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Who’s the better narrator for an audiobook: the author of the book or a professional voice actor?

Trick question. The answer is both, and/or, it depends.

Let’s leave nonfiction out of this discussion because I find that just about any personal writing will benefit from the author’s literal voice, whether it’s in memoir-form, personal essay, or reporting in which the author is present. That’s why I begged my publisher to let me narrate my own essay collection, and why, from celebrities to comedians (Alison Leiby’s new one is so good!) to journalists (let Patrick Radden Keefe do whatever he wants!), I tend to enjoy author-narrated performances more.

But fiction is a little thornier. Not all fiction writers are actors and that is more than okay because voice actors exist and many of them are wonderful. In fact, voice actors are very important. In order to buy into such an assertion you must believe, despite what AI companies like to say , that narrating books is an art form and should be treated as such.

More than that, you must believe that human interpretation of a text matters. This is a big reason why fiction matters. It’s not just about the words themselves; it’s about how context and reader experience can change the resonance of those words, and why readers can find different meanings in the same work. The performance of a text by a skilled narrator can tweak those meanings even more.

Dion Graham’s performance of the books in Colson Whitehead’s Harlem Trilogy is one of the all-time great narrator performances, so I’ll use it as a case study. Graham uses subtly different voices with different cadences to portray the series’s wide cast of characters, and taken cumulatively, he evokes a very particular time and place—Harlem in the 1960s, 1970s, and 1980s. Not to mention that Whitehead’s writing is so propulsive that without Graham embodying the characters and occasionally slowing down to pointedly say a particular line, I likely would have read too quickly and missed out on much of the trilogy’s humor.

There is a unique pleasure in hearing a novelist read their work aloud.

But it’s not just Graham. January LaVoy works in a variety of different genres and brings vigor to each one. So do personal favorites like Mara Wilson, Rebecca Lowman, and Julia Whelan, and so many others. I particularly love when a narrator works on enough of an author’s oeuvre that their voices become entangled in a pleasing way. I can’t think of Mona Awad’s dark fantastical novels without hearing Sophie Amoss’s voice , and Roger Clark’s accent work is intimately tied to my understanding of Tana French’s Cal Hooper series.

We can count celebrity narrators here too, with the caveat that your average audiobook narrator lacks the financial stability of your average Hollywood star. But there’s a lot to love: Jeremy Irons narrating Brideshead, Revisited or Marisa Tomei narrating the English translation of Elena Ferrante’s The Lying Life of Adults . A bonus: Did you know that Matt Bomer narrated the 10th anniversary edition of Hanya Yanagihara’s A Little Life ?

But there is a unique pleasure in hearing a novelist read their work aloud, their craft decisions become crystallized. Both lesser known (so far) authors and legends alike have done it well. Recently I’ve loved Mariam Rhamani’s reading of her 2025 debut, Liquid , and Jordy Rosenberg’s bravura interpretation of his latest novel, Night Night Fawn . A special mention for Ann Patchett: she had Meryl Streep narrate Tom Lake , and Tom Hanks did The Dutch House , but Patchett’s own reading of her latest novel, Whistler , is equally exquisite.

My all-time favorite is when an eccentric or singular type of author reads their work and a text you thought you knew makes so much more sense. I’m thinking of Donna Tartt’s reading of The Secret History , her Southern accent emphasizing how out of place her main character is in his New England liberal arts college. The main character’s questionable decisions in Miranda July’s All Fours make way more sense when the author is telling the story. And there is no one other than Bret Easton Ellis who should ever read The Shards : the paranoid ramblings of his narrator make the most sense coming out of his own mouth. I have no idea how the show based on the book will be, but I can say for sure that I was locked in for a 23-hour audiobook.

I also need you to know that Toni Morrison narrated all of her own audiobooks and they are as exceptional as they sound.

There are so many great choices for audiobook narrators. Unless you’re visually impaired, in which case I have absolutely no basis to tell you what you should or shouldn’t do to make the world more accessible, the only bad choice is going with an AI narrator. Reading and listening to fiction is fundamentally about accessing one’s humanity. We simply cannot outsource it to machines.

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The worldwide environmental destruction brought about by the explosive advance of global capitalism has plunged the planet into crisis. The amount of fossil fuels consumed by the world population after 1990 now equals half that consumed during the entirety of human history up to that point. This massive consumption of fossil fuels is causing climate change. Related disasters are occurring everywhere: major flooding in Pakistan, wildfires in California, droughts in Africa, rising ocean levels caused by melting glaciers and ice sheets. The effects of climate change have become unignorable even in Japan, which has seen increasingly heavy rainy seasons and intense typhoons, among other natural disasters.

Meat-centric diets have led to extreme deforestation and the worldwide loss of biodiversity. Many scientists believe that these phenomena are partially to blame for novel viruses emerging and causing pandemics among humans.

Environmental destruction has now reached the point that it can never be fully reversed. Many scholars, in emphasizing how capitalism has fundamentally changed the workings of the planetary environment, have begun using terms drawn from geology to characterize the present era: as the Anthropocene—an age defined by human intervention into the natural world—or even, more specifically, the Capital ocene.

