals who have been accused of blocking any deal is gone. But the attitude of any successor to Sinwar to talks may not be that different, and Netanyahu has always insisted that military pressure is what will bring back the 100 or so hostages in Gaza, of whom only half are thought to still be alive. The chances of Netanyahu now agreeing to release thousands of Palestinian prisoners, including many who have killed Israelis, and make other painful concessions must be slim.

There is a possibility that the US could now press Israel to declare an end to its offensive in Gaza – something that would come as a huge relief to Democratic party campaign strategists. Washington has ramped up pressure on Israel in recent days over increasing access to humanitarian aid for the 2.3 million inhabitants of Gaza, most of them displaced many times, who are facing a winter without adequate food, shelter and medication. A recent surge in airstrikes has pushed the total death toll since October last year to more than 42,500.

But even if Israel did decide to declare victory in Gaza with the death of Sinwar – something that analysts have long predicted – it may not mean the dawning of the “day after”. Israeli officials have made clear their military control and operations will continue in Gaza for as long as they deem them necessary, and no one has yet come up with a new political set-up in Gaza that might be acceptable to all parties.

On Thursday, Benny Ganz, an opposition parliamentarian, praised Sinwar’s death as an “important achievement” but insisted that Israel’s military “will continue to operate in the Gaza Strip for years to come”.

Israel has already switched its focus to the battle against Hezbollah in Lebanon, and more broadly against Iran across the region. Netanyahu has so far rejected any ceasefire in the north, in the probably justified belief that Israel has the upper hand, and is yet to order retaliation for the barrage of 180 missiles launched at Israel by Iran earlier this month. This riposte will undoubtedly come.

The killing of Sinwar will further boost the confidence of Israeli military, intelligence and political officials who have already been greatly encouraged by their recent successes. Much of Israel’s strategic thinking is dominated by the need to restore what it sees as deterrence necessary to its survival, and to permanently weaken Iran.

Sinwar’s elimination will be emotionally satisfying for many Israelis, politically useful for Netanyahu and his supporters and a major blow for Hamas, but it is unlikely to bring the multiple conflicts under way in the Middle East to a sudden end.

Aberdeen, the centre of the UK’s North Sea oil and gas industry for the past six decades, witnessed the launch of a new company this week that aims to sweep away Britain’s dependence on fossil fuels for ever.

Great British Energy is at the heart of the recently elected Labour government’s pitch to decarbonise the UK’s power sector by 2030. Ed Miliband, the energy secretary, told an audience in Aberdeen on Thursday that the company would “harness the potential we have to truly lead the world in renewables jobs”.

With £8.3bn in new government investment, GB Energy is one of the few new spending commitments Labour is planning, amid consternation among ministers over swingeing cuts elsewhere. But the crucial decisions that will determine whether GB Energy can be a success, or not, will be taken far from Aberdeen, in London’s No 11 Downing Street. Rachel Reeves, the chancellor of the exchequer, is finalising her first autumn budget, set for 30 October, and experts fear that though the money for GB Energy will remain intact, she will place such tight restrictions on the company as to effectively cut off its lifeblood.

What’s the plan for Great British Energy?

Great British Energy is one of the most recognisable and popular of the policies that brought Labour to power in July’s general election. A national energy champion, in contrast to the foreign-owned companies that dominate the UK’s energy scene; a company owned by the people of Britain that will invest in a new generation of renewable energy supply; a plan that will cut the UK’s carbon footprint while reducing household bills.

The company will be led by Jürgen Maier, former UK chief executive of the engineering company Siemens, and a longstanding champion of clean technology. With £8.3bn in initial funding, GBE is one of the government’s few remaining green spending pledges, after Labour’s initial plans for a £28bn a year public investment in a “green industrial strategy” were gutted in February.

Offshore wind, including revolutionary floating turbines, tidal power, carbon capture and storage, hydrogen and other emerging technologies will be the focus of the company’s investments. Maier wants GBE to stand alongside globally significant players such as Denmark’s national clean energy company, Ørsted, and Sweden’s Vattenfall.

But when Reeves stands up in parliament on 30 October, she is unlikely to give Maier the boost that many experts say is needed. The Guardian understands that the Treasury is determined to keep GBE within tight fiscal controls. That means it will not have the powers to borrow new money to invest, lest any debt that it accumulates could be counted towards the government’s massive debt pile, and upset delicate calculations on Reeves’s fiscal rules.

Failing to give GBE the freedom to borrow would be a crucial mistake, according to Mathew Lawrence, the founder and director of the Common Wealth thinktank, credited with coming up with the original idea for a national energy company. “Reeves should exempt GBE from public sector net borrowing rules,” he said. “She can do that.”

