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Israeli strikes kill six in southern Lebanon hours after extension of ceasefire

Israel carried out airstrikes in southern Lebanon, killing at least six people, including three paramedics working at a health centre, just hours after its envoys had agreed with the Lebanese government to extend a ceasefire. Israel also said it had killed the Hamas military chief, Izz al-Din al-Haddad, in a targeted strike in Gaza on Friday. Al-Haddad was described by Israel’s army as one of the senior Hamas military commanders who directed the planning and execution of the Hamas-led attacks on 7 October 2023, which killed about 1,200 people in southern Israel and saw more than 250 taken hostage. A Hamas spokesperson, Hazem Qassem, confirmed the killing on social media. In a further sign that the region could be on the brink of a possible return to full-scale war, reports in the US and Israeli press said Donald Trump had been briefed on his military options in Iran, should he decide to break a five-week-old truce and resume strikes in the hope of forcing concessions at the negotiating table. Lebanon’s state-run media reported that at least five villages in the south of the country had been hit by strikes, and the Israeli military confirmed on Saturday that it was targeting what it said was “Hezbollah infrastructure” in southern Lebanon. Lebanese authorities said that an airstrike on Friday had hit a clinic run by the Hezbollah-linked Islamic Health Committee, killing six people, three of them paramedics. An Israeli military statement said it had killed Hezbollah militants preparing to fire rockets at its troops in southern Lebanon. Al-Haddad’s family confirmed his death in Friday’s strike to the Associated Press. Six other people, including his wife and daughter, were also killed, according to reports. His two sons were killed earlier in the war. His body was wrapped in Hamas and Palestinian flags as it was carried by mourners at Saturday’s funeral in Gaza City. Al-Haddad joined Hamas when it was established in the 1980s, and was a member of the Qassam Brigades’ Majd section tasked to go after collaborators with Israel. He was also a member of Hamas’ Military Council, the highest group of commanders that played a key role in the attacks that sparked the war. Israel’s army chief of staff called his killing a significant operation, and said that Israel would continue pursuing its enemies to hold them accountable. The new strikes, which triggered a fresh exodus of civilians from the south, came hours after envoys from Israel and Lebanon completed a round of talks in Washington, with an agreement to extend a month-long partly observed ceasefire for a further 45 days, and to establish a US-supervised security mechanism between their armies. Hezbollah, however, has denounced the talks, while Israel has only partly observed the ceasefire ordered by Trump on 17 April, restricting attacks on Beirut and northern Lebanon in general while focusing its military operations in the south, where its troops have clashed with Hezbollah fighters. Israel has also kept up operations in Gaza against Hamas, confirming on Saturday that it had killed Haddad, the latest acting Hamas military chief to die in Gaza, and the last surviving Hamas senior official suspected of planning the attack on southern Israel in October 2023, which killed 1,200 people and ignited the latest Gaza war. Israel has accused Hamas of violating the fragile eight-month-old ceasefire in Gaza by refusing to disarm. For its part, Hamas has blamed Israel for failing to abide by the first phase of the truce, continuing airstrikes and stealthily moving the agreed demarcation line between the two forces westwards into Hamas-controlled parts of Gaza. In recent days, the Israeli media has been predicting a return to full-scale war across the region, as truces fray amid scant diplomatic progress. As Trump returned to the US from a visit to China on Friday, the New York Times reported that he had been briefed on US options for returning to the offensive in Iran, but that he had yet to make a decision. Pakistani-led mediation has failed to bring diplomatic progress in more than a month since Islamabad brokered a ceasefire in the Iran war, with the negotiating positions of the US and Iran still far apart. With Associated Press