As you might expect, the Capitalocene is characterized by extreme inequality. Capitalism’s rapacious use of the planet has run up a tab to be paid by both future generations and the poor currently living in the Global South. The superrich elite traveling the world in private jets and luxury yachts are responsible for a huge share of the current crisis, yet they refuse to take any responsibility. Perhaps they think they’ll be exempt from its effects.

Ultimately, Marx clarifies, capitalism diminishes societal wealth for every one.

One must ask: Will we survive if we leave the future of humanity up to the forces of capitalism? Will capitalism really generate advances in technology that will save us from catastrophe?

The origins of Marx’s ecological turn can be found in the work of his con temporary, the chemist Justus von Liebig, who taught at the University of Munich and published the book Organic Chemistry in its Application to Agriculture and Physiology (better known as Agricultural Chemistry ), whose seventh edition came out in 1862.

Liebig was a harsh critic of then-current farming practices, which quickly depleted the soil in pursuit of high yields (and profits), calling this failure to replenish the land a “robbery system.” He went on to argue that if such practices continued, they would destroy the very basis on which the nation was built, leading to the eventual collapse of civilization. This famed chemist had previously extolled the virtues of fertilizer as the answer to soil exhaustion, so his sudden reversal on the issue left a lasting impression on his contemporaries.

Marx was no exception. Liebig’s discourse on modern agriculture’s robbery of the soil was of particular interest to Marx, and he produced a set of meticulous research notes on Agricultural Chemistry . Later, in Capital , Marx warns that soil depletion caused by the heedless exploitation of nature would threaten the physical foundation of society itself.

The same blind desire for profit that in the one case exhausted the soil had in the other case seized hold of the vital force of the nation at its roots. (348)

Marx’s excavation into capital’s propensity to loot resources caused him to see that soil depletion and the exhaustion of human vitality shared the same origin: the “blind desire” of capital for endless growth.

Moreover, in chapter 15 of Capital, Volume One , “Machinery and Large-Scale Industry,” Marx discusses the large-scale landholdings supporting the capitalistic management of agriculture. He points out that this looting by capital “disturbs” the metabolic relation connecting humans to nature while also exacerbating the divide between rural and urban workers:

Capitalist production collects the population together into great centers, and causes the urban population to achieve an ever-growing preponderance. This has two results. On the one hand it concentrates the historical motive power of society; on the other hand, it disturbs the metabolic interaction between man and the earth, i.e. it prevents the return to the soil of its constituent elements consumed by man in the form of food and clothing; hence it hinders the operation of the eternal natural condition for the lasting fertility of the soil. Thus it destroys at the same time the physical health of the urban worker, and the intellectual life of the rural worker. (637)

Agricultural production conducted by capital with the aim of making the most money in the least amount of time leads to heedless monocrop farming (the cultivation of the same crops in the same soil year after year). It takes time, though, for soil to replenish the nutrients consumed by crops. Capitalism might accelerate, but natural cycles remain constant. A rift is thus exposed between the temporality of capital and that of nature, the end result of which, in this case, is soil exhaustion. The land’s fertility withers, and harvests dwindle.

Marx also discussed forestry as another example illustrating the same process. It takes decades to grow trees, but capitalism can’t wait that long for forests to renew themselves. Instead, cap i tal ists cut down entire forests in search of profit with no concern for natural cycles of regeneration. As technology advances, the pace of deforestation only quickens, resulting in the penetration and destruction of even the most remote wildernesses. Accordingly, the wastelands left behind capitalism grow only more vast.

Capital takes no responsibility for the exhaustion of the soil or the destruction of the forests. Unable to sync itself with the temporality of nature, capital simply takes what it can to transform into commodities and sell with no concern for the future. Après moi, le déluge! —this is the slogan of the capitalist. While urban lifestyles become richer, as they are ground zero for commodity consumption, the price of this wealth is paid by the rural areas that suffer from issues like soil depletion and the destruction of the landscape. As a result, the quality of life of those that work and live in these rural areas deteriorates.

But as Marx notes in the previous quote, even workers in the urban centers “blessed” with commodities are forced by capital to toil for long hours at the expense of their physical health and well-being. Ultimately, Marx clarifies, capitalism diminishes societal wealth for every one.

Marx studied and wrote about soil exhaustion in the nineteenth century, but the looting of nature continues to this day, albeit in slightly diff er ent forms: from the extraction of fossil fuels and rare metals from the earth to the destruction of the Amazon rainforests.

Just as life in industrial urban centers in the nineteenth century caused hardship in rural villages, the profligate lifestyles enjoyed by those of us in the Global North are underwritten by the immiseration of those in the Global South. Après moi, le déluge —this attitude becomes even more explicit as we pass the environmental costs of our present actions on to future generations. This is what is known as “externalization.”

