Medical News

Leading the FDA has long been one of the greatest professional achievements in American health. At the start of every administration, doctors jockey for the role, hoping to steer an agency that regulates 20 cents of every dollar spent in the United States. To be the FDA commissioner who presides over the approval of a cure for a previously intractable disease, or who launches an investigation into a product that is sickening Americans, is to etch your name into the annals of modern medicine. Perhaps you’ve never heard of David Kessler, the FDA commissioner for much of the 1990s, but he is largely the reason the federal government regulates cigarettes at all.   

Marty Makary, Donald Trump’s pick for FDA commissioner, is undoubtedly qualified for the job. A longtime Johns Hopkins surgeon and best-selling author, he has advised the World Health Organization and been elected to the National Academy of Medicine. (Makary, whose confirmation hearings kicked off in the Senate this morning, told Senator Rand Paul that he spent part of yesterday removing a patient’s gallbladder.) Makary is not universally embraced: As a Fox News contributor, he has repeatedly critiqued the medical establishment on air. But he’s still widely regarded as well credentialed. “He has the ability to become one of the greatest commissioners we’ve seen,” Kavita Patel, a physician and former Obama-administration official who considers Makary a personal friend, told me.

But Makary might end up with one of the worst jobs in the entire Trump administration. His scientific bona fides are at odds with the impulses of his boss, Robert F. Kennedy Jr. The newly confirmed secretary of Health and Human Services, who has a penchant for spreading conspiracy theories, has promised lawmakers that he will empower scientists and won’t “impose my preordained opinions on anybody.” But he has also promised to change the agency so radically that delivering on that vision would require Makary to throw much of his medical training out the window. What Makary decides to do will go a long way in determining the extent to which Kennedy is able to remake American health in his image.

That’s not to say that Makary, who did not respond to a request for comment, will be waging a war of resistance against everything RFK Jr. wants and believes. During his testimony this morning, Makary spoke about his desire to improve America’s diet and address chronic disease—both of which Kennedy has made his central focus as America’s health secretary. “We now have a generational opportunity in American health care,” Makary said. “President Trump and Secretary Kennedy’s focus on healthy foods has galvanized a grassroots movement in America.” Last fall, he took part in a roundtable with Kennedy where he lamented that “highly addictive chemicals” lace the U.S. food supply. Tackling that issue will be Makary’s surest bet for delivering on what Kennedy wants.

Contrary to Kennedy’s long-standing anti-vaccine advocacy, Makary reiterated in his Senate testimony that he believes that “vaccines save lives.” But like Kennedy and several other prominent Trump health advisers, Makary has been a vocal critic of how the Biden administration handled COVID. In 2021, he called out the FDA’s decision to approve COVID boosters for young, healthy Americans, citing a lack of clear evidence for their benefits relative to the potential side effects. The government’s “policies are no longer driven by science,” he wrote at the time, and “data is being cherry-picked to support predetermined agendas.” (The FDA pushed forward with boosters for young adults without convening its own independent advisory committee, though the agency said its decision was supported by data.) Other statements Makary has made are more questionable. In an appearance on Fox News in July 2023, he said that “100 percent” of Kennedy’s book on Anthony Fauci was true. He didn’t acknowledge that the book falsely claims that “COVID vaccines were causing far more deaths than they were averting.” (“The Marty you might see on Fox News clips is obviously not the person I know,” Patel told me.)

Much of what Makary actually wants to do at the FDA remains unclear. He spent little time during his testimony on Thursday outlining his moves once confirmed. Still, most of the changes Kennedy wants to see at the agency are untenable for any FDA commissioner concerned about adhering to basic science. Kennedy has said that the FDA’s “war” on treatments such as stem cells and psychedelic drugs “is about to end.” Decisions on how to regulate these products typically don’t rest with the health secretary or the FDA commissioner, but with the agency’s scientists and doctors. In both cases, there is no scientific reason for the FDA to change course. The agency doesn’t allow stem-cell treatments for most conditions because they aren’t proven to work and can cause people serious harm; last year, the FDA rejected what would have been the first MDMA-based medical treatment, likely due to shoddy clinical-trial data.

On his own, Makary can do only so much. The FDA’s powers are actually given by law to the HHS secretary, who then has historically delegated powers to the FDA commissioner, according to Lewis Grossman, a law professor at American University. What is given can be taken away; if Kennedy wants to meddle in Makary’s work, he’s well within his rights to do so.

Still, should Makary stand up to Kennedy, he will not be the first FDA secretary to clash with more powerful officials in the administration. Kessler’s efforts to investigate the tobacco industry were so controversial in Washington that, as he wrote in his memoir, the White House worried he would resign if they didn’t allow him to continue his work. If Makary can conjure up a similar power—using whatever leverage and cache he would have as FDA commissioner to negotiate with Kennedy and the Trump White House—he may hold his own. Makary “has both a mandate and an authority to not feel like he needs to step in line with any secretary, much less RFK Jr.,” Patel said.

The first major test for how willing Makary is to stand up to his boss will likely center on mifepristone, an abortion pill. Kennedy told senators in January that he would order the FDA and NIH to review the safety of the drug to determine whether access to it should be restricted. (Access to mifepristone varies by state, though prescriptions via telehealth have complicated the picture.) But that review has already been done. The FDA recently rereviewed the drug’s safety information, and determined that previous restrictions around the drug, namely that patients needed to physically go to a clinic to get it, were unnecessary. The agency is unlikely to find any new evidence that the drug is especially dangerous. If Makary comes up with a reason to question its safety, and thus meddles with the agency’s previous findings, it will show that his loyalty rests more with Kennedy than FDA’s scientists. During his confirmation hearing, Makary was unwilling to preview how exactly he would come down on the issue, much to the frustration of some Democratic senators.

