Conceptual Model of State Collapse

by Denis Rancourt / January 13th, 2026

Summary

A minimalist conceptual model of the state is presented in which the fundamental basis of state existence and continuity is the flux of produced resources between producers and the needed state apparatus, while contending with powerful domestic non-state actors and foreign challenges. External conditions that reduce per capita production threaten state continuity, and the state attempts to survive by responding. Every decision either destabilizes the state and creates vulnerabilities or stabilizes the state on a road to recovery. The model provides a general framework for making and evaluating state decisions. It also provides predictions for circumstances that lead to state failure. I conclude that long-term state survival is possible, while describing the structural and dynamic challenges that must constantly be overcome.

Basic conceptual model of the state

The state is a living hierarchical structure that manages itself and controls and extracts cooperation and resources from its subjects and from its environment. It can be healthy or sick, and heal or die. The said structure includes the subjects who produce and state agents who are leaders, administrators, lieutenants, soldiers, teachers, analysts, and so on.

A given state is typically robust enough to thrive for several generations. Typical modern period life expectancy at birth of a new state is one or more centuries before being incapacitated by chronic systemic liabilities (Fischer, 1996; Goldstone, 1991; Turchin, 2003).

The state apparatus (or “state” for short, depending on the context) derives its resources from surplus productive work of subjects (“taxation”) and via pillaging operations abroad. In other words, the energy that feeds the state apparatus (i.e., the agents, equipment and infrastructure composing its structural and leadership or managerial hierarchy) is the labour and extracted physical resources provided by its subjects and provided by its targets and holdings abroad.

The state thrives as long as the influx of labour and physical resources is greater or equal to the resources expended to maintain all of its parts. That is, the resources needed to feed and maintain all of its agents (administrators, lieutenants, soldiers, teachers, analysts, and so on), and to maintain its equipment and infrastructure.

Note that I am purposefully avoiding the language of money and loans. This is because all that matters in reality is the flow of resources. Money instruments for coercion and bribes, and that represent promises to pay back, are irrelevant in themselves. The state is able to balance the fluxes of resources or it is not. It continues to thrive and grow or it degrades and fails, irrespective of the paper concepts of “debt” and “savings”. From the state view, its “savings” are temporarily unused resources whereas interest payments on “debt” owed by the state represent sinks of resources, lost for fear of lender repercussions.

We must add that powerful non-state actors coexist with the state and compete to influence or control the state to their advantage while building and maintaining systems of parallel resource extraction. These are the elite, bankers, industrialists, landlords, organized criminals, and so on, who can eventually form coalitions and overthrow the state, or capture the state and manage it while retaining its organizational structure and facade.

As long as the state survives with its rulers in place, it will constantly address non-state actor challenges, in the same way that an organism, to the best of its ability, defends against aggressive parasites. In practice, the state will make many accommodations and reciprocal agreements with powerful non-state actors, rather than expend too much energy combating these persistent forces. In this way, the state will integrate many non-state actors into its hierarchical structure, thus keeping and securing control.

Regarding continued state stability, the state apparatus (agents), the subjects and the integrated non-state actors are embedded in a changing world. One gauge of changing overall conditions is population growth or decline, which in turn depends on many factors, including environmental capacity to provide resources and violent aggression (both intra-societal oppression and war campaigns). Population growth rate is associated with fetal, neonatal and infant mortality rates, and recently in many countries population growth rate is associated with fertility control and abortion rates. Individually experienced biological stress (Selye, 1956) undoubtedly plays a major role in fertility, as do societal norms.

However, contrary to suggestions by several authors, population growth or decline by itself does not destabilize the state. This can be demonstrated as follows.

From a theoretical perspective, let us say under constant division of labour and age structure conditions, if population grows at the same rate across social classes while each subject maintains its per capita capacity to generate resources, then there is no problem. The state simply grows accordingly and the balance of flows of resources (producers to state apparatus) per capita is maintained without friction. Likewise, if population decreases (at the same rate across social classes) while other conditions do not change, then the state only needs to downsize accordingly and the balance of flows of resources per capita is again maintained. Even population-growth-driven increased geographical distance between producer subjects and consuming state agents does not create significant transportation or distribution losses because the state apparatus can be optimally dispersed near production regions.

This is just to say that the total population quantum in itself does not affect or determine state stability.

What then can irreversibly destabilize the state?

A balanced flux of resources is the first consideration irrespective of size. Here is a general scenario under select constant conditions.

State stabilization under conditions of constant trade, technology, structure and population

For simplicity, we first keep as constant:

1. the state’s ability to extract foreign resources (e.g., no wars),
2. foreign trade,
3. technology and resource-production practices,
4. the state’s hierarchical (social) structure, and
5. the population.

In this thought experiment, we then postulate that the capacity of subjects to generate resources diminishes because of external factors not controlled by the state.

Such external factors might include:

• diminishing soil fertility
• diminishing crop yields (environmental or ecological)
• diminishing individual health (biological, evolutionary or epidemiological)
• diminishing personal ability or motivation for productive work
• increasing scarcity and cost of extraction of resources from wells, rivers, mines, forests, wildlife…

We can imagine that these factors would be caused by external circumstances such as:

• unchanging ill-conceived agricultural practices
• extended drought conditions
• solar radiative output variations
• solar constant (perpendicular solar irradiation onto the atmosphere) variations
• variations in large-scale cloud dynamics (e.g., from geomagnetic changes)
• over-exploitation without exploration or regeneration
• volcanic eruptions of toxic substances (e.g., mercury) and dimming aerosols
• invasive spread of insects or other species, including parasites and disease-carrying animals
• development of allergic intolerance and nutritional deficiencies
• inadequate waste disposal and management
• external societal influences (including propaganda, inter-state exchanges, world religions) that affect the population age structure, work ethics, morale, nuclear family structure and dynamics, religious preoccupations…

  and so on.

