The 2026 Commonwealth Games medallist hopes more women, of any age, can feel inspired to take up space in the gym

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America formally eradicated measles in the year 2000. But like many other remnants of the 1990s — flip phones, CDs, baggy pants — measles is now regrettably and undeniably back. 

More than 2,300 Americans have come down with measles so far this year — the highest number since 1992. New data from the Centers for Disease Control and Prevention shows that there’ve been more cases in the country in the last two years than in the 24 years prior. 

Many of the cases trace back to large outbreaks in South Carolina, Utah, Virginia, and Pennsylvania, some of which have ended. But the underlying problem is both much broader and much trickier to address: As more parents pass on routine childhood vaccinations for their kids, these once-eradicated viruses have more chances to spread.

For measles, which is incredibly — almost frightfully — contagious, 95 percent of people in any given community must be immune to stop its transmission. But today, only 28 percent of US counties vaccinate enough of their kindergarteners to meet that threshold. 

Another record-setting year for measles

Lower vaccination rates are, in large part, a result of political polarization, misinformation, and declining trust in health authorities and institutions. But there’s another, more ironic reason for measles’ resurgence: We did such a good job getting rid of it.

As late as the 1950s, virtually every American child contracted measles before age 16. Roughly 48,000 patients were hospitalized each year with measles, which is among the most contagious infections known to humanity. 

But the development of a highly effective vaccine in the 1960s, and a series of aggressive public immunization campaigns in the decades after that, all but eradicated a once-common childhood illness. The federal government poured millions of dollars into vaccination programs, especially for low-income kids. Everyone from Michael Jackson to the Teenage Mutant Ninja Turtles championed measles immunization. 

All that campaigning worked. By the end of the 1990s, more than 90 percent of Americans had received the measles vaccine, and a similar percentage agreed that it was important to vaccinate children. As a result, most people born in the last 40 years have no firsthand experience of how dangerous measles is.

“We’ve done too good of a job,” one doctor joked to Vox last December. In other words, ironically, America’s success at vaccinating against measles … has made Americans complacent about measles vaccination. 

One link for later

➨ Go with your gut. The hashtag #GutTok has over 6 billion views on TikTok, and viral trends that promise to “hack your gut” through miracle products and cleanses are all the rage. But you don’t need an influencer-endorsed supplement for digestive wellness. Instead, actual experts recommend basic lifestyle steps like eating a high-fiber diet and reducing stress. 

Before you go…

• Did you know…that there are more endangered species in California than in any other US state? But more surprising is the runner-up: After California, Alabama has the most endangered species. 
• Today’s trivia: Which Irish musician sings the song “Orinoco Flow”? (You can find this and other brain puzzles in Vox’s daily crossword. Look for the answer in tomorrow’s edition.)
• Yesterday’s trivia: On Friday we asked you for the four-letter university located in Athens. That would be Ohio. But there are more than two dozen Athenses in the US, and a rival Athens is also home to the University of Georgia. 

This story was originally published on June 29 in The Highlight. To get access to member-exclusive stories like this every month, become a Vox Member today.

America in the summer of 1976 was not in a good place. 

The president who presided over the country’s bicentennial, President Gerald Ford, only had the job because the previous president and vice president had resigned in disgrace, making him the sole US president who was never actually elected. The Vietnam War had ended in defeat and disgrace when Saigon fell the year before, after the deaths of nearly 60,000 American servicemembers. Inflation hit double digits in 1974 and stayed ugly, unemployment sat near 8 percent, and economists had to invent a word — stagflation — for an economy that seemed to encompass the worst of both worlds.

Given all that, you might assume the national mood leading up to the 200th anniversary was grim. And, yet, on July 4, 1976, something strange happened: Americans threw themselves a hell of a party. 

In New York Harbor, more than 200 tall ships sailed up the Hudson for Operation Sail, drawing an estimated six million spectators — the largest crowd in the city’s history. Ford reviewed the fleet from the deck of the aircraft carrier USS Forrestal. It was the same scene up and down the country that day: parades in small towns, fireworks over the National Mall, church bells ringing in unison at 2 o’clock. It was one cathartic day of celebration after a decade that had offered little reason for it.

And when pollsters asked people how they felt about the country’s future that year, the mood was, improbably, sunny. A Roper survey found more Americans were optimistic than pessimistic about the future by a nearly three to one ratio. More than three-quarters told Gallup the nation had already achieved at least a fair amount of its founding ideals. Somehow, a nation that was in the middle of a genuinely miserable decade looked in the mirror and liked what it saw.

Jump forward 50 years, to this year’s 250th anniversary, and you’ll find the vibes flipped. Roughly 60 percent of Americans tell pollsters the nation is on the wrong track. A majority say its best years are behind it. About three-quarters think today’s children will end up worse off than their parents. Asked a version of that same founding-ideals question from 1976, 77 percent now say the founders would be disappointed in what we’ve become.

But just as they were in 1976, the vibes don’t match reality. Set the mood aside and look only at the numbers, and the country that felt so good in 1976 was, by the most important measures, a worse place to be alive than the country that now feels so terrible on its 250th birthday.

Start with whether you’re alive

Let’s start with the most basic test of how a society is doing: how long its people live.

Life expectancy at birth in the US was 72.6 years in 1976. In 2024, it reached a record high of 79 years — an extra six and a half years of life. At the start of life, a baby born now is far more likely to survive its first year than one born during the Bicentennial, while cancer, once nearly a synonym for a death sentence, now kills a much smaller share of the people it strikes. 

The US made those gains by stopping some of its worst habits, things that were commonplace in 1976 . You might have seen the Bicentennial celebrations through a cloud of smoke, as cigarettes were woven into ordinary life — on airplanes, in offices, in hospital wards — and roughly 37 percent of adults smoked. Today, it is closer to one in 10, and it keeps falling. 

The heart disease and lung cancer that were connected to all that tobacco have receded with it. Add seatbelts and airbags, better trauma care, and cheap drugs that lower cholesterol and blood pressure, and the result is a country where the things that were most likely to kill an American in 1976 are less deadly now.

The America of 1976 sat at the leading edge of a brutal crime wave; the murder rate would peak in 1980 and stay high for more than a decade. By the early 2020s, however, violent crime had fallen back to roughly a 50-year low, and homicide rates this year may end up at a record low. And the single most dangerous thing most Americans do — get behind the wheel of a car — is far less likely to kill them, with the death rate per mile driven now a fraction of what it was at the Bicentennial.

The country got cleaner, and richer, and fairer

In 1976, the air in American cities carried lead, an honest-to-God neurotoxin that was pumped out of every tailpipe of the more than 90 percent of American vehicles that used leaded gasoline. 

Rivers literally caught fire: The Cuyahoga in Cleveland had burned so many times it became a national joke, and Lake Erie was widely written off as dead. And things were bad outside Ohio, too. In Los Angeles, the smog got thick enough to keep kids inside at recess and erase the nearby mountains from view.

Since 1970, however, the combined emissions of the six main air pollutants the EPA tracks have fallen 78 percent — even as the economy nearly quadrupled in real terms, the population grew by tens of millions, and Americans drove far more miles. That split, with growth going one way and pollution the other, is one of the least celebrated but most consequential triumphs of the past half-century, the product of legislative efforts and technological response. And lead? It’s essentially disappeared from the air. 

And it’s not just economic or environmental statistics that have improved; society advanced, as well. Women now earn the majority of college degrees. The Black poverty rate sits near a record low. Support for same-sex marriage is now the norm — maybe the single biggest social change from 1976, when homosexuality was criminalized in most states. Pick a metric more or less at random, and the line usually runs the right way.

This is not a matter of cherry-picking a few flattering numbers. It is the overwhelming direction of the evidence, across health, wealth, safety, rights, even the basic cleanliness of the physical world an American walks through every day. Measured against its own recent past, the US is in some of the best shape it has ever been.

So what’s with the bad vibes?

A more perfect union doesn’t mean perfect

Well, some things genuinely got worse, and they are not insignificant. 

Americans’ faith in their government has collapsed; fewer than one in five now trust Washington to do the right thing, down from solid majorities in the 1960s — and the country is more polarized than it was in 1976. Democratic decline and even collapse is a live threat. Those economic gains I highlighted above have flowed disproportionately upward. The top 1 percent’s share of income, near a historic low in 1976, has since roughly doubled.

Climate change barely registered in 1976. The carbon dioxide in the atmosphere has since climbed from around 330 parts per million to about 427, and warming will only get worse in the future. And buying a home increasingly feels out of reach for many. By 2024, a record share of households spent more than a third of their income on housing. (Notably, though, the percentage of Americans who own a home is slightly higher than it was in 1976, and those homes are much larger on average.) 

These are real problems, but they remain exceptions to a broader half-century trend of improvement. And a country that scrubbed the lead from its air and put out smoking can overcome new challenges, as well. 

Which brings us back to a tale of two birthdays. In 1976, Americans had less of nearly everything you can count, and, yet, they reported feeling good about the future anyway. In 2026, we have more, and we don’t. 

Just as it can be for a person, a country’s mood is a poor instrument; it measures the story we are telling ourselves more than the lives we are actually living. For all our pessimism about the state of the nation, more than three-quarters of Americans say they are satisfied with their own lives.

The Americans crowding New York Harbor in 1976 were cheering a country that was sicker, dirtier, more dangerous, and less free than the one we live in now. But they were right to cheer; the line was already bending the right way, and it kept bending. It turns out a nation can travel a long way, even while it is convinced it is going nowhere.

A version of this story originally appeared in the Good News newsletter. Sign up here!

Medicine has come a long way. We are living longer than ever, we have eradicated diseases that once seemed like a certain death sentence, and new improvements  are constantly being made to our quality of life. But despite all the advances, there’s a huge gap in women’s health. “I think there’s such an interconnectedness between society, culture, medicine, and science,” Dr. Elizabeth Comen told Vox. She’s a medical oncologist who specializes in breast cancer and an associate professor at NYU Langone. She says medicine often mirrors what’s happening in society at large. “For many societies across the globe, women did not have equal agency or power over their bodies, and that’s really reflected in the history of medicine.”

It’s reflected in medicine’s present, too. The share of women with heart disease in the United States is rising, there’s a cultural backlash and skepticism surrounding birth control, and almost half Americans are turning to social media influencers (many of whom aren’t credentialed) for medical information. 

Why is there such a disconnect when it comes to health care for women? And what will it take for it to end? We find out on this week’s episode of Vox’s weekly call-in podcast, Explain It to Me.

Below is an excerpt of my conversation with Evans, edited for length and clarity. You can listen to the full episode on Apple Podcasts, Spotify, or wherever you get your podcasts. If you’d like to submit a question, send an email to askvox@vox.com or call 1-800-618-8545.

We are at this point where we know more about our bodies than we ever have before. Sometimes you go to the doctor, and it feels like they’re still catching up on some pretty basic aspects of women’s health. Why does it feel that way?

Because it’s true. It takes a long time for medical science to catch up with the glaring gaps in our healthcare system. The gaps are not just about the obvious women’s health issues. We focus a lot on breast cancer. We focus a lot on reproductive function or our gynecological needs. But the gaps exist head to toe from our neurologic care, our gastroenterology care, how our hearts function, how our immune system functions, how our joints function. The gaps are real, and the experiences are real.

Can you walk me through some of the history? What did it look like to study women’s health before the 20th century? What were we dealing with?

When we think about modern medicine today and these specialties of urology, gastroenterology, they really didn’t exist before the 1900s at all; those are relatively new concepts. For much of the history of medicine, at least in the Western world, the idea was that, at best, we were small men and, at worst, there were many ridiculous diagnoses like hysteria and a long legacy of dismissing women’s medical needs because we were largely not taken care of by women. Those women that were caregivers in the history of medicine, whether it was the midwives or other types of healers, were largely pushed out of medicine as it became codified, and the idea of medical science really came to rise in the late 19th century.

So, I’m guessing that they weren’t really talking about menopause at the time, let alone perimenopause.