In Brazil, both the Amazon rainforest and the vast grassland known as the Cerrado have been rapidly transformed through clearing and logging operations into pastures and cropland. Why? Because of the production of beef for export to the Global North—the land is cleared to both raise cows and grow the crops to feed them. To take another example, the production of smartphones and computers uses large quantities of rare metals found in South Amer i ca and Africa. The mining of these metals frequently involves human rights violations, including the use of enslaved labor and child labor—the ILO (International Labor Organization) estimates that over 50 million people are currently working in conditions of enslavement.

Externalization occurs in Japan as well. Japan is the second-biggest importer of lumber in the world, bringing in considerable quantities of wood from Southeast Asian countries like the Philippines, Malaysia, and Indonesia, as well as from Siberia. Paradoxically, almost 70 percent of Japan is covered in rich forestland, providing enough resources that local cedars and cypresses are left unharvested and mountains covered in wild forests, yet large amounts of cheap lumber from overseas are imported anyway, leading to the decline of the domestic forestry industry. In this way, simple cheapness becomes the rationale for pumping yet more carbon emissions into the atmosphere to import lumber produced through the destruction of overseas forests.

We’re so preoccupied with cost-performance thinking, diligently weighing the cost of a steak against the cost of a computer, that we lose sight of the true cost of the things we use to make our lives.

All of this is ultimately unsustainable. It reflects how the metabolic relationship between humans and nature has become so distorted on the global scale. Marx predicted this outcome, writing in a draft version of Capital ’s third volume about this metabolic rift:

In this way, [large-scale landownership] produces conditions that provoke an irreparable rift in the interdependent process between social metabolism and natural metabolism, resulting in the squandering of the vitality of the soil, and trade carries this devastation far beyond the bounds of a single country (Liebig).

The endless movement of capitalism commodifies the entire world while allowing only a small subsection of the population in a small subsection of the planet to profit—this is the monopoly form (or, as in the previous passage, “large-scale landownership”). Globalization has expanded the rural-urban divide far beyond the boundaries of the nation. However, while capitalism seeks the limitless increase of value, the planet itself is limited. Capital always works to externalize the costs of its operations, but the planet acts as a limit on this “externality.”

After the collapse of the Soviet Union, the globalization of capitalism sped up even more, globalizing the environmental crisis as well; now we can say with confidence that there is nowhere on earth the crisis has not touched. Even countries like Japan and the United States, well ensconced in the Global North, aren’t exempt from the effects of climate change, as super-typhoons and extreme heat have become routine occurrences. The “metabolic rift” has deepened to the point of no return.

The metabolic relationship between humans and nature was once a cycle—a process that could be represented as a circle. But the movement of capital is one-way. It unilaterally extracts what it can from workers and the natural world, while foisting the costs of this extraction onto a perceived “outside” in a similarly one-way fashion.

By contrast, ecological systems are complexly interconnected, meaning that when one element is disturbed, all the other components linked to it are affected, too, spreading the disturbance throughout the system. Capitalism is unconcerned with such complexity and mutual interdependence. Money empowers and encourages us to assign a price to all things, making them directly comparable and exchangeable with one another. There’s certainly a convenience to this, but it’s a simplification that can have extremely violent effects, as it allows things that were originally incomparable—like forms of societal wealth and use-value—to be measured against one another according to the abstract concept of “value.”

The mutual interdependence of an ecosystem and the valorization of capital operate according to two completely differ ent logics, and it’s impossible to reconcile the great divide between them. The simplifying logic of capital, which seeks to commodify anything and everything and which operates solely on the basis of the “value” of the commodified object, cannot ever truly grasp the complexity of the process by which an ecosystem—a system that includes humankind!—operates.

The same holds true for us as individuals. We’re so preoccupied with cost-performance thinking, diligently weighing the cost of a steak against the cost of a computer, that we lose sight of the true cost of the things we use to make our lives. What went into producing that steak? How much carbon dioxide was emitted to feed the cow it came from? To deliver its flesh to us? We simply don’t think about it.

It is precisely this sort of simplification that is necessary for capital to increase itself so swiftly and completely, opening up a rift in our metabolic relation to nature and in turn causing the current environmental crisis. We can no longer afford to keep the true cost of commodification and the valorization of capital out of sight and out of mind.

Don’t misunderstand me—Marx, too, recognized the fact that capitalism had, in its fashion, enriched our lives as well. However, he also saw that its fixation on raising profits by recklessly increasing productivity by any means necessary was also a major hindrance on humanity’s ability to protect collective planetary abundance for future generations. Marx speaks to this in a famous passage from the preface of his 1859 treatise, A Contribution to the Critique of Political Economy :

At a certain stage of development, the material productive forces of society come into conflict with the existing relations of production or—this merely expresses the same thing in legal terms—with the property relations within the framework of which they have operated hitherto. From forms of development of the productive forces these relations turn into their fetters. Then begins an era of social revolution.

It’s impossible to raise productive forces any more under capitalism without completely destroying the planetary environment. We cannot manage the environment—a resource that ultimately belongs to no one—in a sustainable way as long as we operate within a system founded on ceaseless exploitation in the name of private ownership and profit seeking. We’ve reached the point at which capitalism itself has become the “fetters” on society’s development.

