Health | The Atlantic

It’s Maddeningly Difficult to Ban Smoking

2026-05-19T15:10:05-04:00

Since tobacco first arrived on the shores of England in the late 16th century, some Brits have wanted to eradicate it. Back in 1604, King James I was so alarmed about his country’s new smoking habit that he imposed a 4,000 percent tariff on the crop. That year, he wrote one of the world’s first anti-tobacco essays, declaring smoking “lothsome to the eye, hatefull to the Nose, harmefull to the braine, dangerous to the Lungs.”

Despite the best efforts of the king and the generations of anti-tobacco activists who followed him, people in the United Kingdom still smoke. Now advocates are hoping a new law that prohibits anyone born on or after January 1, 2009, from ever buying cigarettes will finally end the habit for good. But the tobacco-free generation, at least in the short term, is unlikely to truly be tobacco free.

Generational tobacco bans were first proposed in 2010 by a group of researchers in Singapore. Around that time, less extreme anti-tobacco measures—such as media campaigns, clean-air laws, and taxes—had reduced smoking in many countries to such a point that public-health advocates started to seriously consider policies that could shrink rates to effectively zero. A tobacco “endgame,” as it has become known, was in sight. “I want to stamp out smoking for good,” Rishi Sunak, the former U.K. prime minister, said in a statement when he first proposed the plan in 2023.

Currently, U.K. residents need to be 18 or older to purchase cigarettes. The new generational ban will introduce a more unusual paradigm: Beginning on January 1, 2027, an 18-year-old born on New Year’s Day 2009 will not be able to buy products such as cigarettes and chewing tobacco for the rest of their life. But a friend born one day earlier would face no such barrier. That means, as some critics of the ban have pointed out, that 18-year-olds will almost certainly bum cigarettes from older friends—the same way younger teens have acquired them since time immemorial. Data suggest that most adolescent British smokers get cigarettes for free from older people they know. In one study, in which researchers interviewed British smokers as young as 12 about how they obtained cigarettes, kids who waited outside of tobacco shops in the hopes that an older customer would buy for them reported mostly targeting people under 25.

[Charles Fain Lehman: The end of cigarettes is coming]

Lawmakers included language in the bill designed to dissuade older people from buying cigarettes for their underage acquaintances. But, more important, that issue will likely work itself out over time. By 2034, no one under 25 will be able to purchase cigarettes. And with each passing year, kids’ sources of illegal cigarettes should progressively dwindle. Because having peers who smoke increases young people’s chances of starting themselves, fewer kids being able to get their hands on cigarettes should have a ripple effect, dissuading more and more of their peers from experimenting. By 2079, no one under 70 will be legally able to smoke. It will become the habit not of teenage rebellion but of retirement homes.

This all depends, of course, on retailers actually following the law—a big if, according to some tobacco-control experts I spoke with. In a 2023 NHS survey, one-third of youth smokers reported regularly (and illegally) buying cigarettes from shops. “I don’t think we should play down the need for enforcement,” Nathan Davies, a doctoral fellow at the University of Nottingham who studies tobacco control, told me. And even if shopkeepers play by the rules, other people might not. Consider the small Himalayan nation of Bhutan, where all tobacco sales were banned in 2004 but cigarettes remained easy to access because a black market quickly cropped up. Those dealers didn’t serve just existing smokers but also young children. In 2019, nearly a quarter of 13-to-15-year-olds in the country used tobacco.

Nigel Farage, the leader of the right-wing Reform U.K. Party, has repeatedly insisted that such a black market could appear in the U.K. too. But the country’s experiment was not technically a generational tobacco ban, unlike the policy in the U.K., which was crafted to ensure that most current smokers can continue to buy their products legally, thus shrinking the profitability of any black market. The Bhutan and U.K. policies are “structurally so different in scope, sequencing, enforcement infrastructure, and market context that the comparison generates more confusion than insight,” Kashish Aneja, who leads initiatives in Asia at Georgetown University’s O’Neill Institute for National and Global Health Law, told me via email.

[Read: What’s so bad about nicotine?]

No actual generational tobacco ban has existed for enough years to reveal its long-term effects. The Maldives, a small island nation south of India, implemented such a policy in November. Several Massachusetts towns have also passed similar bans. Brookline, a wealthy suburb of Boston, was the first, enacting its own version in 2021. Available data suggest the ban has had little effect on cigarette smoking thus far, but according to advocates, real change will take much more time. “It is a slow and gentle policy change which will result in changes over the mid and long-term,” Mark Gottlieb, the executive director of the Public Health Advocacy Institute at the Northeastern University School of Law, told me in an email.

New Zealand’s left-wing Labour Party passed a tobacco-free-generation policy in 2022. But the country’s new center-right coalition government, on taking power in 2024, repealed the law before it went into effect. The government’s stated reasons for the repeal were so that cigarette-tax revenue could pay for a slew of new tax cuts, and because, it was argued, the policy would have fueled illegal smuggling. Something similar might happen in the U.K. Farage, himself a smoker, has called the ban “puritanical” and vowed to repeal it if his party takes power.

He’s probably not the only one who’d like to see that happen. Tobacco companies urged Parliament not to pass the law, arguing that it was discriminatory and would not prevent youth smoking—and would increase crime, to boot. “Every year from 2027 onwards a generational ban will hand more of the UK tobacco market to the serious organised criminal groups who will use the proceeds of illegal tobacco to fund activities including terrorism, weapons trading, the distribution of narcotics and people smuggling,” Japan Tobacco International, which owns a number of the most popular cigarette brands in the U.K., wrote. (In a statement, a JTI spokesperson added to that list, writing, “Illegal tobacco in the UK has been linked to organized crime, including activities such as money laundering, human trafficking, and violence.”) The tobacco industry, along with smokers’-rights groups, also aggressively courted certain U.K. conservatives as the new ban was being debated, hosting them for lunches and at least one party.

[Read: The allure of smoking rises again]

I asked several major British tobacco companies whether they would like to see the ban repealed, but they declined to answer, instead emphasizing that they will work with the U.K. government to determine how the law is implemented. If the industry wants to continue fighting the ban, they’ll be aided by the fact that the policy will take so long to have real effects. A recent modeling study led by Davies found that the ban should result in smoking rates among people under 30 dropping below 5 percent—a commonly accepted goal of so-called endgame strategies—by 2049. That would give cigarette makers decades to publicize middling results, along with any instances of smuggling they can uncover.

Some proponents of tobacco-endgame policies have their own doubts about the feasibility of generational tobacco bans. Ruth Malone, a UC San Francisco professor who wrote one of the first articles articulating the idea of a tobacco endgame, has suggested that governments could instead pursue a “rapid ban” on cigarettes for people of all ages, additional restrictions on where tobacco can be sold, and prohibitions on all flavored tobacco products. Whereas generational bans give cigarette companies time to influence policy, Malone says, immediate policies would more quickly diminish the industry’s profits, and thereby its power.

[Read: America just kinda, sorta banned cigarettes]

Despite the debate, generational smoking bans are broadly popular. A poll commissioned by the anti-smoking group Action on Smoking and Health found that 68 percent of English people support the new ban. In New Zealand, about 60 percent of voters opposed the country’s about-face. Perhaps that’s because smoking remains one of the world’s leading causes of preventable death, or because the overwhelming majority of smokers regret ever starting. The new policy might not make much difference for today’s teens, but decades from now, a new generation really might avoid that lifelong error—as long as the ban actually sticks around.

This Ebola Outbreak Will Be Hard to Contain

2026-05-19T11:11:47-04:00

Updated at 6:24 p.m. ET on May 19, 2026

Quite abruptly, the world has jolted into another infectious-disease crisis. On Friday, Africa CDC confirmed a new Ebola outbreak, centered in the Democratic Republic of the Congo; within two days, the World Health Organization declared the epidemic a public-health emergency of international concern. The virus, which has also spread to Uganda, is suspected to have sickened more than 500 people and killed more than 130—counts that suggest to experts that it has been spreading largely undetected in the region for several weeks, if not months.

Central and West Africa have weathered dozens of Ebola outbreaks before. But this new epidemic has already surpassed most others in size, and “my projection is that it will get worse before it gets better,” Nahid Bhadelia, the director of Boston University’s Center on Emerging Infectious Diseases, told us. The global-health backdrop is simply different in 2026, largely the result of a series of public-health decisions made by the United States in the past year and a half—among them, dismantling USAID, withdrawing from the WHO, and ousting infectious-disease experts en masse from the CDC, which remains without a permanent director. As things stand, the outbreak has already reached a point at which experts feel certain it will be very difficult to contain. The world’s fractured global-health community is now playing a lethal game of catch-up with an extremely dangerous virus.

Experts suspect that a number of epidemiological factors helped the crisis quickly swell in size, mostly under the radar. The outbreak so far centers on two mining towns—Mongbwalu and Rwampara—in a region of the DRC where access to health care is inconsistent and traffic in and out is high. During a press conference on Saturday, Jean Kaseya, the director general of Africa CDC, described the area as “very vulnerable and fragile.” Relatively remote regions with high mobility and porous borders can be ideal settings for viruses to spread unnoticed, especially for pathogens such as Ebola, whose early symptoms can resemble those of typhoid and malaria, also endemic to the region. Those parts of the DRC have been plagued by civil unrest and intense armed conflict, raising substantial barriers for sick people to seek care and access tests, Krutika Kuppalli, a Dallas-based infectious-disease physician who ran an Ebola treatment unit in 2014, told us.

The strain driving the outbreak, known as Bundibugyo, is hard to catch and challenging to fight. Rapid diagnostic tests for more common versions of Ebola—the ones most readily deployed—often miss it; early test results using these tools came back negative. The epidemic’s hot spot is also far from the main DRC-based microbiological laboratories that do more precise testing, prolonging the time from sampling to confirmation, Boghuma Titanji, an infectious-disease physician at Emory University, told us. To compound the challenges, Bundibugyo has no approved vaccines or treatments. According to The New York Times, the local response may have been lacking as well: Officials in Ituri province, at the center of the outbreak, were slow to report the first patients to show concerning symptoms, and didn’t immediately dispatch test samples to Kinshasa, the capital.

But a strong international response is a crucial partner to a domestic one. When Ebola has sparked outbreaks in the past—including the recent, record-breaking one that began in 2014 and reached 28,000 cases—USAID and the CDC, in coordination with the WHO, played instrumental roles in the global response, including detection and early containment. “During the first Trump administration, when they were faced with a situation comparable to this, they did a pretty good job of it,” Jeremy Konyndyk, who led the U.S. government’s humanitarian response to Ebola under President Obama during the 2014 outbreak, told us. In 2018, for instance, the Trump administration sent teams from USAID and the CDC to the DRC within days of an Ebola outbreak being declared. The CDC collaborated with the WHO to distribute experimental, single-dose Ebola vaccines.

But under the second Trump administration, which has disparaged public health, cut foreign aid, and demeaned vaccines and other crucial components of the infectious-disease tool kit, U.S. support for global health has been severely weakened, sapping surveillance networks, laboratories, and health-care response teams of resources and personnel. In 2024, some $1.4 billion of the DRC’s foreign aid—more than 70 percent—came from the U.S.; that number has since plummeted, a loss that has kneecapped local health delivery. (In a January 2025 executive order, the White House justified the U.S.’s withdrawal from the WHO by criticizing its “mishandling of the COVID-19 pandemic” and failure to reform.)

The Trump administration’s early freezes on USAID funding compromised the DRC’s ability to deliver medicine to rural clinics, which are typically funneled through pharmacies via a USAID-supported pipeline, as the physician Céline Gounder wrote; those aid cuts also happened around the time that a local rebel group known as M23 took over a province that houses a major humanitarian operation for the eastern DRC, compounding aid groups’ difficulties. Local mortality rates have since skyrocketed, likely from infectious diseases, including ones that can resemble Ebola in symptoms—which, in the case of an outbreak, has made it that much more difficult “to identify the signal from the noise,” Bhadelia told us.

More recently, the U.S. delivered another blow to the DRC. This year, the State Department declined to renew funding for more than 100 foreign-aid programs that the department classified internally as lifesaving. One program under that umbrella, providing “vital emergency health” support in the region where the outbreak is occurring, had its U.S. funding end in March, according to an internal State Department document reviewed by The Atlantic.

In February, the U.S. did commit to supporting health in the DRC in some form: The two countries agreed on a strategic health partnership, to cover infectious disease and other expenditures—though that deal includes just $900 million of U.S. aid, spread over the next five years. This week, the State Department also announced that it would mobilize additional funds to support outbreak containment. (The White House, CDC, State Department, and WHO did not respond to requests for comment at the time of this story’s publication.)

Ultimately, though, the U.S.’s withdrawal from the WHO has still meant that the organization lost its largest funder and one of its most prominent partners in global health, shrinking its capacity to respond to any crisis. And the U.S.’s posture toward global health and foreign aid is now substantially more hostile. A senior State Department official told us that the WHO has been excluded from receiving humanitarian funding from State—which he described as “a major constraint for emergency health programming.” (The official requested anonymity out of fear of retribution for speaking publicly.)

Amid the U.S.’s pullback, other high-income countries have stepped in to help. The European Union, for instance, has announced that it has personal-protective-equipment stockpiles ready to deploy to the region. After decades of battling Ebola, West and Central Africa also have plenty of experience to leverage, including in the absence of typical American assistance: This past December, the DRC declared the end of a separate Ebola outbreak. But the U.S.’s absence from the WHO is especially apparent in conditions of crisis. Under an administration that was friendlier to global public health, “we may have quicker mobilization of resources,” simply because more of them would already be there, Bhadelia said.

In the days since the outbreak was declared, the U.S. government has indicated that it is willing to respond in some capacity. The CDC has held press conferences and announced a travel ban on people returning from the DRC, Uganda, and South Sudan; agency staff based in the DRC and Uganda are assisting with contact tracing and local border screening.

Experts also told us that the country’s ongoing participation in the recent hantavirus cruise-ship outbreak may bode well: At the very least, American public-health officials are still coordinating with international colleagues. Still, “CDC’s capacity to respond is substantially lower than it was a year and half ago,” Tom Frieden, a former CDC director and the president and CEO of Resolve to Save Lives, a global-health nonprofit, told us.

In the meantime, the Ebola outbreak already has spread to multiple countries, and the virus has been detected in regions separated by hundreds of miles; cases have also been reported in some densely populated regions, heightening the risk for further spread. Experts are still trying to suss out when and how, exactly, the virus moved from one place to the next. In all likelihood, the epidemic is even larger than what’s been reported, with many cases still transmitting without notice. Ebola is “very unforgiving,” Frieden told us. “The response has to be close to be perfect” to bring the virus to heel; missed cases mean missed contacts—and lead to more clusters, more deaths, and more chaos. To begin the response this belatedly only lengthens the road to resolution.

“The loss of the chains of transmission is what concerns me most,” Bhadelia said. Ideally, an outbreak would be contained in part through careful contact tracing of all individuals who might have been exposed to infectious people. But the larger an outbreak grows, the less possible that becomes—especially with fewer on-the-ground resources than usual. In recent memory, the U.S.’s leadership and coordination with the WHO was “absolutely essential” for managing the world’s largest Ebola outbreak to date, Frieden said; now the U.S. has “walked away, and that’s a real problem.” The clearest remedy to an outbreak like this is for the world to collaborate on limiting the damage. But that’s precisely the commitment that American leaders have reneged on.

This article originally misspelled Jeremy Konyndyk’s last name.

A Perfume With a Whiff of MAGA

2026-05-15T08:00:00-04:00

Walking through Bloomingdale’s on the Upper East Side of Manhattan, Brittany Aldean passed the counters for Lancôme, which made her signature scent from high school (Miracle), and Chanel, whose Chance Eau Fraîche she wore in college. Now the former NBA dancer and American Idol contestant, a mother of two, has her own fragrance line, Vada, which recently released its first three scents. But, she told me, she didn’t expect Vada to end up at a store like Bloomingdale’s, and she wouldn’t want it there.

These days, Aldean is most famous for her marriage to the country-music star Jason Aldean and for her rising profile as a right-leaning lifestyle influencer. She’s selling her perfume directly to fans, with the aim of reaching women who, she said, “don’t feel like they’re seen by the beauty industry”—who prioritize family and faith, even if they’re building a career. If the point of a perfume is not just to smell nice but also to project an identity, Aldean is selling the vision of a conservative woman who has it all.

Aldean certainly seems to. On Instagram, she posts idyllic shots from her Nashville-area farm, at the rodeo, and from backstage at Jason’s concerts. Her kids, who are 7 and 8, are regularly featured in scenes from their family life—Little League games, Easter-egg hunts, moments goofing around at home. She is a vocal supporter of Donald Trump and visited the Oval Office earlier this month, during which time the president asked her to choose between two samples of marble, then handed her selection to a contractor to use in the new White House ballroom, she said. (A White House official told me that it cannot comment on private conversations that may or may not have happened.) When Vada had a pop-up event in Athens, Georgia, women wrapped around the block to buy a bottle and take a picture with Aldean.

Vada is not explicitly MAGA, but it codes conservative because Aldean herself does. One of her most attention-grabbing posts, from 2022, provoked a strong reaction from those who saw it as anti-trans: “I’d really like to thank my parents for not changing my gender when I went through my tomboy phase,” reads the caption on a video of her applying makeup. “I love this girly life.” She told Evie, a sort of conservative women’s Cosmopolitan, that the backlash fueled her to start Vada: “I needed to stick to my values and be honest.” An Austin-based jewelry and eyewear company that’s also called Vada is suing Aldean’s company over the name, and a spokesperson told beauty journalists that it wants to make clear that its brand is “run by somebody with completely different political affiliations.” (Both Vadas declined to comment on the pending litigation.)

Conservative women such as Aldean are part of a lucrative and potentially growing market. Evie was founded in 2019 on the premise that beauty magazines had gotten too “woke,” and it has built a small but dedicated audience, as well as an outsize media presence. The Christian makeup company Elevate Beauty sells lip products in shades such as “Called to Boldness,” “She Will Not Fall,” and “Uncancellable”; the company Nimi offers “Anti-Woke Skincare” (a kind of virtue signaling about virtue signaling) and has partnered with the conservative podcaster Candace Owens. These new brands saw an opening “to market products, particularly beauty products, at a pretty high price point to conservative women,” Kristin Kobes Du Mez, a historian at Calvin University and the author of Live Laugh Love, a forthcoming book about white-Christian womanhood, told me. At just under $100 for a full-size bottle, Aldean’s perfume isn’t exactly cheap, but she said that she wants it to be an aspirational luxury for her fan base.

Aldean’s own approach to beauty is traditionally feminine—the day we met, her long blond hair was blown out, and her full-face makeup was so flawless that the woman behind the Chanel counter complimented it. She was wearing a long, black trench coat and black stiletto boots, accessorized with a leopard-print headband and zebra-print acrylic nails. She told me that she is not a tradwife. “Love them. All power to them,” she said. “I’m just more of a go-getter.” For Aldean, femininity is fueled by the distinctiveness between men and women. “I mean, there’s a reason God created women and men, and we’re very separate,” she told me. Women have “got the magic,” and she wanted her brand to “lean into that.” The fragrance’s tagline is: “For women who effortlessly do it all.”

That have-it-all ideal of womanhood is far more common among young conservative Christian women than anything resembling a tradwife model, Katie Gaddini, a sociology professor at University College London and the author of a forthcoming book on conservative Christian women, Esther’s Army, told me. Of the more than 90 women she has interviewed, only one followed a tradwife influencer on social media. (However, dozens of my liberal friends follow the most prominent account, Ballerina Farm, out of morbid curiosity.) By and large, Gaddini has found that young Christian women want to be a wife and a mother and have a high-powered job; their models are conservative figures such as Megyn Kelly and Erika Kirk, who combine a hyperfeminine appearance with “a hardbitten toughness,” she said. “Even though the emphasis is still on traditional marriage and having children, career is still front of mind.” If a liberal have-it-all womanhood says, “Have a career and a family,” this conservative womanhood says, “Have a family and a career.”

That hierarchy has its own challenges. Finding independence can be hard “when you are in a relationship where it’s so much about the man, and you’re trying to find your place in it all,” Aldean said. Her husband’s fame and music career are always going to carry a certain amount of weight in their lives. Sometimes her ambitions and his line up: The Aldeans recently released a duet, in one of her first major performances since American Idol. But unlike music, Vada is entirely hers.

And so far, the company’s sales have surpassed her expectations. (She had been nervous about selling a direct-to-consumer perfume that buyers couldn’t try on, but the reception has been “very, very dreamy,” she said.) She spent two and a half years building the brand, working with the French perfumer Robertet to concoct her ideal scents: crisp, citrusy “1924” “embodies confidence”; “Georgia Dream” is flirty and peachy (good for a music festival, she said); and “Muse,” which I bought because I’d heard it was the subtlest, is “romantic.”

I tried it in the office, and no amount of rose, jasmine, and sandalwood could make me feel “romantic” beneath the fluorescent lighting. Maybe I should have opted for 1924 and its promise of self-assured professionalism. But I liked the way I smelled, even if I could not say exactly what, olfactory-wise, differentiates this perfume from one that does not “honor the multi-facets of feminine strength.” Many commercial perfumes are made by the same small number of manufacturers, and Robertet has collaborated with several brands that Aldean and I saw on the Bloomingdale’s floor. But a perfume’s success, ultimately, depends not just on its scent but on the promise it makes about who a woman will be when she wears it. Aldean is betting that plenty of women want what she’s promising.

Why Did Bill Cassidy Do It?

2026-05-13T11:22:17-04:00

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Bill Cassidy did not want to talk about Robert F. Kennedy Jr. Last month, as we shuffled through the U.S. Senate subway, a subterranean corridor connecting lawmakers’ offices to the Capitol, the senator from Louisiana was fielding rapid-fire questions from reporters about two of his favorite topics: drug pricing and college sports. But I asked him about his least favorite: Did he regret confirming Kennedy as health secretary?

I was eager to know because, in spite of that decision, Cassidy may be looking at the end of his political career. This weekend, after 11 years in the Senate, he is headed into a Republican primary election with polls trending out of his favor. His vote last year to hand the keys of America’s immunization policy to one of America’s most prominent vaccine skeptics now hangs over him as a political move that may not have been enough to save his life in politics.

Cassidy—who was one of the few Republicans to initially balk at confirming Kennedy—is pro-vaccine. As a liver specialist in a crowded Baton Rouge charity hospital at the turn of the new millennium, he saw firsthand the effects of hepatitis B, a vaccine-preventable disease; he later set up a school-based program in Baton Rouge that inoculated tens of thousands of children against the virus. At Kennedy’s confirmation hearing, Cassidy justified his vote by claiming that Kennedy could help restore faith in the medical establishment. It was, by all apparent measures, a vote against his values, an attempted olive branch to the new administration.