Perimenopause wasn’t even discussed. That’s a relatively new term and new part of our lexicon when it comes to lay discussion and the public at large. With respect to menopause, one of the famous physicians, Roger Wilson, wrote a book [called] Feminine Forever and referred to women going through menopause as vapid cows. He was the one that advocated in the 1960s and 1970s for women to be on hormone replacement therapy. But understand that, in the 1850s, it’s not like people really were wildly aware of what estrogen, and testosterone, and progesterone did. These are all relatively new ideas — the concept of hormones and how they can travel in our body. And again, we have a long way to go.

I read that women were rarely included in clinical trials until the National Institutes of Health mandated it in 1993. I find that so surprising. Why were women missing there? 

Well, these studies were not designed with women in mind. Some of the massive cardiology studies for drugs that we use day in and day out were done on thousands of men and not women. There is so much to that history, including the animal models on which many of these drugs were developed. In order to develop a drug, often, they are developed on mouse models first. It wasn’t until 2016 that you were even required to state the sex of the mice that you were studying. In many of these instances, female mice were not even included in drug development.

Oh my gosh — even the mice? How were these hormones marketed to people when hormone replacement therapy first became a thing?

It depends on which advertisements that you look at. If you look at advertisements of women in the 1950s, ’60s and ’70s, a lot of women were being prescribed anti-anxiety medicine. “Can’t manage your household at home? Don’t want to take care of your kids? Here’s what will sedate you and at least make you able to prepare breakfast for your husband.” It’s really shocking, and yet, not that surprising. If you look at Instagram today, are we really that far off from what gets marketed to women? Women sink billions of dollars probably into sham supplements and sham treatments, because they don’t feel cared for when they go to the doctor. And what fills that space? A lot of people trying to market things that have no proven evidence.

I think it’s really interesting that, at one point, hormone replacement therapy was this big thing, because I feel like growing up in the ’90s and 2000s, hearing women who are older than me speak, they were kind of anti-hormones. How did the pendulum swing that way?

Well, the pendulum has swung in wildly different directions. At first, it was: Every woman needs to be on it. And there were wildly successful sales. Then, there was the women’s health study that exaggerated the risk of breast cancer. Understandably, women were terrified. They were told by the media and by reputable scientists that these risks were significantly high and that they could not be on it, and we didn’t leave them with any alternatives. Now, we’ve become much more granular about what we know and what we don’t know, but I still think we’re far behind on the science. There’s still a lot that we need to learn, but, fortunately, an understanding of the prior studies and what their limitations are has come to light.

There are all these gaps in trust and treatment. There’s going to be a fair amount of snake oil out there, but are there ways that this moment is actually driving better treatment for women?

I’m so grateful that we’re talking about it, but I am terrified of what I see from influencers on Instagram. People can fake their knowledge. There’s so much fake imagery and information that is out there. I wish that we could invest this in quality science, which is long and laborious and painful at times but gives us the quality answers that we need. Every day, I see the consequences of fake information online, whether it’s an incredible loss of financial resources or just wasting money so that you could buy a nice pair of shoes. That would make you feel better than the ridiculous thing online that’s over promising and under delivering. The fear mongering is out of control.

What do you think it will take to trust their doctors again, rather than turning to the treatments they’re being sold online that might be dangerous? What will it take for them to feel good about the interactions they’re having at the doctor’s office? 

I think it’s going to be really challenging. We can’t blame patients, because we’ve done them a disservice. Medicine has fragmented the care of many patients — not just women, but men as well. We have to build a health care system that allows for time to be with patients and really hold space for them. I think that’s where the trust is really going to be built, because, at the end of the day, despite all the technology that’s available, medicine is about human to human care. That is what everybody wants to be treated as: a human to be seen and heard in the ways that you can’t just reduce a body to biology.

Last week, the Food and Drug Administration (FDA) approved a small pill called enlicitide. It is a tablet you swallow once a day on an empty stomach with a sip of black coffee, water, or tea. But it does something that until now took a needle and a specialist’s prescription: It lowers the most dangerous kind of cholesterol by nearly 60 percent, about as much as the strongest injectable drugs on the market.

If that sounds less innovative than some of the medical advances I sometimes cover here — there’s no AI or gene editing involved — you’re missing the story. Enlicitide is just the latest example of how medicine has been quietly making progress against the deadliest thing in the modern world.

That thing is heart disease. It has been the leading cause of death in the United States for essentially a century, and in 2025 it killed 694,708 Americans — about one in five deaths — more than every form of cancer combined. Around the world, cardiovascular disease kills roughly 20 million people a year, the biggest cause of death on the planet.

But today, our enemy is on the retreat. In the US, the age-adjusted death rate from cardiovascular disease has fallen about three-quarters since 1950. In plain terms: A 60-year-old today is roughly four times less likely to die of heart disease this year than a 60-year-old was when Harry Truman was president. As I wrote last year, deaths specifically from heart attacks are down 89 percent since 1970.

That progress comes down to a single number. Low-density lipoprotein, or LDL, aka the “bad” cholesterol your doctor always wants you to lower. Until recently, a high LDL score was all but inescapable, something you could nudge lower with a better diet and willpower but struggle to really fix. What has changed is that we can now lower LDL for nearly anyone who needs it — further, more easily, and earlier in life than before.

A lifesaving genetic mutation

It’s a story that goes back 20 years. In the early 2000s, two geneticists at University of Texas Southwestern, Helen Hobbs and Jonathan Cohen, wanted to solve a medical mystery: Why did some individuals have striking low cholesterol levels? They combed the Dallas Heart Study for an answer. They found a handful — many of them Black Americans — carrying a broken copy of a gene called PCSK9. Their bodies cleared LDL from the blood with unusual efficiency, and the payoff was staggering: carriers of the strongest variant had about 28 percent lower LDL and roughly 88 percent lower risk of heart disease than people who did not carry the mutation.

That finding proved lowering LDL prevents heart attacks, and it handed drugmakers a target: copy that gene. Every PCSK9 drug since — including the new enlicitide — imitates a mutation a few people in Dallas were simply born with.

Millions of Americans still take the old cholesterol-lowering workhorses, statins, and they’ve proven highly effective at reducing heart disease for most people. But not everyone: Some people can’t tolerate the muscle aches; others take them faithfully and still don’t get their LDL low enough. Enlicitide is built for exactly those people: a pill as cholesterol-lowering as an injection but without the needle, and a drug that spares them the statin muscle aches.

Closing the loop

If the pill is today, gene editing is tomorrow — and it may be the answer to a problem no pill can reliably solve: getting people to keep taking their medicine.

About half of patients on statins quit them within a year, and a daily pill, however potent, only helps the people who actually take it. So that demands a fix you can’t forget. A company called Verve Therapeutics, now owned by Eli Lilly, has been testing a treatment that makes a single-letter edit to the PCSK9 gene in the liver — one infusion, in theory for life. In its first human trial, published over the spring in the New England Journal of Medicine, a single dose cut LDL by as much as 62 percent, and held it there for more than a year. Instead of a pill mimicking the effects of the genetic mutation that protected those people in Dallas, gene editing just switches off the gene.

As important as it is, cholesterol isn’t the whole story when it comes to heart disease. There’s smoking, which declined from about 40 percent of US adults in the 1960s to under 15 percent today, sparing countless arteries. High blood pressure — the silent condition that killed President Franklin D. Roosevelt at 63 in 1945, when doctors had few effective ways to treat it — can now be caught early and treated with cheap generic pills.

And then there are the GLP-1s. More than one in 10 US adults say they are currently on an anti-obesity drug, and whatever else you may think of them, they’ll make a significant dent in heart disease. In one major trial semaglutide cut cardiovascular events by 20 percent.

The war continues

Still, the war on heart disease won’t be easy to win.

Just because a pill like enlicitide has been proven to lower a lab value does not mean it’s yet proven to lower deaths. They should — the injectable versions of these drugs cut heart attacks and strokes by about 20 percent in long trials. But enlicitide’s own outcomes study won’t conclude for years.

Precisely because the condition itself so widespread, treatments for heart disease will only be effective if they are equally widespread.

Heart disease is shifting, too. The same research showing heart-attack deaths down 89 percent found deaths from other heart conditions — heart failure, arrhythmias, hypertensive disease — up 81 percent since 1970, though because heart attacks were killing several times as many people, overall heart-disease deaths have still dropped by about two-thirds since 1970.  Some of that shift is perversely the result of success: people who might have died of an initial heart attack now live long enough for the heart to wear out in other ways. And some of this is the reverse of progress: As smoking and cholesterol fell, obesity climbed to about 40 percent of US adults, pulling diabetes and high blood pressure with it.

And then there’s perhaps the biggest problem in medicine: access. A 60 percent drop in cholesterol helps only the people who can actually get the drug. Half of patients abandon cheap statins within a year. Enlicitide arrives at about $300 a month with uncertain insurance coverage. The gene edit, whenever it becomes available, will certainly cost far more, and at first will reach only the sickest.

More than 60 percent of US adults are projected to have some form of heart disease over the course of their life. Precisely because the condition itself so widespread, treatments for heart disease will only be effective if they are equally widespread.

Which brings us back to that unassuming little pill. It’s just a tablet, doing what a generation of scientists spent their careers trying to do: turning one of the deadliest numbers in medicine into one you can change. It’s the kind of progress that’s too easy to miss — until it saves your life.

A version of this story originally appeared in the Good News newsletter. Sign up here!

Ensuring the right fit matters. Inadequate support could contribute to breast pain, impact movement and cause stretching of breast tissue

Ticks are taking over the United States. Due to climate change, changing land use, and an explosion in the deer population, ticks have been expanding their territory and infecting more people than ever. They carry pathogens that cause everything from Lyme disease to the red meat allergy-inducing Alpha gal syndrome. In some cases, tick bites can be fatal.

Ticks usually lurk in the tall grass in wooded areas. That means going on a hike or even just hanging out in your backyard or a park can expose you to a tick bite. In many parts, of the country fear of ticks is changing how people live their lives, including the way they dress, how they enjoy their hobbies, or even whether they spend much outdoors at all. 

The tick surge is catching public health officials off guard. Emergency room visits due to tick bites are the highest they’ve been since 2017. In spite of the uptick, most public health departments still focus on lowering the population of mosquitos in their areas over ticks. 

Climate reporter Jonthan Mingle says we can fix this problem. As Mingle explained in a recent New York Times op-ed, encouraging the public to do tick checks and use bug spray is a part of the solution, but we’re leaving a bunch of larger interventions on the table. Mingle joined Today, Explained co-host Sean Rameswaram to explain why ticks are expanding their range and what we can do about it. 

Below is an excerpt of their conversation, edited for length and clarity. There’s much more in the full podcast, so listen to Today, Explained wherever you get your podcasts, including Apple Podcasts, Pandora, and Spotify.

We covered Lyme disease and tick bites on this show back in 2018 because the tick situation was getting out of hand. How much more out of hand has it become since then?

You know some experts I talked to used the word exponential. So what’s happening is that some of these tick species are spreading into areas where people aren’t familiar with them, doctors aren’t familiar with them. Thanks to warmer winters, ticks are expanding their hunting season. You may have a day that’s like 40 degrees in January, ticks are out looking for you, waiting for you to walk by and grab on and grab a meal. 

In 2024, a pilot named Brian Weitzel, father of three in northern New Jersey, had a hamburger, at a barbecue, went home to mow his lawn, and a few hours later was unresponsive on the floor and he died that night. His family was left in shock, of course, trying to figure out why he had died. And it turned out that he had likely been bitten by the lone star tick and had developed an allergy to red meat. This is referred to as Alpha-gal syndrome, which is just the latest entrant into the files of all the many ways in which tick bites can make us sick. The most familiar one, of course, is Lyme disease. Each year, about half a million people are treated for Lyme disease. It’s the fastest growing vector-borne disease in the US. Cases have more than doubled over the past decade, and those cases are mostly as a result of getting bitten by the black-legged tick or the deer tick. The thing is both of these ticks — and many other ticks that are also marching northward and westward and expanding their empires rapidly across North America — they can deliver all kinds of pathogens.

They’re claiming more and more of the map, and they’re claiming more and more of our psychic map right? I tell people I’m not a tick expert, although I’ve talked to a bunch of them, but I’ve become a tick expert in the sense that I am very familiar with tick paranoia and how it can keep you from venturing out into the places you love: hiking paths or picnic grounds or parks. And so that was part of the story I wanted to write about, too — Why are we letting the ticks keep us, if not out of these places that we need and love, why aren’t we fighting back?