We can thus say that Marx advocates for revolutionary change that would usher in a completely different social system, a change that urgently needs to happen before the “irreparable rift” in the metabolic relation between humans and nature destroys civilization for good.

__________________________________

Excerpted from Capital From Zero: Reading Marx in the Age of Climate Catastrophe by Kōhei Saitō, translated from the Japanese by Brian Bergstrom. Published by Astra House. Text copyright © 2026 by Kōhei Saitō. Translation copyright © 2026 by Brian Bergstrom. All rights reserved.

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'A silent pandemic': How Japan is curbing antibiotic resistance, $5 at a time

This is the third story in a series about antibiotic use in Japan and the U.S. I've explored how an incentive program in Japan has reduced antibiotic misuse and what research shows about the social dynamics behind the problem . Now, I'll speak with the doctors who prescribe antibiotics and the caregivers whose children receive them. This report was supported by a fellowship from the Association of Health Care Journalists and The Commonwealth Fund.

It's a Tuesday morning, and you're getting your toddler ready for daycare. But as you brush her hair into a ponytail, you notice that her cheeks are flushed, her nose is runny and her breathing is phlegmy. Instead of daycare, you head to your pediatrician, who offers a solution: a prescription for antibiotics.

This scenario has played out many times in clinics around the world. The problem is that most common childhood infections are caused by viruses, which antibiotics don't treat. In the long term, unnecessary antibiotic prescriptions can foster resistance in bacteria, thereby reducing the drugs' potency and fueling the rise of dangerous superbugs .

That's why, in recent years, there's been a huge push in many countries to raise awareness of antibiotic misuse among doctors and to reduce the overprescription of these drugs. In Japan, the government noticed that the country's pediatricians were prescribing too many antibiotics, especially to young children, and offered them a financial incentive to break the habit .

It's been working remarkably well. Among young kids directly affected by the incentive, it slashed antibiotic prescriptions by 20%; it also contributed to a spillover effect in older kids and teens, as under-20s have seen a 50% reduction in prescriptions in recent years. I went to Japan to examine why the program has been so effective and to learn whether similar approaches could work in the U.S.

Understanding why a fairly modest incentive of 800 yen (about $5) a visit is so effective requires unpacking why Japanese doctors overused antibiotics in the first place. If doctors face similar pressures stateside, maybe the same strategy could work here too.

I spoke with Fumie Kuchiba, a mother whose daughter can be seen here playing with a toy doctor's kit. Kuchiba and other Japanese parents told me about their views on antibiotics and pediatric care. (Image credit: Nicoletta Lanese) A culture of overprescription

Japan started out with a big problem of antibiotic misuse, especially among prescriptions for kids. From 2013 to 2016, over 30% of children with respiratory tract infections were given antibiotics, despite most of those infections being viral . (The U.S. started at a slightly better baseline regarding antibiotics given for respiratory conditions, with about 23% of outpatient prescriptions being unnecessary.)

For decades, it was common in Japan to routinely prescribe antibiotics for sniffles and tummy bugs, Dr. Takemi Murai, deputy head of the Infectious Diseases Division at Nagano Children's Hospital in Azumino, told me. That's in part because medical education there didn't emphasize the risk of "superbugs," meaning bacteria that can withstand many antibiotics.

"When I trained, antimicrobial stewardship wasn't yet a formalized part of the curriculum in the way it is now," said Murai, who finished medical school in 2006.

There also may be a generational divide, Dr. Tatsuki Ikuse , a pediatric infectious disease specialist at the National Center for Child Health and Development in Tokyo, told me. Ikuse, who finished medical school in 2013, suspects that older doctors "experienced many cases of bacterial infections when there was no vaccination."

Dr. Tatsuki Ikuse, a pediatric infectious disease specialist, said parents sometimes request antibiotics for their children when the drugs are not needed. "I try to convince them and try not to prescribe antibiotics as much as possible," he said, "but I think some doctors cannot convince them and end up prescribing antibiotics." (Image credit: Nicoletta Lanese) Now that vaccines for whooping cough, diphtheria and pneumococcal disease are routine, children face a lower risk from the bacteria that cause those illnesses. But those early experiences treating children with serious bacterial infections may still be shaping doctors' prescribing patterns, even decades later, Ikuse thinks.

Surveys conducted in Japan suggest that doctors under 50 are more likely than doctors over 50 to see antimicrobial resistance as an urgent issue. Clinic doctors — those likeliest to see kids as outpatients for acute illnesses — also skew older than doctors in hospitals; in 2024 , clinic doctors averaged about 60 years old, while those in academic and nonacademic hospitals averaged 40 and 48 years old, respectively.

Historically, Japanese doctors also had a strong bias toward prescribing antibiotics for "feverish" diseases, noted Dr. Norio Ohmagari , director of disease control and prevention at Japan's National Center for Global Health and Medicine.

Murai agreed with that sentiment. "If doctors saw a fever and a high CRP level [a sign of inflammation], they prescribed antibiotics," Murai said. "Doctors were following such a practice for a long time, so they didn't question it."

