Medical News

Photographs by Kristian Thacker

This article was featured in the One Story to Read Today newsletter. Sign up for it here.

A few years ago, West Virginia, which has the highest obesity rate in the nation, quietly began a small and unusual pilot program that would touch hundreds of lives: It started covering obesity drugs for state employees—even as many other insurers balked at what they considered expensive “vanity” drugs.

The program was, by health measures, a success. Patients shed as much as 120 pounds, their cholesterol dropped, their prediabetes faded, and they cut down on blood-pressure meds. As word began to spread, more patients wanted to join. A school nurse told me her weight loss inspired at least six other teachers and staff to get into the pilot program too.

Then it all came to an abrupt end. In March, the state’s Public Employee Insurance Agency (PEIA) decided it could no longer bear the crushing costs of Wegovy and Zepbound. (These obesity drugs are sometimes better known by the brand names Ozempic and Mounjaro, respectively, which is how they are sold for diabetes.) In the months after, PEIA patients began running out of medication. They rationed their remaining supplies, stretching the weekly injections to 10 days, two weeks, even three weeks. They considered copycat compounded versions. One woman began sharing her diabetic mother’s Ozempic. Those who could no longer get the drugs felt their “food noise,” the constant thoughts about eating that the obesity drugs suppress, return with a vengeance. And they have regained weight.

West Virginia’s pilot program is a microcosm of the dilemma posed by new obesity drugs that are at once effective and shockingly expensive. Patients, doctors, and insurers alike are stuck in an intractable situation. Since the program ended, Laura Davisson, the director of medical weight management at West Virginia University, told me, “there’s a lot of desperation that we’re seeing in our practice.” Her center was one of a handful in the state’s pilot program, which was always small; it enrolled about 1,000 patients at its peak, a tiny fraction of the more than 200,000 West Virginians who rely on PEIA. (About two in five people in West Virginia have obesity.) And these 1,000 patients have since become unwitting subjects in an experiment about what happens when patients are given a life-changing drug—only to have it taken away.

Megan Pigott is what one might call a Wegovy super-responder; she lost 120 pounds, more than a third of her body weight, after starting the drug in 2022. Before that, she had been counting calories since elementary school; she had tried SlimFast shakes, a cabbage-and-green-pepper-soup diet that left her miserable, and an older obesity drug called liraglutide. Nothing worked as well as Wegovy, which WVU prescribed for her as part of a weight-management plan that also included dieting and exercise. The drug is meant to be taken indefinitely, first to help patients lose weight and then to keep it off. Wegovy, Pigott told me, finally gave her hope.

After PEIA cut off coverage, she ran out of Wegovy in July. Half of the weight she lost has already come back. She is now considering a generic version of liraglutide, despite the drug causing vomiting and diarrhea when she previously took it. (Wegovy can cause these side effects, too, but Pigott personally found them milder.) To afford even this cheaper and less effective medication, she plans to drive an hour and half to the nearest Rite Aid, which takes a coupon that reduces the cost to $245 a month. Wegovy’s out-of-pocket price, which is more than double that even with a manufacturer’s coupon, is out of the question. “I felt like a drug seeker,” Pigott told me, going to such lengths for medication to lose weight. She is willing to try because, like other PEIA patients I interviewed, she found that managing her obesity had reversed so much of what ailed her body.

When Cassie Hornbeck Maxwell started Wegovy, she had already been diagnosed with prediabetes, sleep apnea, and polycystic ovarian syndrome, a hormonal disorder that can cause irregular periods—all of which are associated with obesity. “I had given up on myself,” she told me. “I had given up on my health.” With Wegovy, her health problems faded away one by one: Her blood sugar went down, she stopped needing a CPAP machine to sleep, and her periods became regular. Her experience matches growing anecdotal and clinical evidence that obesity drugs can mitigate these associated conditions.

Hilaria Ireland Swisher has cut her use of blood-pressure medication in half. She told me she had cried when she first started on Zepbound, so overwhelmed was she to have—after a lifetime of dieting, dieting, dieting, and regaining the weight anyway—a drug that might finally end her health struggles. Obesity made her everyday life difficult: She used to lose her breath climbing a flight of stairs, and her feet would ache for days after outlet shopping with friends. But the drug-induced weight loss kicked off a virtuous cycle. She can move without pain, so she can be more active and keep healthier habits. Now she goes to the gym twice a week.

This is why patients on PEIA don’t want to lose access to the drugs. Whatever the downsides of the drugs—the long-term side effects are still unknown—patients don’t want to go back. The pilot program has been a bit of a roller coaster for patients, says Bisher Mustafa, a weight-management specialist at Marshall Health, one of the centers in the PEIA pilot program. Davisson at WVU has been advocating for PEIA to keep at least the patients in the pilot program on the drugs. Kicking them off Wegovy and Zepbound now, she argues, would reverse the progress already made: “All that money you just put in, you’re going to throw away.”

Around the country, however, other insurers faced with the same costs as PEIA have been largely unswayed by the argument that covering obesity drugs will ultimately save money, by preventing obesity-related conditions such as diabetes and heart attacks down the line. North Carolina also dropped coverage for state employees earlier this year, and private insurance has been cutting patients off too. Wegovy and Zepbound are still new enough that firm evidence of cost savings is hard to come by. A handful of studies and simulations, though, suggest that any future health savings will still be dwarfed by the cost of the drugs, at least at current prices. A simulation from Wegovy’s manufacturer, Novo Nordisk, for example, found a savings of $85 million over five years for 100,000 patients—but the current list price of Wegovy over that same period would run $8 billion, a huge discrepancy even if insurers do not pay full price.

In West Virginia, PEIA says it was struggling with costs: The pilot program for 1,000 patients ran at roughly $15 million a year at its peak. Expanding it to 10,000 patients would require $150 million a year, or 40 percent of the agency’s total prescription-drug budget. “I’ve laid awake at night pretty much since I made the decision,” the agency’s director, Brian Cunningham, said in June. “But I have a fiduciary responsibility, and that’s my No. 1 responsibility.” (PEIA did not respond to The Atlantic’s questions about ending the pilot program.) Shutting down the pilot program puts West Virginia in line with other states: Most never covered the obesity drugs for state employees in the first place. Only about a quarter of Americans, with any sort of insurance, have coverage for these medications, according to Obesity Coverage Nexus.

For the West Virginians who briefly gained and then lost coverage, this talk of numbers can feel rather abstract compared with the change they feel so viscerally in their bodies every day. To insurers, a heart attack averted might be a number in a spreadsheet, but to patients, this is their life. Some have written letters to PEIA and state legislators pleading their case. Angela Young, a retired state employee (who wasn’t part of the pilot but lost coverage when she got on PEIA after a divorce), put it to me most bluntly. She feels the extra weight in the knee she had replaced. She struggles with shortness of breath and heart problems. “I’m assuming,” she said, “this is eventually going to kill me.”

Even a short stint on the obesity drugs, PEIA patients told me, changed their lives in ways beyond the physical. “When you’re an overweight person, it’s like you’re invisible,” Lory Osborn said. “Like you’re less than a person,” Randi Bourne, the school nurse with six co-workers in the pilot program, told me. They had always been aware of the fat-shaming, the willful ignoring, the subtle and not-so-subtle disrespect, but losing weight opened their eyes to just how differently society treated people with obesity. Maxwell felt she had lost part of her identity when she was seen first as “the fat person.” Losing weight finally let her be seen as herself—as Cassie—but would regaining it erase a part of her identity again?  

The drugs also made Maxwell rethink how she thought about herself and about obesity. Like many, she had long considered obesity a problem of self-discipline and motivation. Being on Wegovy and then Zepbound—feeling the food noise disappear with a tweak in brain chemistry—made her see it as a medical condition. Obesity is more complicated than a simple imbalance of the hormone mimicked by these drugs, but doctors do now generally consider it a chronic disease. Maxwell now sees it that way too.

To her, and other patients, that makes PEIA’s decision all the more unjustifiable. “It’s the same thing as giving someone with cancer a cancer drug, or someone with diabetes their insulin,” Swisher said of the obesity drugs. Putting them in a different category, many said, felt like yet another instance of discrimination. Historically, the reluctance of insurance companies to cover obesity medications is born out of a belief that obesity is a personal failing. Medicare is still prohibited by law from covering medications for weight loss; the Biden administration recently proposed a rule to sidestep that law, but the Trump administration would need to approve it.

In the fall, PEIA proposed raising premiums for next year. It even cited the high cost of GLP-1 drugs, the class that includes Wegovy and Zepbound, as a key reason. But PEIA had already canceled the obesity-drugs pilot program. The cost, going forward, would be from funding the drugs prescribed for diabetes. (The pilot program was so small that some 86 percent of the money PEIA had been spending on GLP-1 drugs was still for diabetes treatment. However, about two or three times more people in West Virginia have obesity than diabetes, so expanding the pilot program would make obesity costs much higher.) The agency did not propose eliminating coverage for diabetes.