Maier is more circumspect. He appears to still hold out hope of a change of mind from the Treasury at some point, telling the Guardian: “Whether in the future we can borrow or not, I think is a discussion for later on.”

Reeves also seems to prefer GBE to take minority stakes in large renewable energy projects. That too is a problem, according to Lawrence. “GBE should take majority stakes, in order to have control over these projects,” he said.

According to Lawrence, the key benefits that GBE can deliver to boost the UK’s green energy sector are: cost, coherence and certainty. On cost, GBE can lower costs by using the government’s might to invest capital more efficiently and at lower interest rates than private companies can access.

Coherence means that the government can take an overview of the UK’s energy needs and invest strategically to meet them, unlike private companies, which can only take a piecemeal view. Certainty reflects the fact that the government is driven not by short-term profit like the private sector, but by a long-term goal of decarbonising power, which gives a clear future direction that all its investments and policies must work towards.

Industry is ready to work with the government, the Guardian has found, but businesses want to see more clarity from ministers over the plans. One senior industry source told the Guardian that “increasingly there is a meeting of minds” between investors and government officials over the role for the new entity.

That marks a change in attitude, as GBE was initially a cause for concern among businesses. Senior executives within Europe’s largest energy companies feared that a state-backed enterprise would lay claim to preferential treatment in the government’s clean energy schemes – and potentially edge out private capital. Miliband has been quick to reassure the industry that GB Energy would seek to “crowd in” new investment rather than crowd it out.

Emma Pinchbeck, the chief executive of Energy UK, the industry’s trade body, who is shortly to take up a new role as chief executive of the Climate Change Committee, the statutory adviser to ministers on climate policy, said the public energy company had “great potential to advance the UK’s clean energy ambitions” if it tried to “support and complement – rather than duplicate – the investment, expertise and experience of the private sector”.

“Kickstarting the development of newer technologies and supporting community projects while larger and established sources like wind and solar continue to grow, would also fulfil an existing need,” she said.

Which areas will it invest in?

GB Energy’s first step has been in the direction of Britain’s world-leading offshore wind sector. It has included a partnership with the crown estate, which aims to accelerate the build-out of enough giant offshore windfarms across the estate’s seabed off the coastlines of England and Wales to power 20m homes.

Through this partnership GB Energy will undertake early development work on sites before the seabed licences are granted to windfarm developers to help speed up the process. In exchange it will claim a small stake in the windfarm. This is expected to accelerate the £60bn of private sector investment in the government’s green energy goals – and deliver healthy returns for GB Energy.

Keith Anderson, the chief executive of Scottish Power, which recently doubled its spending plans for the UK for the next four years to £24bn, said: “More than ever, the government is heading in the right direction. If targeted properly, GB Energy will directly support [the 2030 clean energy target] by producing a plan we can all get behind and deliver.”

There remains uncertainty over which areas the government will target beyond offshore wind. Anderson believes that emerging technologies – controversial with many environmentalists – such as green hydrogen and carbon capture and storage are ripe for “tailored support” from the government, which could include investment from GB Energy. “Funding for Britain’s ports will also speed up the development of offshore wind and create growth for coastal communities,” he said.

Greg Jackson, the chief executive and founder of Octopus Energy, pointed to long-duration energy storage as another example of currently underfunded emerging technologies where GB Energy could “unlock private capital through co-investment”.

Ahead of the budget, investors are less concerned about the amount of public sector funding available than about gaining clarity around the government’s plans, and the policies and regulations which will underpin them.

“Whether investment comes from the government or from the private sector – the key thing is policy,” said Jackson.

GBE is also critical for Scotland, for the 200,000 jobs in North Sea oil and gas, which Labour is anxious to reassure voters will still be stable for decades to come. Aberdeen was chosen as headquarters for political reasons: to help offset the complaints from North Sea oil and gas companies about the Treasury’s decision to increase windfall taxes, partly to fund GB Energy, and Miliband’s determination to block new oil exploration licences – complaints the Scottish Conservatives and Scottish National party have amplified.

The UK government also faces a further stiff test next summer, when 400 oil industry jobs will be lost with the closure of Scotland’s only oil refinery at Grangemouth, with over 2,000 more in the supply chain threatened.

That is intensifying pressure on the Treasury to properly fund projects on the so-called just transition, where unemployed oil workers are helped to find new jobs in the green economy, including new college courses or a government-funded “skills passport” where oil workers can transfer their oil industry skills to renewables.