Cassidy has since criticized some of Kennedy’s actions as secretary, namely his decision to stack the CDC’s vaccine advisory committee with vaccine skeptics. Cassidy was also among a group of Republican senators who declined to publicly endorse the surgeon-general nominee Casey Means—a Kennedy ally and wellness guru. (Trump announced a new candidate for the job late last month.) But Cassidy refuses to acknowledge that he made a mistake by confirming Kennedy. In the months since the vote, his staff has repeatedly declined my requests for a sit-down interview. In the Senate subway that day, he sidestepped. “I’m a doctor. You make a decision, you move on,” he told me. “You don’t sit around and say, ‘Oh my gosh, that was a great decision. Oh my gosh, that was a bad decision.’ No, you just move on.”

In Louisiana, being anti-Kennedy means being anti-Trump. And the problem for Cassidy is that many of his constituents already see him as both.

Cassidy’s career in government has been predicated on the claim that he has approached politics as a doctor first. One of his earliest campaign ads for Senate, in 2014, featured him in scrubs and a white coat decrying the Affordable Care Act, which he said would give politicians power over Louisianans’ health care. Once elected, he established himself as the health-policy wonk of the Republican caucus. Cassidy’s efforts to replace the Affordable Care Act failed, but since then, he has ushered major health-care reforms through Congress, including laws targeting surprise medical bills and fentanyl trafficking. A Louisiana medical school and several centers for health education and research have recently gotten multimillion-dollar makeovers thanks to Cassidy, and he has taken credit for tucking more than $200 million in funding for the state’s rural health care into the tax bill Republicans passed last July.

Cassidy remains well liked among major Republican donors, as evidenced by the fact that he has far outpaced his competitors in fundraising. But Louisiana voters are shunning him. In February 2021, he was one of seven Republican senators who voted to convict Trump of inciting the January 6 insurrection. The Republican Party of Louisiana censured him, and one of the state’s most prominent conservative-talk-radio hosts dubbed him “Psycho Bill.” Five years later, a subset of Republican voters still talk about him as if he had set fire to the French Quarter. At an event for one of Cassidy’s challengers, John Fleming, I met Linda Verzwyvelt, a former real-estate agent from Lafourche Parish. Verzwyvelt was eager to strike up a conversation with me, offering me snacks and introducing me to her neighbors. But when the topic turned to her sitting senator, her demeanor shifted. “I want to just strangle him,” Verzwyvelt told me.

[Read: MAHA swing voters are an illusion]

Cassidy’s challengers have sought to foment that anger, framing themselves as more loyal to Trump. “I just think he’s ineligible to serve again because of what he did,” Fleming told the crowd at his event. He touted his own service in the first Trump administration, during which he rose to be an adviser to the president. In her campaign-launch video, Julia Letlow, a current House representative for Louisiana and Trump’s pick for Cassidy’s Senate seat, includes a montage of photos of herself alongside the president. She declares, “A state as conservative as ours—we shouldn’t have to wonder how our senator will vote when the pressure is on.”

Many of the state’s Republican activists, including members of powerful GOP women’s clubs and local Republican Party offices, have abandoned Cassidy. When I spoke with a group of women outside of the monthly luncheon for the Republican Women’s Club of Jefferson Parish, only one told me she was definitely voting for Cassidy. Another, Linda Doyle, told me that the first time she ever knocked doors for a campaign was to get Cassidy elected, but now she can’t trust him because of the Trump vote. I heard something similar from Jacques Migues, an attorney from Iberia Parish who serves on the area’s Republican Executive Committee. Cassidy “can’t be a trusted member of the team,” he told me. The women’s club has not officially endorsed a candidate, but the Iberia committee has endorsed Letlow.

With the primary less than a week away, Cassidy has a real risk of losing: A recent survey from Emerson College found him in third place. Trump has recently attacked Cassidy, blaming him for preventing Means’s confirmation. Kennedy and his allies appear out for revenge too. “Bill Cassidy once again did the dirty work for entrenched interests seeking to stall the MAHA movement and protect the very status quo that has made America the sickest nation on earth,” Kennedy wrote on X after Means’s nomination was pulled. MAHA Action, the political arm of Kennedy’s “Make America Healthy Again” movement, has pledged $1 million to unseat Cassidy.

Cassidy is anti-abortion, pro-gun, and tough on immigration. He is further left than some of his party, but he certainly isn’t liberal, and he hasn’t changed much since he was elected to the Senate in 2014. Instead, Louisiana has. Cassidy’s predecessor in the Senate was a Democrat, Mary Landrieu, who had served for nearly 20 years. Over Cassidy’s tenure, the number of registered Republicans in the state has grown by 30 percent. Now Republican voters want a lawmaker who reflects their MAGA views, not a moderate.

That includes their views on vaccines. Ever since COVID shots became available, Louisiana's uptake has been among the lowest in the country; as of January, only 10 percent of Louisiana adults had received a 2025–26 booster. When Louisiana attempted to require COVID vaccinations for schoolchildren in 2021, Kennedy, then the chair of the anti-vaccine advocacy group Children’s Health Defense, came to the legislature to oppose the move, calling the shot the “deadliest vaccine ever made.” The mandate was never implemented. (HHS declined to comment for this story.)

[Read: The states are going full RFK Jr.]

The specter of COVID has faded, but many Louisianans remain fixated on the idea that mandating public-health measures, such as vaccines, infringes on their freedom. In 2022, roughly three dozen anti-vaccine bills were introduced in the state legislature. Last year, Ralph Abraham—then Louisiana’s surgeon general—banned the health department from promoting seasonal vaccines or conducting mass-vaccination drives. When I visited the state capital in April, three committees were simultaneously considering vaccine-related bills. One would outlaw monetary incentives for doctors to administer vaccines; one would lift the school requirement for immunization against meningitis; and one would ban Louisiana organizations and businesses from denying services to the unvaccinated.

These actions come as Kennedy pushes to cement vaccine skepticism into national policy. In addition to stacking the CDC’s vaccine advisory panel with skeptics, he has pledged to rework the government system that tracks suspected vaccine injuries, and has used the CDC’s website to cast doubt on the scientific consensus that vaccines do not cause autism—all of which, according to Cassidy, Kennedy promised not to do during the confirmation process. According to The New York Times, Kennedy is currently overseeing a CDC inquiry into whether, as he believes, immunization can be linked to chronic diseases including autism.

[Read: Bill Cassidy’s failure on vaccines]

Most of the bills in Louisiana haven’t become law, and a judge has invalidated many of HHS’s most dramatic anti-vaccine actions. But the focus on the purported harms of vaccines—in Washington and Baton Rouge alike—has raised suspicion toward immunizations, according to multiple Louisiana doctors I spoke with. When Mikki Bouquet, a pediatrician in Baton Rouge who also serves on the board of Louisiana Families for Vaccines, was starting out in medicine, parents refusing to vaccinate their newborns against hepatitis B, for instance, were rare. “Now it’s like every day I have one, maybe two moms out of 10 babies that are not for it, and they won’t even have a conversation,” Bouquet told me.

Many Louisianans still see benefits to vaccination. A recent poll sponsored by Louisiana Families for Vaccines found that 80 percent of voters in the state still support school vaccine mandates. When I caught up with Bouquet, she had just finished testifying against a bill that would lift the school requirement for meningitis immunization and was being swarmed by a group of students who thanked her for her testimony. But in recent years, vaccination rates have been dropping across the state. As of 2024, just 44 percent of children 2 and under in Concordia Parish, which had the lowest vaccination rate in the state, were fully up-to-date on their shots. The Washington Post recently reported that not a single parish in Louisiana has kindergarten vaccination rates high enough to reach herd immunity against measles, mumps, and rubella.

In late 2024 and early 2025, Louisiana was hit with another vaccine-preventable disease: whooping cough. The outbreak was the worst in three decades; two infants died. In September, Cassidy asked Kennedy to call for parents in the state to get their kids immunized. But Kennedy gave no public response.

The Louisiana Senate race isn’t primarily about vaccines, or about Kennedy. But Cassidy’s tumultuous relationship with the health secretary provides Trump with yet another way he can attack the senator, whom he once called a “disloyal lightweight.” Kennedy’s supporters seem happy to contribute to the senator’s demise. Cassidy does, after all, have some power to be a check on Kennedy’s agenda, as evidenced by his role in canceling Means’s nomination. And while he won’t acknowledge any regret about confirming Kennedy, he has contradicted some of Kennedy’s claims. When I asked him during our brief hallway interview last month about Kennedy’s impact on efforts to vaccinate American children, Cassidy told me that the “confusion” and “mixed messages” around vaccines “has certainly not been helpful.”

The result is that Cassidy has developed a reputation as the rabidly pro-vaccine candidate that parents should fear. When I spoke to Charles Owen, who represents Vernon Parish in the Louisiana House, he claimed that Cassidy supported going door to door checking people’s vaccination status. Working against “health freedom” in that way, he told me, is a losing issue in Louisiana.

But Cassidy’s record suggests he would not be in favor of that sort of policy. He vocally backed a plan in the Senate to block COVID mandates during the Biden administration. Both of his competitors toe a similar line. “I’m not against vaccines, but I am for informed consent and against mandates,” Fleming, who is also a medical doctor, told me. After Letlow’s husband died of COVID in late 2020, she urged Americans to get their shots, calling herself “a huge proponent of the vaccine.” And she has fully vaccinated her own children, according to Abraham, the state’s former surgeon general who is now Letlow’s campaign chair. In a statement, Letlow’s campaign also told me, “Congresswoman Letlow believes vaccines should be a personal decision made between individuals, parents, and their trusted medical providers. She does not support government vaccine mandates and never has.”

[Read: The Trump administration is trying to have its vaccine policy both ways]

At the time of Kennedy’s confirmation, Cassidy openly struggled in making his decision. “If there’s any false note, any undermining of a mama’s trust in vaccines, another person will die from a vaccine-preventable disease,” Cassidy told Kennedy during the hearing. The senator’s public waffling provided evidence to his constituents that he was only reluctantly a member of the president’s team. “The way that he held out, that was pathetic,” Lisa Neal, a self-described health-freedom advocate, told me at the Fleming meet and greet.

Most Louisiana voters are not as vehemently against public-health mandates as Neal, but many are angry at Cassidy for the same reason: In the age of Trump, there are no half-gestures of loyalty. You’re MAGA or you’re not. Cassidy traded his legacy for an attempted show of loyalty by voting in Kennedy. But it seems to not have even registered with many voters in his state.

A Profound Mismatch in Modern Medicine

2026-05-12T13:02:02-04:00

“You’re the eighth rheumatologist that I’ve seen,” the patient told me. She ticked off her symptoms—pain, fatigue, and what she described as a sense of brain fog—which she’d lived with for years. Some doctors had no answers for her; others had said that she likely had fibromyalgia, a poorly understood pain-processing condition, and that they could do little to help. She began to cry, and I began to sweat.

My medical training had prepared me for seemingly everything—diagnosing heart attacks, treating life-threatening infections—but not for this kind of problem. I knew the technical definition of fibromyalgia, but my confidence in making the diagnosis correctly was exceedingly low: The disease can cause the symptoms my patient described but cannot be proven by lab or imaging studies. And even if fibromyalgia was the cause of her suffering, I had few concrete solutions to offer her.

Modern medicine is excellent at delivering treatments that precisely target the biological cause of a disease and produce clear, measurable improvement. The promise of such magic bullets shapes both doctors’ training and patients’ expectations. But for some of the most disabling conditions physicians treat today, no magic bullet exists, and doctors often struggle to identify what it is, exactly, that they’re shooting at.

Illnesses such as fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome (also known as myalgic encephalomyelitis, or ME/CFS) rarely reveal a single malfunctioning molecule or damaged organ. In such cases, the best medicine can offer is often a patchwork of modestly effective medications and nonpharmacological interventions such as cognitive behavioral therapy, exercise, and tai chi. The result is a quiet but profound mismatch between what modern medicine was built to do—identify targets and take aim at them—and the kinds of suffering many patients now bring into the exam room.

The concept of the “magic bullet” arrived at exactly the right moment. The German physician Paul Ehrlich first came up with the metaphor in the early 20th century, when infectious disease was the leading cause of death worldwide. Ehrlich imagined a medicine that could act like a perfectly aimed projectile, striking a disease-causing organism while leaving the rest of the body unharmed. Two years later, he demonstrated the idea experimentally, curing syphilis-infected rabbits with a chemical compound later named salvarsan, and within a few decades, the era of highly effective, modern antibiotics was under way. The success of the magic bullet helped establish a framework that shapes medicine to this day. Drug development focuses on discrete biological targets; medical training teaches physicians to think about disease in simplified terms, as a set of problems with clear mechanisms that can be addressed with specific interventions.

But not all diseases cooperate with this framework. Fibromyalgia, for instance, likely arises from abnormal pain processing in the nervous system rather than tissue damage; research studies have shown that, when exposed to the same stimuli, patients with fibromyalgia exhibit greater activation in brain regions associated with pain than healthy individuals. Many cases of IBS begin with an insult to the gut (such as an infection) that triggers persistent pain but over time also becomes a problem of the nervous system, which amplifies discomfort even in the absence of ongoing injury. “The brain is not the origin of the problem, but it is the organ that’s ultimately affected,” Braden Kuo, the chief of digestive and liver diseases at Columbia University’s Irving Medical Center, told me. Tests examining muscle response have shown that IBS patients experience pain when the rectum is stretched to levels that most people barely notice.

These tests, however, are not used in clinical practice, in part because of their high cost and the need for specialized expertise to interpret them. Efforts to identify biomarkers for these diseases in the blood have also been largely unsuccessful, and so biomarkers aren’t used to diagnose these conditions. According to Michael Kaplan, a rheumatologist at Mount Sinai whose research focuses on chronic pain, this poses a problem for patients trying to understand the root of their symptoms. “Patients come to the doctor expecting their suffering to be translated into the language of objectivity, but that’s just not possible for these conditions,” Kaplan told me. Instead, patients are left trying to understand how their symptoms can be so intense even though their lab and imaging results appear “normal.”

One reason that physicians aren’t pushing for more testing, according to several I spoke with, is the paucity of targeted therapies. When a doctor orders a test, they mostly want to know: Will the result change my management of this patient’s symptoms? For fibromyalgia and IBS, spending time and money on knowing exactly what’s wrong with a patient doesn’t help if the conversation still ends with “And there is not much we can do for you.” Physicians often dread these appointments not because they lack empathy, but because they have no magic bullet to offer the person sitting in front of them. “I say to patients, ‘If I had you on the perfect pharmacologic cocktail, it would only get us about one-third of the way to making you better,’” Kaplan said. Instead, managing chronic-pain syndromes in many cases requires long conversations about coping strategies, behavioral therapies, and lifestyle changes—precisely the kind of time-intensive care that modern medical systems are poorly designed to deliver.

For some conditions, a discrete biological target and its magic bullet may exist, even if no one has found it yet. For decades, obesity—a complex, multifactorial disease shaped by genetics, environment, and behavior—was regarded as a pharmacological lost cause. Then came GLP-1 agonists, which, though not a cure-all, have driven dramatic weight loss for millions of patients. Philip Mease, the director of rheumatology research at Swedish Health Services, in Seattle, told me he believes that a similar sea change could come for conditions such as fibromyalgia. The challenge, he argued, is clarifying what the disease is—and what it is not. Disorders such as long COVID share many overlapping symptoms with fibromyalgia, making misdiagnosis common. The result is a cascade of consequences: blurred disease boundaries, a grab bag of patients in clinical trials, stalled therapeutic progress.

Nortin Hadler, an emeritus professor of medicine at the University of North Carolina, told me that the issue extends far beyond subtle distinctions. In his view, doctors must be willing to confront a more fundamental divide: the difference between illness and disease. Patients with fibromyalgia, he argues, clearly experience illness—real, often-debilitating symptoms that disrupt daily life. But Hadler does not believe that fibromyalgia should be classified as a disease in the traditional biomedical sense, because medicine has yet to identify a discrete, demonstrable pathophysiological process underlying it. The problem, as he sees it, is that the medical system reflexively applies the label of “disease” and then looks for a targeted biological fix, creating expectations that may be misplaced. “The endless search for a cure may actually increase disability, because patients are distracted from learning how to live with their symptoms,” Hadler said.

Debates over conditions such as chronic fatigue syndrome and long COVID reveal how difficult it can be for modern medicine to balance the recognition of subjective—yet real—suffering with the quest for objective proof. The question of whether ME/CFS is a distinct biological disease or a psychosomatic problem has been contested for decades; the medical community’s interest in long COVID can depend, too, on whether it’s regarded as an illness or a disease. At a recent medical conference, I watched a speaker describe patients’ symptoms of brain fog to a relatively disengaged room of physicians—who suddenly sat at attention as he cited a study showing that, in people who died from COVID-19, viral genetic material persisted in multiple organs, including the brain, for up to 230 days after symptom onset. What changed in that moment was not the description of the patients’ suffering, but the possibility of a biological explanation linking subjective symptoms with an objective, see-for-yourself finding. Only then did the problem become legible to the room full of physicians.

But to meet the needs of patients with diseases such as fibromyalgia, IBS, chronic fatigue syndrome, and long COVID, medicine will need to loosen its reliance on the magic-bullet model. Not every illness will reveal a single molecular target, and not every treatment will come in the form of a pill or an injection. In many cases, the work of medicine will look less like marksmanship and more like navigation: helping patients experiment with therapies, manage symptoms, and rebuild a life shaped by chronic illness.

I found this to be the case with my patient. Over time, we used a combination of medications, exercise, and behavioral therapies to treat her symptoms, with some success. We never found one single, comprehensive solution, and at visits in which she described herself as really struggling, I wondered if I was providing any benefit to her care at all. But she kept coming back, and I kept trying. My medical training had taught me to search for the magic bullet—and to feel disappointed when I couldn’t find it. My patient showed me that medicine must move forward even without one.

I Remember America Before the Measles Vaccine

2026-05-11T07:00:00-04:00

Lately, I’ve come to notice that the strangest and most terrible pieces of my childhood are roaring back. I was born in 1933, and much of what I remember as a little girl was defined by either the war or what we called, simply, sickness.

I myself was blessed with exceptionally good health, but my friends, family, and community were regularly struck with childhood diseases. Neighborhoods were frozen in fear when maladies suddenly erupted: pool closures during polio epidemics, quarantines when mumps or measles raged. I remember one particularly galling time when my older sister Mimi and I were confined to the house, morosely watching our friends playing on the construction site of a new house across the street. We were fine; they all had whooping cough. Whooping cough was often deadly for babies and toddlers but among the less debilitating of childhood diseases past for older children, thus the freedom to play while coughing. Neither Mimi nor I ever caught it—a fact I was grateful for 40 years later, when I met with a pulmonologist about my cigarette-compromised lungs and he remarked, “At least you never had whooping cough.”

We did, however, catch chicken pox simultaneously with our older sisters, Jane and Helen; we were then 5, 7, 11, and 13. Just thinking of it can resurrect the itch. (And lest I forget, some 70 years later, following a time of extended stress, that long-dormant varicella-zoster virus returned as a bout of shingles.) But that was nothing compared with the measles Jane contracted. Memories of those days, among the most vivid of my early life, still evoke tremors in the bottom of my stomach. There was widespread fear of measles causing blindness, which had indeed happened to a young family acquaintance. So for several days at the height of her illness, Jane was quarantined in one bedroom while Helen moved in with Mimi and me. The shades were drawn and curtains closed in Jane’s room, and the door was opened only after the hallway was darkened. She survived—and later went on to become a wife, mother, and well-regarded artist. But that was just the luck of the draw. Measles killed some 10,000 American children in the 1930s and ’40s—roughly 500 kids died every year. In my generation, we were the guinea pigs for what science would soon discover: This pesky childhood sickness increases the risk of stroke, chronic lung problems, and impaired neurodevelopment.

[Read: His daughter was America’s first measles death in a decade]

Health Secretary Robert F. Kennedy Jr. was not born yet when all of this took place. By the time he turned 13, in 1967, most of the diseases that ravaged my childhood had been eradicated by the vaccines he now disdains. The unfortunate thing about that disdain is that Kennedy has the power to impose his bizarre notions on the entire country. It’s too bad that we have no way to time-capsule him back several decades (or time-travel forward, for that matter) in hopes that he might understand the havoc he will wreak upon future generations.

RFK Jr. would have liked my friend Jack, a rambunctious child given to sudden mischief. Jack was part of a foursome, the others being Mary Sue and Tommy and me. We bonded days after I arrived in Ashland, Virginia, having just turned 6. For several years we were inseparable, even when Jack developed rheumatic fever and was bedridden for weeks. We simply detoured from climbing trees and playing ball into spending afternoons staging battles with toy soldiers on his bed or listening, enraptured, to his favorite radio serials, including The Lone Ranger and Jack Armstrong, the All-American Boy. Jack was isolated even from the three of us when whooping cough rampaged through the town, but he still managed to catch that too. He died of heart failure at age 19; how much of that good young heart’s failure was due to those earlier illnesses, we’ll never know. That was more than half a century ago. I never forgot Jack. I wish I could tell Kennedy about him, and the pain his death caused everyone who loved him.

[From the January 2026 issue: Why is Robert F. Kennedy Jr. so convinced he’s right?]

The other childhood friend I would most like our health secretary to know is Susan, who moved to our neighborhood in second grade and contracted polio when we were in our early teens. I remember being taken to visit her when she was in an iron lung. Though she was in a highly restricted part of the hospital, I was allowed to visit, largely because she was not expected to live and we were desperate to see each other. In those days of family doctors who made house calls for everything but major emergencies, I had been in a hospital once or twice at most. I knew all about the iron lung and was thoroughly familiar with Susan’s precarious state; still, I was not prepared for the sight of a giant monster of a machine on sturdy legs, with only my friend’s head protruding from one end.

There were six of them in all, I think, in a cold room smelling of ether and rubbing alcohol: six futuristic creatures with human heads. Nurses in starched white uniforms and rubber-soled white shoes walked wordlessly among the machines, which kept up a steady thrum as they forced air in and out of failing lungs. Susan’s mother stood on one side, stroking her daughter’s hair, while Susan and I talked in voices just above a whisper, as if we were in church. She wanted to tell me about the boy who had been in the iron lung behind where I sat, who was there when she arrived but a few days ago had vanished. There was only one other visitor, another mother stroking another small head. Happy as I was to see Susan, I couldn’t help wondering if I would be able to summon the courage to endure such hardship just to survive. But survive she did, unexpectedly, to live to adulthood with some disabilities.

[From the February 1957 issue: How good is the polio vaccine?]

The disabilities resulting from those childhood diseases far exceeded the recorded life-and-death statistics: the compromised lungs, the weakened hearts, the bones and muscles and systems unable to develop as they might have. It’s impossible to calculate the awful toll. Vaccines, though, changed it all, essentially vanquishing those diseases in the United States and much of the rest of the world. The rejection of science is sending us back to those dark ages.

When I was 12, Americans everywhere threw what can only be described as a two-day party. It was 1945, and Japan had surrendered. Euphoria swept across the country, including in small towns like Ashland, where my friends and I had pulled red wagons around to gather scrap for the war effort. There had been a slight exhaling of breath the previous May, on what came to be known as V-E Day, and another one after the bombs were dropped on Hiroshima and Nagasaki in August. (Only later would I learn the grim moral complexity of such weapons.) But with the end of the war came a widespread belief that lasting peace was no longer just a dream. Flags went up on every front porch, the sounds of long-hoarded firecrackers pierced the air, perfect strangers hugged each other on sidewalks, and high-school bands paraded in the streets.

