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Gold-medalist Mauricio Valencia of Team Colombia poses for a photo during the medal ceremony for the men’s shot put F34 final on day 10 of the Paris 2024 Summer Paralympic Games. Valencia had his canine teeth modified to look like fangs in order to break down any stereotypes people may have about Paralympic athletes. He says, “I didn’t want to have the same smile as the rest of the world. I’ve always said that Paralympic sport has to be a spectacle.”

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From left: Silver medalist Johannes Floors of Team Germany, gold medalist Hunter Woodhall of Team USA, and bronze medalist Olivier Hendriks of Team Netherlands pose for a photo after the men’s para-athletics 400m T62 final race, on day nine of the Paris 2024 Summer Paralympic Games.

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Plenty of occupations in the United States have justifiable age limits. Commercial-airline pilots cannot be over 65. Mandatory retirement for all federal law-enforcement officers is 57. Two-thirds of S&P 500 corporations have mandatory age limits for board members, mostly 72 or 75. Many consulting and law firms require their partners to retire in their 60s.

The presidency, right now, has no such official restrictions. Age might still disqualify a candidate: After President Joe Biden’s horrendous debate performance earlier this year, his party pressured him to recognize how his more obvious limits, and appearance of cognitive decline, were hurting Democrats’ chances of keeping the Oval Office. Former President Donald Trump, at 78, is still his party’s candidate, despite delivering incoherent speeches that raise legitimate questions about his mental capacities.

Beyond Biden and Trump, other political candidates and elected officials have displayed signs of age-related cognitive decline: Think of Dianne Feinstein and Orrin Hatch. The country has an interest in ensuring that cognitively impaired people are not elected to office—and, in particular, to the presidency, the most powerful job in the world. The simplest and fairest mechanism to protect the United States from this problem is to institute an upper age limit for all federal elected officials and judges.  

Currently, 32 states and the District of Columbia have age limits for judges. Mostly, these are set at age 70, but some are higher: 72, 73, 75. Vermont’s mandatory age limit for judges is 90. South Dakota is voting on a ballot measure this year to amend the state constitution to limit the age of its congressional candidates to 80. There is bipartisan support for such age limits. Nearly 80 percent of the American public endorses an age limit for federal elected officials, and 74 percent for Supreme Court justices. Most respondents to one CBS poll thought the limit should be under 70 years of age for politicians.

Opponents of age limits sometimes argue that these measures usurp the public’s right to choose our leaders—that democracy can self-correct, because voters can decline to endorse aging politicians who are losing mental function. If Biden had stayed on the ballot, no one would have been forced to vote for him.

But incumbent advantage makes elections poor vehicles for rejecting cognitively declining politicians. Biden’s 2024 presidential campaign was a clear example of this: By insisting on running as the incumbent, Biden cleared the field, scaring away other potential candidates. Challenging an incumbent elected official in a primary can be career-ending and is not something politicians undertake voluntarily. Consequently, when Representative Dean Phillips tried to recruit a plausible alternative to run against President Biden, no one accepted, leaving him, a junior member of the House of Representatives, the only candidate to challenge the president. Unsurprisingly, this ended Phillips’s political career. And because Democratic voters had few other choices, they handed Biden primary after primary, even though the majority thought he was too old and becoming too impaired. Only deus ex machina in the form of Nancy Pelosi, Barack Obama, Chuck Schumer, Hakeem Jeffries, big-money donors, and a few others forced the unprecedented: a candidate with sufficient delegates to be nominated the presidential candidate of a major party withdrawing from the race. It took Biden’s exit for a full field of possible successors—including Vice President Kamala Harris—to come into public view.

Another objection to mandatory age limits is that any cutoff would be arbitrary, given that age-related mental decline is not the same for every person. Some people lose fluid intelligence at a young age, whereas some octogenarians are still mentally sharp enough to hold office and be wise judges. And, yes, age limits are arbitrary. So are age minimums, which almost all countries—including ours—have for voting and for holding office. But the alternative is mandatory mental-competency tests. These, too, are arbitrary, vague, and easily manipulated. Some people are great at test-taking, and others (like me and my two brothers) are bad at standardized tests of any kind. Screening tools and assessments for dementia may examine different dimensions of cognitive ability, but they are almost never diagnostic by themselves. Any system of testing would first have to determine the right cognitive test for being a senator, a federal judge, or the president, and developing a validated instrument for these unique positions would require data that do not exist. Second, a testing system would need someone to determine what constitutes passing. Who would that be, and how would they be insulated from special pleading by powerful people? An age limit, conversely, is unambiguous and not open to manipulation.