Bulgaria wins 70th Eurovision contest with Dara and Bangaranga

Bulgaria has won the 2026 Eurovision song contest after singer Dara swept to victory with the song Bangaranga. The 27-year-old singer’s triumph is a first victory in the 70-year history of the song contest for Bulgaria, which only joined Eurovision in 2005 and sat out the last three editions. Described by its performer as “pop music with folklore bones”, Bangaranga is a pulsating party anthem inspired by kukeri – an ancient Bulgarian ritual where men roam through villages dressed in furry costumes with bells and animal masks. The precise meaning of “bangaranga” became one of the running jokes of the night. Singer Dara said “bangaranga is a special energy that everyone has got in themselves, a feeling that everything is possible.” Bulgaria’s surprise win means the European Broadcasting Union (EBU) and other participating broadcasters will be spared a major headache. Had second-placed Israel won, organisers would have faced difficult questions over where to host the song contest’s 2027 edition. The 70th anniversary of the musical extravaganza took place in Vienna, after Austria’s operatic contestant JJ triumphed last year. About 10,000 spectators watched the show at Vienna’s Wiener Stadthalle venue, with an expected TV audience in excess of 100 million. It was the third time the Alpine republic has hosted the event. The grand final saw musical acts representing 25 countries, with Bulgaria, Moldova and Romania returning after being absent in previous years. Controversially, Eurovision’s anniversary was celebrated without five nations who boycotted the event over the continued participation of Israel while attacks continue in Gaza. Ireland, Spain, the Netherlands, Slovenia and Iceland all declined to participate after the EBU changed the rules around multiple votes and state-sponsored promotion of songs, but stopped short of preventing Israeli broadcaster Kan participating. In December, Nemo, the Swiss singer who won the 2024 Eurovision song contest said they were handing back their trophy in protest over Israel’s presence in Vienna. Police said about 2,000 people turned out for a protest against Israel’s inclusion in Vienna’s city centre earlier on Saturday. On the night, Israel’s entry Michelle, a romantic pop song about a toxic relationship performed by Noam Bettan, came in at second place after performing strongly in the public vote. Austrian broadcaster ORF had said in advance it would not officially employ so-called anti-booing technology for home viewers used at some previous editions, but the crowd reaction to Bettan taking to the stage was warm compared to singer Yuval Raphael’s reception in 2025. There was some booing during the read-out of Israel’s public vote, in response to a group of fans continuing to chant Israel’s name. In the highly polarised previous two editions of the song contest, Israel had performed strongly in the public vote, coming second in 2025. Other nation’s broadcasters voiced concerns about the Israeli government’s heavy promotion of its acts through its social media channels, however, leading voting rules to be changed for Vienna. This year, fans were allowed to cast ten individual votes, down from 20 in previous years. Voting for the same act ten times was allowed, but voting for the act from the country fans are calling from wasn’t. During the read-out of the jury votes, the presenter representing Israel’s broadcaster KAN appeared to reference last year’s voting controversy when he said he already knew who was going to win this year. In the run-up to the final, KAN was forced to apologise after mocking Croatian group Lelek by comparing their traditional makeup to “henna tattoos in Eilat.” Lelek condemned the comments as a disrespectful slight against their culture and the history of oppressed women. Their song, Andromeda, centres on Catholic resistance to the Ottoman Empire, with their makeup featuring sicanje – a folk tattooing custom used to prevent forced conversions. The UK finished last with Look Mum No Computer, AKA Sam Battle. The YouTube star makes his own synthesisers, but failed to win over neutral voters with song Eins, Zwei, Drei. The song received nul point in the public vote, meaning it did not make it into the top ten in any of the voting countries. With the exception of Sam Ryder’s Space Man in 2022, the UK has enjoyed poor fortune in the competition over the last decade or so, including picking up the dreaded nil points with James Newman in 2021. Belgium and Germany also received zero points in the public vote. Another UK-based act, Boy George of Culture Club, failed to appear in the grand final after the San Marino entry that he had a cameo role in – Senhit’s Superstar – failed to qualify from the first semi-final. Australia’s entry, sung by Delta Goodrem, came 4th.

