By SARAH EL DEEB, MOHAMMED JAHJOUH and LEE KEATH

KHAN YOUNIS, Gaza Strip (AP) — Nearly seven months pregnant, Yasmine Siam couldn’t sleep, living in a crowded tent camp in Gaza and shaken often by Israeli bombardment. She couldn’t find proper food and hadn’t eaten meat for more than a month. Weak and losing weight, she saw doctors every day. There was little they could do.

One night this month, pain shot through her. She worried labor was starting but was too terrified of gunfire to leave her tent. Siam waited till daybreak to walk to the nearest mobile clinic. The medics told her to go to Nasser Hospital, miles away.

She had to take a donkey cart, jolted by every bump in the bombed-out roads. Exhausted, the 24-year-old found a wall to lean on for the hourslong wait for a doctor.

An ultrasound showed her baby was fine. Siam had a urinary tract infection and was underweight: 57 kilos (125 pounds), down 6 kilos (13 pounds) from weeks earlier. The doctor prescribed medicine and told her what every other doctor did: Eat better.

“Where do I get the food?” Siam said, out of breath as she spoke to The Associated Press on April 9 after returning to her tent outside the southern city of Khan Younis.

“I am not worried about me. I am worried about my son,” she said. “It would be terrible if I lose him.”

With Gaza decimated, miscarriages rise

Siam’s troubled pregnancy has become the norm in Gaza. Israel’s 18-month-old military campaign decimating the territory has made pregnancy and childbirth more dangerous, even fatal, for Palestinian women and their babies.

It has become worse since March 2, when Israel cut off all food, medicine and supplies for Gaza’s more than 2 million people.

Meat, fresh fruits and vegetables are practically nonexistent. Clean water is difficult to find. Pregnant women are among the hundreds of thousands who trudge for miles to find new shelters after repeated Israeli evacuation orders. Many live in tents or overcrowded schools amid sewage and garbage.

Up to 20% of Gaza’s estimated 55,000 pregnant women are malnourished, and half face high-risk pregnancies, according to the United Nations Population Fund, or UNFPA. In February and March, at least 20% of newborns were born prematurely or suffering from complications or malnutrition.

With the population displaced and under bombardment, comprehensive miscarriage and stillbirth figures are impossible to obtain. Records at Khan Younis’ Nasser Hospital show miscarriages in January and February were double the same period in 2023.

Dr. Yasmine Shnina, a Doctors Without Borders supervisor of midwives at Nasser Hospital, documented 40 miscarriages a week in recent weeks. She has recorded five women a month dying in childbirth, compared with around two a year before the war.

“We don’t need to wait for future impact. The risks are emerging now,” she said.

A love story in the tents

For Siam and her family, her pregnancy — after a whirlwind, wartime marriage — was a rare joy.

Driven from Gaza City, they had moved three times before settling in the tent city sprawling across the barren coastal region of Muwasi.

Late last summer, they shared a meal with neighbors. A young man from the tent across the way was smitten.

The next day, Hossam Siam asked for Yasmine’s hand in marriage.

She refused initially. “I didn’t expect marriage in war,” she said. “I wasn’t ready to meet someone.”

Hossam didn’t give up. He took her for a walk by the sea. They told each other about their lives. “I accepted,” she said.

On Sept. 15, the groom’s family decorated their tent. Her best friends from Gaza City, dispersed around the territory, watched the wedding online

Within a month, Yasmine Siam was pregnant.

Her family cherished the coming baby. Her mother had grandsons from her two sons but longed for a child from her daughters. Siam’s older sister had been trying for 15 years to conceive. Her mother and sister — now back in Gaza City — sent baby essentials.

From the start, Siam struggled to get proper nutrition, relying on canned food.

After a ceasefire began in January, she and Hossam moved to Rafah. On Feb. 28, she had a rare treat: a chicken, shared with her in-laws. It was her last time eating meat.

A week later, Hossam walked for miles searching for chicken. He returned empty-handed.