Concerns over secondary infections were also a big driver of unnecessary antibiotic use, said Dr. Masahiko Sakamoto, a hospital pediatrician in Saku, a highland city about an hour northwest of Tokyo by bullet train. Even if doctors suspected a viral infection, like the common cold, they worried that the illness could open the door for secondary bacterial infections, such as bacterial pneumonia. However, recent studies suggest this scenario is uncommon and shouldn't prompt doctors to use antibiotics preventatively.

Is antibiotic misuse still a problem in the U.S.?

Young children in the U.S. were once the most likely group to receive unneeded antibiotics, but now, those unnecessary prescriptions have "dropped dramatically," Dr. Sarah Kabbani, director of the U.S. Centers for Disease Control and Prevention's (CDC) Office of Antibiotic Stewardship, told me in an email.

Between 2011 and 2016, children's antibiotic prescriptions decreased 13% overall. "Overall declines in antibiotic use over the past decade have been driven in large part by reductions in prescribing for children," Kabbani noted.

Japan has also decreased its overall antibiotic use in younger populations, halving its outpatient prescription rates for patients under 20 between 2011 and 2022, Dr. Yusuke Okubo , division chief of clinical epidemiology and health services research at the National Center for Child Health and Development in Tokyo, told me.

The decrease in antibiotics overuse syncs with parents' lived experiences in both countries.

"I was taking antibiotics quite often" as a kid, Tatsuya Kanno, a software engineer and father of two in Tokyo, told me. "Nowadays, we don't get really prescribed those antibiotics easily."

"It has definitely been different from my childhood," said Gabby Brown, an apparel consultant and mother of two in Littleton, Colorado. "There was always a bottle of pink stuff in the fridge, you know? And now they're very hesitant to give it out."

Brown's pediatrician actually has an explicit policy on their website stating that they don't overprescribe antibiotics and instead follow evidence-based guidelines to determine when the drugs are truly necessary. I've found a number of other U.S. pediatric clinics that do the same.

One reason U.S. pediatricians have been able to improve several key metrics of antibiotic use is that the issue has been on their radar for a while.

Pediatricians in the U.S. have greatly improved their use of antibiotics over the years, but still, not all antibiotics that children get prescribed are actually needed. (Image credit: Halfpoint Images via Getty Images) "Antibiotic stewardship was a core tenant of my residency training 20 years ago," Dr. Morgan Leafe , a U.S.-based pediatrician who worked in inpatient and outpatient settings for 11 years after residency, told me in a direct message. "So I would say it's not new in pediatrics."

But there remains room for improvement.

Prescription rates vary widely among states and among different types of outpatient facilities , such as community practices versus those affiliated with academic medical centers. Rural communities often use antibiotics at higher rates and log more inappropriate use , compared with urban areas. These regional variations are "not explained by clinical factors," said Julia Szymczak , a medical sociologist and associate professor in the Division of Epidemiology at the University of Utah School of Medicine.

Nowadays in the U.S., urgent care clinics might be a hotspot for antibiotic misuse. These and other walk-in clinics serve an increasing number of pediatric patients, with an estimated 26% of children visiting one in the past 12 months. Urgent cares may prescribe antibiotics to children at a higher rate than other ambulatory settings do; in one study, 42% of the children seen at urgent cares were prescribed antibiotics at their visit, while the national average across all pediatric ambulatory visits is 21% .

It may be that urgent cares are more likely to prescribe antibiotics for conditions that they're explicitly not recommended for. One national analysis found that urgent cares prescribed antibiotics for 20% of allergy cases, 42% of viral upper respiratory infections and 52% of uncomplicated ear infections, while doctor's offices wrote far fewer of these inappropriate prescriptions. Other studies highlight similar patterns .

Among children, inappropriate prescriptions are less likely at urgent cares that specialize in pediatrics , highlighting doctors at general clinics as a potential population to target . Additionally, research has found that visits with nurses or physician assistants are more likely to end in an antibiotic prescription than those with doctors. (Only licensed doctors can write prescriptions in Japan, so this factor is more unique to the U.S.)

Different systems, similar pressures

Dr. Yusuke Shibata, who runs the clinic pictured above, notes that children's caregivers don't often understand that antibiotics are specifically used for bacterial infections. (Image credit: Nicoletta Lanese) Japan's nationalized healthcare provides a staggering degree of choice, because insurance coverage doesn't tie you to specific clinics or require you to get referrals to access certain care. Young children's care is virtually free thanks to national and local subsidies. So on paper, parents can easily shop around for a pediatrician that best suits their family's needs, as well as pop into any healthcare facility with flexibility should the need arise.

While this system is convenient, it has its downsides, some parents told me.

"In the U.S. and in Switzerland, they try to get to know you and know your child," said Reid, a fundraiser and father of two based in Okinawa, who recently moved to Japan with his sons and husband. "They don't at all in Japan."

In contrast, about 9 in 10 children in the U.S. have a primary care provider, although that percentage has fallen in recent years as the use of urgent care has increased. Primary care providers can be a go-to for sick visits as well as an ongoing monitor of kids' health via annual check-ups. (Annual check-ups in Japan are handled by local municipalities, not by children's regular doctors, Reid noted.)