Canada confirms first hantavirus case in isolation in British Columbia

Canadian officials said on Saturday that a test for one of the four Canadians currently quarantining in British Columbia after being exposed to the hantavirus while on board the cruise ship where the outbreak occurred indicated a positive result. Speaking at a news conference, Dr Bonnie Henry, British Columbia’s provincial health officer, said the individual developed mild symptoms, including fever and headache, two days ago, and that the individual and their partner, who had also been on board the cruise ship where they had been isolating together, were transferred to a hospital in Victoria for assessment and testing. Henry said that on late Friday evening the test results for the individual who had been experiencing mild symptoms came back positive, but she stressed that the results were currently “what we call a presumptive positive” and that the samples have been sent to the national microbiology lab in Winnipeg for confirmatory testing. Results from those tests were expected to be confirmed over the course of the weekend, Henry said. “Clearly this is not what we hoped for, but it is what we planned for,” Henry said. “The patient is stable, and their symptoms remain mild,” Henry said. “And they are still in hospital, in isolation, being monitored and receiving care as needed.” The patient’s partner tested negative, but will also remain in hospital for further monitoring and assessment, Henry said. Out of what Henry described as “an abundance of caution”, the third individual who had been isolating in the same lodging has also been transferred to hospital for monitoring. The fourth person continues to isolate at home under daily observation, she said. The four Canadians who had been on board the Dutch cruise ship MV Hondius, where the hantavirus outbreak occurred, arrived in Victoria on 10 May, Henry said, adding that on arrival, all four of them were assessed and none of them had any symptoms. They were transferred directly to lodgings to begin a period of quarantine for a minimum of 21 days. Meanwhile, France’s Pasteur Institute said it has fully sequenced the Andes virus detected in a French passenger from the MV Hondius cruise ship and found that it matched viruses already known in South America, with no evidence so far of new characteristics that would make it more transmissible or more dangerous. Pasteur said genomic analysis confirmed that the virus found in the French passenger matched the virus detected in other cases aboard the ship and closely resembled known Andes virus samples circulating in South America. Pasteur said the viruses detected in patients from the ship were identical to each other and about 97% similar to some Andes viruses circulating in South America, including those identified in rodents. Jean-Claude Manuguerra, who heads Pasteur’s environment and infectious risk unit, said the remaining variation appeared to reflect natural viral variation and did not seem to affect the characteristics of the virus detected among travellers. Since 11 April, three people who were on board the cruise ship have died of suspected hantavirus infections of hantavirus, including a Dutch couple and a German woman.

Tens of thousands attend London pro-Palestine rally to mark Nakba Day

Tens of thousands of people are estimated to have attended a pro-Palestine rally in London on the same day as a protest organised by Tommy Robinson in the capital. Armoured vehicles, police horses, dogs, drones and helicopters were deployed along with about 4,000 officers on duty to avoid clashes between Robinson’s Unite the Kingdom march and the pro-Palestine rally. A total of 43 arrests were made at both marches, police said. A large group of protesters carrying banners and placards reading “Bristol stands with Palestine”, “Stop Trump, Stop Farage”, and “Free Palestinian Hostages” gathered with many wearing keffiyehs while one demonstrator carried a St George’s Cross that bore the words “have a heart”. Organisers of the pro-Palestine rally, which began in South Kensington before heading to Waterloo Place, claimed at least a quarter of a million people attended, while the police previously estimated 30,000 would attend. The MP Diane Abbott was among the attenders and told demonstrators that those gathered faced a “common enemy” in the “far right”. She added: “They are viciously rightwing, viciously racist, they are anti-black, anti-Muslim and viciously antisemitic. We have to come together … to fight the racists, to fight the fascists, to fight the antisemites.” The Former Labour leader Jeremy Corbyn told demonstrators in Pall Mall that Westminster needed a change in policy, not “personalities”. The Your Party co-founder said: “Whatever happens to Keir Starmer, I don’t know if he’s going to survive the coup, he should know about coups. I know about coups. I know what goes on. “But I would say that if there’s to be a change, it’s got to be a change of policy, not the personalities.” He added: “To those in Reform and the far right that do so much to attack us all and attack our communities, your hatred can succeed in dividing people, but your hatred will not build one council house, will not improve one hospital, will not teach one child, will not end somebody’s homeless life on the streets of London. “The only thing that can change that is a change of economic, social, and international policy – that’s what brings us together.” Zarah Sultana, who is also a co-founder of Your Party, told the protesters that Andy Burnham was “not an alternative” to Starmer and “is another establishment politician cut from the same Zionist cloth”, while the Labour MP Apsana Begum said the movement would not be divided by the far right.

As Aukus spending and delays blow out, will Australia’s nuclear submarines ever materialise?