Note that the latter category “external societal influences” is not strictly external since it is societal. It will typically be a convolution between worldwide or multi-state changes and domestic contribution and response. Todd (2024) has explained the transformational impact of such a change on the Western world, leading to a dramatic reduction in the ability of the Western world states (vassal or not) to produce both competent agents and highly trained subjects.

If we relax the condition of keeping foreign trade constant, then another mechanism that in-effect diminishes the capacity of subjects to generate resources is for a trade deficit to result from external trading partners demanding an increased exchange advantage, which is equivalent to a state currency devaluation in economic terms. This occurs via trade intimidation or when the state’s resources produced for export become less desirable to the outside.

Overall, from all such factors, the consequences to state viability are potentially serious. The postulated reduced capacity of subjects to generate resources implies that less taxes can be leveraged from the subjects. As a result, if nothing else changes, then the flux of resources to maintain the state apparatus becomes insufficient.

The state can respond in any combination of various ways, including the following.

1. The state can increase the taxation rate, meaning that it deprives the subjects of their usual personal resources in order to extract the needed quantum of resources to feed the state apparatus. With this policy, the subjects bear the cost of the externally imposed drop in resource production. This can heighten the resistance against taxation and diminish the subjects’ fitness to produce.
2. The state can decrease resource delivery (aka salary) to its agents and expect them to continue performing the same tasks. With this policy, the state’s agents bear the cost of the externally imposed drop in resource production. This can increase internal opposition to the state hierarchy, thereby reducing service quality and dedication, and it can also reduce the agents’ fitness to perform their duties. This also thereby makes the state less able both to enforce taxation and address the constant non-state actor challenges.
3. The state can increase demands (taxation) on the powerful non-state actors that coexist within the state (the said elite, bankers, industrialists, landlords, organized criminals, and so on). This has at least two effects: It produces destabilizing tensions within the systems of resource extraction controlled by the non-state actors; and it increases non-state actor opposition to the state. This in turn creates conditions for increased competition between non-state actors, likely leading to aggressive takeovers and larger and more powerful non-state actors. (E.g., smaller players with less defences may be regulated and taxed out of existence.)
4. Taking the latter point further, the state can capture the holdings of powerful non-state actors (so-called nationalization) and dismantle non-state structures. This can provide a temporary influx of resources but it does not on its own solve the fundamental problem of resource flux imbalance caused by the externally imposed reduced capacity of subjects to generate resources.
5. The state can sell off or lease its holdings (infrastructure, land, water, intellectual property, and so on) to non-state actors in exchange for resources. This, again, on its own does not solve the fundamental problem of resource flux imbalance caused by the externally imposed reduced capacity of subjects to generate resources. It only delays the inevitable. (Unless, of course, the new influx of resources is successfully used to make game-changing structural changes, such as technological developments or war, which are explored below.) Note that this sell off of holdings is distinct from so-called “privatization”, which is usually an outright giveaway ―under non-state actor pressure and manipulation―having the effect of expending state holdings and resources to contract out the depriving of subjects (point “1”) and of state agents (point “2”) of their usual resources.

The above picture, so far, under the given assumptions of constant conditions (above points “a” through “e”), means that the externally imposed reduction in capacity of subjects to generate resources, if the said reduction is too large and too prolonged, will lead to a breakdown or dissolution of the state.

As long as the external hardship conditions persist, the positive feedback reactions contained in the presented state responses (above points “1” through “5”) are such that the state system will experience a non-linear (accelerating) spiralling down into destruction, and only the accelerating rate of this downfall can be mitigated by state reactions.

State stabilization with unconstrained trade, technology, structure and population

Longer state lifetimes can be achieved, for example, in the following creative and adaptive ways, allowed by relaxing the above-postulated constant-condition constraints (points “a” through “e”).

One oft illustrated approach in history is for the state to raise an army and practice war, slavery and imperialism. If successful, this creates a larger state, an empire. However, the law of balancing fluxes of resources from subjects to the state apparatus (which now includes a maintained occupying army) remains the same, and such an empire can spiral down towards oblivion under a strong and growing pressure of reduced capacity of subjects to generate resources. An empire will generally have a longer lifetime than a small state, but the same law of balanced resource flux applies.

In this version of our hypothetical world which allows inter-state competition, wars and empire building, each state now has a defence burden as part of its apparatus, not only police and soldiers for domestic order.

In addition, having relaxed condition “d” (above) of a constant or unchanging social structure, the state’s administrative apparatus of service agents itself will be driven to grow larger in size and more demanding of resources through careerism and social-class greed, which must also be countered by the state.

Another approach to solving the deficient resource flux problem is for states to practice pillaging, which is the iconic resource supplementation strategy of the Vikings. Similarly, a large state can use protection-racket coercion, a popular method of the USA empire practised against its so-called allies through arms sales, military bases, corporate not-so-free trade and control of the world currency (Rancourt, 2019).

The now relaxed hypothetical rules (of our thought experiment) also allow improving technology and resource-production practices (point “c” above). Our hypothetical state therefore now has many new inventive ways to solve or alleviate its deficient resource flux problem (of externally imposed diminished capacity of subjects to generate resources).