[Tom Nichols: Reclaiming real American patriotism]

Those of us who are now in our 90s might be forgiven a twinge of nostalgia for that moment. But this is no plea to return to some imaginary good old days. Indelibly etched into my brain are memories from the decade leading up to our entry into the war. I was 4, at most, the night my father woke Mimi and me in what seemed the middle of the night and gently carried us downstairs into the living room. He deposited us on the floor in front of the Philco radio. We sat at the feet of our mother, who was on the sofa darning socks. There were crackling sounds coming from the radio, someone speaking over the noise of a crowd. My father explained that we were in no danger but that terrible things were happening in the world, largely because of one very bad man, and he wanted us to hear what this madman sounded like: Adolf Hitler on a shortwave-radio broadcast. We, of course, had no idea what Hitler was saying. But the angry shouts to a cheering crowd, sounds reinforced later in newsreel clips shown at movies we occasionally attended, carried a powerful message I have never forgotten. They were the sounds of evil, the antithesis of “Love thy neighbor.”

Americans survived those years on kindness and collective effort. In the 1930s, when hunger, poverty, and despair were at levels hard to imagine today, you could have nothing and still be kind. As a child who never went hungry, I was spared the traumas suffered by many, but I witnessed hardship in the nation’s psyche. My father had a job that paid enough to feed four daughters and cover the mortgage on our tiny three-bedroom house, albeit just barely. Several times a week, men in worn coats and brown fedoras in search of food and work would knock on our back door. My mother would make peanut-butter-and-jelly sandwiches, hand them to me with glasses of milk, and instruct me to be very polite to “our visitors.”

[From the November 2025 issue: I don’t want to stop believing in America’s decency]

Throughout World War II, we knitted socks for soldiers and went with our mother to deliver hot cross buns to neighbors when a new Gold Star was hung in someone’s front window. We kids were also serious about collecting scrap and were occasionally enlisted to help watch the skies from a small rural hut for the rare passing airplane, whose description we would carefully record in a government logbook. My memories of these long-ago years are spotty; I was just a child. Far more clearly I recall the aftermath, when all of those men (and a few women) in uniform came home—Jane married one of them—and war stories were left behind. Everyone was in a hurry to move forward into a newly peaceful world, a world without the tragedies of war abroad and the curse of sickness at home.

It was a time of singular, optimistic patriotism. No one thought the road ahead would be easy; everyone believed that peace and shared prosperity were possible. For nearly a century, I’ve been privileged to watch the fits, starts, and swings of that optimism: the forward leaps of science and technology, the backward falls into tragic wars, the sidesteps into misguided ideologies. But the collective effort behind those hot cross buns and front-porch flags? That is still who we are, if we choose to be.

This article appears in the June 2026 print edition with the headline “The America I’ve Known.”

Marty Makary Set the Conditions for His Own Downfall

2026-05-10T08:00:00-04:00

Marty Makary, the Johns Hopkins surgeon who has led the FDA for the past year, is facing criticism from all sides. Vaping advocates are angry because of the FDA’s slow progress on green-lighting their products. Pro-life groups have called for Makary’s firing because he has not been tough enough on abortion. Current and former FDA officials have repeatedly warned that the agency is in turmoil. Even drug companies, typically cautious about criticizing regulators, have raised concerns about the state of the agency. Donald Trump has now reportedly signed off on a plan to fire Makary—although when exactly that axe might fall is unclear. On Friday evening, the president told reporters gathered at the White House that he knew nothing about Makary’s future.

Traditionally, FDA commissioners have been less dramatic figures; they have approached their role as steward of an organization whose strength stems from its independence. The logic of that position is simple: Putting a drug on the market simply because of a commissioner’s or a president’s preference, or burying politically inconvenient research, doesn’t inspire much confidence in the safety of America’s food and drugs. But Makary has shown again and again that he’s willing to put politics first, a strategy that may have created the conditions for his own fall from power. (Neither Makary nor the White House agreed to comment for this story.)

The problems began shortly after Makary’s confirmation. In June, he announced the launch of the Commissioner’s National Priority Voucher, a pilot program meant to dole out speedy approvals for drugs that “align with one of five critical U.S. national health priorities.” The program quickly became a tool for political influence. The FDA frequently does speed up review for important drugs, but drugs that are given a golden ticket must address a serious, unmet medical need. For the new program, all decisions to award vouchers were cleared by the White House, STAT News reported. As such, the vouchers appeared to have become a bargaining chip in negotiations with drug companies over their pricing. On the same day that the White House announced that Eli Lilly and Novo Nordisk would drop the price of their GLP-1 weight-loss drugs and sell them on a Trump-branded website, both companies were also granted vouchers for new weight-loss drugs.

Makary and his deputies have also regularly overruled career staff, often with nakedly political motives. During his confirmation hearing, for instance, Makary promised lawmakers that he would “take a solid, hard look at the data” concerning the safety of the abortion drug mifepristone. And although Makary has claimed that FDA scientists have begun reviewing the data, news broke in December that he had also instructed FDA staff to delay the review until after the midterm elections. (At the time, the Department of Health and Human Services, which oversees the FDA, denied any political motivations.) Vinay Prasad, whom Makary hired as the director of the Center for Biologics Evaluation and Research, replaced a longtime FDA official who had disagreed with Secretary Robert F. Kennedy Jr. over the safety of vaccines; Prasad quickly moved to limit young, healthy people’s access to COVID vaccines. Prasad was also behind the FDA’s short-lived decision to block the review of a new mRNA flu vaccine. He said that these decisions were motivated by a need for stronger evidence, but they also aligned with Kennedy’s personal skepticism of COVID and mRNA vaccines. Both of these decisions were reportedly made against the advice of FDA staff. (Prasad has since been pushed out of the agency.)

Ironically, the scandal that may cost Makary his job—the FDA’s reluctance to authorize the sale of flavored vapes—involves him ignoring the advice of FDA officials while apparently misreading, or perhaps disregarding, the politics of the issue. The commissioner has shown himself to be exceptionally skeptical about these products. He has publicly said that he does not believe the government’s own data showing that the epidemic of youth vaping has improved and only 5 percent of young people now vape. At a September 2025 press conference, he claimed that “the broken CDC that we inherited under the Biden administration” had used a flawed methodology to collect the data. (The long-running survey he alluded to is generally regarded as the best source of national data on youth vaping.) According to The Wall Street Journal, Makary personally overruled FDA scientists who recommended authorizing flavored vapes that include features designed to prevent use by anyone under 21.

But Makary was putting his own preferences before the president’s. Trump appears to see vaping as a political issue: During his campaign, he publicly promised to save the industry, and he reportedly confronted Makary about the FDA’s approach toward vaping. It’s unclear whether this frustration in particular is what has prompted Trump to seriously consider firing Makary, but shortly after the dressing down, the FDA announced that the vapes the commissioner had originally blocked would now be authorized.

Makary came into this job with gripes about the agency. His 2024 book, Blind Spots, is full of criticisms of FDA decisions that he says represent “medical dogma.” And in a recent CNBC interview in which he was confronted about the decision during his own tenure to not approve a skin-cancer drug, he sounded a lot like his predecessors by decrying political pressure. “You have a decision when you come in as commissioner: Do you throw science out the window and do whatever the media tells you to do, and whatever the lobbyists and corporate interests tell you to do, or do you do what’s right?” he said. And some of the recent flak the FDA has received has come from companies and commentators who thought that the agency was holding back approvals or asking for too much evidence. Not all of the controversial calls for better data came from Makary or Prasad, either; during the review of the skin-cancer therapy, for instance, the calls for more data came from longtime FDA officials.

It’s easy enough for an FDA commissioner to make enemies. What people put in their bodies is controversial, and an FDA commissioner has to make hard decisions about the products of powerful, well-resourced companies. Makary is not the first commissioner to buckle to political pressure, but he’s the only one who has so evidently made it a habit. The disparate critiques of Makary are interrelated: They show how, time and again, he’s put his or his bosses’ preferences first. These decisions may end his career as commissioner, but they’ve already set a dangerous precedent for political interference at the agency.

Admit It, That Protein Shake Is Basically Soylent

2026-05-09T07:45:00-04:00

From the beginning, Soylent was shorthand for a certain kind of guy. A guy who worked in tech and probably wore a hoodie. A guy who, despite his six-figure salary, lived in an unfurnished apartment. Soylent Guy, above all else, did not have time for quotidian tasks such as cooking and chewing. One way you knew this was that he slugged the nutrient-dense slurry known as Soylent.

Remember Soylent? In the mid-2010s, Soylent promised to change the world by solving a timeless problem: Everybody has to eat. Instead of chopping vegetables or defrosting a meal, you could fertilize yourself, like a needy rhododendron, with a blend of oat flour, maltodextrin, brown-rice protein, canola oil, fish oil, and just enough sucralose to mask the flavor. For a brief moment, Soylent was beloved—at least in Silicon Valley, where venture capitalists helped turn it into a $170 million brand. It was also a dystopian punch line: What if you stripped life of all joy and bottled the result? Ha! In 2023, Soylent was sold off for a fraction of its former valuation.

John Coogan, who co-founded Soylent in his early 20s and now co-hosts the popular tech-business talk show TBPN, chalks up the company’s decline largely to inexperience. “We were always trying to be a little bit too clever,” he told me. But perhaps Soylent’s greatest fumble was that it came too soon.

You can find Soylent-like drinks almost everywhere these days. Fairlife—a line of protein shakes that bills itself as “a satisfying way to get the nutrition you’re looking for”—is so popular that it has become Coca-Cola’s fastest-growing U.S. brand. One of its competitors, Huel, recently sold to Danone for $1 billion. You can buy nutrition drinks from Rebbl and Orgain and Koia and Oikos, along with many, many other companies whose names have the wrong number of vowels.

If you are one of the many Americans who chugs these shakes on the regular, perhaps you might balk at the comparison to Soylent. (You don’t even wear a hoodie!) The point of nonfood nutrition is no longer to fuel yourself so that you can sit at a computer longer. You are instead becoming healthier, hotter, more beautiful, more jacked. The shakes are engineered for our protein-obsessed times. Fairlife’s Nutrition Plan shake, for example, comes with 30 grams of protein in a mere 150 calories. But many of the shakes do not stop at protein. They want to talk to you about adaptogens and your gut health, your antioxidants and your immune-boosting support. Only some of them explicitly identify as a meal replacement. Instead, they are “next-level nourishment” to “fuel every move.” They go from “gym bags to lunchboxes to morning smoothies” and match pace “with your everyday, get-strong hustle.”

[Read: America has entered late-stage protein]

Still, there is a striking resemblance to Soylent, and not only in form. These shakes aren’t meals, but they aren’t not meals. “There was a time when you had eggs for breakfast and a sandwich for lunch and a TV tray for dinner,” Leigh O’Donnell, an analyst at the market-research firm Kantar, told me. But we have become a nation of snackers. Instead of having three meals a day, she said, many Americans now eat “maybe six … somethings.” This is because of our lifestyles but also because of our newfound dietary needs. GLP-1s, for example, have created a new customer: people trying to mitigate potential muscle atrophy, a side effect of rapid weight loss, by consuming more protein, ideally in a form that doesn’t require eating all that much. The current high-protein, low-calorie, micronutritionally supplemented ready-to-drink shakes may not exactly constitute a “meal” in the conventional sense, but they certainly constitute a “something.”

The shakes are portable and easy and wildly efficient, in that they deliver a lot of meticulously calibrated individual nutrients and require no thinking. As a person who is not generally doing anything particularly demanding with my body (or, arguably, my time), I know that traditional eating should be just fine. All else being equal, eating food, not too much, mostly plants is probably superior to downing ultra-processed shakes. And still, I find myself drawn to these drinks. Food is fraught and confusing, but the shakes are reassuringly precise: This much protein! This much fiber! These carbohydrates! This unquantifiable but still notable immune-boosting defense! I am, as the protein-shake brand OWYN promises, getting “Only What You Need.” This was, of course, the promise of Soylent: You could glug down everything you needed and get on with it.

In recent years, “what you need” has only escalated. The list of nutritional necessities now “contains all these things that you didn’t even know you needed five minutes ago,” O’Donnell said, “whether it’s turmeric or potassium.” Obviously, you can be generally healthy, eating your beans and grains and salads, but can you reach the pinnacle of your potential? Can you maximize, in one single serving, your protein, your fiber, your ashwagandha, and your time? That’s the appeal of something like Ka’Chava, an “all-in-one nutrition shake” enhanced with antioxidants, probiotics, prebiotics, and digestive enzymes. Or consider Rebbl, which includes, in addition to protein and fiber, 2.2 milligrams of zinc and “adaptogenic Reishi mushroom extract.” Even Soylent itself has pivoted its messaging to keep up with the times, updating not only its recipe but also its mission. “We’ve shifted from being a meal replacement company to a complete nutrition company,” then-CEO Demir Vangelov told the tech newsletter dot.LA a few years ago. In an interview with Food Dive, he went further: “Every one of our consumers, they know what they believe they need in terms of protein, in terms of carbs, in terms of fiber and vitamins and minerals, and they’re curating their nutrition across their week to fit those needs.” (Soylent did not respond to several requests for an interview.)

[Read: Soylent, meal replacements, and the hurdle of boredom]

Soylent had a bold, even ridiculous vision for a post-food future. So far, it has not materialized. After several days of searching, I finally got my hands on a bottle of Soylent through the magic of the internet. It tasted strikingly similar to the other shakes on the market—dominated by notes of their low-calorie sweeteners. Coogan, the Soylent co-founder, has given up the stuff. “I have a very regimented schedule now where I have breakfast with my team every morning,” he said. But when you walk into a grocery store and glance at the refrigerated row of shakes, with their minimalist packaging and maximalist promises, the original dream of Soylent can seem comparatively quaint. The goal is no longer to match food. The goal has become to transcend it.

‘This Is Not Going to Be the Next COVID’

2026-05-08T12:55:56-04:00

The MV Hondius, the cruise ship where an outbreak of hantavirus was confirmed over the weekend, is moving once again. On Wednesday, after three people were evacuated, the ship departed from Cabo Verde. By Sunday, it will arrive at the Canary Islands, where the Spanish government says it can dock. So far, though, three people have died in the outbreak, and the ship’s remaining passengers still need to be monitored for illness. Local leaders would rather the ship go somewhere else. And a chorus of TikToks that have each been viewed and liked millions of times call for a different approach: “Sink that ship.”

That’s probably (hopefully) a joke. But a perusal of the internet—both the memes and the upswell of concerned armchair epidemiologists—suggests that some people at least semi-sincerely fear that a pandemic is imminent. “I don’t want your rat poo virus. I have summer plans,” one woman posted on TikTok. (Hantavirus infects humans mostly through contact with excretions from infected rodents.) Yesterday, I saw that an old friend had posted on her Instagram story about a patient who had been medically evacuated to a town next to hers in Switzerland. “I just finished mentally recovering from Covid man,” she wrote next to a crying emoji. A new TikTok of a guy doing the Renegade—a dance inextricably linked to the early pandemic and the new influencers it minted—has been watched 20 million times and counting.

That people are concerned, or at least keeping an eye on hantavirus, makes sense. But all of the epidemiological evidence so far suggests that the general public has very little to worry about. “This is not going to be the next COVID,” Marion Koopmans, a virologist at Erasmus Medical Center, in the Netherlands, told me.

Hantavirus is a respiratory illness that starts out much like the flu: fever, aches, and chills. In severe cases, breathing becomes difficult, and the heart struggles to pump blood. Andes hantavirus—the species that the World Health Organization confirmed is causing the outbreak on the MV Hondius—has a fatality rate of about 40 percent.

Most types of hantavirus cannot spread among humans; everyone who gets sick must have been exposed to an infected rodent’s bodily fluids. But Andes hantavirus can, on occasion, be passed among people in extremely close contact. In one study of Andes hantavirus in Chile, sex partners of the infected had an 18 percent risk of catching the virus, but the risk to other members of the household was just 1 percent. In countries where Andes hantavirus is endemic, contact tracing classifies as high-risk people who are either sleeping next to or caring for the infected, Koopmans, whose work focuses in part on the transmission of zoonotic disease, said.

The cruise-ship outbreak is the first of its kind. But experts I spoke with told me that it’s no more alarming than the normal spread of the virus in countries where it’s endemic—it’s just a logistical nightmare because of the number of governments involved. “It’s very serious for the people exposed, and there’s some transmission to people that are very close contacts. But beyond that, there is very little risk,” Koopmans said. Alasdair Munro, an immunologist working to develop a hantavirus vaccine, told me in an email that the only way a pandemic could result from Andes hantavirus is “if the virus had somehow mutated,” becoming a fast-moving infection that, like measles or COVID, can spread more readily. “So far there is no indication of that,” he added.

Cruise ships are great breeding grounds for viral transmission. They assemble a group of people from around the world, keep them in close quarters with one another’s germs, and then release them back to their homes. But the contained setting of this outbreak has delivered at least one win for public-health officials: “We know precisely who was exposed and where all of those people are,” Munro said. That includes passengers who disembarked two weeks ago on the remote island of St. Helena. The WHO is holding regular meetings to coordinate contact tracing and medical evacuations of people aboard the ship who are showing symptoms.

The United States elected to leave the WHO earlier this year, and public-health experts are already critiquing what they’ve deemed to be a lackluster federal response. (The Department of Health and Human Services did not return a request for comment.) Still, health departments in five U.S. states—Arizona, California, Georgia, Texas, and Virginia—have identified people within their state’s borders who were on the cruise ship, and are monitoring them for symptoms. Signs of infection can take as long as eight weeks to appear, which can make for onerous contact tracing and quarantine protocols. But that long incubation period is still factored into containment strategies, Munro said.

During a press conference yesterday, a reporter asked how the WHO’s leaders could be so confident that Andes hantavirus won’t start a pandemic. COVID, the reporter noted, had also started small. Maria Van Kerkhove, the WHO’s acting director of epidemic and pandemic management, pointed out that whereas COVID had been novel, hantaviruses are not. The experts I spoke with emphasized that the only thing unusual about this outbreak is that it occurred on a luxury cruise ship. Unexpected things, of course, can and do happen in epidemiology. But all evidence suggests that hantavirus will remain an intimate tragedy.

The online response, meanwhile, has felt more like a soap opera. People on TikTok are posting daily updates on the “hantavirus drama,” thanking the Spanish passenger who “got the tea” on passengers who disembarked early and vowing that they’d choose social isolation over going back to Zoom parties. Nurses that worked through COVID are dissecting the news on Reddit. Marjorie Taylor Greene is posting about ivermectin. Hantavirus is almost certainly not the next COVID. But it has provided the world with an excuse to revisit and rehash a time when a virus actually did change all of our lives.

What Happened on the Hantavirus Cruise, According to a Doctor On Board

2026-05-07T17:27:46-04:00

When Stephen Kornfeld set sail aboard the MV Hondius in early April, his grand plan for the cruise was to add as many new species as possible to his birding list. A medical oncologist based in Bend, Oregon, Kornfeld is also an avid birder—second on eBird’s renowned rankings of birders worldwide—and the ship would visit several remote islands, where he might spot some of the globe’s most obscure avians. But last week, Kornfeld’s trip took an unexpected twist: He stepped in to care for three people thought to be sick with hantavirus, a severe respiratory pathogen that can kill roughly half of the people it infects. Kornfeld was, and still is, “a passenger on this boat,” he told me. “But I became the doctor on this boat.”

Since the MV Hondius departed, at least eight people have come down with suspected or confirmed cases of hantavirus; three have died. People typically get infected by the virus via the aerosolized feces or other bodily secretions of infected rodents. But the World Health Organization has confirmed that this hantavirus is a species called Andes virus, which has sometimes spread person to person, under conditions of close and prolonged contact—such as, say, on a cruise ship with about 150 people on board.

A month ago, as the cruise departed from Argentina, Kornfeld and the other passengers—among them, dozens of birders—were buzzing about the whales, seals, and dolphins they’d spotted cavorting in the South Atlantic Ocean, and gossiping about the adventures ahead. When a 70-year-old Dutch man, one of the birders, died aboard on April 11, Kornfeld and the others were shaken but considered the incident a freak accident, with no implications for anyone else on board. But then, roughly two weeks later, the Dutch man’s wife fell sick, too, dying shortly after she was taken off the ship. After another birder, a British man, grew feverish and began struggling to breathe, he was evacuated to a South African ICU, where he remains in care.

By the end of April, three other people on board had started to feel quite ill—including two crew members, among them the ship’s doctor, who had been assessing the other patients. Many people on the ship’s small crew were trained to provide some degree of medical support. But there was no official backup physician, Kornfeld said, and when the crew started asking who among the passengers had a medical background, few were able to help.

Feeling the urgency of the situation, Kornfeld stepped in. He officially began assisting the crew on May 1—last Friday—at first assuming that the doctor would need aid for just a day or two while he recovered from a presumably short-lived, flu-like illness. But the situation rapidly began to intensify. The next day, the ailing passenger, a German woman, died; at about the same time, test results from sick passengers who had left the cruise were beginning to trickle back—sending the word hantavirus surging through the ship. The ship’s doctor was so stricken with symptoms that he had to confine himself to his quarters. A deadly infectious disease was likely on board, and “the ship’s doctor was not going to be able to function as the ship’s doctor,” Kornfeld said. The cruise’s main medical duties now, by default, fell to him.

Kornfeld had retired from his full-time oncology job more than a decade ago, although he still picks up shifts here and there at several of Oregon’s rural hospitals. Now he was being thrust into a nerve-racking, life-or-death situation, and caring for ill and potentially infectious patients while trying to communicate with the rest of the passengers on board, all with very limited resources. Several members of the crew assisted him where they could. But although the ship had a medical facility of sorts, Kornfeld told me he found little more than the supplies that a cruise doctor would need to deal with routine illness at sea: some anti-inflammatory drugs, a few over-the-counter medications, a fleet of oxygen tanks—unsurprisingly, not the sorts of chest scanners or ventilators that could come in handy for diagnosing and managing severe respiratory illness. The ship did have plenty of surgical masks, though, plus some N95 respirators. Kornfeld strapped one on each day that he was with the sick, along with goggles, an apron, and gloves.

Kornfeld’s new role on the boat put him at one of the central nodes of a global effort to save these patients—and, ultimately, contain the outbreak. In between checking on his patients, he juggled phone calls, emails, and WhatsApp messages from medical and research professionals from several groups, he told me, including the WHO and Oceanwide Expeditions, the company running the cruise. Among the experts he connected with were some of the world’s foremost hantavirus researchers; whatever questions he had, he got the answers to. (When reached for comment, the WHO pointed me to a Thursday press conference, but declined to comment on Kornfeld specifically. Oceanwide declined to comment on “individual stories” from the MV Hondius, instead pointing me to its press releases on the outbreak.)