Senior Labour sources in Scotland said they wanted to see progress on cutting household electricity bills and new rules to ensure communities that host these new green energy projects, including the new pylons and subsea cables needed, get a share of the profits.

Michael Shanks, a Scottish MP who became a junior energy minister in July, told UK Labour conference in Liverpool last month that “quite significantly” improving these community benefit schemes was a priority – including giving them a direct stake in GB Energy projects.

“We want to look at how communities can be in the driving seat of some of that. So instead of developers deciding what that looks like, it should be compulsory, but also a community has some stake in designing it. And that goes for network infrastructure as well, not just the generation,” he said.

A senior Labour figure said there were early indications the Treasury would authorise spending on enlarging Scotland’s coastal ports, which are ill-prepared for the huge wind turbines and installation vessels needed for the vast new offshore windfarms being planned.

The Scottish Trades Union Congress has told Labour ministers GB Energy needs to focus a significant proportion of its investment in Scotland, because a disproportionate number of North Sea jobs are there.

Roz Foyer, the STUC’s general secretary, said 84,000 Scottish workers depended on oil and gas jobs, while the numbers employed in renewables, estimated at 6,000 people, had barely risen in Scotland over the past decade despite the heavy investment in windfarms. “The investment in GB Energy has to go disproportionately to Scotland because of the disproportionate amount of oil and gas jobs that are going to be lost,” she said.

Decarbonising UK electricity by 2030 will be a stretching target – even if new renewables are built swiftly and grid connection problems resolved, a small amount of gas-fired power is still likely to be needed. But experts told the Guardian that even if the target was missed, the effort should put the UK on track to meet net zero and help dispense with volatile fossil fuels. Shaun Spiers, the executive director of the Green Alliance, said: “Lots of questions remain, but the government has hit the ground running in setting up GB Energy to speed the transition to clean power, and that should be strongly welcomed.”

Liam Payne died of multiple traumas and internal and external bleeding caused by a fall from a third-floor hotel balcony in Buenos Aires, the Argentinian prosecutor’s office has said. An autopsy showed that the pop star’s head injuries were sufficient to cause death.

An ongoing investigation – including the interview of five witnesses in an attempt to reconstruct the 31-year-old musician’s final hours – indicated that he was alone at the time of the fall. Substances were seized from Payne’s hotel room indicating alcohol and drug consumption.

The former member of One Direction died on Wednesday at 5pm local time. Guests at the Casa Sur hotel told the Guardian that they heard banging and shouting for hours before Payne fell.

“I thought they were doing construction, there was so much banging, doors slamming, most of the day. It was loud, bizarre,” said Doug Jones. “Later I heard the sirens, thinking perhaps there was a fire somewhere. And then I heard a very loud scream.”

A hotel receptionist called emergency services to notify police of an “aggressive man who could be under the effects of drugs and alcohol”, according to Reuters. The hotel manager said he heard a loud noise at the back of the hotel, and when police arrived they found that a man had fallen over the balcony in his room.

Photos purporting to show Payne’s room in disarray, published in local news and online, were believed to have been taken by hotel employees, sparking a backlash about journalistic ethics.

Payne’s family said in a statement that they were “heartbroken” by his death. “Liam will forever live in our hearts and we’ll remember him for his kind, funny and brave soul. We are supporting each other the best we can as a family and ask for privacy and space at this awful time.”

One Direction were formed on The X Factor in 2010. Host Dermot O’Leary paid tribute to Payne, describing him as “a joy” who “had time for everyone, [was] polite, grateful, and was always humble”.

Ronnie Wood – who performed with the band when they returned to guest on the show in 2014 – said it had been “a pleasure to work with him”, while pop star Charlie Puth, who co-wrote Payne’s 2017 solo song Bedroom Floor, called him a “major artist”.

Payne’s former One Direction bandmates Harry Styles, Louis Tomlinson, Zayn Malik and Niall Horan are yet to comment on his death. Cheryl Tweedy, with whom Payne had a son, Bear, in 2017, has also not commented.

Rebecca Ferguson, who was runner-up in the seventh series of X Factor, in which One Direction placed third, and has been outspoken about abuse within the music industry, recalled meeting Payne in a taxi from Euston station to the show.

“I can’t help but think of that boy who was hopeful and looking forward to his bright future ahead,” she tweeted.

“I’ve spoken for years about the exploitation and profiteering of young stars and the effects – many of us are still living with the aftermath and the PTSD. Many of us are devastated and reflective today as it has finally taken its first victim.”

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.”