And why is it? Are we not fighting back against the ticks?

Not really. I mean, this is one of the surprising takeaways from my reporting is that we’re barely even trying. One way of understanding that is to think about two numbers. One number is 90 percent. 90 percent of vector-borne disease cases in the US are from ticks.

90 percent?

Yeah. And yet despite the fact that 90 percent of cases of vector-borne illness come from tick bites, if you look at what local city, county health agencies do in terms of vector control, 80 percent of what they do is mosquito control, and only about 10 or 11 percent of these local health agencies around the country do any kind of tick control. So why is that? It’s a familiar story in the public health world. It’s not enough funding or policy support for trying out, testing, deploying new approaches to controlling ticks.

Even though people are dying?

We’re just kind of taking for granted that, ‘Oh, well, what can you do? You just tuck your pants in and spray some insecticide on your boots and that’s all you can do.’ It’s like, well, actually we have a long history of going to war with mosquitoes. Before there was tick control, there was mosquito control. The CDC was founded with the sole mandate in 1946 of wiping out malaria and fighting mosquitoes. 

It feels like they lost that fight because in my neighborhood you can’t go out between the hours of seven and nine o’clock.

The mosquitoes haven’t gone away, but malaria did for the most part. You know, in talking to experts today, including folks at the CDC, they told me that there’s a suite of tools we could be using if we wanted to get serious about fighting ticks. As one veteran tick expert at the CDC told me, if you want to make a dent in this problem, you have to get to the deer. The deer are the engine driving a lot of these tick species spreading, and we just have way more deer than we did decades ago, especially in the eastern US and suburban parts of America. So how do you get to the deer? I had people in the comments section of my piece saying the clear answer is just we should all be hunting deer. But in talking to the experts, they’ll tell you it’s not really a feasible solution. You would have to knock deer populations way down to make a dent in the tick populations. 

What is more promising is a combined approach of stuff like vaccines. There are people developing vaccines that you could deliver to deer or to rodents, which are another important host for these ticks so that when the tick bites them, they’ll die. That, I learned from talking to folks who do this kind of research for a living, is a more promising avenue for controlling ticks than all of us picking up crossbows and becoming deer hunters.

So why is it that we’re not doing anything?

What I heard from experts is that we’re not even funding this research in a serious way. We do this stuff for mosquitoes. People don’t realize it, but your local county health agency, they go out and they find where the mosquito breeding grounds are and stagnant pools the water and they treat it. It takes this sustained quiet effort. 

We saw the consequences of not doing that recently. This is a bit tangential, but screwworm. Screwworm was this flesh eating larval pest that devastates cattle herds that it was eradicated in the US in 1966, and it was kept at bay by the vigilance of people at USDA and USAID who ran these programs to release millions of sterile screwworm males out of airplanes. It created this wall that kept the screwworm from coming into the southern US. And probably if we stopped doing the mosquito control at a local scale, we’d see more cases of dengue fever, West Nile virus, and all these other rare but serious illnesses that climate change is making more of a threat here in the US.

Could you just practically help people understand how they can protect themselves in the absence of, I don’t know, a functional government?

Doing tick checks. And we do it in my household pretty much daily when you come home, do a thorough tick check, throw your clothes in the dryer. Ticks hate heat. And some people like to use permethrin spray, which is this insecticide that’s designed to kill ticks on your boots or your pants when you go out for a hike. Researchers have known these things are really effective if you keep doing them, if you stay vigilant. And all it takes is that one time, that one time you go out for a hike and you come back and you forget to do the tick check. 

So we need those kinds of personal measures of vigilance and protection, but we still need to kind of push for a bigger public health response to this. The ticks are going to keep spreading into the calendar, too, in the sense that as winters get warmer, more and more days of the year when you’re outdoors, you’re going to encounter ticks who are hungry, and they’re looking for you. 

The England and Manchester Thunder netball player talks affordable kit, martial arts and unexpected hobbies

What caused the ongoing outbreak of cyclospora, the diarrhea-causing parasite currently spreading across the United States? Michigan officials have been saying for weeks that they believed the outbreak may be linked to bagged salad or salad kits. What we were waiting to learn was the specific brands and specific products in question. 

And late last week, it looked like we finally had the answer — but then things quickly got cloudy. 

On July 16, the Washington Post reported, citing anonymous sources, that the outbreak had been linked to shredded iceberg lettuce supplied to Taco Bell by Taylor Farms. A day later, Taylor Farms said it was withdrawing products from US stores and restaurants based on information from the FDA.

But then on July 19, per NBC News, the FDA said that there had been a false positive for cyclospora when testing a sample of Taylor Farms iceberg lettuce; Taylor Farms said in its own statement that the FDA had “apologized” for the mix-up. The next day, the company and the federal government were stuck in a semantic argument: Per NOTUS, the FDA insisted it did not “officially apologize” to Taylor Farms but “explain[ed] factually the issues” with the false positive. 

So where does that leave us right now? Officials still believe that Taylor Farms iceberg lettuce was the source of the Michigan outbreak. But whether those are the only products driving the outbreak remains unclear, with almost every state now reporting at least one cyclospora case in 2026. And on Thursday afternoon, the FDA announced that it was tracking a second outbreak linked to other unspecific products, though details were otherwise scarce.

Any outbreak of food-borne illness requires careful public communication. Officials need to tell people how to avoid contaminated food without scaring them away from eating fresh fruits and vegetables altogether.

But instead, many Americans have been left wondering what, exactly, they’re supposed to do. As one frustrated Reddit user put it: “So is the damn lettuce bad or not????” (If you need some advice on what foods are safe and what foods to be cautious about, we have a story for you.)

It may sound like a funny question, but it’s a profoundly serious one. The problem isn’t just that people are confused about their lettuce. The Trump administration’s handling of the cyclospora outbreak — from its conflicting public messages to accusations of political favoritism — has left many Americans even more confused about whether they can trust anything they’re hearing from the government. That’s a dangerous place to be during any public health emergency.

The cyclospora outbreak has become a communications nightmare

We are approaching 10,000 cyclosporiasis cases across the US this year: Michigan alone has recorded 7,664 as of this morning, Ohio has seen more than 1,200, and more than 40 states have now reported at least one case in 2026. The country usually sees a few hundred cases at most in a given year. Cyclosporiasis, the disease caused by the cyclospora parasite, leads to what public health experts describe as “watery” and “frequently explosive” diarrhea. While it isn’t typically life-threatening, it can cause serious complications: 160 people have been hospitalized in Michigan since the outbreak began.

And so for those of us who very much hope to eat fresh produce but do not want diarrhea, there’s a bit of urgency to figure out where the cyclospora is coming from. Food-borne illness investigations are already inherently difficult because of how globalized our food supply has become: Produce can travel all over the country and the world before it comes to your grocery shelf, and the process of government health workers interviewing the people who get sick and cross-checking to identify the shared foods that they might have in common is laborious.

Once investigators find a source, the information has to be shared clearly and responsibly. That is where the Trump administration has tripped up this week. 

Trump — and Health Secretary Robert F. Kennedy Jr. in particular — came into office criticizing the public health establishment. They accused officials of misleading the public about the novel coronavirus and the vaccines developed to fight it, while failing to convey the nuances of the pandemic. But now, as they grapple with the incomplete picture of the cyclospora emergency, they are making many of the same mistakes.

“They’re very similar problems, even if on the outside, they don’t look quite the same,” said Michael Mackert, director of the Center for Health Communication at the University of Texas at Austin. “The underlying commonality is very much that we are dealing with imperfect information all the time.”

In any outbreak, some uncertainty is to be expected. Investigators have struggled to identify the source of earlier cyclosporiasis outbreaks too. And the FDA maintains that the likely source of the outbreak is Taylor Farms iceberg lettuce, based on the information they have gathered from sick patients and other sources, no matter the false positive result that has sparked so much confusion.

“The epidemiological evidence is so strong that the lack of a positive test is almost meaningless,” said Francisco Diez-Gonzalez, director of the Center for Food Safety at the University of Georgia. 

But the mistake that the Trump administration made was in sharing preliminary results and then having to issue a seemingly contradictory statement shortly afterward.

“FDA should have waited for confirmation of the presumptive results before going public,” Diez-Gonzalez said.

The larger stakes of the Trump administration’s poor communication

Investigations like these are hard enough — but when you add in the public health funding cuts of the past 18 months and the casual and widespread corruption characteristic of the Trump administration, trust in the government’s public health apparatus has sunk even lower.

It’s created just the conditions for conspiracies to bloom. “Unfortunately our FDA is compromised,” wrote one top commenter on Reddit. “I would not trust what comes out of it during this administration.” 

Several news outlets and influential social media accounts noted that Taylor Farms had donated $1 million to Trump’s MAGA super PAC and, in the middle of the controversy, received a private White House meeting. According to the New York Times, Taylor Farm officials used that meeting to dispute the findings that their products were responsible for the outbreak — and shortly thereafter, the FDA made its “false positive” announcement.

The administration insists that their decision-making is being guided by science, but even the appearance of impropriety has become a common theme in the press coverage. The broader uncertainty and distrust may help to explain why it’s not only Taco Bell and Taylor Farms taking a hit right now: According to Market Watch, Chipotle and the fast-casual salad chain Chopt have also seen a decline in traffic in recent weeks.

Public health requires public confidence. Perceived influence from special interests is a problem, even if the interactions didn’t alter the FDA or CDC’s actions.

Kennedy, who helms our government’s health department, should understand this well: His Make America Healthy Again movement made restoring public trust a central part of its message while accusing the existing public health establishment as being in league with special interests. 

The cyclospora outbreak has revealed how difficult that is to do in practice. 

In trying to communicate nuanced information during an active outbreak — while consulting interested parties like Taylor Farms itself — the administration has instead fueled doubts about the credibility of its messaging

Even before cyclospora turned eating salad into a leap of faith, Trump had a poor track record: His administration has slashed CDC staff, brought on vaccine skeptics to set vaccine policy, and clashed with the scientific establishment on a number of high-profile issues, like the time Trump held a televised press conference to argue a disproven theory that Tylenol can cause autism.

“Unfortunately, this is another example of a missed opportunity to establish credible and trusted communications to prepare the public to understand the real risks from the pathogen and confidence in the food safety and information from the FDA,” Scott Ratzan, editor-in-chief of the Journal of Health Communication: International Perspectives, told me. “Faith in our institutions continues to erode. We could do better.”

We are lucky cyclospora is not a deadly disease. Next time, the stakes for these miscues could be much higher.

This story was originally published in The Highlight. To get access to member-exclusive stories like this every month, become a Vox Member today.

Emily Hoffman was walking home from lunch in the Pittsburgh neighborhood of Squirrel Hill in February 2023, when a driver turning left struck her on the crosswalk.

Hoffman was 34. By the time paramedics arrived on the scene, she had gone into a traumatic cardiac arrest. They strapped her onto a machine that delivered automated chest compressions and rushed her to UPMC Presbyterian, a major trauma hospital in Pittsburgh.

Over the next several days, doctors performed multiple surgeries, kept Hoffman on a ventilator, and waited until she was stable enough for an MRI. The scans showed multiple strokes and severe traumatic brain injury. She was alive, but her family understood that she was not going to make a meaningful recovery to a life she would have wanted.

The next Thursday, a week after the crash, Emily’s parents and her sister Beth Hoffman met with the care team and decided to remove ventilator support to allow her to die naturally. Organ donation came up only afterward. Emily was already a registered donor, and Beth knew it was what her sister wanted.

For most of the short history of organ transplantation, Emily would not have been the usual kind of organ donor.

Almost all transplanted organs once came from patients who died in one specific and rare way called brain death, in which the brain has irreversibly stopped functioning, even as machines keep the heart beating and the organs supplied with oxygen. Brain death is extraordinarily rare,  but it happens often enough to create a workable — though far from sufficient — supply of life-saving organs.

But Emily was not one of the brain-death donors. Even after the strokes and brain injury, she still had some reflexes. She was dying, but not brain dead.

Her donation followed a different path, one that has transformed American transplantation in the last decade. It is called donation after circulatory death, or DCD. Instead of death being declared because the brain has stopped functioning, in DCD, death is declared after circulation ceases and the heart stops beating. Many more people die this way than by brain death.

