Medical News

My first thought upon seeing the Halloween-candy display at my local CVS last week was: Ooh, new treats! Then a second thought barged in: These new treats seemed awfully light on the chocolate. The Hershey’s Nuggets contained a pumpkin-spice-latte cream. The M&M’s were filled with, from what I could tell, berry-flavored peanut butter. And the Ghost Toast Kit Kats were covered not in chocolate, but in a fawn-colored cinnamon coating.

Candy manufacturers release new versions of old sweets all the time, but the timing of these decidedly un-chocolaty varieties is curious: They’ve all launched within the past two years, as the world supply of cocoa beans has dwindled, causing prices to skyrocket. Making cheap chocolate treats is no longer a cheap endeavor—unless they contain less chocolate.

Novelty is core to the candy business. It is especially important to Gen Z and Millennial consumers—the most candy-hungry demographic in recent years. This group seeks out taste mash-ups, unexpected textures, and flavor “experiences,” Carly Schildhaus, the communications director of the National Confectioners Association, an industry group, told me. Nostalgia is trending too: Sweets from the 1990s, such as Gushers and Nerds, are having a moment, as are childhood flavors such as PB&J. Plus, even before the cocoa crisis, plenty of mass-market chocolate candies contained add-ins. Mixing in more, or different ones, gives the impression of innovation, not cost cutting. For example, the vibe of M&M’s upcoming Bakery Collection—which includes such flavors as cherry chocolate cupcake, lemon meringue pie, and peanut-butter cinnamon roll—is fun, not frugal.

But candy-industry insiders know that the pressures for companies are twofold. Less chocolaty candies are “certainly a response to cocoa prices,” Nicko Debenham, a cocoa-industry expert and the former head of sustainability at the chocolate giant Barry Callebaut, told me. Since 2023, West Africa, where most of the world’s cocoa is grown, has had consecutive below-average harvests, owing to bad weather, crop disease, and illegal gold mining on farmland. A global shortage ensued, and the price of cocoa fluctuated wildly, reaching a record high of more than $12,000 a ton last December (in recent history, prices stayed below $4,000 a ton). Cocoa prices have become so volatile that banking on chocolate-based products is now a huge risk for candy makers. Companies are being forced to acknowledge that the cocoa crisis is a long-term threat, Ignacio Canals Polo, a chocolate-industry equity analyst with Bloomberg Intelligence, told me. “Three weeks of bad weather can completely change the dynamics of the market,” he said. “If you’re a chocolate manufacturer, you have to adjust your portfolio.” (None of the candy companies I reached out to for this article returned my request for comment.)

“Cocoa cutting,” as one might call it, has turned some sweets into (literally) paler imitations of their former selves. This year, Hershey’s rolled out a chocolate-free Cinnamon Toast Crunch version of its classic Kisses; last year, it launched Reese’s Werewolf Tracks, which replaced half the chocolate coating with a vanilla cream. The Ferrara Candy Company’s newest versions of Butterfinger bars swap the milk-chocolate coating for salted caramel or marshmallow cream. Last year, Hershey’s released a white Kit Kat enveloped in vanilla-flavored cream. Non-chocolate versions of these treats have been sold before, of course, but their sheer prevalence in the midst of a cocoa crisis is notable.

Observant consumers have noticed another ploy to use less chocolate: smaller candies. Standard Reese’s cups, for example, come in a package of two that weighs 1.5 ounces, but Reese’s Peanut Butter Pumpkins, which are typically sold during Halloween but launched this year in July, are sold in individually wrapped, 1.2-ounce servings. Bags of newly launched Kit Kat Counts, a vampire-shaped reimagining of the chocolate-coated wafers, are more than an ounce lighter than bags of their snack-size counterparts. (Last year, even former President Joe Biden complained that Snickers bars had undergone shrinkflation. Mars denied the allegations.)

Should the chocolate crisis worsen, candy companies have an especially springy cushion to fall back on: Gummies—shaped like bears, worms, NBA stars—are growing in popularity, as are other chewy, fruit-flavored candies. Most of the candy giants have thrust these alternatives into the spotlight. Hershey’s latest Halloween lineup includes Shaq-a-Licious XL Gummies, which were launched last year, and new Jolly Ranchers Trickies, gummies with intentionally mismatched colors, shapes, and flavors (a pink cherry gummy may, for example, taste of green apple). Ferrara just released a juice-filled iteration of its ultra-popular Nerds Gummy Clusters. Mars, meanwhile, is pushing Halloween variety packs that include Starburst, Skittles, Life Savers, and Hubba Bubba. Freed from the cocoa supply chain, and with a seemingly limitless range of synthetic flavors to choose from, fruity candies are an ideal vector for novelty. (Among Mondelez’s new offerings this year are Sour Patch Kids that, uh, glow under black light.)

Although next year’s cocoa harvest is looking up, its fate remains uncertain. The current price of cocoa is still more than twice as high as it was in 2022. Still, the future of American candy consumption seems fairly stable. People tend to buy chocolate even when prices fluctuate, Canals Polo said. More pertinently, most trick-or-treaters (and, in some cases, their parents) expect not chocolate specifically, but candy—lots of it, and the more variety, the better. The pastel-green, marshmallow-flavored Witch’s Brew Kit Kats for sale at my CVS initially struck me as an unnecessary addition to the world’s confectionery lineup, but it seemed unfair to rob my 2-year-old of a core Halloween experience: eating dumb, fun sweets. They were not great, and certainly not chocolate, but that didn’t stop me from gobbling them down too.

Ask most pediatricians about the finances of vaccines, and they’ll tell you that vaccines are not a big moneymaker. Providing them might generate some profit, but generally, “the margin you make is exceptionally small,” Robert Lillard, the medical director of the Cumberland Pediatric Foundation, told me.

Health Secretary Robert F. Kennedy Jr., without citing specific evidence, has claimed otherwise—that vaccination generates massive profits for doctors. In a June interview with Tucker Carlson, he put it at “50 percent of revenues to most pediatricians,” and said those profits create “perverse incentives” to push shots on their young patients. This description is so far from reality that Rana Alissa, the president of the Florida chapter of the American Academy of Pediatrics, told me that any actual vaccine provider would find it laughable. In fact, immunization is a dicey-enough financial proposition that the administration’s anti-vaccine policies already are discouraging providers from stocking some immunizations.

Pediatrics is one of the lowest-paid specialties in medicine. Now the Trump administration’s approach to vaccines “has made the job of being a pediatrician that much more challenging,” Jason Terk, a pediatrician in northern Texas, told me. “Is that going to hasten people leaving the practice? Probably.”

Health-care providers purchase roughly half of the vaccines given to children in the United States directly from manufacturers, sometimes paying hundreds of dollars per dose. They don’t recoup any costs until they administer those vaccines to privately insured patients, and bill the companies. That’s an enormous up-front investment for pediatric practices, generally second only to employees in terms of cost. At Scott Huitink’s pediatric practice in Tennessee, his team spends well over half a million dollars a year purchasing vaccines from manufacturers, he told me.

The other half of pediatric vaccines are purchased by the federal government, then distributed to providers across the country through the Vaccines for Children Program to support the immunization of children whose families can’t otherwise afford it. Regardless of who pays for the doses themselves, pediatricians’ offices must then shoulder the costs of storage and administration: specialized refrigerators, alarms to monitor for temperature issues, highly trained staff. Insurers generally reimburse for some of those costs, but not for unexpected problems—a refrigerator failure, a dropped vial, a dose drawn into a syringe and then declined by a patient’s family. Lose just one vaccine, and providers may have to administer dozens more to break even. In one study from 2017, 12 percent of pediatric practices and 23 percent of family-medicine practices surveyed reported that they had stopped purchasing at least one vaccine because the financial risk was too great. (In those cases, they can refer families to local health departments or pharmacies to receive those immunizations.)

Providers have generally counted on consistent vaccine recommendations from the federal government to create relatively predictable demand. But this year, they cannot. President Donald Trump has advocated for Americans to delay or space out vaccines—waiting until the age of 12 to receive a hepatitis-B shot, normally given on the first day of life, or taking the measles, mumps, and rubella shots separately. Kennedy, meanwhile, has touted the debunked claim that MMR vaccines cause autism, and baselessly described COVID and HPV vaccines as dangerous. He has also repopulated the CDC’s Advisory Committee on Immunization Practices, or ACIP, with researchers who have little to no experience in vaccine science or have publicly endorsed anti-vaccine views and who are now restricting or removing recommendations for various vaccines.

When reached for comment, Andrew G. Nixon, the director of communications at the Department of Health and Human Services, wrote via email, “Claims that this administration is undermining pediatricians or seeking to reduce childhood care are categorically false. Vaccine policy is guided by gold standard science and radical transparency.” The White House did not return a request for comment.