‘Even the basics are impossible’

Israel has leveled much of Gaza with its air and ground campaign, vowing to destroy Hamas after its Oct. 7, 2023, attack on southern Israel. It has killed over 51,000 Palestinians, mostly women and children, according to Gaza’s Health Ministry, whose count does not distinguish between civilians and combatants. Hamas has been designated as a terrorist organization by the United States, Canada and the European Union.

In the Oct. 7 attack, terrorists killed about 1,200 people, mostly civilians, and abducted 251. They still hold 59 hostages after most were released in ceasefire deals.

In Gaza’s ruins, being pregnant is a formidable struggle.

It’s not just about quantity of food, said Rosalie Bollen, of UNICEF, “it’s also about nutritional diversity, the fact that they have been living in very dire, unsanitary conditions, sleeping on the ground, sleeping in the cold and just being stuck in this permanent state of very toxic stress.”

Nine of the 14 hospitals providing maternal health services before the war still function, though only partially, according to UNFPA.

Because many medical facilities are dislocated by Israeli military operations or must prioritize critical patients, women often can’t get screenings that catch problems early in pregnancy, said Katy Brown, of Doctors Without Borders-Spain.

That leads to complications. A quarter of the nearly 130 births a day in February and March required surgical deliveries, UNFPA says.

“Even the basics are impossible,” Brown said.

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Under the blockade, over half the medicines for maternal and newborn care have run out, including ones that control bleeding and induce labor, the Health Ministry says. Diapers are scarce. Some women reuse them, turning them inside out, leading to severe skin infections, aid workers say.

Israel says the blockade aims to pressure Hamas into releasing the remaining hostages. Rights groups call it a “starvation tactic” endangering the entire population and a potential war crime.

At Nasser Hospital’s maternity ward, Dr. Ahmad al-Farra witnessed things go from bad to worse.

Israeli forces raided the hospital in early 2024, claiming it housed Hamas fighters. Incubators in a warehouse were wrecked. The maternity ward was rebuilt into Gaza’s largest and best equipped for emergencies.

Since Israel broke the two-month ceasefire on March 18, the hospital has been flooded with wounded.

Up to 15 premature babies at a time need respirators, but the hospital has only two CPAP machines to keep preemies breathing. Some are put on adult respirators, often leading to death, al-Farra said.

Twenty CPAP machines languish outside Gaza, unable to enter because of the blockade, along with 54 ultrasounds, nine incubators and midwifery kits, according to the U.N.

A lack of cleaning supplies makes hygiene nearly impossible. After giving birth, women and newborns weakened by hunger frequently suffer infections causing long-term complications, or even death, said al-Farra.

Yasmine Zakout was rushed to Nasser Hospital in early April after giving birth prematurely to twin girls. One girl died within days, and her sister died last week, both from sepsis.

Before the war, al-Farra said he would maybe see one child a year with necrotizing pneumonia, a severe infection that kills lung tissue.

“In this war, I treated 50 cases,” al-Farra said. He removed parts of the lungs in nearly half those babies. At least four died.

Pregnant women are regularly among the wounded.

Khaled Alserr, a surgeon at Nasser Hospital, told of treating a four months pregnant woman after an April 16 strike. Shrapnel had torn through her uterus. The fetus couldn’t be saved, he said, and pregnancy will be risky the rest of her life. Two of her children were among 10 children killed in the strike, he said.

The stress of the war

In her sixth month of pregnancy, Siam walked and rode a donkey cart for miles back to a tent in Muwasi after Israel ordered Rafah evacuated.

With food even scarcer, she turned to charity kitchens distributing meals of plain rice or pasta.

Weakened, she fell down a lot. Stress was mounting — the misery of tent life, the separation from her mother, the terror of airstrikes, the fruitless visits to clinics.

“I just wish a doctor would tell me, ‘Your weight is good.’ I’m always malnourished,” she told the AP, almost pleading.

Hours after her scare on April 9, Siam was still in pain. She made her fifth visit to the mobile clinic in two days. They told her to go to her tent and rest.

She started spotting. Her mother-in-law held her up as they walked to a field hospital in the dead of night.

At 3 a.m., the doctors said there was nothing she could do but wait. Her mother arrived from Gaza City.