When Pigott started Wegovy, she was prediabetic. “One of the reasons I took the medicine was to prevent myself from getting diabetes,” she said. And it worked: Her blood-sugar levels went down. Now her premiums are going up, and she still can’t get the drug—not unless, of course, she eventually does develop diabetes. “It doesn’t make sense,” she said. To get help, she would first have to get sicker.

What have you experienced while taking GLP-1 drugs? Share your story with us.

(By writing to us, you are agreeing to let The Atlantic use your response, which we may edit for length or clarity. You are also agreeing that The Atlantic’s reporters may contact you at the address provided to discuss whether you would be willing to be interviewed.)

Robert F. Kennedy Jr.’s personal health-care routine is perplexing in its inconsistencies. He decries seed oils, despite near scientific consensus that they’re harmless; drinks raw milk, which has been proved to get people sick; and takes testosterone as part of his anti-aging routine while insisting he’s not on anabolic steroids.

Some of his routines, such as downing raw milk for its purported health benefits, are based on bunk science. But his anti-aging protocol seems to be serving him well, even if its most obvious effects look a lot like juicing. While many men in their 70s are focused on staving off broken hips, Kennedy’s use of testosterone—which, despite his protestations to the contrary, is in fact a steroid—means he can crank out a set of pull-ups with ease.

What RFK Jr. does with his own body isn’t anyone else’s business. But his wellness routine is instructive in understanding how he views health-care regulation and self-experimentation. RFK Jr., should he be confirmed as secretary of Health and Human Services, will be America’s self-experimenter in chief. And taking testosterone is his most noticeable experiment.

Testosterone is best known for its role in puberty and in promoting traditionally male characteristics such as muscle mass and facial hair, but it affects countless other bodily functions. Men who don’t have enough testosterone to power these processes might be diagnosed with what’s often called hypogonadism, or low T. Some have testicles that are malfunctioning in testosterone production, while others see a decline in the hormone because of age. Regardless of the underlying cause, the deficit causes the body to function less efficiently.

But the condition can be treated with a relatively simple prescription of testosterone injections or gel, and research shows the impact can improve some of the symptoms of hypogonadism. One large clinical trial found that hypogonadal men on testosterone saw “modest but significantly greater improvements in mood and energy” compared with placebo. Researchers also found that older men with low T and mobility issues saw their ability to walk improve after supplementation, and that testosterone improved bone density.

Although doctors seem to be in agreement about treating men who have an actual problem with their testes, the question of whether to treat men who see their testosterone drop as they age has divided the medical community. There’s no clear reason an aging man with withering testosterone levels would not respond just as positively to testosterone as a man with testicular issues would, but critics argue that for aging men, the benefits are typically modest and can come with downsides. For example, Steven Nissen, a cardiologist who has been involved in testosterone research, has published a paper showing that testosterone supplementation was associated with an increase in bone fractures. The hormone, he told me, “should not be used as a fountain of youth.” The FDA, too, says that testosterone shouldn’t be prescribed to aging men experiencing natural decline, because the “benefits and safety of this use have not been established.”

Kennedy’s use of the hormone as what he calls an “anti-aging protocol” counts as an experiment, given the FDA’s stance. And he is far from the only man in this experiment. Anti-aging clinics ready to provide testosterone prescriptions to men they deem qualified have become ubiquitous online. The company Blokes warns on its website that “men will naturally decline testosterone levels due to aging.” Another, TRT Nation, promises “affordable medications for LOW TESTOSTERONE and Anti-Aging remotely and delivered to your door!”

Every doctor I spoke with was emphatic that only men with low testosterone levels should be on the drug. The long-term side effects of what’s called “hypersupplementation” are largely unknown, and some evidence suggests that benefits are limited when a man is already in the normal testosterone range, Landon Trost, who helped write the testosterone-treatment guidelines for the American Urological Association, told me. Many doctors are also understandably cautious about prescribing the drug to people who don’t have an actual medical condition, because it’s been abused for decades by athletes and healthy men looking to improve their physique. Advertising from telehealth companies, along with data showing that a sizable portion of men who get testosterone don’t even get their levels checked beforehand, lends credence to their fears. “Right now, it’s very much Wild West, buyer beware,” Trost said.

Should Kennedy be confirmed to lead HHS, his interest in testosterone could push the conversation about this hormone to more solid ground. He could, for example, encourage the National Institutes of Health, which he would oversee, to fund additional trials into the hormone’s potential use in aging men; work with the surgeon general to create a public-service campaign that both urges older men to get their testosterone levels checked and warns young people about the risks of abusing the drug; encourage drug makers to conduct more clinical trials; and and even advocate for the drug to be removed from the controlled-substances list, where it has been since 1990, when Congress hastily added it in response to doping scandals and over the objections of the American Medical Association, and where it is now classified as being as dangerous as ketamine.

Some of these actions would likely be applauded even by doctors who take a more conservative approach toward testosterone therapy. But the would-be health secretary has yet to signal any interest in bringing testosterone into the fold of modern medicine.

Kennedy seems attracted to certain wellness products precisely because they don’t have regulators’ stamp of approval. He has not spoken directly about the FDA’s regulation of testosterone, but he has said he wants to end the FDA’s “war on public health” by deregulating “psychedelics, peptides, stem cells, raw milk, hyperbaric therapies, chelating compounds, ivermectin, hydroxychloroquine, vitamins … [and] nutraceuticals.”

The amount of evidence supporting these different therapies and their relative risks varies wildly; what connects them is the FDA’s insistence that people should not self-experiment with them. And should Kennedy succeed in ending what he calls the agency’s “aggressive suppression” of his favored compounds, some Americans could die (using chelating compounds or stem cells, for instance, can be dangerous); others will needlessly throw their money and hope behind treatments that might be marketed as healthy but are no more effective than sugar pills. The FDA was created more than a century ago for the exact purpose of helping Americans avoid these types of problems. By calling for looser oversight of these compounds, RFK Jr. is signaling that patients should no longer trust the FDA’s judgments of what is safe. Instead, the logic follows, they should self-experiment—just like him.

Kennedy might have reasons for finding regulators’ historically conservative approach toward wellness products grating: His anti-aging protocol seems to be working so well that he looks as or more jacked at 70 years old than he did nearly three decades ago. If you got in the best shape of your life with the help of testosterone against regulators’ advice, you might be skeptical of them too.

The best-case scenario, if the country follows RFK Jr.’s lead, will be that self-experimentation pushes forward in some form the science behind these treatments. But each person who forgoes medical care for self-experimentation is one less data point that helps us as a society decide where we have therapies that work, and where we still need more research. That lack of data leaves everyone, except those willing to risk their own health on either their own hunches or those of wellness influencers, worse off. If Kennedy truly believes that these products can make America healthy again, he should channel his experience with self-experimentation into thoughtful regulatory policy. Testosterone could be his first target. With a little faith in the regulatory system he’s been so intent on trashing, he could help the many people who depend on the government to work out these questions. And ultimately, he might convince more of them that some of his favorite experiments stand up to scrutiny.

In 1829, the Presbyterian minister Sylvester Graham invented a cracker made from coarse wheat that he believed would help restore American health. He lamented the “miserable trash” that made up the average diet, especially white bread, and thought his eponymous crackers would curtail masturbation, which he deemed deleterious to both moral and physical well-being. (As someone who condemned sweet treats, he would have seen the s’more as an abomination.)

Graham was, in many ways, what we might today call a wellness influencer. Nineteenth-century Americans opened Grahamite boarding houses so that travelers could eat his chaste and bland foods, and catch up on that week’s copy of The Graham Journal of Health and Longevity. And like many of today’s wellness influencers, he advocated for an ideology that mixed truth and nonsense. Yes, it’s healthy to eat fiber; no, pleasurable foods are not linked to deviant sexual behaviors. Robert F. Kennedy Jr., a wellness influencer who is also President-Elect Donald Trump’s pick for secretary of Health and Human Services, is similarly inconsistent. Kennedy has correctly identified an association between the ultra-processed American diet and high rates of chronic disease, but he’s also an anti-vaccine advocate who has suggested that AIDS deaths are caused by poppers and that seed oils are poison.