As Australia’s Aukus spending blows out further, US submarine building falls years further behind: the strongest signal yet that America’s promised Virginia-class submarines are increasingly unlikely to ever materialise under Australian command. This week the US navy admitted it would take until 2032 before it was building two Virginia-class boats a year – still below the rate needed to supply Australia. Australia’s budget, released Tuesday, put an extra $400m towards the Aukus agreement over the next three years: the Australian Submarine Agency’s total resourcing is now $2.13bn to the middle of 2029. In addition, Australia has sent A$2.76bn (US$2bn) to the US, and A$863m (£469m) to the UK, to boost their flagging submarine-building industrial bases. It remains a fraction of the total: to 2055, the Aukus deal is conservatively estimated to cost Australia $368bn. But the US Congress and navy, on which Australia will depend for its first nuclear-powered submarines – two second-hand Virginia-class attack submarines – continues to signal that it is not building enough submarines for its own fleet, let alone any to sell to Australia. Sign up for the Breaking News Australia email Submarine building in the US has slowed dramatically over decades. It now takes US boatbuilders 10 years to build an attack submarine. Twenty years ago, it was taking them six. For the past 15 years, the US navy has ordered Virginia-class submarines at a rate of two a year, but its shipyards have never met that build rate “and since 2022 has been limited to about 1.1 to 1.2 boats per year, resulting in a growing backlog of boats procured but not yet built”, the Congressional Research service says. As a result, the US Navy has only 49 of the 66 submarines it needs. Shipyards must build Virginia-class submarines at a rate of two a year to meet the US’s own needs, and lift that to 2.33 boats a year to be able to supply submarines to Australia. The navy initially forecast that it would reach that build rate – two Virginia-class boats a year – by 2026. Navy officials then forecast that date at 2028. Now it has been pushed further again: to 2032. Giving evidence before the House Appropriations Committee defense subcommittee this week, the chief of naval operations, Admiral Daryl Caudle, said: “I would say we’re going to be up on step with that [production rate] around 2032 based on the things we’ve done … we should be up to two-per-year in the early 2030s.” Caudle gave evidence he believed Aukus was progressing apace. “I just got back from Perth, they’re making their milestones. There’s a couple things they’re behind on, I’m frustrated with, that are part of the support system there … But all the production work there on the pier … they’re making their marks. “The integration of their sailors and officers and maintenance personnel at Pearl Harbor naval shipyard is fantastic. This is working and we want to support them and it is going to turn out really great when we get it delivered.” But even if US boat-builders reached a production rate of two Virginia-class submarines a year, it would still be insufficient to contribute to Aukus – short of the 2.33 boats a year required to have sufficient submarines to sell even one to Australia. The US legislation governing Aukus states that the president of the US can only transfer a submarine to Australia if losing that submarine from US service “will not degrade the United States undersea capabilities”. There is further evidence of the structural challenges facing US shipbuilding, emerging from Washington, and from yards across the country. The US Navy’s shipbuilding plan – a detailed 30-year roadmap of all of the navy’s planned vessels, released this month – does not account for building any additional submarines for Aukus. The entire document mentions Aukus only once, as a footnote, saying it has been excluded from the navy’s projections. A report issued last month – Challenges Facing the Navy’s and Coast Guard’s Shipbuilding Programs and the Shipbuilding Industrial Base – paints a dire picture of an industry that has consistently failed to meet targets. “The Navy and the shipbuilding industrial base have had the resources, but have been unable to deliver the ships that the service has ordered in a timely manner.” In the 2000s, it took US boat-builders six years to build and deliver an attack submarine the report said. In the 2020s, it takes 10 years. Workforce challenges were the greatest brake on production rates. “Nearly all the major shipyards are having difficulty hiring and retaining workers, and a generation of longtime shipyard workers has retired or soon will. As a result, the workforces in many of those yards are, overall, less experienced than they were in the past.” As well, up to 70% of suppliers of parts have no competitors, so “a single supplier of a critical component could disrupt ship construction if it encountered difficulties in production”. The US Congressional Research Service has openly countenanced “alternative divisions of labour” under which no Virginia-class submarines are ever transferred to Australian control. The research service’s latest report on Aukus, issued in January, considered a revision under which the submarines earmarked for sale to Australia are instead retained under US command to be sailed out of Australian bases. The report argued both for and against the US selling three Virginia-class submarines to Australia, beginning in 2032. But it makes the case that, in the event of a “conflict or crisis” with China over Taiwan, submarines under Australian command could not be ordered into operation, whereas US-commanded vessels, operated out of Australian bases, could be immediately deployed. Acting secretary of the navy, Hung Cao, appearing before the same house subcommittee as Admiral Caudle this week, gave an insight into the US perspective. He said he felt the submarines – under US or Australian command – were, essentially, interchangeable. “The enemy will not know if it’s an American submarine out there or an Australian submarine, because it’s going to all be the same… let them guess what’s out there.”

