By Will Atwater, Anne Blythe, Michelle Crouch, Taylor Knopf
Our most-read story of 2025 had a distinctive “eew!” factor. It was about new research showing that emissions from hog operations can travel beyond farm boundaries and into nearby homes. Another study cited by NC Health News found DNA from swine feces in household dust collected from residences near industrial hog farms.
The Tar Heel State is third in the nation in hog production. In 2023, hogs generated $2.7 billion in cash receipts, accounting for 16 percent of North Carolina’s nearly $17 billion in total farm revenue, and they are a significant contributor to the state’s $111 billion agriculture and agribusiness sector.
But there are other industry numbers that many would rather forget.
Statewide, roughly 9.5 million hogs generate more than 10 billion gallons of waste annually, according to a 2020 document published by the Duke Nicholas School of the Environment. The spraying of hog waste on agricultural fields can spread fine particulate matter (PM 2.5), and long-term exposure to these tiny particles has been linked to an increased risk of cardiovascular disease.
Health concerns extend beyond air quality. A 2022 study found that people living near concentrated hog feeding operations were treated for acute gastrointestinal illness more frequently than those living farther away. Researchers said exposure to drinking water contaminated by pathogens from hog waste — or inhaling airborne waste from sprayfields — can cause diarrhea, vomiting, nausea and other gastrointestinal distress.
The tension between the industry’s economic benefits and quality-of-life concerns is a reality Whiteville resident Larry Sparrow knows well. Since moving to Whiteville from Virginia in 2019 and learning that one of his neighbors operated a hog farm, Sparrow has waged an ongoing effort to monitor, document and challenge conditions.
Sparrow said he has recently recorded fewer days with strong odors, which means he and his wife, Susan, have been able to spend more time outdoors.
“I should not be the police,” Sparrow said. “Residents should not have to police this, but we’re the only ones out here. DEQ can’t do it — they don’t have enough people, and they don’t have the power either.”
Atrium Health’s executive compensation growth mirrors company’s rapid expansion
As Atrium Health and its parent company Advocate Health continue to grow their footprint, news of double-digit pay raises for its senior leaders raised eyebrows in 2025 and was NC Health News’ second most-read story this year. An article co-published by NC Health News and our publication partner The Charlotte Ledger in May revealed that the compensation of Atrium Health’s top executives in 2024 jumped by an average of 41 percent.
In November, tax filings revealed that Advocate Health CEO Gene Woods earned $25.8 million in 2024, a 49 percent increase from the previous year. That meant Woods’ total pay had jumped more than 400 percent since 2017, his first full year as CEO of Atrium Health, before the merger that created Advocate.
Most other North Carolina hospitals CEOs also received sizable raises in 2024, including a 41 percent increase for Novant Health CEO Carl Armato to $8.2 million, a 33 percent increase for Duke Health CEO Craig Albanese to $2 million and a 21 percent increase for ECU Health CEO Michael Waldrum to $1.7 million.
News of Atrium’s executive pay hikes spread widely on social media, prompting complaints that they far outpaced those given to doctors, nurses and other patient-facing staff. Some critics said such generous compensation is inappropriate for a tax-exempt nonprofit that gets millions in tax breaks.
In a statement, Atrium maintained that its executive pay reflects the “scale and complexity of guiding one of the nation’s largest health care systems.” It noted that the majority of its compensation is performance-based, tied to patient safety, quality and community impact metrics.
Atrium has been on an aggressive expansion campaign in recent years. In 2025 alone, it opened a new hospital in the Lake Norman area of Charlotte, announced plans for a $450 million hospital in Fort Mill, South Carolina, and opened a $1.5 billion medical innovation district in Charlotte that features the city’s first medical school, a surgical training center and a growing number of medical technology companies.
Atrium reported $10.5 billion in revenue and $1.4 billion in net income, or profit, for the first nine months of 2025 — already surpassing the $1.31 billion in net income it earned in all of 2024.