The state, its subjects, and its agents can, under the newly considered relaxed constraints, respond in any combination, for example, of the following:

1. develop improved and sustainable agricultural practices giving higher yields in both food quantity and quality (such as optimized livestock and crop rotations, improved water management methods, imported crop varieties, improved pest management methods, improved pollination strategies, and so on)
2. increase, adjust or redistribute resource allowances to subjects in order to make them more productive (this is partly achieved through taxation policy and is akin to reducing poverty and unemployment, while improving living conditions and increasing individual fitness)
3. develop improved state-run education and religious practices that increase national (state) identity and allegiance, while responding to worldwide changes in values
4. develop improved intelligence systems for rooting out and discouraging subversion and corruption (thus keeping non-state actor ambitions and out-of-state infiltration more efficiently in check)
5. adopt or adapt social and work-environment structures that strengthen state subject and state agent dedication and efficiency (such as highly stratified hierarchies with merit-based assignations) (Note that the Qing Dynasty (1644-1912) in China, for example, had a robust merit-based hierarchy for its elite educated state public service agents, see Turchin, 2023.)
6. develop improved and novel state management practices to continuously optimize the mosaic of production specialization and agent duty specialization, adjusting compartment populations as needed, in ways that do not create destabilizing tensions
7. develop improved education or mentorship structures and incentives to transmit and develop technical skills and practices
8. develop improved energy use technology in both mechanization and transportation
9. develop improved and sustainable mining and energy extraction and refinement technologies
10. develop improved land use practices, including specialization based on regional climate and ecological conditions
11. develop improved waste management strategies and sanitation practices

and so on.

In all of this, the state must have breadth and depth in its own increasing and institutionalized knowledge of state management principles and response strategies and tactics. This knowledge base must be state-owned and independent. It should not rely on or be corrupted by non-state actors or foreign influence.

In this way, creative and coordinated state responses to external factors that would diminish the capacity of subjects to generate resources can ensure that the law of balanced resource flux (from subjects to the state apparatus) is dynamically maintained. Surpluses can be used to reduce poverty and increase employment in socially rewarding work, for both subjects and agents, thus strengthening the state and reducing internal frustration against the state.

As long as the state project is alive in the minds and hearts of subjects and agents, then such creative state responses to external factors that would diminish the capacity of subjects to generate resources can continue without state collapse except for the most extreme external shocks.

Regarding keeping the state project alive in minds and hearts, at the psychological level the individual is expected to largely take their identity from their place in the state-structured and maintained social hierarchy. The state is aided by a large biological impetus to belong, as is the case with all social animals, such that early and continued state education and institutions (including state religions) that promote state ideology do well in this regard. With vassal jurisdictions (states in facade only) the empire may provide globalized generic ideologies (Rancourt, 2019). Individuals (especially males) also have a natural impetus to rebel and to seek more power if promotion within the established hierarchy is not forthcoming or sufficient, especially among the elite social classes (Turchin, 2023). This biological impetus drives the growth and multiplication of non-state actors, if it is not accommodated by the state.

In all of this, population need not increase or decrease, although an increased and integrated population in-effect increases the size and power of the state in the world. Likewise, loss of population can so diminish the state’s effective size as to make it more vulnerable to external pressures and threats. Furthermore, an artificial or accelerated increase in state population, if not integrated, can cause an impetus for war, both civil and predatory.

Presently, it seems superficially that large societies that have long historic traditions of intended merit-based state management hierarchical structures (Russia, China) and experience with long-lived recent empires (Tsarist Russia, 1547-1917; Qing Dynasty, 1644-1912) are able to apply the above responses well, whereas states that have more colonizing traditions (Western world) tend to stick with the colonizing model, using both military projection and financial predation.

Can the state survive?

Finally, regarding the cycles of state breakdown that are observed historically from the late-Middle Ages through the early modern period (Fischer, 1996; Goldstone, 1991), it appears that these collapses were due to state failures to cope, in the presence of large intra-state and inter-state pressures, in which competing non-state actors played major roles. There are two main striking features of these cycles, in the particular (mostly European and northern Asian) states studied by Fischer (1996) and Goldstone (1991).

First, state stability periods did not last much more than approximately 100 years (3 generations), up to approximately 200 years; again, for these particular states studied by Fischer (1996) and Goldstone (1991). It seems one century or so was long enough for threatening non-state forces to generate and cause severing changes, while exploiting external conditions such as trade conflicts and war. Elite greed and ambition was certainly a driver, and relative inflation of cost of basic commodities was always a factor (Fischer, 1996; Goldstone, 1991; Turchin, 2023).

These events suggest that the state, like the body of a living animal, has a finite and species-specific lifetime. Once enough damage is accumulated in the process of living, then a non-linear final failure (death) precipitously occurs. Has modern technology and civilizational management experience made a new species of state having a super immune system? It is doubtful. However, as argued above, unlike with the body of a living animal, state longevity is not limited by biological laws, only by unchecked internal rot, conquest or external catastrophic shock.

From another perspective, the state is a social dominance hierarchy and all social dominance hierarchies are subject to a dynamical law of spontaneous creep away from merit-based stratification towards competing mega-players and a totalitarian end point (Hickey and Davidsen, 2019). The loss of merit-based social stratification is the death of a state. The theoretically predicted death by dominance dynamics is postponed by optimal choices of the rules of social-status competition (Hickey and Davidsen, 2019), which the state can control.

Overall, statecraft is the most challenging human endeavour. Long-lived states and empires are possible, where longevity depends more on autonomous internal management than on external factors. Every legislative, legal and policy decision of the state either stabilizes or destabilizes, in the changing environment of external factors.