Some of these actions are affecting pediatricians’ vaccine purchasing directly. In its first meeting, for instance, Kennedy’s ACIP voted to remove recommendations for flu vaccines that contain the preservative thimerosal, following the counsel of an anti-vaccine activist. Most flu vaccines in the U.S. were already thimerosal-free. But Terk, in Texas, told me that about 70 percent of his practice’s supply of flu shots contained the compound, which prevents contamination in multidose vials. Switching over to single-dose, thimerosal-free vials eats up far more space in refrigerators, forcing his practice to place more frequent orders of fewer, more expensive doses. Under Kennedy’s leadership, the FDA has also restricted the approvals for COVID shots, while ACIP has substantially softened recommendations for their use—prompting weeks of scramble for pharmacies, doctors’ offices, and patients, as they have tried to figure out who is eligible for the shots and whether insurers will cover them.

For a time, staff at Weill Cornell Medicine were having patients sign waivers pledging to pay out of pocket if insurers wouldn’t cover COVID shots, Adam Stracher, the system’s chief medical officer, told me. That has since stopped, as providers have grown more confident that coverage will come through. (AHIP, the national trade association that represents the health-insurance industry, has pledged to continue covering vaccines, including COVID vaccines, through the end of 2026. But not all insurance plans are expected to fall under that umbrella, experts told me.) Other pediatricians, who might normally place orders for autumn vaccines in the late spring or early summer, waited until Kennedy’s ACIP met to discuss the shots in September. Terk, for instance, didn’t receive his first batch of shots until the end of September; prior to that, he had to turn away families that wanted the vaccine.

Eliza Varadi, a pediatrician in South Carolina, told me that the murkiness around insurance coverage, coupled with lower demand, has prompted her practice to start ordering COVID vaccines just one box at a time—each a batch of 10 doses—to minimize the potential for loss. “We’re very nervously waiting for the claims to go through the insurance companies, to make sure they are being paid,” Varadi told me. “We could be okay, or we could lose several thousand dollars.” (Providers can sometimes return unused vaccines to manufacturers, but in many cases, only for credit or a partial refund.)

Because neither Kennedy nor Jim O’Neill, the CDC’s acting director, has yet signed off on ACIP’s new recommendations for COVID vaccines, states haven’t been able to order the shots through the Vaccines for Children program. “The program basically said, ‘You can’t order COVID vaccines. We don’t know when you can. We don’t know when you’ll have them, or if you’ll have them at all. But at this point, all orders will be denied,’” Varadi told me. The lack of availability is now creating a two-tiered system of vaccine access, Deborah Greenhouse, another South Carolina pediatrician facing similar issues, told me. (Nixon did not respond to questions about this disparity, or when states would be able to order COVID vaccines through VFC.)

The downturn in COVID-vaccine purchasing may be bleeding into other shots. As orders of COVID shots have decreased, so have orders for flu and HPV vaccines, Lillard, of the Cumberland Pediatric Foundation, said. (Several pediatric practices in Tennessee purchase vaccines through Cumberland, which runs its own vaccine buying group.) Greenhouse told me she’s been encountering far more resistance to the HPV vaccine in recent months, with families citing misinformation they’ve heard on social media. “It happens several times a week at this point,” she said.

In general, demand for vaccines had already fallen, especially since the start of the coronavirus pandemic. At the same time, Lillard told me, the cost of labor and the price tag of many individual vaccines have continued to rise, while payments from insurance companies have remained relatively flat. Now that the federal government has adopted an antagonistic stance toward vaccines, the business of immunization looks even worse. Under these pressures, Varadi expects that more pediatricians will soon decide to stop offering certain vaccines.

By helping to keep children healthy, vaccines actually drive down demand for pediatric services, Alissa, of the Florida Chapter of the American Academy of Pediatrics, pointed out. In theory, pediatricians abandoning vaccines would help their businesses. But as the Trump administration continues to feed doubts about shots, doctors are being forced to confront just how costly vaccine hesitance can be. Greenhouse’s visits are now stretching out longer, she told me—putting her behind schedule, or leaving no time for other important discussions about her patients’ health. Families in many parts of the country are now requesting personalized, delayed vaccination schedules, which can drastically increase the number of routine visits that families must make, Huitink told me, as well as provider workloads. Juggling all of these bespoke schedules for families, Stracher said, makes mistakes more likely. Several pediatricians told me they worry that they and their colleagues might eventually need to see fewer patients, or cut other costs at their practice to compensate. “You’re going to see physicians leaving the workforce because of this,” Varadi told me.

Pediatrics has for years been enduring a workforce shortage—to the point where pediatrics training programs are struggling to fill slots. “We cannot find, we cannot hire, we cannot recruit,” Anita Henderson, a pediatrician in Mississippi, told me. And the pediatricians I spoke with told me they expect that deficit to worsen. So when more children fall ill amid rising rates of outbreaks, fewer doctors will be available to care for them.

Donald Trump, always one to tout his knack for dealmaking, declared on Tuesday that he’d just struck one of his best deals ever. “This is one of the biggest medical announcements that this office has ever made,” Trump said in the Oval Office, flanked by his top health officials. They’d gathered to announce that the administration had cut a deal with the pharmaceutical giant Pfizer. Trump couldn’t help but smirk. “I’m surprised you’re agreeing to this,” he told Albert Bourla, the CEO of Pfizer.

Even drug-industry lobbyists are reportedly surprised by what Pfizer agreed to. The company has a history of outmaneuvering Trump’s attempts to lower drug costs, yet it pledged to cut the costs of its drugs in the United States to match the lower prices it charges other developed countries. Pfizer also agreed to participate in TrumpRx, a new website the administration announced on Tuesday that will allow Americans to buy certain drugs at steep discounts.

Since he entered politics a decade ago, Trump has been obsessed with his belief that pharmaceutical companies are ripping off Americans by jacking up the price of drugs they sell for less in other developed countries. In his first press conference as president-elect in 2017, Trump declared that drugmakers were “getting away with murder.” By the end of Trump’s first month in office, he had summoned pharmaceutical executives to the White House to needle them about the issue. “I think you people know very well, it’s very unfair to this country,” he told them. He spent much of his first term unveiling policy after policy meant to reduce what Americans pay for prescription drugs. Time and time again, Trump’s attempts failed—until now. By getting one of the world’s most powerful drug companies to finally agree to his demands, Trump has caught a white whale.

The president has reason to be angry about drug prices. In 2022, drugmakers charged Americans nearly three times as much for drugs, on average, than they charged residents of comparable countries, according to a government report. A sizable percentage of Americans struggle to pay for their prescriptions, sometimes leading to tragic results. But Tuesday’s victory was mainly a symbolic one, at least for the time being. It’s still unclear how much relief Pfizer’s move will end up bringing to patients at the pharmacy counter. Pfizer did agree to launch all new drugs at prices “at parity with other key developed markets.” But for its existing portfolio of drugs, the company agreed only to bring its drug prices in line with other countries’ for people on Medicaid, the government-run insurance program for the poor. Drugmakers already offer substantial discounts to Americans on Medicaid, and people covered by the program pay only a tiny co-pay for their prescriptions.

There is also a lot of ambiguity about the degree to which Americans will benefit from TrumpRx, which is reportedly set to launch next year will offer drugs directly to consumers. According to a Pfizer spokesperson, the specific details of the company’s deal with the administration are confidential; she did tell me that Pfizer’s ointment for eczema will be offered on TrumpRx at an 80 percent discount. But Americans will still have to pay for the drugs out of pocket rather than using their insurance. Patients could still have to fork over hundreds or thousands of dollars for their prescription. “It’s not at all clear to me which patients actually have the financial resources to do this,” Rachel Sachs, a drug-pricing expert at Washington University School of Law, told me. (The White House did not respond to a request for comment.)

Still, the announcement marks the first time that Trump has successfully brokered a deal that would bring U.S. drug prices in line with those in other countries. Pharmaceutical companies have been wary of even minor concessions, insisting that the high prices paid by Americans subsidize the huge sums that go into researching and developing new drugs. Other countries are “not paying their fair share,” Stephen Ubl, the president of PhRMA, an industry lobbying group, said earlier this year. In Europe, countries negotiate with drugmakers over the price they pay for drugs—which leads to lower prices.

Now the drug industry’s previously united front against anything close to Trump’s coveted “America First” pricing has collapsed. (In a statement, Bourla said that Pfizer had made the deal for “certainty and stability.”) What’s most notable about the Pfizer announcement is not how much money it may save Americans, but how the administration extracted the deal. In May, the president signed an executive order directing the administration to explore implementing a so-called “most favored nation” policy, meaning that drug companies would be forced to offer Americans the same price paid by those in other developed nations. Letters to drug companies soon followed, demanding that they essentially make the concessions Pfizer agreed to Tuesday. “We will deploy every tool in our arsenal to protect American families,” the administration warned drugmakers, giving them a deadline of September 29.