Over the past weeks, journalists, doctors, and scientists have rushed to correct Kennedy’s false statements. More than 75 Nobel Prize winners signed a letter this week asking senators to oppose Kennedy’s confirmation, given his “lack of credentials” in medicine, science, and public health. But a better way to understand his appeal is to situate him, with Graham, in a long lineage of American wellness figures waging a battle against conventional medicine. For more than a century, alternative health practices—what we now call wellness—have seduced Americans not because of the accuracy of their claims, but because of what else they offer: a sense of certainty, an outlet for mistrust, a pseudo-religious belief in the “natural,” and an affirmation of modernity’s limits. Because it satisfies those needs, wellness has a pattern of success in presenting itself as a replacement for the failures of medicine, even though the goals of wellness radically diverge from those of public health. The history of wellness suggests that the best way to defuse Kennedy’s power is not by litigating each one of his beliefs, some of which are irrefutable health truisms, but by understanding why the promise of being well has such lasting appeal.

Our Goop-ified world may seem fundamentally modern, but there is a direct line between today’s wellness industry and the 1800s, when what was then called “irregular” medicine exploded in popularity. Through the early 20th century, people sought out homeopathy, osteopathy, naturopathy, water cures, and chiropractors. Religious and spiritual movements such as New Thought and Christian Science promoted the idea that bodily health came from the right state of mind, not medicine.

[Read: I Gooped myself]

These health interventions were largely a response to disillusionment with 19th-century medicine, which was, by today’s standards, painful and ineffective. Doctors depended heavily on bloodletting, vomitive drugs, and other “heroic” treatments that shocked the body into purging its contents. A commonly used drug, calomel, was made of a mercury compound and caused the gums to bleed, the mouth to swell, and teeth to fall out. Irregular medicine offered another option, with conspiratorial undertones: There was a gentler cure that conventional doctors weren’t telling you about. (And unlike calomel, irregular treatments wouldn’t cause your teeth to fall out.) A 1903 osteopathic text decreed, “The world is becoming too intelligent to be drugged and hacked in a search for health when more agreeable methods can be obtained at the same price.”

In response to the unregulated health products being distributed by irregular practitioners and conventional physicians alike, as well as uproar over the unsafe food-handling practices revealed in Upton Sinclair’s The Jungle, the contemporary American public-health apparatus was born. The FDA was created to enforce the Pure Food and Drug Act of 1906, which, among other things, required safe practices for manufacturing food, drugs, medications, and liquors as well as labels that included a product’s dangerous ingredients. Laws limiting the practice of medicine to those with proper licenses became more widespread and more consistently enforced; Benedict Lust, the father of American naturopathy, had to pay hundreds of dollars in fines and legal fees after giving one of America’s newly minted medical detectives an electric-light bath, a treatment that involved sitting in a cabinet with incandescent lights pointed at the body.

As part of their advocacy for the natural, Lust and other irregular doctors also vehemently opposed vaccines. Lust called compulsory vaccination the “most heinous of all crimes.” He even helped nominate a chiropractor for president in 1920 and joined him to promote what they called the American Drugless Platform. Lust was remarkably similar to Kennedy, who decries pesticides, opposes fluoride in tap water, and has long stoked baseless fears about vaccines. Kennedy has said doctors should recommend gym memberships and “good” food to diabetic patients. He has proposed that people who are dependent on antidepressants or opioids could recover on “wellness farms,” an idea remarkably similar to Lust’s well-known naturopathy retreat in New Jersey, which opened in 1896. “His arguments are variations on the same theme that’s been present in public discourse about health in the Western world for a long time,” Colleen Derkatch, a rhetoric professor at Toronto Metropolitan University and the author of Why Wellness Sells, told me.

Many of Kennedy’s most popular crusades are easy to debunk—just as irregular medicine was at the turn of the 20th century. Horace Fletcher, a trendy nutritionist in the early 1900s, told Americans to chew their food until it was liquid before swallowing, and proposed that this would be the solution to starvation and poverty. He inspired the celebrity doctor John Harvey Kellogg, whose name still graces our cereal boxes and who promoted electric-light baths and 15-quart water enemas. Bernarr MacFadden, another immensely popular health figure, and a bodybuilder, thought that the 1918 Spanish-flu pandemic was caused by poor diet. Even at the time, these ideas were fringe among experts. But they caught on because they spoke to people’s real concerns: about rapid urbanization’s effects on health and lifestyle, and about medicine’s inability to prevent widespread death.

The concerns of modern wellness adherents are no less valid than their 20th-century counterparts. Medical treatment in general has become more effective, but still has sins to atone for: The pharmaceutical industry fueled an opioid epidemic that has killed 800,000 Americans and counting, all while drug prices in the U.S. are nearly triple what they are in other well-off countries. Most of the food available at the average American grocery store is ultra-processed. Some aspects of the public-health response to the coronavirus pandemic, such as shutdowns and school closures, led to distrust of public-health officials—just as happened after the flu pandemic of 1918.

“Low institutional trust is central to RFK Jr.’s popular appeal,” Stephanie Alice Baker, an associate professor at City St George’s, University of London, and the author of Wellness Culture, told me. Kennedy provides what irregular medicine did: an outlet for feelings of betrayal at medicine’s failures, plus the promise of reclaiming control through “natural” means, such as the right diet and supplements. “It’s an empowering message,” Alan Levinovitz, a religion professor at James Madison University and the author of Natural: How Faith in Nature’s Goodness Leads to Harmful Fads, Unjust Laws, and Flawed Science, told me. “It means you don’t have to be scared of getting sick if you eat the right foods.”

Irregular medicine began to fade out only once the U.S. entered the “golden age of medicine,” when conventional treatments became more effective and less terrifying. The first antibiotic was discovered in 1928 and was widely available after World War II. The polio vaccine was released in 1955, and two years later, annual cases had dropped almost 90 percent, making older arguments against “germ theory” far less compelling. Practices like homeopathy and osteopathy took a back seat to “wonder drugs” that could address infectious diseases such as smallpox and tuberculosis. But after these successes, medical and public attention shifted to chronic, noncommunicable ailments: cancer, diabetes, heart disease, and the like. The golden age of medicine was ill-equipped to counter these maladies, and once again, as the luster of conventional health expertise waned, wellness surged.

Halbert L. Dunn, the chief of the National Office of Vital Statistics, coined the term wellness in 1959 when writing about health-care providers’ dissatisfaction with the ability of medicine to care for the “spirit.” He helped to reignite interest in alternative medicine, and its emphasis on vegetarianism, exercise, and natural living. Alternative medicine became a national trend in the 1970s, entwined with the antiauthoritarian countercultural movement. Crucially Dunn considered wellness not a replacement for or foe of medicine, but its complement. Medicine was a reaction to illness; wellness was a practice you engaged in when healthy. But doctors rushed to defend the ways of conventional medicine. In the late 1970s, the prominent physician Lewis Thomas wrote a commentary in The New England Journal of Medicine warning that the new field of lifestyle medicine was “wide open for magic.” Today, an evidence-based cohort of conventional doctors are still set on debunking wellness practices, while wellness figures decry the failures of medicine and the corruption of Big Pharma.

The pull toward the “natural” can be especially enticing when the world seems designed to make people sick. There’s concern about “forever” chemicals while food comes wrapped in plastic, and wildfires send smoke pouring across continents. Levinovitz has argued that, in the wellness world, the term natural assumes a pseudo-religious status. It provides comfort, ritual, and community. If wellness is a church that views “clean” or “natural” food as sacred, and additives or vaccines as profane, then Kennedy fits neatly within it. Religious beliefs famously cannot be dispelled through arguments over evidence, which does not bode well for anyone who wishes to wrest the American public out of Kennedy’s grasp.

[Read: The sanewashing of RFK Jr.]

Like religion, wellness doesn’t captivate by empirically proving its truth to adherents. But it does meet certain psychological needs. By contrast, the crucial project of the U.S. public-health apparatus is not to soothe its citizens’ existential woes, but to make policies that address the health of the masses. An administration that prioritizes the sacraments of wellness above all—especially if it undermines the efficacy of vaccines, cuts funding for infectious-disease research, and reduces regulation around raw milk—won’t make Americans healthier. This country reckoned with the limitations of wellness’s promises in the last century; perhaps, in this one, Americans can resist substituting wellness for what public health has to offer.

Robert F. Kennedy Jr. has some thoughts about Ozempic. According to the nominee to run the Department of Health and Human Services, the government should not provide the drug for millions of Americans, but instead address obesity and diabetes by handing out organic food and gym memberships. Like many of RFK’s statements, these ideas have elicited some outrage. Their basic premise, though—that Americans should control their weight by eating better and getting exercise—could not be more mainstream.

But this commonsense philosophy of losing weight, as espoused by RFK, the FDA, and really almost any doctor whom you might have asked at any time in recent memory, has lately fallen out of step with the scientific evidence.