Second, state stability (and instability) periods were essentially synchronous across continental-scale geographic space. This led Goldstone (1991) to conclude that there must be an overarching common external factor driving all state instabilities: Population growth pressure on natural resources. I disagree. The approximate said synchrony of state stability and state meltdown can be induced by several strong coupling forces that include:

• • • • inter-state trade
      • inter-state technology transfer (including agricultural practices)
      • war and territorial disputes
      • climatic change (e.g., Little Ice Age conditions, 1300-1850)
      • large volcanic eruptions

These coupling forces draw the states into a single dominance hierarchy which will then follow its own whole-system dynamics. Simply put, the states have synchronized cycles because they are integrated parts of one world.

This does not mean that an individual state is not self-determined. Only that its downfall is coupled to the downfalls of other states. Strong states follow their own paths. Failing states fail together.

Acknowledgement. I thank my colleague Dr. Joseph Hickey for a critical review of the paper and several suggestions regarding content and clarity.

References

Fischer (1996): David Hackett Fischer, The Great Wave: Price Revolutions and the Rhythm of History Oxford University Press, p. 536, ISBN 0-19-512121-X (Pbk.)

Goldstone (1991): Goldstone, Jack A., Revolution and Rebellion in the Early Modern World, University of California Press, p. 608, ISBN 0-520-08267-2

Hickey and Davidsen (2019): Hickey J, Davidsen J, “Self-organization and time-stability of social hierarchies.” PLoS ONE 2019, 14(1): e0211403. https://doi.org/10.1371/journal.pone.0211403

Rancourt (2019): Rancourt, Denis G., Geo-Economics and Geo-Politics Drive Successive Eras of Predatory Globalization and Social Engineering – Historical Emergence of Climate Change, Gender Equity, and Anti-Racism as State Doctrines /// (April 02, 2019) /// Available at SSRN: https://ssrn.com/abstract=5403798 or http://dx.doi.org/10.2139/ssrn.5403798

Selye (1956): Hans Selye, The Stress of Life, McGraw-Hill, p. 515, ISBN 0-07-056212-1

Todd (2024): Emmanuel Todd, La Défaite de l’Occident, Gallimard Publ., p. 384, ISBN 978-2073041135

Turchin (2003): Peter Turchin, Historical Dynamics: Why States Rise and Fall, Princeton University Press, p. 245, ISBN 978-0-691-18077-9

Turchin (2023): Peter Turchin, End Times: Elites, Counter-Elites, and the Path of Political Disintegration, Penguin Press, NY, p. 352, ISBN 9780593490501 (hardcover)

Denis G. Rancourt was a former tenured full professor of physics at the University of Ottawa, Canada. He is a researcher for the Ontario Civil Liberties Association. He has published more than 100 articles in leading scientific journals, on physics and environmental science. He is the author of the book Hierarchy and Free Expression in the Fight Against Racism. Denis can be reached at denis.rancourt@gmail.com. Read other articles by Denis, or visit Denis's website.

Marxists.orgwww.marxists.org/reference/archive/kropotkin-peter/1896/state/index.htm

The State: Its Historic Role - Marxists Internet Archive

Kropotkin explains in the French edition of his Memoirs “The research that I carried out in the course of familiarizing myself with the institutions of the ...

RACIST MISOGYNY

Pregnant mom dies as red state docs fear abortion — and leave heart crisis untreated

Lizzie Presser, PropublicaKavitha Surana, ProPublica
January 14, 2026

RAW STORY
Ciji Graham and her son, SJ Courtesy of the Graham family

When Ciji Graham visited a cardiologist on Nov. 14, 2023, her heart was pounding at 192 beats per minute, a rate healthy people her age usually reach during the peak of a sprint. She was having another episode of atrial fibrillation, a rapid, irregular heartbeat. The 34-year-old Greensboro, North Carolina, police officer was at risk of a stroke or heart failure.

In the past, doctors had always been able to shock Graham’s heart back into rhythm with a procedure called a cardioversion. But this time, the treatment was just out of reach. After a pregnancy test came back positive, the cardiologist didn’t offer to shock her. Graham texted her friend from the appointment: “Said she can’t cardiovert being pregnant.”

The doctor told Graham to consult three other specialists and her primary care provider before returning in a week, according to medical records. Then she sent Graham home as her heart kept hammering.

Like hundreds of thousands of women each year who enter pregnancy with chronic conditions, Graham was left to navigate care in a country where medical options have significantly narrowed.

As ProPublica has reported, doctors in states that ban abortion have repeatedly denied standard care to high-risk pregnant patients. The expert consensus is that cardioversion is safe during pregnancy, and ProPublica spoke with more than a dozen specialists who said they would have immediately admitted Graham to a hospital to get her heart rhythm under control. They found fault, too, with a second cardiologist she saw the following day, who did not perform an electrocardiogram and also sent her home. Although Graham’s family gave the doctors permission to speak with ProPublica, neither replied to ProPublica’s questions.

Graham came to believe that the best way to protect her health was to end her unexpected pregnancy. But because of new abortion restrictions in North Carolina and nearby states, finding a doctor who could quickly perform a procedure would prove difficult. Many physicians and hospitals now hesitate to discuss abortion, even when women ask about it. And abortion clinics are not set up to treat certain medically complicated cases. As a result, sick pregnant women like Graham are often on their own.

“I can’t feel like this for 9mo,” Graham wrote her friend. “I just can’t.”

She wouldn’t. In a region that had legislated its commitment to life, she would spend her final days struggling to find anyone to save hers.