Eight hours later, the fetus was stillborn. Her mother told her not to look at the baby. Her mother-in-law said he was beautiful.

Her husband took their boy to a grave.

Days later, she told the AP she breaks down when she sees photos of herself pregnant. She can’t bear to see anyone and refuses her husband’s suggestions to take walks by the sea, where they sealed their marriage.

She wishes she could turn back time, even for just a week.

“I would take him into my heart, hide him and hold on to him.”

She plans to try for another baby.

El Deeb reported from Beirut. Keath reported from Cairo.

By Karen Brown, New England Public Media, KFF Health News

Michele Andrews had been seeing her internist in Northampton, Massachusetts, a small city two hours west of Boston, for about 10 years. She was happy with the care, though she started to notice it was becoming harder to get an appointment.

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“You’d call and you’re talking about weeks to a month,” Andrews said.

That’s not surprising, as many workplace surveys show the supply of primary care doctors has fallen well below the demand, especially in rural areas such as western Massachusetts. But Andrews still wasn’t prepared for the letter that arrived last summer from her doctor, Christine Baker, at Pioneer Valley Internal Medicine.

“We are writing to inform you of an exciting change we will be making in our Internal Medicine Practice,” the letter read. “As of September 1st, 2024, we will be switching to Concierge Membership Practice.”

Concierge medicine is a business model in which a doctor charges patients a monthly or annual membership fee — even as the patients continue paying insurance premiums, copays, and deductibles. In exchange for the membership fee, doctors limit their number of patients.

Many physicians who’ve made the change said it resolved some of the pressures they faced in primary care, such as having too many patients to see in too short a time.

Andrews was floored when she got the letter. “The second paragraph tells me the yearly fee for joining will be $1,000 per year for existing patients. It’ll be $1,500 for new patients,” she said.

Although numbers are not tracked in any one place, the trade magazine Concierge Medicine Today estimates there are 7,000 to 22,000 concierge physicians in the U.S. Membership fees range from $1,000 to as high as $50,000 a year.

Critics say concierge medicine helps only patients who have extra money to spend on health care, while shrinking the supply of more traditional primary care practices in a community. It can particularly affect rural communities already experiencing a shortage of primary care options.

Andrews and her husband had three months to either join and pay the fee or leave the practice. They left.

“I’m insulted and I’m offended,” Andrews said. “I would never, never expect to have to pay more out of my pocket to get the kind of care that I should be getting with my insurance premiums.”

Baker, Andrews’ former physician, said fewer than half her patients opted to stay — shrinking her patient load from 1,700 to around 800, which she considers much more manageable. Baker said she had been feeling so stressed that she considered retiring.

“I knew some people would be very unhappy. I knew some would like it,” she said. “And a lot of people who didn’t sign up said, ‘I get why you’re doing it.’”

Patty Healey, another patient at Baker’s practice, said she didn’t consider leaving.

“I knew I had to pay,” Healey said. As a retired nurse, Healey knew about the shortages in primary care, and she was convinced that if she left, she’d have a very difficult time finding a new doctor. Healey was open to the idea that she might like the concierge model.

“It might be to my benefit, because maybe I’ll get earlier appointments and maybe I’ll be able to spend a longer period of time talking about my concerns,” she said.

This is the conundrum of concierge medicine, according to Michael Dill, director of workforce studies at the Association of American Medical Colleges. The quality of care may go up for those who can and do pay the fees, Dill said. “But that means fewer people have access,” he said. “So each time any physician makes that switch, it exacerbates the shortage.”

Blue Canyon Primary Care offers “direct primary care” in Northampton, Massachusetts, for patients who pay $225 a month. Direct primary care is similar to concierge medicine but does not accept insurance. Patients must pay out-of-pocket and can seek reimbursement from their insurers afterward. (Karen Brown/New England Public Media/TNS)

His association estimates the U.S. will face a shortage of 20,200 to 40,400 primary care doctors within the next decade.

A state analysis found that the percentage of residents in western Massachusetts who said they had a primary care provider was lower than in several other regions of the state.