Drugmakers had been there before. In 2020, the Trump White House issued a similar ultimatum. Instead of capitulating, pharmaceutical companies stonewalled, and went as far as declining an invitation with Trump to discuss his demands. “I don’t think there is a need for, right now, for White House meetings,” Pfizer CEO Albert Bourla said at the time. Drugmakers did eventually proffer their own, less sweeping drug-pricing proposals, but negotiations went nowhere. The Trump administration resorted to rushing the “most favored nation” policy through the often arduous process of enacting regulations; drug companies sued, successfully blocking the policy from going into effect. Trump then lost reelection in November, effectively killing the policy. (The Biden administration enacted its own drug-pricing policy, which allowed the government to directly negotiate with drug companies over the prices they charge in Medicare, the insurance program for seniors.)

In his second term, however, Trump has proved more adept at figuring out how to get his way. Law firms, news outlets and universities have all given in to the president’s various demands during his first nine months in office. Pfizer is no different. In the days leading up to the September 29 deadline, the president announced that drug companies that aren’t already making some of their products in the United States will face 100 percent tariffs. The announcement was not explicitly framed as a cudgel against drugmakers that had failed to agree to Trump’s previous pricing demands, but a three-year exemption from the tariffs was apparently enough to get Pfizer on board. Tariffs are “the most powerful tool to motivate behaviors,” Bourla said on Tuesday, acknowledging that they’d “clearly motivated” the company’s concessions.

The fact that it’s Pfizer giving Trump such a win likely sweetens the deal even more for the president. Trump has had a complicated relationship with the company: Pfizer was part of Operation Warp Speed, the first Trump administration’s effort to quickly develop and manufacture COVID vaccines. But after he lost the White House in 2020, Trump accused Pfizer of hiding the big news that its COVID vaccine was effective against the virus until days after the election (which the company has denied). Since then, he has tried to play it both ways with Pfizer. “It is very important that the Drug Companies justify the success of their various Covid Drugs,” he posted on Truth Social last month. “I have been shown information from Pfizer, and others, that is extraordinary, but they never seem to show those results to the public. Why not???” Now Pfizer’s CEO has kissed the ring, thanking the president for his “friendship” during his appearance in the Oval Office.

The experience appears to have only emboldened the president. He told reporters on Tuesday that all of the top drugmakers are coming to the White House over the next week to cut similar deals. “We’re making deals with all of them,” Trump said. “And I said, if we don’t make a deal, then we’re going to tariff them.” The terms of any further deals will determine exactly how big the drug-pricing changes will prove to be for Americans. It’s hard to argue against lower drug prices, especially if the cuts end up applying to more than just Medicaid. But major changes could have global ramifications. Companies may also just raise their prices in other countries to compensate for the cuts.

Regardless, the Pfizer deal has put drugmakers at a negotiating deficit unlike anything else seen in the Trump era. The pharmaceutical industry has shown itself to be a worthy opponent for Trump, but its lobbyists haven’t yet figured out how to fight back against a president who has been much more brazen in his second term than in his first. The rules of the game have changed. Pfizer’s deal might have taken Trump by surprise, but other companies may soon very well top it.

At a press conference today, President Donald Trump dispensed one clear piece of medical advice to American parents in a rambling, repetitive monologue: Don’t. Take. Tylenol. He told pregnant women that they could help keep their children safe from autism by not taking the drug whenever they could avoid it (“fight like hell,” he instructed). He advised parents not to give Tylenol to their young children. He denounced giving the hepatitis B vaccine to infants and suggested that parents space out their children’s immunization schedule. (“They pump so much stuff into those beautiful little babies, it’s a disgrace,” he said.) He declared that children ideally should be given the measles, mumps, and rubella vaccines separately, though such individual shots are not available in the United States. “This is based on what I feel,” the president said.

Trump had been hinting at his big announcement for weeks, and it was evident that he wasn’t interested in making sure the contents had passed through the normal research process. “I don’t want to wait any longer. We don’t need anything more. And if it’s wrong—it’s not going to be wrong, but—if it is wrong, it’s fine. We have to do it,” Trump told the audience at a dinner for the American Cornerstone Institute on Saturday. Today, instead of opting for measured guidance, or urging additional research, Trump borrowed a strategy from his health secretary, Robert F. Kennedy Jr.: pushing ahead with a sensational conclusion based on a handful of disputed studies.

Researchers have been studying possible causes of autism for decades, and they generally dismiss singling out one culprit like a drug or a vaccine ingredient. (Instead, the consensus is that genetics play a large role, along with an array of environmental factors.) Some studies have found a possible association between acetaminophen and neurodevelopmental disorders. In 2015, the FDA issued a notice about a possible link between prenatal Tylenol use and ADHD, though it also mentioned that the cited studies had design flaws. Last month, Andrea Baccarelli, the dean of Harvard’s school of public health, published a review of other studies in which he and his co-authors concluded that acetaminophen use during pregnancy is associated with neurodevelopmental disorders, including autism, and that pregnant women should be advised to limit their use of the drug. (Baccarelli was invited to appear at today’s announcement but did not attend, a Harvard spokesperson told me. In a statement sent to reporters shortly before the White House announcement, he wrote that his August review suggests the “possibility of a causal relationship” between Tylenol and autism, but also noted that acetaminophen is “an important tool for pregnant patients and their physicians.”)

[Read: RFK Jr. is neglecting a legitimate autism concern]

Two recent large studies, meanwhile, challenge any connection at all. A Swedish study, published last year, analyzed the health records of more than 2 million children and found that acetaminophen use was not associated with autism. A study of more than 200,000 Japanese children, published earlier this month, likewise didn’t find any meaningful association. That paper suggested that links in other studies could be explained, at least in part, by “misclassification and other biases.” A spokesperson for Kenvue, the company that makes Tylenol, told me in an email, “We believe independent, sound science clearly shows that taking acetaminophen does not cause autism. We strongly disagree with any suggestion otherwise and are deeply concerned about the health risks and confusion this poses for expecting mothers and parents.”

None of that nuance was aired during the announcement. Instead Trump professed to feel “very certain” about the Tylenol theory, and repeatedly warned Americans off the drug. This is not how science—or public health—normally works. The president of the United States doesn’t tease that he’s figured out the cause of a disorder before the research has been done to support that conclusion. Nor does he warn the American people against a common medication or the childhood-vaccine schedule without detailed evidence of his reasoning, or the full support of his staff. “It may be stronger from me than from the group,” he said in his speech, referring to Kennedy, FDA Commissioner Marty Makary, NIH Director Jay Bhattacharya, and Mehmet Oz, his head of Medicare and Medicaid. “They are waiting for certain studies. I don’t—I just want to say it like it is.” (Trump’s spokesperson, Kush Desai, wrote in an email that “the Trump Administration does not believe popping more pills is always the answer for better health” and that “there is mounting evidence finding a connection between acetaminophen use during pregnancy and autism.” The Department of Health and Human Services did not respond to a request for comment.)

Trump also went further than his deputies in calling out even fringier theories of autism. Of all the speakers at the White House today, Trump was the most explicit in blaming vaccines for poor health outcomes—a notion that has been repeatedly debunked—and he did so at length, at one point going on an extended tangent about a worker at Trump Tower whose son was supposedly “fried” by a fever following a childhood immunization. As I reported earlier this month, Kennedy has been in regular contact with a former Duke University researcher, William Parker, who believes that Tylenol given to young children is mostly responsible for autism. (Parker’s theory is such an outlier that none of the autism researchers I spoke with had heard of it, or him.) Today, Kennedy, Bhattacharya, Makary, and Oz didn’t bring up Parker’s theory, though Trump seemed to endorse it. “Don’t have your baby take Tylenol,” Trump said.

[Read: RFK Jr.’s calls with a scientist who says kids get autism from Tylenol]

Ever since Trump announced that his administration would find the cause of autism within months, researchers have feared that the team would jump to unsupported conclusions. But Trump hardly seems to care if he’s wrong. Besides, he repeatedly insisted, eschewing Tylenol during pregnancy has “no downside.” (Tylenol is considered the safest fever reducer available for pregnant women.)

During today’s announcement, Kennedy at least acknowledged the trade-offs inherent in scaring pregnant Americans off Tylenol, and allowed that, sometimes, using it is unavoidable. “The FDA also recognizes that acetaminophen is often the only tool for fevers and pain in pregnancy, as other alternatives have well-documented adverse effects,” Kennedy noted in his remarks. “HHS wants therefore to encourage clinicians to exercise their best judgment in the use of acetaminophen for fevers and pain in pregnancy by prescribing the lowest effective dose and shortest necessary duration, and only when treatment is required.” (Today, the FDA posted an even more measured notice to physicians, signed by Makary, that underscored a possible association between acetaminophen and autism is “an ongoing area of scientific debate.”) Trump, meanwhile, repeatedly instructed pregnant women to “tough it out.” Sowing doubts regarding vaccines, going all in on fringe theories, and opting for extreme positions instead of embracing nuance: At MAHA’s big reveal, Trump seemed determined to steal Kennedy’s spotlight.

Frank Charles, a pet-resort owner and former five-term mayor of St. Augustine, Florida, wanted a tattoo. He just wasn’t sure that he could take the pain. Then he started seeing advertisements for a place in Miami called Sedation Ink, which offers clients the attention of its licensed anesthesiologists. “You’ll enjoy a deep and peaceful sleep, allowing our artists to create breathtaking designs on your skin,” the studio’s website reads. “Join us and experience the future of tattooing, where pain is eliminated, and dreams become reality.”

Charles is no stranger to elective anesthesia, he told me. He’d gone under in the past for a nose job, a chin-reconstruction surgery, and hair transplants (twice). So the idea of being inked up while unconscious didn’t bother him at all. As for the actual experience, well, it’s hard to say. In photos of the operation, his face is covered with a dark and heavy cloth. (He looks a little bit like someone being waterboarded.) The only thing he can remember is a vision that he had while on the table. “I dreamed of waking up,” he said, “and the tattoo was in the wrong location.” It was not: Eight hours and $29,000 later, Charles came back to his senses with a picture of a blue-eyed, bejeweled lion on his right pectoral, which morphed into an American flag and then a bald eagle along his forearm (also part of this tattoo: the Statue of Liberty and the preamble of the U.S. Constitution).

This design may now belong to Charles and Charles alone, but the way that he received it—fully zonked on fentanyl and propofol—has been gaining popularity, especially among the young and rich. Two years ago, the Dallas Cowboys quarterback Dak Prescott went under for almost half a day, during which time multiple artists worked together on producing a full leg sleeve depicting, among other things, a Pegasus, a moose, the Dallas skyline, and a firm handshake. More athletes followed, getting very large tattoos that would otherwise have needed to be created across multiple sessions in a parlor, with bouts of healing in between—an arduous process that can take many weeks to complete. Even the singer Post Malone, one of pop culture’s most conspicuously tattooed celebrities, has gotten work done while medically unconscious.

To a certain type of person, the appeal of these procedures is self-evident: Getting a needle jabbed into your skin hurts. But for another type of person—one who feels personally, professionally, or even ideologically invested in the culture and traditions of tattooing—this trend will be unnerving. Blasphemous, even.

Getting tattooed is a way of “teaching you something about what you’re capable of,” Don Ritson, an artist based in Winnipeg, Canada, told me. “In this postmodern world where we don’t have these same feats of strength, it gives us an opportunity to prove to ourselves that we’re capable on some level.” As someone with a few dozen tattoos, each of which was at least a little painful to receive, I appreciate that argument. But I also balk at the idea that having a doodle dug into your body is a measure of your prowess. I don’t think anyone would take a look at my tattoo referencing a joke from the sitcom Frasier and think, Wow. What a strong guy. I wonder what feats of strength he’s capable of? Even the outward projection of physical strength—something I also value, and work to maintain with waffling levels of commitment—seems preposterous in a world of pricey gyms and personal trainers.

For Ritson, who delivered a recent TEDx Talk called “Marked Without Feeling: What Tattooing Loses Under Anesthesia,” the experience of pain is a stamp of one’s personal resolve, and without it, tattooing risks losing whatever remaining connections it has to various underground subcultures. The anesthetized tattoo is “tied to these athletes or actors, people who have money, but they don’t have time,” he told me. “They kind of want to skip the line a little bit. They want the thing, but they can’t actually commit to doing what it takes to get the thing.”

Tattoo culture has in many other ways been normalized and gentrified over the past few decades. Once the province of bikers and sailors and scumbags, tattoos now appear on nearly one-third of all Americans. Modern shops look less like punk bars than pricey hair salons or smartphone showrooms. But tattoos like Frank Charles’s, produced in an operating theater at much higher cost, would seem to be the culmination of this trend. If a standard tattoo parlor might refuse service only when a customer is clearly underage or way too drunk, or both at once, the people who come into Sedation Ink in Miami are screened as if they’re getting rhinoplasty or some other cosmetic procedure. They need “a full medical clearance from a physician,” Noel Pace, a health-care attorney who works with the studio, told me. “It’s like going into a surgery.” Indeed, Sedation’s customers are described not as clients but as “patients.”

For “Sweet” Dave O’Connor, a tattoo artist in Hamilton, Ontario, who has done a number of my tattoos, the transformation of a parlor into a medical clinic negates its social meaning. O’Connor works in what’s called the “traditional” style, characterized by bold outlines, a crisp color palette, and familiar tattoo-shop imagery: anchors and horseshoes and vipers and clipper ships and jaguar heads and whatnot. His thinking about the enterprise is similarly old-school. The move toward tattooing under anesthesia is “the complete end-game of the ‘Customer is always right’ attitude,” he told me. “The one common thread through every tattoo, regardless of the size, shape, style, the person getting it, is that there’s pain involved. It’s the one thing that unifies all tattoos. And if you take that out of it, then what is there? You didn’t do anything for it. Other than pay for it. And take a nap.”

[Read: The new meaning of tattoos]

Other tattooers aren’t quite so ruffled by the practice. The L.A.-based artist Romeo Lacoste has tattooed celebrities including Kendrick Lamar, Ariana Grande, and Justin Bieber. He has tattooed backstage at concerts. He has even tattooed on a private jet. He told me that he regards tattooing in a surgical room with the aid of anesthetic as just another step in the evolution of his art. There are practical benefits too. Without sensitive patients squirming under the buzz of the needle, he said, he’s able to get cleaner work done more efficiently. He also enjoys collaborating with other artists on a single, large piece of art. “A lot of those guys want to complain now,” he told me, but their fixation on the old way of doing things will soon be left behind. “The mentality that you have to earn your pain is just going to get more watered down. Eventually, I don’t even think that mentality will exist anymore.”

At the very least, that mentality will face commercial pressure to adapt. In July, shortly after the heavy-metal singer Ozzy Osbourne’s passing, I went into a small tattoo shop around the corner from my house. Since I was a teenager, I’ve told myself that I’d get a tattoo of his name when he died. Hellbent on making good on the dopey promise of my younger self, I forked over $50 to have the letters OZZY inked onto my forearm. During the (very brief) session, I asked the artist what he thought about the entry of anesthetics into tattoo culture. He said he had compunctions—in theory. But he also copped to the fact that he’d be glad to take the daily rate of $10,000 that one gets to do that kind of work.

[Read: Tattoos do odd things to the immune system]

The allure—for artists and their clients alike—is clear enough, even if the new approach carries certain hazards. Earlier this year, a 45-year-old Brazilian social-media star named Ricardo Godoi went into a private hospital for a full-back tattoo while sedated and intubated. Near the start of the procedure, he went into cardiac arrest and died. Although dozens of cases of death from anesthesia are recorded every year in the U.S., the risk to any individual is very low: Fewer than one anesthesia-related mortality occurs for every 100,000 procedures, according to a 2018 study. And the notable tattoo parlors that offer this procedure—Sedation Ink, as well as The California Dream Tattoo and Ganga Tattoo in Los Angeles—tend to operate more like medical centers than studios. At some studios, artists dress in surgical scrubs and are overseen by a board-certified anesthesiologist.

But maybe even just that teeny-tiny chance of death can make the anesthetized tattoo a test of mettle, too, in the way that Ritson meant: The added risk becomes a counterbalance for the loss of pain, on some kind of toughness scale. Or perhaps the rise of sedation-assisted tattoos will serve to raise the floor for every other form of body art, no matter how routine, if it comes without the benefit of propofol. Sure, you may have gotten a pencil-thin etch of a wheat sheaf inked into your arm at a shop that looks like an Apple store. But at least you were there. At least it felt like something. At least it hurt.

As far as sticker price goes, the recommended vaccines for kids in the United States do not come cheap. The hepatitis-B shot, given within the first hours of life, can be purchased for about $30. The rotavirus vaccine costs $102 to $147 a dose. A full course of the vaccine that protects against pneumonia and meningitis runs about $1,000.

Virtually all children receive these shots for free. The federal government legally requires most insurance to cover the roughly 30 different shots for kids, without a co-pay. Kids who are on Medicaid or who don’t have insurance coverage can get free shots as well, thanks to a CDC program known as Vaccines for Children. Among public-health experts, VFC, as it’s commonly known, is widely seen as an unmitigated success. After the program was created in 1994, “disease went down, and life was a lot simpler for the families,” Anne Schuchat, a former top CDC official, told me. Roughly half of American children are eligible to receive vaccines through VFC.

