Americans with H.I.V. are achieving the once unthinkable: a steady march into older age. But beginning around age 50, many people living with the virus face a host of health problems, from heart disease and diabetes to social isolation and cognitive decline.

And so the medical research community, which some three decades ago developed lifesaving drugs to keep the virus at bay, is now hunting for new ways to keep people with H.I.V. healthier in their later years.

A recent study, for example, showed that a statin drug significantly lowered the risk of heart attacks and strokes among middle-aged and older adults with H.I.V., and may reveal biological insights into why this group tends to age faster than others. And a crop of academic hospitals have established specialized clinics for older people with the virus, offering medical experts as well as social workers, substance abuse counselors, psychologists and nutritionists.

“I have been unbelievably impressed at how care for the older H.I.V. population has really exploded,” said Dr. Nathan Goldstein, who heads one such clinic at Mount Sinai in New York City. “I get emails every day about new models, new grant funding. People are paying so much attention to this.” More than two dozen H.I.V. and aging experts also expressed optimism, in contrast to the more grim perspective many held a decade ago.

Researchers have often referred to a looming “silver tsunami” of older people with H.I.V. needing better care. In 2021, there were 572,000 Americans aged 50 and older diagnosed with H.I.V., up 73 percent from 2011.

Today, two-thirds of deaths in the H.I.V. population are from causes other than the virus. This aging group faces an increased risk of diabetes, liver and kidney disease, osteoporosis, cognitive decline and various cancers.

But perhaps their most pressing health concern is a doubled risk of cardiovascular disease compared with people who do not carry the virus. Researchers in the Netherlands estimated that by 2030, more than three-quarters of that country’s H.I.V. population will have cardiovascular disease, including high blood pressure, high cholesterol, heart attacks or strokes.

Seeking a bulwark against this mounting threat, the National Institutes of Health invested $100 million in a randomized controlled trial, called Reprieve, that tested a statin medication against a placebo among 7,769 people with H.I.V. 40 to 75 years old. The volunteers were relatively healthy and on stable antiretroviral treatment, so they typically would not have been recommended a statin. But the results of that trial, published in The New England Journal of Medicine, showed that the drug lowered the volunteers’ risk of major cardiovascular events by more than one-third.

“This is really an important study,” said Dr. Anthony S. Fauci, who as the former director of the National Institute of Allergy and Infectious Diseases — he retired in December — was among the N.I.H.’s leaders who approved Reprieve’s mammoth budget. “The results, in some respects — they’re even better than I would have expected.”

Donté Smith, a health consultant from Kansas City, Mo., is 37 but began taking a statin earlier this year. Mx. Smith, who is genderqueer and uses gender-neutral pronouns, said they were motivated to take the medication because, in addition to H.I.V., they had a family history of cardiovascular disease and diabetes and had smoked on and off.

Mx. Smith also noted that the virus took an extra toll on Black and L.G.B.T.Q. people. Of the nearly 1.1 million Americans diagnosed with H.I.V., 63 percent are gay and bisexual men, and 40 percent are Black.

“A lot of us don’t make it,” Mx. Smith said. “It’s important to buck that trend. The best revenge for me is being an elder and being able to share and exist and to still be here.”

Heart disease and other conditions occur disproportionately among H.I.V.-positive people in part because of environmental risk factors that are more common among this group.

“People aging with H.I.V. are more likely to continue to smoke cigarettes, consume unhealthy amounts of alcohol and use cocaine than people aging without H.I.V.,” said Dr. Amy Justice, a clinical epidemiologist at Yale School of Medicine who studies this population. “Each of these behaviors adds to the excess risk of cardiovascular disease.”

Even without those risk factors, aging is accelerated in people with H.I.V. Researchers have long believed the reason to be chronic inflammation and immune dysregulation spawned by the virus, even when it is controlled by antiretroviral drugs.

Dr. Steven Grinspoon, Reprieve’s lead author and a professor at Harvard Medical School, said that the clinical trial also measured many chemical markers of inflammation in the volunteers’ blood and scanned their coronary arteries. The researchers are now looking at whether these data can help explain why the statin lowered cardiovascular events. The researchers will present their findings at a meeting in November.