Graham hated feeling out of breath; her life demanded all her energy. Widely admired for her skills behind the wheel, she was often called upon to train fellow officers at the Greensboro Police Department. At home, she needed to chase her 2-year-old son, SJ, around the apartment. She was a natural with kids — she’d helped her single mom raise her nine younger siblings.

She thought her surprise pregnancy had caused the atrial fibrillation, also called A-fib. In addition to heart disease, she had a thyroid disorder; pregnancy could send the gland into overdrive, prompting dangerous heart rhythms.

When Graham saw the first cardiologist, Dr. Sabina Custovic, the 192 heart rate recorded on an EKG should have been a clear cause for alarm. “I can’t think of any situation where I would feel comfortable sending anyone home with a heart rate of 192,” said Dr. Jenna Skowronski, a cardiologist at the University of North Carolina. A dozen cardiologists and maternal-fetal medicine specialists who reviewed Graham’s case for ProPublica agreed. The risk of death was low, but the fact that she was also reporting symptoms — severe palpitations, trouble breathing — meant the health dangers were significant.

All the experts said they would have tried to treat Graham with IV medication in the hospital and, if that failed, an electrical shock. Cardioversion wouldn’t necessarily be simple — likely requiring an invasive ultrasound to check for blood clots beforehand — but it was crucial to slow down her heart. A leading global organization for arrhythmia professionals, the Heart Rhythm Society, has issued clear guidance that “cardioversion is safe and effective in pregnancy.”

Even if the procedure posed a small risk to the pregnancy, the risk of not treating Graham was far greater, said Rhode Island cardiologist Dr. Daniel Levine: “No mother, no baby.”

Custovic did not answer ProPublica’s questions about why the pregnancy made her hold off on the treatment or whether abortion restrictions affect her decision-making.

The next day — as her heart continued to thump — Graham saw a second cardiologist, Dr. Will Camnitz, at Cone Health, one of the region’s largest health care systems.

According to medical records, Graham’s pulse registered as normal when taken at Camnitz’s office, as it had at her appointment the previous day. Camnitz noted that the EKG from the day before showed she was in A-fib and prescribed a blood thinner to prepare for a cardioversion in three weeks — if by then she hadn’t returned to a regular heart rhythm on her own.

Some of the experts who reviewed Graham’s care said that this was a reasonable plan if her pulse was, indeed, normal. But Camnitz, who specializes in the electrical activity of the heart, did not order another EKG to confirm that her heart rate had come down from 192, according to medical records. “He’s an electrophysiologist and he didn’t do that, which is insane,” said Dr. Kayle Shapero, a cardio-obstetrics specialist at Brown University. According to experts, a pulse measurement can underestimate the true heart rate of a patient in A-fib. Every cardiologist who reviewed Graham’s care for ProPublica said that a repeat EKG would be best practice. If Graham’s rate was still as high as it was the previous day, her heart could eventually stop delivering enough blood to major organs. Camnitz did not answer ProPublica’s questions about why he didn’t administer this test.

Three weeks was a long time to wait with a heart that Graham kept saying was practically leaping out of her chest.

Camnitz knew about Graham’s pregnancy but did not discuss whether she wanted to continue it or advise her on her options, according to medical records. That same day, though, Graham reached out to A Woman’s Choice, the sole abortion clinic in Greensboro.

North Carolina bans abortion after 12 weeks; Graham was only about six weeks pregnant. Still, there was a long line ahead of her. Women were flooding the state from Tennessee, Georgia and South Carolina, where new abortion bans were even stricter. On top of that, a recent change in North Carolina law required an in-person consent visit three days before a termination. The same number of patients were now filling twice as many appointment slots.

Graham would need to wait nearly two weeks for an abortion.

It’s unclear if she explained her symptoms to the clinic; A Woman’s Choice spokesperson said it routinely discards appointment forms and no longer had a copy of Graham’s. But the spokesperson told ProPublica that a procedure at the clinic would not have been right for Graham; because of her high heart rate, she would have needed a hospital with more resources.

Dr. Jessica Tarleton, an abortion provider who spent the past few years working in the Carolinas, said she frequently encountered pregnant women with chronic conditions who faced this kind of catch-22: Their risks were too high to be treated in a clinic, and it would be safest to get care at a hospital, but it could be very hard to find one willing to terminate a pregnancy.

In states where abortions have been criminalized, many hospitals have shied away from sharing information about their policies on abortion. Cone Health, where Graham typically went for care, would not tell ProPublica whether its doctors perform abortions and under what circumstances; it said, “Cone Health provides personalized and individualized care to each patient based on their medical needs while complying with state and federal laws.”

Graham never learned that she would need an abortion at a hospital rather than a clinic. Physicians at Duke University and the University of North Carolina, the premier academic medical centers in the state, said that she would have been able to get one at their hospitals — but that would have required a doctor to connect her or for Graham to have somehow known to show up.


Had Graham lived in another country, she may not have faced this maze alone.

In the United Kingdom, for example, a doctor trained in caring for pregnant women with risky medical conditions would have been assigned to oversee all of Graham’s care, ensuring it was appropriate, said Dr. Marian Knight, who leads the U.K.’s maternal mortality review program. Hospitals in the U.K. also must abide by standardized national protocols or face regulatory consequences. Researchers point to these factors, as well as a national review system, as key to the country’s success in lowering its rate of maternal death. The maternal mortality rate in the U.S. is more than double that of the U.K. and last on the list of wealthy countries.

Graham’s friend Shameka Jackson could tell that something was wrong. Graham didn’t seem like her usual “perky and silly” self, Jackson said. On the phone, she sounded weak, her voice barely louder than a whisper.