Death by circulatory criteria has been legally recognized since the 1980s, but for decades, doctors rarely recovered organs this way, because, once blood stops moving through the body, organs begin to deteriorate within minutes. In recent years, however, new machines and surgical techniques have helped change that, giving doctors the ability to preserve organs outside the body, making DCD far more viable.

↗ Explore the interactive version of this chart.

Hoffman’s donation is hardly an outlier anymore. In the last decade, DCD has gone from a rare practice to something that now accounts for nearly half of all organ donors who have died in the United States. In 2000, DCD donors supplied just 219 organs (kidneys, livers, lungs, hearts, and pancreas combined) to the transplantation system in the US. In 2025, DCD brought in close to 17,000 organs. (Most transplanted organs, about 85 percent, come from dead donors, though some organs, most often kidneys, can also come from living donors.)

That growth has saved lives, but it has also pushed transplant medicine into an unusually sensitive moment: the time after a family has decided to let their loved one die but before death has actually occurred.

In brain-death donation, a patient has already been declared dead before the possibility of donation is raised with the family. Because most brain-dead donors are on ventilators, with machines supplying oxygenated blood to their organs, transplant teams can take their time with the donation process.

DCD doesn’t offer that same cushion. Because organs deteriorate so quickly after circulation ceases, the work of donation — the testing, matching, surgical teams flying in — has to be set in motion once the family has decided to withdraw life support but before the patient has died.

This is where the tension in DCD begins. The process pushes transplantation into the narrow interval between that decision to let someone die and the moment death occurs. It creates a situation with almost no parallel in medicine: one set of hands caring for the dying, even as another prepares to recover and transplant their organs.

The medical system tries to manage that complexity with a strict procedural sequence. First, hospital doctors and family conclude that no treatment will bring the patient back to a life they would have wanted. Only then, and only from a separate team, does the word donation come up. The firewall is in place so that the need for organs never shapes the decision to let someone die. 

“Ethically, you want to make sure that those two are uncoupled,” said Wade Smith, director of the Neurovascular Service at the University of California San Francisco.

But as DCD has scaled up, more weight is put on that narrow interval. What was once a rare event is now routine in hospitals across the country, carried out by teams with different levels of experience and overseen through rules that can vary from one place to another. At the same time, the organizations that handle organ donations are under new federal pressure to acquire and distribute more organs from eligible donors.

DCD has saved thousands of lives by making donations possible from patients who once wouldn’t have been donors. Hoffman’s donation improved several lives at once: Her kidneys went to two men, her liver to a third recipient, and her corneas helped give sight to a nine-month-old baby. 

But its growth has also made the fragile period before death more consequential: how families are told, which steps can be taken while the patient is still alive, how consistently hospitals and organ donation teams follow safeguards, and who has the authority to stop the process if something feels wrong.

When DCD was still rare, these questions stayed at the edges of transplantation. Now, they are moving towards its center, as a lifesaving practice becomes a routine part of how Americans die and donate.

The breakthrough

Modern transplantation is a relatively young field, only about 70 years old. And from the beginning, transplantation has depended on the novel medical achievement of keeping organs functional after a person had been declared dead.

The mechanical ventilator, developed in the 1950s, made that possible. It could keep a body breathing, and its heart beating, even after the brain had stopped for good. That created, for the first time, a situation where patients were deceased by every older measure, even as their organs were still functional.

Surgeons were initially wary of recovering organs, largely because the legal lines between life and death had never been clearly drawn. Then, in 1968, a Harvard committee proposed a definition of brain death. By 1981, a model law gave states the language to recognize two ways of legal death. Your heart and lungs could stop for good (circulatory death) or your entire brain could (brain death). Today, every state recognizes some version of that framework.

With those lines in place, transplant teams could work with more confidence, and brain death turned out to be close to ideal for them. Because a ventilator kept the heart beating and blood moving through the organs, even after death, there was no ticking clock to race against. The hospital staff had time to evaluate the organs, sometimes convince families to donate them, find the right recipients, and bring in surgical teams before recovery began.

The problem was always with the math. Brain death is rare — only about three in 1,000 deaths happen in a way that leaves organs usable for transplant. That puts a hard biological ceiling on how many ideal donors there could ever be.

But demand for the organs had no such ceiling. Nearly a million Americans are diagnosed with heart failure each year, while surgeons performed just 4,636 heart transplants in 2024, after DCD became a widely used part of transplantation, up 81.5 percent from 2013. There are “just not enough organs to go around,” said Ashish Shah, chief of cardiac surgery at Vanderbilt University. The kidney numbers are even bleaker. Over 500,000 people are on dialysis in the US, but only a fraction will ever reach the waiting list, and even among those who do, many will die before receiving a transplant offer, said Dorry Segev, a transplant surgeon and researcher at NYU Langone.

The modern DCD boom grew out of this desperation, presenting the possibility of donation in far more common cases of death that transplantation surgeons had rarely been able to draw on before: catastrophic strokes, car crashes, cardiac arrests, and other injuries that left patients with no meaningful chance of recovery but short of brain death. But with DCD, the clock suddenly became a factor. Once circulation stopped, the organs deteriorated fast, and, in many cases, they were ruined before surgeons could recover them. 

Because of those challenges, DCD stayed marginal for decades, at well under a tenth of all donations. Those numbers ultimately spiked because of several things that happened almost simultaneously.

The first was technological. New machines, like TransMedics’ Organ Care Systems — which were first used in 2015 in the UK — could keep a recovered organ alive outside the body, pumping it with warm, oxygenated blood instead of packing it in ice, allowing a heart to beat and function as normal inside a box. This meant that even if there was delay in recovering an organ, that damage could be limited, even reversed, once the organ was put in the machine. 

Other teams found ways to use machines originally developed to support failing hearts and lungs to restart circulation inside the bodies of donors after death had been declared. Transplant teams in Spain and the UK began adapting that technology before American programs picked it up for DCD hearts around 2019. Both approaches helped extend the time to successfully perform DCD.

“As soon as the results were good, the big American centers took it on,” said John Dimarakis, a cardiac transplant surgeon at the University of Washington.

Policy changes also helped push DCD further. In Hoffman’s case, the donation process was coordinated by CORE, the nonprofit responsible for organ donation in the Pittsburgh region. Organ procurement organizations, or OPOs, cover a particular region in the US, and they work with hospitals in that region to evaluate potential donors, speak with families, arrange testing, and offer organs to transplant centers. There are 54 such OPOs in the US, which are certified and regulated by the Centers for Medicare and Medicaid Services (CMS). 

For years, critics argued that OPOs were judged according to weakly defined standards based on numbers they reported themselves, and poor performers were rarely penalized. But in 2020, new federal rules began ranking them against one another, with a mechanism to strip the worst performers of their territory. Facing the threat of losing their monopolies, many OPOs began pursuing harder cases they would’ve earlier passed over, according to Greg Segal, who founded patient advocacy group Organize. A larger share of those more complicated donors were DCD.

Still, no single force explains the speed of DCD’s rise. “Technology plays a big role in it,” said Nader Moazami, a cardiac surgeon at NYU Langone who helped pioneer one of the new techniques. “But it doesn’t explain how suddenly 50 percent of our donors are DCD.” In 2000, there were only 118 DCD donors in the United States. By 2025, there were 8,137. Brain death donation grew over that same period but far more slowly — from 5,867 donors a year to 8,416.

↗ Explore the interactive version of this chart.

Whatever the mix, it’s clear that DCD has led to more organs, shorter waits, and saved thousands of lives that otherwise would have ended on a list. “People who have been waiting now wait less,” Dimarakis said.

On a chart, it looks like an unambiguous triumph — until you step into a hospital room.

The passage

Beth Hoffman remembers her sister Emily’s last morning. She read aloud an email from Bradley Whitford, Emily’s favorite actor from the TV drama The West Wing, who had written after hearing what had happened. Then, a playlist of Emily’s favorite songs played as the breathing tube came out. Within about 10 minutes, while “For Good” from Wicked filled the room, her sister was gone.

What Beth mostly didn’t see was the second sequence unfolding around her: the referrals, tests, calls, and scheduling that would turn Emily from a dying patient into an organ donor. 

Federal rules require every hospital to alert their organ procurement organization whenever a person may be nearing death. The OPO screens those referrals, and most go nowhere. Alexandra Glazier, who runs the OPO that covers most of New England, says hers get about 50,000 such referrals a year. Only 2 or 3 percent turn out to have any medical possibility of donation at all. 

Emily was one such possible case for her Pittsburgh hospital’s OPO. The organization had to reach out to her family; explain what DCD would involve; and, then, start the work that had to happen while she was still alive: reviewing her medical history, testing whether her organs could be used, matching them to recipients, and arranging the surgical teams who might fly in to recover them.

Most families never see much of that work, but some do. Smith, the UCSF neurologist, watched a family agree to withdraw life support and donate, set a time, and gather relatives for a final goodbye, only to learn that the withdrawal had to wait because the OPO still needed more tests. Some families, after being told their dying relative must stay on machines longer for donation’s sake, walk away.

For the Hoffmans, things proceeded more quietly. When the time came, Emily was wheeled into the operating room, and the breathing tube was removed there. The surgeons who would recover her organs were kept away from the withdrawal and death declaration. They often fly in from their own hospitals — sometimes several at once for different organs — but they’re walled off from everything that comes before. “We are not involved in that process,” said Dimarakis, the cardiac transplant surgeon at the University of Washington, “because it’s not ethical for us to be involved.”

That separation is the line DCD depends on. One team cares for the dying patient, withdraws support, and declares death. The other waits outside that decision and recovers the organs only after. The OPO stands between them, coordinating the donation without letting the firewall be breached.

Then comes the waiting. Once the ventilator is out, the clock starts ticking. If the heart doesn’t stop within a window — often about two hours — the organ recovery may be called off, and the patient is returned to end-of-life care. But when circulation does stop, as it did for Emily, the team counts exactly five more minutes to make sure it won’t restart on its own. Only then can a hospital physician declare death, and only then can the transplant surgeons begin.

DCD rests on a simple promise: The need for organs never causes the death. The death is already coming, and donation only changes what can come from it. 

But a new frontier in DCD complicates that promise.

The reversal

Normally, after death is declared, most DCD organs are removed and preserved outside the body, either on ice or on machines that circulate oxygenated fluid or blood. The goal is to slow the damage that begins the moment circulation stops.

Then, around the mid-2010s, transplant teams in Spain and the UK began using a newer technique that restores circulation inside the dead donor’s body, before the organs are removed. It’s called normothermic regional perfusion, or NRP.

In one version of NRP, called abdominal NRP, blood is meant to be restored only below the diaphragm to preserve organs such as the kidneys and liver. In a more controversial version called thoracoabdominal NRP, it runs through the chest, as well, and the heart starts beating again.

For the transplant team, especially heart surgeons, the appeal is clear. Kidneys and livers can survive a stretch without circulation, but a heart is harder to preserve. Once it has stopped, there’s no easy way to know whether it will beat reliably again. NRP helps answer that question by restarting it inside the donor’s body after death has been declared, where surgeons can watch it work before deciding whether to recover it.

Shah, the Vanderbilt cardiac surgeon, says the technique lets doctors take hearts from donors who otherwise would not be able to yield a workable one.

But this kind of NRP is unsettling for the very reason that it is useful. If a death is declared because the heart has stopped, what does it mean to start it again inside a donor’s body, often only minutes later? Is that still death? Or something else?

The controversy isn’t simply that the heart beats again. A beating heart is not, by itself, the same as a living person. The heart of a brain-dead patient can beat, too, can be kept going by machines, and that doesn’t mean the person is alive. The deeper concern is whether restored circulation in the body could reach the brain, which could potentially restore consciousness.

To prevent blood from reaching the brain, surgeons clamp or cut the vessels that carry blood to the head before circulation is restored. That distinction is central to the defense of NRP, and it lets surgeons say they are restoring circulation and restarting the heart, not the person. 