And choosing one based on when people are more likely to start losing function is possible. Higher age cutoffs, such as the one in Vermont for judges, would be riskier: At age 80, the risk of Alzheimer’s dementia, for instance, is nearly 20 percent, and at 85 is greater than 33 percent. In adults with at least college education—which all judges and almost all elected officials have—the first signs of cognitive impairment appear at an average age of 76. In line with the age limits for boards at many corporations, I would propose 75 as the age cutoff.

Some people argue that such a cutoff would exclude the many older people who are mentally intact from providing valuable leadership to the country. An upper age limit of 75 would have excluded from service people such as Benjamin Franklin, who at age 81 was an active participant in the Constitutional Convention, as well as Oliver Wendell Holmes and John Paul Stevens, who both retired from the Supreme Court at age 90, having continued to make significant contributions. Maybe the most pertinent of all to this debate is Pelosi, who was 82 when she stepped down as speaker of the House and is still as sharp as ever at 84, wielding tremendous political power (and running for reelection this fall).  

But age limits would not preclude these people from serving the country. They could offer counsel and influence in many ways beyond holding an elected political position or judgeship. Today, sitting presidents call former presidents or Cabinet officials for advice. Presidents have often sent retired politicians on important international missions and even to head delicate negotiations. Mandatory age limits for elected officeholders and judges would not prohibit this type of national service and assistance.

Biden’s exit from the presidential race in July is already seen by most as central to his legacy as a public servant. Using his exit as the impetus to bring mandatory age maximums for all federal elected officials and judges would require a constitutional amendment, the campaign for which former Presidents Biden, George W. Bush, and Bill Clinton could all lead. That, more than anything, would cement Biden’s place in history.

Oksana Masters of Team USA celebrates winning the Women’s H5 Road Race on day eight of the Paris 2024 Summer Paralympic Games, on September 5, 2024. This win is Masters’ second gold medal of the 2024 Paralympic Games, after she placed first in the Para Cycling Road Women’s H4-5 Individual Time Trial the day before.

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Diego Meneses, of Colombia, competes in the Men’s Javelin Throw F34 Final at the Stade de France stadium during the 2024 Paralympics, on September 4, 2024. Meneses won the bronze medal in the event.

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You might have already guessed this from the coughs and sniffles around you, but a lot of people are sick right now, and a lot of them have COVID. According to the CDC’s latest data, levels of SARS-CoV-2 in wastewater are “very high” in every region of the country; national levels have been “very high” for about a month. Test positivity is higher now than it was during the most recent winter surge: Many people who seem like they might have COVID and who are curious or sick enough to get a test that’s recorded in these official statistics are turning out to, indeed, have COVID.

COVID-19 remains deadlier than the flu, and has the potential to cause debilitating symptoms that can last for years. It sends far more people to the hospital than RSV. But as of March, the CDC does not distinguish among these respiratory viruses—or any others—in its advice to the American public. If you’re sick, the agency advises, simply stay home until you’ve been fever-free and your symptoms have been improving for 24 hours. These days, hardly any public spaces specifically exclude people with an active COVID infection. Numerous sick people are not bothering to test themselves for the virus: Compared with 2022 and even 2023 numbers, sales of at-home COVID tests have tanked.

Why, at this point, should anyone bother to figure out what they’re sick with? One answer is treatment. Getting a prescription for the antiviral Paxlovid requires confirming a COVID infection within the first five days of sickness. But there’s an extra reason for every American to test this second if they’re feeling under the weather: Our current COVID wave is crashing right into vaccine season, and knowing when your most recent infection was is crucial for planning your autumn shot.