Dill said the impact of concierge care is worse in rural areas, which often already experience physician shortages. “If even one or two make that switch, you’re going to feel it,” Dill said.

Rebecca Starr, an internist who specializes in geriatric care, recently started a concierge practice in Northampton.

For many years, she consulted for a medical group whose patients got only 15 minutes with a primary care doctor, “and that was hardly enough time to review medications, much less manage chronic conditions,” she said.

When Starr opened her own medical practice, she wanted to offer longer appointments — but still bring in enough revenue to make the business work.

“I did feel a little torn,” Starr said. While it was her dream to offer high-quality care in a small practice, she said, “I have to do it in a way that I have to charge people, in addition to what insurance is paying for.”

Starr said her fee is $3,600 a year, and her patient load will be capped at 200, much lower than the 1,000 or even 2,000 patients that some doctors have. But she still hasn’t hit her limit.

“Certainly there’s some people that would love to join and can’t join because they have limited income,” Starr said.

Many doctors making the switch to concierge medicine say the membership model is the only way to have the kind of personal relationships with patients that attracted them to the profession in the first place.

“It’s a way to practice self-preservation in this field that is punishing patients and doctors alike,” said internal medicine physician Shayne Taylor, who recently opened a practice offering “direct primary care” in Northampton. The direct primary care model is similar to concierge care in that it involves charging a recurring fee to patients, but direct care bypasses insurance companies altogether.

Taylor’s patients, capped at 300, pay her $225 a month for basic primary care visits — and they must have health insurance to cover care such as X-rays and medications, which her practice does not provide. But Taylor doesn’t accept insurance for any of her services, which saves her administrative costs.

“We get a lot of pushback because people are saying, ‘Oh, this is elitist, and this is only going to be accessible to people that have money,’” Taylor said.

But she said the traditional primary care model doesn’t work. “We cannot spend so much time seeing so many patients and documenting in such a way to get an extra $17 from the insurance company.”

While much of the pushback on the membership model comes from patients and policy experts, some of the resistance comes from physicians.

Paul Carlan, a primary care doctor who runs Valley Medical Group in western Massachusetts, said his practice is more stretched than ever. One reason is that the group’s clinics are absorbing some of the patients who have lost their doctor to concierge medicine.

“We all contribute through our tax dollars, which fund these training programs,” Carlan said.

“And so, to some degree, the folks who practice health care in our country are a public good,” Carlan said. “We should be worried when folks are making decisions about how to practice in ways that reduce their capacity to deliver that good back to the public.”

But Taylor, who has the direct primary care practice, said it’s not fair to demand that individual doctors take on the task of fixing a dysfunctional health care system.

“It’s either we do something like this,” Taylor said, “or we quit.”

This article is from a partnership that includes New England Public Media , NPR , and KFF Health News.

©2025 KFF Health News. Distributed by Tribune Content Agency, LLC.

Hyunmin Kim, Margaret Giles of Morningstar

A 529 college savings plan can be a powerful tool when saving for future education expenses because investments in the plan can increase tax-free, but many savers don’t take full advantage of all the benefits that 529 plans have to offer.

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One common deterrent to investing through a 529 plan is the concern that assets in a 529 account will reduce financial aid eligibility. While it’s true that 529 assets have an impact on financial aid, the effect is likely smaller than you think.

Do 529 plans affect financial aid?

The short answer is yes. An increase in the means to fund higher education naturally means the beneficiary is eligible for less need-based aid.

However, assets in a 529 plan have a lesser impact on financial aid packages than income does. A student’s federal financial aid is based on an estimate of what a family can contribute annually from their income and assets. Income is the largest portion of this measurement of a student’s ability to pay for college, which is represented by the Student Aid Index, or SAI, on the Free Application for Federal Student Aid, or FAFSA. The SAI replaced the expected family contribution, which was previously used on the application.

Typically, the SAI calculation expects parents to use 25% to 35% of their adjusted available income to cover college costs, though that number can go as high as 47%. Parental contribution from assets, including 529 account balances, is assessed at a much lower maximum of 5.64%. So, if a family has a 529 account with $10,000, this raises the expected family contribution by at most $564 and reduces the federal aid package by the same amount.