Lifestyle interventions have been central to the nation’s decades-long attempt to curb its rates of chronic illness. Eat less, move more: This advice applies to almost everyone, but for those who have obesity or are overweight—about three-quarters of the adult population in the U.S.—dieting and exercise are understood to be among the most important methods to improve their health. Even now, when doctors have access to Ozempic and related GLP-1 medications, which deliver lasting weight loss and a host of life-extending benefits without the need for surgery, changes to behavior still take precedence. Formal treatment guidelines for obesity have affirmed RFK’s approach, more or less, and argued that “lifestyle therapy remains the cornerstone of treatment.” And according to the government, the drugs themselves are fit for use only “as an adjunct” to a reduced-calorie diet and increased physical activity.

This insistence on the status quo has begun to seem a little strange. It’s long been known that prescribing dieting and exercise simply isn’t that effective as a treatment for obesity. People may slim down enough, at least initially, to prevent or help control type 2 diabetes, said Tom Wadden, an obesity researcher at the University of Pennsylvania who has been involved in clinical trials of both lifestyle modifications and GLP-1 drugs as treatments for obesity. But he told me that amount of weight loss will not reverse sleep apnea or prevent heart attacks or strokes.

For people with severe obesity today, even the modest benefits of dieting and exercise seem moot. Over the past few years, clinical trials of Ozempic and related drugs have shown that the “cornerstone” of treatment adds almost nothing to these medicines’ effects on people’s body weight.

The mere possibility that dieting and exercise no longer matter like they used to has produced its share of awkwardness within the field. “I’m going to answer carefully,” David Saxon, an obesity specialist at the University of Colorado’s Anschutz Medical Campus, said when I brought this up with him last spring. “I don’t want you to quote me saying, ‘He doesn’t think lifestyle is important.’” For older anti-obesity drugs, he said, the evidence in favor of prescribing dieting and exercise first (and in addition) is very clear: In clinical trials, patients who received a lifestyle intervention in addition to the drugs lost twice as much weight as those who didn’t.

[From the June 2024 issue: Ozempic or Bust]

But the data tell a different story for the newer drugs, Saxon and other doctors told me. In most of the clinical research on GLP-1s, patients get the medicine in combination with a modest lifestyle intervention: monthly, 15-minute check-ins with a counselor, for example, and advice to cut back on calories and do a couple hours’ worth of exercise, like walking, every week. In one of the large trials of Wegovy, called STEP 1, this approach produced a weight loss among participants of about 15 percent of their body weight. Another trial of Wegovy, called STEP 3, tried something more: Participants were offered biweekly check-ins with a registered dietitian, and they spent their first two months on the drug consuming very-low-calorie meal replacements. Evidence suggests that, in the absence of Wegovy, all of this extra coaching would make a major difference to people’s health. But for people on Wegovy, the benefits were negligible: Those enrolled in the STEP 3 trial lost an average of 16 percent of their body weight, just a hair more than the people in STEP 1 lost. “That speaks to the point that maybe the intensive lifestyle program is not necessary with these new medications,” Saxon said.

He’s seen this play out within the Veterans Affairs system, where he also works. Patients on the older, less potent anti-obesity drugs were expected to participate in an ongoing lifestyle-modification program with monthly check-ins, Saxon told me. Now that he and his colleagues are prescribing GLP-1s, “we don’t really mandate that anymore,” he said, “because we see that even without it, people are maintaining their weight loss with these newer meds.” Eduardo Grunvald, the medical director of the weight-management program at UC San Diego Health, told me that he had the same impression. “The bottom line is that you don’t necessarily need intense lifestyle intervention for these drugs,” he said when we spoke in March.

Even so, obesity specialists, including Saxon, haven’t given up on dieting and exercise. But the field has begun to reevaluate the nature of such guidance. “We need to figure out what it’s going to look like,” Sue Yanovski, who co-directs the Office of Obesity Research for the National Institute of Diabetes and Digestive and Kidney Diseases, told me. Since last year, a series of reviews, editorials, and perspective papers, mostly published in obesity journals, have explored this very question. One paper, for instance, argued that instead of aiming to produce a “quantity” of weight loss, obesity specialists should now emphasize its “quality.” A co-author on that paper, the Wake Forest University obesity doctor and epidemiologist Kristina Lewis, told me that GLP-1 drugs don’t make dieting and exercise irrelevant at all; in fact, they free up patients “to focus on lifestyle intervention in a more refined way,” by clearing out cravings and tabling the need for counting calories. People on Ozempic, she said, and their doctors, too, can start to think about switching to a wholesome diet, being more active, getting more sleep. All of these interventions will be beneficial regardless of your weight.

This all sounds very reasonable, but in a broader context, it also feels like a concession. For decades now, the most ardent critics of the weight-loss industry and of its associated doctors have been saying something similar: Healthy behaviors can and should be decoupled from the single-minded goal of making people smaller. Now, ironically, the tenets of this movement, which came to be known as “Health at Every Size,” are being adapted for the treatment of obesity.

But if lifestyle interventions are meant to have the same benefits for people diagnosed with obesity as they would for anyone, how special is their role in treatment? Lewis and other doctors told me that people on Ozempic might still need some tailored dieting and exercise advice, because rapid weight loss can create specific health needs. For instance, clinical trials found that people on GLP-1 drugs were losing lots of muscle and bone as their bodies shrank in size; in fact, these and other fat-free tissues accounted for 25 to 40 percent of their total weight loss. To mitigate any added risk of weakness or fractures that might result, some experts now suggest that people on these medications should eat more protein and engage in more resistance training than they might in a traditional lifestyle intervention.

[Read: The science behind Ozempic was wrong]

Advice on muscle-building diets and workouts could end up as part of standard care for people on Ozempic. “On a rational basis, I would say that we should be doing this,” Wadden, who was a member of the research team for the STEP 1 and STEP 3 trials, told me. Still, he acknowledged that the evidence for this approach isn’t yet complete. Wadden has been studying lifestyle interventions for people with obesity for decades. Some of that work found that adding resistance training and aerobic exercise to very strict diets did nothing to prevent the disappearance of lean body mass. The people who did these workouts were “really swimming against the current” of the effects of rapid weight loss, he told me. Other obesity researchers have contested the very idea that muscle loss is a problem to begin with. A recent paper from the Journal of the American Medical Association argues that the link between physical frailty and GLP-1 drugs is not supported by the data, and observes that if more than half the weight someone on Ozempic sheds is fat, then they’re sure to end up with a higher muscle-to-fat ratio than they had before.

[Read: The ‘peak obesity’ illusion]

Doctors still don’t fully understand why people on GLP-1s lose so much weight to begin with. Ozempic may be working, on its own, to foster different ways of eating, Wadden told me. “The drug changes your diet dramatically without a lot of conscious effort,” he said. “How does it change? We don’t know.” People on the drug may end up eating less across the board, while sticking to whatever diet they had before: One Pop-Tart for dinner, let’s say, instead of five. (In that case, meetings with a dietitian would be very helpful.) But the drugs might also work to shift people’s tastes. “So all of a sudden you like more fruits and vegetables,” Wadden said, “and you like lean proteins.” Similar questions may apply to exercise: The mere fact of losing lots of weight could lead someone to engage in more physical activity, regardless of their access to a gym or time spent with a trainer. The studies that might sort this out haven’t yet been run.

Wadden, like many other doctors, remains convinced that dieting and exercise should continue to be the standard therapy for people who are overweight or who have moderate obesity. But for people with more weight to lose—the tens of millions of Americans whose BMIs are higher than 35, let’s say—he now believes the rules are changing. For this group, he said, “I don’t think lifestyle modification is any longer the cornerstone of obesity treatment.”

Two very ugly, uniquely American things happened yesterday: A health-care executive was shot dead, and because he was a health-care executive, people cheered.

UnitedHealthcare CEO Brian Thompson was murdered yesterday outside his hotel in Midtown Manhattan by an unknown assailant. In response, a post on X wishing that the murderer would never be caught racked up 95,000 likes. Social media was littered with jokes about Thompson’s pending hospital bills, and the tragedy of him not returning to his “mcmansion.” The mood was summed up by the journalist Ken Klippenstein, who posted a chart on X showing that UnitedHealthcare refuses to pay a larger percentage of users’ health-care bills than any other major insurer. “Today we remember the legacy of UnitedHealthcare CEO Brian Thompson,” he wrote.

There’s no excuse for cheering on murder. But Americans’ zeal for the death of an insurance executive demonstrates both the coarsening of public discourse and the degree of rage Americans feel over the deficiencies of the U.S. health-care system. Gallup polling shows that just 31 percent of Americans have a positive view of the health-care industry. Of the 25 industries Gallup includes in its poll, only oil and gas, the federal government, and drug companies are more maligned.

America’s entire health-care system is designed in a way that makes some level of fury unavoidable. Although the governments of most wealthy industrialized countries provide all of their citizens some level of insurance, the majority of Americans rely entirely on the whims of private health insurers. The system is supposed to keep costs down enough to turn a profit. The insurance industry’s eagerness to save money by denying people care is a feature, not a bug, of this country’s system. Americans, in their anger toward Thompson and other health-care CEOs, are expressing frustration with a system that causes real and preventable harm. Those cheering Thompson’s death are arguing that taking away sick Americans’ pills or denying them needed surgeries is immoral and should be punished by death.

That logic is indefensible, but people do have a reason to be angry: Roughly half of Americans report difficulty paying for their health-care costs. A single denied insurance claim can force a patient into financial ruin, and health insurers have gotten more clever at finding ways to deny claims. Until Congress intervened in 2020, patients were frequently being saddled with unexpected medical bills for hospital visits all because the specific doctor on rotation, unbeknownst to them, was out of their insurance network. And even less egregious maneuvers, such as step therapy, which requires patients to try cheaper medications before insurers will pay for more expensive therapies, can delay treatment needed to stave off suffering.

UnitedHealthcare is particularly infamous for its aggressive use of these tactics. Reporters at the health publication Stat (where I worked until this September) spent the past year documenting the myriad ways UnitedHealthcare has extracted profits at the cost of patients’ lives. They found, for example, that the company has used AI algorithms to justify kicking elderly patients out of nursing homes, despite evidence that some of those patients still needed round-the-clock care. Doctors who worked for United (which has also been buying doctors offices) told Stat that the company applied pressure to see more patients, and diagnose them with additional conditions, presumably to increase the company’s profits. United has also faced lawsuits from patients and from the federal government regarding its aggressive business tactics. (United has refuted the claim that it relied solely on AI to deny care, and has said in response to Stat’s reporting that it trusts its doctors to “make independent clinical decisions.”)

But the issue is the health-insurance system, not the CEOs. As long as the majority of health insurance in America is run as a private enterprise, it will work according to this logic. UnitedHealthcare’s aggressiveness is exactly the reason its parent company is now the largest health insurer in America. It has undeniably been successful in its primary business goal to deliver profits for its shareholders.

Compassion and capitalism can coexist, and this country has operated on the premise that the government’s job is to mediate between companies’ profit-making and citizens’ unassailable needs. Insuring people with high-cost conditions wouldn’t comport with thinking merely in terms of profit, which is why it took the Affordable Care Act to require companies like UnitedHealthcare to insure people with preexisting conditions. The recourse that unsatisfied Americans are supposed to have is to either switch insurers or elect politicians who will reform the current system. The ugly reaction to Thompson’s death shows how many people clearly feel that neither of those options is serving the country’s true needs.

The identity and motivation of Thompson’s killer are still unknown. His death could have nothing to do with the U.S. health-care system. (Though shell casings reportedly found at the scene, and inscribed with the words “deny,” “defend,” and “depose,” seem to suggest otherwise.) Even if the killer targeted Thompson for a reason unrelated to his job, the act has laid bare that Americans are so angry about their health care, they would publicly celebrate a man’s death. Cheering on a vigilante may be cathartic for those who are fed up with the rot of America’s current health-care system, but it won’t fix a thing.

Across the country, the thirst for an illicit beverage is growing. Raw milk can’t be sold legally for human consumption in many states, but some 11 million Americans drink it anyway as wellness influencers, including Robert F. Kennedy Jr., extol its benefits. They do so despite a well-established risk of disease and death: E. coli, salmonella, and listeria have all been found in unpasteurized milk.

This year, a new pathogen has been added to the list. Bird flu was first detected in American dairy cows in March, and in June, an FDA study found infectious viral particles in dozens of raw-milk samples. Previous bird-flu outbreaks have collectively killed more than half of people who get infected. This week, California health officials temporarily shut down production at Raw Farm, a raw-milk dairy, because they detected bird-flu virus in its products. Mark McAfee, who runs Raw Farm, told me that “our consumers are freaking out”—not because they fear being exposed to a potentially deadly virus, but because their supply is at stake. According to McAfee, concerns about further shutdowns have led raw-milk drinkers nationwide to “try to get what they can.”

Stocking up on bird-flu juice may seem senseless to most Americans, and yet it’s a logical extension of the ideology that drives raw-milk enthusiasts. The fundamental appeal of raw milk is that its rawness—which includes all of the biologically active molecules passed down from udder to glass, be they strengthening or sickening—makes it both healthy and safe. To the people who drink it, the perceived health benefits of raw milk outweigh, or even negate, the risks.

Health agencies maintain that pasteurized milk is the healthiest and safest choice. From 1998 to 2018, 202 foodborne-illness outbreaks were linked to raw milk; only nine were linked to pasteurized milk. When bird flu first showed up in dairy cows, the CDC and FDA assured the public that the virus was inactivated by pasteurization, rendering conventional milk safe (albeit full of harmless virus particles). The milk industry echoes these points. “There are no demonstrated benefits to consuming raw milk compared to pasteurized milk,” a National Dairy Council spokesperson told me. “Some people have a strong emotional investment in believing so, but scientific research does not validate this.”

Even though enthusiasm for raw milk isn’t backed up by research, the arguments in favor of the beverage are couched in scientific terms. The main health argument in favor of the drink is that it contains biologically active compounds, or bioactives—chemicals whose actions in the body may provide a health benefit—that are present in foods such as fruits, whole grains, and red wine and can be inactivated by pasteurization. McAfee cited a 2021 study, led by Tiantian Lin at Cornell University, that showed raw milk can contain bioactives that are known to work against hypertension, cancer, inflammation, and viruses. When I called Lin this week, she told me that these bioactives are indeed present at low concentrations in raw milk, but to reach the daily recommended intake of any particular bioactive, you’d have to drink a lot of raw milk—up to four liters a day for the protein lactoferrin, for example. Pasteurized milk is sometimes fortified with additional bioactives, such as calcium and vitamin D, to add health benefits. No matter what benefits may be reaped from the bioactives in raw milk, Lin said, drinking it is simply too unsafe to recommend.

[Read: Milk has lost its magic]

Raw-milk drinkers also assert that unpasteurized milk boosts immunity, so drinking it is not harmful but protective. The basic idea, according to the trade and advocacy organization Raw Milk Institute, is that exposure to the “active immune factors, biodiversity, prebiotics, intact protective proteins and other elements” in raw milk builds up the immune system, helping to defend against infectious disease and lower rates of asthma, eczema, and allergies. Raw milk is also thought to support the health of the gut microbiome, much like yogurt. These arguments date back more than a century; in 1910, at New York’s Conference on Milk Problems, “raw milk supporters argued that heating destroyed many of the nutritious properties of milk, as well as the beneficial bacteria,” the Pace University sociologist E. Melanie Dupuis wrote in her book Milk: Nature’s Perfect Food. McAfee told me that bird flu doesn’t worry him because the virus is “inactivated by the bioactives and the antibodies in raw milk.” Some bioactives have antiviral activity, but raw milk has not been shown to neutralize bird flu. Earlier this year, wellness devotees largely hailing from California sought out raw milk contaminated with bird flu in the hopes that drinking it would give them antibodies. Drinking raw milk, in this view, is like bringing kids to a measles party: Immunity may result, as long as everyone survives.

The other key piece of the raw-milk claim is that it is held to higher safety standards than pasteurized milk. This, too, is an old argument. Dupuis told me that when pasteurization was first introduced to major American dairies in the 1890s, raw-milk supporters argued that America’s dairies could simply be kept so clean that the milk they produced would be as safe as pasteurized milk. Certifying raw-milk dairies was a nice idea, but maintaining those high standards was so costly that the resulting milk was wildly unaffordable, Dupuis wrote in Milk. This week, McAfee told me that his farm maintains the production standards of the Raw Milk Institute, which he founded. These include testing regularly for pathogens in milk and screening for diseases in cattle, and maintaining the same maximum level of bacteria as pasteurized milk. Of course, this point doesn’t fit into the argument that raw milk isn’t risky in the first place.

So far, no other raw-milk farms in the United States have been shut down because of bird flu. But nationwide, 695 dairy herds in 15 states have tested positive for bird flu; the idea that Raw Farm is the only raw-dairy provider with bird flu in its product seems far-fetched. The exact risk that poses to people who drink it remains unclear. There are no reports of people becoming infected with bird flu after drinking tainted raw milk, but cats that did so have died.

[Read: Bird flu is quietly getting scarier]

Amid this uncertain risk and rising bird-flu rates in cattle, raw milk is becoming ever more politicized. In Arkansas, a “Raw Milk Revolution” rally in October preceded the proposal of a bill to deregulate sales. The Texas agricultural commissioner, arguing to legalize raw milk in a recent editorial, wrote, “There’s nothing more American than the freedom to choose what kind of food you eat.” Several weeks ago, Kennedy, who could soon lead the Department of Health and Human Services, promised to end the FDA’s “aggressive suppression” of raw milk.