Those figures do not include revenue from Atrium Wake Forest Baptist Health or from hospitals in Illinois and Wisconsin that joined with Atrium in 2022 to create Advocate, the nation’s third largest public hospital system. Advocate reported about $35 billion in revenue in 2024.
follow our coverage of health policy
North Carolina’s not immune from changes to public health roiling the U.S.
Robert F. Kennedy Jr.’s first 10 months as U.S. Secretary of Health and Human Services have had a profound impact in North Carolina, bringing radical changes to public health infrastructure, academic research across the state and prevention recommendations that have caused concern among providers.
Under Kennedy’s guidance, the Centers for Disease Control and Prevention moved away from blanket vaccine recommendations for COVID-19, chicken pox and hepatitis B and instead developed guidelines for what his administration describes as shared decision making with health care providers. Many of those changes sowed confusion and chaos at pharmacies and pediatric facilities here in North Carolina.
Kennedy has pushed back against long-held scientific consensus in many public health areas. He’s been a vocal critic of the fluoridation of community water systems — a practice previously described by the CDC as one of the “great public health achievements” of the 20th century.
Although much scientific research contradicts Kennedy’s positions, he has called fluoride “an industrial waste” linked to lower IQ and neurodevelopmental disorders in children, bone cancer and arthritis.
In North Carolina, decisions about fluoridation in public water systems largely rest with local governments and utilities. Even before Kennedy was sworn in to lead federal health agencies, several North Carolina counties waded into the fluoride debate.
In February, Lincoln County became the second in this state to ban fluoride from its public water system, nearly a year after Union County took the same action.
A wealth of research has found that adding fluoride to water is a safe way to reduce tooth decay and its severity. The recommended level for the past nine years in the U.S. has been 0.7 milligrams per liter, which the North Carolina Dental Society likens to 70 cents out of $1 million. The studies often cited by Kennedy and other critics of community fluoridation often are based on populations exposed to fluoride at much higher levels than used in U.S. water systems.
In April, Kennedy announced plans to put together a task force to review the CDC guidance on fluoride in drinking water and study potential health risks. The Environmental Protection Agency also will look into health outcomes related to water fluoridation.
Who decides where health care resources get built?
Laws that cap the kinds of medical facilities, equipment and services that can be offered in specific geographic regions of the state have been controversial for years. In 2025, that debate played out in several state courtrooms.
Critics say such statutes — known as certificate of need, or CON, laws — stifle free market competition in the health care industry. They contend they protect established systems by creating powerful entities that lack cost transparencies and contribute to higher prices.
Supporters counter that CON laws foster systematic health care facility planning that prevents over-saturation of markets and allocates resources based on community needs, ensuring more equitable access to care. They argue that is especially the case in rural areas, where sparser populations might not be as enticing to private market systems motivated by profit.
The owner of Singleton Vision Center filed a lawsuit in April 2020, arguing that the certificate of need law has restricted his right to earn a living and reap the full fruits of his labor. He further contended that the statute violates the anti-monopoly clause of the state constitution.
The case initially was dismissed by Superior Court Judge Michael O’Foghludha in 2021. It went all the way to the state Supreme Court on appeal, and on Oct. 18, 2024, the justices issued an unsigned, unanimous four-page ruling giving the case new life while leaving open the question of the constitutionality of the law.
In October, New Bern eye surgeon Jay Singleton went before a three-judge panel in Wake County Superior Court to challenge the constitutionality of the law.
At the October hearing, Singleton’s attorneys argued that although his center is “a full-service eye clinic,” he has had to perform most of his surgeries at the hospital just two miles from his clinic.
Derek Hall, the special deputy attorney general representing the state Department of Health and Human Services, countered that the CON law doesn’t block Singleton from doing the kinds of procedures he wants. Singleton, Hall argued, would be using a “procedure room” at his center and a certificate of need is not required for that. The CON law, the special deputy attorney general argued, requires a certificate to open an operating room.
Earlier this month, the three-judge panel — Republicans Jeffrey Foster and Troy Stafford and Democrat Jacqueline Grant — issued a unanimous ruling dismissing Singleton’s case. In their 11-page order, the judges concluded that nothing in the CON law prevents Singleton “from performing the eye surgeries patients require in [a] procedure room as a certificate of need is not required to develop a procedure room” and therefore did not prevent him from entering the market.