Immunology is a slippery science, so vaccine timing is not one size fits all. But as I reported in 2022, immunologists generally advise spacing out your doses from one another, and from bouts of COVID itself, by at least three months in order to maximize their effects. (The CDC advises waiting three months after COVID but four months after a shot if you’re eligible for more than one a year.) If your immune system is left in peace for long enough after a vaccine or infection, it can generate cells that provide durable protection against disease. Getting a COVID shot too soon after an infection might interrupt that process, compromising your long-term defenses. At the very least, in that scenario the vaccine “just probably won’t really do much,” says Jenna Guthmiller, an immunologist at the University of Colorado, because your immune system would already have been activated by the infection.

[Read: A simple rule for planning your fall booster shot]

This is why knowing whether you have COVID right now is worthwhile. Pharmacies around the country are currently giving out Moderna’s and Pfizer’s 2024 vaccines; last week, Novavax received FDA authorization for its updated formula, which should be available soon. But if you’ve just had COVID, now is exactly when you don’t want a shot. (There are some exceptions to the three-month rule: For people who are immunocompromised, older, or otherwise high-risk, the short-term protection against infection that vaccination offers can outweigh any drawbacks.) When you do want the shot is another question. Ideally, you would get the vaccine a couple of weeks before you’re most likely to be exposed, whether because you’re gathering in large groups for the holidays or because the virus is surging in your community. If, say, you come down with COVID today, you might want to wait until as close to Thanksgiving as possible before getting an updated shot.

If you do have COVID this month—or if you had it this summer—the genetic makeup of the virus that infected you is almost certainly not identical to what’s in the newest vaccines. Pfizer’s and Moderna’s shots were based on a variant called KP.2, which was dominant in May. The Novavax formula is built around JN.1, which ruled the COVID landscape way back in January. Newer variants are far more common now, including KP.3 and LB.1. But wait long enough past an August or September infection and a somewhat-outdated vaccine should still boost your immunity. “If the vaccine is X and you got infected with Y, the vaccine of X is going to boost immunity that cross-reacts with Y,” Guthmiller told me. “And that still puts you in a fine place to combat Y, and then Z”—whatever variant comes next.

Part of the reason that infection and vaccination timelines are colliding is because, despite attempts to respond to COVID with the American flu toolkit, SARS-CoV-2 is simply not following flu’s usual winter schedule. “Flu is, for the most part, very predictable,” Guthmiller said. COVID has an approximate seasonal pattern, but instead of a single winter wave, it’s so far landed on twice-yearly surges, the timing, size, and precise dynamics of which remain unpredictable. This year’s summer wave, for example, dwarfs last year’s, and started earlier. And yet the CDC recommends most Americans get a COVID vaccine once a year, beginning right around now, when many people have recently been infected. (People over 65, and those with certain immune conditions, are allowed multiple shots a year.)

[Read: Why are we still flu-ifying COVID?]

All of this is happening while Americans are getting progressively less information about how much COVID is spreading through their communities. The CDC stopped reporting new daily COVID infections in May 2023. This April, it stopped requiring hospitals to submit their COVID data to its national disease-monitoring network. (Last month, the agency announced that hospitals must report on COVID, RSV, and flu beginning on November 1.) Still, the information we do have suggests that any respiratory illness you might get right now has a decent chance of being caused by SARS-CoV-2. Testing remains the best way to know, with reasonable confidence, whether it is. But unless you have some tests stockpiled, you’ll have to buy them yourself. The program that sent a handful of free kits to each American household in 2022 and 2023 was paused in March, and the federal government won’t start taking orders for free COVID tests again until the end of the month.

Kinga Dróżdż of Team Poland competes against Xufeng Zou of Team China during the Women’s Sabre Category A fencing quarterfinals on day six of the Paris 2024 Summer Paralympic Games at the Grand Palais. In wheelchair fencing matches, competitors are seated in opposing wheelchairs that are fixed to a platform, ensuring close-combat tactics and limiting their ability to dodge attacks. In the sabre and épée categories, hits above the waist are counted.