Tommy Robinson’s ‘far-right Glastonbury’: a distinctly lower energy affair

On a big screen yards from Downing Street, Marco Rubio was midway through a paean to western civilisation when the sound went down, and not for the first time. “I don’t know who you are mate but I agree with you,” shouted a woman, draped like so many of those on the self-styled “Unite the Kingdom” march in the flag of St George and soaking up the atmosphere at what has emerged as the nearest thing to a far-right Glastonbury. As with the praise lavished by speakers on Donald Trump, the inclusion of a recording of the US secretary of state’s recent address to the Munich security conference appeared designed to catch the eye of would-be backers in the US and perhaps even in the White House itself. Yet, if last year’s rally – also organised by Tommy Robinson – took many by surprise for its sheer size and was by some margin the biggest far right event in British history, this year’s was a distinctly lower energy one. One factor may have been the UK government’s blocking of 11 international activists who were due to speak, but there was a flatness to this year’s speeches and an absence of last year’s equivalent of a rabbit out of the hat when Elon Musk appeared via video link. As ever for Robinson, a tanned lover of frequent sun holidays and veteran of the far right whose real name is Stephen Yaxley-Lennon, it was often about money. As he introduced a range of speakers from a stage in Parliament Square, he claimed to have raised more than $300,000 (£225,000) from two US conservative donors he had met on a recent US trip. The push for support continued on Saturday as he repeatedly urged supporters to take out their phones and scan a QR code in order to share their details with his operation, now a burgeoning multimedia enterprise flogging merchandise on the back of a platform that has increasingly added Christian nationalism to its anti-Islam message. In the crowd, who had marched through Trafalgar Square and Whitehall after gathering earlier at London’s Euston Station, the usual tribes from past Robinson bandwagons such as the English Defence League were there. Largely male and white, it included the Fred Perry-clad football casuals, men in clothing emblazoned with various iterations of “Patriots” and various extremely online young men, often seemingly alone, in Maga hats. Continuing a theme from last year too, Christian iconography was particularly visible. Marchers had earlier helped themselves to piles of large wooden crosses left out on the route while evangelical preachers joined Robinson on stage and Christian activists in the crowd handed out free copies of leaflets and books. But also present – and as much as some may wish this was not the case – were the politically unaffiliated as well as many families with groups of children. Mingling in the crowd the Guardian spoke to those who simply said they were there out of curiosity, or out of a vague sense of community with others who felt “silenced”. “I’ve just come along because something feels wrong in the country,” said a man who identified himself as a small business owner in south London. Yet new tribes were also growing in number. Some carried flags or wore the emblem of Restore Britain – the party set up by former Reform MP Rupert Lowe. Robinson himself, having previously been linked to Advance UK party, encouraged his supporters to get involved in politics and smiled and said “I’m hearing Restore” as those close to the main stage chanted “Rupert, Rupert”. But while the usual flags of St George and union jacks flew over the crowd, two others in particular seemed more prominent than ever. They were the flag of Israel – hoisted by long-term Robinson supporters but also by groups with T-shirts saying things such as “Jews for Tommy” – and the flag of Persia, or pre-revolutionary Iran, with a golden lion and sun at its centre. “For years I have been trying to warn the British people about the dangers of Islam,” said Kamran Soltani, pushing a bike with photographs of the last Shah of Iran and his exiled son, and who said his own father had been a general in the shah’s army and was executed after the Islamic revolution. Like some British Iranians – including those on what were said to have been eight coaches of Iranians who travelled from Manchester – he had found common cause with Robinson. Others too were out and prouder than ever in a different way. Explicitly white nationalist groups such as White Vanguard were present with banners that appeared to meet with no opposition from stewards. “End Zionist Occupation of Britain, Stop White Replacement,” said one. Other extreme rightwingers in the crowd included Mark Collett, the co-founder of Patriotic Alternative, and Sam Melia, an activist from the group who was released from prison last year after serving time for inciting racial hatred. They were later happy to claim they had handed out thousands of leaflets. “There seems to have been a lot of very hardline little far right and fascist groups there who were operating quite openly,” observed Nick Lowles, chief executive of the anti-fascist organisation Hope Not Hate. “It gives them a whole new audience. Many of these groups would not get to a thousand people at events, so for them it’s great promotion.” Yet, overall, Lowles suggested that this year’s event will have been a disappointment to Robinson. It appeared to have been both smaller than last year and also lacking in high profile speakers. At one point, there was consternation when Led by Donkeys, a group born out of anti-Brexit activism, snuck a screen into the rally, which blasted out the message that “Immigration is great” to the sound of Wake Me Up Before You Go-Go. The faces of George Michael and other celebrated sons and daughters of immigrant families flashed on to the screen as the police were forced to gather around the vehicle and protect it from angry marchers.