But those safeguards haven’t always worked. In a safety notice last November, the Organ Procurement & Transplantation Network (OPTN), the federal system that oversees transplant policy and data, said it had received “verified reports” that blood had unintentionally reached the brain and brainstem during NRP. Such events are extremely rare, the notice said, but can occur when a clamp fails or blood reaches the head through an unrecognized route. The notice asked transplant programs using either form of NRP to strengthen their safeguards and report any failures. But those recommendations were not national requirements and as of May 2026, the OPTN was still developing formal standards for NRP. For Claire Morgan, a transplant surgeon from North Carolina who has criticized NRP’s rollout, that is a central weakness. “It’s a bulletin. It’s not a policy,” she said. “There’s no punishment for not reporting.”

But even if blood never reaches the brain, NRP can still introduce deeper ambiguity into our understanding of circulatory death. In the first few minutes after a heart stops, it can often be brought back, an event that happens every day in a busy emergency department. In conventional DCD, however, doctors don’t try to restart the heart, because a patient or family has already decided against being revived. It is that decision, not just the stopped heart itself, that turns the moment into a death. The same goes for anyone who dies under a do-not-resuscitate order.

NRP puts pressure on that logic. The circulation declared permanently gone is deliberately brought back. “There’s a misalignment between NRP practices and the legal standard for how death is defined,” said Glazier. You cannot, critics argue, pronounce someone dead because the circulation will never return — and then return it.

Robert Truog, professor of Medical Ethics, Anaesthesia, & Pediatrics at Harvard Medical School, supports NRP but thinks the possibility of blood returning to the brain is the issue that matters most. “The only questions are, is there a risk of pain or suffering in the procurement of the organs?” he said. And there’s a possibility of that if the circulation is restarted in the brain.

None of this is settled, which is why some hospitals refuse to perform NRP at all. Moazami pioneered the NRP heart technique in the US and practices it at NYU Langone. “But you cannot do it at Columbia,” he said, “just five miles away.” Glazier’s OPO, one of the country’s largest, said her organization has done roughly 650 NRP cases since adopting the practice — but only the abdominal kind, holding off on the heart version until the national protocols are better standardized.

Claire Morgan, a transplant surgeon from North Carolina who has criticized the rollout of NRP, is more worried about what happens if something goes wrong. The donor cannot complain, families may never know if there was a concern, and clinicians who speak up may have limited protection if they challenge what happened in the operating room. 

All of that matters, because NRP is already far from marginal. The Organ Procurement & Transplantation Network (OPTN), the federal system that oversees transplant policy and data, only began collecting data on whether NRP was used in a DCD recovery in October 2025. In the first five months of that reporting, from October 1, 2025, through February 28, 2026, 3,463 DCD donors were recovered nationally, according to data shared by the OPTN with Vox. More than half of those involved NRP; though, OPTN doesn’t collect data on which kind.

Vox’s analysis also found that NRP cases were concentrated among some organ procurement organizations. The top 10 OPOs accounted for 47 percent of all DCD recoveries that used NRP.

The patchwork

The core safeguard in DCD — that the decision to withdraw life support must come before questions about donation — is widely accepted. But many of the details around that sequence that shape a family’s experience, or a patient’s protection, are still handled differently from hospital to hospital, OPO to OPO.

“The entire process of DCD or donor withdrawal is not very standardized across the United States or even within states, even within different hospitals in the same city,” Moazami said.

That can mean differences in what families are told about the donation process, what medications are considered appropriate before death, whether NRP is allowed and how it is performed, and who has the clear authority to pause or stop the process if someone believes something is wrong.

That unevenness matters more now, because the transplant system has been trying, with good reason, to recover more organs. For years, many in the field, and those who depended on it, argued that the organ procurement organizations were leaving transplantable organs on the table. Greg Segal, whose advocacy group Organize helped push for stronger OPO accountability, compared the old system to a canvassing campaign where you only knock on the easiest doors. “The problem with OPOs is they were only doing the much easier ones,” he said.

A 2020 rule from the Centers for Medicare & Medicaid Services, the federal agency that oversees OPOs, was meant to change that. It ranked OPOs against one another and created a path to penalize low performers by stripping them of their territories. That policy appears to have had some impact, but it is hard to separate from other forces driving DCD’s rise including new preservation technology, like NRP and broader clinical adoption. Jeffrey Trageser and Charles Strom from the Association of Organ Procurement Organizations, the trade group that represents OPOs, argued that the metrics are too broad, evaluating OPOs partly on whether transplant centers ultimately accept organs and not fully accounting for regional differences such as age of potential donors, local rates of cancer, or how far organs must travel to reach transplant centers.

This pressure to recover more organs has also made some OPOs seem more aggressive to the clinicians working besides them. “Some people view them as vultures, which is horrible,” said Smith, the UCSF neurologist who has experienced the tension from the hospital side. “They’re trying to do their job.” Still, he added, “when you impose that [pressure], then it changes how aggressive they are.”

Both things can be true. The old system needed pressure to perform better. And pressure can create risks, or perceived risks, in a process that depends on careful judgement around a dying patient.

And the safety question isn’t a theoretical concern either. A March 2025 investigation from the Health Resources and Services Administration (HRSA), the federal agency that oversees the national transplant system, documented what can happen when those safeguards fail. In a review of attempted DCD cases at Kentucky Organ Donor Affiliates, an OPO that covered Kentucky and parts of Ohio and West Virginia, HRSA found recurring problems about staff missing vital signs in patients that raised concerns, failed to work collaboratively with hospital medical teams, failed to respect family decision-making, and documented medical data poorly. HRSA said the pattern suggested “organizational dysfunction” and a weak safety culture.

One OPO’s failure does not prove that DCD is broadly unsafe or that OPOs across the country behave the same way. But the Kentucky review showed how badly things can go when the line between patient care and organ recovery is not honored.

Since then, federal officials have been trying to close some of the gaps. HRSA has pushed for clearer family education around DCD and more standardized reporting on ventilated patients referred to OPOs, as well as opened up a reporting channel that sends misconduct concerns directly to HRSA. In a separate case, the Department of Health and Human Services also moved to shut down an OPO in South Florida after finding unsafe practices, underperformance, and paperwork errors.

Organ donation is a touchy subject, because it relies so much on the goodwill and the trust of the people who agree to give their organs so they can live on in others. But the procedural issues also matter, because there are lives at stake on both sides of the process. 

Around 13 people die each day in the US waiting for organs. In that desperate landscape, the rise in DCD has led to many lives saved and helped several more live better, fuller lives. The dearth of organs even compelled my former Future Perfect colleague Dylan Matthews to sign up as a living donor and donate his kidney to a complete stranger. (You can read his story here).

And the value of the donation is not just measured in recipients saved. For the Hoffmans, the knowledge that Emily’s organs helped others offered a solace they had not expected. Emily “gave the gift of life in her death,” Beth told me.

That is the highest ideal organ donation — and DCD – can achieve: a death already coming that still changes the lives of others in need. The case for DCD is clear, but its future depends on its proponents’ ability to protect both patients and public trust.

Clarification, July 1, 6 pm ET: A previous version of this post described how the NRP process intends to stop blood from reaching the brain, but did not acknowledge cases where that does not go according to plan. The post has been updated to include a safety notice from the Organ Procurement & Transplantation Network, which said it had received “verified reports” that blood had unintentionally reached the brain and brainstem during NRP. The post has also been updated to clarify that Dorry Segev and Nader Moazami are doctors at NYU Langone. 

In 2019, the AI researcher Rich Sutton published a short essay called “The Bitter Lesson.” Seventy years of AI research, he argued, kept demonstrating the same thing: The most effective ways to train AI rely on raw, brute-force computing power — simply scaling up — rather than clever approaches built on human insight. It didn’t matter how elegant the researchers’ work was. More compute would win every time. It’s a bitter lesson because, well, no one wants to accept that even the best efforts can go unrewarded.

This summer, climate change has been teaching its own kind of bitter lesson. Last week smoke from out-of-control Canadian wildfires reached more than 120 million Americans, sending out air quality alerts across 18-plus states from Minnesota to Virginia. Those wildfires, which were made more likely by the effects of climate change, followed record-breaking heat waves in Europe that contributed to the deaths of thousands of people.

Disasters like these inevitably renew calls for climate action, but no current US emissions policy, no amount of carbon cutting now, could clear the air, just as nothing Europe has done on climate — and it has done more than any other region, at no small cost — could protect it from those killer temperatures. Not this summer, not this decade, not the one after. The steps countries take now to reduce carbon emissions, to mitigate climate change, will not protect them from the present-day effects of climate change.

That’s the bitter lesson of climate change, and 2026 is the summer it has become unignorable. The dangerous effects we’ve been warned about are here, locked in on every timescale that matters to the people living through them. We can’t prevent the worst from happening right now, so we need to figure out how we’re going to adapt to it. 

The smoke we can’t stop

Canadian wildfire smoke is as close to an unstoppable disaster as exists today. The fires are Canada’s, the ignition is mostly lightning, the fuel is a subcontinent of boreal forest no fire agency can manage, and the whole system sits outside US jurisdiction. While strategies like prescribed burning and forest thinning can help reduce the wildfires that crop up in the western US, the sheer scale of Canadian forests makes such management far more difficult, maybe impossible. There is no timescale on which American mitigation clears American air of Canadian wildfire smoke. 

What this means is that for this wildfire smoke, at this moment, adaptation may be all there is.

American law has already conceded the point. Under the Clean Air Act’s Exceptional Events Rule, a state can petition the Environmental Protection Agency to strike wildfire-smoke days from the record used to judge whether its air is legally clean. In other words, the official response to one of the country’s fastest-growing air-quality threats is to delete it from the ledger. 

It’s true that climate attribution science ties heat waves to warming with the highest confidence of any extreme, while wildfire is messier — a compound event filtered through ignition, fuel, and fire weather. But fire seasons are lengthening, fuels are drying, and the most extreme wildfire events on Earth more than doubled between 2003 and 2023. The pattern is intensifying fire in particular regions — the boreal north among them — and the smoke goes where the wind says.

And that smoke is worse than it looks. Wildfire PM2.5 — the microscopic particles that are particularly dangerous —  is roughly three to four times more toxic to the lungs, per unit of mass, than ordinary urban particulate matter. During major smoke events, pediatric asthma visits can spike by more than 30 percent, and Harvard researchers have found the cardiorespiratory damage persists for months after the sky turns blue again. That’s especially dangerous for vulnerable populations like babies and pregnant women.

We can’t affect the winds, we struggle to stop the fires, and any current attempt to reduce warming enough to make those infernos less likely won’t be felt for years. But that doesn’t mean we’re helpless to protect ourselves from wildfire smoke, any more than we are from extreme heat.

We can purify indoor air, and it costs less than you probably think. Strap four furnace filters to a box fan — creating a Corsi-Rosenthal box — and indoor PM2.5 drops by roughly half; in testing during actual wildfire smoke, a DIY unit cut fine particles by about 56 percent in a large room and close to 99 percent in a small sealed one.

For heat, the toolkit is even better known — and one of the best proofs it works is in, of all places, France. The historic 2003 heat wave killed some 15,000 people there, most of them elderly and alone. The national heat plan built in its aftermath — tiered alerts, registries of vulnerable residents, check-in calls, cool rooms — cut the death toll of comparable heat waves by roughly 90 percent: When France hit its all-time record of 114.8°F in 2019, fewer than 1,500 died, per the Christian Science Monitor. A recent European analysis estimates a rerun of 2003 would now kill 77 percent fewer people in France than in a world that never adapted.

So technologies exist to protect ourselves. What’s too often missing are the standards, money, and the drive to deploy protection before the disaster arrives instead of after.

Catching up to today

When it comes to wildfire smoke, some governments are ahead of the game — and some aren’t. Washington state, Oregon, and California now regulate outdoor workers’ smoke exposure by air-quality index, under rules like Cal/OSHA’s wildfire-smoke standard; California funds “clean air centers” with upgraded filtration where people can shelter on bad-air days; Colorado’s Clean Air for Schools program ships free HEPA units to K-12 classrooms. A purifier humming in a classroom is essentially doing for smoke what a cooling center does for heat.

When it comes to heat, some parts of Europe are catching up. Barcelona now runs a network of nearly 400 “climate shelters” — libraries, museums, retrofitted schoolyards — with the goal of putting one within a 10-minute walk of every resident. For the first time, the city is keeping libraries open through August to do it, which, as anyone who has visited Europe in the late summer knows, is no small thing.

So adaptation exists, and it is saving lives. But this summer has also shown what happens when cities, states, and countries aren’t ready. 

In the US, the Midwestern and Northeastern states that spent last week under smoke alerts have almost none of the protections against wildfire smoke that have become more common in Western states, and no one is required to build them, because the country has no enforceable national indoor air-quality standard at all. In Europe, national heat plans are still reluctant to reach for the most powerful tool on the shelf. About one European household in five has air conditioning, compared to nearly nine in ten in the US, in large part because much of the continent still treats the machine as a moral defect. 

In both cases, rich regions that have largely taken climate mitigation more seriously than some of their neighbors aren’t pursuing adaptations they need. Which really means not taking climate change as seriously as they should. 

Accepting the bitter lesson

For a generation, adaptation was the word climate advocates were often reluctant to say out loud. In his 1992 book Earth in the Balance, Al Gore called adaptation “a kind of laziness, an arrogant faith in our ability to react in time to save our skins.” (He later changed his mind.) And in fairness, “we’ll just adapt” has often been a delaying tactic, an easy out for polluters. 

But the ground has shifted under that caution, because the projections did exactly what projections are supposed to do: they came true. 

Longer fire seasons, deadlier heat waves, smoke reaching places that never used to see it — this summer is the confirmation. And that changes what seriousness requires. If you’ve spent decades warning people that the effects of climate change are coming, you can’t treat readying for those effects as a distraction from the real work. None of this argues for easing up on emissions — each ton that isn’t emitted is adaptation nobody has to build. But preparing for what you predicted is what believing your own prediction looks like.

For AI researchers, Rich Sutton’s lesson was bitter for a specific reason. Those who resisted its conclusion weren’t foolish; they resisted it because it seemed to undercut all their hard work. They resisted it because it didn’t seem fair, just as it’s not fair that countries and states that have in many ways done much to mitigate climate change find themselves just as vulnerable, if not more so, than peers that have done comparatively little. 

But here’s the other half of Sutton’s lesson: The researchers who accepted it won. They stopped defending their cleverness and built what worked. That option is open to climate politics too. The atmosphere isn’t fair, but it is consistent, and it will deliver next summer’s version of this one on schedule. We can be ready. The bitter lesson is only bitter until you have the will to act on it. 

A version of this story originally appeared in the Future Perfect newsletter. Sign up here!

In January 2025, Linda-Gail Bekker stood inside a vaccine manufacturing plant and allowed herself to believe that the first HIV vaccine candidate conceived through African science and led by Africans might finally become a reality.

The vaccine would be built on mRNA technology, the same platform that had helped tame the Covid-19 pandemic. Bekker hoped it might finally crack the puzzle that had frustrated HIV researchers for more than four decades.

No virus has proved more evasive. Hundreds of HIV vaccines have entered testing; none has succeeded at providing durable protection against infection. And the need remains vast: In 2025, roughly 1.2 million new HIV infections were reported; anti-retroviral treatments have turned it into more of a survivable disease, but more than half a million people died from AIDS-related causes the same year. There is still no known cure.

So researchers like Bekker, an infectious disease specialist at the University of Cape Town, have more hope now, in part because there is finally a clearer idea of what an effective vaccine needs to do. It must coax the immune system into producing a particular type of protective antibody, a rare class of defender, capable of recognizing and disabling HIV despite the virus’s extraordinary diversity and rapid ability to mutate.

No one yet knows how to reliably do that. But mRNA is uniquely suited to the task of finding out, vaccinologists say. Thanks to the platform’s speed and flexibility, researchers can iterate rapidly through the otherwise laborious process of designing, testing, and refining the series of vaccine components needed to guide the body toward making those essential antibodies.

At the start of last year, Bekker and her colleagues were ready to put that strategy to the test. The clinical trial for their new mRNA-based HIV vaccine was just on the verge of enrolling its first participants. But the project depended on the same backing that had sustained HIV vaccine research for decades: US government funding. Washington had long supplied roughly 90 percent of the world’s investment in the field. Then President Donald Trump returned to office.

Within hours of his inauguration, Trump signed an executive order freezing foreign aid. The $45 million contract from the US Agency for International Development (USAID) that was supposed to fund clinical trials like Bekker’s disappeared, as did a web of other funds, many routed through the National Institutes of Health (NIH), that had helped fuel the field’s progress for years.

The timing could hardly be more cruel. After 40-odd years of chasing a shape-shifting foe, scientists believe they now know what kind of immune response an HIV vaccine must generate — and have in mRNA a powerful new tool for pursuing it. But just as many researchers have finally glimpsed a path to victory, the United States and much of the funding has pulled away from the fight. 

Pushing the envelope

From the outset, the target for preventing HIV was clear. Within a year of identifying the virus as the cause of AIDS in 1983, researchers had zeroed in on its envelope protein as the most promising point of attack for a vaccine.

Protruding from the virus’s surface in knobby clusters, the envelope protein acts like a molecular grappling hook, latching onto immune cells before pulling the virus itself inside. Without this feature, HIV cannot infect a cell.

Much as the coronavirus spike protein would later become the basis for Covid vaccines, this protein on the surface of HIV seemed an obvious bullseye. But identifying the target didn’t mean researchers could hit it. Most of what the immune system sees of the envelope protein is actually just a decoy. The parts that stick out and draw the strongest immune response are also its most changeable, differing from one strain to the next and mutating freely whenever antibodies close in, leaving the body to waste its firepower on a target that keeps slipping away.

Candidate vaccines kept making the same mistake. They would elicit plenty of antibodies, but not the kind that could keep up with the virus. Time and again, promising candidate vaccines generated excitement in the laboratory, only to come up empty when it mattered most in large-scale clinical testing.

The field’s fortunes started to change in the late 2000s when researchers began studying the small fraction of people living with HIV who developed antibodies capable of recognizing the virus’s concealed, conserved features. Though these hard-won antibodies came too late to protect their makers, they gave scientists a molecular blueprint for the defenses a vaccine would need to build.

As the field came to learn, these “broadly neutralizing antibodies” do not appear overnight but rather after years of battle with the virus. 

The challenge, then, was to design a vaccine that would not just trigger an immune response but guide a person’s immune system through the same evolutionary journey. This would require a succession of vaccine components to prompt a carefully choreographed process within the body, rather than the single, fixed target that suffices for shots against measles or hepatitis B.

It was a strategy rooted in rational design but dependent on trial and error. Progress would come through a steady stream of small proof-of-concept studies, each informing the next generation of vaccine candidates. Ordinarily, it would take at least a year — often longer — to manufacture and prepare each vaccine iteration before it could be tested in people. 

But then the Covid pandemic rocketed mRNA into the spotlight.

The mRNA advantage

mRNA technology upends the old recipe of vaccine development. Conventional shots work by showing the immune system a mugshot of the enemy: a killed or weakened germ, or one of its proteins, grown batch by batch in vats of cells or eggs. An mRNA vaccine takes a different route. Rather than supplying the mugshot, it supplies the instructions to draw one: a short, lab-printed strip of messenger RNA, the molecule cells normally use to ferry genetic directions from DNA to their protein-making machinery.

Inject the right sequence, and it will program the body’s own cells to become tiny factories, producing the target protein and presenting it to the immune system as if it were the real intruder. Because it is all just code, refining a design means editing text, not rebuilding a factory — the work of days, not months.

“We’ve been able to design vaccines in real time,” said University of Pennsylvania Perelman School of Medicine assistant professor Ted Kreider, who is a specialist in infectious diseases.

To HIV researchers, the appeal was obvious. HIV’s greatest weapon was its ability to shift and adapt. Now, at last, a vaccine could, too. 

The timing was ideal. Just as researchers were beginning to map the path to an effective vaccine, mRNA offered a way to move down that path at speed. With vaccine designs no longer bottlenecked by design and manufacturing, what once might have taken decades of stepwise vaccine development could, thanks to mRNA, be compressed into years.

Across a growing number of clinical trials, researchers are now testing different vaccine components, different sequences, and different delivery platforms, searching for the combination that most effectively nudges the immune system toward a truly HIV-thwarting response.

A paper published last month in Nature offered one such path forward, showing in monkeys that a painstaking sequence of eight shots could coax the immune system into producing potent antibodies capable of neutralizing a broad range of HIV strains. But even the study’s authors see a catch. “It’s still too many [shots] to be practical in humans,” said Dennis Burton, a professor of immunology and microbiology at Scripps Research who worked on the project.

Whether mRNA ultimately becomes the vaccine itself — or simply the tool that helps researchers discover it — remains an open question.

The fundamental challenge for now, after all, is vaccine design, notes Mark Feinberg, president and CEO of IAVI, a nonprofit research organization focused on developing vaccines against HIV. And for that task, he says, “the most obvious advantage of mRNA is simply the speed of getting an idea from the laboratory to the clinic.”

But if the technology reaches the finish line, researchers say it could offer other advantages as well. Because the protein is made inside the body’s own cells rather than in a lab, it folds and displays itself much as it would on the real virus, giving the immune system a more faithful target to train against. That way, when the real virus arrives, the body already knows its true face.

It also gives vaccine designers an unusual number of knobs to turn, notes Kristie Bloom, an mRNA vaccine researcher and molecular biologist at the University of Witwatersrand in South Africa. By altering the vaccine’s formulation, dose, or genetic design, researchers can shape not just the magnitude of the immune response but also its balance: favoring antibody-producing B cells, virus-killing T cells, or some mix of the two.

With mRNA, “there’s quite a bit of flexibility,” she said.

Not so fast

For all the putative upsides, however, mRNA does carry some baggage. There are concerns about public acceptance given the intense backlash and misinformation campaigns that followed the rollout of Covid-19 vaccines. And though those shots ultimately proved remarkably safe, with very low rates of serious side effects, a peculiar skin problem has emerged in early-stage trials of mRNA vaccine candidates for HIV specifically. 

In two separate trials reported last year, around one in 12 participants who received mRNA-based HIV vaccines manufactured by Moderna developed chronic urticaria, a form of persistent hives that in some cases endured for years. The vaccines encoded different portions of HIV’s envelope protein, yet both produced the same unexpected side effect.

The fact that the reactions appeared across distinct vaccine designs — but never before in Moderna’s other mRNA vaccine programs — has fueled suspicion that something about HIV’s envelope protein itself may be involved. Even so, no clear explanation has emerged. 

“We’ve ruled a bunch of things out,” said William Schief, a professor at Scripps Research’s department of immunology and microbiology who doubles as vice president for protein design at Moderna, “but there’s no smoking gun.”

Schief is continuing to investigate the source of the immune reactions. But not wanting an unresolved safety signal to bring the program to a halt, he and his collaborators have pressed ahead with lower-dose versions of the vaccine, betting that the hives will fade while the desired immune response remains intact. 

That strategy is now being evaluated in an IAVI-backed trial led by Bekker in South Africa. Known as IAVI G004, it has yielded encouraging early results. (Unlike the African-developed vaccine whose launch was derailed by the USAID funding freeze, this study is testing a different mRNA vaccine candidate, manufactured by Moderna.)

At the lowest dose tested, just one-tenth of the amount used in the original studies, the hives that had troubled earlier trials never materialized, Bekker said. Her team has since moved on to a somewhat higher dose, seeking the sweet spot between safety and immune potency. 

All of these discoveries and challenges along the way have helped map a path forward. “We know what we need to do,” said Barton Haynes, director of the Human Vaccine Institute at the Duke University School of Medicine. The task for them now is to move through the necessary iterations as quickly as the science — and the funding and political landscape — allow.

“A black hole”

When Bekker and her team learned about the sudden funding cut that would halt their African-designed, USAID-funded vaccine study in January 2025, they were already in Tanzania to prepare its launch. They immediately had to stop work on the project, which had been years in the making. “It was like falling into a black hole of depression,” she said. 

And the setbacks kept coming. With prominent vaccine critic Robert F. Kennedy Jr. overseeing US health policy, the federal government moved to undermine both vaccine science broadly and mRNA technology in particular.

The NIH, in addition to terminating dozens of smaller HIV-related grants, began winding down its flagship Consortia for HIV/AIDS Vaccine Development (CHAVD) program, which has long served as a cornerstone of global HIV vaccine research, while other federal agencies curtailed support for mRNA vaccine projects across multiple disease areas.

At the same time, South Africa, the continent’s leading center for biomedical research, found itself in the Trump administration’s crosshairs over allegations of anti-white discrimination. New federal research grants were no longer permitted to support collaborations with South African scientists, severing ties that had underpinned years of international HIV research.

“That’s a perfect storm to prevent us from building on the most exciting science HIV vaccines have had in 45 years,” said Mitchell Warren, executive director of AVAC, a nonprofit dedicated to HIV prevention access and policy. 

Yet for all the financial and political disruption, the scientific momentum hasn’t stopped. Philanthropic organizations and governments elsewhere have stepped up to help fill the funding gap, allowing key trials to move forward, although in scaled-down forms with more modest ambitions. 

The Africa-led effort that Bekker had dreamed of was salvaged, with emergency backing from the South African Medical Research Council, albeit in diminished form and built, in the end, on the same protein-based technology that mRNA was meant to leapfrog.

The only mRNA-based HIV vaccine study that is actually underway in Africa is IAVI G004: a program designed by US scientists, not by locals, and funded largely by the Gates Foundation.

A longtime backer of HIV research, that foundation is estimated to invest around $70 million annually — with $64 million being invested in 2022, and $70 million in 2026 — across a global portfolio of HIV vaccine programs. That’s a substantial sum, though only a fraction of the hundreds of millions of dollars once provided by the NIH, USAID, and other federal agencies. 

For now, some of that funding continues to flow. But even what remains is far from assured. The Trump administration’s proposed 2026 budget would slash the National Institute of Allergy and Infectious Diseases — the NIH institute that has long anchored HIV vaccine science — along with the Office of AIDS Research that coordinates HIV research across the entire NIH, leaving the field’s longer-term future in doubt.

“We’re not going to be able to fill the gap that’s been left by the US government,” said Nina Russell, director of TB & HIV research and development at the Gates Foundation. Still, she says, the foundation remains determined to keep the most promising vaccine programs moving forward: “We are super committed to it.”

All of these changes have left the research field daunted, but not hopeless. “It’s been a very disruptive time,” said Burton, who leads one of the CHAVD research hubs. But he remains convinced the field is on the right track. “The pieces of the puzzle are in place,” he said. “It’s obviously been a long, long journey, but you can begin to see the end.”

A higher bar

The funding crisis and political challenges are not the only forces reshaping HIV vaccine development.

For much of the HIV epidemic, which has killed over 40 million people worldwide, even a partially effective vaccine might have been enough to transform the course of HIV. Today, however, vaccine researchers are also competing against long-acting preventive drugs that can protect people for months at a time with just two injections. 

These drugs are an enormous step forward for HIV protection, but they also raise the standard the vaccine field must meet, Warren said. “The bar for a licensed vaccine that is going to have a public health impact has gotten much higher,” he said.

But these prophylactic drugs, which began as daily pills and have evolved into long-acting injectables, are only as good as the systems that deliver them. Cost, stigma, and the need for regular clinic visits have limited access in many countries with the highest HIV burdens. A vaccine, by contrast, that provided years of protection after a handful of doses could overcome many of those barriers.

That is precisely why many scientists view the current retreat of the US government with such alarm. After decades of disappointments and billions of dollars in investment, the field finally believes it has a coherent strategy for building an effective HIV vaccine. The fear is that momentum could stall just as researchers have begun to see a path across the finish line. As a result, what once seemed like a scientific problem increasingly looks like a political one.

For Bekker, the current moment feels all too familiar. In the early 2000s, South Africa’s government embraced AIDS denialism, delaying the rollout of lifesaving treatments and forcing researchers and clinicians to battle both the virus and the state. A quarter-century later, she says, the political opponent has merely changed address to Washington, DC, threatening once again to undermine the fight against HIV and cost countless lives.

“When politics interferes in science,” Bekker said, “that is the death of scientific progress.”

Bekker still does not know whether the vaccine she watched being manufactured last year will ever reach the people it was designed to protect. She and her colleagues still hope to carry out the made-in-Africa mRNA vaccine trial they spent years designing — if they can find a way to pay for it. But Bekker remains convinced that the scientific strategy behind it is the right one, and that mRNA may yet do for HIV what it did for Covid-19, rapidly transforming decades of scientific groundwork into an effective shot.

She only hopes politics does not succeed where HIV itself has failed in slowing the field’s progress. “We should only be fighting the virus,” Bekker said. “But we’re fighting the administration and its policies, and that is a waste of our energy.”

If the US wanted to be the world’s police officer, then why not try to be its doctor too? 

Just two months before the invasion of Iraq in 2003, George W. Bush announced an ambitious plan to pump $15 billion into the global fight against HIV, stunning his allies in Congress, health advocates, and heads of state of the program’s intended beneficiaries. 

The President’s Emergency Plan for AIDS Relief, or PEPFAR, was the largest commitment by any nation in history dedicated to addressing a single disease, a disease that killed about 3 million people in 2003, most of them living in sub-Saharan Africa, and infected 5 million more. “Ladies and gentlemen,” Bush proclaimed in his State of the Union address that year, “seldom has history offered a greater opportunity to do so much for so many.”

On that, he was right. In the two decades to follow, PEPFAR would save an astounding 25 million people’s lives through lifesaving HIV therapies, and prevent millions of babies from being born with HIV in the first place, all at a cost of about 0.08 percent of the federal budget. 

And yet, in the wake of the Trump administration’s foreign aid cuts, one of the greatest achievements in American history is now at risk. PEPFAR, mercifully, still exists, saved from the sledgehammer by an outpouring of bipartisan support last February. But experts say the program has been transformed beyond recognition by countless small cuts, and the abrupt gutting of global health architecture, reshaped not by decades of accumulated wisdom around HIV prevention, but by at times absurdly petty ideology.

Over the past year, more than 77 percent of PEPFAR grantees have lost funding or had their payments delayed, according to a survey released Tuesday by the HIV research group amfAR. 

Nearly two-thirds of grantees — especially those supporting vulnerable populations such as LGBTQ people, young women, and sex workers — said the cuts had disrupted their ability to offer HIV treatments and other services. The Trump administration released limited data showing a deep reduction in HIV prevention services, but a relative consistency in access to treatment earlier this year. However, this new survey paints one of the first pictures available of how PEPFAR cuts are actually being felt on the ground, and how the administration’s priorities are reshaping who and what gets funded.

According to the survey’s authors, at least 1,700 HIV-related sites or clinics have shut down as a result of cuts. Well over 16,000 health workers — including those going door to door to make sure pregnant parents get tested for HIV or children get on treatment — have lost their jobs. 

Many organizations surveyed reported receiving emails when their PEPFAR grants were terminated, noting that their work violated President Donald Trump’s executive order against “unlawful diversity, equity, and inclusion.” It appears, they say, that many of these groups were flagged not because they embraced the distinctly American concept of DEI in their work, but because their name or mission description included a phrase like “gender” or “LGBTQ.”  

A health clinic serving survivors of domestic violence in Mozambique, for example, might now be flagged just for using the phrase “gender-based violence” in their name. This may be part of the reason why even pregnant women — who even the Trump administration has emphasized as a critical demographic in its HIV goals — have lost access to services. 

Back in 2003, Bush defied conservative critics in his own party who attempted to redirect PEPFAR funding to abstinence-only programs. For decades, American presidents have been able to see past their ideology in service of saving lives. They largely understood that contraceptives like condoms and special interventions for those most at risk, including LGBTQ people, were necessary for stopping the spread of HIV. Under the Trump administration, this norm is unraveling. 

“This administration has zero interest in addressing clinical outcomes for vulnerable people with HIV,” said Asia Russell, executive director of the advocacy group Health GAP, who noted that “to be effective, HIV prevention and treatment services actually have to go where the disease is, and that risk is not evenly distributed,” surging in certain geographies like South Africa or within key populations like trans people or young women. Getting support to these groups is “morally right,” she said, but it is also “the only way to do effective HIV work, regardless of your stance on the morals or the merits.”

The fight against HIV is running on fumes

When HIV aid does get doled out these days, it is distributed with far less transparency than in the past, and in ways that often appear to be ideologically or politically driven, both in terms of the populations they serve and the countries they operate in, rather than guided by best practices. 

In theory, lifesaving HIV care was exempted from sweeping aid cuts last year. But in reality, access to even the most basic HIV services and treatments has also atrophied across the board, while falling disproportionately on at-risk populations. 

That’s come both in the form of direct cuts and as a byproduct of broader disruptions to the kind of outreach services, testing, and socioeconomic programs that get patients in the door to begin with. 

“You can’t cut pieces of the architecture of how PEPFAR functions and expect to maintain a really robust treatment program in the long term,” said Jennifer Sherwood, director of research and public policy at amfAR. “If you cut the testing program, the prevention programs, the kind of services that allow people to stay in care and return to care, you’re going to see that you can’t maintain a treatment program.”

The number of people getting on treatment for the first time has sharply declined over the past year, even according to the administration’s own limited data drop, while access to testing, contraceptives, and other preventative services — all critical to keeping infections down in the long run — face cuts that threaten their ability to function at all. 

To make matters worse, amfAR’s survey shows that services designed for the populations most at risk of HIV — such as sex workers, LGBTQ people, young women, and teenage girls — have been disproportionately affected by PEPFAR cuts. Among those who lost funding, a staggering 90 percent of organizations that serve gay and bisexual men were forced to slash access to PrEP — which strongly protects against HIV infection — and many stopped offering it entirely. The same was true for over half of organizations serving pregnant women, whose children now face a higher risk of contracting HIV in the womb.  

The majority of new HIV infections are concentrated in these “key populations,” as they’re known in public health parlance, many of whom face stigma or other obstacles to obtaining care. “One really powerful aspect” of how PEPFAR used to work, said Thomas McHale, public health director at Physicians for Human Rights, was that it consistently “followed the science and followed the epidemiology” to serve “groups that are at the margins of society.” That approach appears to have been thrown out under the new administration, and in at least some cases, actively discouraged.

McHale has been documenting the impact of PEPFAR cuts in South Africa in recent months, and “what we saw was a system under severe stress and strain,” he said. It is one in which a bisexual man stopped taking his HIV medications for weeks because the LGBTQ clinic he used to go to closed. “He just couldn’t bear the stigma of accessing services in a place that’s not meant for him,” according to McHale. Similarly, a young woman was forced to wait in line for 10 hours just to refill her PrEP prescription. 

“If we’re not focusing on preventing disease,” McHale said, “it’s just a more expensive and more devastating challenge to address in the future.”

Some countries may soon stop receiving PEPFAR funding altogether

As I’ve written previously, the Trump administration has attempted to remake foreign aid into a dealmaking enterprise, one in which money flows directly through national governments rather than through large, western-led non-governmental organizations or NGOs. 

In theory, there are benefits to this approach, because it prioritizes the expertise of local health groups and policymakers who are often best equipped to evaluate and address the needs of those in their care. In practice, however, amfAR’s survey shows that so far, under the Trump administration, local organizations have actually lost more funding and been forced to close more sites than international groups have. “These cuts fell heavily on locally-based organizations” while NGOs have fared somewhat better, said Sherwood, “and that really runs counter to all of our global health goals.”  

“I’m concerned because public health is no longer how we’re measuring success” when it comes to reaching PEPFAR’s goals, said Jirair Ratevosian, a senior fellow at the Duke Global Health Institute who served as chief of staff of PEPFAR under the Biden administration. He is especially alarmed by the decision last month to end PEPFAR support for South Africa, which has the largest HIV epidemic in the world. The administration appears to have done so in part because of Trump’s insistence that the nation is waging a nonexistent “genocide” against white Afrikaners. 

“If we’re not focused on preventing disease, it’s just a more expensive and more devastating challenge to address in the future.”

Thomas McHale, Physicians for Human Rights

“HIV control is not their chief concern,” said Ratevosian, who recently ran the numbers on a separate fissure with Zimbabwe, finding that cutting PEPFAR would lead to 75,000 new HIV infections in just one year. In South Africa, similar cuts could lead to over 2 million more infections over the next two decades, a toll that would invariably cross borders, and could threaten the world’s immense, hard-won progress against HIV. “You can’t have a global HIV strategy,” said Ratevosian, “if you’re not engaging these countries.”