That ease and simplicity may be about to change. This week, the CDC’s Advisory Committee on Immunization Practices (ACIP)—which guides America’s vaccine policy—convened for just the second time since Robert F. Kennedy Jr. fired the entire panel and appointed new members, some of whom lack vaccine expertise or have expressed anti-vaccine views (or both). The meeting was chaotic, contentious, and plagued by indecision. But the votes it got through are starting to point toward a shifting, more fractured landscape for kids’ access to vaccines.   

Yesterday, ACIP voted to remove the joint measles-mumps-rubella-varicella (MMRV) vaccine from the childhood-immunization schedule for children under 4, and instead recommended that kids get two separate shots: one for measles, mumps, and rubella, and another for varicella. This morning, the panel also voted to remove the combination shot from the VFC program. Both votes were motivated by a concern about the safety of the vaccine, including an elevated risk of febrile seizures. (As the CDC’s website points out, these seizures can be stressful for families, though most children fully recover.)

The effect of the move away from the combination vaccine will be limited, because most children in America already receive the separate shots. However, one group would bear the brunt of the changes more than others: children on VFC. Some parents opt for the convenience of a single shot, and those who are covered by private insurance may still be able to get it. Although private insurers will no longer be required to cover the joint MMRV vaccine free of charge, they are already pledging to continue with business as usual: On Tuesday, AHIP, a lobbying group that represents the health-insurance industry, announced that its members will continue to cover shots under the pre-ACIP vaccine schedule until the end of 2026. (A spokesperson for AHIP declined to comment on what happens after that.) Parents could, hypothetically, also pay for these vaccines out of pocket. The disproportionately poor children covered by VFC do not have the same kind of wiggle room. What shots they can get for free from the program, and when, are directly tied to ACIP’s recommendations. (A Department of Health and Human Services spokesperson told me that the move will not increase vaccine inequality but did not explain further.)

Mainly, the changes that ACIP is currently considering would create inconveniences for poor families—more trips to the doctor, more needle pricks. But as my colleagues Tom Bartlett and Katherine J. Wu wrote yesterday, the change to the MMRV policy, while minor, can send the message that vaccines are dispensable. The committee also discussed delaying when kids should get the hepatitis-B shot but ultimately decided to table an anticipated vote on whether they would recommend the delay. (Kennedy has intimated that the hepatitis-B vaccine may cause autism, despite the lack of data showing a link between the two.) If the hepatitis-B vaccine or another shot is removed entirely from the schedule, that will immediately hit kids served by VFC.

Beyond potentially serious disparities, more alterations to childhood vaccines would likely cause more confusion. Kennedy’s recent changes to COVID-vaccine policy, which narrowed the approval for COVID shots so that they are recommended only for people over 65 or who have certain underlying conditions, left many Americans unsure about if and how they could get one. (Today, ACIP also voted that every person should consult with a clinician before receiving a COVID shot.) Americans who rely on VFC may soon have to similarly figure out what shots they can get, and where. The confusion over COVID shots “is a small glimpse of what may happen” if ACIP moves forward with changes to the childhood-vaccine schedule, Schuchat told me.

In the event that a vaccine is removed from the schedule, the experts I spoke with remain hopeful that some entity, such as a state health department, a community health center, or philanthropy, would step in to provide uninsured kids with free shots. But who or what, besides the federal government, could provide vaccines at the necessary scale is an open question. “It’s going to require some sort of extraordinary effort to provide that access,” Richard Hughes IV, a professorial lecturer in law at the George Washington University Law School, told me. VFC works so well not only because it provides vaccines free of charge but also because it is designed to ensure that doctors always have a supply of vaccines on hand—the CDC purchases vaccines and then provides them for free to doctors, who then dole them out to children in need.

Medicaid could still provide some backstop for the poorest children, experts told me, but a likely scenario seems to be a system in which private insurers continue to cover vaccines, while poor children are left behind. Such a scenario is “the definition of a health-care disparity,” Christoph Diasio, a pediatrician in North Carolina, told me.

America has seen this type of vaccine inequity before. Beginning in 1989, measles tore through several cities—including Los Angeles, Houston, and Chicago—precisely because many low-income children were unable to access the vaccine. “A big part of the problem was, kids were in the doctor’s office, but because they weren’t insured, the doctors were referring the family to the health department,” Schuchat told me. “That extra visit was something that was not easy for parents to find the time to get to.” Researchers estimated that nonwhite preschoolers were seven to 10 times more likely to contract the virus than white children. It was this outbreak that led to the formation of the VFC program in the first place.

In his time as secretary of Health and Human Services, Kennedy has claimed that reforms to Medicaid would improve the program, despite projections from the Congressional Budget Office that the change would kick millions off of the safety-net program. He has decimated minority-health offices in his department in the name of government efficiency. And he has said that vaccine changes will be made in line with the latest science, despite overwhelming evidence to the contrary. Now, in the name of following the science, Kennedy is on the cusp of creating a two-tiered vaccine system.

As far as sticker price goes, the recommended vaccines for kids in the United States do not come cheap. The hepatitis-B shot, given within the first hours of life, can be purchased for about $30. The rotavirus vaccine costs $102 to $147 a dose. A full course of the vaccine that protects against pneumonia and meningitis runs about $1,000.

Virtually all children receive these shots for free. The federal government legally requires most insurance to cover the roughly 30 different shots for kids, without a co-pay. Kids who are on Medicaid or who don’t have insurance coverage can get free shots as well, thanks to a CDC program known as Vaccines for Children. Among public-health experts, VFC, as it’s commonly known, is widely seen as an unmitigated success. After the program was created in 1994, “disease went down, and life was a lot simpler for the families,” Anne Schuchat, a former top CDC official, told me. Roughly half of American children are eligible to receive vaccines through VFC.

That ease and simplicity may be about to change. This week, the CDC’s Advisory Committee on Immunization Practices (ACIP)—which guides America’s vaccine policy—convened for just the second time since Robert F. Kennedy Jr. fired the entire panel and appointed new members, some of whom lack vaccine expertise or have expressed anti-vaccine views (or both). The meeting was chaotic, contentious, and plagued by indecision. But the votes it got through are starting to point toward a shifting, more fractured landscape for kids’ access to vaccines.   

Yesterday, ACIP voted to remove the joint measles-mumps-rubella-varicella (MMRV) vaccine from the childhood-immunization schedule for children under 4, and instead recommended that kids get two separate shots: one for measles, mumps, and rubella, and another for varicella. This morning, the panel also voted to remove the combination shot from the VFC program. Both votes were motivated by a concern about the safety of the vaccine, including an elevated risk of febrile seizures. (As the CDC’s website points out, these seizures can be stressful for families, though most children fully recover.)

The effect of the move away from the combination vaccine will be limited, because most children in America already receive the separate shots. However, one group would bear the brunt of the changes more than others: children on VFC. Some parents opt for the convenience of a single shot, and those who are covered by private insurance may still be able to get it. Although private insurers will no longer be required to cover the joint MMRV vaccine free of charge, they are already pledging to continue with business as usual: On Tuesday, AHIP, a lobbying group that represents the health-insurance industry, announced that its members will continue to cover shots under the pre-ACIP vaccine schedule until the end of 2026. (A spokesperson for AHIP declined to comment on what happens after that.) Parents could, hypothetically, also pay for these vaccines out of pocket. The disproportionately poor children covered by VFC do not have the same kind of wiggle room. What shots they can get for free from the program, and when, are directly tied to ACIP’s recommendations. (A Department of Health and Human Services spokesperson told me that the move will not increase vaccine inequality but did not explain further.)

Mainly, the changes that ACIP is currently considering would create inconveniences for poor families—more trips to the doctor, more needle pricks. But as my colleagues Tom Bartlett and Katherine J. Wu wrote yesterday, the change to the MMRV policy, while minor, can send the message that vaccines are dispensable. The committee also discussed delaying when kids should get the hepatitis-B shot but ultimately decided to table an anticipated vote on whether they would recommend the delay. (Kennedy has intimated that the hepatitis-B vaccine may cause autism, despite the lack of data showing a link between the two.) If the hepatitis-B vaccine or another shot is removed entirely from the schedule, that will immediately hit kids served by VFC.

Beyond potentially serious disparities, more alterations to childhood vaccines would likely cause more confusion. Kennedy’s recent changes to COVID-vaccine policy, which narrowed the approval for COVID shots so that they are recommended only for people over 65 or who have certain underlying conditions, left many Americans unsure about if and how they could get one. (Today, ACIP also voted that every person should consult with a clinician before receiving a COVID shot.) Americans who rely on VFC may soon have to similarly figure out what shots they can get, and where. The confusion over COVID shots “is a small glimpse of what may happen” if ACIP moves forward with changes to the childhood-vaccine schedule, Schuchat told me.