In some ways, the likely presence of hantavirus made the situation simpler. “In medicine, sick is sick,” Kornfeld said. Hantavirus doesn’t have a specific cure or treatment; helping those who had been presumably infected wasn’t a matter of administering a particular drug but of monitoring, preventing deterioration, and triaging any other passengers or crew who came to him with worrying symptoms.

After the German passenger died, the ship docked off the shore of Cabo Verde to await the crew members’ medical evacuation. Doctors from the island came on board to assess the patients but did not stay for long. Kornfeld continued to attend to his patients almost around the clock: On Tuesday, he told me, he spent nearly 18 hours anxiously monitoring their fluid status and oxygen levels, hoping that their heart and lungs would not fail; that night, he estimates he cobbled together three hours of sleep.

By then, Kornfeld had also become a key source of intel for his fellow passengers. They wanted to know the risks of the situation; they wanted him to tell them how concerned to be about diarrhea, a backache, an errant cough—could some of it mean that they had the virus too? Some also approached him with worries about their medications, which were running dangerously low, conversing with him through masks between his shifts caring for patients. Eventually, he became known by many around the boat as “Doctor Steve.”

With hantavirus now a clear and present threat, the ship’s crew took action, too, Peter Marsh, one of the ship’s passengers and birders, told me—“trying to contain the situation and keep the rest of us safe.” They advised masking and distancing, and asked passengers to stay in their cabin as much as they could when they weren’t carefully socializing on the outdoor deck; the crew doubled down on sanitization procedures all across the boat. Essentially, “we started adopting the previous COVID protocol,” Kenneth Petersen, another bird-watcher colleague of Kornfeld’s on the ship, told me. Kornfeld’s presence was especially reassuring to the ship’s many birders, among whom the doctor was something of a celebrity for his species-spotting prowess, Marsh, who has known Kornfeld for more than a decade, told me: “When he gave medical advice, they were very receptive.”

The two sick crew members were evacuated on Wednesday, along with—out of an abundance of caution—the traveling companion of the female passenger who died aboard last week. In the meantime, no one else has come to Kornfeld with concerning symptoms, he told me. Overall, the mood aboard has remained relatively optimistic, the passengers I spoke with said: Many people are still (carefully) participating in morning outdoor exercise classes, and in the afternoons, Kornfeld still spots a bit of dancing around the deck as people enjoy their drinks. And they’ve shown up in whatever ways they can for one another. Even as crew members ailed, their colleagues passed them words of encouragement through their closed cabin doors; when they were medically evacuated, passengers signed get-well cards.

The ship left Cabo Verde yesterday and is expected to dock in the Canary Islands this weekend. Now aboard are officials from the WHO and Europe’s CDC, plus two infectious-disease doctors from the Netherlands, Maria Van Kerkhove, the acting director of epidemic and pandemic management at the WHO, told me. They will watch and wait to see if others fall sick. The next big hurdle will be getting everyone else home, as officials assess the boat and its passengers, and countries with nationals aboard weigh how to handle their return.

Kornfeld expects to be monitored closely in the coming days, given how much time he spent with sick patients. He told me that he’s taken at least some comfort in knowing that this species of the virus seemed to require intense, prolonged exposure to do damage, and that he took the proper precautions; as a physician, part of his charter is to help others, even at his own personal risk. Now “if I’m not helpful anymore, I’m happy to just fade back and become a passenger again,” he said. Although this trip may be more remembered for its hantavirus troubles, Kornfeld told me his initial birding ambitions weren’t for naught. He saw roughly two dozen new species on the weekslong trip. And although the boat never landed on Cabo Verde, he still spotted one of the birds he had hoped to see there, flying over the island. His most recent eBird log is marked May 3, 2026: a Cape Verde swift.

Misoprostol Could Be Next

2026-05-06T15:57:28-04:00

Over the weekend, reproductive-health-care providers across the country confronted a puzzle they had never before needed to solve at scale: how to offer medication abortion without mifepristone. The drug, also known as the abortion pill, is the first in a two-pill regimen that the FDA approved for pregnancy termination in 2000. Last Friday, the Fifth Circuit Court of Appeals blocked providers nationwide from prescribing it online or mailing it to patients, delivering the most sweeping shock to U.S. abortion policy since the overturning of Roe v. Wade.

Some abortion providers suspended telehealth services immediately. Others moved toward using only misoprostol, the second pill in the usual protocol, which can end a pregnancy on its own. Misoprostol-only abortion has long existed at the edges of American abortion care; now, for providers, it could serve as a strategic hedge against an unstable legal future.

Already, the Supreme Court has issued a one-week stay on the Fifth Circuit’s order, allowing mifepristone to once again be administered via telehealth. But mifepristone has been in the crosshairs of anti-abortion activists for as long as it’s been available in the United States. Even now, federal lawmakers are advancing legislation to ban mifepristone for medication abortion on the grounds that it is dangerous and likely to be abused. To assuage concerns about the potential for serious side effects, such as heavy bleeding and abdominal pain, the FDA long required doctors to prescribe the drug in person and supervise patients taking it. During the coronavirus pandemic, after reviewing data showing that patients could safely take the pills without an in-person clinical visit, the agency began allowing mifepristone to be prescribed via telehealth and delivered by mail.

Those changes were the focus of the case before the Fifth Circuit, a lawsuit in which the Louisiana government has argued that mail-order access to mifepristone has circumvented the state’s near-total abortion ban and that the FDA’s decision to remove the in-person dispensing requirements was based on flawed data. In court, the FDA has defended its current policy, but in September, the agency announced that it would revisit the drug’s prescribing rules. The Fifth Circuit’s Friday ruling barred telehealth prescription and mail delivery of mifepristone while that review proceeds.

[Read: A convenient piece of junk science]

If the ruling is upheld in the Supreme Court, it will affect a significant number of Americans. Medication abortion has been growing in use since its FDA approval and, as of 2023, accounts for nearly two-thirds of pregnancy terminations in the United States, according to the Guttmacher Institute, a nonprofit focused on sexual and reproductive health. About a quarter of all abortions are provided via telehealth. In states with abortion bans or heavy restrictions, receiving mifepristone and misoprostol by mail is one of the only paths to ending a pregnancy.

Misoprostol-only abortion is common around the world, especially in countries where abortion laws are restrictive or mifepristone is not widely available. “Of the two drugs, misoprostol was always the workhorse,” Heidi Moseson, a senior research scientist at Ibis Reproductive Health, an international research and advocacy group, told me. In the standard two-drug regimen, mifepristone is taken first to block progesterone, the hormone that helps sustain a pregnancy, and misoprostol follows 24 to 48 hours later, causing the uterus to contract in a process that mimics miscarriage. Taken alone, misoprostol yields the same result.

But in the United States, misoprostol-only abortion has generally been treated as a fallback option. This approach was built on studies published between 1994 and 2019 estimating the typical mifepristone-and-misoprostol regimen to be roughly 95 percent effective, compared with about 78 percent for misoprostol alone. The misoprostol-only approach was also thought to carry more side effects and a higher risk of incomplete abortion, which sometimes requires additional doses of abortion medication or a procedural abortion to resolve.

Recent evidence is more bullish on the efficacy and safety of misoprostol-only abortion. The studies included in the early reviews varied in dosage, timing, and route of administration of both mifepristone and misoprostol, making the two protocols difficult to compare directly. However, in 2023, the National Abortion Federation and the Society of Family Planning shared a standardized misoprostol-only protocol for medication abortion. A 2024 review of studies that followed this specific protocol found effectiveness rates ranging from 82 to 100 percent. Moseson, who led that review, is now helping lead the first randomized controlled trial to compare the two medication-abortion protocols. Recent research has also yielded mixed conclusions about whether misoprostol alone is associated with elevated rates of nausea, vomiting, and diarrhea, as was once believed. And serious complications are rare: Fewer than 0.2 percent of patients undergoing misoprostol-only first-trimester abortion require hospitalization or a blood transfusion. Studies in the United States and in countries where the misoprostol-only protocol is more common have found that patients can safely self-manage the regimen, even when they obtain misoprostol through online services rather than formal clinics.

[Read: The other abortion pill]

Stronger data on misoprostol-only abortion, Moseson told me, could expand the options available to patients. Misoprostol is typically cheaper and easier to access than mifepristone, including in states with abortion restrictions. Unlike mifepristone, which in the U.S. is primarily used for medication abortion, misoprostol can treat a variety of conditions, including stomach ulcers and postpartum hemorrhage. It has never been subject to the FDA’s special prescribing requirements and sits on retail-pharmacy shelves. (As of 2023, mifepristone can be dispensed by certified retail pharmacies, but in-store availability remains limited in practice.)

But for providers, rapidly moving more patients to a misoprostol-only protocol would not be simple. Many clinicians have less experience counseling patients through the regimen, including advising them on how to identify possible complications and confirm that an abortion is complete. New restrictions on mifepristone could also bring a fresh wave of scrutiny to abortion and reproductive health care more broadly, Lauren Ralph, an epidemiologist at UC San Francisco, told me. Ralph, who has studied the safety of telehealth and self-managed medication abortion, said she is not worried about the minimal medical risks of misoprostol-only abortion. The greater danger, she suggested, would be a legal one: In states with strict abortion laws, patients might delay seeking follow-up care or struggle to find a provider willing to risk criminal exposure by treating them.

Although untouched by the Fifth Circuit’s ruling, misoprostol is not necessarily immune to legal attacks. Louisiana’s lawsuit and parallel suits filed by Florida and Missouri argue that the Comstock Act—a dormant, 19th-century anti-obscenity statute that anti-abortion legal strategists have spent years working to resurrect—bars the mailing of any drug used to induce abortion. This reading would apply to misoprostol just as readily as to mifepristone. (The Fifth Circuit did not address that argument; whether the Supreme Court will do so remains an open question.) In 2024, Louisiana became the first state to classify both mifepristone and misoprostol as controlled dangerous substances, a designation that requires prescribing clinicians to acquire special licensure from the state and mandates that facilities store the drugs under lock and key. All prescriptions must be tracked through a state database, and anyone possessing the pills without a valid prescription faces fines or jail time. Lawmakers in Texas, Missouri, and Kentucky have proposed copycat bills.

[From the January 2024 issue: A plan to outlaw abortion everywhere]

The places least equipped to absorb new storage and prescribing requirements are the same places where access to health care is already most precarious. Michelle Erenberg, the executive director of the reproductive-rights organization Lift Louisiana, told me that some rural and small community hospitals—which typically have limited capacity to store controlled substances—have effectively lost access to misoprostol for any kind of care. Pharmacists across the state have stopped stocking the drug, or grown wary of filling prescriptions, she said, leaving patients in limbo as they seek misoprostol for outpatient miscarriage care or to prepare for procedures such as IUD insertion. In December 2024, two months after Louisiana’s law took effect, a doctor performing an emergency C-section preordered misoprostol—previously kept within arm’s reach on delivery-room trays—in anticipation of a possible hemorrhage. Yet when the patient began losing blood on the table, the medication was still in a locked pharmacy cabinet across the hospital.

Abortion providers can adapt to mifepristone’s absence, as many already have. Misoprostol, by contrast, is harder to replace, as a mainstay of obstetric care and the most viable alternative to the standard regimen for pregnancy termination. If it becomes widely restricted, Americans seeking abortion care will have no ready substitute.

A Brutal First for the Cruise Industry

2026-05-05T17:26:34-04:00

Norovirus loves a cruise ship. So did the coronavirus responsible for COVID-19. The crowded rooms, stuffy air, and communal dining of a giant boat filled with humans create the ideal conditions for pathogens to spread. Now hantavirus—a highly deadly rodent-borne pathogen that typically spreads when people breathe in the aerosolized feces or other bodily secretions of infected animals—may have discovered this too: The world now appears to be experiencing its first documented cruise-ship hantavirus outbreak.

Over the weekend, health officials contacted the World Health Organization to report a cluster of serious illnesses aboard a cruise ship bound for South Africa. Among the roughly 150 passengers and crew on board, three have died and four have fallen ill—one critically. The vessel, the MV Hondius, is now anchored off the coast of Cabo Verde, as those on the ship await further instructions.

The situation is serious and frankly a bit unnerving. For now, officials are scrambling to assess the situation. Only two of the seven supposed cases of hantavirus have been confirmed by laboratory testing; the rest are still “suspected,” according to the WHO. And as health officials investigate, more cases may appear. Hantavirus can simmer in the body for weeks before sparking symptoms, and the seven people who have fallen sick so far might have all caught the virus through a common animal exposure before they got on the ship.

But that’s not guaranteed. The possibility remains that hantavirus-ridden rodents stowed away on the ship, which could mean more exposures, more illnesses, and perhaps even more deaths. A less likely, but still very real alternative: People could be catching the virus from one another, which could pose an additional threat to those at the ship’s destination and beyond—and to the health-care workers treating them. At least one type of hantavirus may be capable of limited person-to-person transmission, in situations involving close and prolonged contact—the sort that a cruise ship certainly encourages. And that version, known as Andes virus, just so happens to be found in Argentina, from where the ship departed just weeks ago. Researchers are sequencing the virus detected on board to confirm its identity, but currently, “our working assumption is that it’s Andes virus,” Maria Van Kerkhove, the acting director of epidemic and pandemic management at the WHO, told me via email.

No matter which version of reality this is, scores of people are now trapped on a cruise ship, potentially with a lethal virus that is perhaps being ferried about by infected rodents and/or humans. The virus can kill up to half of the people it infects, so any further spread could have horrifying results. At least one person who fell ill was taken off the ship to be treated in a hospital; more evacuations are planned. But most of those on board have no clear indication of when they’ll be freed. Oceanwide Expeditions, the company operating the cruise, has said that the ship is facing a “serious medical situation” and that the company is cooperating with authorities and working to “uphold stringent health and safety procedures.”

Eventually, of course, all of the ship’s passengers will have to disembark; Spain has agreed to receive the ship in the Canary Islands. Still, health officials can’t yet say how much risk the passengers and crew will pose to the broader global community. All told, this incident is a deeply sobering reminder that cruise ships can be the setting for infectious-disease nightmares—because they offer pathogens so many simple opportunities to spread.

The perils of cruise ships became painfully apparent during the early days of COVID, when the coronavirus zoomed through hundreds of people aboard the Diamond Princess. In many ways, the ships represented—and, really, embraced—the exact conditions that the pandemic-wary were cautioned to avoid: close quarters, communal indoor dining, crummy ventilation in public spaces.

That setup also favors the norovirus, one of the most common pathogens aboard cruise ships, Vikram Niranjan, a public-health researcher at the University of Limerick, in Ireland, who has written about the vessels’ risks, told me. Norovirus is wildly contagious, and transmitted when people come into contact with infected feces or vomit. Contaminated food, water, and surfaces are common culprits—easy to come across when dealing with shared utensils and cafeteria-style dining.

What’s more, cruise-ship interiors, where passengers from all around the world mingle and breathe in stale air, are especially friendly to any respiratory pathogens that make it onboard—COVID, flu, and now perhaps hantavirus. And for a virus that seems capable of human-to-human spread, prolonged journeys that last for several weeks, like this one, are ripe for facilitating repeated exposure. The people suspected to have been sickened with hantavirus started showing symptoms several weeks apart, which raises the possibility that the illnesses represent a chain, rather than a cluster of cases with the same source. Plus, one of the individuals who is ill and will soon be evacuated is reportedly the ship’s doctor, a likely common contact of the confirmed cases.

Van Kerkhove said the WHO team suspects that “there may be multiple ways in which people have been infected—through exposure to rodents but also possibly through human to human transmission via close contact.” The researchers were told rodents weren’t on the ship, but “I, obviously, can’t confirm that,” she added. “As it’s a ship, there is always the possibility.”

All things considered, “it’s increasingly looking as if there is at least some human-to-human transmission,” Bill Hanage, an epidemiologist at Harvard’s School of Public Health, told me. At the same time, Hanage noted, the cruise-ship conditions that might have allowed for that sort of spread could be making it harder for scientists to confirm the possibility. Even on land, human-to-human transmission is very difficult to confirm: People who tend to spend a lot of time together are among the likeliest to spread disease to one another, but they’re also prone to having the same exposure to an external source. Aboard a ship, even strangers are constantly schmoozing, widening the net that researchers have to cast.

Neither Niranjan nor Hanage thinks the takeaway is to swear off cruise ships. (Quite the opposite, Niranjan said: He’d still love to go on a cruise someday.) But realistically, the risks are at least as high as they would be for any other packed, prolonged party. If nothing else, pathogens thrive on our fondness for one another.

What Adding Race to BMI Can Do

2026-05-05T08:00:00-04:00

In recent years, the perils of body mass index, or BMI, have become a hobbyhorse for professionals in several fields of medicine and research. For decades, doctors have used BMI to help diagnose and treat obesity, diabetes, and other chronic conditions, even as evidence has accumulated that the metric is a poor proxy for excess fat. BMI factors in height and weight but not actual body composition; many people with high BMIs are the picture of health, and many with “healthy” BMIs are at serious risk of metabolic disease. The case against BMI is strong enough that many in medicine would like to be free of it.

Gripes have been raised, too, about medical guidance that relies on race. Although race can track with some factors that influence health, such as lifestyle and socioeconomic status, its relationship to genetic differences is tenuous: Designations such as “Black” and “Asian” cover so many people, with such varied backgrounds, that they’re essentially meaningless as biological categories. When doctors have used race to assess well-being, they’ve missed diagnoses and discriminated against patients. Experts now widely consider many race-based tools in medicine to be harmful and outdated, and are eager to leave them behind.

But researchers and clinicians still rely deeply on both BMI and race, in some cases at the same time. When screening for type 2 diabetes, for instance, race-sensitive BMI cutoffs identify more at-risk people than either factor alone. And however conflicted experts are over how to use that tool and others like it, finding alternatives comes with its own baggage.

When weighing the risk factors for type 2 diabetes, doctors generally flag a BMI of 25 or higher—what’s usually considered “overweight”—as a factor for further testing. But experts have known for a long time that this universal cutoff makes little sense. The original calculation of BMI arose nearly 200 years ago, was never intended for medical use, and was based on data from primarily white, European populations. And so researchers, clinicians, and policy makers around the world have pushed for people of Asian descent to get that same screening at a lower BMI threshold, of 23. The American Diabetes Association and the U.S. Preventive Services Task Force have supported that guidance for years; the CDC’s online prediabetes test has lower BMI cutoffs for Asian Americans than for people from other backgrounds. In Asian countries such as South Korea and Singapore, the lower threshold has been adopted as the national standard. At this point, the reality for people of Asian descent seems quite clear: “We do know that certain groups would benefit from more aggressive therapy at lower BMI cutoffs,” Fatima Cody Stanford, an obesity-medicine specialist at Massachusetts General Hospital, told me.

In this case, applying a race-and-ethnicity filter may help address some of BMI’s shortcomings. Studies suggest that many people of Asian descent—especially of South Asian descent—might have more trouble regulating their blood sugar than other racial and ethnic groups do, and seem more likely to store fat “in places that it shouldn’t be,” such as around visceral organs, in the abdomen, in the liver, and in muscles, Alka Kanaya, a diabetes researcher at UC San Francisco, told me. That so-called visceral fat seems to drive inflammation and insulin resistance, and has been linked to serious medical issues. But BMI can’t account for the location of fat in the body and so can mask diabetes risk for populations in which bodies might appear thin but have more centralized fat. Using a BMI of 25 to screen for diabetes could mean missing one-third to one-half of Asian Americans with type 2 diabetes; a threshold of 23, meanwhile, could cut that missed proportion in half.

At the same time, racialized cutoffs reveal the drawbacks of relying on race at all. “Asians” is a big group—billions of people—that itself contains immense diversity. And when researchers parse out people of, say, Vietnamese descent from those of Indian, Filipino, Chinese, Korean, or Pacific Islander heritage, they find different risks (without much insight into whether those differences are driven by lifestyle, socioeconomic factors, genetics, or a combination). Not everyone knows their full racial or ethnic makeup; people of mixed backgrounds are one of the fastest-growing demographic groups in the United States. “How do you classify them?” Maria Rosario Araneta, an epidemiologist and a diabetes researcher at UC San Diego, asked me. Ideal screening tools excel both at identifying risky cases and at excluding healthy ones. But lowering the BMI cutoff for people of Asian descent starkly increases the number of patients who are unnecessarily flagged for further testing.

Experts also disagree on what could be used instead of BMI to screen people. Body-composition scans can measure fat directly, but they’re expensive and impractical to use on everyone. Another option could be to screen everyone above a certain age for diabetes, using a fasting glucose test or another test that measures a blood sugar called A1C. But fasting glucose tests—which require, well, fasting—may not come with ideal compliance. And Araneta and her colleagues have found that A1C cutoffs for diagnosing diabetes may need to be reevaluated, especially for certain Asian populations that may develop diabetes at lower levels than people of European descent.

Alternative strategies for estimating excess fat have their challenges too. Goutham Rao, a family physician at the University Hospitals Health System, told me that he favors using waist circumference or waist-height ratio. But other researchers find any tool that relies on measuring waists to be impossibly messy. Even well-trained professionals will sometimes take measurements from different parts of a patient’s midsection; the person being measured, too, can skew the results: “You take a small breath in and you change your waist circumference by two centimeters,” Kanaya said. And research suggests that cutoffs that rely on waist circumference may, yes, also need to take into account a person’s ethnicity or race. “Of course, BMI is not perfect,” George King, the chief scientific officer at the Joslin Diabetes Center, in Boston, told me. “But we don’t really have much else to guide us.”

For now, several researchers told me, race-sensitive BMI risk cutoffs could stand to be used more widely, not less. In the United Kingdom, says Rishi Caleyachetty, a general practitioner and an epidemiologist who has studied BMI, although the National Health Service uses the 23 cutoff for some ethnic populations, including those of Asian descent, those thresholds haven’t been consistently adopted across the country. In the U.S., Stanford said, the Mass General Weight Center still uses a universal set of BMI cutoffs to admit patients, and she has had to overrule those standards in several cases to ensure that certain patients are seen. And many insurance companies have relied on BMI to determine whether they’ll pay for GLP-1 medications, without carving out exceptions for particular racial or ethnic groups that might have distinct risk profiles.

Scientists haven’t been able to rigorously study how much of an impact calls to “screen at 23” have had—in part because Asian Americans weren’t well represented in the U.S.’s National Health and Nutrition Examination Survey, which includes estimates of diabetes prevalence, until 2011. King said he thinks that the available evidence hints at a drop in the prevalence of undiagnosed diabetes in Asian American communities. But one small study from 2022, based on self-reported data on diabetes screening, found no change in diabetes-screening rates among Asian Americans after the change in guidance.

BMI cutoffs that take into account race and ethnicity may be short-lived, as researchers develop better tools and protocols to help people identify and manage chronic metabolic conditions. But BMI is still everywhere for a reason: “No single measure will compete with BMI in simplicity,” Samar El Khoudary, a women’s-health researcher and an epidemiologist at Virginia Commonwealth University’s School of Public Health, told me. Across the board, the researchers I spoke with told me that they understand the serious limitations—and major risks—of overusing or misusing BMI and race, separately or together. But many of them also worry that too hastily casting these categorizations aside could do more harm than good. “To be able to remove it, you need to be able to replace it,” El Khoudary said. And she doesn’t yet see a clear plan for what metric can accomplish that—certainly not one that can also avoid all of BMI’s pitfalls.