In any administration, overseeing the FDA’s sprawling, vital work is a colossal undertaking. Should he be confirmed, Makary will be tasked with safeguarding the infant formula Americans feed their newborns, the cosmetics we use on our skin, the painkillers we take when we have a headache, the chemotherapy we receive to fight cancer, the pacemakers that keep hearts ticking, the flu shots we get every fall, and even the hand sanitizer we reach for when our hands are dirty. Makary’s biggest challenge, however, could turn out to be his ability to manage up. His ideal version of the FDA presumably is different from Kennedy’s. They both can’t get their way.

Last month, during Elon Musk’s appearance at the Conservative Political Action Conference, as he hoisted a chain saw in the air, stumbled over some of his words, and questioned whether there was really gold stored in Fort Knox, people on his social-media platform, X, started posting about ketamine.

Musk has said he uses ketamine regularly, so for the past couple of years, public speculation has persisted about how much he takes, whether he’s currently high, or how it might affect his behavior. Last year, Musk told CNN’s Don Lemon that he has a ketamine prescription and uses the drug roughly every other week to help with depression symptoms. When Lemon asked if Musk ever abused ketamine, Musk replied, “I don’t think so. If you use too much ketamine you can’t really get work done,” then said that investors in his companies should want him to keep up his drug regimen. Not everyone is convinced. The Wall Street Journal has reported that Musk also takes the drug recreationally, and in 2023, Ronan Farrow reported in The New Yorker that Musk’s “associates” worried that ketamine, “alongside his isolation and his increasingly embattled relationship with the press, might contribute to his tendency to make chaotic and impulsive statements and decisions.” (Musk did not respond to my requests for comment. In a post on X responding to The New Yorker’s story, Musk wrote, “Tragic that Ronan Farrow is a puppet of the establishment and against the people.”)

Ketamine is called a dissociative drug because during a high, which lasts about an hour, people might feel detached from their body, their emotions, or the passage of time. Frequent, heavy recreational use—say, several times a week—has been linked to cognitive effects that last beyond the high, including impaired memory, delusional thinking, superstitious beliefs, and a sense of specialness and importance. You can see why people might wonder about ketamine use from a man who is trying to usher in multi-planetary human life, who has barged into global politics and is attempting to reengineer the U.S. government. With Musk’s new political power, his cognitive and psychological health is of concern not only to shareholders of his companies’ stocks but to all Americans. His late-night posts on X, mass emails to federal employees, and non sequiturs uttered on television have prompted even more questions about his drug use.

Ketamine’s great strength has always been its ability to sever humans from the world around them. It was first approved as an anesthetic in 1970, because it could make people lose consciousness without affecting the quality of their breathing. In the 1990s, as a street drug known as Special K, ketamine took ravers to euphoric states. Then, in the 2000s, researchers found that doses of ketamine that didn’t put people to sleep could rapidly reduce symptoms of depression, because, the thinking went, the drug altered the physical circuitry of the brain. In 2019, the FDA approved a nasal spray containing a form of ketamine called esketamine (sold under the brand name Spravato) for patients with depression who hadn’t responded to other treatments. Spravato came with a list of rules for how the drug should be administered: in a certified medical setting by a health-care professional, and with limited dosage amounts determined by how long a person has been in treatment.

But Spravato’s approval was followed by a surge in prescriptions for generic ketamine, which, because it’s already FDA-approved as an anesthetic, can be administered off-label without the rules that govern esketamine. (Recreational use has shot up over the past decade too.) Some providers pair low-dose injections with talk therapy. Across the country, bespoke ketamine clinics offer shots and lozenges to treat a wide variety of mental-health conditions, including anxiety and PTSD; some focus on IV drips at doses high enough that maintaining a conversation is not feasible. Few take insurance. One market report estimated that the ketamine industry was worth nearly $3.5 billion in 2023. Outside the clinic, the drug is reportedly popular among Silicon Valley’s tech elite, and a feature at some wellness retreats, including those for leadership development, corporate team building, or couples counseling.

[Read: The horseshoe theory of psychedelics]

Research has not yet established the side effects of long-term ketamine therapy, but older studies of recreational users offer some insight on heavy, extended dosing. Celia Morgan, now a psychopharmacology professor at the University of Exeter, in England, led a 2010 study that followed 120 recreational ketamine users for a year. Even infrequent users—those who used, on average, roughly three times a month—scored higher on a delusional-thought scale than ex–ketamine users, people who took other drugs, and people who didn’t use drugs at all. Those who averaged 20 uses a month scored even higher. People believed that they were the sole recipients of secret messages, or that society and people around them were especially attuned to them. The psychological profile of a frequent ketamine user, Morgan and her team concluded, was someone who had “profound” impairments in short- and long-term memory and was “distinctly dissociated in their day-to-day existence.” Morgan’s study was not designed to determine whether people who are more likely to be delusional are also more likely to recreationally use ketamine, but Morgan told me that stopping the drug, in most cases, will dramatically reduce these side effects.

Psychedelic enthusiasts have for decades cautioned about the dangers of prolonged ketamine use, including serious damage to the bladder, intense stomach cramps, and a struggle to stop using. In 1994, the researcher D. M. