Every once in a while, I feel the urge to shout “women are not small men!” at inanimate objects. Today, that object is the flat-chested plastic torso typically used for CPR training. 

Breasts, it turns out, are really the bane of every woman’s existence — the back pain, the boob jail, the running. But here’s a new one: In a public cardiac arrest, they may be the reason nobody helps you.

Two years ago, an analysis of over 300,000 cardiac arrests showed that women are 14 percent less likely than men to receive CPR from a stranger if they have a cardiac arrest in public. Bystanders tend to be more hesitant and feel less comfortable providing CPR or using external defibrillator paddles, called AEDs, on people with breasts. Experts have time and again pointed, in part, to the fact that nearly everyone learns to perform CPR using the traditional, flat-chested dummies called “manikins,” which overwhelmingly represent the male anatomy. If the first time a stranger has to perform CPR on someone with breasts is in the middle of a high-stakes emergency — what else would you expect? 

For the last 20 years, not only has the survival rate for out-of-hospital cardiac arrests been around 10 percent, but also the chances of the victim surviving decrease by 10 percent every minute that interventions like CPR are not performed. It makes it all the more harrowing that women are not receiving the care they need when they experience cardiac arrests — especially in places where they are surrounded by people. 

Whether it is manikins used for CPR training, crash tests or medical care in combat, the default stand-in for what is “human” has long been male. 

But recently, researchers, advocates and governing bodies like the American Heart Association and European Resuscitation Council are pushing for better representation in CPR training and education. Increases in simulation-based research on the use of representative manikins, like ones that accurately represent female anatomy, are changing how people train to respond to cardiac arrest — and simultaneously exposing bigger gender gaps in design that systematically exclude women from experiencing the same level of safety and care as men. 

One size doesn’t fit all

The first CPR manikin was developed in 1960 by the Norwegian toy manufacturer Laerdal. The manikin, called Resusci Anne, which had the anatomy of a prepubescent teen, was ironically modeled off an unnamed girl who was thought to have drowned in the river Seine in Paris. Laerdal famously wanted a female face on the manikin since he thought men might hesitate to practice mouth-to-mouth resuscitation on a male manikin. It’s not surprising that women trainees didn’t factor into the equation at all back in the 1960s — they weren’t even included in clinical trials yet — but the norm of designing with the comfort of men at the forefront continues to this day. 

Since then, Resusci Anne has been reengineered many times over, and today’s manikins are surprisingly high-tech and interactive. However, as of 2022, about 95 percent of manikins on the market from mainstream manufacturers were still flat-chested and androgynous. 

So why does this matter?

In the past, research has hinted at three main reasons why bystanders don’t immediately rush to the aid of a woman in cardiac arrest. One, they are hesitant to expose or touch her in any way that could be misconstrued as inappropriate and are worried about sexual assault allegations after the fact. Two, they don’t want to accidentally hurt them, perceiving them as generally more fragile than the average man. And three — perhaps saddest of all: bystanders often don’t recognize that a woman is in cardiac arrest if, say, she collapses in public, misattributing it as overreacting, simply fainting or faking it. 

CPR training with female manikins would go a long way in teaching people to be comfortable with the female form.  

In one study, people at MassCPR — the free CPR certification program offered by Massachusetts Institute of Technology for the MIT community — were trained using standard manikins,  as well as a few which were retrofitted with a mold resembling breasts. At the end of the certification, participants who practiced on the manikin with breasts reported greater comfort performing CPR on women. 

If there was widespread adoption of manikins that looked and felt different, this could ultimately become the norm. 

It’s really only in the past five years or so that research on this disparity has sped up, offering some evidence for the need for more representative manikins. Even then, widespread adoption of female manikins is hindered by commercial availability of anatomically correct models and the cost of switching existing CPR training programs over to using them.   

Closing the design (gender) gap

There are two main ways to go about increasing the availability of female manikins: Either you retrofit existing standard manikins with breasts or you design completely new ones. 

When Christoph Veigl and colleagues at the Medical University of Vienna surveyed 133 training organizations across 43 countries from six continents, they found that of more than 5,000 manikins in use, only a fifth of organizations owned a female one. While that number is still low, adoption is triple what it was four years ago. The researchers acknowledge that just the availability of female manikins is not necessarily an indication of how much they are used in training — about a quarter of the organizations were also employing makeshift adaptations, like placing a bra on standard manikins, to simulate training on women. 

Dr. Pooja Nawathe, a resuscitation science researcher and pediatric critical care clinician at Cedars-Sinai Hospital, chose to focus her research on gender disparity in resuscitation for a specific reason. 

“Skin color is about implicit biases, but female breast tissue, which is a normal physical characteristic, is about the actual science of this,” she said, speaking about variations in care during cardiac arrests. “Are we teaching how to place the pads on the breast tissue?”  

She also stresses the importance of gathering good, granular data on how CPR performance changes when people are exposed to diverse populations.     

CPR manikins are just one example of the gender gap in design: Across fields like crash testing, the “human” body has long been modeled on men.

CPR manikins are just one example of the gender gap in design: Across fields like crash testing, the “human” body has long been modeled on men. But that’s starting to change, too. Last year, the National Highway Traffic Safety Administration (NHTSA) released the design details for THOR-05F, the first detailed female crash-test dummy.

Before this, the standard female crash-test dummy was a model called the Hybrid III 5th percentile female dummy — literally just a scaled-down version of the Hybrid III 50th percentile male dummy that represents the average male body dimensions. But the THOR-05F — every woman’s dream name, I’m sure — is a much more anatomically accurate female dummy, and includes a female pelvis, breasts, and a flexible spine. 

THOR-05F has arrived just as new research by the NHTSA affirmed the need for better crash-testing on women. Although the gap in vehicular accident fatality rates between the sexes has narrowed significantly in newer car models, women continue to experience a higher injury rate compared to men in multiple different types of vehicular accidents. The hope is that testing with the THOR-05F will provide a better understanding of this trend and help engineer safer vehicles and regulations for women.

Women are not small men!

Women are often referred to as the “invisible sex,” and the lack of female manikins really brings that to the forefront. It’s not like the manufacturers or policymakers intentionally excluded women from this area — they simply ignored them, accepting an androgynous body as the standard with an unchallenged assumption that what applies to it will undoubtedly apply to women too. 

In 2019, Joan Creative, the New York-based ad agency, launched the Womanikin, a universal attachment for CPR manikins, in partnership with United State of Women, a now-shuttered organization focused on gender equity. Launched during National CPR Week, the Womanikin is a neoprene vest with silicone breasts that can be zipped onto any standard manikin. Built as an awareness campaign, they open-sourced the design for the breasted vest and helped spark a broader conversation about the CPR gender gap. But we don’t have any detailed information about its success or adoption. 

More recently, other manufacturers like Prestan have come out with newly designed female manikins that can be purchased as is. They also sell “replacement female skin” that retrofits any existing Prestan adult manikins. Notably, these are now available on the American Red Cross store, increasing visibility for female manikins.

The fact that women account for 50 percent of the world’s population and yet have to mold themselves to standards not designed for them in the first place is atrocious. Not only is it frustrating to live in a world not built for you, but in cases like CPR training, the gender gap can quite literally be fatal. This is true whether it is for motor vehicle crash-test dummies or those used to train battlefield medics — another field where women injured in battle have a higher fatality rate than their counterparts.

The basic idea is that repeated exposure to female bodily characteristics during training or testing can significantly alleviate discomfort that causes dangerous hesitation. If people had more practice administering CPR to models that looked more feminine, they wouldn’t be thrown off by breasts, would understand how to cut away clothing like bras if needed, and learn how to efficiently place the pads of the external defibrillator on a female body. 

CPR techniques remain largely the same irrespective of sex. Chest compressions are performed on the sternum, which is the flat bone running down the center of your chest. For women, it lies between the breasts, so there are some additional considerations. That is what representation in training manikins is meant to address — not new skills, but familiarity. 

Ultimately, it really comes down to not feeling awkward about putting your hand in between two breasts, if it means you save a life.

When the NFL season kicks off next month, millions of Americans will gather around their televisions to watch athletes of comic book proportions crash into each other at breathtaking speeds. Inevitably, those players’ heads will smash into each other, leaving them dazed on the field. And according to a major new study, these repeated head-on collisions may eventually lead to a degenerative brain disease for many — if not most — of the players long after they’ve left the field.

For years now, America has been reckoning with the tension between its love for football and the growing evidence of its dangers. Those concerns can be boiled down to three letters: CTE, or chronic traumatic encephalopathy, which is the progressive brain disease that can lead to dementia, depression, suicide, and other serious mental health problems.

One major question over the past 20 years has been: Exactly how often does playing football lead to CTE? What are the risks for peewee players versus pros? How quickly does the brain deteriorate once the disease takes hold? And new research, published this week in BMJ, has provided us with some staggering answers. After analyzing the death records for hundreds of former NFL players, the co-authors concluded that at least 25 percent of the former players who died between 2016 and 2021 had CTE at the time of their death. 

And the actual prevalence could be much higher, but more players’ brains would have to be given over to scientists for a CTE assessment for us to know for sure. Because among the 338 players whose brains were donated and studied, the CTE rate was an astonishing 93 percent. The question is, according to the researchers: Is that percentage skewed because the players exhibiting CTE symptoms were more likely to offer up their brain for research? Or, as the authors suggest is possible, is the real CTE rate closer to 90 percent? Only further research will be able to tell us, but even the latest estimate — one in four — is cause for concern.

It’s a stark reminder of football’s risks, delivered right on the cusp of a new season for pro, college, and high school teams around the country. And according to the Aspen Institute’s annual State of Play report, there are signs that the game’s future may actually be at risk. 

More and more American parents are steering their kids away from tackle football. How long can an elite league like the NFL last when the pool of players is getting smaller and smaller — at the same time the scientific evidence of its dangers is becoming clearer and clearer?

The youth football pipeline is drying up

Despite the latest research, the NFL is going to be fine in the short term. Professional football is the biggest TV show in the country: Last year, 83 of the top 100 rated TV shows were NFL games, up from 72 in 2024. The next Super Bowl will almost certainly attract more than 100 million viewers and end up the single most-watched TV program in the US for the whole year. Football is one thing that transcends politics in an increasingly polarized America.

But with each new piece of evidence about the physical and mental costs of playing football, football’s long-term dominance looks less and less certain. Already, if you dig into the trend lines for youth participation, they reveal a real threat to the sport’s future.

Let’s start with the good news for football enthusiasts: Flag football has become more and more popular among kids, supported by investments and promotion by the NFL itself and expert consensus that it’s much safer than tackle, especially when it comes to head injuries. According to the Aspen Institute’s State of Play survey, flag football participation among kids ages 6 to 12 grew by 13.6 percent from 2019 to 2024, while tackle football play dropped 7 percent among the same age group over that time.

But it’s participation among the next age group that may be most revealing. According to the Aspen Institute, tackle football participation rates among Americans ages 13 to 17 — the prime age for middle school and high school teams — decreased 9 percent from 2019 to 2024. It has even fallen behind tennis among the teenage cohort. Many of the tweens who play flag football may never strap on a helmet to play tackle.

Even if fewer kids play tackle football year over year, the sport may still subsist on its promises of upward mobility for people who come from poorer backgrounds. With the recent introduction of compensation for college players, elite athletes can make millions of dollars in income before they even reach the NFL. It may be no surprise, then, that the young people still playing tackle football are more likely to be lower-income and live in conservative states. 

Another study found that Black and Hispanic parents, who on average earn less money than their white counterparts, are more likely to see football as a path to college scholarship or even a professional career; the Washington Post reported in 2023 that the proportion of white players at the college level is falling while the percentage of Black players is rising. Football players are often thought of as modern gladiators: participants disproportionately from lower classes aspiring to riches and glory in a violent game for the viewing pleasure of the general public. That’s becoming more and more true as we learn more about its dangers. 

As the annual hoopla around the NFL kickoff makes clear, football’s cultural dominance remains unrivaled among professional sports. But this new study has left even me, a lifelong football fan, wondering how much longer it can, and should, last.

The fatalities come amid declining vaccination rates and calls from President Donald Trump to split up the MMR vaccine.

In an episode from the fifth season of Grey’s Anatomy, Miranda Bailey, played by Chandra Wilson, orchestrates an ambitious 12-person paired kidney transplant surgery. Six living donors each give one of their kidneys to a stranger and six recipients receive one in return. While the show, which is still on the air almost 18 years later, often blurs the line between fact and fiction, this particular form of kidney transplant, called a paired kidney exchange chain, has become increasingly common in the United States. 

Rewatching the show (sue me), I wondered if such donation chains are viable for other organs (or tissues) that can be donated by living donors. The liver, the only organ that can regenerate itself over a span of six to eight weeks, struck me as a particularly notable candidate. As with any surgical procedure, donating part of one carries some risk, but in most cases a person can safely continue to lead a healthy life afterward. And the need for them far exceeds what deceased donors can provide. Right now, there are more than 100,000 people on the waitlist for organs.

Over the past decade, using organs from living donors to meet organ demand has emerged as a particularly effective strategy. 