Dr. Fauci suspected that this analysis will likely reveal that the statin tamped down the volunteers’ chronic inflammation, and in turn prevented the plaque buildup in the arteries that can precipitate a heart attack or stroke.

But experts said that the long-term care of people with H.I.V. will depend on much more than prescription drugs. An array of social problems are especially prevalent among older people with H.I.V. and can exacerbate the perils of aging, including poverty, loneliness, addiction, mental illness, stigma and housing insecurity.

Paul Aguilar, 60, was given five years to live when he was diagnosed with H.I.V. in 1988. He has survived, but not without struggle. The fat has drained from his face, a side effect of the toxic early generation of antiretroviral drugs. And he has weathered waves of lost peers in San Francisco: first from AIDS and more recently from other illnesses.

Last year, he began going to the “Golden Compass” program for aging H.I.V. patients at the University of California, San Francisco, which provides a panoply of services, including cardiology, exercise classes and dental, vision and mental health care. He said that the psychological counseling and support he received there helped him cope with his closest friend’s death by suicide and his own subsequent mental health crisis.

The university’s program is “really a godsend,” Mr. Aguilar said, noting that he has no out-of-pocket costs, thanks to his coverage from Medicare and Medicaid.

But the vast majority of older people with the virus still lack the type of high-quality care that has helped Mr. Aguilar thrive, experts said. Such programs are often prohibitively expensive and pose staffing and space demands that many clinics, especially in resource-poor areas, cannot hope to meet.

“Patients are falling through the cracks,” said Jules Levin, 73, a leading activist holding the bullhorn on behalf of H.I.V.-positive seniors such as himself.

After learning about the Reprieve study’s findings, Mr. Aguilar asked his doctor about starting a statin.

“I’m going to be crotchety and telling kids to get off my lawn,” he quipped.

At the age of 58, stuck in her house through the long nights of the coronavirus pandemic, Michelle Brennen started to spend more and more of her time thinking about the worst thing that had ever happened to her.

She was 10, on summer vacation. She had been playing in the yard in Essex, Vt., and when she came inside, she found her mother standing in the archway between the kitchen and the living room, crying.

“Daddy’s plane crashed,” said one of her five siblings — she has never known which one. The information did not register; she thought they meant one of her father’s model airplanes. No big deal, she thought. Just glue it back together.

It was 1973, a time when adults didn’t talk to children about death. That afternoon, a neighbor took the children to the beach so they wouldn’t see news coverage of the crash, among the deadliest in New England’s history.

The following week, when their father was buried, they weren’t allowed to attend the funeral. When school started, a guidance counselor called her in and asked her how she was doing. Michelle said, “Fine,” and that was that.

Maybe that’s why, all these years later, something kept steering Michelle’s mind back to the plane crash.

Clearing out her mother’s basement after she died in 2021, Michelle found a cardboard box where her mother had stored everything related to the flight, Delta 723 — newspaper clippings, correspondence with lawyers, journal entries.

Once she began reading, Michelle found that she could not stop. She was especially drawn by the dog-eared passenger manifest, 89 names on a battered sheet of paper. How many of them had left children like her behind? Where were those children now? How had their lives turned out?

And so, planting herself in front of an iPad at the dining room table, she tracked them down one by one. She popped up in their DMs. She called their landlines. She invited them to exchange stories on a Facebook page. She hoped she didn’t sound like a kook.

In her own way, she was exploring questions that have preoccupied the field of mental health. How does traumatic loss alter the course of a person’s life? Does grief subside more fully when left in a box, or when it is shared? Does it subside at all?

These questions hung in the air on a Sunday morning in July, when Michelle, now 60, awaited the arrival of around 200 people, nearly all of them strangers. Over two years, she had managed to track down survivors for all but four of the 89 people who had been aboard the plane, and persuade them to gather in person on the 50th anniversary of the crash.

She had chosen for the location of their one and only meeting an obvious and terrible place — Logan Airport, not far from the runway where Flight 723 had burst into flames.

The plane was descending through dense clouds surrounding Boston when something seemed to go wrong in the cockpit. “Going like a son of a bitch,” said the pilot, John Streil, to his co-pilot, Sidney Burrill, who was trying to line up the jet to approach the runway properly.

Thick fog in Boston had caused many flights to be diverted, so Flight 723, from Burlington, Vt., had made an unscheduled stop in Manchester, N.H., to pick up stranded passengers. Most of them were probably looking at their watches, worried about making connecting flights.

On the instructions of air traffic control, the crew had made a series of turns intended to align the aircraft with a localizer beam, which demarcates the centerline of the runway and acts as a guide for pilots in low visibility.

But they were moving too fast — 237 miles per hour — and they were too high. They overshot the localizer, and then scrambled to correct course, descending too quickly.

The crew had been told that the cloud cover was at 400 feet, and peered into the whiteness, expecting to break through at any moment. But a thick bank of sea fog was moving across the airport. They saw nothing.

“OK, just fly the airplane,” the pilot said, according to cockpit voice recordings. Two seconds later, Mr. Streil understood that the plane’s flight director was malfunctioning, and he said: “You better go to raw data. I don’t trust that thing.”

For the first time, his voice betrayed strain. “Let’s get back on course if you can,” he barked at his co-pilot. The plane was traveling at around 150 m.p.h. when it hit the concrete sea wall that separates the airport from Boston Harbor.

The impact shattered the plane, and pieces of the cabin rocketed forward onto the runway. A construction worker nearby described a “large, long flame” appearing on the runway, rising “as if it were a curtain.”

When rescue workers arrived, they found fragments of the plane and its passengers scattered down the runway, covering an area the size of three football fields. There were blue and red seats, some with passengers still strapped in.

The remainder of the aircraft had broken with such force that, a spokesman with the National Transportation Safety Board later said, “you could pick up almost any of the pieces in your hands.”

Many things went wrong simultaneously during the landing, Paul Houle, a former U.S. Army accident investigator, concluded in his 2021 book on the disaster. The plane’s flight director was faulty; the air traffic controller was distracted; the crew had been misinformed about the weather. Each of these factors, he said, carried equal weight.

But at the time, the public was offered only one explanation: pilot error. Aviation officials “would only say that the pilot, Captain John N. Streil Jr., was flying the jetliner 230 feet too low and 3,500 feet short of the usual touchdown point,” The Associated Press reported.

Fishermen told The Boston Globe that the fog had been so thick that they hadn’t been able to see their hooks hit the water. “The goddamn fools, flying in this weather,” one of them said.

The box

On the day of her father’s funeral, Michelle watched the adults leave in their church clothes.

She had shouted at her mother — she thought she was old enough to go — but now the fight had drained out of her, and she sat on a cement floor in an unfinished part of the house, behind a piece of lumber, where they couldn’t see her cry.

To comfort her, an aunt promised to bring her a gift: a bottle of Shower to Shower baby powder. But nothing could comfort her.

She came to understand her role in the family tragedy. “You knew something big was going down, and you didn’t make any waves,” she said. Her mother was “constantly trying to get us to go outside and play — go outside and play.”

In all that silence, terrible thoughts snagged in her mind. The night before the crash, she had gotten into an argument with her father, and, “in my 10-year-old, very stubborn and bossy way,” muttered to herself: “I wish you would die.” This ate at her, this unforgivable thing, but she never told. Whom would she tell?

And somehow it transpired that she did not quite take in her father’s death. Years later, she still sometimes thought she spotted him in crowds. She would look for him in Barre, Vt., where he had grown up. Her sister Denise, who was 8 when their father died, felt the same way. “I kept thinking for years that he was coming back,” she said.

Her father, Michael Longchamp, was 39 that summer, working as a draftsman at an architectural firm. He was an outdoorsman and a former Air Force tail gunner. By temperament, he was preternaturally even-keeled. At home, he would lie back in an armchair and let his six children crawl over him like puppies.

That summer was a perforated line, separating life with their father from life without him: Tear here.

The extended family closed ranks; their aunt moved her family back to Vermont so she could be near. Michelle remembers her mother, Patricia, as always busy in the years that followed. Chris was 9; Denise was 8; Anthony was 6; Renee was 5; and Joseph was 2. “It wasn’t like she could sit and cry over it with nobody around,” she said. “She had stuff to do.”

In that sense, they coped well. They moved on. “My family did a fabulous job of making sure that we didn’t feel any repercussions over it,” she said. “You know, we didn’t dwell on it.” But something was off-kilter, like a bone that had not been set properly. Even today, she wonders: Who would they have been if their father had not died?