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Gold medalist Nicholas Bennett of Team Canada celebrates during the victory ceremony for the men’s SB14 100-meter breaststroke final event at the Paris La Defense Arena in Nanterre, France, on September 2, 2024. The SB14 classification is for swimmers with an intellectual impairment. Bennett, who is autistic, won his second medal of the games, and Team Canada’s first gold medal of the 2024 Paralympic games.

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Hicham Lamlas of Team Morocco collides with Maximiliano Espinillo of Team Argentina during a men’s preliminary group B blind football match on day four of the Paris 2024 Summer Paralympic Games at Eiffel Tower Stadium. Blind football is played between two teams of five, made up of four vision-impaired outfield players wearing blindfolds and a goalkeeper who is sighted or partially sighted. Players keep track of the ball by listening for a bell inside and pay attention to strategic cues shouted by their goalkeeper. Even with the amazing spatial awareness on display, not every collision can be avoided.

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This article was originally published by Undark Magazine.

About three years ago, Soumya Rangarajan struggled day after day with exhaustion, headaches, and heart palpitations. As a frontline hospital doctor during the coronavirus pandemic, she first attributed her symptoms to the demands of an unprecedented health-care crisis.

But a social-media post got Rangarajan thinking about the possibility that she might actually be the victim of something more mundane: an iron deficiency. She requested a blood test from her doctor, and the results determined she had anemia, a condition caused by lower-than-normal levels of iron in the blood.

It was the first step toward relief, recalls Rangarajan, who is a geriatrician at the University of Michigan. Her symptoms, she adds, had made it so she “had difficulty getting through a full week at work.”

Although estimates vary, some research suggests that about a third of women of reproductive age in the United States may not get enough iron, which helps support various functions in the body. But despite the high prevalence of iron deficiency, it isn’t routinely screened for during annual health examinations.

“Women are only tested if they present to a health-care provider and are having symptoms,” says Angela Weyand, a pediatric hematologist at the University of Michigan. And although the American College of Obstetricians and Gynecologists does recommend screening pregnant people for anemia—which can result in the body having too few healthy red blood cells—providers likely miss many patients who are iron-deficient but not anemic, Weyand says, because it requires other testing.

Meanwhile, the U.S. Preventive Services Task Force, which makes recommendations about clinical preventive services, recently reviewed studies on iron-deficiency screening and supplementation practices for asymptomatic pregnant people. On August 20, it concluded that there was insufficient evidence to recommend routine screenings, because the existing data did not clearly indicate whether screening for iron deficiency absent symptoms made a significant difference.

But some clinicians disagree. And the ambiguous nature of iron-deficiency signs—which can include lethargy, irritability, and pale skin—coupled with the lack of specific recommendations for nonpregnant women means the condition can be easily overlooked, Weyand says. Doctors might simply suggest that tired women should get more sleep, for example.

Margaret Ragni, who recently retired as a hematologist, recalls that female patients fairly commonly came in with symptoms pointing to low iron levels.

“Iron deficiency is associated with a really poor quality of life,” says Ragni, also an emeritus professor of clinical translation research at the University of Pittsburgh. Annual screenings could go a long way toward offering relief: “These poor women really could feel so much better.”

Iron is a vital component of a protein in red blood cells, hemoglobin, which helps carry oxygen to every part of the body. The mineral is also essential for a number of various other cellular functions, including energy production and maintenance of healthy skin, hair, and nails.

The body can store some iron temporarily in the form of a protein called ferritin, but if the levels dip too low for too long, so does the hemoglobin in red blood cells, resulting in anemia. But even without anemia, low iron levels can cause health problems.

In addition to physical symptoms such as lightheadedness and shortness of breath, women with iron deficiency can struggle with anxiety, depression, and restless legs syndrome, Weyand says. Iron deficiency has also been associated with heart failure, hearing loss, and pica—a craving for substances such as ice, dirt, or clay. “People can have hair loss and nail changes,” she says. “They can have decreased cognitive abilities, which is hard to tease out.”

Many physicians “think of iron deficiency in terms of anemia, but that’s the last manifestation of iron deficiency,” Weyand says. “And we know iron is important for a lot of other things.”