A 529 plan’s impact depends on who owns the account

The impact of 529 assets on a beneficiary’s financial aid package depends on who owns the account. As outlined above, if the plan is owned by the beneficiary’s parent, then 5.64% of the account’s value is considered in the SAI, which determines a student’s financial aid eligibility on the FAFSA.

On the other hand, if the plan is owned by the student, then up to 20% of the account value may be considered in calculating financial aid eligibility.

With changes to the federal student aid calculation as part of the FAFSA Simplification Act that took effect for the 2024-25 academic year, 529 accounts owned by grandparents or other relatives are not considered student assets and won’t impact the beneficiary’s financial aid.

Siblings’ 529 assets don’t count for federal financial aid

After the FAFSA Simplification Act, assets in 529 accounts are counted as parental assets only for the beneficiary of the account. That means, if you have 529 accounts set up for your other children, the assets in those accounts are no longer counted toward the expected family contribution. As mentioned above, accounts owned by grandparents or other relatives will also be excluded from determining federal financial aid eligibility.

Financial aid eligibility differs between FAFSA and CSS profile

There are also schools that use the College Scholarship Service, or CSS, Profile (primarily private schools) to calculate their financial aid packages. The CSS Profile’s formula to calculate aid differs from FAFSA’s. For instance, the CSS Profile asks for all 529 accounts owned by the beneficiary’s parents, whereas the FAFSA only counts 529 accounts for which the student is the beneficiary. Moreover, the CSS Profile is customized by the institution, so each school can have its own formula to calculate its aid packages. While each school that uses CSS Profile information applies its own standards, this calculator estimates what your family might be expected to pay.

This article was provided to The Associated Press by Morningstar. For more personal finance content, go to  https://www.morningstar.com/personal-finance

By MATT O’BRIEN, AP Technology Writer

CAMBRIDGE, Mass. (AP) — After retreating from their workplace diversity, equity and inclusion programs, tech companies could now face a second reckoning over their DEI work in AI products.

In the White House and the Republican-led Congress, “woke AI” has replaced harmful algorithmic discrimination as a problem that needs fixing. Past efforts to “advance equity” in AI development and curb the production of “harmful and biased outputs” are a target of investigation, according to subpoenas sent to Amazon, Google, Meta, Microsoft, OpenAI and 10 other tech companies last month by the House Judiciary Committee.

And the standard-setting branch of the U.S. Commerce Department has deleted mentions of AI fairness, safety and “responsible AI” in its appeal for collaboration with outside researchers. It is instead instructing scientists to focus on “reducing ideological bias” in a way that will “enable human flourishing and economic competitiveness,” according to a copy of the document obtained by The Associated Press.

In some ways, tech workers are used to a whiplash of Washington-driven priorities affecting their work.

But the latest shift has raised concerns among experts in the field, including Harvard University sociologist Ellis Monk, who several years ago was approached by Google to help make its AI products more inclusive.

Back then, the tech industry already knew it had a problem with the branch of AI that trains machines to “see” and understand images. Computer vision held great commercial promise but echoed the historical biases found in earlier camera technologies that portrayed Black and brown people in an unflattering light.

“Black people or darker skinned people would come in the picture and we’d look ridiculous sometimes,” said Monk, a scholar of colorism, a form of discrimination based on people’s skin tones and other features.

Google adopted a color scale invented by Monk that improved how its AI image tools portray the diversity of human skin tones, replacing a decades-old standard originally designed for doctors treating white dermatology patients.

“Consumers definitely had a huge positive response to the changes,” he said.

Now Monk wonders whether such efforts will continue in the future. While he doesn’t believe that his Monk Skin Tone Scale is threatened because it’s already baked into dozens of products at Google and elsewhere — including camera phones, video games, AI image generators — he and other researchers worry that the new mood is chilling future initiatives and funding to make technology work better for everyone.

“Google wants their products to work for everybody, in India, China, Africa, et cetera. That part is kind of DEI-immune,” Monk said. “But could future funding for those kinds of projects be lowered? Absolutely, when the political mood shifts and when there’s a lot of pressure to get to market very quickly.”