The Cost of ‘Natural’ Womanhood

2026-05-03T08:00:00-04:00

Updated at 9:04 a.m. ET on May 13, 2026

Supposedly, the menstrual cycle is a gift. It’s a product of good design. It’s a miraculous dance of hormones that can’t be contained. Such are the messages flooding the internet these days, courtesy of lifestyle influencers, crunchy moms, so-called hormone coaches, and all sorts of popular entertainers.

The menstrual cycle, according to these same voices, is also an emotional roller coaster, best ridden with the aid of bespoke products. Viral memes and TikTok trends play up women’s purportedly excessive spike in libido during ovulation and dramatic irrationality during menstruation and the luteal phase (the 14 days or so between ovulation and menstruation). The cycle-tracking app Belle Health has used Moana’s verdant mother goddess and her volcanic counterpart to illustrate the difference. The meal-kit company Hungry Root recommends ordering sweets during the luteal phase. Every stage of the cycle has its own skin serum. You can test your hormone levels at a boutique women’s clinic, or at home using a $100-plus device and a monthly app subscription. (Evidence for the efficacy of most of these tests, devices, and apps is mixed at best.)

Riding the hormonal highs and lows is supposed to be worth it in part because of ovulation, a purportedly glorious, clear-skinned moment that justifies all the cramps and that one influencer calls women’s “secret superpower.” Advocates for a “natural” menstrual cycle argue that modern medicine—especially birth control—has robbed women of this gift, and therefore their true selves. If reclaiming it comes with wild mood swings, well, that’s a small price to pay. But in the long term, buying into these stories about mood and biology could have a higher cost.

Hormone shifts, of course, can exert some influence on mood. Progesterone, estrogen, and other hormones fluctuate throughout the menstrual cycle, and many people feel the effects of the sudden peaks and dips. Nearly all women report some mood changes and discomfort in the week prior to menstruation. Roughly 3 percent of premenopausal women likely experience premenstrual dysphoric disorder, which is characterized by severe mood swings related to one’s cycle. PCOS, fibroids, and endometriosis come with additional hormonal fluctuations, which can cause intense pain and bleeding, irregular periods, hair growth, and weight gain. Menstruation itself can be painful (not to mention annoying), which is unlikely to put anyone in a good mood. Menopause—and the hormonal changes that can last for years leading up to it—can also wreak physical and psychological havoc.

[Read: Women in menopause are getting short shrift]

But despite their use of scientific-sounding language like follicular and luteal, content creators severely exaggerate the influence of hormonal changes and the euphoria they can supposedly inspire. Hormones are not just powerful, they insist, but empowering, the ticket to health, harmony, and femininity. If your follicular phase doesn’t make you feel extra beautiful and sexual, or if you feel generally out of whack, something must be interfering with your hormones. Maybe that’s because you’re eating wrong, exercising wrong, too stressed, too caffeinated, or—God forbid—taking hormonal birth control.

Contraceptive pills, hormonal IUDs, birth-control implants, and Plan B all work at least in part by suppressing ovulation. And for that reason, hormonal contraception has in recent years been presented as a harmful disruptor of the natural joys of womanhood. “When you change your hormones, you change who you are,” Sarah Hill, an evolutionary psychologist at Texas Christian University and author of The Period Brain said in a 2024 interview. “If you want women to be feminine again, and soft again and beautiful,” the right-wing wellness podcaster Alex Clark declared last year, “women need to be ovulating.”

The only way to really get in touch with your body, according to this line of thinking, is to give your hormones free rein. In a Rolling Stone interview last year, the singer Lorde described how she stopped taking birth control before writing her most recent album. Her next ovulation, she said, was “one of the best drugs I’ve ever done.” (She chalked her decision to go off birth control up to right-wing influence, acknowledging a split from her usual politics.)

[Read: Why are so many women being told their hormones are out of whack?]

The promise of a “natural” approach to women’s health is seductive, in large part because of the ways that modern medicine has failed women. Women’s health is perennially understudied: In 2024, for instance, 6 percent of the annual National Institutes of Health budget went toward studying women’s health, and that was before the wave of scientific-grant terminations under the Trump administration. This could help explain why hormonal birth control is so often prescribed for dozens of ailments—including painful periods, fibroids, and PCOS—that have few other effective treatments. Plus, the side-effect profile of hormonal birth control can be brutal: It can cause weight gain, exacerbate some underlying mood disorders, and raise the risk of blood clots (but much less than pregnancy does), which in turn can increase the risk of stroke. It also increases the risk of certain types of cancers (while reducing the risk of other types).

But jettisoning hormonal treatments also means losing their benefits. Decades of research indicate that the hormones used in contraceptives, menopause care, and IVF are safe for the large majority of people. Hormonal IUDs and birth-control pills are highly effective, especially compared with more MAHA-aligned fertility-awareness methods. Hormones are also a lifeline for women who have uncomfortable-to-debilitating conditions such as endometriosis and premenstrual dysphoric disorder, as well as a range of autoimmune disorders that have nothing to do with reproduction. Hormonal infertility treatments have helped people safely create and expand families since the late 1970s.

Claiming that the menstrual cycle is mystical and powerful might sound feminist. But teaching women that they should naturally feel erratic at virtually every point in their cycle could lead women to downplay—and miss out on treatment for—actual mood or hormonal disorders. The attitude also has social consequences. Denigrating hormonal birth control when access to abortion is restricted could leave more women with unwanted pregnancies; it dovetails with some pronatalists’ argument that women should dedicate themselves to motherhood and the conservative push for women to embrace traditional gender roles. “Whenever we see a precipitous rise in hormones as an area of interest, it usually also indicates shifting ideas of gender and culture,” Alexander Borsa, a public-health researcher at Columbia University, told me. If women are susceptible to biologically driven instability, how could Americans possibly trust them to be equal to men? To hold political power? To run companies? (In fact, an essay arguing that women are not fit to do such things went viral last fall.)

[Read: No, women aren’t the problem]

Urging women to “balance” their hormones “naturally” perpetuates an insidious, age-old idea that women are especially close to nature and God. “There’s a long tradition of linking women to nature, men to culture,” Helen King, a historian and the author of Immaculate Forms, told me in an email. “In Ancient Greek medicine, women’s flesh was seen as more absorbent, as resembling a fleece, whereas men’s flesh was like a fabric garment. Women were closer to the natural product, the raw materials, men were superior as the finished product.”

At their most chilling, such beliefs are paired with arguments that women not only are especially natural, but also should stay that way—that modern medicine shouldn’t try to understand or interfere with women’s bodies. Many in the MAHA movement, for example, urge women of childbearing age to be as “natural” as possible—to embrace traditional gender roles while rejecting chemicals, vaccines, additives in foods, and of course birth control. The federal government has, to its credit, recently championed the use of estrogen to relieve symptoms of menopause. But at the same time, for women of childbearing age, it is promoting restorative reproductive medicine, a form of fertility treatment that eschews hormonal intervention and is not empirically backed.

The more people believe that women are ruled by their untamable hormones, the more women stand to lose actual power. Leaning into the supposed euphoria of ovulation is fun, sure—who wouldn’t want to try the best drug Lorde has ever taken? But that drug trip is fleeting. When it ends, what are women left with?

This article originally stated that various hormonal contraceptives, including IUDs, work by suppressing ovulation. In fact, hormonal IUDs do not always suppress ovulation.

Your Next Dog May Live Longer

2026-05-02T08:00:00-04:00

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One day last November, my dog, Forrest, sat on the cold marble steps of the Smithsonian’s natural-history museum in Washington, D.C., ready to meet Celine Halioua, a woman who may one day add a tail-wagging year or so to his life, and also the lives of millions of other dogs. In 2019, Halioua founded a company called Loyal, and in February 2025, a pill that she developed for dogs was deemed likely to be effective by the FDA. If the company ticks a few remaining boxes, the drug could soon be on sale, kick-starting a new era of longevity medicine that could eventually also lengthen humans’ lives.

More than 10,000 years ago, dogs made a farseeing bet on humans. They padded carefully up to our campfires, ate scraps, and kept watch, hitching their fates to a species that would soon bestride the planet. They have since become the fourth-most-populous large land mammal, trailing only sheep, cows, and goats, which all lead less pampered lives. Now we’re trying to keep our best animal friends around longer too.

If only I could have explained all of this to Forrest before our walk with Halioua. As a Portuguese water dog, he hails from a clever breed, but he doesn’t understand advanced pharmacology, so I worried that he might be indifferent to her, or even rude. But Halioua, who is 31, had arrived with a plan. She stooped down, squealed his name, and opened her hand, revealing a treat that he promptly devoured.

Halioua was 18 years old when the cold fact of death blew through her. She was working at a neuro-oncology lab and couldn’t unsee the cosmic unfairness of a brain-cancer diagnosis, the way it constricted the possibilities of a person’s life and cut short their closest relationships. Death had an important role to play back when life was single-celled and simple, Halioua told me. It helped evolution iterate rapidly and build up more complicated organisms. But now that natural selection has created complex, intelligent animals—namely, us—we should stretch out the good, healthy part of our lifespan as well as that of our dogs, too. With extra decades, she said, we might even become more forward-looking, and less likely to wreck a world that we will have to keep living in.

After college, Halioua enrolled in a doctoral program in genetics at Oxford and worked in life-extension research during her time off school. The field has never been uniformly rigorous in its approach to research. Over the years, Halioua has developed an aversion to what she described as longevity “bro science.” She’s not into the translucent-skinned gurus who primarily experiment on themselves and post their physiological data, including the duration of their sleeping erections, on X. She’s not trying to gain eternal life through obsessively healthy living, she once told me over a tray of french fries.

Halioua got her big break from Laura Deming, a former child prodigy who was accepted to MIT at age 14 and later co-founded the world’s largest venture fund for longevity research. Halioua was only 23 when she started interning at Deming’s offices in San Francisco, but after two weeks, Deming hired her, and eventually promoted her to chief of staff. Early on, she gave Halioua a blunt pep talk. “I didn’t really speak the Silicon Valley language,” Halioua told me. Deming told Halioua that she didn’t sound smart. That made Halioua self-conscious, but she was grateful and resolved to assimilate by listening to every last episode of the Y Combinator Startup Podcast. It wouldn’t make for the most cinematic training montage if there were ever a movie about her life, but it helped her pick up the local lingo and speak at a more rapid clip.

At Deming’s fund, Halioua sat in on start-up pitches and broadened her view of the longevity industry. She saw that serious money was flowing into it. Investors have dropped more than $10 billion on life-extension companies in just the past five years. Most of that has gone to long-term bets on radical life-extension projects for humans, some intended to defeat aging altogether. Jeff Bezos and Sam Altman have both bankrolled new efforts to wind back the internal clocks of our bodies’ cells using epigenetic techniques that have already extended the lives of mice. But the companies that they have invested in—Altos and Retro Biosciences—are focused on preclinical or early-phase work. The same goes for Calico, Alphabet’s secretive life-extension company. It may be decades before we know if those bets have paid off.

Halioua wanted to move faster, and she had personal reasons for focusing first on dogs. She grew up on Austin’s semirural outskirts, the lone daughter of immigrant parents from Germany and Morocco, and like many children—especially only children—she formed intense relationships with animals. Her family had 15 cats and several dogs, most of them strays. In middle school, she started visiting an old cowboy who lived in a run-down house nearby. She began taking his retired racehorse, Ziggy, on walks, and her family later bought the horse. Years later, when the horse died, she got a tattoo of its racing name next to her heart.

Halioua has made a habit of adopting senior dogs, and that means she more frequently has to experience the heartbreak that she’s trying to forestall for dog owners. Four years ago, she brought home a 10-year-old Rottweiler named Della that had been found wandering Oakland’s streets. In 2024, I visited Halioua in San Francisco, and Della came with us almost everywhere we went—to the local coffee shop, to the stables where Halioua keeps a dressage horse. Shortly before I saw Halioua in D.C., I learned that she’d had to put Della down. On the plane, she’d made the mistake of scrolling through old pictures. She spotted Della in one and felt her vision blur with hot tears. “Della would literally spoon me at night,” she said. “They’re such pure souls.”

Halioua had another reason for starting with dogs, beyond her connection to them: Federal approval for animal drugs is easier to come by than it is for human drugs. And because dogs tend to live only a decade or so, she can quickly tell whether a life-extension drug is working in them. Her end goal is to lengthen human lives. For thousands of years, dogs have gone out ahead of humans as wilderness scouts. They have ventured into buildings to sniff out explosives. Some even got killed rocketing into space before us. Now they’re entering another new frontier that may be fraught with its own unforeseeable dangers.

Illustration by Gaia Alari

Scientists have already dramatically lengthened the lives of many animals, but they’ve mostly been tiny ones that people don’t care much about. By the early 1990s, a molecular biologist named Cynthia Kenyon had for years been arguing that aging is not simply a matter of accumulated wear and tear. To Kenyon, who now serves as the vice president of aging research at Calico, the fact that animals have such a wide range of lifespans was evidence that the aging process is directed by genes.

In 1993, Kenyon doubled the lifespan of a roundworm, Caenorhabditis elegans, with the tweak of a single gene that targeted its insulin receptors. Scientists have since used similar genetic tricks to substantially extend the lives of flies. Most tantalizing, they have done it in adult mice.

Dogs are nearer to us, genetically, than mice are, and they age in many of the ways that we do. We suffer from some of the same cancers and use some of the same chemotherapies to treat them. The human brain’s neurons experience similar modes of decay, and so, too, do our downstream behaviors. Dogs can lose control of their bladder in old age. They can forget faces, become more grumpy, and bump into walls. Kenyon told me that although the mice research is encouraging, a drug pathway that successfully extends a dog’s life will generate more enthusiasm among scientists who hope to try similar treatments on humans.

Forrest is four years old, and although not a dot of gray appears in his glossy black muzzle, he is already showing some signs of aging. He catches fewer cases of the zoomies, and before he leaps up onto the bed, he takes its measure. As we walked on the National Mall, Halioua explained that inside him—as in humans of every age—cancer cells are constantly popping up. His immune system still has lots of ways of zapping cancer cells out of existence before they multiply into tumors. But by the time Forrest reaches age 10, when dogs become eligible for Loyal’s pill, those defenses will more often misfire and fail to stop not just cancer but also other life-abbreviating ailments.

On her tricep, Halioua has another tattoo, this one of a Labrador retriever, but it doesn’t pay tribute to a previous pet. It’s a tribute to the 48 Labrador puppies who participated in a 14-year study by scientists at the dog-food company Purina. They split the puppies into two groups and fed one group 25 percent less than the other. After tracking the dogs for the rest of their lives, they found that those who were fed smaller bowls of kibble lived nearly two years longer, on average. By making one crude shift to the dogs’ metabolism, the scientists had extended their lives by more than 15 percent.

Several recent biomedical findings suggest that a profound link exists between an animal’s metabolism and its lifespan. The potential life-extending effects of Ozempic and other GLP-1s have been especially intriguing on this score. The drugs treat obesity by slowing the movement of food through the gastrointestinal system and suppressing appetite, but they also seem to trigger a cascade of other unexpected benefits all across the body. They appear to improve the condition of people’s kidneys, liver, heart, and even their brain. Some longevity researchers now argue that GLP-1s are the first de facto anti-aging drugs because they slow so many of the life-shortening processes that operate inside of us.

[From the December 2022 issue: Sarah Zhang on how much a cat’s life is worth]

But GLP-1s are blunt instruments. The longevity benefits they confer are a byproduct of appetite suppression. Loyal’s drug is designed to trigger some of the same effects, without a dog having to face any of the deprivations experienced by GLP-1 users or the Labradors in the Purina study.

Scientists who studied the Purina data noted that the calorie-restricted dogs were less awash in insulin, a metabolic hormone that is known to accelerate certain aging processes, in excess. The exact mechanism of Loyal’s drug is still proprietary, but scientists at the company told me that the pill tinkers with a dog’s insulin sensitivity.

Every time Forrest eats, his small intestine breaks down the resulting slurry of kibble into glucose and other compounds. His pancreas then produces a tiny pulse of insulin, a chemical whisper that echoes all through his bloodstream, telling different kinds of tissues to absorb the glucose. In a young, healthy dog, this system is precise; it requires only that whisper. But like us, dogs become less sensitive to insulin as they get older and require more of a clanging cymbal. The resulting glut of insulin can inflame tissues all across the body, and over time, this can weaken the immune system and contribute to all manner of chronic diseases, including cancer and heart disease. When a dog or a person becomes less sensitive to insulin, brain decay can set in quicker, and the operations of neurons can be scrambled.

Loyal’s daily pill is intended to restore a dog’s insulin sensitivity. It dissolves into particles that travel throughout the body, like little Paul Reveres, telling tissue systems to be on the lookout for insulin and to respond quickly when it reaches them. That way, the glucose doesn’t linger, and the pancreas doesn’t keep flooding the blood with the hormone.

Federal regulators have generally preferred drugs that target specific diseases, classified by organ systems, an approach that may simply miss certain whole-body aging processes. That the FDA has taken the unusual step of allowing Loyal to develop a drug specifically for life extension, as opposed to for some particular ailment, suggests a shifting approach. After reviewing Loyal’s early data, the agency found that by operating across different organ systems, the drug was reasonably likely to extend a dog’s life. Whether it works or not, this new openness on the part of the FDA is exciting all by itself.

Loyal hopes to be able to start selling its drug next year, for about $100 a month for dogs of most sizes. (The pill has met FDA requirements for an expectation of safety and efficacy, but it needs to meet a core manufacturing requirement before the company can receive conditional approval to market the drug.) The unpublished study that the FDA reviewed was relatively small, involving about 50 dogs whose aging-related biomarkers were tracked for three months. There were clear improvements, but improvements in biomarkers are not enough to know that a drug works. As part of its campaign to secure full approval from the FDA, the company has launched a roughly five-year clinical trial to know, with greater certainty, whether and how much it extends a dog’s life.

Illustration by Gaia Alari

As late as the 1980s, animal-health divisions at pharmaceutical companies were lightly staffed backwaters. At Merck, “you only worked in that part of the company if you weren’t very ambitious,” Linda Rhodes, an industry veteran, told me. Back then, the sector focused on drugs that helped cattle and swine survive long enough to make slaughter weight. Dog owners were regarded as a niche market inside a niche market.

In the ’90s, the blockbuster sales of two flea-and-tick medications, Frontline and Advantage, demonstrated untapped demand, and then intensified that demand by enabling new levels of indoor intimacy between dogs and people. Dogs have been bed warmers since the time of ancient Egypt, at least, but many more of them were invited to sleep with us after they were reliably rendered tick-and-flea-free.

Even just decades ago, fewer people described their dogs as family members. Now seniors spend as much on gifts for their dogs as they do for their grandchildren. People buy their dogs health insurance, take them in for regular dental visits, and sign them up for memberships at concierge-style veterinary clinics modeled after One Medical. Families are willing to go into debt to finance a surgery if doing so means saving a beloved dog’s life.

If dogs start living longer, these familial feelings of obligation may intensify. People may feel guilty if they can’t afford a daily pill that keeps their dog alive longer. Above a certain socioeconomic threshold, not spending an extra $1,000 a year or more in the hopes of doing so could seem neglectful. Elderly people may think twice about adopting dogs that have the potential to live much longer. Euthanasia decisions are already brutalizing for dog owners, and those decisions may become even more fraught.

The fundamental sadness of loving a dog is knowing that you are more likely to lose them than vice versa, because their lifespan is easily contained by yours. There’s every reason to try to keep them around longer, especially if the extra years are healthy ones. But our relationship with them may change if we succeed, perhaps in some ways that we don’t expect.

Loyal’s clinical trial, which the company says is the largest one ever run on an animal drug, began in December 2023. More than 1,300 dogs enrolled, all at least 10 years old and weighing at least 14 pounds, and representing many different breeds. Age verification at times proved difficult; some owners submitted screenshots of Facebook posts they’d made back when the dogs were puppies. Most clinical trials for dogs last a month or two, but the owners of these dogs have committed to keeping at it for at least half a decade. They don’t even know whether their pet might be taking a placebo, as half of the test population is. The FDA expects the pill to be safe, but no dog has yet had it in their system for five years.

By the time the trial finishes, Halioua may already have had the drug on the market for years. She recently assembled a focus group of 20 taste-tester dogs to get the flavor just right at launch. One day of taste-testing wasn’t enough, because many dogs will inhale just about anything with gusto the first time they eat it, and this is a pill they’ll have to take for the rest of their life. Compared with cats, dogs tend to chomp down on pills easily, but some of Halioua’s taste-testers were quite discerning; one spat out a disagreeable flavor variant and then, to underscore his verdict, peed on it.

Halioua is trying to anticipate other ways that her business might fail, even if the science proves out. In 2007, a much-hyped appetite suppressant for overweight dogs flopped spectacularly, not because it tasted bad or didn’t work but rather, in part, because it removed a dog’s great relish for tasting things in general. The human-dog bond has been food-based since its earliest campfire beginnings. Halioua explained that people didn’t like it when they couldn’t use treats to motivate their pets.

Halioua wants the pill to sell well so that she can build up a war chest. That way, the company could fund its own clinical trials for a human-longevity drug without having to sell out to “Big Pharma Daddy,” as she put it. Halioua doesn’t want to forfeit control of the process to a larger, more risk-averse, and possibly slower-moving company.

She has plenty of years left to see her plan through. I asked her if she wants to live for centuries, or even forever. “It’s not an obvious yes,” she told me. No one knows how much a human’s life can be extended, but whether it’s a few years or decades or more, Halioua said she wouldn’t want to keep living just for the sake of it.

She’d want to continually remake herself—“update,” in the founder parlance that she has adopted—try lots of new things. When I’d seen her in D.C., she was on the verge of one such change. I’d asked her if she would keep adopting older dogs. She told me that part of her felt like she had an ethical mandate to. “But also part of me is like, ‘Holy fuck, I don’t think I can sign up to do this again,’” she said. A few months later, Halioua did get another Rottweiler, a rescue named Squish. She will most likely get to spend more time with her than she did with Della, whether the pill works or not. Squish is not even two years old.

The Secret to Success Is ‘Monotasking’

2026-05-01T07:00:00-04:00

If Isabel Allende’s office needs to be painted, it has to be done by January 8 or put on hold. Every year, that’s the day she starts writing.

The pattern goes back to January 8, 1981, when Allende began her first novel, The House of the Spirits. Ever since, she has cleared her calendar and started a new book on that date, assuming she had finished the previous one. The ritual has helped her publish a book about every 18 months for 43 years. Today, at age 83, Allende is the most translated female Spanish‑language author in the world, by far.