After graduating from high school, she got a job at a flower shop and married her high school boyfriend, more or less to get out of the house.

She is sure that would not have happened if her father had been alive. He would have insisted that she go to college. Maybe she would have followed her father into the military. At the least, she would have left Vermont. “I think about that every day,” she said.

It was worse for her brothers, though. “You’re the man of the house now,” one of the grown-ups told Chris.

“I think my mother, to her deathbed, would say that just crushed him,” Michelle said.

When Michelle found the box in her mother’s basement, she realized how much her mother had carried alone. There were her father’s death certificate — “two broken legs and generalized thermal burns” — and her mother’s handwritten journals.

“Anthony asked tonight to see a picture of his daddy, because he had forgotten what he looked like,” read one of the entries. “I showed everyone a picture and Joseph laughed right out loud and said, ‘That my daddy.’ It hurts so much sometimes I don’t think I can make it.”

“In 48 years, we never knew that side of her, the pain she was going through,” Michelle said. She wondered if the box was a form of communication, whether she was meant to look inside.

“My mother had saved that whole box of stuff,” she said. “And I’m thinking that maybe, I did it for her, too. Like, maybe in the back of her mind, she thought this was important.”

On the phone

Tracking down the other families felt satisfying. When she finally did get her bachelor’s degree, racking up one or two credits each semester while working two jobs, she had majored in psychology. Now she rolled up her sleeves and began collecting data.

There were, as a social scientist might put it, correlations. Many of the passengers’ children recalled feeling completely alone in their grief, excluded from the rituals of mourning. Douglas Watts, an IT manager in Portland, Maine, was 8 when his mother, Sandy, died in the crash. “It was basically: She died, we had a service, it was done,” he said. His job, he understood, was “to never do anything that brought pain or emotion to anybody.” So he did not cry, not once.

Many shared the feeling that the crash had radically changed the circumstances of their lives, setting them on a new path. Albert Holzscheiter, a building contractor in Fredericksburg, Texas, was 3 when his father died in the crash. His mother moved the family to Key West, Fla., as far as she could get from the extended family in Vermont.

“It has totally changed and rewired who I probably would be,” he said. “I do not know if I would recognize the person that I would have been.”

Even their memories of the day itself lined up with hers. Cornelia Prevost, who was 12 when her father, Count Laszlo Hadik, died in the crash, had written a poem that made Michelle cry when she read it, it was so close to her own recollection.

“A glorious, simple / summer day tripped / into slow motion,” it read in part. “Expectant, heavy calm / an approaching thunderhead / and sibilant grownups roboted. / We knew not to be boisterous.”

But not everyone understood what she was trying to do. “I’m barely getting people to tell me who they are,” she complained a year into the effort. It was too painful, some of them told her. “You know, my family was ripped apart, and I can’t even talk about it,” she recalled some saying.

Cindy Provost Long, 66, a nurse in Bennington, Vt., felt that way. She was 16 when the plane crashed; her grandmother, two cousins and her 14-year-old brother, Michael, were on board. She remembers a doctor coming “and giving my mother some kind of injection to calm her down.” After that, her mother “had, essentially, a nervous breakdown.”

She never really got better. Ms. Long used to wait for the mail so she could throw out her brother’s Mad magazine, to spare her mother the pang of seeing it. When dementia clouded her mother’s memories, she said, it was a blessing.

For Ms. Long, discussing the loss on Facebook was not therapeutic. The scab that had formed in her mind, slowly, over decades, was prized off, and she started having bad dreams again, lying awake at night, “asking what-ifs.” Michelle’s whole outreach project, she said, was “an intrusive act.”

“It’s too late, and it’s still too personal,” she said. And as for getting together at Logan Airport? No, thank you. “I don’t understand how this could be, like, a celebration,” she said. “Is it the airport asking forgiveness? Is it Delta that is doing this? I don’t even know what it is.”

Michelle didn’t argue when she got that kind of response. But there were a few families she kept going back to, because their story troubled her so deeply: the families of the men in the cockpit. Early in her research, she learned something she found wrenching. As New Englanders mourned the dead of Flight 723, some had turned their anger on the pilots’ families.

“They got death threats over the phone. They got death threats in the mail,” said Hollie Streil, who married the pilot’s son, John Randolph Streil. The experience, she said, “turned his mother into an alcoholic.”