The foundation of Kennedy’s crusade is defying establishment views, not just on raw milk but also on beef tallow, fluoride, and vaccines. Among his followers, the action against Raw Farm by California public-health officials can only add to raw milk’s edgy appeal. All this is happening just as the danger raw milk poses could skyrocket thanks to bird flu, the very reason Raw Farm was put on ice. Even if bird flu is found in more raw-dairy products—and more farms are shut down by the government—the thirst for raw milk will only grow.

Updated at 11:23 a.m. on December 4, 2024

The second time I freaked out about bedbugs, my landlord suggested I might be overreacting, just a tad. My husband and I had fought back an infestation just five months earlier; now, after finding a single bedbug on my pillow—sated because, I presumed, it’d bitten me—I was demanding that the building respond. “You know they don’t cause disease,” the landlord told me.

Common wisdom holds that bedbugs do not spread diseases to humans, just as my landlord said—or at least that the bugs are so widespread and bite humans so often that if they were carrying dangerous diseases, we’d know it. Most other bloodsucking insects that regularly bite humans, such as mosquitoes and ticks, are vectors for horrifying human pathogens. But recent research suggests that bedbugs might be capable of transmitting human diseases after all—if they’re not quietly doing so already.

Proving that bedbugs transmit human disease would mean demonstrating three key things: first, that those microorganisms can survive and thrive in the body of a bedbug. And recent studies have demonstrated that bedbugs naturally harbor plenty of viruses. The genetic material of several human pathogens—among them MRSA, Bartonella quintana, and hepatitis C—has also been found in bedbugs outside the laboratory.  

The second criterion is that bedbugs are capable of transmitting the pathogen. In a laboratory study published in January, Jose Pietri, an associate entomology professor at Purdue University, and his colleagues showed that bedbugs were capable of both contracting and transmitting MRSA while feeding. (They used a membrane contaminated with MRSA to stand in for human skin.) Research from 2014 showed that bedbugs were capable of spreading to mice the pathogen that causes Chagas disease.

And third—the missing piece—transmission must occur in the wild, not just in the lab. “There could be some variables that we’re not understanding” that have prevented us from detecting bedbug disease transmission, Pietri told me. “Or it could simply be that it’s not so common.”

Pietri, like several scientists I spoke with, was drawn to studying bedbug disease-transmission potential because existing research didn’t seem conclusive to him. Scientists first confirmed that insects could act as disease vectors in the late 19th century, and in the decades after, researchers tried to discern whether bedbugs were dangerous too. They attempted to infect bedbugs with microbes; they crushed bedbugs and injected them under a monkey’s skin; they looked at whether a sexually transmitted infection might reproduce in bugs sampled from a West African brothel. None of the experiments directly linked bedbugs to human illness.

With no real-world evidence of human disease transmission and enough failures to make a connection in the lab, eventually many researchers concluded that bedbugs were harmless, at least in this one way. As a 2012 paper put it, “With over 200 million bed bugs biting (and biting multiple times), and without any evidence of any disease resulting, the indications are that the risk of contracting an infectious disease through the bite of a bed bug is almost nonexistent.”

To Pietri, who studies urban pests and vector-borne disease, all of this evidence is not only inconclusive, but out of date. Plenty of bedbugs’ close relatives transmit diseases, so why not bedbugs? “I don’t think it’s a solid scientific argument to say we haven’t seen this thing, so it doesn’t happen,” he told me. “It’s an incomplete picture.”

About 15 years ago, bedbugs were reinvading cities around the world, including New York, after disappearing for decades because of DDT and other pesticides. Amid the growing bedbug panic, Pietri wasn’t the only scientist who started wondering whether bedbugs’ potential as disease vectors had been understudied. The lab that demonstrated bedbugs’ potential as vectors of Chagas disease got the idea from a paragraph-long description of a study from 1912, says Michael Levy, an epidemiology professor at the University of Pennsylvania who led the 2014 study. The team confirmed the century-old results, and found that the bugs’ fecal matter could transmit the disease via mouse skin punctured by a needle or a bite. Technology that allows researchers to more easily identify any microorganism in an insect, such as genetic sequencing, has made it much easier to explore this question. Only in the past five years, Pietri said, have researchers been able to comprehensively survey the viruses and bacteria that a bedbug might carry.

None of the researchers I spoke with thinks that a bedbug is likely to be as harmful a vector as, say, a mosquito. For one, bedbugs don’t fly, are lousy walkers, and must hitch a ride to travel any significant distance. So they have relatively little potential for spreading disease far and wide. “The ecology of the bedbug makes it an unlikely transmitter of disease,” Coby Schal, an entomologist at North Carolina State University, told me. “But is it capable of doing that? Probably so.” In certain places, though—such as hospitals and shelters, where infection rates are high and beds turn over quickly—more significant transmission could be possible. Pietri thinks researchers may simply not be looking in the right places for bedbugs transmitting human disease. Bartonella, a bacterium commonly spread by fleas and body lice but also carried by bedbugs, is especially common among people experiencing homelessness, for instance, but very little research on bedbugs has been done in transient homeless populations. Levy told me he also worries that bedbugs could spread diseases such as Chagas among people sleeping in the same bed in a home.

The bedbug-research community is small, and some within it hold fast to the old wisdom: Bedbugs very likely do not spread disease. If you Google bedbugs, or go to the CDC website, or talk with your friendly local exterminator, you’ll find that’s the consensus. And if bedbugs don’t transmit disease, that could yield important insights, too. One hypothesis is that the bedbug immune system may have evolved to be especially robust because of a brutal copulation ritual that routinely exposes them to microbial invasion. Understanding the mechanism preventing transmission could, for example, help fight transmission by other insect vectors, such as mosquitoes, Pietri said.

If researchers do prove a link between bedbugs and human illness, it would add a new dimension to the already significant torment that the bugs unleash on their hosts. At the same time, the discovery might help marshal more funding toward understanding a pest that’s broadly viewed as a lesser public-health threat than those that clearly spread disease, Levy told me. (In his experience, he said, the sleep center was the only part of the National Institutes of Health interested in funding bedbug research.) Better knowledge of bedbugs could be especially important as their numbers and ability to evade treatment continue to grow. Into my own life, they’ve brought insomnia, paranoia, and the itchiest, longest-lasting bites I have ever experienced. Whether or not they spread disease, bedbugs certainly aren’t harmless.

This story originally misstated Levy’s experience with government funding for bedbug research.

Abortion policy in America is at a stalemate. Republicans will take control of Congress in January, ready to block any national protections—but with a slim majority, making a national ban unlikely. At the state level, pro-choice advocates have focused for the past two years on ballot measures to protect abortion rights. Most of those measures have passed; now there are only two states left that have severe restrictions, allow constitutional amendments, and haven’t already failed to pass constitutional protections.

Since Roe v. Wade was overturned in 2022, U.S. abortion rates have held steady, or even risen. That’s in part because tens of thousands of women in states with extensive restrictions have ordered the two-pill medication-abortion regimen, mifepristone and misoprostol, by mail. Many thousands more have sought out procedural abortions in states with more lenient rules, and that number may soon begin to rise more steeply. The pills don’t work in every scenario, many women who use them to circumvent restrictions fear being prosecuted, and a lawsuit brought by the attorneys general of three conservative states seeks to both outlaw mifepristone for minors and prevent it from being mailed. Project 2025, a blueprint for Donald Trump’s second term created by people with close ties to his incoming administration, outlines a plan to have the FDA pull mifepristone from the market. (Trump himself has flip-flopped repeatedly on whether he might try curbing access to the pill.)

Further restrictions on abortion pills could push more women to cross state lines to receive an abortion. That travel can cost thousands of dollars. Since Dobbs v. Jackson Women’s Health Organization, a network of so-called practical-support groups has played a growing role booking and funding abortion-related travel. Their work is quieter than the fights in courts and legislatures, but perhaps as crucial to determining the future of abortion in America. As options for major policy changes winnow, this approach is likely to play an even more important role in maintaining access to abortion in the U.S.—and to attract more opposition.

Abortion care, like virtually all medical treatment in America, has always been geographically fractured, with people in poor and rural areas traveling farther to reach services. A study published last month found that people who travel out of state for an abortion are more likely to face expenses that threaten their ability to pay for basic needs. The tighter restrictions get, and the more states put them in place, the greater the distance the average patient must cross, and the greater the average cost of doing so. Practical-support organizations might provide gas money, arrange airport pickups and drop-offs, or even fund the purchase of a winter coat if the travel involves a colder climate. Nancy Davis, a Louisiana resident, sought help from a group called the Brigid Alliance in 2022 when an ultrasound revealed at about 10 weeks that her fetus had acrania, a rare and fatal condition in which the skull does not fully form. Her doctor recommended ending her pregnancy, but abortion had just been banned in Louisiana, so Davis booked an appointment in New York. Brigid took care of the cost of plane tickets, a hotel, and food for Davis and her fiancé, as well as funding child care for her three kids at home. Megan Kovacs, a volunteer and board member with the Northwest Abortion Access Fund, told me that this level of logistical support is becoming more and more necessary.