In some ways, pediatric clinics in Japan can be considered more analogous to urgent care in the U.S., in that they're intended to address acute cases of illness as they emerge. For more serious illnesses, caregivers bring their children to hospitals, parents in Japan told me.

Diagnostic uncertainty

For a typical respiratory or tummy bug, doctors in both the U.S. and Japan make diagnoses based largely on a patient's symptoms and timeline of illness. In the U.S., most minor infections are "generally assumed to be viral unless certain criteria are present," Leafe said. These criteria are spelled out in manuals used by pediatricians.

The Karugamo Clinic in Tokyo (pictured here) is run by Dr. Atsushi Miyahara, a pediatrician who consistently uses the government incentive aimed at improving antibiotic use. (Image credit: Nicoletta Lanese) The criteria enable doctors to "feel reassured" that they've correctly classified an infection as viral or bacterial, even in the absence of a highly sensitive diagnostic test, said Dr. Ilan Shapiro , a community pediatrician at AltaMed Health Services, a nonprofit health network in Southern California.

Rapid tests are available for only a handful of bacteria, including Streptococcus pyogenes (also called group A strep), a common culprit behind strep throat and scarlet fever. These tests are "definitely underutilized" by Japanese clinics, Ohmagari noted, while U.S. clinicians are encouraged to use them more widely .

"For strep throat, we never treat [give antibiotics], now, without a positive test," said Dr. Jennifer Shu , a pediatrician with Children's Medical Group, a group of pediatric offices in the Atlanta metropolitan area. (That said, electronic medical records suggest that not all doctors' offices use these tests before prescribing antibiotics, despite these recommendations.)

In both countries, doctors can use rapid tests to diagnose common viral infections, such as influenza and RSV. But those tests don't always catch every case. And even if they come back positive, they can't rule out the possibility of simultaneous infections with viruses and bacteria, Shu noted.

Shu's practice also uses a 45-minute test that looks for multiple viruses and bacteria in the nose and throat, including the bacteria behind whooping cough and Mycoplasma , which causes "walking pneumonia." Not all clinics use this type of test, though, because they require a special certification and equipment to run on-site, Shu said.

Such panel tests can be helpful but also tricky to interpret. Bacteria can sometimes be detected in a patient's nose without being the cause of their symptoms. "That's where clinical judgment comes in," Shu said, emphasizing that a doctor must combine test results with the timeline of a patient's symptoms.

Time crunches

The lack of quick, surefire diagnostic tests for bacterial infections can leave doctors with a degree of uncertainty, which can sometimes prompt unnecessary prescriptions, Szymczak said.

"Our number one motivation is to not harm somebody; that's the main thing," said Dr. Shruti Gohil , an infectious-disease specialist at UCI Health who designs interventions to improve doctors' antibiotics use. Worries about potential missed diagnoses can prompt doctors to reach for an antibiotic now "in exchange for a potential future, untoward consequence," such as a greater chance of resistant infections, she said.

In both countries, doctors must make diagnoses and treatment plans in a limited amount of time. "Pediatric outpatients in Japan are very busy and can only secure a few minutes for each patient," Ikuse told me.

Such time crunches are common in the U.S., too.

"I had a pediatrician who said they had — I can't remember the figure — but it was like 800 seconds for a sick visit," said Szymczak, who studies the factors that drive clinicians to misuse antibiotics. "They broke it down into seconds."

Given that antibiotics are generally very safe drugs, pediatricians can be tempted to prescribe them "just in case" in these situations, even if the need isn't certain, a 2019 review found. In these scenarios, patients end up taking courses of antibiotics they likely don't need.

Doctor shopping and bad reviews

One factor driving antibiotic misuse that might be unique to Japan is the competition between clinics and the customer service culture it motivates.

Japan's mandatory national health insurance makes it easy to "doctor shop." Depending on where a family is based, there may be a glut of pediatric specialists to choose from — as in metropolitan centers like Tokyo — or very few. For instance, in Okinawa, general family doctors are easier to come by than pediatricians, said Sandra Miller*, a researcher and mother of one based in the prefecture.

But across all settings, families can still flexibly choose which clinic they go to. Meanwhile, pediatricians in Japan, who make less than their peers who care for adults, can worry about losing clients to nearby practices.

Dr. Yusuke Okubo of the National Center for Child Health and Development said that, historically, doctors were often wary of bad clinic reviews and also fearful of a patient's prognoses getting worse if they denied them antibiotics. (Image credit: Nicoletta Lanese) Japanese clinicians used to worry that, after being denied antibiotics for their sick kids, dissatisfied parents would leave poor reviews online — particularly in Google Reviews — and thus drive away business, Okubo said. "They feared such clinic reviews."

Parents frequently used to demand antibiotics from their children's pediatricians, Okubo added. "Ten years ago, it was a common situation," he told me.