Mr. Streil, who was 12 at the time of the crash, began drinking heavily in his teens, and struggled with addiction throughout his life. “He, his family, bore the brunt of everyone’s anger,” Ms. Streil said. “I just remember my husband just sitting and crying and saying they blamed him.”

She and Mr. Streil divorced in 2013 but lived together until he died of a heart attack in 2015. Her feelings about the crash and its aftermath were complicated and dark. But Michelle kept reaching out to her, and Ms. Streil became convinced that her intentions were good.

So she arranged to attend, with three children and two grandchildren.

She was dreading it, she confessed. “This has been buried under the rug for so long. All of a sudden people are going to rip up the pieces,” she said.

“I will be glad when it is over,” she said. “I don’t think I will ever go back into Boston.”

In the ballroom

On the night before the big gathering, Michelle was frazzled and anxious. She had developed a sinus infection, and was so hoarse she could barely speak. Also, she was acutely aware of the things that might go wrong.

Culpability was litigated, slowly and painfully, for nine years after the crash. Passengers’ families sued Delta; Delta argued that the air traffic controllers were responsible; the pilots’ families sued the manufacturer of the faulty flight director.

But none of it, not the settlements or the court decisions, fully put to rest the question of blame. Two years of research had given Michelle a sense of the anger that some families still harbored, burning as steadily as a pilot light.

Now, at her request, they would all be in the same room, with an open microphone. This was a minefield. Delta had donated money for the buffet lunch. Then there were the Streils, whom she had coaxed into attending. What was she thinking?

It was true, she had shaken things loose. Mr. Holzscheiter, who had driven 30 hours from Texas, felt a wave of sickening panic after he checked into his hotel; he wasn’t sure he could go through with it. His wife, Ginger, compared the gathering to the story of Pandora’s box from Greek mythology, releasing all manner of phantoms.

On her way to the ballroom, Liz Axness, who lost her mother in the crash, found herself in an elevator with a group that appeared to be headed to the event. When she asked, “Who was your loved one?” one of them replied — meekly, she thought — that they were from Delta.

“I’m like, What do you think I’m going to do, kick you in the tummy or something?” she said. “You weren’t even born.”

The night before, Jim Fuller, a sportswriter who lost his mother and father in the crash, had met the Streils. It had been a pleasant interaction; they had participated in a memorial blood drive he had set up.

He had nothing but compassion for the Streils; their family, he said, “had been through more than any of us.” He would never assign blame. But a question had gnawed at him since he was 8, and he could not help asking it aloud now.

“Why,” he said, “would you try to land a plane if you can’t see the runway?”

Coming to terms

One thing that has changed in this country since 1973 is the way we respond to traumatic losses.

When a child dies in a car accident, grief counselors are on hand at schools, to help students process their feelings. Police officers attend debriefings. Bereaved people send out flares of raw grief on social media. This is viewed as healthy. With luck, it gives us closure.

But researchers trying to pin down this phenomenon have been left with doubts. Two years after the terrorist attacks of Sept. 11, Roxane Cohen Silver, a social psychologist at the University of California, Irvine, and a team of researchers looked at a group of people who had been asked to describe their emotions on the day of the attacks.

What they discovered, she said, was that “those who emoted most, wrote the most words, actually did the worst over time.” It wasn’t that emoting was bad, Dr. Silver said. More likely, those who emoted more were simply in more distress.

Her research has also called into question a much larger assumption: that people who suffer terrible losses eventually come to peace with them. In a 1989 study, she and Rosemary Tait interviewed 45 older men and women — the mean age was 76 — about the worst thing that had ever happened to them. For most, it was the death of a spouse or a close family member.

These were old losses; the average elapsed time was almost 23 years. What the researchers found was that the pain had not gone away. Seventy-one percent said they still experienced mental images or memories of the loss, and 96 percent said they sometimes ruminated about it. Thirty-seven percent said they were still searching for meaning in it.

“There are some for whom resolution never happens,” Dr. Silver said. “And there is some acknowledgment that, for some people, they will never resolve their sudden tragic loss, and they will probably function well. It’s not that they will not be able to get out of bed. But they will not, quote, get over it.”