Until recently, practical-support organizations such as the Northwest Abortion Access Fund existed mainly to help, say, someone in rural eastern Oregon travel a few hours to a clinic in Boise, Idaho. But when Dobbs overturned Roe in 2022, aid organizations’ work became more in demand, more expensive, and more complicated, Marisa Falcon, the executive director of a hub for practical-support groups called Apiary, told me. A patient from Arkansas who has scheduled a procedure in Chicago, for example, might rely on a group in Illinois to book flights and hotels and another in Arkansas to drive them to the airport. Because of new restrictions in Idaho, the Northwest Abortion Access Fund spends more money sending patients from eastern Oregon to farther-away urban areas like Portland, as well as helping patients in Idaho leave the state. According to data that Kovacs shared with me, the organization spent an average of $585 on things like hotels and gas money per client in the two years before Dobbs; since Dobbs, the average is nearly $875. The number of clients seeking practical support has almost tripled.

[Read: There’s no coming back from Dobbs]

Support groups also told me that costs are rising because, as the number of clinics dwindles, appointment waiting lists are getting longer, so people wind up having abortions further into pregnancy. The longer a person waits to end their pregnancy, the more complicated and expensive abortion becomes; patients also take longer to recover. “What used to be a one-day activity is now a four-day activity where people need to leave their kids behind,” Falcon said. “Not only are the logistics more complicated, but it costs significantly more.”

In the Dobbs decision, Justice Brett Kavanaugh wrote that U.S. citizens have a “constitutional right to interstate travel,” including for abortions. But abortion opponents are nonetheless trying to prevent people from crossing state lines for care that they see as a threat to unborn life. In Alabama, for example, Attorney General Steve Marshall has said helping someone travel for an abortion is akin to a “criminal conspiracy.” Last year, Idaho outlawed helping a minor travel out of state for an abortion without parental permission. Tennessee passed a copycat law this year. So far both of these efforts have faced legal challenges, and similar bills introduced in other states have failed to advance. Texas has taken a different approach: Some local laws allow residents to sue anyone who assists a woman in traveling through their city or county to get an abortion in another state. At least one Texas man has already taken legal action against his former girlfriend, expressing an intent to file a wrongful-death suit against anyone who assisted her in allegedly pursuing an abortion out of state.

Even if none of these legal efforts succeed, abortion opponents can try to limit the work of practical-support groups by restricting their funding. The organization representatives I spoke with said that the pace of their funding has not kept up with demand for their services. Some smaller groups simply don’t have enough money to meet demand. If abortion is further restricted—if, for example, mifepristone’s FDA approval is revoked, or if the lawsuit challenging it succeeds—demand for out-of-state travel will skyrocket again.

[Read: Abortion pills have changed the post-Roe calculus]

Abortion support services rely mostly on donations, but some also receive funding from state or local governments. That government money has already become a target for anti-abortion groups seeking to curtail abortion travel. In 2023, for example, Ohio voters approved a constitutional amendment enshrining the right to an abortion; in response, a state legislator introduced a bill that would withhold state funding from cities and counties that give money to practical-support groups. Last month, ballot measures protecting abortion rights passed in seven states, and legislators in some of them may attempt to repeat the Ohio strategy. Kristi Hamrick, the vice president of media and policy for the anti-abortion group Students for Life Action, told me that the group opposes using any taxpayer funding for abortion travel and has already asked that Trump restrict the military’s funding of travel for service members seeking abortions.

As travel plays a larger role in how Americans access abortions, it will also inevitably become a bigger target for abortion opponents. Practical-support groups told me that in recent years, abortion-rights advocates have focused on funding campaigns to pass legislation, leaving practical support groups short of the money necessary to serve a growing number of would-be travelers. People still need to travel or obtain medication to end their pregnancy in huge swaths of the country—even in places where abortion rights have notched recent victories. In Missouri, for example, a November ballot initiative made abortion legal, but a host of other laws could mean a long wait before abortions are widely available there. “Without abortion support organizations, people just won’t access abortion,” Serra Sippel, the executive director of the Brigid Alliance, told me. If advocates could wave a magic wand and reinstitute Roe tomorrow, it wouldn’t make a difference if people can’t get to a clinic—many of which no longer exist post-Dobbs. The most consequential fights, for now, may be the practical ones, even if they’re just about some gas money, a babysitter, and a winter coat.

Leading the Department of Health and Human Services seems, at first glance, like a dream job for Robert F. Kennedy Jr., quite possibly America’s most infamous anti-vaxxer. If confirmed, Kennedy will oversee the agencies that play a central role in researching, reviewing, and recommending vaccines. But promoting his own vaccination views will likely be a long push for subtle changes—rulings that Americans may get vaccinated, rather than should—and he’s said, at least, that he’s not aiming to “take away anybody’s vaccines.” Based on his recent public statements, he appears much more interested in cutting down on America’s consumption of seed oils, and frozen school-lunch pizza. In nominating Kennedy to lead the health department, Trump is kneecapping one of the few bipartisan issues he campaigned on this election: improving the diet, and overall health, of Americans. If Trump truly wanted RFK Jr. to fulfill those parts of their pledge to “Make America healthy again,” he should have picked a different job for the would-be health secretary.

Since endorsing Donald Trump for president, Kennedy has pledged that he will “get processed food out of school lunch immediately,” argued that the government must stop subsidizing the crops that make seed oils, and urged Trump to stop allowing people to buy soda with federal food benefits. The “Make America healthy again” agenda also advocates for more comprehensive pesticide regulation, and for regenerative agriculture, which aims to improve soil biodiversity and limit chemical inputs. Kennedy won’t be able to do any of this as the head of the federal health department.

Trump has already signaled that the EPA, which has the power to crack down on pesticides, is off-limits, because RFK Jr. “doesn’t like oil.” But Kennedy could have been an era-defining leader of the USDA, which regulates school lunches, doles out subsidies for oilseed crops, and sets rules for public-assistance programs including SNAP, the Supplemental Nutrition Assistance Program. Before being nominated for HHS, RFK Jr. even posted an Instagram video filmed outside the Department of Agriculture, promising in the caption to enact the MAHA agenda “when @realDonaldTrump gets me inside the USDA.”

At HHS, he’ll still have some influence over his favorite food-related issues, such as banning certain food additives. He’ll also have direct impact on the next round of federal dietary guidelines, which are due to be released in 2025. But HHS’s powers to change Americans’ food intake are either indirect or slow.

To remove a food ingredient as health secretary, for instance, Kennedy would have to pressure the FDA to issue ingredient bans. Because Kennedy would oversee the agency, Marty Makary, Trump’s pick for FDA commissioner, would have to at least entertain that request, but even so, the agency would likely need years to pull any ingredient off shelves. Banning an ingredient requires significant science and legal justification. Earlier this year it banned brominated vegetable oil, a chemical added to certain sodas that has been banned in Europe and the United Kingdom for years. Right now, the agency relies on just a few people to do this kind of work. (The staff reviewing the safety of food additives is small enough that the head of the FDA’s food center recently boasted that he was able to add five full-time staffers.) Speeding up the office’s work—which includes policing new additives that food companies are regularly launching—would require more funding and cut against Trump’s pledge to limit government spending.

But the negative effect of the food additives that Kennedy seems most worried about is felt by only a small subset of eaters. He has spoken, for instance, about a yellow dye known as tartrazine. He has claimed that the dye is tied to asthma, but a 2001 meta-analysis found that avoiding tartrazine “may not benefit most patients, except those very few individuals with proven sensitivity.” (Many of Kennedy’s other claims about the dye’s harms are highly debated among toxicology experts.) By contrast, a program to restrict soda in SNAP, as Kennedy has proposed, might require its own bureaucratic finagling at USDA, but could affect a significant portion of the 42 million people who use the program. Changes to school lunch, similarly, would affect some 28 million young people.  

Putting RFK Jr. at HHS also doesn’t totally make sense as a political decision. Confirmation fights are less contentious when the nominee has bipartisan bona fides; few Democrats support most of Kennedy’s health-care views, and his historically liberal views on abortion could cost him some Republican votes. But plenty of liberals like his take on food and agriculture. As HHS secretary, RFK Jr. is also likely to be dragged into the politics of Trump’s mass-deportation plan, an issue he’s largely steered clear of, because Health and Human Services is in charge of caring for unaccompanied children who are apprehended for being in the United States illegally. Trump’s last HHS secretary, Alex Azar, quickly became what Politico called the “public explainer and punching bag for the migrant crisis.” While Azar was getting tongue-lashed by Congress in 2018, RFK Jr. was tweeting that the policy amounted to immigration officials “forcing beleaguered parents to make Sophie’s Choice at America’s borders.” Trump’s USDA secretary will have to navigate calls from the farm industry to spare agricultural laborers from the administration’s mass-deportation plan, but as health secretary, Kennedy will likely have to be the face of any policy detaining migrant children, or openly criticize his boss.