In 2025, around 24 percent of kidney transplants used living donors, according to preliminary data from the Organ Procurement and Transplantation Network (OPTN), the public-private partnership responsible for maintaining equitable organ allocation policies. Infrastructural advances, such as the establishment of the National Kidney Registry (NKR) in 2007, have helped reduce wait time for kidneys, provided financial support for donors, and facilitated close to 11,000 paired exchange kidney transplants. In a paired exchange, two patients who each have a willing but incompatible organ donor simply swap donors — my donor gives to you, yours gives to me. Ultimately, both of us receive a kidney that our bodies are more likely to accept.

By contrast, only about 6 percent of the roughly 12,000 liver transplants performed in the US last year used living donors. 

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This is not the case around the world. Countries that face a shortage of deceased liver donors rely almost entirely on livers from living donors. In 2022, India placed third, behind the US and China, in terms of the overall number of liver transplants but performed the most living donor liver transplants in the world — 81 percent of all liver transplants there were from living donors. 

While the number of living donor liver transplants has trended generally upwards over the last decade, the success of living kidney donation suggests that a similar path might be possible for the liver here, too. The US already has what it takes — a potentially lifesaving supply of living donor livers — but it lacks the infrastructure to turn willing liver donors into transplants at scale. That may actually be starting to change, as surgeons around the country are working to build out the interconnected systems and standards that they need to do their work. 

Why parting with part of your liver makes all the difference

Organ access is a multifaceted problem in the US. While the country has largely drawn on organs from deceased donors to meet organ demand, living donors grow more important by the day. A patient’s position on the liver waitlist is determined by their Model for End-Stage Liver Disease (MELD) score. It is a number between 6 and 40 that helps doctors decide how soon the patient needs a new liver. Sometimes, if a patient gets too sick, surgery is unsafe, or if they have problems with substance abuse, they are no longer transplant eligible. 

Living liver donors are especially important because transplantation is the only treatment for end-stage liver failure — there are no alternative options. For patients in end-stage kidney failure, a dialysis machine can artificially take over the function of a kidney, and temporarily help manage their condition as they wait for an organ match. But a person experiencing liver failure has no such interventions available to them. They continue to get sicker and sicker the longer they hold on. Around one in five liver transplant candidates die waiting for a new liver. 

Living liver donors go through extensive health screens to ensure that their liver quality is good for transplant. Research indicates that the resulting donated organs lead to equal or better overall survival, compared to deceased donors. A transplant surgery with a living donor can also be scheduled, unlike those that rely on deceased donors, which are based on when an organ becomes available. This means that living donor livers usually don’t have to be transported long distances (since the donor can travel to the recipient before the surgery) and the amount of time the liver is without blood and has to be artificially preserved is very short — an important metric in donor organ viability.  

Earlier this year, doctors at the University Health Transplant Institute in San Antonio performed a seven-pair living donor liver exchange, the largest such chain in the country. Over a period of six weeks, the liver transplant surgeons matched seven people willing to donate a portion of their livers to seven other recipients who needed the life-saving transplant. Like most of these paired exchange chains, the logistically complicated process was set into motion by a non-directed living liver donor — someone who was willing to donate a liver to a stranger.. Other donors in the chain, by contrast, had a specific person they hoped to donate to with whom they weren’t immediately compatible.

Blood type and liver size are two main considerations when doctors match donor livers to recipients. Individuals with Type O blood usually have the longest wait times for donor livers because they can only receive them from others with the same blood type. In other cases, the size or anatomy of the donor liver can be incompatible with the recipient. 

An estimated 2 percent to 17 percent of living liver donors are rejected from donating to their intended recipient because of blood type, size, or anatomical incompatibility of the system of bile ducts. A major benefit of living donation is that if someone wants to donate their liver to a specific person, but they are not a match, both the donor and the recipient can participate in liver paired exchange programs — two or more incompatible donor-recipient pairs can swap donors. 

“For each living donor transplant that you do, you are actually doing two transplants,” said Dr. Jonathan Cullen, a liver transplant surgeon who participated in the liver paired exchange at University Health Transplant Institute. 

By that, he means that any time a living donor provides a liver, they also free up an organ on the deceased donor list for someone who might need it more. If we had more living donors, we could save even more lives — especially of those lower on the waitlist — but we need to overcome a few barriers first.  

Growing the donor pool isn’t enough

If living donor liver transplants have so much potential, why are they still so underutilised? The answer depends on whom you ask. 

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When medical researchers from Weill Cornell Medicine and the University of Colorado Denver surveyed 99 liver transplant programs in the country, surgical and medical directors identified different barriers to living donor liver transplants based on whether their program already performed such procedures. Out of the 83 that responded to the survey, around 60 percent of the centers performed living donor liver transplants. Notably, 34 percent of the responses from centers that don’t perform living donor liver transplants cited institutional issues such as lack of financial support or a lack of surgeons trained in living donor procedures, which are meaningfully more complex than kidney transplants. 

“Center expertise is very important when it comes to living donations. You want to obviously have your operation done at a center that’s done a lot of these,” said Alyson Kaplan, a transplant hepatologist at Tufts Medical Center and lead author of the study. “Not every transplant center has a living donor program — and so, as you can imagine, not every transplant fellow is going to get exposed to living donation.”

The surgeries are also resource intensive, especially when they are paired exchanges. In the seven-paired liver exchange at the University Health Transplant Institute in San Antonio, two attending faculty surgeons were required for every donor operation and two to four of the same for the recipient surgeries, according to Cullen. 

Plus, many of the steps in the liver transplant process are not standardised. There doesn’t yet exist a central organ matching organization for living donor livers along the lines of the National Kidney Registry, and there are no formalized protocols for how living livers are chosen and allocated, or how potential donors are screened. These procedures can differ from center to center, which can complicate attempts to collaborate or share resources. 

With living kidney donation, by contrast, the NKR partners with transplant centers and helps them standardize their processes, said Kaplan. The majority of certified kidney transplant centers in the US perform living donor transplants. That combination of shared standards and widely available surgeons makes it easier for one team to procure the organ from the donor and another to perform the recipient transplant, even if the donor-recipient pair is geographically separated.

Donor kidneys can be matched efficiently to recipients thanks in part to the work of American economist Alvin Roth, who won the Nobel prize in 2012 for the theory of stable allocations and practice of market design. His work increased the efficiency and speed of several matching processes, including paired donor-recipient kidney allocations and residency matching for medical students.

“The kind of algorithmic help that people like me can give is very, very similar,” said Roth on whether his work can be applied to liver transplants too. “Almost the same software works. What changes is the compatibility matrix.” 

For now, individual institutions that perform paired exchange living donor liver transplants usually do the matching in-house, manually comparing donor-recipient profiles and screening for risks. Kaplan’s study found that 92 percent of living donor liver transplant programs that had never performed this surgery would consider conducting it. 

But without enough funding, Kaplan said, a big infrastructural boost like this one is hard to execute on a national scale.  

Who protects the donors?

Both infrastructure and funding are necessary to scale living donor liver transplants nationwide. However, without a large pool of willing donors, these resources alone are insufficient. 

But building a bigger pool of donors is difficult, partly because becoming a living donor is difficult. 

Living liver donors often have to travel to their recipients, pay for associated lodging, and take weeks off work for both the operation and the recovery. The cost of donor screenings and transplant surgeries is usually taken on by the recipient’s insurance, but many programs recommend that the donor plan for any additional expenses, including follow-up appointments, continued medications, and caregiver expenses. 

Nonprofits like the National Living Donor Assistance Center (NLDAC) can help living liver donors subsidize costs, but only if the recipient’s household income is 350 percent below the federal poverty guidelines. For a household of two in the 48 contiguous states, that is an annual income of $75,740. Some states also provide income protection for living donors who have to take time off work, but others don’t. In the absence of more universal protections and other forms of support, building the donor pool may be a bottleneck for also building out broader living liver donation infrastructure. 

“Donors should never have a penalty to be a donor. They are definitely the national heroes, and they should have all the protections that they deserve. Nobody should have to go into debt to be a donor, for goodness sakes,” said Dr. Julie Heimbach, director of the Transplant Center at Mayo Clinic. The center performed its first paired living liver transplant in 2024. 

Moving the needle — and the organs

One major roadblock in establishing national collaborative programs for living liver transplants comes down to what’s called the organ’s cold ischemia time. This is the time between organ procurement and transplantation, during which the organ is kept cool, and no blood flows through it. 

Kidneys can hold on for longer than livers, which means that they can be transported across significant distances without the quality of the organ deteriorating. With livers, it becomes all the more important to quickly procure and transplant them because they can’t stay on ice too long. 

This limits how far a liver can be transported. A liver from a living donor across the country might not be viable by the time it reaches the recipient and is transplanted — and even if it could be, a transplant surgeon may not be willing to take a risk on it. 

In 2023, when United Network for Organ Sharing (UNOS) Labs, the innovation arm of the private non-profit that manages the organ transplant system in the US, attempted to pilot a nationwide liver paired donation program, this proved to be one of the biggest stumbling blocks. The program was anonymously funded by a private benefactor and involved 15 transplant centers across the US. However, the program shut down less than a year later. Even though one recipient-donor pair was enrolled for a liver paired exchange, the transplant surgeries were ultimately not executed. Many of those I spoke to for this story — transplant surgeons from centers that participated in the pilot — said that the funding dried up before the challenges of a collaborative liver paired exchange surgery could be resolved. 

“One of our key learnings was that moving donors, rather than organs, created major barriers. Donors are connected to their care teams and support systems, and asking someone to relocate for surgery and recovery is difficult,” Dr. Benjamin Samstein, the lead on this pilot and chief of liver transplantation at NewYork-Presbyterian and Weill Cornell Medicine, said in an email. 

He believes that there is still potential to revisit the concept, this time with a focus on moving organs instead of donors and exploring regional hub models. 

As Vox reported earlier this year, some transplant surgeons now rely on a new method of organ preservation where an external pump is used to circulate oxygenated blood or other fluids through an organ after it is procured from the donor. This keeps the donated organ viable for much longer and has been shown to outperform standard “icebox” preservation where the organs are cooled on ice. That could, transplant surgeons say, spare living donors the obligation of traveling to their recipients. 

While this technology, which is also revolutionizing the use of organs from deceased donors, may eventually reduce the pressure to recruit living donors, Dr. Jason Hawksworth, Director of the Robotic Liver Surgery Program at New York-Presbyterian/Columbia University Irving Medical Center, doesn’t think that it will diminish their importance. 

The MELD score used to prioritize patients on the liver transplant waiting list does not capture all clinical symptoms. Patients with low MELD scores can also face life-threatening complications of liver failure such as abnormal buildup of fluid in the abdomen. Such patients benefit most from living liver donations because they don’t have access to machine-perfusable organs usually reserved for those higher on the waitlist, said Hawksworth. 

To meet at least some of the need, the American Liver Foundation launched the first-ever non-directed living liver donation network to connect those who would like to donate to a stranger to transplant centers who can access this network free of charge. While the network has already saved two lives as of June this year, it remains to be seen if the program will run into the same issues as its more ambitious UNOS counterpart. 

Ultimately, optimizing the field of organ procurement and transplant is both a medical problem and an infrastructural one. OPTN data shows that 95 percent of those on the organ waitlist are in need of a kidney or a liver — the two organs a living person could give. Kidney donation has already been transformed by a combination of smarter algorithms, better standards, and trained surgeons. While living liver donation presents more challenges, there’s a real possibility to revolutionize the process and save lives.

“If these particular barriers were not an issue,” Kaplan said. “I think everyone would be interested in it.”

A few things are certain in life: death, taxes, LeBron James playing professional basketball — and Americans’ belief that crime is getting worse. Since Gallup began asking about national crime in 1989, a majority of respondents said they thought crime in the US was higher than the year before in every survey year except 2000, 2001, and 2025. Even in that last year, 49 percent still said more crime was happening. It’s perhaps the archetypal example of negativity bias, the mental habit of giving more weight to bad news than good.

Last week, the FBI put some numbers on just how big that bias is. The American murder rate — which peaked in 1980 at 10.2 per 100,000 — fell to an estimated 4.1 per 100,000 people in 2025, matching the rates recorded in 1955 and 1956 for the lowest ever measured in the country. The violent crime rate (murder, rape, robbery and aggravated assault) fell 9.7 percent, the largest single drop since J. Edgar Hoover was running the bureau in 1936. 

That much is known. But what’s not known for sure about the crime drop is almost everything else. Adam Gelb, who runs the Council on Criminal Justice, says that there is no single or easy explanation for the historic lows, while Jeff Asher, the analyst who spotted this decline before nearly everyone else, agrees. For every leading candidate — federal pandemic spending, some normalization after the 2020 social collapse, better violence prevention, even the decline of drinking — there is a corresponding hole. 

But there is one American city where researchers can point to a specific program, measure what it did, and put real numbers on it. And it just happens to be the city that spent 50 years — and five award-winning seasons on HBO — as America’s shorthand for murder.   

What Baltimore did

Baltimore recorded more than 300 homicides a year for most of the last decade, and more than 200 for most of the past half-century. In one month, July 2015, 45 people were killed — an astounding figure for a city of just around 600,000 people at the time. 