Priorities shift under any new administration, and it’s not abnormal for an organization to tweak its language or services to adapt. But PEPFAR, the bipartisan program which began under Republican leadership, and thrived and expanded under three successive presidencies, including during Trump’s first term, has never faced such turmoil. 

“Even among organizations who didn’t lose US funding, we’re still picking up changes to the way they work, the populations they serve, the words they use,” said Sherwood of amfAR. Her group’s survey showed that nearly 80 percent of organizations that did not lose funding still altered the way their organization worked to comply with new policies. “This network of changes from the US,” she said, “are prompting a lot of changes on the ground.”

Gut health is everywhere right now. The hashtag #GutTok has over 6 billion views on TikTok, the global digestive health product market is worth over $60 billion, and viral trends that promise to “hack your gut” through miracle products, cleanses, and restrictive diets are all the rage. But what does gut health really mean, and what can science tell us about how to make sure our gut is in good shape?

The gut microbiome, a complex network of trillions of microorganisms living inside our digestive system, may hold the key to the mysteries of gut health. We have a symbiotic relationship with all of those little guys; we keep them well-fed and they produce substances that can benefit our body and brain. These microbes help regulate bodily functions, protect against disease, and recover from illnesses like cyclosporiasis, which is spreading right now across the US.

But with so many voices chiming in on gut health, pushing everything from probiotic foods and supplements to wellness shots and coffee enemas, it can be hard to tell what information is based on real research and what might just be a marketing gimmick or social media clickbait. Vox spoke to doctors and visited Cedars-Sinai in Los Angeles to bust some gut health myths for science-backed advice. 

Read more about gut health and gut microbiome research:

• Vox editor Katherine Courage’s book, Cultured: How Ancient Foods Can Feed Our Microbiome.
• Cedars-Sinai’s Human Microbiome Research Institute.
• The MAST program at Cedars-Sinai.
• Trisha Pasricha’s book, You’ve Been Pooping All Wrong. 
• Vox’s explainer video on probiotics in yogurt.
• Pew Research Center’s findings on why people look to influencers for health and wellness information.
• The Myths and Scientific Realities About Gut Microbiota.

This video is presented by Colgate. Colgate doesn’t have a say in our editorial decisions, but they make videos like this one possible.

Fermented food is the hottest new trend in the halls of the White House. Members of President Donald Trump’s Cabinet are reportedly walking about with jars of sauerkraut in the hopes that it will give them glowing skin and tiny waists. 

Wall Street Journal’s Liz Essley Whyte told Today, Explained co-host Sean Rameswaram that “Health Secretary Robert F. Kennedy Jr. Commerce Secretary Howard Lutnik, Transportation Secretary Sean Duffy, and Vice President JD Vance are all on this eat-a-lot-of-steak-and-sauerkraut diet.”

So, should we all be eating jars of sauerkraut? Or are ferments just the new Florsheims?

Below is an excerpt of their conversation, edited for length and clarity. There’s much more in the full podcast, so listen to Today, Explained wherever you get your podcasts, including Apple Podcasts, Pandora, and Spotify.

Is there a name for this diet?

Kennedy calls it the carnivore diet. I think people mean different things when they say that, but for him, it includes a lot of yogurt, a lot of kimchi or sauerkraut, a lot of steak, a lot of eggs. Kennedy now travels with sauerkraut. His wife has said that he has asked her to carry it in her purse for him, and she has said, “I actually cannot,” which is an amazing phrase. It seems they all think their skin is glowing, and people online have commented that JD Vance is looking good.

Are we sure it’s not Wegovy?

We don’t have any public knowledge of that, but we do know that he is eating eggs, sauerkraut, pickles, blackberries, and raspberries for lunch pretty often — and beef and lamb with sauerkraut for dinner. Then, when he’s on Air Force Two, he snacks on beef jerky and maybe eats a hamburger with cheese, no bun, and a side of fermented vegetables.

Now that you’re mentioning the full spectrum of JD Vance’s diet, it’s kind of reminding me of their new food pyramid. Is this part of that?

Earlier this year, Kennedy and the other health officials like to say they flipped the food pyramid. They recommended a lot more fruits and vegetables, red meat — which was controversial — and whole grains, and whole milk, that kind of thing. They also, and for the first time in the nation’s dietary guidelines, recommended fermented foods, which was something that was actually agreed upon by a lot of people, and they thought that was a good part of this, even if they had qualms about the red meat recommendations, because those can introduce more cardiac risk and risk of bad cholesterol.

How widespread is this in the White House? Does it go up all the way to the top, to the president?

Given what we have seen of his recent public dieting, I don’t think so. At the Knicks game, he was eating pizza and french fries, and, you know, he still has his Diet Coke button on his desk where he just pushes it and a Diet Coke comes. Kennedy said, once said on a podcast about him, “I don’t know how he’s alive.” 

Does the science back this up, or is this some kind of quackery that ferments can make your skin healthier and help you lose weight?

I don’t think there are a lot of good studies that show exactly that sauerkraut can help you lose weight, but there have been a number of studies that have shown health benefits. Researchers have generally agreed that sauerkraut and other fermented foods can help with digestion and inflammation. There was a 2025 study from UC Davis that suggested fermented cabbage could protect your gut and protect against illness. Basically, they found that the intestinal cells do better with sauerkraut. They help maintain the integrity of those intestinal cells. And, in general, that has a lot of other good health effects. Mainstream scientists, dieticians, are pro-fermented veggies. This is not something that is hotly debated.

Most people in the scientific community are realizing there’s a lot of good fresh science out there about how important your gut really is in your overall health. The part of the diet that is a little more controversial is the focus on red meat. Obviously, that comes with some cardiac risk and some cholesterol risk. That is why when the new dietary guidelines came out and recommended more of that for Americans, that part, in particular, made some dietitians a little upset.

Do you think fermented foods could help people with this parasite that gives you explosive diarrhea?

I personally have not seen any studies on whether fermented foods help with explosive diarrhea, but let me know if you find one.

Update, July 20, 2026, 2 pm ET: This story, first published July 17, has been updated with the current case numbers and developments in the search for the source of the outbreak.

Have you been looking at the lettuce aisle at your grocery store with a wary eye since the diarrhea outbreak began? You’re not alone. This is the summer, which should be high time for fresh produce. But the ongoing emergency has even doctors asking themselves unthinkable questions: Should I stop eating salad? Are any fruits and vegetables safe?

The disease in question, cyclosporiasis, is caused by the parasite cyclospora, which can infect people when it is attached to fresh produce and then consumed. Watery diarrhea — described by public health authorities as “frequent” and “sometimes explosive” — is the most common symptom.

Michigan health officials said last week that they suspect lettuce or bagged salad to be the culprit for the parasite-driven outbreak in the state that has sickened more than 6,100 people. But identifying the specific products to blame has been a challenge. On Thursday, the Washington Post, citing anonymous federal officials, reported the outbreak may trace back to Taylor Farms products that were used by Taco Bell. But then, on Sunday, the FDA said that the tests showing the Taylor Farms product contained cyclospora had been false positives. As of Monday afternoon, the source of the outbreak is still unclear, although Taylor Farms has continued a voluntary recall of its iceberg lettuce products.

I live in Ohio, where there have been nearly 1,200 cases, and I love salad kits. The current outbreak is a major cramp on my lunch plans — and I know I’m not alone. 

So, what do we do? I’ve consulted with a food safety expert and a dietitian to get the answers. The topline message is: Don’t stop eating your fruits and vegetables. They’re good for you. But be smart with your food hygiene.

“I don’t think we’re at that point of shying away from eating your green vegetables,” Francisco Diez-Gonzalez, director of the Center for Food Safety at the University of Georgia, told me. “The benefits overall still outweigh the risks.”

How can we still enjoy our summer produce in this time of cyclospora? Here’s a guide.

Here are the “red light” foods linked to prior outbreaks

While we don’t know for certain the cause of the current outbreak, cyclosporiasis has been linked with specific foods in the past. Let’s start with that list:

• Basil
• Bagged salads and salad mixes
• Cilantro
• Mesclun lettuce
• Parsley
• Raspberries
• Snow peas
• Sweet peas

These foods — either because of where they’re grown or their texture or both — have historically had a higher risk of carrying cyclospora. It might be wise to steer clear entirely for the time being — especially the prepackaged salad products.

The Michigan health department, for example, is urging people to avoid bagged lettuce and salad kits and to purchase whole heads of lettuce instead. And since the outbreak is impacting most states now, it’s advice we’d all be wise to heed.

Then there are “yellow light” foods that need careful cleaning

But for a lot of fruits and vegetables, including whole lettuce, you should still wash them thoroughly — because that’s always a good idea. If you need tips for washing your produce, we’ve got them. For heads of lettuce, for example, cut away the outer layers and wash in between each leaf as best you can. 

“Fresh produce is still generally safe, delicious and nutrient-dense,” Rosemary Trout, a food scientist at Drexel University, told me over email. 

But she gave a yellow light for any leafy greens or fruits and veggies that have textured edible skins. The more texture there is, the more of a risk there is because the parasite can stay attached more easily — even if it’s been diligently washed. Raspberries carry a higher risk than blueberries, for example, and those have been associated with earlier cyclosporiasis outbreaks.

Another point of emphasis: Several doctors have told me that, even if an item says it is prewashed, you should wash it again. And again.

But there are lots of “green light” foods you probably don’t need to worry about

Trout gave a green light to any canned fruits and vegetables, any produce that you cook — importantly, at high heat — at home, and any frozen fruits and veggies.

In general, these are Trout’s safety tips for prepping fruits and vegetables at this uncertain time:

• Be consistent and thorough — at least 20 seconds — when washing your hands and always use hot, soapy water. 
• Peel or remove the outside layer of the fruit or veggies — the rind of a watermelon or cantaloupe, for example, or the outer layer of a head of lettuce.  
• Don’t consume damaged, bruised produce. 
• Keep produce cold in storage, ideally for a relatively short amount of time. 

Get creative with your recipes

If you want to steer clear of any questionable produce or take the safest preparation route that you can, you might want to get a little creative with your recipes. With your lunch salad, for instance, “peeled, shredded carrots, thinly sliced radish, or thinly sliced cooked beets might be a nice substitute for leafy greens,” Trout said.

Heat remains the most surefire way to eliminate any cyclospora parasite that might be lingering on your produce. So look through your cookbooks for any dishes that feature grilled vegetables. Vox Even Better editor Rachel Miller (a more accomplished cook than I) suggested a few recent New York Times Cooking recipes, which you can check out via these gift links:

• Grilled halloumi and vegetables
• One-pan orzo with spinach and feta
• Orzo salad with peppers and feta

Peppers, eggplant, squash, and zucchini are your friends. They respond well to heat, and they are easy to clean. And even some leafy greens — like spinach — hold up nicely to sautéing. 

Support your local farmer’s market

Right now is also a great time to check out your local farmer’s market for produce. 

Dr. Kathleen Linder, who is the hospital epidemiologist at the Veterans Affairs hospital in Ann Arbor, Michigan, told me that she has been buying locally since the outbreak began. Prior outbreaks have been linked to produce that was grown elsewhere — whether in the US or internationally — and shipped long distances before it arrived on our grocery shelves. Summer is a crucial season for small farms and farmers’ markets; they shouldn’t be penalized for a health emergency that they had nothing to do with.

Buying locally could reduce the risk that your produce has been exposed to the parasite. Trout said you can ask your local growers about their water supply to make sure that what you are buying is safe.

“Single-source produce from a local farm with good manufacturing/farming practices in place, with a safe water supply, are good,” Trout told me. “Commercially processed, pre-packaged foods are likely combining produce from various farms, which may increase risk, despite good manufacturing practices in place.”

So while cyclosporiasis is an unwelcome concern as we plan our summer cookouts, it doesn’t need to stop you from enjoying fresh fruits and vegetables. Be a little more diligent about your food hygiene, get a little creative with what you’re preparing, maybe stop by a farmer’s market — and you’ll be fine.