The need for iron especially increases during pregnancy, when people are even more vulnerable to anemia, says Michael Georgieff, a pediatrics professor and co-director of the Masonic Institute for the Developing Brain at the University of Minnesota.

But even when a growing fetus demands more iron intake, pregnant patients may not always be screened for iron deficiency. Georgieff recalled that three years ago, he accompanied his pregnant daughter to see her obstetrician and was surprised to learn that her blood wouldn’t be tested for iron deficiency. When he asked why, he was told that only people who reported symptoms were screened.

“Pregnancy itself is essentially an iron-deficient state,” he says. “In other words, the iron requirements of the mom go up dramatically during pregnancy. And if you don’t screen and supplement, it’s very hard to keep up with her iron status.”

[Read: The foods that hurt your iron levels]

Moreover, when pregnant women develop anemia, they likely will have difficult pregnancies, Georgieff says. The consequences can be “more premature births, more low-birth-weight babies. And those babies are not loaded with enough iron, then, for their needs once they are out.”

During pregnancy, the fetus depends on the maternal iron it gets through the placenta, a temporary organ that also provides nourishment and oxygen. If mothers-to-be have low iron or anemia, it can affect newborn development. Some research suggests that if a woman is iron-deficient when she conceives, or during the first trimester, the child may be at higher risk of a future cognitive impairment.

Anemia early on in pregnancy has long been associated with greater risks of delivering premature babies and possible health conditions for mothers, including preeclampsia. But research suggests that even though the condition can have an impact, it’s still unclear whether iron therapy can adequately reduce the risks. And although many experts agree on the need to treat iron-deficiency anemia, there’s no consensus for treatment of iron depletion not associated with anemia.

Ragni says she made it a point to screen patients for depleted iron to catch iron deficiency before anemia develops. But, she adds, recommendations from institutions such as the U.S. Preventive Services Task Force could prompt more American providers to screen. “For women of reproductive age, whether they’re pregnant or not, it’s really critical to test,” Ragni says. “There should be a standard test for these women.”

A major reason for iron deficiency among nonpregnant women is menstrual bleeding, which is why they’re at comparatively higher risk to men. “Women who have excess blood loss are really at an even higher risk,” Ragni says.

The World Health Organization has estimated that, globally, about 30 percent of women between 15 and 49 years old were anemic in 2019.

And some research suggests that vulnerability to iron deficiency can start at a young age. A 2023 study that Weyand co-authored found that the overall prevalence of iron deficiency among women and girls aged 12 to 21 was more than 38 percent; the prevalence of iron-deficiency anemia was about 6 percent. But that rate changes depending on how iron deficiency is defined.

To determine someone’s iron count, labs look at the concentration of ferritin—the protein that stores iron—in their blood. A common threshold established by the WHO says that anything below 15 micrograms of ferritin per liter of blood is iron-deficient. When Weyand’s team used that threshold, they found that 17 percent of participants were iron-deficient. But when they upped the threshold cutoff to 50 micrograms per liter, the number of iron-deficient participants climbed to nearly 78 percent.

Weyand says the results reflect a need for a higher threshold for women of 50 micrograms per liter for ferritin, because some studies suggest that such a cutoff is consistent with iron deficiency. But there’s no consensus about which cutoff is most accurate to indicate iron deficiency; other research, for example, suggests 30 micrograms per liter is an effective cutoff.

Still, researchers like Weyand call for raising the thresholds to avoid false negative results that would keep people with iron deficiency from being diagnosed and treated. This would, she says, “capture patients who otherwise have been ignored and dismissed or told their symptoms were due to some other issue.”

Weyand became an advocate for people who struggle with iron deficiency after seeing many patients with heavy menstrual bleeding and iron depletion. Most had never been screened or received treatment.

Although iron deficiency in nonpregnant women is primarily associated with menstruation, other risk factors include iron-poor diets and gut disorders, like celiac disease, that cause poor iron absorption. There’s also evidence that women in poverty are at higher risk of iron deficiency because of food insecurity.

[Read: Warding off anemia with small iron fish]

Iron deficiency is an easily treatable condition with iron supplements, Weyand says, but “it’s difficult to treat if you don’t know it’s there.”