In the event that a vaccine is removed from the schedule, the experts I spoke with remain hopeful that some entity, such as a state health department, a community health center, or philanthropy, would step in to provide uninsured kids with free shots. But who or what, besides the federal government, could provide vaccines at the necessary scale is an open question. “It’s going to require some sort of extraordinary effort to provide that access,” Richard Hughes IV, a professorial lecturer in law at the George Washington University Law School, told me. VFC works so well not only because it provides vaccines free of charge but also because it is designed to ensure that doctors always have a supply of vaccines on hand—the CDC purchases vaccines and then provides them for free to doctors, who then dole them out to children in need.

Medicaid could still provide some backstop for the poorest children, experts told me, but a likely scenario seems to be a system in which private insurers continue to cover vaccines, while poor children are left behind. Such a scenario is “the definition of a health-care disparity,” Christoph Diasio, a pediatrician in North Carolina, told me.

America has seen this type of vaccine inequity before. Beginning in 1989, measles tore through several cities—including Los Angeles, Houston, and Chicago—precisely because many low-income children were unable to access the vaccine. “A big part of the problem was, kids were in the doctor’s office, but because they weren’t insured, the doctors were referring the family to the health department,” Schuchat told me. “That extra visit was something that was not easy for parents to find the time to get to.” Researchers estimated that nonwhite preschoolers were seven to 10 times more likely to contract the virus than white children. It was this outbreak that led to the formation of the VFC program in the first place.

In his time as secretary of Health and Human Services, Kennedy has claimed that reforms to Medicaid would improve the program, despite projections from the Congressional Budget Office that the change would kick millions off of the safety-net program. He has decimated minority-health offices in his department in the name of government efficiency. And he has said that vaccine changes will be made in line with the latest science, despite overwhelming evidence to the contrary. Now, in the name of following the science, Kennedy is on the cusp of creating a two-tiered vaccine system.

The world’s market for vaccines, as it exists today, depends on the United States. The U.S. has poured immense resources into the design and development of vaccines, and has paid far higher prices for doses than most other nations can afford. The federal government has issued broad vaccine recommendations, generating strong, consistent demand. “That’s a predictable market,” Richard Hughes IV, a public-health-law expert and the former vice president of public policy at Moderna, told me. It’s also a huge one. Seth Berkley, the former CEO of Gavi, which supports the immunization of about half the world’s children, told me that the U.S. accounts for 35 to 40 percent of global vaccine revenue at a minimum, more than all of Europe combined.

But since the start of this year, when Robert F. Kennedy Jr.—one of the nation’s most prominent anti-vaccine activists—took charge of the Department of Health and Human Services, the federal government has signaled that it is no longer a reliable partner in the business of vaccines. The Trump administration has fired vaccine experts, tightened vaccine regulatory policies, restricted vaccine recommendations, and spread misinformation about vaccines’ harms. It has halted its funding of Gavi. It has canceled hundreds of contracts for vaccine research across multiple agencies. “Even before the change in policies that are being implemented now, vaccines were a difficult business,” Andrew W. Lo, an economist at MIT, told me. “It’s just become that much harder.”

In response, companies are paring back. Multiple vaccine makers suffering from the American government’s recent attacks have announced layoffs or a demerger of their vaccine division, as their stocks fall. These include Moderna, which HHS recently stripped of more than $700 million in grant funding for its pandemic-flu shots. Also among them is the Australian biotechnology company CSL, which sells two flu vaccines to the U.S. that contain thimerosal, a mercury-based preservative that Kennedy’s handpicked CDC vaccine-advisory panel recently recommended against, despite decades of evidence showing the additive is safe. (Last month, CSL noted that a recent dip in flu-vaccine uptake in the U.S. had put “competitive pressure” on its vaccine profit margin; a CSL spokesperson told me in an email that the company expects American vaccination rates to recover. Moderna declined to comment.) More instability is likely ahead. The CDC’s vaccine advisory panel meets again today and could vote to restrict guidance for several immunizations, including ones that protect infants against measles, mumps, rubella, chicken pox, and hepatitis B.

When reached for comment, an HHS spokesperson wrote over email that “Secretary Kennedy serves the American people, not the interests of Big Pharma,” adding that the department was “not limiting access to vaccines, but rather returning focus to the doctor-patient relationship.”

Legitimate critiques can be made of the pharmaceutical industry’s incentives and pricing strategies. But from a financial standpoint, vaccines have always been a bit of an underdog for pharmaceutical companies. As preventative products, designed for healthy people, they’re held to an especially high safety standard—a requirement that reliably drives up the expenses of development and testing—and they need to be widely accessible, which puts pressure on manufacturers to keep their price tags low. Individual vaccines are also used, at most, a few times over a lifetime—another cap on potential revenue. What’s more, “it’s very hard to charge money for something that patients don’t immediately need,” Lo told me: They might clamor for a new heart medication or cancer drug, but persuading healthy people to inject a foreign substance into their body can be trickier. Throughout the past half century, the vaccine industry has also been threatened repeatedly by lawsuits over potential vaccine side effects.

To their makers, then, vaccines are a big risk for a potentially low reward. That makes the market for them one of the most fragile in the pharmaceutical industry, Rajeev Venkayya, the former head of Takeda Pharmaceuticals’ vaccine unit, told me. Those realities have driven plenty of vaccine makers out of the market, experts told me—whether via mergers, bankruptcy, or strategic decisions to focus on other products. In 1967, 26 companies produced vaccines for the U.S.; by the mid-2000s, fewer than half a dozen were left—and the nation was staring down shortages of nine of the 12 childhood vaccines recommended at the time.  

In the two decades since, the industry has rallied, Berkley told me, especially as profitable “blockbuster” vaccines, including pneumococcal vaccines, HPV vaccines, and, most recently, COVID-19 vaccines, have grown into billion-dollar markets or more in the United States. The U.S.’s deep pockets helped—as Berkley pointed out, the federal government pays about 20 times what Gavi does for pneumococcal vaccines—but so did federal policies that have increased incentives and lowered risks for manufacturers. And when the public’s trust in vaccines has been threatened, often the government has emphasized that American immunizations have been well vetted and urged the public to continue getting them, Jesse Goodman, who served as the FDA’s chief scientist until 2014, told me.

Now the Trump administration is doing essentially the opposite—most dramatically, so far, for COVID vaccines. Trump’s FDA has limited who can access the shots and made seeking approval for new versions more difficult. The CDC has also muted its COVID-vaccine guidance. Every expert I spoke with for this story expected more changes to the regulatory pipeline that all vaccines must pass though. And the people Kennedy has chosen to oversee vaccine policy and sit on the CDC’s vaccine-advisory commitee—COVID contrarians and vocally anti-vaccine researchers—are making the U.S. a highly unappealing market for all vaccine makers, experts told me.

Without clear, strong recommendations, demand will likely be uneven, making it difficult for manufacturers to estimate how much product to make; without vaccine experts using evidence to advise the government, companies can’t trust that the clinical-trial data they produce, vouching for vaccine safety and performance, will be fairly or accurately assessed. Across the National Institutes of Health and the Biomedical Advanced Research and Development Authority, Trump officials have also defunded billions of dollars’ worth of vaccine-related grants. That includes half a billion specifically for mRNA-based vaccines—jeopardizing the development of future immunizations, including those designed to protect against pandemic flus. And new roadblocks in the approval process will hinder companies trying to bring products to market, making the up-front costs of research, development, and testing that much bigger a gamble. “All of this creates more chaos and uncertainty for vaccine manufacturers,” Grace Lee, a pediatrician and a former chair of ACIP, told me. “Why would you take these additional risks, where it is not clear from week to week what will happen?”

Large, long-established pharmaceutical companies with wide-ranging drug portfolios will likely have the resources to weather a dip in demand. But smaller biotechnology companies, which already tend to operate on thin margins, “will get out of the business,” Lo told me—which, in turn, will likely discourage other vaccine-focused companies from starting up. Venture capitalists have taken note of the circumstances: “The sense right now is that the market’s going to be unstable,” Berkley told me. “This is not the time to invest heavily in new or better products.”