Among the clientele of Shu's Atlanta clinic, she's "seeing a trend where people aren't asking for antibiotics as much." But still, parents sometimes request the drugs when she's determined they're not needed. These requests often stem from the parents' past experiences.

"They'll say, 'Well, last time they took an antibiotic they got better faster, the next day,'" Shu said. Because mild viral infections often go away on their own in a few days, that timing could have just been a coincidence, but it leaves an impression on the caregiver nonetheless.

Tatsuya Kanno, a father of two in Tokyo, said he recently learned about antibiotic resistance through a television program. He said he'd learned that using too many antibiotics could cause bacteria to gain strength while the drugs become less effective. (Image credit: Nicoletta Lanese) A parent in Japan told me about the other side of this conversation.

Kanno once brought his daughter into a clinic after she developed a bad cough after catching the flu. Their doctor prescribed antibiotics, and the cough resolved within days. Later, Kanno's son had similar symptoms, but the doctor didn't recommend an antibiotic in his case. When his son's coughing and wheezing persisted, "I asked him to prescribe that antibiotic, the same one that my daughter took," Kanno said.

The pediatrician said it likely wouldn't help but didn't explain why. The doctor said he would provide the antibiotic if the family wanted it. He ultimately prescribed it, and it didn't help. "He got my trust after that," Kanno said.

Szymczak's research has identified this "it-helped-last-time" bias as a common driver of patients' antibiotic requests that can be difficult for doctors to negotiate.

Parents' understanding of antibiotic resistance

In Japan, parents' awareness of antibiotic resistance has grown in recent years, Japanese doctors told me, but research suggests many still don't know much about it .

"I don't think parents generally understand that antibiotics don't work for colds, much less [understand] antibiotic resistance," said Dr. Yusuke Shibata of the Shibata Pediatric Clinic in Tokyo. "Explaining antibiotic resistance to parents is difficult," though he still tries to do so, he told me in an email after I visited his clinic.

Studies of U.S. parents suggest that many don't understand resistance or proper antibiotic use and that a misunderstanding of the purpose of antibiotics can drive requests for the drugs . In my interviews, I found that parents in both countries had some grasp of the concept of antibiotic resistance, but the depth of that understanding varied.

Risa, a mother of two in Saku, generally prefers to limit her children's exposure to medications in the interest of strengthening their immunity. But if their symptoms seem serious or long-lasting, she brings them to a doctor to see if medicine is needed. (Image credit: Nicoletta Lanese) Tomomi Sato*, a New York City-based teacher and mother of two who lived in Japan as a child, said she'd heard that taking antibiotics too often could make it so your body didn't respond to them well in the future. She likened it to an urban legend about roaches that she heard from her mother and others from her hometown of Tokyo.

"You know how they talk about, in Japan, roaches are getting bigger and bigger?" she said. "They just build immunity … they don't respond to the old type of roach spray, so you have to get a new version."

Some parents are cautious about overusing medications in general but don't worry about antibiotic resistance, specifically.

"I want them to recover by trusting their own immunity, rather than relying on medication," said Risa, an HR representative and mother of two in Saku, Japan. But that said, "if it's something that's difficult to heal naturally, I think professional judgment and a prescription are necessary," she added.

Fumie Kuchiba and her three-year-old daughter play on the floor of their living room in Saitama. Kuchiba trained as a pharmaceutical salesperson and understands that antibiotics only treat bacterial infections. She said she doesn't think most parents consider the germ at play in a given infection. (Image credit: Nicoletta Lanese) Risa told me she thinks antibiotics may be medically appropriate when an illness is particularly severe or prolonged. She doesn't weigh whether the cause is likely viral or bacterial, even though antibiotics don't treat viral illnesses.

"I think that's probably the general mindset," said Fumie Kuchiba, a mother of one in Saitama, Japan, who previously worked as a registered pharmaceutical salesperson .

Other parents have a clear sense of the threat resistance poses.

"Resistance is a threat because if something is powerful enough to beat our current modern medicine, then it can wreak real havoc," said Malcolm, an editor and father of one in Atlanta. On the individual scale, he knows that resistance can emerge within an individual, potentially raising their personal risk of resistant infections. But on a global scale, he thinks of resistance as a threat as formidable as that posed by viral pandemics, such as COVID-19.

Difficult conversations

When parents seek an antibiotic that isn't medically needed, that can prompt difficult conversations with their children's doctors.

A Philadelphia-based doctor summed up the dynamic in an interview with researchers : "If patients feel like they need an antibiotic, it's very, very hard to talk them down from that. So, antibiotics are definitely overprescribed. And, you know, it's easier to say yes rather than taking time and, like, so much time to say no." This doctor and several other participants in that study felt they had "little autonomy to stand up to patient demand."

Some studies find that, when a pediatrician withholds antibiotics and a parent questions them, doctors can perceive that as negative pushback and give the drug against their initial judgment. But if a pediatrician denies antibiotics while also providing guidance for symptom relief, that conflict can be avoided and prescription becomes less likely .

Shapiro, the pediatrician in California, told me he handles such requests by walking parents through his diagnostic process and explaining the downsides of using unnecessary prescriptions. He also offers options for seeking further care — via phone, telehealth or an in-person visit — should the infection not improve as expected.