Still, something seemed to be happening that morning in the lobby of the airport Hilton, as those who had come recognized one another. They embraced each other, squeezed each other’s hands. They ran their fingers over a memorial plaque of Vermont granite that had been mounted in the airport’s chapel.

It was a comfort. There were so many of them. “My mother was on the plane,” a woman in dreadlocks told a man in Bermuda shorts. “My father was on the plane,” he responded.

Finally, they took their seats in a ballroom, where photographs of the dead were projected onto a screen. Michelle’s sister sang with her barbershop quartet. Someone read a poem by Robert Frost. Michelle said she hoped they could set aside whatever anger and bitterness remained, to honor the dead.

Then Jillian Streil, the pilot’s granddaughter, made her way to the microphone. She was 37, a waitress in Manchester, N.H., with blond bangs and cat’s-eye glasses.

She never met her grandfather, but when she searched online for information about the crash, the phrase that came up was “pilot error.” She had read through the passenger manifest many, many times. “I almost feel like it’s my responsibility,” she said.

Standing before the passengers’ siblings and spouses, their children and grandchildren, she held up a piece of paper on which she had written down what she wanted to say.

“He deserved to be remembered for more than this awful tragedy,” she said. So she said a few words about him. That he had been a devoted son. That he had loved to fly. That when he died, he had a son who was about to turn 13. That as his wife and son mourned, they absorbed the hatred of those who blamed him.

“They are no longer with us, and that’s why I am here today, to speak for them,” she said.

Standing up there, she set aside passages of the speech — things she had been thinking about for 20 years — because she couldn’t get through them.

“From the Streil family, thank you all,” she said.

She returned to her seat, looking pale.

And then a row of people were lined up to put their arms around the young woman.

The son of Bette Vincent, who died in the crash, hugged her.

The son of Sandy Watts, who died in the crash, hugged her.

The son of Al Holzscheiter, who died in the crash, hugged her.

The sister-in-law of Michael Longchamp, who died in the crash, hugged her.

The sister-in-law of Maria Abrams, who died in the crash, hugged her.

Michelle hugged her. And, for the first time that day, she wept.

Closing the box

Then it was done. The families dispersed quickly, stopping by a desk outside to validate their parking tickets, vanishing into the hubbub of the airport.

On the long drive back to Texas, Mr. Holzscheiter had time to consider something that had been proposed at the gathering: that this group reconvene every 10 years. “I think the word ‘generations’ was used,” he said.

He disagreed; his children didn’t have strong feelings about the crash, and he thought that was as it should be. “Daddy’s memory will die when I die,” he said. “My generation, and my mother’s generation, remembers them, and I think it should probably pass on.”

Michelle returned to Vermont the same day, loading up her S.U.V. with tote bags and centerpieces. All morning, people had been praising her, thanking her for bringing them together, and this made her uncomfortable; she shook it off reflexively, the way a dog shakes off water.

She was now finished with the memorial, a moment her friends and family had long pondered. What would she do without her project? The next day, she spent some time with her chickens. She went to see “Barbie” with her girlfriends.

But it didn’t take long before she started thinking about the crash again. Strangers were reaching out through the Facebook page. She still had questions; she had never known what meetings her father had been headed to in Boston that day, and it bothered her.

So her mother’s box of documents stayed in its spot at the dinner table, and before long, she was back at her iPad, looking for those four families she had never been able to reach.

Audio produced by Tally Abecassis.

In the weeks after Rachael Shaw-Rosenbaum, a first-year student at Yale, died by suicide in 2021, a group of strangers began convening on Zoom.

Some of them knew Ms. Shaw-Rosenbaum. But many only knew what she had been going through, as she struggled with suicidal thoughts and weighed the consequences of checking herself into the hospital.

One, a physician in her early 40s, had been told years ago to withdraw from Yale while she was hospitalized after a suicide attempt, an experience she recalls as chillingly impersonal, “like you’re being processed through this big machine.”

Another, a classical pianist in his 20s, withdrew from Yale amid episodes of hypomania and depression, feeling, as he put it, “not just excluded but rejected and cut off and forgotten about.”

Members of the group, which took the name Elis for Rachael, shared a complaint that Yale’s strict policies on mental health leaves — requiring students to withdraw without a guarantee of readmission, stripping them of health insurance and excluding them from campus — had penalized students at their most vulnerable moments.