The person Trump did pick to lead the Department of Agriculture—America First Policy Institute CEO Brooke Rollins—has much less obvious interest in its purview than Kennedy does. Beyond an undergraduate degree in agricultural development, she doesn’t have any direct agricultural experience that prepares her for the job, and her current organization’s related policy work seems focused on concern over U.S. agricultural land being purchased by China.

Trump’s choice to nominate RFK Jr. for HHS seemed like a last-minute decision. After all, in late October, a co-chair of the Trump transition team promised that Kennedy would not be picked to lead the department, only for Trump to name him to that position two weeks later. Maybe it just resonated as a sound-bite to have the head of the “Make America healthy again” movement lead the health department. Maybe Trump wanted to stash RFK Jr. at an agency where he can’t actually do much harm to the big food companies that have historically allied with the Republican Party. Either way, the result is that RFK Jr.’s desires to improve our food supply—the parts of his agenda that have the most bipartisan appeal—will be stymied at HHS. Trump put Kennedy in the position where he will both face the most political friction and be least effective. RFK Jr. might try to nudge or influence Rollins to his way of seeing things, but the health secretary demanding that the agriculture secretary change farm and food policy is the equivalent of the governor of California urging the governor of Texas to change that state’s immigration policy. It just won’t happen.

Robert F. Kennedy Jr.’s latest spin on MAGA, “Make frying oil tallow again,” is surprisingly straightforward for a man who has spent decades downplaying his most controversial opinions. Last month, Kennedy argued in an Instagram post that Americans were healthier when restaurants such as McDonald’s cooked fries in beef tallow—that is, cow fat—instead of seed oils, a catchall term for common vegetable-derived oils including corn, canola, and sunflower. Americans, he wrote, are “being unknowingly poisoned” by seed oils; in his view, we’d all be better off cooking with solid fats such as tallow, butter, and lard. In a video that Kennedy posted on Thanksgiving, he deep-fries a whole turkey in beef tallow and says, “This is how we cook the MAHA way.”

Cardiologists shuddered at the thought. Conventional medical guidance has long recommended the reverse: less solid fat, more plant oils. But in recent years, a fringe theory has gained prominence for arguing that seed oils are toxic, put into food by a nefarious elite—including Big Pharma, the FDA, and food manufacturers—to keep Americans unhealthy and dependent. Most nutrition scientists squarely dismiss this idea as a conspiracy theory. But the movement probes some unresolved, fundamental questions about nutrition. Are saturated fatty acids—the kind in animal fat—actually dangerous? And are polyunsaturated ones—found in plant-derived oils—really all that great for your heart? The fact that these debates remain unsettled does not validate Kennedy’s view on fats, which represents a complete reversal of conventional health beliefs. But it does leave plenty of room for his philosophy to proliferate.

When McDonald’s started using beef tallow in the 1950s, relatively little was known about the relationship between fat and heart health. Tallow was used because it was cheap and tasty. Previous animal studies had already hinted at a link between fat intake and heart disease. Subsequent research on humans pegged the correlation to saturated fat, which comes from animals and is typically solid at room temperature. In contrast, polyunsaturated fat, which is derived from plants and is generally liquid at room temperature, was found to reduce levels of the “bad” LDL cholesterol associated with increased risk of heart disease. By the 1970s, a large body of research had demonstrated that the typical American diet, high in saturated fat and cholesterol, was associated with a high risk of heart disease. The first U.S. dietary guidelines, released in 1980, recommended reducing total fat, saturated fat, and cholesterol. (They also advocated for eating more carbohydrates, which backfired.) In 1988, a Nebraska-based businessman launched a passionate nationwide crusade calling on McDonald’s to end its use of tallow and stop its “poisoning of America.” (This rhetoric, like Kennedy’s, is an exaggeration, but at least it was rooted in reality.) In 1990, McDonald’s switched to 100 percent vegetable oil, as did chains such as Wendy’s and Burger King.

[Read: Americans have lost the plot on cooking oil]

The shift from saturated to polyunsaturated fats—not just in restaurants but in home kitchens—corresponded with major health gains in the United States. In 1962, Americans began to consume more vegetable fats, largely in the form of margarine; four years later, cardiovascular deaths began a decades-long decline. From 1940 to 1996, deaths from heart disease fell by 56 percent, and they continued falling through 2013, albeit at a lower rate. Although the decline can be partly attributed to factors such as better blood-pressure control and lower rates of smoking, “the increase in polyunsaturated fat is probably one of the primary factors, if not the primary factor, in dramatically reducing heart-disease death” as well as lowering the risk of diabetes, dementia, and total mortality, Walter Willett, a Harvard professor of nutrition and epidemiology, told me.

The research has continued to bear out the dangers of saturated fats—and, crucially, the benefits of replacing them with polyunsaturated ones. The most recent version of the U.S. dietary guidelines caps saturated fat intake at roughly 20 grams a day. Federal guidance holds that “the best way to protect your health is not just to limit saturated fat—it’s to replace it with healthier unsaturated fats.” That is to say, no one should be replacing their seed oils with beef tallow.

The arguments in favor of saturated fats can largely be split into three categories. The first questions the validity of the research that established the harms of saturated fats. Two commonly cited meta-analyses—studies of existing studies—published in 2010 and 2014 concluded that the evidence for consuming less saturated fat and more polyunsaturated fat was inconclusive. Both stoked fiery debates and rigorous scrutiny. A correction to the 2014 study essentially nullified its findings. Neither study accounted for what people ate in place of saturated fat. More to the point, the authors of these studies questioned the existing consensus on dietary fats—but did not call for the total elimination of seed oils from the American diet.

[Read: The vindication of cheese, butter, and full-fat milk]

The second category alleges the harms of seed oil. Some tallow truthers claim that consuming too much omega-6, a polyunsaturated fatty acid commonly found in seed oils, allows it to outcompete its more healthful cousin, omega-3, which is found in nuts and fish. But, according to Willett, the body’s regulatory mechanisms prevent such imbalances, and viewing individual fatty acids as competitors is “an extreme oversimplification of what actually goes on in our metabolic system.” The physician Catherine Shanahan’s book Dark Calories, an exhaustive account of the arguments against seed oil, posits that polyunsaturated seed oils promote oxidative stress, which drives all disease. When I asked Shanahan, popularly known as Dr. Cate, why this was not reflected in the existing scientific literature, she questioned its credibility. “They haven’t seen all the data,” she told me. “They’ve only seen what we’ve been fed.” Another popular wellness influencer known as Carnivore Aurelius, who advocates for an all-meat diet, has claimed without evidence that seed oils are “toxic sludge” that disrupts the functioning of mitochondria.

The third category, which is perhaps the most puzzling, comprises a bona fide enthusiasm for tallow—which, to be fair, makes a delicious french fry. Tallow, according to certain corners of the internet, can drive weight loss, boost the immune system, and improve cognition. (No substantial evidence exists to support any of these claims.) Americans aren’t just eating beef tallow—they’re also smearing it on their faces as a supposedly natural alternative to conventional moisturizer, despite a lack of scientific evidence, and, sometimes, the faint smell of cow.

The crux of the anti-seed-oil, pro-tallow position is a belief that the medical consensus on dietary fats is compromised by financial interests—of the seed-oil and medical industries, of universities, of the government. Suspicion of corporate interests is central to Kennedy’s views on health in general. His campaign to “Make America healthy again” is rooted in stamping out corruption in government health agencies. As I wrote previously, this anti-establishment attitude resonates throughout the wellness space: among seed-oil truthers, sure, but also proponents of raw milk, carnivorism, and alternative nutrition in general. Arguments for these dietary choices have been endlessly debunked by mainstream scientists and journalists. But such corrections will hold little sway over people who fundamentally distrust the data they are based on.

[Read: ‘Make America Healthy Again’ sounds good until you start asking questions]

For Kennedy and his supporters, the science isn’t really the point—bucking convention is. Rejecting the consensus about saturated fats makes a political statement. (As a bonus, it creates a market for Make Frying Oil Tallow Again crop tops, trucker caps, and dog bandanas.) But as far as scientists can tell, it’s not going to make anyone healthier. Between potatoes deep-fried in tallow or in seed oils, the latter is “for sure better,” Willett said. Still, no matter your political stance, no french fry is ever going to be healthy.