“When I am writing a book, I need to close the door when I finish, and no one should get in,” she explained when I visited her home in Sausalito, California. “I have the idea in my mind that the story is an entity that lives in that room, with the characters and the emotions that I have been putting together. And when I come back the next day, I open the door and it’s waiting for me intact. I don’t want anybody to go in and vacuum, or to use my computer—that would kill me!” She paused for a moment. “Without the silence, and the structure, I wouldn’t be able to do it.”

Allende’s January 8 ritual is a form of what social scientists call a “commitment device”: a self‑imposed restriction of freedom in service of a larger goal. Commitment devices have been shown to help people save more money, by having a bank account with limited withdrawal windows, and exercise more, by signing a contract to pay a fine if they skip too many days at the gym.

Allende’s reward for her rigid schedule is unadulterated focus. As the computer scientist Cal Newport has noted, writers were the original remote workers, and anyone who studies the great ones will notice that they tend to go out of their way to designate a specific space and time for their work. Maya Angelou famously rented hotel rooms and stripped the artwork from the walls so as not to be distracted. Victor Hugo locked up his clothes while writing so he wouldn’t be tempted to change and go outside. Marcel Proust lined the bedroom where he worked with cork to dampen outside sound.

The reason such practices are important is that sustained focus is highly unnatural for human beings. Our brains evolved to be extremely distractible, to attend to any novel sights and sounds in our vicinity. Unsurprisingly, research has found that people instantly become more creative when distractions are removed. The science writer Annie Murphy Paul explains in her book, The Extended Mind: “It was only when we found ourselves compelled to concentrate in a sustained way on abstract concepts that we needed to sequester ourselves in order to think. To attend for hours at a time to words, numbers, and other symbolic content is a tall order for our brains.”

And these days, we’re struggling. Gloria Mark is a psychologist at UC Irvine who studies what, exactly, workers in a knowledge economy do all day. Early in her career, she shadowed office workers with a stopwatch and logged all of their activity. Mark and her co-author found that the typical worker switched tasks about every three minutes, on average. For the title of the resulting paper, in 2004, she used a quote from one of her subjects: “Constant, Constant, Multi-tasking Craziness.”

Over the next 20 years, Mark studied work activity at large organizations such as Microsoft using increasingly sophisticated tools, including cameras and programs that recorded computer activity. In 2012, she found, office workers were switching tasks every 75 seconds. By 2022, it was about every 45 seconds.

Multitasking is the act of distracting yourself. It comes with a cost even when tasks feel related, because it requires you to switch the “mental rules of the game,” as the cognitive scientist Daniel Willingham puts it. Even when people are allowed to switch between tasks at their own discretion, the more they switch, the longer everything takes. As Mark has written: “We find that in real‑world work, the more switches in attention a person makes, the lower is their end‑of‑day assessed productivity.”

They also perform worse on important tasks. Multitasking ER doctors make more errors in prescribing medications, and multitasking pilots make more errors in flying. The famed investor Charlie Munger had it right when he said: “I see these people doing three things at once, and I think, God what a terrible way that is to think.” Compare constant goal-switching with Allende’s approach to her workspace: “I go there, and there is a state of mind that is: I’m here to do this and nothing else and no one can interrupt.”

Here’s the frightening part: We gravitate to a customary level of interruption. If you are disrupted by notifications all day, every day, then even if those external triggers magically disappear, you will unconsciously start interrupting yourself to maintain the rhythm of distraction you’re used to. That is why the mere presence of a smartphone on a desk or in a pocket—even if it is turned off—has been shown to impair performance on cognitive tests, particularly among people who are more phone dependent.

The year before I encountered Mark’s research, I had to get a few stitches in my head. It was no big deal, just uncomfortable. I was told to move slowly for a few days, ice regularly, refrain from jerking my head, and sleep sitting upright. All of that was annoying. Yet after three days, I was surprised by how happy I felt. I started tracking what I was doing in a journal to see if I could figure out what was going on.

My conclusion: It wasn’t so much what I was doing as what I wasn’t doing. Whether I was reading, working on my computer, or brushing my teeth, I was “monotasking,” concentrating on one thing at a time. Not being able to move quickly or turn my head had the effect of forcing me to focus. I remembered that I really like my work when I can do it in a focused manner and at a steady pace. I think the discomfort even helped: If I started to multitask, I could feel pain and tingling near the stitches. It was like I suddenly had some sort of multitasking monitor implanted in my skin.

That feeling started to make conceptual sense when I read Mark’s work, which found that the faster people switch attention between devices, the higher their stress level. Laboratory experiments by other scientists have shown that multitasking leads to a jump in blood pressure, and intense multitasking causes changes in immune-system activity. While my wound was healing, I was more aware of physiological changes any time I tried to multitask, which led me to stop doing it.

As I was chronicling those days in a journal, I thought about the discomfort of two writers who, in my opinion, are among the best alive. Laura Hillenbrand wrote the nonfiction books Seabiscuit and Unbroken, and Susanna Clarke wrote the fantasy novel Piranesi. Both authors have experienced chronic-fatigue syndrome and discussed how it forced them to simplify their work routine.

I would not, in a bazillion years, wish chronic fatigue (or even a few stitches) on anyone. But I find it telling that unwelcome conditions can force limitations that lead to effective and sane work habits. In a frantically paced world, the literal and figurative space to think long thoughts requires curation and constraint.

Herbert Simon, a groundbreaking computer scientist, psychologist, and economist, once said that all his work was devoted to a single subject: how humans make decisions. Simon emphasized that we are always faced with imperfect information about our options and the potential consequences of our choices. Rather than “maximize,” or make the best choice from all available alternatives, he argued that people “satisfice”—consider a limited menu of options and choose one that is “good enough.”

Simon was, in his own words, an “incorrigible satisficer.” He didn’t agonize over keeping his options open. “He wore one brand of socks, thus, after the first purchase, never having to select the color or style of what he put on his feet each day,” his eldest daughter, Katherine, wrote. Simon “always had the same breakfast (bowl of oatmeal, half grape‑fruit, black coffee), and lived in the same house for 46 years.” One might be tempted to accuse him of a lack of ambition, if he hadn’t won a Nobel Prize.

Simon believed that technology now delivers so much information that it exceeds our capacity to attend to it. “The design principle that attention is scarce and must be preserved is very different from a principle of ‘the more information the better,’” he said. How would we live and work if we prioritized the principle that attention is scarce? For one thing, we wouldn’t check email 77 times a day—the average in one of Mark’s studies.

With Simon’s insight, Mark’s research, Allende’s example, and my own experience with the stitches all in mind, I set about tweaking my own work habits to impose constraints. Every change was simple. I resolved never to start the day with email, because for me email is an instant gateway to multitasking. And since I can never get through everything in my inbox, it leaves an attention residue that makes it difficult for me to switch wholeheartedly to my most important work.

When I make a list of tasks for the day, I put fewer items on it. I had been underestimating the cost of switching, so I was chronically overestimating what I could actually get done in a day. (This pervasive cognitive bias is known as the planning fallacy.) The result was that I would end up trying to multitask to keep up with my list, which meant that I both performed worse and took longer. I would then carry over unfinished tasks to the next day’s list, until it got so long that I gave up and threw it in the trash. Then the cycle would begin again. Now I start my daily list with a single task that, if accomplished, will mean it was a good day.

In an effort to curtail interruptions, I started using focus mode on my phone to avoid constant notifications. Then I turned my phone off while I was working and left it in another room. It didn’t immediately make a difference, but pretty soon the internal metronome that prompted me to check various feeds and inboxes slowed to a crawl. I cut down looking at my phone to once or twice a day, and on days when focused work was the priority, only at the end of the day. When I interrupted myself with thoughts about other things I had to get done, I would immediately write them down in a notebook. That cognitive outsourcing prevented unfinished tasks from lingering in my mind.

Not everyone can turn off their phone and leave it in another room. But whatever your job, many of the highest-cost attention switches have nothing to do with the actual demands of work—they’re just a matter of habit. Nurses can’t ignore a page, but they can stop checking email between patients. Teachers can’t shut the door on students, but they can do administrative work in a single batch instead of scattering it through the day. Even modest reductions in switching pay off disproportionately in improving productivity and reducing stress.

Finally, I took Mark’s advice to work in intervals. Attention is like a bucket, she told me; you want to take a break from intense focus before the bucket is filled and you’re exhausted. Angelou would periodically take a break from writing to do crossword puzzles. She framed it as toggling between her “big mind,” which she used for writing, and her “little mind,” which she could use for something simple.

Taking a break to use your little mind for rote activity replenishes your big mind. The neurobiology behind this is only beginning to be understood. In 2022, scientists showed that hours of concentration leads to a buildup of the chemical messenger glutamate in the brain. Too much glutamate is poison to brain cells, so it could be that part of mental fatigue is your brain reducing its activity to prevent getting to that point. Whatever the reason, little-mind breaks help you recover focus before reaching exhaustion. Plus, they’re fun.

When Allende felt tired or stuck in her writing, she turned to beading. If you check social media for a focus breather, Mark suggests setting a time limit so you won’t get sucked into scrolling, or doing it before a meeting so you’ll be forced to stop. When I’m working and my attention starts to wane, I try to find some natural stopping point and then use my little mind to recover, just like the jogging between sprints I used to do as a competitive runner.

The cost of not structuring our attention is higher stress, lower productivity, and impaired performance on the most important tasks. In a harrowing example, a study of nearly 1 million surgeries found that if a procedure was performed on the surgeon’s birthday, patients were more likely to die soon thereafter, apparently because the surgeon faced more distractions.

Everyone is familiar with one way to coax the best from our big mind: deadlines. Frank Lloyd Wright famously put off working on the design of Fallingwater for months, then drafted his masterpiece in a few hours when the client called to say he was about to visit. Duke Ellington liked to say: “I don’t need time. What I need is a deadline!” But a tight deadline can either enhance or destroy our thinking, according to research on time pressure. It depends on whether we respond by rushing to multitask or to monotask.

Deadlines are just another form of commitment device. The way Wright and Ellington worked, I think, was a version of what Allende does, except her January 8 deadline marks the start of her focus, not the end. When I read articles about Allende in preparation for visiting her, I was struck by how often they described her writing in mystical terms. Sometimes the journalists were just following her lead: Allende told me that there were two times in her career when a book just poured out of her as if dictated from beyond. That’s remarkable, and magical in its own way, but it’s also the exception. Her extraordinary productivity depended on carefully curated space, rhythm, and discipline. The real story of creation is not about boundlessness, but boundaries.

This article is adapted from David Epstein’s forthcoming book, Inside the Box: How Constraints Make Us Better.

The Trump Administration Casts Out the ‘Soul’ of MAHA

2026-04-30T19:40:09-04:00

As of today, it seems likely that the nation’s next surgeon general will, at least, have an active medical license. President Trump announced that he was pulling his nomination for Casey Means, a wellness influencer who dropped out of her surgical residency in 2018, in a Truth Social post this afternoon. The move is the latest setback for Health and Human Services Secretary Robert F. Kennedy Jr.’s Make America Healthy Again movement, which has embraced Means’s criticism of the medical establishment along with her fondness for raw milk and psychedelics. Her book, Good Energy, might as well be MAHA’s bible. Vani Hari, an activist and influencer better known as the Food Babe, told me recently that if Means wasn’t confirmed, it would “ruin the soul of MAHA.”

Earlier this month, the White House seemed to still believe that Means could be confirmed. The president invited her to a roundtable for several MAHA influencers. (Among them was Kelly Ryerson, who told me that the group made clear to administration officials that Means’s troubled nomination was killing the mood of MAHA activists.) But when I spoke with Means this afternoon, shortly after Trump’s announcement, she told me that it had become obvious, over the past week, that she would not become the next surgeon general. In our conversation, Means emphasized that she remained upbeat about MAHA, but she was clearly frustrated by what she repeatedly described as a victory for the status quo. Her nomination had been stalled in the Senate since February, and three Republicans—Bill Cassidy, Lisa Murkowski, and Susan Collins—appeared to have strong reservations about her. Means called them “disgruntled senators who don’t fully understand the incredible movement that’s happening in our culture right now.”

The senators’ skepticism is understandable. As she tells her story, Means had trained as a physician only to decide that the medical system wasn’t doing enough to combat chronic disease. Since then, however, she has adopted some decidedly out-there views. Means has declared that Americans’ chronic health problems are part of a “spiritual crisis,” recounted her use of psychedelics, and argued that pesticides and hormonal birth control both indicate a “disrespect of life.” (During her Senate hearing, Means said that she had been referring to certain women with medical histories that might increase their risk of side effects from taking birth control.) She has decried seed oils for their unproven, supposedly ill effects on health and advises her Good Energy readers to avoid all conventionally grown foods. During a 2024 appearance on Tucker Carlson’s podcast, she questioned the universal birth dose of the hepatitis-B vaccine. Her close association with Kennedy, a longtime anti-vaccine activist, doesn’t help either.

[Read: America’s would-be surgeon general says to trust your ‘heart intelligence’]

Means insisted when we spoke this afternoon that vaccine safety isn’t one of her primary issues and that her message is instead “about empowerment and about fixing broken health-care incentives.” During her Senate confirmation hearing, she indeed struck a moderate tone, telling Cassidy she believes that “vaccines are a key part of any infectious-disease public-health strategy.”

But Means’s lukewarm endorsement of immunization seems to have been insufficient. She believes, based on her conversations with Murkowski and Collins, that concerns about the anti-vaccine coalition in the MAHA movement helped tank her nomination, she told me. In another Truth Social post today, Trump blamed Cassidy, who chairs the Senate’s health committee, for blocking Means’s nomination, accusing the senator of playing “political games”; in an email, a White House spokesperson doubled down on blaming Cassidy and added that the president “remains committed to the MAHA agenda.” Means’s brother, Calley, a senior White House adviser and her co-author on Good Energy, was harsher, writing on X that Cassidy is a “mindless avatar for his donors.” (In response to a request for comment, Cassidy’s office sent a link to an X post from the Republican members of the Senate’s health committee, which said that Means clearly “did not have the votes on committee or on the floor.”)

The new surgeon-general nominee is Nicole Saphier, a radiologist and Fox News contributor. A number of her views align with Kennedy’s and fall outside the public-health consensus. In 2021, for example, she published a book arguing that the United States overreacted to the coronavirus pandemic for political reasons. She has also endorsed Kennedy’s upside-down food pyramid and echoed his praise for whole milk, both of which have received mixed reviews from nutrition experts. But Saphier is far more mainstream than the loudest MAHA activists. As a radiologist at Memorial Sloan Kettering (and the head of breast imaging for its clinic in Monmouth, New Jersey), she advocates for conventional cancer treatments. She has argued that the alleged evidence connecting vaccination with autism is inconclusive, has spoken in favor of the shots for measles and polio, and questioned Defense Secretary Pete Hegseth’s recent decision to repeal the flu-vaccine mandate in the military. (Saphier did not respond to a request for comment.)

Means’s defeat comes at a time when MAHA seems to have lost much of its momentum. Last month, a judge issued a preliminary ruling against several of Kennedy’s most anti-vaccine moves at HHS. The White House has reportedly told Kennedy to stop talking about that topic, for fear that it could hurt Republicans in the midterms. (Kennedy has instead been touting less controversial initiatives, including a plan to improve military food.) The administration has also orchestrated a series of staff changes at the CDC, including the nomination of a new director who has conventional public-health bona fides. In February, Trump signed an executive order that could give liability protection to manufacturers of glyphosate, an herbicide that some studies have linked to cancer and that MAHA activists have railed against; then, this morning, the House removed liability protections from the Farm Bill, which is now on its way to the Senate.

[Read: A new level of vaccine purgatory]

At the end of his 2024 campaign, Trump promised to let Kennedy “go wild on health” if he won the presidency. But now the White House and Republican lawmakers seem conflicted about just how much they’ll tolerate Kennedy’s MAHA movement. Apparently, having Means as the nation’s top doctor was further than they were willing to go.

Is It the Shoes?

2026-04-27T20:36:00-04:00

Updated at 11:05 p.m. ET on April 27, 2026

To understand the significance of someone running a marathon in less than two hours, you also need to understand that, until recently, the notion of this actually happening was truly, utterly absurd. Sure, a physiologist named Michael Joyner had floated the idea that such a feat might be humanly possible in a journal paper way back in 1991. But his peers laughed off the idea, and not much changed over the succeeding decades. In Runner’s World in 2014, I predicted that it would happen in 2075. Frankly, even that forecast seemed overly optimistic to me, but I figured I’d be dead by then, so no one would be able to call me on it.

Well, I was wrong. Yesterday morning, the two-hour marathon barrier finally went down. A relatively unheralded 31-year-old Kenyan named Sabastian Sawe won the London Marathon with a time of 1:59:30. That is, for reference, 26.2 miles run at an average of 4:34 a mile—or, put another way, a pace that most recreational runners would struggle to sustain for more than a few seconds, if they could hit it at all. Perhaps even more arresting was the fact that the man who took second place, Ethiopia’s Yomif Kejelcha, also ran under two hours, finishing just 11 seconds behind Sawe.

The feat was the culmination of a shift—or, perhaps more aptly, a total disruption—in marathoning over the past few years, in which the eventual breaking of the mythical two-hour mark went from an impossibility to a guarantee. When sports are young, they progress by leaps and bounds. The first marathon over the now-standard distance of 26 miles, 385 yards, contested at the 1908 London Olympics, was won in 2:55:19. Progress in the succeeding decades was rapid, but by 1991 the sport was mature, professionalized, and lucrative. When Joyner made his prediction, the world record was 2:06:50 and had advanced by less than two minutes since the 1960s. Logic dictated that future decades would see even slower progress, as runners approached insurmountable limits in factors such as how much training they could handle and how much fuel their muscles could store.

The turning point came in 2016, when Nike announced its Breaking2 project. The famous Kenyan runner Eliud Kipchoge and two others were chosen as the centerpieces of a multimillion-dollar attempt to engineer every detail of a sub-two-hour marathon: nutrition, hydration, training, shoes, weather, drafting, pacing, and so on. On a Formula 1 track in Monza, Italy, in May 2017, Kipchoge ended up running 2:00:25, astonishingly and unexpectedly close to the barrier. He ran virtually the entire race behind an arrowhead formation of six pacers who blocked the wind for him; the pacers swapped in and out throughout the race, intentionally violating the rule that all competitors must start at the same time, which meant it didn’t count as a world record. But at that moment, the conversation shifted from if to when.

What remained unclear after Breaking2 was how Kipchoge had run so fast. Was he simply a generational talent? Was it the drafting, which aerodynamics experts argued could shave several minutes off his time all by itself? Or was it the shoes? Nike had unveiled a radically new design for Breaking2, incorporating a curved carbon-fiber plate into a thick wedge of springy midsole foam, which external lab data suggested would make runners several percent faster. Two years later, when Kipchoge ran 1:59:41 under similar non-record-eligible conditions at Ineos’s 1:59 Challenge in Vienna, those questions still lingered. But it was clear that the shoes really worked. National and international records at every distance were falling, and every major shoe company had come up with its own version of Nike’s plate-and-foam supershoe design.

Now that everyone has supershoes, you might think the playing field is level. In reality, the innovation arms race has continued. The exact workings of the plate-and-foam architecture still aren’t fully understood, so shoe companies keep tinkering and producing better shoes. For yesterday’s record-setting marathon, Adidas launched a new shoe featuring an ultralight midsole foam that reduced the overall weight of the shoe to just 3.4 ounces. Sawe was wearing the shoe; four of the top five men’s finishers, including Sawe, are sponsored by Adidas.

It’s hard to overstate how strange this situation is for the running world, which used to pride itself on being the simplest and most gear-agnostic sport. Every year since time immemorial, shoe companies have launched new shoes with the promise that they will be game changers. Until 2017, this was never actually true. But now the record books keep being rewritten. Kipchoge brought the official record down to 2:01:39 in 2018, then 2:01:09 in 2022. The following year, another Kenyan, Kelvin Kiptum, ran 2:00:35 at the Chicago Marathon. This was proof that Kipchoge wasn’t an irreplaceable freak of nature—and invited only more questions about the shoes and what it means to compare runners year by year. Could Sawe have broken two hours in different shoes? Could he even have done it in last year’s shoes? Head-to-head comparisons are difficult: Kipchoge, now 41, is past his competitive peak, and Kiptum was killed in a car accident at age 24, just a few months after setting his world record.

Then there’s the question of drugs. If sprinters on steroids was the cliché of the 1980s, blood-doping endurance athletes has become a similarly familiar trope. Kenya, in particular, has been singled out as a serial offender: More than 140 runners from the country are currently serving doping suspensions, including the women’s marathon world-record holder, Ruth Chepngetich, who tested positive for drugs in the summer of 2025. (Kipchoge and Kiptum have not faced any formal doping accusations.) In this respect, Sawe and Adidas have been prescient. In the two months prior to last fall’s Berlin Marathon, Adidas ponied up a reported $50,000 to have World Athletics’ Athletics Integrity Unit test Sawe 25 times. Berlin turned out to be too warm for a fast time, but Adidas and Sawe continued the arrangement this year. “I wanted people to know that whatever happened in the race, I was not to be doubted,” Sawe told the running website LetsRun.

Sawe’s extraordinary performance justified the extraordinary precautions. In London, a pack of six runners broke away early, tucked behind three pacemakers until the halfway mark, reached in 1:00:29—which, you’ll note, is considerably slower than a two-hour pace. Sawe looked barely conscious, conserving his energy, his eyes locked onto the back of the pacemaker in front of him. One of the pacemakers continued until just after the 25-kilometer mark, by which time the pack had been reduced to three. Once that final pacemaker dropped out, Sawe came alive and began to turn the screws.

If the magic of Kipchoge’s unofficial sub-two-hour race was in the drafting, then Sawe having to lead for more than 10 miles should have doomed him. Instead, he got steadily faster. Only in the final few miles did the BBC’s race commentators suddenly realize that history might be beckoning. You can’t blame them: Nobody could have foreseen how much Sawe would accelerate. He ran the second half in 59:01—a time that, on its own, would be a national record in all but a handful of countries. And glued to Sawe’s shoulder until the final mile was Kejelcha, the Ethiopian runner, waiting for him to falter. Sometimes top runners prefer to minimize competition when they’re chasing world records so that they don’t need to worry about getting passed if they misjudge the pace. But in this case, it seems likely that Sawe’s acceleration was fueled at least in part by the desperate desire to shake off his persistent shadow.

All told, Sawe’s breakthrough—the head-to-head throwdown, the drug-testing program, the dramatic finale—was exactly how you’d script an all-time performance. He did everything right—which is why I feel bad about the lingering hint of anticlimax I feel in myself and sense in my running friends. The truth is, Sawe’s performance was only the second-most-surprising marathon result of the weekend. At a marathon in Toledo, Ohio, an unheralded local 25-year-old named Vincent Mauri won in 2:05:55, beating the previous course record by more than 13 minutes. This makes him the fourth-fastest American in history. These are both, in their own way, performances for the ages, unless next year’s shoes turn out to be even better.

This story originally misstated Sawe’s time at the halfway point of his record-setting marathon as 1:00:26.