Seven people injured after man drives car into pedestrians in northern Italy

Eight people were injured, two seriously, on Saturday after a car rammed into a group of pedestrians in the northern Italian city of Modena. Police said the driver, in his 30s, had been arrested. He is also alleged to have attempted to stab a passerby who had tried to stop him from fleeing the scene. According to reports in the Italian press, the car crashed into a shop window after hitting the pedestrians on a road in the central area of the city. The driver is alleged to have “aimed for the pavement, hitting a bike” before crashing “head-on” into a woman, the Modena mayor, Massimo Mezzetti, told the Ansa news agency. The mayor said the woman’s legs were crushed on the impact. The driver is an Italian national born in the Lombardy city of Bergamo and of north African origin, the mayor said, adding that he lives in the Modena area. The two seriously injured pedestrians were taken to Maggiore hospital in Bologna. Mezzetti said the circumstances of the incident were still unclear. Italian press reports said four or five people had helped to capture the driver after chasing him. One man told Ansa that he disappeared behind parked cars before reappearing, allegedly “with a knife in his hand”. Mezzetti said “he was seen with a knife in his hand, but he didn’t manage to stab anyone. It seems like he was trying to hit someone”. He added: “We need to understand what’s behind this act. But it was a dramatic event. I am deeply shaken. Whatever it was, it was extremely serious. If it turns out to be an attack, that would be even more serious.” The mayor said he wanted to thank the people who helped to capture the driver, saying “they showed courage and great civic sense”. One of the injured pedestrians told Rai news that he saw the car crash on to the pavement “at high speed” and heard the sound of “people being hit”. “It was coming in the same direction as me, and I managed to jump out of the way,” he said. The man added that the driver appeared to be under the influence of alcohol or drugs, although authorities haven’t confirmed this. In a message posted on social media, Italy’s prime minister, Giorgia Meloni, expressed her solidarity “with those who were injured and their families”.

Abortion providers brace for more disruptions after mail-order mifepristone whiplash