But Baltimore finished 2025 with 133 homicides, the fewest since 1977 and about 60 percent fewer than in 2020. Through the first eight months of this year, the city has seen 60 murders, and the police commissioner’s target is to stay under 100. 

What caused this? Three things at once.

Baltimore Mayor Brandon Scott’s Group Violence Reduction Strategy identifies the few people most likely to shoot or be shot — two groups that heavily overlap — and sends people to their doors with two messages: you are on our radar, and here is housing and job training. Separately, the longer-running Safe Streets program puts outreach workers with real street credibility between disputes, aiming to interrupt them before they become shootings.

That’s the harm reduction element. There’s also a tough-on-crime component. The state’s attorney office says it has secured 2,129 convictions since 2023 across several gun-related violent-crime categories, with over 1,700 of those defendants incarcerated. 

Meanwhile, Baltimore’s homicide clearance rate reached 60 percent by mid-2026. Its nonfatal-shooting clearance rate was 54 percent, up more than 12 percentage points from a year earlier. Criminologists have long held that the certainty of being caught deters criminals more than the severity of the sentence, and more successful shooting investigations are a common thread where violence is falling around the country. 

How do you tell whether a program worked, or whether a city just got lucky? Drug trials get a control group; cities don’t. Baltimore got one almost by accident: the strategy launched in the city’s Western District in 2022 and nowhere else, which left the rest of the city as a comparison.

That’s what a team of economists and criminologists used. They measured the Western District against Baltimore neighborhoods that hadn’t started the program yet, and over 18 months the number of people shot there, fatally or not, ran about 30 percent below that stand-in. Killings alone fell by a similar share, but deaths are rare enough that chance couldn’t be ruled out. Police made no more arrests than before. Arrests for serious violent crime rose 81 percent.

A second, looser test set the whole city against a composite of other big American cities and put Baltimore’s murder rate about 25 percent below it. The authors are careful with that one: too much changed in Baltimore at once to say how much it the strategy was responsible for.

Murder is contagious

Baltimore’s success is built on two ideas, and they came from two very different places. 

The first came from a doctor named Gary Slutkin, who spent the 1980s and early 1990s fighting tuberculosis in San Francisco, cholera in Somali refugee camps, and AIDS across Africa. He came home to Chicago in 1995, a year the city recorded over 800 homicides. 

When Slutkin examined the city’s shooting maps, they looked familiar. Clustered in space, clustered in time, and spreading case to case — murder resembled the outbreaks he used to fight. Slutkin reasoned that the way to treat violence was to treat it like cholera: find the people most likely to transmit. Interrupt the transmission. Change the conditions that let it spread. Slutkin built the model into a program called CeaseFire, now Cure Violence Global, and its Baltimore descendant is Safe Streets.  

The second idea came from a criminologist. David Kennedy, working in Boston in the 1990s, found that 61 gangs with about 1,300 members — under 1 percent of the city’s young people — were tied to at least 60 percent of its youth homicides. Get those people in a room with police, prosecutors, and community elders, tell them plainly what comes next, and the shooting slows down.

That approach is called focused deterrence. Baltimore’s Group Violence Reduction Strategy is a version of it. To see how it works over a longer period of time, take a trip across the Atlantic to Glasgow in Scotland, which in the early 2000s was considered the murder capital of Europe.

In 2005, in the midst of that wave of violence, Glasgow’s Strathclyde Police established a Violence Reduction Unit that operated with a basic thesis: evidence shows that violence can be prevented. Among other interventions, the unit sent trauma surgeons into schools to describe what a blade does to a face and stationed outreach workers at hospital bedsides to reach victims in the vital hours after an attack, the moment when retaliation can still be stopped. 

In 2024-25, Scotland recorded 45 homicide victims, the fewest since comparable records began in 1976 and down from 96 two decades earlier. Every case was solved.

Pull the handle

So we have clues to why crime has dropped so much, but not clear conclusions. As successful as Baltimore’s group violence strategy has proved, a 2023 study of a similar street-outreach effort in Boston found no effect whatsoever. And the latest evaluation of Baltimore’s own Safe Streets — 11 sites, each measured against a stand-in version of the same neighborhood without the program — produced numbers that sound terrific but settle very little: youth homicides down 42 percent and youth shootings down 21 percent, but neither is strong enough to rule out chance. And while some sites saw youth homicide fall by as much as 100 percent, two sites saw it rise by 42 and 89 percent. 

Some experts, like the UC Irvine criminologist Emily Owens, argue the crime decline has been so widespread and similar — big cities and small, red and blue governments — that the true cause is some larger social change rather than what any one city is doing. Nor can we be sure the fall will continue. Billions in federal pandemic relief money has supported many of the programs that have worked well in places like Baltimore, and that money is already running out. But we can identify one reason why it happened, and learn from that success. 

As it happens, Gary Slutkin was not the first doctor to look at a map of the dead and see a pattern in it. In September 1854, a cholera outbreak was killing hundreds of people in London’s Soho district. A doctor named John Snow had mapped the outbreak and saw the dead were clustered disproportionately close to the district’s Broad Street water pump. Snow had a theory that water was connected to the disease and convinced a Soho parish board to remove the handle of the pump. 

Nobody in Soho at that moment could have told you what caused cholera. It would only be 29 years later that someone would definitely identify the responsible pathogen, and in doing so, explain why Snow’s intervention worked. But the explanation could wait. The dying stopped that month in Soho, just as it is stopping in Baltimore and around the US today. And that’s what counts.

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If you’re like me, and you grew up in a house where your mom refused to let you get a video game console, because she believed sitting and staring at a TV was bad for you, you might think of video games as antithetical to health. And there is plenty of research about the ways in which gaming too much can harm your physical and mental well-being. I don’t think anyone would argue that eight hours of Call of Duty every day is doing your body or your mind much good.

But the old caricature of video games as simple brain rot is increasingly out of date. Even some normal, non-educational games can help with brain function (as long as they are played in moderation — and some games are better than others). 

Beyond that, what if we could take something that is wildly popular (there are 3 billion gamers worldwide, 190 million in the United States) and reimagine it in a way that goes beyond just entertainment? Gaming tech has advanced to the point that we can put people into hyperrealistic virtual realities or use AI to create new personalized gaming apps with a brief voice prompt. These and other capabilities are unlocking new ideas from ambitious physicians and game developers that would have sounded like science fiction when I was a teen.

There’s increasing evidence that these platforms can be adapted to do genuinely incredible things to benefit our health. Here are just two ways in which video games are poised to change medicine — including one that allows any of us to game out in the name of advancing science. I can’t wait to tell my mom.

Video games could solve some big challenges in caring for kids

My perspective on video games in medicine started to change when I learned about one specific use: as an alternative to anesthesia for children and adolescents.

Here is a genuine clinical problem: For years, doctors have had few options beyond general anesthesia for kids who need to undergo imaging or minor surgeries. An MRI, for example, really only works when the patient is able to stay completely still and, as anyone who has spent a single minute around a child can attest, that’s hard for kids to do. So, children have been put under during routine MRIs or minor procedures that, when they’re performed on an adult, require only local anesthesia or no anesthesia at all.

But giving children general anesthesia comes with health risks. The FDA warns against repeated or lengthy use of general anesthesia for children 3 and younger because of the risks to their growing brains and future learning development. Other studies have suggested that general anesthesia also poses some risk to the development of older children, and its use should be minimized as much as realistically possible.

Enter virtual reality video games.

“Games and VR can be especially effective for reducing pain and anxiety during pediatric procedures, including burn care, needle procedures, and other medical treatments,” Dr. Kimberly Hieftje, co-director and co-founder of XR Pediatrics and the Yale Center for Immersive Technologies in Pediatrics, told me over email. “If we can help a child get through a procedure comfortably without sedation, that’s a significant benefit. Sedation and anesthesia carry risks, and minimizing unnecessary or repeated exposure is particularly important in children.”

Several small-scale studies have examined using virtual reality games as an alternative to general anesthesia for minor and routine surgeries and for MRI imaging — with promising results. In one 2024 experiment, more than 100 kids (average age of 11) wore a mobile VR headset during a minor procedure (most frequently a hormone implant) and played a relaxing game such as Pebbles the Penguin (in which players navigate a snowy world and collect pebbles) or Space Pups (in which they play as a canine soaring through outer space and eating treats) while doctors performed the operation.

The surgical team kept general anesthesia on hand in case it was needed, but none of the children involved in the experiment required it or any other kind of sedation. They were also able to follow simple directions from their physician during the procedure. Their post-surgery reports of pain were similar to patients who did receive anesthesia, and they had shorter recovery times.

Likewise, a study out of Canada published in December 2025 tested how younger patients responded to VR as an alternative to anesthesia when they needed an MRI. It was a small study of only 18 patients, but, once again, the results were encouraging. The kids (average age of 5) went into a VR game prior to the MRI scan, learning about the procedure while collecting magic fairy dust. Then, they went into the actual MRI. And all of the kids who had played the VR game prior to the procedure were able to complete the imaging scan without any additional sedation or anesthesia.

The foundational idea here is: Kids are not little adults. It’s harder for them to sit still. They get anxious about even imaging scans. “We create for adults and, then, put kids in it,” Hieftje said, “and we need to think backwards.”

Video games can help kids stay calm and stop moving — or, for kids with different medical needs, start moving. As any parent knows, children also aren’t very good at following directions or being self-motivated to exercise — even if it would be good for their health, like if they have Type 1 diabetes, for example. That’s why a group of researchers from Yale, as described in a study published earlier this year and which Hieftje co-authored, experimented with introducing kids with Type 1 diabetes to a virtual reality video game that coached them through exercises. 

It was a small group — 17 adolescents, an average age of 15 — but patients who participated were motivated to play the game, followed through with their routines, and even registered a small but detectable decrease in their blood sugar levels. The researchers are hoping that larger studies could demonstrate the program’s effectiveness and continue taking it mainstream.

The list goes on: Hieftje said their work uses games and immersive technologies to address everything from substance use and human trafficking prevention to mental health, child loss and grief, and infection prevention for infants in a natal intensive care unit.

But video games are doing more than changing clinical care for challenging patients. They are also unlocking the basic science that leads to new breakthroughs in treatment for everybody.

Video games could allow all of us to contribute to future scientific advances

When I think of massive multiplayer online games, I think of my friends and I camping out in somebody’s basement to play Halo against strangers for hours on end. But Attila Szantner, the co-founder and CEO of Massively Multiplayer Online Science, has found a more productive use for these remarkable platforms that can connect hundreds of people from all around the world.

What his company has done, in tandem with academic scientists, is integrate important but tedious basic research tasks into the gameplay of popular commercial multiplayer games like Borderlands 3. When I attended the Aspen Ideas: Health summit this summer, Szantner presented a demo of one of his company’s modules. What appeared to be players sorting colorful tiles in gameplay that would look familiar to anyone who’s played Tetris, he said, was actually players — normal people with no special training — helping to sequence DNA samples for people’s gut bacteria. Players in the game learn the task from a Borderlands character — including its ultimate scientific aim — and, then, complete the puzzles that the scientists have set up.

“Games are the absolute masters of engagement. They found the magic formula to make repetitive tasks feel fun,” he said. “In citizen science, people have intrinsic motivation to help, but standard tasks get monotonous and people drop off. Games solve that completely.”

They’ve turned the boring but vital work of number crunching and sequencing into gameplay — and convinced millions of their fellow citizens to help. In a paper published in October 2024 in Nature Biotechnology, Szantner and his co-authors described a project that involved more than 4 million individuals completing more than 135 million science puzzles in order to align a million human microbiome sequences. They found that the players’ collective contributions led to better sequencing than the current state-of-the-art computational methods. In another project, they turned some basic cellular analysis tasks into gameplay on the multiplayer game EVE Online that, once again, performed better than what is now the standard.

We have only scratched the surface of gaming’s awesome potential. Clinicians are also optimistic about gaming’s ability to preserve the cognitive health of aging adults and coach them through exercise routines (much like the kids in that Yale experiment), especially as the native gamer generations get older. Video games could revolutionize trauma care by placing burn victims inside of a cold VR environment — and what if you could reduce PTSD by playing Tetris? In 2020, the FDA approved the first video game for ADHD treatment: EndeavorRx. Experts confronting a male loneliness epidemic believe they can use video games to bring young men together. These programs could also transform medical training and allow surgeons to preplan and practice surgeries using their patient’s unique data to produce a bespoke virtual reality practice module.

The point is: The caricature of video games as a gateway to couch potato-itis is a relic of the past. Gaming could help all of us stay healthy — seriously.

Since January, many Cubans have lived a life of near-constant darkness. The Trump administration’s oil blockades have led the country into a worsening energy crisis, collapsing what was already an eroding national power grid. 

Daily blackouts have plunged the Cuban nationalized, universal health system, once the pride of the country, into a humanitarian crisis. For months, hospitals have been without necessary power and ambulances strapped for fuel. Piles of trash line the streets, increasing the risk of disease. Cold storage issues threaten lifesaving vaccines, and a combination of the frail economy and US sanctions has left pharmacy shelves almost empty. 

The public health crisis exposes an often overlooked aspect of the way we tend to think about the promise of universal healthcare. Having accessible and free medical services is only one part of the solution. While Cuba’s once-vaunted health system is bound up in its own history and national context, it still demonstrates that public health of all kinds can only be as resilient as the electricity, water, transportation, refrigeration, supply chains, and institutions that enable it. 

An old prototype for universal healthcare 

Not long ago, Cuba’s health system was seen as a promising model for successful free universal healthcare. In the years following Fidel Castro’s rise to power, health authorities focused on the integration of healthcare delivery models into a single public system. The Castro government aimed to expand services once concentrated in Havana into rural areas, such that the entire population would have access to basic care services. In 1974, the government launched community-based polyclinics that placed primary care specialists in almost every Cuban community. 

Over the decades that followed, that widened access to healthcare led to significant, measurable returns. Infant mortality in the country has dropped from 37 per 1,000 live births right after the revolution to seven per 1,000 live births in 2024. Infectious and parasitic disease mortality also improved, dropping from a rate of 45.4 per 100,000 inhabitants in 1970 to 9.8 per 100,000 inhabitants in 2019, according to data reported by the Cuban Public Health Ministry. 

It’s not entirely surprising that the successful Cuban national health model has been the site of curiosity and enthusiastic scrutiny in American health equity circles, despite vast differences in state ideologies. The US has never ensured that every citizen has affordable access to healthcare, and large disparities persist in low-income and rural populations. The chokehold of private insurance has ensured that, unlike nearly every other country in the world, the US has largely rejected the prospect of universal care. Even historic gains in insurance coverage have faced rollback threats under the One Big Beautiful Bill. 

On certain key metrics, the US also falls far behind Cuba, which boasted 9.5 physicians to 1,000 people in 2021. That same year, the US reported just 3.7 physicians to every 1,000 people. The 2019 measles epidemic demonstrated a gap in childhood vaccination rates as well: 92 percent of children ages 13 to 17 in the US received two doses or more of the measles, mumps, and rubella vaccine. In Cuba, the childhood completion rates were well over 99 percent, and the country has not seen a measles outbreak since 1993. 

From its early years, the Cuban health system has functioned against a background of economic decline particular to the country, one attributable to a complex combination of external pressures, among them US blockades, a complicated economic reliance on Venezuela, a struggling state-run economy, and a flailing industry heavily impacted by the Covid-19 pandemic. 

While other sectors faced attrition, Cuba’s health system, at least, appeared capable of weathering these crises. During the pandemic, the country proved to be a model in global health, having developed a homegrown Covid-19 vaccine rapidly and reaching a 95 percent vaccination rate. Its robust supply of trained health professionals made headlines when Cuban healthcare workers provided essential pandemic aid to a small town in Italy.

 So why has this system proved to be so fragile now? 

New blockades deal the final blow after Hurricane Melissa 

Torrents of rain and flooding from the Category 3 Hurricane Melissa hit Cuba in October of last year, affecting much of the island’s eastern provinces. More than 735,000 people were evacuated, and the environmental disaster has put the country’s basic health infrastructure in a precarious state. 

In the storm’s wake, a combination of flooding and damaged water systems increased the spread of viral infections of arboviral diseases such as dengue and oropouche. A report by the Pan American Health Organization published in March placed water, food, and vector-borne diseases in the “very high” health risk categories. Apart from damaged water and sanitation infrastructure, the report describes how disruptions to health service access, routine surveillance of disease vectors, and environmental conditions that breed mosquito-borne disease outbreaks have dramatically increased the risk of infectious disease spread. 

Hurricane Melissa arrived during a recovery period from earlier storms, such as Hurricane Rafael in late 2024, as well as sporadic earthquakes in recent years. These natural disasters also heavily damaged health facilities, leading to collapsed roofing, damaged roads and cables, and the loss of supplies and equipment. 

For years, Cuba’s economy was propped up in large part by its relationship with Venezuela. In exchange for support from Cuba’s highly trained professionals — especially healthcare workers — Venezuela long provided a critical supply of crude oil, which helped the country keep the lights on even in the face of US sanctions. 

That partnership ended in January after the nighttime capture of former Venezuelan President Nicolás Maduro, and the sweeping Trump oil blockade soon after has dealt a challenge too difficult for the energy infrastructure to withstand. 

Already struggling to recover from other disasters, Cuba plunged further into its present crisis. Mario Cruz Peñate, Pan American Health Organization representative for Cuba, said that while the public health situation has been evolving for a while, he has seen more acute upheavals as sanctions persist, causing mass blackouts that have made it impossible to sustain vital health services and emergency care.

Disease control continues to struggle post-Melissa, with aid organizations worrying about communicable food- and water-borne diseases, such as hepatitis A and diarrhea, that can be caused by unrefrigerated food. On the administrative level, limited transportation resources and electricity have led to a dearth of vaccine supplies, which typically require cold rooms for transfer and storage. 

Continuity of care, in particular, has been affected for the worse. More than 100,000 elective and reconstructive surgeries have been postponed, for example, because of a lack of supplies and a backlog of emergency surgeries. At a briefing in May, representatives of the UN Office for the Coordination of Humanitarian Affairs and the World Health Organization reported that over 32,000 pregnant women faced limited access to diagnostics and limited amounts of the stable electricity needed to sustain neonatal units. Prenatal care faces delays because of the lack of everything from testing supplies to available facilities. And now, even once successful improvements in health indicators have fallen: a report from the Center for Economic and Policy Research measured an increase in infant mortality rates from 4.0 to 9.9 per 1,000 births between 2018 and 2025. 

For humanitarian aid organizations, alleviating this health crisis also poses a stark challenge. Cruz Peñate ascribes this to availability, timing, and opportunity to distribute aid supplies, all of which have been made inconsistent by the ongoing blockade. 

“The response to the situation in Cuba has to increase; we have to scale up the response. All the support we can manage to receive will be important,” Cruz Peñate said. “Here in Cuba there is really a situation that needs attention.”

Is Cuba now an outdated prototype for universal healthcare? 

While Cuba’s healthcare system was never bound to map precisely onto the US, some of its most notable successes — the high physician-to-patient ratio, the almost entirely vaccinated population, the ample health screenings — still remain desirable. And yet those very accomplishments have crumbled under the threat of extreme weather events and the country’s inability to restore its broken power grid.  

Trump targeted even more petroleum suppliers in his latest round of sanctions on July 23, leaving Cuba scrambling still further to revitalize its energy sector. Those same sanctions also took aim at the Cuban healthcare export economy, alleging that it involves forced labor. 

Earlier this month, Cuba’s government loosened constraints on a handful of private operations, including pharmaceuticals and elder-care facilities, in response to the shortage of medicine in the country.  With state-stocked shelves running empty, the new decree allows private pharmacies with Cuban health registration to fill in the medicine gap. Similarly, privatized elder facilities are also allowed to operate at a capped rate of 60 people per home, with mandatory visits from state physicians. 

The government still prohibits private sector medical and dental care, and Cuban officials remain adamant that the “socialist state enterprise keeps its central role,” so it’s difficult to claim that the country’s medical model is being pressured towards privatization. But the erosion of some of its elements still speaks to a state-run health system under strain. 

We often think of healthcare itself as an equation of medical services along with healthcare personnel and the authorities — government, industry, or both — that control it. But the crisis facing Cuba gets at the dependence of all of these factors on the broader energy ecosystem. Even a once-promising healthcare model can quickly collapse when a crucial component is missing: fuel.

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

Just last month, I marked my 25th year as a professional journalist, which I guess means my journalistic career is old enough to rent a car, no questions asked. Work in the news for that long, and you’ll occasionally find yourself surprised by things you published in the past. Like, I had all but forgotten that I had written this Time magazine cover story in 2008:

A couple things here. One, as the cover demonstrates, journalistic sensitivity was…less than ideal then, to say the least. And two, over a quarter-century occasionally covering obesity (both childhood and adult), that story only seemed to go in one direction: worse.

It wasn’t for lack of trying. We put calorie counts on menus, taxed soda (well, in some places), built workplace wellness programs, and funded a small library of diet research. We deplored food deserts and promoted farmers’ markets. We told people — again and again — to eat less and move more. But the lines just kept going up.

By the CDC’s measured survey, the share of US adults with obesity did not change meaningfully between 2013 and 2023. The age-adjusted obesity rate sat at 40.3 percent, while the age-adjusted severe obesity climbed from 7.7 percent to 9.7 percent over the same stretch.

While the question of weight in America is inextricably tied to body image and moralizing, those numbers had a deadly effect. One demographic model estimated that obesity was associated with roughly 18 percent of deaths among Black and white Americans ages 40 to 85 between 1986 and 2006. From diabetes to kidney failure, heart disease to sleep apnea, obesity is the delivery system for other diseases.

Which is what makes a Gallup report published in July so surprising. In Gallup’s self-reported height-and-weight series, the US adult obesity rate fell to 36.4 percent, down from a peak of 39.9 percent in 2022. Over roughly the same period, the share of adults who said they were currently taking a GLP-1 drug for weight loss rose from 3 percent in 2024 to 11 percent in 2026 — approximately 29 million people. While this only shows correlation, not causation, and Gallup’s self-reported measure should not be compared directly with the CDC’s measured rate, the timing is suggestive to say the least. 

And the weight might be the least interesting thing about these drugs. 

Semaglutide — the molecule sold as Ozempic and Wegovy — was first developed and approved as a treatment for type 2 diabetes, not obesity. It was only after earlier GLP-1 drugs and diabetes trials showed substantial effects on appetite and weight that researchers deliberately tested a higher dose for obesity, resulting in Wegovy in 2021. 

But as it turns out, the list of things that have been noticed happening on the side with GLP-1s has gotten so long it’s begun to eclipse the main event. The coverage of GLP-1s has barely kept up with this news, because weight loss is what made these drugs famous and what we continually obsess over. But it turns out, weight loss may not be what they’re best at.

Side effects may include…

Let’s start with sleep apnea, which, untreated, drives up blood pressure, strains the heart, and raises the risk of stroke. These are people whose breathing stops dozens of times an hour, all night, every night. Two year-long trials put 469 of them on tirzepatide — the drug sold as Mounjaro and Zepbound — and cut those interruptions by more than half. Roughly half the group finished the year with no apnea at all, or with so little left that they stopped being tired all day.

Then there are the kidneys. A major trial followed 3,533 people with type 2 diabetes and chronic kidney disease for a median of 3.4 years. Semaglutide reduced the relative risk of a composite of kidney failure, a sustained loss of at least half of kidney function, or death from kidney-related or cardiovascular causes by 24 percent; all-cause mortality was 20 percent lower.

And the liver: A trial, still underway, biopsied the livers of 800 people whose organs had grown fatty, inflamed and scarred and randomly assigned them to semaglutide or a placebo. After 72 weeks the inflammation had cleared in nearly 63 percent of those on the drug, with no worsening of the scarring, against 34 percent on placebo. 

And the knees: In 407 adults with obesity and moderate knee osteoarthritis, pain scores on the 0-100 WOMAC metric fell 41.7 points against 27.5 on placebo. 

And to top it off, a 17,604-person trial of participants who were overweight or obese but did not have diabetes found a 20 percent drop in major cardiovascular events.

These results may not be as grabby as cultural debates over “Ozempic face,” but they deserve far more attention.

Medicine’s happy accidents  

As GLP-1s — which in part came out of a hormone in Gila monster venom — demonstrate, medicine has long found some of its biggest wins in the margins of drugs ostensibly built to do something else entirely. 

Sildenafil, better known as Viagra, began life at Pfizer as a candidate treatment for the heart disease angina. It failed at that, and its now-famous use turned up in data as a side effect in what must have been a very interesting trial for its subjects. Minoxidil (Rogaine) was a blood pressure pill that turned out to help patients grow hair. Finasteride (Propecia) was approved for enlarged prostates before anyone thought to sell it for baldness — and then a trial of more than 18,000 men found it cut prostate cancer diagnoses by about 25 percent, a benefit that took 20 years of follow-up to fully vindicate. 

Perhaps the most famous example is aspirin, which spent most of a century as a painkiller before a doctor in California named Lawrence Craven noticed that the patients he’d given aspirin gum to after tonsillectomies bled more than they should. He guessed the aspirin thinned the blood, and started handing it out to middle-aged men, who were at higher risk of heart attacks. Craven died in 1957; the trial that ultimately proved that he was onto something — showing that aspirin in heart attack victims cut vascular deaths by a fifth — didn’t run until 1988. 

The strange morality of Ozempic

Viewed this way, GLP-1s can seem like miracle drugs — but even miracle drugs can’t cure everything.

There had been great hope that GLP-1 might reduce dementia rates, but when Ozempic maker Novo Nordisk ran a proper trial, it didn’t show evidence of slowing clinical progression of Alzheimer’s. Much the same happened with cancer. Observational data had hinted that GLP-1 users developed tumors less often, but when a Harvard team pooled 48 placebo-controlled trials covering 94,245 people, they found the drugs have little to no effect on the risk of thyroid, breast or kidney cancer, though evidence for other cancers was less certain, leading to FDA boxed warnings. One plus: In some early animal studies, high doses of GLP-1 drugs caused thyroid tumors in rodents, but further research largely hasn’t validated the fears that it could be more widespread, though uncertainty about some rare thyroid cancers remains.  

For many people, weight loss isn’t the end of what these drugs seem able to do. It’s where the benefits begin.

The bigger concerns largely remain the known ones, starting with muscle loss. Across 22 randomized trials, about 25 percent of the weight lost on these drugs turns out to be lean muscle mass. Some of that is simply unavoidable in any weight loss, but too much can mean a great deal, especially if you’re 75. 

And cost remains a barrier: In a 2025 KFF poll, 56 percent of adults who had ever used a GLP-1 said the drugs were difficult to afford; 27 percent said they had insurance but paid the full cost themselves. In a separate Cleveland Clinic chart review of 288 adults without diabetes who stopped injectable semaglutide or tirzepatide within a year, 47.6 percent stopped because of cost or insurance problems, compared with 14.6 percent because of side effects. (The money, at least, is improving. An oral GLP-1 drug was approved in April, and it starts at $149 a month for people paying cash, while Medicare trial pricing of $50 a month for some GLP-1s went live in July.)

A stickier obstacle is the one that can’t seem to be divorced from questions about weight: judgment. As my colleague Dylan Scott wrote recently, researchers at Rice University found that people rate a GLP-1 user more harshly than someone who never lost weight at all. That makes perfect sense when you consider how contentious weight is in America — and none at all when you think about just how many people have benefited from these drugs in so many different ways.

I sometimes wonder how we would view GLP-1s if they could do everything they’ve been shown to do, but somehow not change a person’s appearance. 

So much of the discourse around these drugs has been shaped by the fact that many of the earliest and most public and apparent users were already thin people, often celebrities, using them to get even thinner. But that framing has become increasingly difficult to square with reality. 

Two things can be true at once: American culture has a toxic relationship to weight, and millions of Americans can and are benefiting from these drugs. For many people, weight loss isn’t the end of what these drugs seem able to do. It’s where the benefits begin.

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

Over the weekend, Rep. Alexandria Ocasio-Cortez (D-NY) announced on Instagram that she had joined the thousands of American women who freeze their eggs every year, a number that has been steadily growing for the past decade.

“This is a choice that I am making to feel more in control of my life,” Ocasio-Cortez said in her Instagram story sharing her decision. 

As politicians in the public eye often do, Ocasio-Cortez turned her personal choice into a statement:

Usually I keep my private life quite private, but I have made the decision to start freezing my eggs, and I want to share this because I was weighing it for a very long time. I was saving for it for a very long time, and there just isn’t a ton out there, I feel, and sometimes it can feel very daunting. As women in general, we are not taught about our own bodies. We are not prepared for our own lives. … We need to show more depictions of women having full lives.

At the same time, she acknowledged being “in a very privileged position” to be able to take advantage of egg freezing. The process still typically costs $10,000 or more — and most insurance still doesn’t cover it. Not even AOC’s federal health plan. Egg freezing is a luxury afforded only to the people who can pay for it and take on the significant burden of the treatment and all of the uncertainty that comes with it.

Ocasio-Cortez’s announcement underscores the awkward place that egg freezing still occupies in the landscape of fertility access — at a moment when Republicans in power are lamenting falling birth rates and searching for ways to encourage more people to start families. In theory, egg freezing gives women the flexibility to take more control of their decisions about having kids and preserve that possibility for themselves in the future. But in reality, the promises of this important procedure have often been unfulfilled. 

Beyond the intimidating price tag, as AOC alluded to, many young women don’t know some of the basics about age-related fertility decline and how to maximize their chances that egg freezing will lead to an actual pregnancy. There are some “significant gaps in fertility knowledge amongst Gen Z women in particular,” said Danielle Melfi, CEO of Resolve, a fertility treatment advocacy group. 

“That points to why someone like AOC who has such broad awareness and broad reach across her channels,” Melfi told me, “specifically younger people who aren’t tuned into any politician but would be tuned into her. Her sharing her story and journey matters.”

Egg freezing is not a panacea, and it never will be. But it can give individuals options and a sense of empowerment. And right now, as AOC acknowledged in her video, those are privileges reserved for the people who are in the know and have the means to take advantage of it. For everyone else, significant barriers still remain.

Freezing time doesn’t come cheap — or easily

On average, the cost of egg freezing averages between $10,000 and $20,000. And, for most people, including AOC, who makes $174,000 a year on her congressional salary alone, health insurance coverage is not an option. According to a 2024 KFF employer survey, just 12 percent of large employers who offer health insurance provide egg or sperm freezing.

That’s not for lack of trying.

As of now, 21 states have mandates requiring health insurers to provide some level of coverage for “fertility preservation” when it is deemed medically necessary — for a younger cancer patient who is about to undergo chemotherapy, for example, a more and more common scenario these days. But coverage for what is viewed as elective freezing, as AOC is doing, is still generally not included in those requirements.

But even the state-level mandates come with a huge carveout. Under America’s Frankenstein healthcare system, there is a very important type of health insurance plan that is exempt from such state laws: self-funded employer plans, meaning those that fully cover their workers’ medical expenses without relying on an outside insurance company. They are governed only by a federal law known as the Employee Retirement Income Security Act, and that law provides no guarantees for egg freezing or other reproductive care. 

About half of Americans get their insurance through their work, and of those employer plans, more than 60 percent are self-funded. That is a lot of people who have no guarantees for this kind of service, even when a serious medical reason is motivating them to freeze their eggs. The select few who can get egg freezing covered are typically higher-income, too, adding to the disparity between the US healthcare system’s haves and have-nots.

Support for IVF among the American public has been rising, with 70 percent saying in 2024 that access to IVF was a good thing. And fertility coverage is having a political moment, too: the HOPE With Fertility Services Act, which would require insurers to cover some basic fertility treatment when it is deemed medically necessary, was introduced this year with a bipartisan slate of more than 20 sponsors, though it remains stuck at the committee level for now. The Trump administration has fixated on dropping fertility rates, but, beyond a limited IVF executive order, they have not seriously pursued plans to expand access to egg freezing. A national mandate to cover egg freezing, even only when medically necessary, could end up being opposed by both health insurers (which have fought all kinds of benefit requirements in the past) and the religious right (which has specifically challenged mandates for reproductive healthcare, like the Affordable Care Act’s contraceptive mandate).

It will likely take a variety of policy changes to give people more financial support for this important but expensive service. So what now? Unfortunately, I think we are stuck with patchy coverage and can expect only incremental improvements for the foreseeable future. On the plus side, Melfi said, more employers may increasingly offer these benefits as a competitive advantage.

But access isn’t the only problem.

Egg freezing works best when people actually know how to take advantage of it

Even if a person is able to access egg freezing, it doesn’t always pay off. 

A study published in the American Journal of Obstetrics and Gynecology in February found that fewer than 6 percent of people who froze their eggs electively had come back to thaw them within five to seven years. Of those people, 79 percent had a usable embryo after warming and 29 percent had a pregnancy that resulted in a live birth.

Of course, just because some people haven’t warmed their eggs within seven years doesn’t mean they won’t come back in nine: The point of this service is you could freeze your eggs at 30 even if you’re not ready for kids until you are 40. Those numbers will likely grow with time. And some of those people might end up successfully getting pregnant on their own the old-fashioned way, which means they won’t need their frozen eggs at all. 

“Typically, people who are coming in to freeze their eggs haven’t actually tried to conceive yet. When they are ready to start conceiving, a lot of people may not have any issues conceiving,” said Dr. Mabel Lee, a reproductive endocrinologist and infertility specialist at HRC Fertility in Pasadena, California who led the published study. 

What is true is that getting pregnant is difficult no matter how you go about it — even conceiving through intercourse only results in a 20 to 25 percent success rate on a given try, Lee said — and success with frozen eggs depends on how young the person was when their eggs were preserved: The younger they are, the higher the chances of success. That makes it all the more important that people — particularly younger people — know about the realities of egg freezing and how to make the most of it, whether they are spending thousands of dollars of their own money or whether they are using insurance to pay for it. Awareness among young people of the basic relationship between age and fertility remains discouragingly low. Lee said she has patients come in all the time who say they wish they had known more about egg freezing sooner.

The likelihood of a live birth may go up if the eggs were younger, but is that enough to convince someone in their mid-20s to pay out of pocket to freeze their eggs? In the midst of an affordability crisis, is that even an option? It might not be; in the meantime, Lee said women could get a blood test to measure their ovarian reserves, which estimates a person’s egg count, and use that to make an informed decision about egg freezing in consultation with their doctor.

Once you have decided to freeze your eggs, using a high-quality clinic is a must: That’s the other major variable in success, Lee told me. The Society for Assisted Reproductive Technology maintains a national database covering clinics across the country and tracking birth success rates and other metrics. It’s like a report card of sorts, so you can hopefully choose the best provider for you.

There are still no guarantees. Fertility is too fickle. But by improving access and raising awareness, there are clear steps we can take to try to maximize egg freezing’s potential.

Of all the extinction-level threats vying for our attention, AI, climate change, and nuclear war tend to get most of the airplay. But Annie Jacobsen thinks biological war should be near the top of our mental list of doomsday scenarios, too.

She should know — Jacobsen has carved out a unique niche as America’s foremost reporter on the ways we could end the world. Her bestselling 2024 book Nuclear War: A Scenario terrified readers and experts alike, and has been optioned by Hollywood. 

It was while conducting dozens of interviews with high-level government sources for Nuclear War that Jacobsen was told repeatedly that biowarfare should be her next focus.

She took their advice. Her gripping new book Biological War: A Scenario follows a similar ticking-clock format that shows, step by step, just how a humanity-threatening man-made biological catastrophe could play out. (Spoiler alert: not great.)

The result feels like dystopian science fiction, albeit the kind that comes heavily footnoted with government studies that come to similarly grim conclusions. The fact that tech CEOs are also sounding the alarm that advanced AI could make creating killer germs even easier only adds to the growing sense of anxiety. And this book has also been optioned by Hollywood for a TV adaptation. 

Jacobsen sat down with Today, Explained host Noel King to talk through the plot of her nightmare scenario, why we’re still developing biological weapons despite the clear risks, and what needs to happen to avoid disaster. 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 podcasts, including Apple Podcasts, Pandora, and Spotify.

How does your book start?

The inciting incident in the book is an accident at a Biosafety Level 4 lab, shorthand BSL-4, in Siberia called Vector. And it’s an actual BSL-4 lab, the highest classification. … And there was an actual accident, an explosion there in 2019. 

In that real-life incident, a deadly pathogen was not released that we know of. But of course, in Biological War: A Scenario, a deadly pathogen is released. And it’s a form of pneumonic plague, which is a nightmare pathogen and sits at the top of the Tier 1 select agent list of the CDC. And so in the first act of the book, I show the scrambling of the intelligence community and the Defense Department, trying desperately to determine if something got out and what it is. … The release of the pathogen widens, and so once you have escape. You do not have mitigation, which has to happen in the first 24, 48 hours. Now you have a situation which is unstoppable.

You say this is now an unstoppable scenario. What is it?

A plague itself, of course, conjures up images and ideas of the bubonic plague of the 14th century, the Black Death. That killed between one half and one third of Europe. The bacteria is called Yersinia pestis. And pneumonic plague is the airborne version of plague. The problem with an airborne pathogen is that because the delivery system is the human lungs, it can move very quickly from a scientist in that lab who now has Yersinia pestis in his lungs out to the general public. And that is precisely what happens in the scenario.

How does it spread from there? The city where this BSL-4 lab sits isn’t Moscow. What happens once the pathogen is in the lungs of the people who work in that lab, or the janitor who was cleaning it that night?

That’s right. Well, suddenly it’s in everyone’s lungs, and those people go out into their community. And even though Koltsovo, the science town where Vector is located, is a small town, it is just 12 miles from Novosibirsk, which is the third-largest city in Russia. And, also, there happens to be in this scenario a group of international hunters on a hunting trip in that area who come across a dying scientist in the snow. One of them gives him CPR, being the Good Samaritan that he is. And lo and behold, those travelers suddenly are now getting on an airplane in Novosibirsk, flying home to where they reside in five or six of the continents.

What makes this form of plague so novel, so dangerous?

I pull this information from actual facts of the Soviet Cold War-era biological weapons program that we know about from Soviet defectors. And I want you to keep in mind: This is 40 years ago when gene editing was in its infancy. But there are two things specifically that the Soviet bioweapons engineers did to plague. 

Their idea was to create a super plague weapon. And one of them has never been revealed before. They were working to insert the gene for euphoria into the plague pathogen. … When you get a disease, a pneumonic-type disease, pneumonia, tubercular, you want to go home and get under the covers because you feel terrible. And when you do that, you’re infecting a lot less people than you would if a gene for euphoria had been inserted into the pathogen, which would make you feel terrific, which would make you want to go out and socialize with people, perhaps even go to a crowded disco. 

And the other thing that the Soviet scientists were working on was a way to defeat medical countermeasures, but with an added component of psychological distress. They inserted a gene into the pathogen that would be triggered by the taking of antibiotics. And that second pathogen would give you encephalitis, which is a swelling of the brain. The psychological part of it, according to the Soviet scientists, was that they wanted the last thought of the person dying of what they thought was pneumonic plague, but would in fact be encephalitist to be, “My government and Western medicine has failed me.”