MAHA’s Perfect Villain

2026-04-27T19:57:37-04:00

This morning, a crowd gathered near the Supreme Court to protest the weed-killer Roundup. Inside, justices heard arguments for Monsanto v. Durnell, weighing whether to exempt the company that created Roundup from lawsuits alleging that it failed to warn users that its herbicide causes cancer. Outside, the protesters rehearsed long-running grievances against Monsanto: One man was passing out flyers about “the hidden truth” of genetically modified food, and one speaker railed against “Mon-Satan.”

Developed by Monsanto and now owned by the German conglomerate Bayer, Roundup and its active ingredient, glyphosate, have long been concerns for left-leaning environmentalists; now the MAHA coalition has taken up the cause with enthusiasm. The headliners of “The People vs. Poison” rally were a who’s who of MAHA: The HighWire’s Del Bigtree; the host of the Turning Point USA podcast, Culture Apothecary, Alex Clark; the founder of Moms Across America, Zen Honeycutt; and the “Food Babe” and the rally’s organizer, Vani Hari.

In this way, the event was a very public demonstration of MAHA’s horseshoe politics. The rally’s roughly 30 speakers included environmental activists and politicians from both parties. “This is not a left or right issue,” Democratic Senator Cory Booker, a surprise guest speaker and potential 2028 presidential candidate, told the crowd. “This is a right or wrong issue.” If Democrats have balked at MAHA’s rejection of vaccines, battling glyphosate has a chance of locking in the movement’s wider base of support.

The safety of glyphosate is still contested. Bayer continues to emphasize that scientific assessments have not definitively linked glyphosate to cancer. It says that because pesticides are federally regulated and the EPA has deemed glyphosate safe, the company should not be subject to state-level lawsuits such as Durnell. The U.S. government, meanwhile, as Booker would tell it, has been on the “wrong” side of the issue. In February, President Trump passed an executive order to boost domestic glyphosate production; later this week, the House is expected to vote on the Farm Bill, which contains provisions that would also limit pesticide manufacturers’ legal liability. Earlier this month, the White House invited MAHA leaders, including Clark, for a roundtable to discuss their views on the issue. “We gave them ideas of things that they could do that would be an olive branch for moms that are upset about the glyphosate executive order,” Clark told me. She is hopeful, but said “it’s up to them if they’re going to do something or not.”

For the moment, MAHA is still waiting, although the White House spokesperson Kush Desai told me that the administration has “more announcements on sustainable agriculture practices and other policies in store to build on MAHA victories from the past year.” He also stood behind Trump’s glyphosate order, which he said “simply seeks to strengthen our national security and end America’s decades-long reliance on foreign imports and supply chains,” adding, “This is ‘America First’ in action.” (HHS did not respond to a request for comment.)

In theory, today’s MAHA rally was another nudge for the administration. Clark told me that she truly believes that MAHA won the presidency for Republicans in 2024, so for the administration to do anything to “jeopardize that or let it slip through your fingers is just moronic.” (The back of her jacket read: I Turn Into Erin Brockovich When I’m Angry.)

As my colleagues have reported, Trump does seem to believe that HHS Secretary Robert F. Kennedy Jr. and his followers will be an important electoral force in the midterms, whether or not that’s true. Hari had previously told Politico that she expected more than 1,000 people at the protest, and judging by the number of babies in strollers and children holding handmade signs, the so-called MAHA Moms were out in full force. But by my count, the crowd capped out at a couple hundred. “I wish more people were here,” Sharon Juraszek, who’d traveled from Florida for the rally, told me. She owns an organic-food company and has been speaking against glyphosate for years because her mother died of cancer that she believes was brought on by Roundup. She is a fan of Kennedy and hoped he would be one of the day’s surprise guest speakers. (He was not.)

Still, Clark thought that the crowd should show the administration that “this is extremely serious,” she said. “I mean, you’ve got moms and babies out here.” And despite MAHA’s frustrations with Trump’s recent actions, the rally today ultimately aligned with the administration’s goals before the midterms. The White House has reportedly encouraged Kennedy to focus more on the healthy-food aspects of his MAHA agenda this year instead of his divisive anti-vaccine policies. The rally basically did the same. Besides Hari, Bigtree seemed to be the unofficial headliner of the protest; several people told me they’d come to see him. His organization, Informed Consent Action Network, is known for opposing vaccines, but today, his speech didn’t mention any of that. Instead, he talked about “the food that sits on the table before us.” That, he said, is “an issue that is bringing America back together.”

MAHA Swing Voters Are an Illusion

2026-04-22T14:56:00-04:00

Updated at 7:11 a.m. ET on April 23, 2026

Earlier this month, MAHA moms went to the White House. Several key figures in the “Make America Healthy Again” movement gathered around a table in the Roosevelt Room to speak with Health Secretary Robert F. Kennedy Jr. and other top administration officials. The invitees—who included the health activist Kelly Ryerson, the wellness podcaster Alex Clark, and the nutritionist Courtney Swan—were all women. They’re influential among the loose coalition of Kennedy supporters known as MAHA moms, many of whom are worried about their children’s health. This was a chance for them to air their grievances with the Trump administration—which have grown in recent months. Afterward, they were ushered into the Oval Office to see President Trump, who, according to Ryerson, welcomed them as “my MAHA leaders.”

The alliance between MAHA and MAGA was always an unlikely one. Kennedy was a Democrat before his independent presidential run in 2023, and many of his priorities—such as encouraging healthy eating—have traditionally been the domain of the left. Lately, the partnership has started to fray. Core MAHA supporters were infuriated when Trump signed an executive order in February that could give liability protection to manufacturers of glyphosate, the weed killer used in Roundup that studies have linked to cancer. (Ryerson is so against the chemical that she goes by “Glyphosate Girl” on Instagram.) The movement has also been frustrated by the stalled nomination of perhaps the most famous MAHA mom, Casey Means, Trump’s pick for surgeon general, who has yet to receive a Senate confirmation vote. Means was also at the recent White House gathering, which appeared to be an attempt to smooth things over with MAHA before the midterms.

[Read: Well, that didn’t sound like Casey Means]

Not unlike the “silent majority” that pushed Richard Nixon to victory in 1972 or the Tea Party movement that ushered in the red wave during the 2010 midterms, MAHA moms have been billed as a significant factor in the upcoming election. MAHA is “central to our coalition,” Steve Bannon, Trump’s former chief strategist, told us. Without the movement’s support, he believes, there’s no chance that Republicans can prevail in November. The president seems to be on the same page: “I read an article today where they think Bobby is going to be really great for the Republican Party in the midterms,” Trump said during a Cabinet meeting in January, referring to the health secretary. “So, I have to be very careful that Bobby likes us.” In an email, the White House senior deputy press secretary Kush Desai told us that the administration is dedicated to delivering on the MAHA agenda. The gathering at the White House “was one of many productive engagements that the Administration has had and continues to have with the MAHA community,” he wrote.

These voters are politically desirable across party lines. Some of MAHA’s priorities—such as getting rid of petroleum-based food dyes or limiting pesticide use—are widely popular. About a third of independent parents, along with one in six Democratic parents, identify as supporters of the MAHA movement, according to a poll from last year. Many Democrats are also trying to win over disaffected MAHA moms.

The most prominent MAHA moms tend to be swing voters rather than Trump loyalists. Vani Hari, an activist known as the “Food Babe,” was a delegate at the Democratic National Convention in 2012 but is now a prominent MAHA influencer (she was invited to the White House meeting but couldn’t attend). Ryerson voted for Trump because of Kennedy. “I probably wouldn’t have voted otherwise,” she told us.

But Hari and Ryerson—both of whom were health activists long before MAHA came along—may not be representative of rank-and-file voters. For this story, we spoke with several MAHA supporters, including a documentarian who had worked on anti-vaccine films, moms with a parenting podcast, and an Instagram influencer who told us about her four-ingredient recipe for homemade Goldfish crackers. One of us chatted with more than a dozen attendees at CPAC, the annual Republican conference. Many were MAGA before they were MAHA, and said their midterm votes don’t hinge on health issues. Virtually none said they would realistically consider voting blue in November.

And then there is the question of numbers. To hear MAHA leaders tell it, their supporters constitute a small army. Tony Lyons, who runs MAHA PAC, the movement’s political arm, has said that there are millions of MAHA moms and, in a memo to GOP leaders, argued that embracing the movement is the way to “win big in the midterms.” Hari claimed on X in January that thousands of MAHA supporters have been calling state legislatures in recent months over concerns about legislation that would give pesticide makers immunity from lawsuits. (When we asked about that, she conceded that the number was more likely in the hundreds. After publication of this article, she said that she had responded too quickly and meant to say thousands—though she declined to produce any evidence for that number.)

In Tennessee, which considered a pesticide bill earlier this year, a lawmaker told us that she received “about 150 emails and around 50 calls to my office.” But in our reporting, we were unable to track down evidence suggesting that moms who will cast their votes based on their MAHA beliefs exist in such numbers that they could swing the midterms. MAHA “is not going to affect the aggregate, but it could affect various districts which are very close,” Bob Blendon, a Harvard professor who studies public opinion on health, told us.

[Read: The man holding MAHA together]

The most prominent contest where MAHA has come into play so far isn’t even a seat that is realistically at odds of flipping from red to blue. MAHA PAC has pledged to spend $1 million to unseat Senator Bill Cassidy of Louisiana, who was the pivotal vote to advance RFK Jr.’s nomination as health secretary but has since publicly called him out on occasion. The group has endorsed another Republican, Julia Letlow, and health hasn’t been a defining issue in the race. Instead, both candidates have competed to prove that they are more loyal to Trump. (Trump has endorsed Letlow over Cassidy.)

Of course, a lot can change from now until November. American elections have been upended before by groups of voters who seemed elusive and seemingly came out of nowhere. The Tea Party, for example, was seen initially as diffuse—much like the modern MAHA movement—but the effort was actually well funded and well planned, Patrick Rafail, a professor at Tulane University who wrote a book on the movement, told us. “I don’t see a parallel for MAHA,” he said.

MAHA seems to be one of the few causes that unites people across the political spectrum. But broad appeal doesn’t necessarily translate at the ballot box.

A ‘Barbaric’ Problem in American Hospitals Is Only Getting Bigger

2026-04-22T07:00:00-04:00

In the last months, weeks, and days of his life, “I will not go to the emergency room” became my husband’s mantra. Andrej had esophageal cancer that had spread throughout his body (but not to his ever-willful brain), and, having trained as a doctor, I had jury-rigged a hospital at home, aided by specialists who got me pills to boost blood pressure; to dampen the effects of liver failure; to stem his cough; to help him swallow, wake up, fall asleep.

“I will not go to the emergency room”—emphasis on not—were his first words after passing out, having a seizure, or regurgitating the protein smoothies I made to pass his narrowed esophagus. He said it again and again, even as fluid built up in his lungs, rendering him short of breath and prone to agonizing coughing spells. He had been a big, athletic guy, but now, in the ugly process of dying, he was looking gaunt. Ours was a precarious existence, but I understood his adamant rejection of the emergency department. Most prior visits had morphed into extended trips into a terrifying medical underworld—to a purgatory known as emergency-department boarding.

I managed to keep Andrej at home while we planned for hospice, until one dreadful night at 2 a.m., when I ran out of hacks. We got into an ambulance and headed together to the hospital.

We had already learned the hard way that if you need admission to the hospital, you can remain in the emergency department—in the hallway or a curtained bay on a hard stretcher or in a makeshift holding area—for more than 24 hours, even for days, while waiting for a real hospital bed. In this limbo state, you’re technically admitted to the hospital but still located in the physical domain of the ER. And the rules governing acceptable care and safety measures become much less clear.

In the summer of 2024, still being treated to keep his cancer at bay, Andrej had suddenly become somewhat delirious, requiring hospital admission to rule out the possibility of infection or, worse, of the cancer having spread to his brain. After we went to an emergency department near our home, in New York City, he lay trapped on a hard stretcher, with its rails up, for more than 36 hours, amid the alarms and calls for the code team, without any clues of whether it was day or night, and with access only to the few toilets shared by the dozens of patients and visitors in the emergency room. None of this helped his mental state. By the end of day two, he knew me—kind of—but had become convinced that the doctors were “the enemy” and that I was their paid accomplice.

After I pressed to move him to a bed “upstairs”—I meant to an inpatient ward—he was transported to a bed five floors higher. I realized too late that this was an “ED overflow area,” according to the paper sign attached to the entrance’s swinging door. A plaque in the hall identified it as a former labor and delivery floor. It had been kitted out with some of the trappings of an actual ward, such as real beds and bathrooms, but not the most important one: adequate personnel.

The space was by turns eerily quiet and wildly cacophonous. Although patients there were undergoing intimate, embarrassing procedures, rooms were gender-neutral. That first night, Andrej’s roommates were a man in a coma and an elderly French woman in a diaper and boots (no pants), who marched around her bed singing like a chanteuse. In the morning, I pestered a harried nurse and got Andrej moved to a quieter room with three beds, where two people died in three days.

The overworked staff did the best they could, but that was far from good care. My husband—who needed protein and calories but could consume only soft foods—was served chicken cutlets. When I noted to one nurse that Andrej’s soiled sheets hadn’t been changed for several days, she directed me to a linen cart so I could change them myself.

That first time, one of several extended ER stays Andrej made as a boarder, I thought perhaps we had just hit a busy time at a busy hospital. When I worked as an emergency-medicine doctor a few decades ago, the ED was mostly empty at the beginning of my 7 a.m. shift. A few patients might be lingering from the day before: alcoholics who would sober up and leave, patients with a severe burn or a bad case of pneumonia who were waiting for a bed in intensive care.

In the decades since, EDs have doubled or even tripled in size. Even so, patients are piling up. When I started asking around, I quickly discovered that ED boarding has become commonplace in the past five or so years and is getting worse, more or less omnipresent in hospitals. “Everyone knows about this problem, and no one cares enough to do anything about it,” Adrian Haimovich, an ED doctor at Beth Israel Deaconess Medical Center who studies ED boarding, told me. “It’s barbaric.”

Measuring the problem has been challenging because data on ED-boarding time are limited. Only this past November did the Centers for Medicare and Medicaid Services finalize a rule that would require hospitals to collect data on ED-boarding times, starting in 2026. Using what other data he could find, Haimovich has shown that boarding for more than 24 hours has increased dramatically for people 65 and older since the coronavirus pandemic.

Once they enter ED boarding, patients exist in a gray zone. There has been a national push to establish “safe staffing” nurse-to-patient ratios in EDs. Even with that, if an ED boarder has a medical complaint that needs quick attention, it’s easy for them to fall through the cracks, Haimovich said: In some hospitals, an admitting team of doctors from upstairs is responsible for the boarders stuck in the ED (but not the associated floor nurses); in others, overstretched ED medical staff must take full responsibility to care for boarders until a bed opens—and that in addition to seeing new patients. Some EDs now routinely hold more boarders—many of them quite ill—than patients being actively evaluated.

Doctors and nurses have complained bitterly about the situation, which forces them to provide inadequate care. Gabe Kelen, the director of emergency medicine at Johns Hopkins University, told me that it’s creating a moral hazard for emergency-department staff. But doctors and department heads such as Kelen are not in control of admissions. Generally, a hospital’s administration parcels out inpatient beds, and emergency-department boarding is in many ways a result of today’s business models and pressures.

When I worked as a doctor, if an ED was overwhelmed beyond capacity, the attending (that was me) typically called in to ambulance dispatch to request “diversion”—ambulances should take patients to another hospital. If a hospital got too full, the admitting office canceled elective admissions. Today, hospitals run like airlines and intentionally overbook, Kelen said. They also have fewer beds than they did a few years ago—in part because nurse (and executive) salaries have risen since the pandemic. An empty, staffed bed is a money loser, so the institution has an incentive to keep beds full and make new patients wait.

“The problem isn’t inefficiency—it’s the way health-care finance is structured,” Kelen said. “Hospitals typically run on thin margins. Elective admissions are prioritized because they tend to be for lucrative procedures like heart catheterizations and joint replacements.”

Admitting patients through the emergency room has business advantages too, even if it means that patients wait for a bed. The evaluation generates charges that typically run many thousands of dollars; once admitted, my husband was still billed the inpatient rate even for a stretcher in the hall. Old, sick, and dying patients are more likely to linger there in part because, after they’re in a real bed, they may take up that spot for days or weeks at a time while waiting for a bed in rehab or hospice, requiring nursing time but not the types of interventions that generate revenue.

Hospitals have tried Band-Aid fixes, such as bed-tracking software and discharge lounges where patients can wait for paperwork or transport home. Many do hire more doctors and nurses and orderlies in the ER to confront the overflow. “Long ED wait times and boarding have root causes that extend far beyond EDs and hospitals themselves,” Chris DeRienzo, the chief physician executive at the American Hospital Association, told me in an email. He listed the high cost of opening beds and the shortage of rehabilitation facilities, and emphasized the precarious financial situation of many hospitals.

But while Andrej waited in the overflow area, we were not thinking of any bigger picture: He was sick, desperate, and still waiting for care. He lingered in boarding for four days before he got a bed. Each time he had to return to the ED, each time he faced a painful wait, he hardened his resolve to never go back.

Thunk. Crash. “Elisabeth, help!” Those were the sounds that woke me at 2 a.m.

I had fallen asleep in our bed, next to Andrej, his head raised with a foam wedge to ease his breathing and make sure food would not come up. Before I dozed off, I listened to his breathing—30 times a minute, two times faster than normal—a sign that he was struggling to get sufficient oxygen. And that racking cough. This was not good.

Now his bruised body was twisted, lying on the floor with his head against the bed frame. He’d attempted to use his walker to go to the bathroom. He was complaining of chest pain, coughing and short of breath. But he managed to get out those words: “I will not go to the ER.”

I knelt by his side in tears, telling him that I loved him but that I could not do anything more right now at home. Carlos, our super, helped me get him into bed and called EMS. I promised Andrej (against hope) that, given his condition, he would surely be quickly assigned to a real room and bed.

What happened next was a blur. I have a vague memory of paramedics arriving, putting him on the stretcher, sliding him into the ambulance, giving him oxygen. I mechanically grabbed his “do not resuscitate” form from under the refrigerator magnet and buckled myself in beside him.

Then he was in the ED, which was thrumming with activity, under the fluorescent lights, with oxygen in his nose, wearing a hospital gown, looking gray and sick. The staff asked what was, for them, the operative question about a guy with widespread cancer: “Does he have a DNR?” Andrej asked me what was, for him, the operative question: “Did you bring my shoes?” He already wanted to leave.

An X-ray showed possible pneumonia, more tumors, and a buildup of fluid in his lungs. A medical team that covers oncology patients wrote an admitting note—he was now a boarder, again—and then retreated upstairs. They started antibiotics and gave him something to help him sleep amid the alarms and shouting. He didn’t.

When I came back the next morning—and two mornings after that—I was alarmed to see him still there on a hard stretcher, his feet dangling off the end, exhausted and in pain. “When will he be admitted to a bed?’’ I implored. If some of the stuff in his lungs was infectious, maybe he could be treated and get home.

Likely soon and I hear your frustration—I came to detest those two phrases.

Neighboring patients came and went 24 hours a day. Some were pleasant; some were screaming in pain or just screaming mad. Pulmonary doctors came and, in this semipublic space, used a large needle to remove three liters of fluid from Andrej’s right lung cavity.

Near the end of the Biden administration, in response to a bipartisan congressional request, the Department of Health and Human Services convened a meeting on emergency-department boarding. Its report, from HHS’s Agency for Healthcare Research and Quality, came out the same month that the Trump administration took office, not long before Andrej’s fall—the last night he spent at home.

“Emergency department (ED) boarding is a public health crisis in the United States,” the report concluded. “Patients who are sick enough to require inpatient care can wait in the ED for hours, days, or even weeks … Boarding contributes to increased mortality, medical errors, prolonged hospital stays, and greater dissatisfaction with care.”

The meeting proposal called for the formation of an expert panel to recommend solutions. In theory, a panel could have weighed in on key questions: Should hospitals—some of which are rich institutions—get paid an inpatient rate for boarding in the ED? Should they have to report boarding times and face penalties for excess? Should they be required to open more real beds, and should requirements for licensing be lessened? How can the country create more rehabilitation beds?

But since then, the Trump administration has dramatically cut that HHS agency’s staffing, as well as its grant programs. (Congress is still pushing to fund the agency.) The expert panel never formed, let alone offered solutions. The Centers for Medicare and Medicaid Services did initiate a program this year that will include voluntary reporting of boarding times in 2027, which will become mandatory in 2028. Bad marks will eventually affect Medicare reimbursement.

In an emailed statement, the Joint Commission, which certifies the nation’s hospitals, called boarding a “serious public health crisis” and “one of the most incredibly complex challenges in healthcare.” Although the organization does indirectly look at hospitals’ “ED throughput” from charts, such data are not comprehensive. Little information exists, for instance, about how many people’s last days are spent on stretchers, in hospital limbo.

None of this knowledge would have helped my dying husband. So I did what I’d promised myself I’d never do: I called a doctor friend, who called the hospital’s VIP office.

Suddenly Andrej was whisked to a real hospital room, with a bed that he could adjust to keep his head elevated, a tray he could eat from, a morphine pump, a TV, a bathroom, and a nurse call button at his side. A room with extra chairs, so his stepkids and friends could visit with gifts and mementos one last time. A room where the caring staff placed a chaise longue, where I could sleep over. That way, when he woke scared and coughing and yelling for me, I was there to hold his hand, adjust the oxygen, and push the button for an extra dose of narcotic.

Until, six days after we got in the ambulance and three days after we’d moved to this room, he woke early one morning, agitated and coughing, calling out, “Elisabeth?” I was there. But then, in a blink, he wasn’t.

A Life Hack for the Ultra-Wealthy Is Going Mainstream

2026-04-21T11:00:00-04:00

Here is the promise of a house manager. Hire one, and soon someone else could be doing your laundry, washing your dishes, prepping your meals, and completing those Amazon returns you’ve been meaning to make. They could reorganize the utensil drawer, notice if your kid is outgrowing their shoes and order more, take your car to the repair shop, and be at home to meet the plumber. If your child needs food for a class party, a house manager could make the dish and drop it off; if that child also has a pet lizard, a house manager could buy the crickets to feed it.

House managers are not a nanny or a house cleaner. They’re a “chief of staff for the home,” a “personal assistant for Mom,” and “a clone of myself,” according to the more than a dozen people I spoke with who have either hired one or work as one. They are, in effect, what might have once been called a housekeeper—a person who helps oversee a household’s basic functioning. Middle- and upper-class families used to more commonly employ this kind of position (the title “house manager” dates back to at least the 1830s), but it has become rare enough that a couple of people I spoke with thought they may have come up with the term.

Whatever you call the job, the ultra-wealthy have maintained some version of this role in their homes for years, but more and more companies are cropping up to serve Americans with salaries in the lower six figures—a cohort that is nowhere near having a private jet but might already use a house cleaner or have a regular handyman.