Abortion providers and advocates are making plans for future disruptions to reproductive care after the US supreme court temporarily continued nationwide access to mail-order mifepristone on Thursday while several legal challenges wind their way through the lower courts. Three lawsuits, including a suit brought by Louisiana against the US Food and Drug Administration (FDA), seek to limit access to mifepristone, one of two abortion medications. Limitations on abortion medication could have significant ripple effects throughout the pharmaceutical industry, allowing a single state to regulate medications for the entire country. At the same time, the FDA is conducting a review of mifepristone; the agency just this week suffered major shake-ups with the ousters of commissioner Marty Makary and the acting director of the FDA’s Center for Drug Evaluation and Research (CDER), Dr Tracy Beth Hoeg, the fifth person to lead the center this year. Hoeg shared on X on Friday that she “was fired”. After the decision on Thursday, “we can take a momentary sigh of relief, but there’s always 10 other threats on the horizon”, said Emily Steinert McDowell, associate director of federal policy at Reproductive Freedom for All. “We have to be prepared for the worst-case scenario,” said Bonyen Lee-Gilmore, chief external affairs officer at Patient Forward, an advocacy organization focused on later abortion care. The Louisiana case is expected to come before the supreme court again in a future term. “The supreme court has already heard a very similar case and said that there was no standing for the plaintiffs,” said David Cohen, professor of law at the Drexel University Kline School of Law. Yet legal and regulatory challenges are likely to be “a constant battle,” Cohen said. “Nothing’s ever settled. Everything is always contested. The attacks are going to keep coming, and providers are going to keep adapting, and patients are going to keep getting abortions.” Telehealth for miscarriage management and abortion care has been a major step forward, said Melissa Bayne, an obstetrician-gynecologist and member of the reproductive freedom taskforce for the Committee to Protect Health Care. She works in rural Michigan, where people in the community remember a time before mifepristone, when miscarrying patients needed to go under anesthesia for midnight procedures to prevent complications like sepsis – and they’re worried about going back to that, Bayne said on a press call on Friday. People can and should still get abortion care, she said, adding: “Michiganders have the right to abortion in our state, but we need our federal leaders to defend it for us.” Patients who need reproductive care shouldn’t have to drive hundreds of miles, Jenna Beckham, an obstetrician-gynecologist in North Carolina, said on the Friday call. “People are struggling to get by, let alone get hundreds of miles away for basic health care.” In Montana, the right to abortion is protected in the state constitution, “but that doesn’t mean that abortion care is accessible”, said Helen Weems, a family nurse practitioner and owner and founder of All Families Healthcare in Whitefish, Montana. The Rocky Mountains bisect the state, and there are expanses in the eastern half with no providers at all. A patient might need to drive 400 miles for about seven hours, sometimes over harrowing wintertime mountain passes, to access in-person care. “Being able to mail abortion pills has revolutionized abortion access in Montana and throughout the country,” Weems said on a press call last week. “There are also people with disabilities or young people who can’t talk with an adult, or people trapped in violent and controlling relationships. We talk to people all the time who can’t leave their home for whatever reason, and getting pills mailed to them means they can have the essential care that they need.” Survivors of intimate partner violence and human trafficking are especially at risk of losing the care they need if abortion medications are restricted, which would have “monumental, tragic consequences”, Julie Dahlstrom, director of the immigrants’ rights and human-trafficking program at Boston University School of Law, said on the call last week. Research from the National Bureau of Economic Research shows that restrictive abortion policies, after the Dobbs decision reversed national abortion rights, led to a 7% to 10% increase in intimate partner violence incidents in states with bans – more than 9,000 cases. With state-level restrictions following the Dobbs decision, more people are being pushed into accessing care later in pregnancy, Lee-Gilmore said. Forty states ban abortion at some point in pregnancy, and 30 of those states ban abortion after the most common period of time during which people use pills to manage abortion, which is up to 12 weeks or so. Only four states – Maryland, New Mexico, Colorado, Illinois – and Washington DC have all-trimester clinics offering later abortion care; some providers in other states may offer the care on a case-by-case basis. “All-trimester clinics are few and far between in this country, and they’re already having a hard time managing the demand for later care, and this mifepristone court ruling could really have a devastating impact on that sustainability,” said Lee-Gilmore. “People will still need abortions. They’ll just become harder to access.” On Thursday, the confusion and chaos around mifepristone access was encapsulated in the roughly 30-minute period when Justice Samuel Alito was late on the deadline he’d given himself to deliver a decision – allowing the stay to expire and temporarily creating a nationwide ban on mail-order mifepristone. “The legal back-and-forth is already creating chaos and confusion,” Beckham said. It’s not just patients but also colleagues who are confused about the “whiplash” on what is and isn’t legal, she said. Bayne said: “All physicians are worried all the time. I can’t take great care of my patients if I’m not working or if I’m in jail.” “Not just physicians and not just [advanced practice clinicians], but also nurses are scared – everyone is afraid of touching and interacting with a patient,” Beckham echoed. “Because of the changing laws and requirements, there’s a constant fear of ‘Is this legal? Am I going to be prosecuted? Am I going to go to jail?’ It impacts our ability to provide care for our patients in that moment, and it adds to the ongoing stress.” Justice Clarence Thomas wrote in his dissent on Thursday that mailing mifepristone to patients is a “criminal enterprise”, claiming that it ran afoul of the 1873 Comstock Act, an anti-obscenity law. Such statements “foreshadow a lot of concerns that we’ve been having” about possible criminal investigations, McDowell said. Even so, providers are creating plans to counter future disruptions to mail-order medications – but they come with some complications. In rural Michigan, where three or four doctors see 40,000 people, staff shortages are one of the biggest barriers to providing care, and switching to more in-person care would be a challenge, Bayne said. If mifepristone is restricted in the future, providers are ready to switch immediately to alternate treatments that are still evidence-based, like misoprostol only. “Abortion care by mail will continue, and that care will be safe and effective,” said Weems. But it is “infuriating” to have politicians and judges attempt to dictate how evidence-based medicine is practiced, she added. Cohen emphasized that people “should know that you can still get care” and that patients in the US “can get abortions safely and effectively, cheaply and widely available, despite what the court might say”. “The irony here is that abortion could be cheaper and more available because misoprostol is cheaper than mifepristone. There are no restrictions on misoprostol like there are on mifepristone – any doctor can prescribe it and any pharmacy can dispense it,” he added. Yet the temporary disruptions and ensuing confusion are reverberating across the country among patients, providers, pharmacists and others, McDowell said. “It really is a tangible impact on people’s healthcare across the country. It creates so much uncertainty for people in the times that they need as much certainty and support as they can get.”