Those of us who try to remain optimistic think there’s a way to stop it. In the movies, there’s an outbreak, then the government gets it under control, and okay, maybe a lot of people die, but we’re all right. That is not where your book is headed. How does your scenario end?

So in the book, I take readers from outbreak to anarchy in six days. Anarchy is what will happen according to Pentagon war gaming and pandemic planning. And this is because fear of infection becomes a secondary weapon, if you will. People begin to behave like they are about to die, which is most certainly underpinning everyone’s mind. And so after those first six days, the Principals Committee, the President’s Biodefense Committee, must make a decision. The president has to declare the Insurrection Act, which allows the military to step in as a law enforcement agency. 

“Imagine the president — with a few Secret Service outside the door, the military aide with the nuclear football — sitting alone in a room wearing a gas mask.”

What happens to the president really blew my mind as a reporter. He goes somewhere in the United States very far away from everyone. Because the idea, the goal, is to make sure that the president doesn’t get the airborne pathogen in his lungs. So maybe I’ll leave you with an image. Imagine the president — with a few Secret Service outside the door, the military aide with the nuclear football — sitting alone in a room wearing a gas mask.

In the book, the people who survive are the ones who have gas masks. Everyone else is gone.

And look, we hope we never get to that, by all means. But yes, the Pentagon has issued 1.7 million gas masks to its military personnel. And that is a spooky thought in and of itself, coupled with the idea that the military is predominantly male. There’s something like 17 percent women in the military. And so, unlike the Nuclear War scenario in which I had science-based nuclear winter theory to work from, in Biological War, nothing has been written on the science record about what it might be after. And so the one imaginative part of the book is the very end where I write about biological twilight. … And it is a very, very ugly world.

Let’s back up. We did outlaw biological weapons at some point, right?

That’s right. Very mysteriously in 1969, President Nixon just unilaterally declared that the arsenal was going to be destroyed. At the same time that all of the nations of the world were working to sign this treaty called the Biological Weapons Convention Treaty, which would outlaw bioweapons. Soviet Russia at the time signed it but immediately began work on an illegal biological weapons program that was colossal. And this went without notice, without any idea really by the CIA and the Pentagon all the way until 1989, when one of the Soviet scientists named Vladimir Pasechnik had a crisis of conscience and he defected and he told British intelligence all about the program.

Where have we seen biological weapons used?

Maybe the most important example of a biological attack in the past, certainly here in the United States, are the anthrax attacks, which occurred right after 9/11. Weaponized anthrax was sent through the mail to US senators and a number of media outlets. So five people ended up dying; 22 got sick in four states. But that really kicked off what can be considered the biological military-industrial complex, if you will, which led to this buildup in BSL-4 labs around the world today. There are 110 BSL-4 labs around the world. There are more than 3,500 BSL-3 labs.

Your book has a map of where those labs are, which I found weirdly comforting, mainly because I don’t live too near any of them. If one of these things is going to be released, either accidentally or deliberately, where is the threat coming from? A rogue nation? Terrorists?

Certainly, bad actors getting a hold of a biological weapon was the great concern of the post-anthrax situation. And that is why so much emphasis was put on bioterrorism. Now I avoided that specifically in the book. … And I didn’t even have an attack. Rather, I had an incident. I had a lab leak because I have learned in the decades since that really is the greatest concern. So many of these BSL-3 and 4 labs are in places without a lot of security, including in countries where there are wars going on.

Could somebody be making a biological weapon in a basement somewhere, off books?

Absolutely. And another disturbing document I came across, unclassified in the Pentagon, was a threat spectrum that showed weapons of mass destruction in terms of destructiveness. And of course, nuclear weapons sit at the far end of the spectrum. They are the most destructive. But very close behind were biological weapons. And even more startling was the notion that biological weapons present the greatest overall threat. 

Nuclear weapons have an extremely high barrier for entry. You have to have fissile material. … You have to have a weapons delivery system like an ICBM or a submarine. … That creates a situation where most nuclear weapons, all nuclear weapons, if you will, are in the hands of a command-and-control system within a nation. 

Biological weapons have no such barriers. In fact, the barriers for entry are getting lower literally by the day. You now can have a situation where someone with very limited knowledge of biology can create a biological weapon in their basement with the use of computational systems like an AI system, for example.

Your book reads like a thriller. How much have you exaggerated? How much have you novelized in order to hold our attention?

Everything in the book is based in science fact, meaning all of the facts, all of the figures. I write a hundred or so pages of notes in the back of the book for readers to be able to answer the question that you are asking me. … In the notes, you can find that answer.

Did any of those people give you good recommendations for how to avoid a disaster scenario, or at least how to avoid these things proliferating?

Well, you know, the ticking clock scenario that I write has an even more urgent ticking clock, which is the public’s pressure on lawmakers to absolutely do something about this nightmare scenario before it happens. Look, we have a world right now where you have the CEOs of the largest AI companies in the world admitting publicly that the lane of bio mixed with AI is of their top concern. You don’t hear that about nuclear. You hear that about bio.

How do you sleep through the night?

Anyone who knows me personally can vouch for the fact that I am an optimist at heart. I really believe that information is king. Once you know things, it gives you a lot of power. Perhaps that’s whistling by the graveyard, but that’s what works for me.

Do you have a biohazard suit?

I do not. I do not. But I do have a few gas masks. I must tell the truth.

On August 5, 2025, the US Department of Health and Human Services canceled 22 mRNA vaccine projects worth roughly $500 million and told the country it would stop investing in the technology that had brought us life-saving Covid vaccines. Health Secretary Robert F. Kennedy Jr., a longtime vaccine skeptic, claimed that the data showed these vaccines fail to protect against upper respiratory infections like Covid and flu. That his claims weren’t true — Moderna had already published Phase 3 trial results showing the opposite — didn’t seem to matter.

On August 5, 2026 — one year to the day later — the Food and Drug Administration (FDA) approved mFLUSIVA, the first mRNA influenza vaccine ever licensed in the United States.

That symmetry, while highly useful to writers like myself who are always looking to identify the rhymes of history, wasn’t planned. The approval landed on the one-year anniversary simply because of the deadline the agency had set for itself in February of this year, after it refused to review Moderna’s application and then, 15 days later, reversed itself. 

The decision didn’t earn a huge amount of press, in part because seasonal flu is a disease Americans have rarely taken seriously — fewer than 50 percent of US adults got their flu shot this past fall and winter. But flu is no joke: The 2024–’25 season produced 51 million illnesses, 710,000 hospitalizations, and 45,000 deaths. That’s more than the number of Americans who died in car crashes last year. And the damage from a flu virus doesn’t stop when the fever does. In the week after a confirmed infection, the risk of a heart attack runs roughly six times higher than normal. 

So a better flu vaccine matters. But the more interesting thing is what the approval says about the year that produced it. The nine experts who voted unanimously that this vaccine’s benefits outweigh its risks were appointed under the very same secretary who was against mRNA technology. Asked to look at the evidence, those experts couldn’t produce a single vote against it. 

That’s not quite a change of heart, but at a dark time for public health, it’s something to hang our hopes on — because flu could just be the start for this technology.

The egg came first

If you’ve ever taken a flu shot, thank a chicken.

Every flu vaccine Americans have received since the 1940s has been grown inside fertilized chicken eggs. It’s a laborious process, closer to agriculture than it is high technology. Each batch incubates for nine to 12 days; the World Health Organization then spends months making the reagents manufacturers need to calibrate doses. The whole sequence runs about six months.

That means that the flu strains in your vaccine in November were selected back in February. Which is a problem, because flu viruses don’t like to stand still. Between February and November, the virus drifts, and the current dominant H3N2 flu drifts especially fast. 

The eggs are a problem, too. Growing flu virus in a chicken egg forces it to adapt to egg cells, and those adaptations alter the very surface protein the vaccine is meant to teach your immune system to recognize. Between the 2011 and 2020 flu seasons, egg-adaptive mutations caused more mismatches than the virus’s own drift did. And more mismatches mean a less effective vaccine — while the flu shot prevented an estimated 12,000 deaths in the 2024–’25 flu season, it is the weakest vaccine in routine American use, landing anywhere between 20 and 60 percent effective depending on how well February’s guess matched November’s virus.

mRNA skips the egg. The shot carries instructions, a strip of genetic code that tells your own cells to build the flu’s surface protein, which your immune system then learns to attack. And swapping in a new strain means retyping that code, not growing a new virus.

As a result, Moderna told the FDA’s advisory panel it can go from strain selection to finished vaccine in two to three months instead of six. That means strain picks could move later, closer to the season they cover, and a novel flu virus surfacing in September could still be blocked by a reformulated vaccine in the same season. Eggs are great, but they can’t do that.

Building off the platform

Back in January I wrote here about the universal flu vaccine — one shot covering every strain for years. It’s a public health dream. mFLUSIVA isn’t that, but some of the best hopes for a universal flu vaccine run through the mRNA platform, and platforms only improve when somebody uses them.

That word — platform — is where last August’s decision went wrong. Kennedy made a claim about one application, mRNA respiratory vaccines, and cut funding for the technology underneath all of them. But over the 12 months that followed, the science on mRNA kept flowing.

In June, five-year melanoma results showed an individualized mRNA therapy given after surgery alongside pembrolizumab cut the risk of recurrence or death by 49 percent. In April, a Memorial Sloan Kettering team reported that among pancreatic cancer patients whose immune systems responded to a personalized mRNA vaccine, nearly 90 percent were alive six years later; the five-year survival rate in that disease sits near 13 percent. And KJ Muldoon, the first person treated with a gene-editing therapy built for his mutation alone, is walking and talking, though half the infants born with his disorder never see a first birthday. The editor that rewrote his DNA was delivered to his liver as messenger RNA — mRNA as the delivery truck rather than the vaccine.

None of those is a flu shot. All of them are the same chemistry — a strip of genetic code wrapped in a lipid nanoparticle — and none of them were what Kennedy was talking about when he defunded it.

Partially as a result, Americans are falling behind. Moderna’s combined Covid-and-flu shot is already licensed in Europe while patients here wait for a resubmission. The Phase 3 trial of its H5 bird flu vaccine — the one meant to be ready if bird flu ever learns to spread between people — runs on money from the Coalition for Epidemic Preparedness Innovations, and the British government, after the administration killed a $760 million BARDA contract. “The United States invented this platform,” Johns Hopkins RNA biologist Jeff Coller wrote on Thursday, “and is the only country walking away from it.”

Of course, you need to actually get the vaccine

mFLUSIVA beat a standard-dose flu shot by 26.6 percent in a 40,700-person trial. (Against flu bad enough to send someone to a doctor, the figure was 33.7 percent — an exploratory finding the trial wasn’t built to prove, but that points in the same direction.) This is a better flu shot, but it hasn’t solved flu.

There are issues with side effects: Two-thirds of recipients reported injection-site pain, against 30 percent for the comparison. Most cleared in a day or two, but in a country where a quarter of the people who skip the flu shot cite side effects, that’s not a minor problem.

And approval, unfortunately, isn’t access. The CDC’s vaccine advisory committee has been frozen by a federal court since March, so there is no clinical recommendation, which means insurers aren’t required to cover mFLUSIVA at no cost. The $500 million in canceled contracts hasn’t been restored. As Michael Osterholm, who runs the University of Minnesota’s infectious disease center, put it after the government reversed its mRNA decision in February: “We don’t have any idea why they reversed course. That’s part of the problem.”

The most optimistic reading is that nine independent experts appointed by this government looked at the evidence on mRNA and could not produce a single vote against it. The more pessimistic one is that it took a refusal-to-file letter, a public outcry and two senior departures to get there.

But here’s what we do know: Some morning this fall a 58-year-old will roll up a sleeve at a CVS for a vaccine designed off a sequence rather than grown in an egg, and will think about none of this. That’s more progress than I would have expected a year ago.

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

GLP-1 drugs promised to usher in a new era of treating obesity as a disease. We could leave behind the anti-fat biases of the past, which blamed obesity on moral failing or personal weakness. Instead, these drugs would allow us to approach it as a medical condition, a complex matrix of genetics and other forces which could be changed with the right dose of these powerful new medicines. 

Or so the thinking went. 

While the clinical potential of these drugs remains immense, they have yet to change how the broader US culture perceives and engages with weight and weight loss. Even as millions of Americans shed pounds in bulk for the first time, they are also contending with fierce stigma and shaming from others — instead of being criticized for being fat, they are being criticized for using GLP-1s. 

The social media communities that have blossomed around GLP-1s are filled with tales of awkward conversations and much worse. Partners who berate a significant other who wants to go on Wegovy or Zepbound. Coworkers who blame the drugs for their rising insurance costs. Even dismissive and unsympathetic doctors and nurses. 

Some people who take GLP-1s must contend with an uneasy sense of living behind enemy lines: Many people describe being at work or out in public and overhearing people talking about GLP-1s and passing judgment on people who they think are taking a “shortcut” to lose weight.