After her anemia diagnosis, Rangarajan says, she started taking iron tablets daily, but cut back to three times a week for a few months. She found it hard to cope with the supplements’ side effects, which included stomach cramps, nausea, and constipation.

Rangarajan, now 39, eventually urged her primary-care physician to switch her treatment to intravenous iron supplements. After waiting for several months for approval from her medical insurance, Rangajaran got her first infusions in March. The effect took hold within a week. “The headaches were gone; I didn’t notice any palpitations anymore; my energy levels were up,” she says. “So I definitely noticed a significant difference.”

In fact, one of Weyand’s social-media posts is what prompted Rangarajan to get tested for iron deficiency. Weyand often advocates on her online platforms for attention to iron deficiency and hears from many working women about how diagnosis and treatment of iron deficiency had finally ended “horrible” symptoms that sometimes lasted for decades. Doctors are greatly “undertreating iron deficiency currently,” she says.

After menopause, women need much less iron. The recommended intake for the nutrient drops from a daily average iron intake of about 18 milligrams to about eight milligrams. “What’s hard is that the vast majority of these women aren’t diagnosed while they are menstruating, and so, going into menopause, they probably are low,” Weyand says. “And depending on how low they are, it would dictate how long it would take them to replenish once they stop bleeding.”

Iron deficiency is rare in men—estimated to affect about 2 percent of U.S. men—but when it develops, similarly to menopausal women, it can signal an underlying condition such as an ulcer or cancer. As Weyand puts it: “It’s more of a red flag in terms of figuring out why they’re iron-deficient.”

Iron deficiency is a significant health problem not just in the United States but worldwide. The International Federation of Gynecology and Obstetrics, which promotes women’s health globally, issued recommendations in 2023 to regularly screen all menstruating women and girls for iron deficiency—ideally, throughout their life.

Weyand says she hopes the recommendations and more research into the health benefits of iron-deficiency screening will help increase awareness among American health providers of the need to screen for iron deficiency. “We screen for lots of things that are less common than this,” she says.

Meanwhile, the findings of the U.S. Preventive Services Task Force didn’t sit well with Georgieff, whose research at the University of Minnesota focuses on the effect of iron on fetal brain development. Health-care providers are not generally screening for iron, he says, and the task force’s decision does not promote change.

Although the task force acknowledged that pregnant people are at risk of developing iron deficiency and iron-deficiency anemia, it concluded that there’s a lack of evidence on the effectiveness of screening pregnant people who show no signs or symptoms.

[Read: The downside of medical screening]

The latest task-force review included more than a dozen studies on the impact of routine iron supplementation on pregnant people. They found that, compared with placebo, prenatal iron supplementation resulted in no significant differences in maternal quality of life or conditions such as gestational diabetes or maternal hemorrhage.

Virtually none of the studies examined the benefits or harms of screening for iron deficiency and iron-deficiency anemia during pregnancy. The volunteer panel issued an “I statement,” which means the evidence is insufficient—perhaps because it’s not available, poor, or conflicting. In 2015, the group also reached a similar conclusion after assessing existing evidence at that time regarding iron-deficiency anemia in pregnant people.

More research is needed to effectively assess the potential health impact of iron screening and supplementation for asymptomatic pregnant people, says Esa Davis, a task-force member and associate vice president for community health at the University of Maryland School of Medicine.

“We need studies that are done to show us the benefit or the harm of screening for both iron deficiency and iron-deficiency anemia,” she says, “and studies that show us the benefits and the harm of supplementing in this group as well.”

Weyand says she hopes ongoing research on iron deficiency in women will boost the chances that the task force and other groups will take up the issue of regular screening again—both for pregnant and nonpregnant people. “Hopefully, it will lead to meaningful change,” she says.

Having felt the debilitating effects of iron deficiency and anemia, Rangarajan says she knows firsthand how crucial screening can be for diagnosis and effective treatment. “I feel like my energy is so much better,” she says. “I feel like my performance at work has improved tremendously with IV iron because I don’t feel so fatigued even at a very busy stretch. I feel like I have this strength that I had when I was in my 20s.”