The Trump administration could also nudge companies to exit the vaccine business by making them more vulnerable to legal risk. Most immediately, Kennedy could rescind a pandemic-era declaration that has protected COVID-vaccine manufacturers from excessive liability. He has also announced his intention to amend the Vaccine Injury Compensation Program, which experts worry could take the U.S. back to a time when lawsuits nearly destroyed the vaccine market. Congress established the VICP in the 1980s, after a flood of litigation against the makers of a pertussis vaccine persuaded all but one company supplying the U.S. to stop selling it. (The lawsuits were spurred in part by since-debunked claims that the vaccine caused permanent brain damage.) Today, the program simultaneously acknowledges the rare but very real side effects of vaccines, and gives vaccine makers an important liability shield. Funded by a tax on manufacturers, it offers compensation for certain vaccine injuries that are already backed by evidence; other claims are heard in a kind of vaccine court. Major alterations to the program, Anna Kirkland, the author of the book Vaccine Court, told me, would require Congress to act. Still, some experts told me they fear that Kennedy could push for autism to be added to the list of compensable vaccine injuries, as part of his effort to advance the debunked narrative that vaccines cause the condition. That change could flood the program with claims, rapidly drain it, and give manufacturers another reason to pull away from making vaccines.

The exit of even just a handful of manufacturers from the U.S. market could mean shortages of certain vaccines, on disastrously quick timelines. In 2004, for instance, the U.S. lost half of its supply of seasonal flu vaccine after one of the country’s two flu-shot manufacturers at the time, Chiron, temporarily shut down one of its factories because of potential contamination. Several vaccines on the American childhood immunization schedule still rely on only one or two manufacturers, Goodman told me. Among them are the shots that guard against HPV, varicella, and rotavirus.

A wind-down in vaccine manufacturing for the U.S. wouldn’t just invite outbreaks of known diseases. The country would also be exceptionally ill-equipped to respond to the next pandemic. Manufacturers managed to debut the world’s first COVID-19 vaccines in less than a year—a record—because the government was eager to fund their development and because companies could trust that the government would buy them. That mRNA vaccines would arrive first was never a foregone conclusion, either; Operation Warp Speed succeeded in part because federal agencies offered resources to a wide range of vaccine companies. Several of the experts I spoke with agreed: If a new pandemic were to ignite in the current climate, “Operation Warp Speed Part 2 would not operate at warp speed,” Lo said.

If the U.S. vaccine market shrinks, it can rebound, as it has before. But the amount of time that will take, experts told me, will depend heavily on just how thoroughly vaccine infrastructure is dismantled. Already, the scale of destruction is unlike any they have ever seen before. Perhaps, if the world is fortunate, demand and supply will rebound within a couple of years, Goodman said. But if manufacturers go out of business, if factories close, if some vaccines have their licenses entirely stripped, rebuilding could take decades. For now, most Americans continue to strongly support vaccination. But if Kennedy and the rest of the Trump administration succeed in draining the U.S. of its vaccine supply, Americans could soon be forced into a position where they cannot access immunizations—no matter how badly they may want them.

Three months into its tenure, Robert F. Kennedy Jr.’s handpicked vaccine advisory committee has taken down one of its easiest targets.

Today, its members voted to limit the national guidance for a childhood vaccine that has helped protect infants against some of the most dangerous and fast-spreading viral diseases in the United States. If the CDC adopts the committee’s advice, the agency will no longer recommend the combination measles-mumps-rubella-varicella (MMRV) vaccine for kids younger than 4, defaulting their first dose of protection against MMR and chickenpox to two separate shots. The committee also discussed shifting the recommended timing for the first dose of the hepatitis-B vaccine from birth to at least one month old, unless the mother tested positive for the virus during pregnancy. It plans to vote on that question tomorrow.

These vaccines are among the most vulnerable to being challenged, on the grounds that they appear more risky or seem less necessary than the rest of the immunizations the CDC recommends. Some other high-income countries, for instance, do not recommend the hepatitis-B vaccine universally at birth; MMRV vaccines have been linked to an increased risk of certain side effects in children under 2.

Helen Chu, an infectious-disease specialist at the University of Washington, told us she sees no reason to alter the current recommendations for these vaccines. But she can imagine how they fit into a broader strategy: “If you were going to pick, these are good ones to pick off first.” (Chu was a member of the vaccine advisory panel, known formally as the Advisory Committee on Immunization Practices, or ACIP, until Kennedy abruptly dismissed her in June along with the other 16 sitting members.)

This seems to be an agenda of Kennedy’s own design. In the past, ACIP has considered changes in guidance prompted by evidence—a new shot being brought to market, the release of new data on a vaccine’s effectiveness or safety. Now Kennedy himself is driving much of what the committee discusses, including today’s deliberations on hepatitis B and MMRV, Demetre Daskalakis, the former director of the CDC’s National Center for Immunization and Respiratory Diseases, told us. “Those were dictated topics,” he said. (A spokesperson for the Department of Health and Human Services told us via email that Susan Monarez, the most recent CDC director, approved the agenda before she was fired last month.)

Going after these relatively weak spots in the national immunization schedule makes it that much easier for Kennedy’s ACIP to cast other vaccines as dispensable. To Margot Savoy, a senior vice president at the American Academy of Family Physicians, this looks like “a very calculated approach.” (The AAFP is one of several professional medical societies that recently published vaccine recommendations that openly diverge from the CDC’s in response to Kennedy’s overhaul of U.S. vaccine policy.) Many of Kennedy’s initial attacks against immunizations have focused on COVID vaccines, capitalizing on lingering and highly politicized resentment over pandemic-era policies. And in June, at the first meeting of Kennedy’s newly reconstituted ACIP, the committee voted to drop its recommendations for flu vaccines containing the mercury-based preservative thimerosal—a decision that played on decades-old fears, fueled by anti-vaccine activists, that the compound can cause harm, despite years of evidence showing that it doesn’t.

Those early decisions were relatively limited in their impact. Last flu season, less than 5 percent of flu vaccines in the U.S. contained thimerosal. COVID-vaccine uptake had already been declining for years and was never very high among children; the previous iteration of ACIP was already considering paring back some of the recommendations for COVID vaccines before Kennedy fired all sitting members. But those restrictions also paved the path for this week’s votes, which could delay protection for millions of children in the years to come.

Compared with MMR and varicella vaccines that are administered separately, MMRV vaccines do have a higher risk of febrile seizures (which, while frightening to watch, usually resolve on their own and don’t generally carry long-term risks). The CDC once recommended MMRV over separate shots, but as the data on seizures emerged, the agency shifted its guidance to prefer giving the first dose of the MMR and varicella vaccines separately. Several ACIP members suggested today that the vaccine and its side effects were still poorly understood, and that safety issues would crater trust in vaccines overall.

But the experts we spoke with pushed back on that notion. The CDC previously kept MMRV as an option in part to offer more choices for families—especially ones that don’t interact regularly with the health-care system or prefer fewer injections. Edwin Asturias, a pediatrician at the Colorado School of Public Health and one of the ACIP members Kennedy dismissed in June, told us. Each year, about 10 percent of families opt to give MMRV as their child’s first dose, a spokesperson for the pharmaceutical company Merck, which manufactures the vaccine, told us. Removing that option, experts said, could dissuade some families from vaccinating their children against those viruses at all. The committee did vote to preserve MMRV’s status in the Vaccines for Children program, which offers shots to millions of families that can’t afford them—but the conflict between today’s votes adds substantial confusion into how to immunize children against these four viruses.

In making the argument for delaying the first dose of the hepatitis-B vaccine—which Kennedy has refused to say doesn’t cause autism, despite numerous studies showing no association—the committee built a more multifaceted case. Its members spent hours today casting doubt on the vaccine’s safety, despite being shown again and again strong evidence that it’s one of the safest shots made today. “I’m just not sure I see the data that suggests: Where is the benefit?” Retsef Levi, one of the ACIP members, said. “I’m not sure I see the impact of universal vaccination, and definitely not on day zero of life.” Martin Kulldorff, the committee’s chair, pushed CDC officials presenting at the meeting to compare the U.S. vaccination schedule with those of other developed nations that don’t recommend a universal birth dose.

But Adam Langer, a CDC official who presented background information about hepatitis-B shots at the meeting, pointed out that those nations tend to have universal health care and screen more than 90 percent of pregnant women for hepatitis B. In the U.S., prenatal care is spottier, especially early in pregnancy, when testing is typically done, Asturias noted. And the people most likely to miss out on prenatal care tend to be the ones at highest risk of having the virus; about 12 to 16 percent of pregnant women are never tested at all. Babies can also contract the highly infectious pathogen shortly after birth from family members, caregivers, children, and even surfaces. Once the virus takes hold in a newborn, it has a high chance of going on to cause liver damage, cancer, or even death.

Researchers credit the guidance to give all infants the vaccine, issued in 1991, with decreasing rates of acute hepatitis-B infection among young children by 99 percent. Delaying the first dose of the vaccine by even a month, experts told us, would risk the health of vulnerable infants and potentially reduce rates of hepatitis-vaccine uptake overall, because it would rely on families receiving the shot at the pediatrician—if they have one—rather than by default at the hospital. “I have not seen any data that says that there is any benefit to the infant of waiting a month,” Langer said during the meeting, “but there are a number of potential harms.”