“It’s like you’re being stigmatized without the person who’s [saying] it even realizing it, necessarily,” said Adriana, a 33-year-old GLP-1 user who lives in the Chicago area. (Vox agreed to identify the people we spoke to by their first name, to protect their privacy when discussing stigma.)

“There’s a lot of internalized stigma and judgment we have from the culture about our bodies and ourselves.”

Erin Standen, psychology professor who studies health and behavior change at Rice University

This is not just evident from anecdotes. Researchers have put the question to the test. And they have found that Americans not only feel more negative stigma toward somebody who lost weight with a GLP-1 than somebody who lost weight through diet and exercise — they also feel more negatively about the GLP-1 user than somebody who never lost weight at all.

“It seems like people are really reacting negatively to the idea that somebody who has lost weight with a GLP-1 might be, quote-unquote, ‘taking the easy way out’ or cheating the system,” said Erin Standen, a psychology professor who studies health and behavior change at Rice University and led one such study. “There’s a lot of internalized stigma and judgment we have from the culture about our bodies and ourselves.”

Americans have internalized the message that being overweight is a personal failure so thoroughly that, now that the kind of extraordinarily powerful weight-loss shots and pills long hoped for are here, many people struggle to see it as good news. They see it as cheating.

GLP-users feel damned if they do, damned if they don’t 

GLP-1 users have found themselves in a trap. They’ve felt judged for years for their bodies: Studies have found that up to 42 percent of adults with obesity have experienced some kind of weight discrimination; and between 40 and 50 percent have internalized weight bias. One survey from this year found that 81 percent of people taking GLP-1s said that they had felt social pressure to be thin, and more than half said that those attitudes influenced their decision to take one of the new weight-loss drugs.

And yet, now that they’re cutting weight, they’re being judged for how they lose it. In the same survey, 69 percent of GLP-1 users said other people saw the drugs as a cheat code, 23 percent said that it was hard to handle other people’s feelings about the meds, and 43 percent said that they didn’t like talking about their GLP-1 use for fear of judgment.

“Culturally we have a widespread belief that weight isn’t complex — it’s simply energy in versus energy out,” Susan Persky, a behavioral scientist at the National Institutes of Health who has studied GLP-1 stigma, told me in an email. “If everyone ‘should’ be able to manage their weight through diet and exercise, engaging willpower and hard work, using GLP-1s is seen as a cheat or a hack. So someone with higher weight who uses a GLP-1 is not only seen as lazy or weak, they’re also seen as cheating to achieve weight loss that other people have ‘earned’.”

Perhaps the most extensive study on GLP-1 stigma so far is from scholars at Rice University, UCLA, and the Mayo Clinic, published in the International Journal of Obesity in April. It followed an earlier paper, published in April 2024 in the same journal, that suggested people had more negative views of a woman who lost weight with a GLP-1 versus somebody who lost weight with diet and exercise.

The new experiment sought to replicate those findings and extend them. How did people feel about somebody who took a GLP-1 versus somebody who never lost weight at all? How would people feel about somebody who regained weight? They gave more than 600 participants short profiles of hypothetical patients who were all alike except for one thing: One had lost weight with diet and exercise, one had lost weight using a GLP-1, one didn’t lose weight. They were asked to rate the person on various positive and negative metrics, to measure how they perceived the person and whether they’d want to associate with them socially.

What they found revealed how deep the bias against GLP-1 users seems to run.

When comparing the two hypothetical people who lost weight, study participants offered far more negative traits and far fewer positive ones to the people who had used a GLP-1, Standen told me. “That really stuck out,” she said. They also ranked the GLP-1 user as more unhealthy. 

But even beyond that, people actually rated the person who didn’t lose weight at all more positively than the GLP-1 user. “People were more likely to say they were willing to connect socially with the person who hadn’t lost weight as compared to the person who was a GLP-1 user,” Standen said.

The study didn’t ask the participants to explain in detail why they felt the way they did about GLP-1 users. But Standen and other experts attributed the attitude to those cultural norms around body weight that have turned obesity in the minds of many into a matter of personal morality rather than the medical and socioeconomic issue that most clinicians view it as.

“Stigma toward GLP-1 use reflects deeply rooted cultural beliefs about effort, discipline, and personal responsibility for weight and health,” Stacy Post, a postdoctoral scholar at Georgetown University who authored the 2024 study on GLP-1 stigma with Persky, told me over email. “In this context, it is not surprising that GLP-1s are often viewed as a ‘quick fix’ for a problem that many believe should be solved through willpower and lifestyle changes alone.” 

And the consequences of stigma go beyond straining someone’s personal relationships. People can feel shame and stress when they think they’re being judged, and that in turn can have direct physical effects that are bad for their health. 

“These small little moments where people feel discriminated against do accumulate in the body,” Standen said. “Experiencing stigma or feeling judged for having used or not used a GLP-1 is directly harmful to your overall physical and mental health.”

Feeling judgment “also might lead you to either avoid health care or be less open when seeking healthcare in ways that could long-term harm your health as well,” Standen said. We know how much GLP-1s can improve the health prospects of somebody who is obese, so if somebody decides not to take a weight-loss med for fear of being judged, that is a net loss to their health. 

What it’s like to be a GLP-1 user when society shames GLP-1 users

The Rice study affirms something GLP-1 users have been saying in online communities since these drugs hit the market a few years ago. I have spent the past few months reading these stories on the various Reddit communities dedicated to GLP-1 drugs and weight loss, and the frustration that users experience in being judged for medications they feel are approaching a miracle drug is palpable.

One poster described her boyfriend becoming “extremely upset” when she said she was considering going on a weight-loss medication; another person also detailed their fight with an unsupportive partner. Others have contended with rude comments from coworkers. People have faced judgmental questions when they were visiting a hospital’s emergency room for something unrelated. One person even encountered the stigma at their cross-stitch club.

I spoke with two people, Adriana and Mike, who had shared their experiences of GLP-1 stigma on Reddit.

Mike, 50, and living near Boston, says he had been big his entire life, but after seeing an unflattering vacation photo a couple years ago, he decided he wanted to get serious about losing weight and thought a GLP-1 could help him. After losing some weight through Weight Watchers, he went on Zepbound; all told, he’s shed about 170 pounds.

He and others have encountered judgment for his weight loss in surprising places. Mike told me the story of going to visit an old friend from college, after he had started taking Zepbound. 

His friend’s mother was there and she inquired about his evident weight loss. He told her he was taking a GLP-1 medication. And for the rest of the weekend, she badgered him about whether whatever he was eating fit with his “diet.”

“It was eye-opening because when I first went on it, I’m like, ‘I don’t understand why people don’t want to tell anybody. This is a good thing. The world should know,’” he told me. “And then you realize, ‘Oh, God, this is affecting my ability to enjoy myself this weekend because I have to answer for it every two seconds.’ That’s when you’re like, ‘Okay, I understand why people don’t want to tell.’” (He added that the incident has, fortunately, become a running joke between him and his friend.)

Adriana from Chicago had been naturally thin for most of her life, never developing particularly good diet or exercise habits. But a couple of years ago, she had a bad mental health episode and started to cope by overeating, she says; she gained 50 pounds in a year. She had a family history of diabetes, and her doctor told her she was prediabetic. She felt an urgency to do something, she told me: “I just need to go on this medication before I do irreversible damage to my health.”

The medicine has revitalized her she said. She hasn’t experienced serious side effects and the food temptations that led her to binge-eat have been quieted. She says she’s seeing a therapist and a dietitian and feels as good as she has in years.

But she’s experienced stigma at every stage of her journey too. Adriana said that growing up, she was often praised by her family for being thin. Then when she gained weight, her family nagged her about it and friends started cutting her out of more physical activities.

Since she started taking Zepbound, she hasn’t told a lot of people — but she has still felt the prejudice toward GLP-1 users in unexpected ways. Many people in her life just assume that she is reverting back to her previous body type and compliment her for looking slim, then turn around and judge somebody else who’s on a weight-loss drug.

“My coworkers will say, ‘Oh, you look so good,’ and then they’ll mention some other person who was maybe always bigger, and they’ll say, ‘But she’s on the shot,’” Adriana said.

And online spaces, where so many of our health and wellness conversations take place these days, are filled with people expressing hurtful opinions about GLP-1 users, often fixating on reports — both credible and not so credible — of dangerous side effects. That was what prompted Adriana to post her frustrations on Reddit.

“What really bothers me is the fake concern for our health, which is the thing that always comes along when people are policing other people’s bodies,” she said. “When people are overweight, people say, ‘Well, I’m just concerned for their health.’” she said. But “now that there is this medication that’s helping, the stigma is: ‘Well, what about the side effects?’”

Will the GLP-1 stigma ever go away?

As GLP-1 use continues to rapidly expand across the country, there are signs that this stigma could eventually be broken down.

It starts with sheer numbers: The more people who take a GLP-1 or know somebody who has, the more likely they might have a more charitable view of GLP-1 users. About 12 percent of Americans said in an August 2025 survey that they had taken a GLP-1 drug. As of May 2026, one in five US households had at least one GLP-1 user, according to data from PricewaterhouseCoopers. This growth may be the best hope for breaking the stigma that is a nasty asterisk on what is otherwise a remarkable moment in medicine. 

“As these medications become more prevalent and more people have either used them themselves or have a close loved one who has used them, it is possible that that will help to reduce the stigma and increase acceptance,” Standen said. “We know that in general, one of the more robust findings in social psychology is that as people have more contact with folks who have identities or situations that might be unfamiliar to them, bias tends to go down over time.”

It is expected to be one of the largest prescription drug rollouts ever.

Mike said he has confronted acquaintances who spoke badly of GLP-1s, explaining how they have worked for him and the hard work he has put into the process. “Your perspective always changes when you suddenly know someone,” he said. 

The number of GLP-1 users is probably as low as it will ever be. Medicare launched its $50 GLP-1 prescription program in July, and millions of Americans will be eligible to receive these medications cheaper. It is expected to be one of the largest prescription drug rollouts ever.

And access should continue to expand. Pharmaceutical executives say they are making inroads with the private employer-based insurance plans that cover about half of the US population; at a health conference — Aspen Ideas: Health — in late June, Laura Steele, group vice president of US cardiometabolic health at Eli Lilly, said the company has seen large employer coverage increase significantly, from about 20 percent covering the medications in 2025 to 67 percent. 

In a decade, 50 percent or more adults in the US may be taking one of these drugs, Alison Furman, partner and US consumer markets industry leader at PwC, said at the Aspen panel. 

As bad as things might still feel to people taking GLP-1s right now, social attitudes do seem to be evolving. According to PricewaterhouseCoopers data shared with Vox, 23 percent of current GLP-1 users openly share that they are on the drugs, compared to the 2 percent who say they haven’t told anyone. People who are considering going on a GLP-1 are even more open-minded. More than half of those considering the drugs (53 percent) say they would share their use with their immediate family members, versus 42 percent of current users.

“The stigma is subsiding,” Furman said. “You see an increase in just openness around this drug. All those signs we believe point to increased adoption over time.”

Adriana has even seen hints of it herself. She has opened up to a few friends who had asked about her weight loss. “Once you start that conversation,” she said, “it’s kind of shocking how many people are like, ‘You know what? I’ve been thinking about going on.’”

Let me start with the most local of local stories: the intersection down the street from my apartment in Brooklyn, New York, where Columbia Street meets Summit Street.

Since my family moved into the neighborhood in 2023, I’ve hated this intersection. It has no stop signs, no crosswalks, no signal. Crossing on foot with my son has meant grabbing his hand and hoping any oncoming cars would slow down, which, given that this is New York City, is maybe a 50/50 proposition at best. Everyone knew a stop sign or signal was needed, but the city did nothing.

That finally began to change late last year, after a 10-year-old girl was struck and injured by a car just two blocks north of the intersection. The neighborhood organized, packed a public meeting, and eventually walked a city official down the block so he could stand in the intersection and see what they saw every day. Which is how I woke up on July 17 to see four stop signs and freshly painted crosswalks at the intersection I hated so much.

My very local story is part of a much bigger one. Cars kill about 1.16 million people a year worldwide — more than the population of San Jose, California erased every year. Road injuries remain the leading cause of death for everyone between the ages of 5 and 29 — ahead of malaria, ahead of war and homicide, ahead of every disease we spend more time worrying about.

For most of the 20th century, that was simply the price of moving around faster. Being in a car was the most dangerous thing most of us did on any given day, and we seemed to have no choice but to accept the consequences.

But, it turns out, we don’t. According to new data released last month, between 2011 and 2025, the rate at which the world’s roads killed people, measured against population, fell 21 percent, even as more than a billion motor vehicles were added to the world’s roads. It’s still far too high, and the death rate actually increased in Africa, as more vehicles are added to often substandard roads. But in epidemiological terms: Globally, exposure went up while deaths went down. What ultimately changed was an argument about whose fault it really is when a car crashes.

The doctor who decided crashes were not accidents

It’s not too much of an exaggeration to say that American cars were once all but literal death traps. In 1966, they killed 50,894 Americans and injured 1.9 million more, in vehicles with rigid steering columns aimed at the driver’s chest and metal dashboards studded with knobs that lacerated and impaled human bodies. The toll was horrific; as President Lyndon B. Johnson put it in 1966, the million and a half Americans who had died on the roads so far that century were “nearly three times as many Americans as we have lost in all our wars.”