Furthermore, they wrote, there are 82 service areas in the state for operating rooms, and many not only had multiple providers but new providers had entered those markets. Moreover, the judges found that while Singleton’s main competitor owns nine operating rooms in the Craven, Jones and Pamlico counties service area where he is, patients there have access in bordering areas to 80 operating rooms owned by nine different providers.
Singleton’s arguments focus on his “own inability to open an operating room without certificate of need, but those allegations taken as true do not demonstrate that the CON Law is invalid in all circumstances,” the judges ruled. “The existence of numerous healthcare providers who have obtained certificates of need statewide confirms that the law operates constitutionally in a wide range of applications.”
Singleton’s attorneys have announced plans to appeal, which could send the case back to the state Supreme Court.
Even as the legal challenge was wending through the courts, state lawmakers modified the law. In 2023, in conjunction with the expansion of Medicaid to at least 700,000 more people in North Carolina, the General Assembly removed certificate of need requirements for ambulatory surgical centers in the 23 counties that had populations greater than 125,000 in the 2020 census. The lawmakers also exempted some MRI equipment and psychiatric and chemical-dependency facilities from the review.
The changes were rolled in gradually, with the requirements for the ambulatory surgical centers taking effect this year on Nov. 1.
Progress and peril in America’s drug crisis
In 2017, the opioid crisis in the United States reached the point of a public health emergency. A year later, our reporter Taylor Knopf boarded a plane to Europe to see firsthand how France and Switzerland dealt with drug use differently. In a multi-part series, she reported on the philosophies and methods they used to tackle their once high rates of drug overdose deaths and related infections — many of which were not widely embraced or illegal in the U.S. at the time.
One story from that series — “Switzerland fights heroin with heroin” — continues to make NC Health News top 10 most-read story list every year, this year it was number five.
The story examines Switzerland’s most controversial drug policy: a heroin-assisted treatment program. It involves medically prescribed heroin given to people with severe opioid use disorder as part of treatment. This approach — which legalized heroin under certain circumstances in 1994 under the country’s four-pillar drug policy — has caused rates of overdose deaths, HIV infections and property crime to plummet. Also reduced: new heroin use.
At face value, the program may sound shocking, but it delivered results. As long as the United States battles this drug crisis, stories like this, which offer solutions and hope, will continue to be read and shared.
There have been steps forward since Knopf traveled to Europe in the fall of 2018. A nationally recognized system for checking street drugs for harmful additives was started in 2021 here in North Carolina through the partnership of a Greensboro-based harm reduction group and a lab at UNC. After a surge in overdose deaths during the COVID-19 pandemic, deaths started to drop at the end of 2024. Though many factors contributed to this decline, drug experts say that flooding the streets with naloxone, the opioid overdose reversal drug, played a big role in keeping people who use drugs alive. Over the past several years, there has been a growing recognition that addiction is a disease that needs treatment, and that people with addiction need support in all areas of life, including housing, education, employment, food assistance and help with legal issues.
Local governments in North Carolina are using their funds from national opioid settlements to help establish many of these types of supports across the state.
However, lately, progress has looked like two steps forward and one step back. Over the past year, President Donald Trump’s administration has been slowly dismantling the infrastructure supporting programs for people with addiction. Trump’s One Big Beautiful Bill Act makes changes and cuts to Medicaid, which many people with substance use disorder rely on for treatment. The Trump administration slashed staffing and funding at the Substance Abuse and Mental Health Services Administration, which supports programs in the states. Trump has undermined evidence-based harm reduction strategies and banned the use of SAMHSA grant money for buying some harm reduction supplies such as sterile syringes, which reduce the spread of infectious diseases including HIV and hepatitis C. In July, Trump issued an executive order that claimed that “so-called ‘harm reduction’ efforts” only facilitate illegal drug use.
Though the gains have been modest, the recent decline in overdose deaths shows progress is possible.
KEEP UP WITH THE LATEST
Republish our articles for free, online or in print, under a Creative Commons license.