“We discovered that there were just generations of Yalies who had had similar issues, who had kept quiet about it for decades and decades,” said Dr. Alicia Floyd, the physician, one of the group’s founders. “And we all felt like something needed to change.”

The organizing that began that day culminated last month in a legal settlement that considerably eases the process of taking a medical leave of absence at Yale.

Under the new policy, students will have the option to extend their insurance coverage for a year. They will no longer be banned from campus spaces or lose their campus jobs. Returning from leave will be simpler, with weight given to the opinion of the student’s health care provider.

Most strikingly, Yale has agreed to offer part-time study as an accommodation for students in some medical emergencies, a step it had resisted.

“My hope is that the changes that have emerged from these discussions will make it easier for students to ask for support, focus on their health and well-being and take time off if they wish, knowing that they can resume their studies when they are ready,” said Pericles Lewis, the dean of Yale College, in a message to students.

Yale declined to comment beyond the statement from Dean Lewis.

Yale’s withdrawal policies were the subject of a Washington Post investigation in November 2022. The same month, Elis for Rachael filed a class-action lawsuit accusing the university of discriminating against students with disabilities.

Yale is not the only elite university to face legal challenges over its mental health policies. The Department of Justice has investigated Brown and Princeton over their handling of withdrawals, and Stanford faced a similar class-action lawsuit in 2019.

By offering part-time study as an accommodation, Yale has provided relief beyond what Stanford did, said Monica Porter Gilbert, an attorney at the Bazelon Center for Mental Health Law who represented plaintiffs in both cases.

“It’s the students and the plaintiffs in this case making their voices heard and bringing Yale to the table to have difficult conversations,” she said. The pandemic years, she added, have brought new urgency to their arguments. “As a nation, we talk about mental health differently now.”

Alicia Abramson, a Yale senior who is one of the two student plaintiffs in the class-action lawsuit, said Yale’s response was swifter and more comprehensive than she had expected. “It’s hopeful, in the sense that maybe they are finally taking this thing seriously,” she said.

She has no plans to abandon her advocacy work anytime soon, though. “I’m certainly hesitant to give Yale infinite praise,” she said. “You know, we had to sue them, right?”

A Campus Shaken

As she struggled with suicidal thoughts in the second half of her first year at Yale, Ms. Shaw-Rosenbaum worried she would be forced to withdraw, jeopardizing the scholarships she needed to stay at Yale, said Zack Dugue, her boyfriend.

She had already been hospitalized once, her first semester. “Basically, if I go to the hospital again, I will not be able to resume college and will lose the opportunity I had to learn at an extremely competitive university,” she wrote in a post on Reddit a few days before she died.

Growing up in Anchorage, Alaska, Ms. Shaw-Rosenbaum had been a debate champion. She dreamed of following her idol, Ruth Bader Ginsburg, to the Supreme Court.

Mr. Dugue, who met her at a scholarship event the spring of their senior year of high school, described her as “a tiny firebrand” and “super-duper kind.” She was still very young: Mr. Dugue was the first boy she ever kissed, her mother said.

She was not from a wealthy family; at home, she had at one time received health care through Medicaid. Withdrawing would mean losing not just her sense of belonging, but her Yale health insurance, a prospect Mr. Dugue said she found “apocalyptic.”

“She also would have lost access to the very care she needed,” he said. “That was like a terrible tightrope to walk.”

For decades, students had criticized Yale’s withdrawal and readmission policies, which were deemed among the least supportive in the Ivy League in a 2018 white paper by the Ruderman Family Foundation.

In 2015, a sophomore math major named Luchang Wang died by suicide after posting a desperate message on Facebook, saying she “couldn’t bear the thought of having to leave for a full year, or of leaving and never being readmitted.”

“Yale was a case where they were being very strict, and people would have to apply multiple times,” said Marcus Hotaling, president of the Association for University and College Counseling Center Directors and director of counseling at Union College in Schenectady, N.Y.

Colleges must weigh the risks of allowing struggling students to remain on campus, he said, since they may be found liable for allowing a student’s condition to deteriorate.