When Jackson offered to come over, Graham said it would be a waste of time. “There’s nothing you can do but sit with me,” Jackson said she replied. “The doctors ain’t doing nothing.”

Graham no longer cooked or played with her son after work, said her boyfriend, Shawn Scott. She stopped hoisting SJ up to let him dunk on the hoop on the closet door. Now, she headed straight for the couch and barely spoke, except to say that no one would shock her heart.

“I hate feeling like this,” she texted Jackson. “Ain’t slept, chest hurts.”

“All I can do is wait until the 28th,” Graham said, the date of her scheduled abortion.

On the morning of Nov. 19, Scott awoke to a rap on the front door of the apartment he and Graham shared. He’d been asleep on the couch after a night out with friends and thought that Graham had left for work.

A police officer introduced himself and explained that Graham hadn’t shown up and wasn’t answering her phone. He knew she hadn’t been feeling well and wanted to check in.

Most mornings, Graham was up around 5 a.m. to prepare for the day. With Scott, she would brush SJ’s teeth, braid his hair and dress him in stylish outfits, complete with Jordans or Chelsea boots.

When Scott walked into their bedroom, Graham was face down in bed, her body cold when he touched her. The two men pulled her down to the floor to start CPR, but it was too late. SJ stood in his crib, silently watching as they realized.

The medical examiner would list Graham’s cause of death as “cardiac arrhythmia due to atrial fibrillation in the setting of recent pregnancy.” There was no autopsy, which could have identified the specific complication that led to her death.

High-risk pregnancy specialists and cardiologists who reviewed Graham’s case were taken aback by Custovic’s failure to act urgently. Many said her decisions reminded them of behaviors they’ve seen from other cardiologists when treating pregnant patients; they attribute this kind of hesitation to gaps in education. Although cardiovascular disease is the leading cause of death in pregnant women, a recent survey developed with the American College of Cardiology found that less than 30% of cardiologists reported formal training in managing heart conditions in pregnancy. “A large proportion of the cardiology workforce feels uncomfortable providing care to these patients,” the authors concluded in the Journal of the American Heart Association. The legal threats attached to abortion bans, many doctors have told ProPublica, have made some cardiologists even more conservative.

Custovic did not answer ProPublica’s questions about whether she felt she had adequate training. A spokesperson for Cone Health, where Camnitz works, said, “Cone Health’s treatment for pregnant women with underlying cardiac disease is consistent with accepted standards of care in our region.” Although Graham’s family gave the hospital permission to discuss Graham’s care with ProPublica, the hospital did not comment on specifics.

Three doctors who have served on state maternal mortality review committees, which study the deaths of pregnant women, told ProPublica that Graham’s death was preventable. “There were so many points where they could have intervened,” said Dr. Amelia Huntsberger, a former member of Idaho’s panel.

Graham’s is the seventh case ProPublica has investigated in which a pregnant woman in a state that significantly restricted abortion died after she was unable to access standard care.

The week after she died, Graham’s family held a candlelight ceremony outside of her high school, which drew friends and cops in uniform, and also Greensboro residents whose lives she had touched. One woman approached Graham’s sisters and explained Graham had interrupted her suicide attempt five years earlier and reassured her that her life had value; she had recently texted Graham, “If it wasn’t for you, I wouldn’t be here today, expecting my first child.”

As for Graham’s own son, no one explained to SJ that his mother had died. They didn’t know how to describe death to a toddler. Instead, his dad and grandmother and aunts and uncles told him that his mom had left Earth and gone to the moon. SJ now calls it the “Mommy moon.”

For the past two years, every night before bed, he asks to go outside, even on the coldest winter evenings. He points to the moon in the dark sky and tells his mother that he loves her.

 ABORTION PILL

The Food and Drug Administration’s regulation of mifepristone

JAMA Network

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About The Study: 

This qualitative analysis characterizes the Food and Drug Administration’s (FDA’s) decision-making with respect to the regulation of mifepristone, with a particular interest in the agency’s rationale for establishing, maintaining, or modifying key components of its regulatory approach over time.

Corresponding Author: To contact the corresponding author, G. Caleb Alexander, MD, MS, email galexan9@jhmi.edu.

To access the embargoed study: Visit our For The Media website at this link https://media.jamanetwork.com/

(doi:10.1001/jama.2025.23091)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, conflict of interest and financial disclosures, and funding and support.

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JAMA

The ‘holy war’: How the far right is trying to hijack Christianity

Left Foot Forward

Gabrielle Pickard-Whitehead 

Yesterday

Right-Wing Watch

Does the far right’s capture of a debased Christianity matter in the UK, where religion holds far less sway than in the US? Given America’s superpower status, and the reluctance of global leaders to challenge Trump, it should concern us all.

Whatever happened to “love thy neighbour,” the foundational Christian principle Jesus identified as the second greatest commandment? In the Gospels, loving one’s neighbour, and even one’s enemies, are central to the faith’s moral vision of compassion, mercy and peace.

Yet in Tommy Robinson’s version of Christianity that ethic is turned upside down. This week, the far-right activist, long associated with divisive and anti-immigrant messaging, celebrated the US military’s controversial operation in Venezuela and called on Donald Trump to “free us” by invading the UK and removing prime minister Keir Starmer.

Trump’s raid in Venezuela, which led to the capture and extradition of President Nicolás Maduro, has been widely condemned as illegal and a breach of international law. Robinson’s comments were criticised as contradictory for professing patriotism while inviting foreign military action on British soil.

This is the man who, in 2025, began promoting himself as a Christian, organising “Unite the Kingdom” rallies and Christmas carol services centred on Christian themes.