Detroit’s answer to all this was that Americans were bad drivers. A doctor named William Haddon Jr. thought the industry was looking at the wrong thing. Haddon trained as a physician and came to car crashes as an epidemiologist. He saw them as systems failures and understood that cars had to be designed to protect drivers against themselves.

Haddon wasn’t working alone. In April 1959, a Labor Department official named Daniel Patrick Moynihan published “Epidemic on the Highways,” making a version of the same argument: The problem was how cars were built, not who was driving them. In 1965, the consumer advocate Ralph Nader — whom Moynihan had hired the year before to help write the government’s highway safety report — published Unsafe at Any Speed, a catalog of everything automakers already knew they should fix and had decided not to.

Nader’s book became a national bestseller, and, in September 1966, Johnson signed the National Traffic and Motor Vehicle Safety Act, which finally gave the federal government power to mandate how cars could be built. Johnson appointed Haddon to lead the new federal traffic- and highway-safety agencies that later became National Highway Traffic Safety Administration (NHTSA).

A safer system

NHTSA estimated that federal vehicle-safety standards prevented more than 860,000 deaths and 49 million nonfatal injuries from 1968 through 2019. Preliminary data released this week showed that the US motor vehicle death rate for the first quarter of 2026 was 0.99 per 100 million vehicle miles traveled: the second lowest first quarter figure on record and down 82 percent from the 1966 death rate, when Congress passed the vehicle safety act.

But while America has largely aimed to make crashes survivable, other countries decided that wasn’t ambitious enough. In October 1997, the Swedish parliament adopted a national policy called Vision Zero, built on the premise that nobody should be killed or seriously injured on the roads — and that, when someone is, ultimate responsibility belongs to the people who designed the system, rather than solely to the person who made the mistake. Sweden began adding median barriers to rural highways in 1998, and a national revision of speed limits rolled out in 2008-’09. Since Vision Zero’s adoption, Swedish road deaths have fallen about 61 percent, from 541 in 1997 to 213 in 2024 — about two deaths per 100,000 people, the lowest rate in the EU.

New York adopted the same framework in February 2014, explicitly modeled on the Swedish work, and cut its default speed limit from 30 to 25 miles per hour that November. By the end of 2025, the city’s traffic deaths were down 31 percent from 2014. The year closed with 205 road deaths, the fewest since New York began keeping records in 1910. In the first half of 2026, pedestrian deaths were more than 42 percent below the comparable period in 2014.

Four stop signs on a Brooklyn corner are what that idea looks like at its smallest possible scale.

The people we left outside the car

But, in our effort to make our cars safer, we neglected to do the same for everyone else on the street. Between 2009 and 2023, US pedestrian deaths rose 80 percent, even as other categories of traffic deaths increased just 13 percent. By 2022, pedestrian deaths had climbed to a 40-year high — back to 1981 levels.

One major contributor is as simple as geometry. The Insurance Institute for Highway Safety (IIHS) found that vehicles with hoods above 40 inches are about 45 percent more likely to kill the pedestrian they hit than vehicles with hoods of 30 inches or less and a sloped profile. A low, sloped hood catches an adult at the legs and rolls the body up onto it. A tall flat one catches the torso and drives the body down and under. Light trucks — which have gone from under a fifth of new vehicle sales in 1975 to more than four-fifths today — accounted for 54 percent of US pedestrian deaths with a known vehicle type in 2023.

It’s only recently that this second curve has begun to bend. Preliminary state data indicated that US pedestrian deaths fell about 7 percent in 2025 to an estimated 6,732, a third consecutive annual decline. Part of it is that a pandemic-era spike in reckless driving is receding. Part is states spending on infrastructure and enforcement. And part is that cars now come with automatic emergency braking with pedestrian detection spreading, which IIHS found cuts pedestrian crash risk by about a quarter.

Pedestrian-detecting automatic emergency braking is spreading, as well. IIHS found that it was associated with a 27 percent reduction in pedestrian crashes, though detection spreading, which IIHS found cuts pedestrian crash risk by about a quarter. (But there is work to do, as those systems don’t reduce risk on unlit roads at night, and more than three-quarters of pedestrian deaths happen after dark.)

Driver Zero

I’m glad there are stop signs at Summit and Columbia now, but it was a good outcome produced by a bad process — one that required a child being hit by a car to get started. There are more dangerous intersections in this country than there are communities with the voice and the stamina to demand fixes. A real Vision Zero wouldn’t wait for the crash; it would identify which intersections could kill someone and fix those first.

For now, though, I’m simply happy that, in my local corner of the world, the streets got just a little bit safer.

New York is also an outlier. As my colleague Marina Bolotnikova wrote earlier this year, Vision Zero hasn’t worked nearly as well elsewhere in the country, largely because the American public is less accepting of road designs that inconvenience drivers.

That’s why the US, for all its long-term improvement, lags behind its peers. Over the decade to 2021, road deaths fell 36 percent in WHO’s European region and did not move at all in the Americas. The US sees about 12 road deaths per 100,000 people, more than twice the rate in Australia, Israel, or South Korea — a gap so large that the International Transport Forum publishes OECD road safety averages both with the US included and without it, presumably to keep us from skewing the results.

Since the US probably won’t adopt Sweden’s approach, a more realistic hope might be autonomous vehicles. This month, the Insurance Institute compared about 50 million driverless Waymo miles across four cities with human driving in the same places and found that, per mile, the robotaxis were involved in 68 percent fewer crashes of the kind a human driver would typically report to police. Waymo’s own tally across more than 220 million driverless miles claimed 93 percent fewer injury-causing crashes involving pedestrians — which is to say the technology is best at precisely the thing American road design has been worst at.

If Haddon fundamental insight was that systems have to be built to counter the inevitable errors when a human drives a two-ton hunk of metal and glass at 60 mph, then maybe it makes sense that the ultimate system response is to remove the human altogether. For now, though, I’m simply happy that, in my local corner of the world, the streets got just a little bit safer.

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

AI is the hottest thing in medical care right now — but many of us feel trepidation about it. Just one illustrative public survey sample: An October 2025 KFF poll found just 8 percent of Americans reported feeling a “great deal” of trust in AI managing their appointments or analyzing their health records, and only 32 percent said they would trust an online health tool that uses AI to access their medical records to provide personalized health information.

But many clinicians and healthcare administrators see AI as a powerful new tool that offers myriad opportunities to streamline and improve treatment. A 2026 survey found that more than 80 percent of US doctors use AI professionally — doubling the share from 2023. Physicians are excited by AI’s potential to keep more accurate notes of interactions with patients, to act as a second pair of eyes for human doctors, and to monitor people at risk of deteriorating and ending up in a dangerous situation.

The disconnect between what people and their providers want from AI could create more distrust, at a time when faith in the healthcare system and the medical profession have slid. Patients today want to feel empowered and in control. How can that be possible when these seemingly godlike machines are becoming more and more entrenched in our hospitals and doctors offices?

The answer comes in four words: “human in the loop.” It’s the principle upon which the ethical integration of AI depends and it could help to bridge the gap between lay people and the professionals on AI in medicine. In surveys, people are much more comfortable with the idea of their doctor using AI as an assistant than with AI acting on its own. And most clinicians want to use AI in that way, as a second opinion or passive monitor, not as a replacement for their judgment. There are real fears among the healthcare workforce about that possibility: A group of NYC nurses who were recently laid off claim it’s because their labor was going to be replaced by AI. “Human in the loop” appears to be a point of agreement between doctors and patients at this pivotal moment.

“Doctors…and nurses and staff always have been interested in primarily making the best decision for the people under their care — and these tools can help with that,” Alison Callahan, a research scientist at Stanford University who works on AI programs used in the university’s health system, told me. “The interest in making sure those tools are accurate is high.”

But what does “human in the loop” really mean in practice? How can you know when and how your doctor is using AI? And what is the best way to talk to your provider about the sudden influx of artificial intelligence in healthcare before a robot starts taking appointment notes or analyzing your MRI? I called some leading experts to find out. 

How AI is currently being used in medicine

Patients and providers alike are incorporating AI into healthcare. Individuals are using commercial AI chatbots to ask about their symptoms or the health metrics tracked by their Apple Watch, while large academic medical centers are developing sophisticated programs and protocols to try to improve medical care at the population level.

It starts with ChatGPT, Claude, etc. — the large language models that are available to the public. People are increasingly turning to them to try to understand what’s going on with their own bodies. Individual physicians are also consulting with large language models to answer questions or get up-to-date on the latest research as they figure out how to best care for their patients. 

Then there are ways in which hospitals and doctors offices are adopting AI at the institutional level. Many facilities are using AI as a way to take, collate, and summarize notes on a patient; in theory, it’s a more organized way to keep track of the informal interactions and observations that doctors have when checking on their own patients. Hospitals are also using AI to handle some administrative tasks, like scheduling follow-up appointments; some health systems have even started to use AI to help patients get ready for appointments — to send reminders about colonoscopy prep, for example.

And finally, you have maybe the most ambitious use of AI by health systems right now: as a diagnostic and risk prediction tool. In these cases, AI might offer a second opinion when, for example, a doctor is triaging a patient in the emergency room. It might help the ER staff figure out how to prioritize patients. Or these programs could monitor people either during a hospital stay or out in the real world (by drawing data from the person’s wearable) and make predictions about who may be at higher risk of complications and require further care. AI could recommend that somebody would benefit from seeing certain specialists or receiving a specific medicine or lab test, and generally offer proactive advice about the patient’s medical care.

But at this point, AI adoption is still “highly localized,” said Jennifer Goldsack, CEO of the Digital Medicine Society, a nonprofit that works with healthcare providers, drug makers, and government agencies on how to incorporate new tech (including AI) into clinical care. It depends on the individual doctor or health system. A lot of them are setting up their own programs and their own protocols for how to use these tools.

That is a big reason why it is so important for patients to be proactive about understanding how AI is being used for their health care. You can’t make assumptions; the only way you’re going to know for sure is to ask.

The questions you should ask your doctor about AI

By and large, experts say, patients should feel confident: Doctors and nurses want to keep a human in the loop, even as they integrate AI into their workflows.

“It will be a doctor who is going to be reading that summary or a nurse who is going to be reading that summary and then taking an action to order a lab or put a recommendation in for a follow-up appointment,” Callahan said. “There is high interest in making sure that that is the right decision for that person. That hasn’t changed.” 

Still, many patients say they’d be more comfortable with AI use if their doctor fully explained it in advance. And health systems may have their own priorities that push their facilities toward more rapid AI adoption and delegating more tasks to these AI tools, as seen in the recent NYC nurse layoffs.

So if you want to be informed on exactly where this technology is present and have the ability to consent to its use, you have every right to ask your doctor, experts say. 

“AI is new, but the trust that serves as the foundation of the physician-patient relationship is not,” Timothy Keyes, a machine learning scientist at Stanford Health Care, told me over email. “To that end, I think that conversations about medical AI use should be open, honest, and transparent — just like any other conversations about shared decision-making in the clinical environment should be.”

For some things, your doctor should be asking you proactively if you consent to AI use — note-taking, for example. At my most recent primary care appointment, my doctor asked me if it’d be okay for him to use AI to take and summarize notes from our conversation; Goldstack told me she’d experienced the same at recent physician visits. (This is probably the most common AI use that you will encounter, and Keyes said it’s worth considering giving your consent: “There is growing evidence that they reduce physician burnout and save them at least a bit of time each day writing notes.”)

There are also a number of direct questions that you can ask:

• Will AI be used in my care and how?
• How is my data being protected?
• Can I opt out of any AI services that I do not feel comfortable with? (Keyes noted that patients should be allowed to opt out of any care, AI-related or not; if opting out is not an option, ask how a human provider will be involved.)
• How is the health system or clinic making sure that any AI system they use is working as intended?

And the transparency goes both ways. If you’re asking a question because you consulted ChatGPT before your appointment, tell your doctor. If you’ve talked with a chatbot because of mental health struggles, tell your doctor. And at the same time, feel free to ask your physician how you yourself could actually use AI in a responsible and productive way to improve your health.

“This opens up the opportunity for both the physician and the patient to be humans-in-the-loop,” Keyes said, “in different parts of the loop, with different perspectives, using an AI system to better understand the bigger picture.”

In a way, the novelty of AI and its rapid adoption is an opportunity for all of us to be nosier and more inquisitive patients. What all of these questions really come down to, Callahan said, is how your doctor is making decisions about your health care. That is relevant to all of us, no matter how AI is involved or even if there is no AI being used at all. 

Callahan said she always has a list of questions for her doctor when they recommend a course of treatment: “What are the factors in my health that are informing this recommendation that you have? Would you be making this recommendation for other patients who are similar to me? What can you tell me about the outcomes that I might expect to experience if I say yes to this?”

“I actually think if they can point to the part of your health that is connected to the decision, whether or not an AI tool helped to make that connection is secondary to their ability to communicate effectively to me about it, and help me to feel engaged in making a decision about my own care,” she said.

AI is changing medicine quickly, for both patients and their doctors. The best way to stay ahead is to talk about it.

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!

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!

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. 

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.

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.”