The committee made its choice about MMRV at breakneck speed. In advance of meetings, ACIP has typically assembled work groups that would evaluate the evidence on vaccines, then share their analyses with their colleagues and the public. Major decisions would not be made without an assessment of the benefits and risks of each option. All of that has gone out the window. Experts from professional societies, in the past invited to advise committee members, have been barred from participating in work groups; five committee members were added to ACIP just days before today’s meeting. At a Senate hearing yesterday, Debra Houry, who resigned recently as the CDC’s chief medical officer, told senators that she was discouraged by a senior adviser at the agency from providing data or asking questions about changes to the hepatitis-B recommendation. (Kulldorff did, at the last minute, announce that the hepatitis-B vote would be delayed until tomorrow, citing a “slight discrepancy” in the proposed voting questions.)

This ACIP, experts pointed out, seems uninterested in discussing vaccines’ benefits. Instead, it has been building the case that many vaccines pose excessive risk, and that the U.S. is pushing far more of them than are necessary. The intention seems to be to “cast the previous committee as less concerned about safety than they are,” Kelly Moore, a former ACIP member and the president of Immunize.org, a nonprofit supporting immunization, told us. They appear to be suggesting that the CDC has saddled the public with an unsafe, bloated vaccine schedule that Kennedy’s chosen cohort will now fix.

These early shifts—less COVID vaccination; fewer options for flu, MMR, and chickenpox vaccines; and, perhaps soon, delays to the hepatitis-B schedule—may seem benign enough. But that may be part of the point. Kennedy and his allies are testing the waters, but they’re also accustoming the public both to the idea of fewer vaccines and to the routine of doubting vetted immunizations. The more logical their early choices seem, the more reasonably Americans might assume the ones that follow are too. “By the time people realize we’re in a bad way, we’re going to be so far in a bad way, we won’t be able to get back out,” Savoy told us. Whether vaccine infrastructure disappears by erosion or rapid demolition, the end result will be the same: a nation far less protected than it once was and could still be.

Americans across the political spectrum are aligned on at least one belief, albeit for different reasons: The CDC is a mess. In a poll conducted this summer by The Washington Post and KFF, a nonpartisan health-policy organization, Democrats and Republicans alike expressed low confidence that the agency could be trusted to make independent decisions based on scientific fact. Robert F. Kennedy Jr., as the head of Health and Human Services, has described the CDC as dysfunctional and politicized; according to the former CDC director Susan Monarez, he has also disparaged the agency’s workers as child murderers. Meanwhile, public-health experts—a group that has historically worked in tandem with the CDC—now question the agency’s credibility with Kennedy in charge. “You can’t trust anything that comes out of the CDC,” Michael Osterholm, who directs the University of Minnesota’s Center for Infectious Disease Research and Policy, told me.

Today, Monarez testified before a Senate committee that Kennedy fired her after less than a month in her role because she refused to accept his vaccine policy. According to Monarez, Kennedy demanded “blanket approval” of all recommendations made by the agency’s Advisory Committee on Immunization Practices, which Kennedy dismantled in June and has since remade in his own anti-vaccine image. Over the next two days, the group is scheduled to discuss vaccines for COVID, hepatitis B, and other diseases. According to a Washington Post report, at the meeting, Trump-administration officials also plan to use a database of unverified vaccine-injury reports to link COVID shots to the deaths of 25 children.

The Department of Health and Human Services and the CDC did not respond to requests for comment for this article. Kennedy has previously claimed that he fired Monarez because she told him she was not trustworthy. And in response to the Post report, Kennedy’s spokesperson said, “Any recommendations on updated COVID-19 vaccines will be based on gold standard science and deliberated transparently at ACIP.”

If the CDC is no longer the reliable source of health guidance it once was, Americans must find reliable information elsewhere. (Even Americans who don’t regularly seek out the agency’s advice generally receive it through their doctors and local officials.) Physicians, researchers, and public-health experts I spoke with told me that academic and public-health institutions can be trustworthy sources but also that no existing institution in the United States is equipped to replace the CDC. Kennedy has long encouraged Americans to do their own research on health matters and especially on vaccines; now we have no choice but to follow his advice.

Some public-health experts I spoke with emphasized that the CDC can no longer be trusted specifically on vaccination. Paul Offit, the director of the Vaccine Education Center at Children’s Hospital of Philadelphia, told me that the agency’s vaccine-credibility problems lie with ACIP. Ashish Jha, the dean of Brown University’s School of Public Health and the Biden administration’s COVID czar, agreed. “Whatever ACIP recommends, it is not coming from expertise and an understanding of the scientific process,” he told me.

[Read: What it’s like to work inside a broken CDC]

To some extent, Americans don’t have much of a choice about whether to follow the CDC’s guidance. It determines, for instance, what vaccines are administered through a federal program called Vaccines for Children that offers free shots to more than half of American kids. Some state governments have updated their policies in response to the vaccine chaos the federal government has inflicted in recent weeks, but many states still follow CDC recommendations to shape school vaccine requirements and regulations on insurance coverage.

When Americans do need vaccine advice, Jha said, most turn to their health-care providers, who themselves generally go to the CDC for information. Physicians “used to have a single place to look, and now we don’t,” Offit said. All of the experts I spoke with agreed that, as an alternative, professional medical organizations are among the most trustworthy sources for vaccine information right now. For many years, these groups have released guidance on vaccination, largely intended for health-care providers, based on the latest science. “The difference today is that they just don’t align with the federal government,” Katelyn Jetelina, who writes the public-health newsletter Your Local Epidemiologist, told me. The American Academy of Pediatrics and the American College of Obstetrics and Gynecology, for instance, recently published their own guidelines contradicting the CDC’s stance on vaccination for children and during pregnancy, respectively.

Medical organizations form their recommendations based on their review of the scientific evidence, not the CDC’s, Jennifer Kates, a public-health expert at KFF, told me. According to other experts I spoke with, additional trustworthy sources include the American Academy of Family Physicians, the American College of Physicians, and the Infectious Diseases Society of America. These groups can be trusted because they review updated scientific evidence every year, Jetelina said. Their leaders are also, crucially, not appointed by politicians.

[Read: A massive vaccine experiment]

Science organizations are also working to interpret the latest evidence for providers and policy makers. Multiple experts applauded Osterholm’s Vaccine Integrity Project, which describes itself as “dedicated to safeguarding vaccine use in the U.S. so that it remains grounded in the best available science.” Caitlin Rivers, a professor at Johns Hopkins Bloomberg School of Public Health, recommends Immunize.org, a nonprofit that gears similar advice toward health-care providers. The Pandemic Center at Brown University publishes a weekly tracking report on infectious diseases. During the recent measles outbreak centered in Texas, the Pandemic Center’s data contradicted Kennedy’s assertions that the crisis was subsiding, Jennifer Nuzzo, the director of the Pandemic Center, told me.

All of these sources provide good information, but they also offer slightly different takes on the available research and data. In the past, the CDC helped unify varying scientific interpretations, incorporating them into consensus guidance. “You really can’t replicate that, not in any academic institution, not any state health department, not in any professional society,” Tom Frieden, a former CDC director who is now the president and CEO of the global-health nonprofit Resolve to Save Lives, told me. Without sound input from the agency, the vaccine-information landscape is fragmented—which, Jetelina told me, will likely accelerate the atomization of American vaccine policies, behaviors, and beliefs. Already, state-level vaccine recommendations are diverging along political lines. After the CDC changed its recommendations to restrict eligibility for annual COVID shots, more than a dozen blue states began changing their vaccine policies to expand access. Meanwhile, Florida and Idaho have attempted to cancel schools’ vaccine mandates. In Louisiana, the health department has forbidden its employees from promoting “mass vaccination.”

The divided vaccine-information landscape will make it even harder for doctors and everyone else to sort fact from fiction. Some of the advice physicians receive from medical societies is already at odds with what the CDC recommends. “It’s going to create real conflict for them about what they should do,” Jha said. Ultimately, politics may determine who providers end up trusting, Offit said. Jetelina worries that the mixed messages, combined with Kennedy’s anti-vaccine signaling, will decrease confidence in vaccines. An obstetrician I interviewed recently told me she has already observed a rise in vaccine hesitancy among her pregnant patients since the CDC stopped recommending COVID vaccines for them.

[Read: Moms are losing options to protect newborns from COVID]

The experts I spoke with agreed that as long as Kennedy oversees the CDC, its trustworthiness is at stake. The continued gutting of its staff—and their replacement with non-experts—will further weaken its ability to vet and publish science-based guidance. Americans have long valued medical autonomy. But we’re now getting a sense of what happens when it’s all we have.