Yet just as the sincerity of his patriotism has been questioned, so too has the authenticity of his newly professed faith.

Following a far-right rally led by Robinson in London last September, bishops, former Archbishop of Canterbury Rowan Williams, and leaders from the Methodist, Baptist, Evangelical, Salvation Army and Catholic traditions, wrote an open letter, condemning the use of Christian symbols. They said they were “deeply concerned about the co-opting of Christian symbols, particularly the cross,” warning that elements of the march contained “racist, anti-Muslim and far-right” themes.

“As Christians from different theological and political backgrounds we stand together against the misuse of Christianity,” they wrote.

Billionaire influence

Tommy Robinson isn’t the only figure on the British right to invoke Christianity while promoting views many Christians regard as deeply un-Christian.

Sir Paul Marshall, the billionaire financier and major investor in right-wing media outlets, including GB News, the Spectator and UnHerd, is a prominent Christian philanthropist. He sits on the board of the Church Revitalisation Trust, which describes its mission as contributing to “the evangelisation of the nations, the revitalisation of the Church and the transformation of society.”

Yet Marshall’s public conduct has drawn scrutiny. He has been accused of supporting extremist voices on social media, raising questions about his suitability for media ownership.

The anti-extremism group Hope Not Hate has pointed to posts he has liked or shared on X, accusing him of endorsing “extreme Islamophobic and anti-migrant activists” and holding “deeply disturbing views of modern Britain.”

Among the content were claims that Europe is heading for civil war because “native European populations” are losing patience with “fake refugee invaders,” and that societies cannot remain peaceful once Muslim populations reach a certain size.

The framing of entire communities as existential threats sits uneasily alongside Christian teachings on human dignity, peace and the welcoming of the stranger, raising questions about how faith is being mobilised in contemporary right-wing politics.

‘Republican Jesus’

As so often when examining the actions of the right, the trail leads us to the United States. There, the rise of self-identified Christians who enthusiastically support Donald Trump raises an unavoidable question: how can a movement that proclaims Jesus Christ as its saviour so readily endorse policies that contradict the values he is said to embody?

Consider the sickening news emerging from Minneapolis this week. Renee Good, a mother of three and a US citizen, was gunned down in cold blood, in broad daylight, by agents of Trump’s Immigration and Customs Enforcement (ICE). Reports also indicate that at least two pastors were shoved and exposed to pepper spray while protesting the actions of federal immigration agents in the city.

After reporting that its pastor had been detained by ICE, the Metropolitan Community Church (MCC) denomination condemned the violence. In a statement, it said that “… the violence of shooting a woman sitting in her own car, the detention of a clergy person who is protesting peacefully by a masked and unidentifiable officer, are all outrages against a just and caring society,”“As MCC, we are committed to resisting the structures that oppress people and to standing with those who suffer under the weight of oppressive systems.”

Critics argue that such events expose the rise of a politicised figure sometimes dubbed “Republican Jesus,” a reimagined Christ invoked to oppose social welfare, sanctify nationalism, justify harsh immigration regimes, and celebrate military power.

One such critic is Stephen Mattson, author of The Great Reckoning: Surviving a Christianity That Looks Nothing Like Christ. Writing for Christians for Social Action, Mattson captures the depth of these contradictions:

“There’s a religion whose savior was a refugee, yet it rejects refugees. Whose God embraces sojourners, yet it deports immigrants. Whose parishioners worship someone called the Prince of Peace, yet they defend violence and are pro-war. Whose hero was an ethnic minority, yet they’re complicit in white supremacy… There’s a popular type of “Christianity” that wants nothing to do with Christ other than to use His namesake to promote its own agendas.”

This is not merely hypocrisy but theological inversion. That inversion was on display this week as Trump hailed the seizure of Nicolás Maduro as “brilliant,” despite reports that dozens of Venezuelan and Cuban security personnel were killed during the operation.

The question is, who is funding right-wing Christian messaging?

Trump’s Christian ‘legal army’

Two US organisations closely linked to Donald Trump have played a major role in funding and exporting Christian nationalist ideology and conservative culture-war activism, the Alliance Defending Freedom (ADF) and the American Centre for Law and Justice (ACLJ). Both use strategic litigation to oppose LGBTQ+ rights and abortion access.

ADF was co-founded by US Christian right leader Alan Sears, who co-authored a book attacking “the homosexual agenda.” The ACLJ was founded in 1990 by televangelist Pat Robertson to counter the American Civil Liberties Union.

An openDemocracy investigation found that between 2008 and 2019 the two groups spent over $20 million in Europe, signalling a concerted effort to export US Christian nationalist priorities.

Britain, in particular, appears to be viewed as fertile ground.

Since 2020, ADF has more than doubled its UK spending and quadrupled its British team. After helping engineer the overturning of Roe v. Wade and repeatedly challenging LGBTQ+ rights in the US, ADF is now deploying the same legal tactics in Britain, including backing Christians prosecuted for breaching abortion clinic buffer zones.

Vladimir Putin and the ‘holy war’

If Trump exemplifies “Republican Jesus,” Vladimir Putin offers a parallel model. In 2014, Putin appeared on the cover of Decision, an American evangelical magazine, with a cover story written by conservative pastor Franklin Graham, who praised Putin’s signing legislation restricting LGBTQ+ expression. The issue was published just as Russian troops were moving into Crimea.