These conversations take time, and they can stir up conflict, which Shapiro said he's grown more comfortable navigating over his career. Early on, "you don't want conflict; you feel that conflict is bad, and you want everybody to be happy," he said. But ultimately, "the objective is for them to be healthy."

Multiple parents in Japan told me their doctors don't usually talk through their reasoning for checking for a given symptom or prescribing X drug over Y. "If we don't ask, he won't explain," Kanno said of their current pediatrician; but if prompted, their doctor provides good explanations, he said.

Nicoletta Lanese Nicoletta Lanese Similarly, Japanese parents told me their doctors don't often say whether or why they suspect an infection is viral or bacterial — a clarification that might help caregivers feel more comfortable forgoing an antibiotic.

Notably, Japan's antibiotic incentive program, which allows pediatricians to earn "tips" for withholding unnecessary antibiotics, provides the payment only if the doctors also explain responsible antibiotic use to children's caregivers. That requirement may be necessary to prompt that conversation.

Some doctors in Japan who claim the incentive provide verbal explanations about resistance or give parents a slip of paper that explains the basics and includes links to further information. Dr. Atsushi Miyahara of the Karugamo Clinic in Tokyo told me that, over time, his clients have become more knowledgeable about antibiotics, and insurance data related to the incentive also hints that this learning takes place. But it's unclear if these interactions can always move the needle.

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Fielding parents' concerns

Shu, the Atlanta-based pediatrician, finds that some parents ask for antibiotics because they think the drugs will speed their child's recovery, without considering whether a bacterium is the culprit. Caregivers in both the U.S. and Japan also told me that they know parents who seek antibiotics as a quick remedy for illnesses.

Parents I spoke to who understood that antibiotics only treat bacterial infections added that it can be frustrating that there aren't many medicines available for viral ailments. Waiting for an infection to clear up can be stressful because you don't want your child to suffer, parents said, and the sickness also disrupts the family's normal routine of work, school or daycare.

"When your kid gets sick, things just kind of fall apart, and you need your life to get back to normal," said Katie, a journalist and mother of one in Jacksonville, Florida, who added that many parents may lack support that would help them take time off to care for their kids.

In both countries, pediatricians feel pressure to leave caregivers satisfied. While clinics in the U.S. aren't necessarily competing for patients in the same way Japanese clinics are, there is still a degree of customer service at play, Szymczak said. "That clinical encounter is very transactional, particularly in the United States," she said.

Doctors want to provide something of value — a diagnosis, medicine, reassurance — in exchange for the caregiver's time and money. Sometimes, pediatricians assume that what the caregiver wants is antibiotics, when really, they want a treatment plan to help their child, Szymczak said.

Could incentives motivate change?

Related stories

Japan's bold experiment to curb antibiotic misuse has been a huge success. Could it work in the US?

'800 seconds for a sick visit': Some factors driving antibiotic resistance have nothing to do with biology, says medical sociologist Julia Szymczak

How fast can antibiotic resistance evolve?

While the U.S. has made progress in curbing antibiotic misuse, there's room for improvement. Could we close those gaps by using a similar approach to Japan's 800-yen incentive?

Similar dynamics are at play in both countries, with parents and pediatricians in both places dealing with similar issues. But while these pressures are similar in the clinic, a key difference sets America's situation apart: Our complex healthcare system, funded through a patchwork of insurers, can be difficult for patients and doctors to fully trust.

In the final installment, I'll talk with U.S. doctors to see what they think about Japan's approach and explain solutions that would suit our own fragmented healthcare system.

Editor's note: The names of some parents quoted in this story have been abbreviated or changed to protect their privacy. Altered names are marked with asterisks (*).

Full text

LONDON — U.S. Ambassador to the U.K. Warren Stephens on Wednesday brushed off strident past criticism of Donald Trump from Britain’s new Foreign Secretary, Ed Miliband.

Miliband, who become Britain’s top diplomat Monday under new Prime Minister Andy Burnham, called Trump a “racist, misogynistic self-confessed groper” after his first election victory in 2016, and subsequently said the U.S. president had “lowered the bar for idiocy.”

But Stephens told Sky News Wednesday “those were some time ago, I think, and, hopefully, his views have changed.”

Pushed on whether Miliband could work effectively with his White House counterparts, Stephens said only: “People were people. People’s view of President Trump in 2016 is probably a lot different than it is … now.”

While Miliband was “wrong then,” Stephens acknowledged he had also made remarks “where you come back a few years later and say, Yeah, why did I say that? I don’t think that’s really right.”

Miliband was previously quizzed about his combative comments following the U.S. president’s second election victory in 2024. He has described his prior statements as “irrelevant,” adding: “I genuinely don’t think that Donald Trump is reading my tweets. I don’t have such a high opinion of myself.”

The foreign secretary’s predecessor-but-one, David Lammy, also had a history of posting critical tweets about Trump before taking on the top diplomacy job. But he was able to point to a friendship with U.S. Vice President JD Vance.