Trump has cut hundreds of science, technology and health funding grants touching on DEI themes, but its influence on commercial development of chatbots and other AI products is more indirect. In investigating AI companies, Republican Rep. Jim Jordan, chair of the judiciary committee, said he wants to find out whether former President Joe Biden’s administration “coerced or colluded with” them to censor lawful speech.

Michael Kratsios, director of the White House’s Office of Science and Technology Policy, said at a Texas event this month that Biden’s AI policies were “promoting social divisions and redistribution in the name of equity.”

The Trump administration declined to make Kratsios available for an interview but quoted several examples of what he meant. One was a line from a Biden-era AI research strategy that said: “Without proper controls, AI systems can amplify, perpetuate, or exacerbate inequitable or undesirable outcomes for individuals and communities.”

Even before Biden took office, a growing body of research and personal anecdotes was attracting attention to the harms of AI bias.

One study showed self-driving car technology has a hard time detecting darker-skinned pedestrians, putting them in greater danger of getting run over. Another study asking popular AI text-to-image generators to make a picture of a surgeon found they produced a white man about 98% percent of the time, far higher than the real proportions even in a heavily male-dominated field.

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Face-matching software for unlocking phones misidentified Asian faces. Police in U.S. cities wrongfully arrested Black men based on false face recognition matches. And a decade ago, Google’s own photos app sorted a picture of two Black people into a category labeled as “gorillas.”

Even government scientists in the first Trump administration concluded in 2019 that facial recognition technology was performing unevenly based on race, gender or age.

Biden’s election propelled some tech companies to accelerate their focus on AI fairness. The 2022 arrival of OpenAI’s ChatGPT added new priorities, sparking a commercial boom in new AI applications for composing documents and generating images, pressuring companies like Google to ease its caution and catch up.

Then came Google’s Gemini AI chatbot — and a flawed product rollout last year that would make it the symbol of “woke AI” that conservatives hoped to unravel. Left to their own devices, AI tools that generate images from a written prompt are prone to perpetuating the stereotypes accumulated from all the visual data they were trained on.

Google’s was no different, and when asked to depict people in various professions, it was more likely to favor lighter-skinned faces and men, and, when women were chosen, younger women, according to the company’s own public research.

Google tried to place technical guardrails to reduce those disparities before rolling out Gemini’s AI image generator just over a year ago. It ended up overcompensating for the bias, placing people of color and women in inaccurate historical settings, such as answering a request for American founding fathers with images of men in 18th century attire who appeared to be Black, Asian and Native American. Google quickly apologized and temporarily pulled the plug on the feature, but the outrage became a rallying cry taken up by the political right.

With Google CEO Sundar Pichai sitting nearby, Vice President JD Vance used an AI summit in Paris in February to decry the advancement of “downright ahistorical social agendas through AI,” naming the moment when Google’s AI image generator was “trying to tell us that George Washington was Black, or that America’s doughboys in World War I were, in fact, women.”

“We have to remember the lessons from that ridiculous moment,” Vance declared at the gathering. “And what we take from it is that the Trump administration will ensure that AI systems developed in America are free from ideological bias and never restrict our citizens’ right to free speech.”

A former Biden science adviser who attended that speech, Alondra Nelson, said the Trump administration’s new focus on AI’s “ideological bias” is in some ways a recognition of years of work to address algorithmic bias that can affect housing, mortgages, health care and other aspects of people’s lives.

“Fundamentally, to say that AI systems are ideologically biased is to say that you identify, recognize and are concerned about the problem of algorithmic bias, which is the problem that many of us have been worried about for a long time,” said Nelson, the former acting director of the White House’s Office of Science and Technology Policy who co-authored a set of principles to protect civil rights and civil liberties in AI applications.

But Nelson doesn’t see much room for collaboration amid the denigration of equitable AI initiatives.

“I think in this political space, unfortunately, that is quite unlikely,” she said. “Problems that have been differently named — algorithmic discrimination or algorithmic bias on the one hand, and ideological bias on the other —- will be regrettably seen us as two different problems.”