Interestingly, the ACLJ operates an affiliated office in Moscow, the Slavic Center for Law and Justice, which also praised Vladimir Putin’s laws banning so-called “gay propaganda,”

Graham visited Russia in 2015, and ever since, has promoted Putin as a godly leader. Days before Russia’s invasion of Ukraine, he urged people to ‘pray for Putin,’ but not for Ukrainians, prompting backlash

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Patriarch Kirill, bishop of the Russian Orthodox Church and long-time Putin ally, has framed Russia’s expansion into Ukraine as a sacred struggle, suggesting that soldiers who die in combat have their sins forgiven.

As with Trump, and figures like Tommy Robinson, Putin’s public identification as a defender of Christian values and his close relationship with the Russian Orthodox Church, has prompted scepticism about the sincerity of his faith.
Christian theologians and clergy worldwide have condemned this rhetoric, with Orthodox clerics accusing Putin and Patriarch Kirill of using “Russian world” ideology as the principal theological justification for a war of aggression.

In 2023, Alexei Gorinov, a Moscow councillor imprisoned for opposing the war, wrote to Kirill asking how the teachings of Jesus could possibly justify the killing of Ukrainians in the name of “Christian values.”

Is there hope?

So does the far right’s capture of a debased Christianity matter in the UK, where religion holds far less sway than in the US? Given America’s superpower status, and the reluctance of global leaders to challenge Trump, it should concern us all.

Yet a counterweight may also come from the US. By continuing papal warnings on climate change, expressing solidarity with the world’s poorest, and renewing calls for peace, Pope Leo, the first American pope, has made clear he is no ally of Trump. In early December, he warned that the US was preparing a military attack on Venezuela. Last weekend, he again stressed the importance of human rights, national sovereignty and justice.

As theology writer Catherine Pepinster, observed this week: “Calling out Donald Trump on the legality and morality of a US military incursion will take courage. The signs so far are encouraging – but the moment has come for Leo’s voice to be louder, stronger and angrier.”

Leo, says Pepinster, “could be their most important ally – without an army.”

The neofascist right has had some success in co-opting patriotism and free speech to its perverted cause: so far at least, Christianity seems more resistant.

Gabrielle Pickard-Whitehead is author of Right-Wing Watch

ANTI-ABORTION LAWS KILL

Targeted regulation of abortion providers laws and pregnancies conceived through fertility treatment

JAMA Health Forum

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About The Study: 

The findings of this study suggest an increase in maternal morbidity among patients using fertility care in states that passed targeted regulation of abortion providers (TRAP) laws relative to states that did not.

Corresponding Author: To contact the corresponding author, Samuel J. F. Melville, MD, email melvills@ohsu.edu.

To access the embargoed study: Visit our For The Media website at this link https://media.jamanetwork.com/

(doi:10.1001/jamahealthforum.2025.5920)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, conflict of interest and financial disclosures, and funding and support.

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About JAMA Health Forum: JAMA Health Forum is an international, peer-reviewed, online, open access journal that addresses health policy and strategies affecting medicine, health and health care. The journal publishes original research, evidence-based reports and opinion about national and global health policy; innovative approaches to health care delivery; and health care economics, access, quality, safety, equity and reform. Its distribution will be solely digital and all content will be freely available for anyone to read.

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JAMA Health Forum

States with abortion restrictions have worse outcomes for patients using fertility treatment

Oregon Health & Science University

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Research from Oregon Health & Science University has found that laws restricting access to abortion may disproportionately affect pregnancies conceived through fertility treatment. 

The study, published today in JAMA Health Forum, found that states with targeted regulations of abortion providers, also known as TRAP laws, have worse maternal health outcomes for patients using fertility treatment compared with states that don’t have such laws.

Patients with infertility diagnoses already carry an increased risk of health complications during pregnancy and childbirth, including hemorrhage, gestational diabetes, growth restriction, hysterectomy, preterm birth and stillbirth. The OHSU study aimed to better understand how a lack of access to full-scope reproductive health care in many states creates additional risk for these patients.

“People with highly planned and desired pregnancies may not be who we typically think of when we discuss the impacts of abortion restrictions, but their health and safety are being considerably impacted,” said Molly Kornfield, M.D., assistant professor of obstetrics and gynecology in the OHSU School of Medicine and the study’s lead author. “These data prove what we already know: Abortion restrictions don’t exist in a vacuum — they affect everyone who needs reproductive healthcare.”

In the retrospective, population-based cohort study, researchers analyzed neonatal and maternal health statistics for over 400,000 births conceived through fertility treatments between 2012 and 2021. The results showed a statistically significant increase in serious maternal health complications, including blood transfusion, ICU admission, unplanned hysterectomy and uterine rupture — which can be life-threatening and have the potential to compromise future fertility.

While more research is needed to understand the root causes of these impacts, researchers hypothesize several factors are at play, including widespread fertility clinic closures, an exodus of abortion providers from restrictive states, as well as an ongoing national shortage of OB/GYNs.

The research team says that the impacts of TRAP laws have changed the way they counsel patients and deliver care. For example, they may advise patients to approach travel with more caution during pregnancy, since they won’t receive the same standard of care in all states. This is especially true for individuals who already face barriers and discrimination within the health care system, including people of color, immigrants and LGBTQ+ people.

“We’re lucky to be living and practicing in Oregon, where we’re able to offer evidence-based, full-scope reproductive health care, but sadly this isn’t the case in so many areas,” said Samuel Melville, M.D., resident physician in OHSU’s department of obstetrics and gynecology and the study’s co-author. “If we want to truly support the health of children and families, we need to acknowledge that safe reproduction includes abortion care.”

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Journal

JAMA Health Forum

Article Title

Targeted Regulation of Abortion Providers Laws and Pregnancies Conceived Through Fertility Treatment

Article Publication Date

9-Jan-2026