Dr. Hotaling cited the case of Elizabeth Shin, a student at the Massachusetts Institute of Technology who died by suicide in 2000. Her parents, who had not been told of her decline, filed a $27 million wrongful death lawsuit against M.I.T.; the case was settled for an undisclosed amount.

Suicide contagion may be a concern for the university; so is the effect a suicide on campus may have on the larger community. “That’s going to have a drastic impact on the roommate, on the residents who live around them, their friends, their peers, their classmates,” he said.

After Ms. Shaw-Rosenbaum’s death, Yale officials took the unusual step of releasing a statement denying an allegation, circulating on social media, that Yale had refused her request to take a leave.

Undergraduate activists began demanding changes to the leave policy, as they had after previous suicides, but there was little response from Yale. “At the end of the day, we recognized we were at the mercy of the institution,” said Miriam Kopyto, who was then a leader in the Yale Student Mental Health Association.

A shift came with the involvement of alumni, who convened their first Zoom meeting just a few days after Ms. Shaw-Rosenbaum’s death. About two dozen people attended, including Mr. Dugue, and all felt some personal connection to the cause, said Lily Colby, a community organizer.

They held a moment of silence, shared pictures of Ms. Shaw-Rosenbaum and told their own stories. “We have been impacted in some way,” Ms. Colby said later, describing the core group. “We’ve had a loss or a tragedy.”

Students had tended to ask the university for accommodations on the grounds that it was the right thing to do, Ms. Colby said. The alumni began educating them on what they could demand under law — like a change to the leave policies.

For student activists, this was a fundamental shift. “Some of it is a favor,” Ms. Kopyto said. “And some of it is not.”

‘Time Away Mentors’

In January, Yale introduced major changes to its policy, reclassifying mental health breaks as leaves of absence rather than withdrawals, extending health insurance benefits and simplifying the reinstatement policy.

The settlement expands those protections by offering part-time study and creating a “Time Away Resource” for undergraduates. The court will oversee Yale’s compliance with the agreement for three years.

Lucy Kim, 22, who was among the last undergraduates to take a medical withdrawal under the old system, recalls crying when she read the news, because the accommodations were the ones that she had needed.

“I just kept thinking, if only I had gotten sick a year later,” she said.

She was a second-semester sophomore, juggling coursework in molecular biology and biochemistry and global affairs, when she stopped sleeping for 40-hour stretches. Her hands shook so violently that she dropped things. She began hallucinating.

Diagnosed with a sleep disorder, she initiated a medical withdrawal in December 2021. She had studied the policies, but was still jolted by the reality: She was given 72 hours to vacate her dormitory and surrender her key card.

“It really is like losing your house, your job and your family, all at the same time,” she said. She drained her savings, she said, spending $15,000 on rent, food and tuition for summer school classes before applying for reinstatement by submitting an essay, grades and letters of recommendation.

Ms. Kim, who will graduate next May, hopes mental health leaves will be seen differently now. This weekend, she began recruiting undergraduates to serve as “time away mentors” who help others navigate the process of taking leaves and returning to campus. She hopes that the university will provide funding.

“I think that Yale does want to move in the right direction,” she said. “It’s a matter of accumulating those voices for change until it reaches the threshold point where Yale says this is probably for the benefit of the greater student body.”

In interviews, students said the new policy opens avenues they had viewed as shut.

“What they’ve done has created an opening where I feel like I could actually go back if I wanted to,” said one former student, Jen Frantz, referring to the option of part-time study. She withdrew from Yale twice because of mental health crises, and finally let go of the idea of finishing her degree.

Ms. Frantz, 26, went on to get an M.F.A. in poetry at the Iowa Writers’ Workshop and now tutors students working on college essays. She said she felt “a little light touch of mourning of what could have been if they had been more prompt.”

As for Ms. Shaw-Rosenbaum, she was a stickler for detail. Had she lived, Mr. Dugue said, she might have sued Yale herself at some point.

“She read the withdrawal policies, she explained them to me, she was thinking about them, she knew they were wrong,” he said.

Rachael’s mother, Pamela Shaw, singled out two provisions of the settlement that she thought would have helped her daughter: part-time study and an administrator dedicated to advising on time away.

“I just wish she’d been here for the fight,” Ms. Shaw said.

Kitty Bennett, Susan Beachy and Alain Delaquérière contributed research.

Audio produced by Sarah Diamond.