Some will argue that shouldering the burden of household work is a necessary part of adulthood. But for many on the high side of the country’s wealth divide, time is at enough of a premium that buying it back feels worth the money. Kelly Hubbell, who in 2023 founded Sage Haus, a company that helps people find house managers, told me that many of her clients are dual-income households where tasks pile up beyond what two adults can handle; a house manager steps in as a third. Several women described their house manager to me as “my wife.” One company offering the service is even called “Rent A Wife—Oregon.” (Its founder, Brianna Ruelas Zuniga, knows what the name sounds like; she still likes it, she told me.)

Many house-managing businesses started around the country at about the same time. In 2022, Amy Root was running a home-organization business in central Connecticut—clearing out people’s garages and adding shelving to their closets—but she realized that even if she got the right home systems in place, “the laundry still needed to get done,” she told me. People needed “help with their regular to-dos but also the aspiration checklist,” such as finally hanging that one painting they bought a year ago, she said. In 2023, she pivoted to running a house-managing business, Personal Assistant for Mom, and now leads a team of five (soon to be seven) part-time house managers.

The crew includes retirees and empty nesters, as well as a woman training to be a doula and an artist who needed an extra gig. Rates for house managers generally are $25 to $50 an hour; some agencies take a cut. (Sage Haus charges clients a finder’s fee; house managers are paid directly.) Today’s version of the job is very much part of the gig economy, and like many gig workers, the managers are usually responsible for their own health insurance. Some of the house managers I spoke with work full-time for one family, but many are cobbling together part-time gigs with multiple families while also working as a nanny or cleaner.

When Root tells people what a house manager does, most of the time, their response is “Someone will do that for me?” A time-saving purchase like that just doesn’t occur to a lot of people, Ashley Whillans, a Harvard Business School professor who studies such spending, told me. About a decade ago, she and her colleagues asked people what they would do with an extra $40, and most of them said they’d use it for bills or a nice experience; only 2 percent said they’d use the money for a service that would save them time. Back then, Whillans said, Taskrabbit was really the only chore-outsourcing platform, but as these services have become more common, more people with the money to spend seem to see it as a way to escape the worst parts of their day. “I’m buying back joy and time where I can right now,” Barbara Mighdoll, a mother of two and a business owner who now has a house manager for 15 hours a week, told me. Each time her house manager does a chore, she said, “that is a tab that is now closed in my brain.” When she’s with her family, she no longer has ticker tape running through her head about the laundry she needs to put away. The house manager already took care of it.

A purchase like that really can buy happiness, according to Whillans’s research. She and her colleagues have found that when people outsource bothersome chores and reinvest that time in something they actually care about, they report being more satisfied with their life. (Anyone who hates doing the dishes will not be surprised by this.) In one study, she and her co-authors found that couples who take that freed-up time and spend it on each other say that it improved their relationship. So far, Whillans has yet to see a point at which couples who off-load their to-dos stop getting happier. Some tentative evidence, she said, suggests that when given money for time-saving purchases, lower-income people report more benefits than their wealthier counterparts. But where someone in the so-called upper-middle class might consider $30 an hour a bargain, being able to buy back time is still a luxury.

If they can afford it, though, “people are now turning to the market for social support,” Whillans said. The gig economy has only made this easier: A person can now order soup on DoorDash when they’re sick rather than asking a loved one to make it, or take an Uber from the airport instead of getting a ride from a friend. Almost everyone I spoke with who has a house manager lives far from their family; several said that they lacked a “village.” Kara Smith Brown, a mother of two and a founder of a PR consultancy, told me that without “grandparents, or aunts and uncles to kick in at all” and be the village, “you kind of have to build your own and pay for it.”

It’s not ideal, but people who’ve hired house managers feel that paying is an improvement on their status quo. Eliza Jackson, the mother of an eighteen-month-old and the chief operating officer of a direct-to-consumer meat-delivery company called ButcherBox, would wake up early before her son so that she could get chores done, cook breakfast, get him ready, drive the hour and a half in traffic to the office, work all day, commute home, cook dinner on the nights her husband didn’t, then do more household administration until bedtime. “I don’t think the day that I’m describing is unusual,” she told me. “I just thought you suffered through it.”

In January, she and her husband hired Katie Eastlack, a 23-year-old recent college grad, through Sage Haus. Eastlack had been living with her parents in Virginia and struggling to find education jobs after graduation, but she realized that she was already doing something she enjoyed: helping someone, in this case her mom, run a home. She hoped to move to Boston and scoured Indeed for personal-assistant and house-managing jobs there, until she came upon Sage Haus’s listing to work at Jackson’s home. Finding the right family was important, Eastlack told me, because she is in their lives full-time. She has a family credit card for household expenses and is trusted to, say, choose the right repairman for Jackson’s car. (She didn’t say this, but working for the wrong family, in a gig job with no HR, could easily turn into a nightmare.) Eastlack likes that her job helps Jackson and her husband, who both have demanding careers, spend more time with their kid. And it has meant that she got to move to Boston and now has her own apartment.

She’s still getting used to the feeling of coming home at night and realizing that she has her own house chores to do. Kristen Milburn, who house-manages part-time for a dual-physician home in Oklahoma City, told me something similar: The role “requires a lot of physical energy,” which she’s not sure she can maintain forever. And as much as she loves her job, doing someone else’s housework all day “does make it a little harder to want to come home and do laundry and dishes,” she said. “But it gets done.” Running one household is a lot of work—let alone two.

RFK Jr.’s New Normal

2026-04-16T17:15:18-04:00

Updated at 6:58 p.m. ET on April 16, 2026

The White House has reportedly urged Health and Human Services Secretary Robert F. Kennedy Jr. to avoid talking about vaccines, but this morning he had no choice. When he appeared before the House Ways and Means Committee—the first of seven congressional testimonies that he’s scheduled to give in the coming days as part of the 2027-budgeting process—members pressed him on the issue, which he has written and spoken about nearly nonstop for two decades.

He mostly sidestepped those questions, declining to repeat claims he’s made before about the supposed links between vaccines and autism (no such links have been found), or about how contracting measles might boost a person’s immune system (the opposite is true). When asked whether an unvaccinated girl who died of measles in Texas last year might have been saved by the shot, the health secretary responded: “It’s possible, certainly.”

Kennedy recently seems to be steering clear of public statements about vaccines because the White House fears that his anti-vaccine agenda will tank Republicans in the midterms. Instead, he’s touted the government’s new inverted food pyramid and the return of whole milk to school cafeterias. The first episode of his new podcast, released this week, features the celebrity chef Robert Irvine—the man “making my dream come true,” Kennedy says, by revamping military meals—who sits with Kennedy in front of shelves displaying several of Kennedy’s conspiracy-theory-laden books and a picture of his father. (Irvine has a history of embellishing his résumé, which he’s called “errors in my judgment.” A Health and Human Services spokesperson did not respond to a request for comment on the department’s recent moves.)

This more restrained version of Kennedy is appearing as the Trump administration is making moves to tamp down turmoil at HHS. Two months ago, Chris Klomp, the head of Medicare, became the department’s chief counselor, reportedly to keep Kennedy in line. And today, after months of confusion and chaos, President Trump nominated a new director for the Centers for Disease Control and Prevention: Erica Schwartz, a former deputy U.S. surgeon general and a retired rear admiral in the Commissioned Corps of the U.S. Public Health Service.

If Schwartz’s nomination is confirmed by Congress, she would step in as head of an agency that, over the past year, has dealt with several high-profile resignations and flagging morale. The CDC has had a confirmed director for only 29 days since Kennedy took office. Right now—at least officially—it has no director at all. The Trump administration missed a deadline last month to nominate a new one, which means the previous acting director, Jay Bhattacharya, can no longer claim that title, even though he appears to remain in charge. Bhattacharya, whose other job is serving as director of the National Institutes of Health, has seemed intent on winning over employees at the beleaguered agency, telling them at an all-staff meeting last month that they needed to “focus on what we know how to do” rather than getting caught up in politics. This month, though, Bhattacharya, who is known for his contrarian views on the public-health response to the coronavirus pandemic, reportedly delayed the publication of a CDC study showing that the COVID vaccine reduced the likelihood of hospitalization. (An HHS spokesperson told The New York Times that Bhattacharya “wants to make sure that the paper uses the most appropriate methodology.”)

[Read: RFK Jr. is losing his grip on the CDC]

Schwartz’s selection could signal a move toward stability. She has a long public-health track record, including serving in the first Trump administration during the coronavirus pandemic. She holds a medical degree from Brown University and a law degree from the University of Maryland. (The acting director who preceded Bhattacharya, Jim O’Neill, has no medical background and was viewed internally as a Kennedy loyalist.) Several current and former CDC employees I contacted welcomed the news of her possible selection.

A number of other key CDC roles that have been vacant for months will also soon be filled with qualified officials. Jennifer Shuford, an infectious-disease specialist and Texas’s health commissioner, who emphasized the importance of measles vaccination during the state’s outbreak last year, will be the agency's deputy director and chief medical officer. Sara Brenner, a physician who is currently serving as the principal deputy commissioner of the Food and Drug Administration, will become a senior counselor to Kennedy.

Such selections by no means guarantee that the agency will return to normal. The CDC’s last permanent director, a longtime government scientist named Susan Monarez, has testified that she lost her job because she refused to rubber-stamp Kennedy’s agenda or to get rid of certain public-health experts. (Kennedy has said she was fired because she denied being a trustworthy person.) If Schwartz in fact becomes the next director, she, like Monarez, could find herself standing between agency staff and Kennedy, who has repeatedly called the CDC corrupt. Daniel Jernigan, the former director of the National Center for Emerging and Zoonotic Infectious Diseases who resigned in protest over Monarez’s firing last year, told me he believes that, for the next director—whoever that turns out to be—acquiescing to Kennedy’s anti-vaccine views is “likely a necessary job skill.”

[Read: A new level of vaccine purgatory]

If Kennedy was circumspect about his own views today, the actions he’s already taken on vaccines as HHS secretary are still bearing fruit. Last summer, he stacked the agency’s vaccine advisory board with allies; this spring, a judge temporarily blocked changes that the board made to the childhood-vaccine schedule and declared most of its members illegitimate. But last week, seemingly in response, Kennedy signed off on changes to the board’s charter, which now says that, among its duties, the board will work on identifying “gaps in vaccine safety research including adverse effects following vaccination.” It’s hard not to read that as code for continuing to cast doubt on vaccines.

When Trump made Kennedy health secretary, he famously promised to let him “go wild.” Lately, Kennedy seems to have been tamed. But that doesn’t mean he’s abandoned his anti-vaccine agenda, or that he won’t push it from behind the scenes.

This article has been updated to reflect Shuford’s and Brenner’s new roles

The DNA Fix for Aging

2026-04-16T13:11:00-04:00

On his son’s fourth birthday, Michael Prescott had his first heart attack. Prescott, who worked as a civil engineer designing bridges in Tennessee, was in his 30s, and until that day, he had appeared to be in excellent health. But within two years of that first heart attack, he had four more. His doctors, who were baffled by his repeated medical crises, decided that he needed a heart transplant. In 2001, he underwent the procedure in Nashville. But a few years later, he needed a kidney transplant too. No one could explain why his organs were failing him.

As time dragged on, Prescott’s symptoms became more outwardly visible. His skin began wrinkling like that of someone decades older than him, and he developed cataracts. By his early 40s, Prescott looked like he was in his 60s. When he attended baseball games with his son, Carter, people would mistake him for the boy’s grandfather.

Frustrated, Prescott decided to diagnose himself. He would sit for hours in the living room in his favorite chair, his slim form enveloped in a sweatshirt with the logo of his favorite football team, the Tennessee Volunteers, as he read one research article after another. “He had a hard time sleeping at night,” Carter told me, “and so he’d be in his recliner with his little lamp, on his laptop, just kind of scouring through stuff, taking notes and trying to figure it out.” Finally, Prescott struck upon a disease that seemed to explain everything. His doctors agreed to test him right away, and the results vindicated his hunch. Prescott had a real illness with a real name: Werner syndrome.

A person with Werner syndrome seems to age at fast‑forward speed. By their mid-20s, they experience hair loss, muscle atrophy, and loss of the fat under their skin. During their next decade of life, many patients develop other early hallmarks of aging, such as hardened blood vessels. Individuals with this condition live, on average, until their early 50s. They lack a functioning version of a DNA-stabilizing protein, and their cells rapidly accumulate sequence errors as they age.

A version of that same process occurs even in those of us without Werner syndrome. We all amass DNA damage and countless mutations in our tissues throughout our lives. We just do so a bit more gradually.

Scientists now recognize that spontaneous DNA errors, which we acquire in early development all the way until our last breath, can drive several ailments such as heart disease, autoimmunity, epilepsy, Alzheimer’s disease, and cancer. These errors could even be the missing piece in explaining the universal phenomenon of aging.

Scientists’ earliest understanding of genetic disease had to do with mutations in the genetic code people inherit at birth. (Think of hereditary disorders such as hemophilia, cystic fibrosis, and sickle cell disease.) Later, they came to understand that epigenetic marks—the chemical tags that sit on top of genes, helping switch them on and off—can play a role too. More recently, scientists have discovered the massive number of sequence mutations everyone experiences throughout life. Consider this stark possibility: Even as you read this sentence, the brain cells you are using to process it might be mutating.

Unlike inherited conditions, spontaneous genetic diseases can emerge at any point in a person’s life. Some non-inherited genetic diseases are rare, such as the bone condition melorheostosis, which was first described decades ago and causes a painful overgrowth of bone that on X-rays resembles dripping candle wax. But the list of diseases linked to spontaneous mutations expands with each passing year, thanks in part to advances that enable scientists to decipher the DNA of single cells rather than bulk-tissue samples alone. In 2020, doctors added a new one to the list. They discovered a sometimes-fatal inflammatory disorder resulting from spontaneous mutations in the UBA1 gene. Non-inherited genetic errors have also been implicated more and more in common conditions: Upwards of one-third of children with autism spectrum disorder possess spontaneous mutations that appear connected to their condition.

Scientists’ greater understanding of acquired mutations is already inspiring major updates to medical treatment. Take cancer: Decades ago, oncologists believed that tumors were driven by a couple of genetic errors. Now they know that cancers are rife with genetic change—by some estimates, thousands upon thousands of mutations per advanced tumor. By sequencing the genetic changes in a tumor, scientists can figure out which mutations fuel its growth, and design drugs to strike those targets. Meanwhile, in neurology, some epilepsy patients have received drugs for their seizures that target specific spontaneous mutations detected in their brains.

For decades, scientists have suspected that acquired mutations might also explain health problems adults experience as they age. Among the earliest researchers to make the connection were physicists who had worked on developing the first atomic bombs. The United States used these weapons to kill hundreds of thousands of people at the end of World War II, and they have since been linked to cancers in people exposed to the bombs’ mutation‑inducing radiation. Understanding the effects of such mutations remained an obsession for some Manhattan Project scientists, including Gioacchino Failla and Leo Szilard. In the 1950s, they theorized that “hits” to the genome could explain the universal process of aging.

By the next decade, British scientists observed that many men seem to be losing copies of their Y chromosome as they age. Scientists now know that almost half of men over the age of 70 have lost the Y chromosome in some of their blood cells—a phenomenon that has been linked to an increased risk of cancer. (Women also seem to lose copies of their X chromosome as they age, but the number of published studies related to this phenomenon is paltry.) In recent years, geneticists have found that people in their later decades of life are more likely to have blood cells with mutations in specific genes. These cells, present in about 10 to 20 percent of people ages 65 and older, double someone’s risk of coronary heart disease and stroke. Medical researchers have estimated that a single white blood cell from a 100‑year‑old can contain more than 3,000 acquired mutations.

Now that scientists have described just how much mutation happens in aging, they’re curious if DNA repair might offer a counteracting force. In other words, does fixing DNA improve longevity? Biologists are taking different tacks to find out. Some have turned to gene editing to try to create antiaging therapies: One company, Spellcheck Bio, has started designing a treatment that relies on the CRISPR-Cas9 genome‑editing system to look for—and correct—DNA mutations.

Vera Gorbunova, a biologist at the University of Rochester, traveled to the sea around Utqiagvik, Alaska, to study the genes of the mammal with the longest lifespan on Earth: the bowhead whale. “This is the only mammal proven to live longer than humans,” she told me. One bowhead whale was estimated to have lived to 211, and genetic clues suggest that members of the species could have a maximum lifespan of 268 years. Gorbunova and her colleagues worked with the local Inupiat community to collect small samples from whales hunted using traditional methods. In the lab, the scientists observed that the bowhead cells mended breaks and mismatches in their genetic sequence extremely well. The cells also contained astronomical levels of a molecule known as cold‑inducible RNA-binding protein, or CIRBP. Gorbunova imagines that proteins such as CIRBP—if they do indeed counteract DNA damage—could perhaps have a place in modern medicine.

Gorbunova is on the scientific advisory board of the start-up Genflow Biosciences, which leans into the belief that activating DNA repair might reduce damage to the genome, and therefore extend life. All of the drugs it has in development involve the SIRT6 gene, which makes a protein that helps guide DNA repair. Gorbunova previously helped lead a genetic-sequencing project that found that some centenarians possessed a rare variant of the SIRT6 gene that enhances genomic stability. The company aims to start clinical trials on a compound to reverse liver damage, and on another one it hopes will have antiaging effects in dogs. Genflow is also developing a drug to treat Werner syndrome, the inherited genetic condition of accelerated aging that affected Michael Prescott.

Prescott, for his part, forged ahead despite his worrisome prognosis. He continued cheering on the Tennessee Volunteers and guiding his son through life. Ultimately, though, Prescott developed cancer—another common complication of Werner syndrome. He died at age 52, weighing only 65 pounds.

The breakthroughs of recent years came too late for patients such as Prescott. But with the new understanding that DNA is dynamic and endlessly changing, modern medicine is now better equipped to adapt to—and perhaps even influence—the cacophony of mutations we all inevitably accumulate.

This article was adapted from Roxanne Khamsi’s new book, Beyond Inheritance: Our Ever-Mutating Cells and a New Understanding of Health.

America Has a New GLP-1 Playbook

2026-04-11T07:30:00-04:00

By most measures, the new GLP-1 pills are underwhelming. Earlier this month, the pharmaceutical giant Eli Lilly debuted a weight-loss tablet that is far less effective than its popular injectable counterpart, Zepbound. Oral Wegovy, which hit the market in December, can hold its own with the shot version—but it has to be taken on an empty stomach with fewer than four ounces of water. And both pills come with many of the same side effects as the shots, namely nausea and diarrhea.

As someone who’s currently on a GLP-1 injection, I still can’t wait to start taking the pills instead. No, I’m not afraid of needles. The injector pens that are used to administer GLP-1s are so quick and painless that sometimes I worry the needle didn’t actually go into my skin. But the shots are a nuisance nonetheless. They’re supposed to be taken on the same day every week, but I struggle to stick to the schedule. The injections also need to be refrigerated—which is especially a hassle whenever I travel. Last month, I visited relatives who don’t know that I’m on a weight-loss drug. I was too sheepish to have a conversation with them about it, so I left the pen in my toiletry bag and didn’t throw it in the trash until I got home.

This might all seem trivial, but a mere annoyance compounds when it must be repeated every week for the rest of your life. Even though many GLP-1 users hit a weight-loss plateau after several months, they have to continue injecting themselves to avoid gaining the weight back. “Over time—particularly as patients transition from the active-weight-loss phase to long-term maintenance—the psychological burden of ongoing injections can become more apparent,” Akshay Jain, a clinical instructor at the University of British Columbia, told me. (Jain has consulted for both Eli Lilly and Novo Nordisk.)

[Read: The Ozempic plateau]

This may be where the true value in weight-loss pills lies. Patients may be able to use the injections to actually lose weight, and then lean on the tablets to keep it off. The pills can be downed with a swig of water just like statins, SSRIs, and so many other pharmaceuticals that are already part of people’s daily routine. On that front, Eli Lilly’s pill, sold under the brand name Foundayo, is especially notable. For most people, the drug doesn’t come with fussy rules about when it should be taken. Doctors I spoke with were enthusiastic about the idea of switching some patients to pills because it allows them to feel as if they’ve made meaningful progress toward normalcy.

So far, doctors just haven’t had very good options for GLP-1 patients who are looking to maintain their weight loss. Some have attempted to switch patients to older weight-loss pills. Others have suggested that patients space out injections to every few weeks. But neither strategy is foolproof. The older drugs have been successfully tested as a way to maintain weight after bariatric surgery, but they haven’t been studied among people coming off of GLP-1s, David Cummings, a professor at the University of Washington, told me. Anecdotal evidence suggests that the method may not be all that effective. “I have a lot of patients that regain all of their weight,” Catherine Varney, the director of obesity medicine at UVA Health, told me. (Varney has done paid speaking gigs for Eli Lilly.) The tactic of taking a GLP-1 shot less frequently, meanwhile, hasn’t been tested in a large randomized clinical trial.

By contrast, a recent clinical trial by Eli Lilly tracked nearly 400 subjects who switched from shots to Foundayo, and found that on average, they maintained most of their weight loss after 52 weeks. (The study has not yet been published in a peer-reviewed journal.) A comparable study hasn’t been done with oral Wegovy, but Novo Nordisk, the company that manufactures the drug, believes that patients should be able to switch from the Wegovy shot without affecting their weight. Because the two drugs are made with the same molecule, “there’s no reason to think that there’d be any difference,” Andrea Traina, the senior medical director for obesity at Novo Nordisk, told me. Doctors told me that they have been encouraged by patients who have already switched from shots to oral Wegovy. “Initial anecdotal reports are promising, but we still need more long data to form conclusions,” Katie Robinson, an assistant professor at the University of Iowa, told me.

All of this comes with a significant caveat. These pills may not remedy the biggest reason people stop taking GLP-1s: price. The new tablets are cheaper than the shots, but they’re still not cheap. If you pay out of pocket, the lowest dose of Foundayo costs $149 a month, which is about half the price of the cheapest version of Zepbound. The Wegovy pill also starts at $149, compared with $199 for the injection. Again, this is $149 every month indefinitely—it quickly adds up. With insurance, the cost of these drugs can be much lower, but few people can count on that. A recent survey of employers found that only about one in five insurance plans at large companies covered GLP-1s for weight loss. The situation gets especially tricky for older Americans. Medicare is technically banned by law from covering weight-loss drugs, though the Trump administration is piloting a program to provide beneficiaries with access.

[Read: The obesity-drug revolution is stalling]

There is hope that the price of Foundayo, in particular, will drop over time because of the way it is manufactured. Unlike all of the other GLP-1s on the market, it is not a peptide—a class of drugs that mimics hormones in the body—which makes it much simpler to produce. But even if the price plummets, not everyone may be as eager to switch to a pill as I am. Everyone who takes a GLP-1 has their own issues that affect whether they stick with their regimen. For some, the once-weekly injection may be more convenient than daily pills; others may want drugs that come with fewer side effects; and still others may just decide to take whatever is cheapest and does the job.

So much of the attention surrounding GLP-1s has been on their remarkable efficacy at shedding weight—and the search for drugs that are even better. Retatrutide, a much-hyped injection that is in the works, can apparently lead to nearly 30 percent loss in body weight on average. But options that lessen the burden of taking a forever drug may matter even more.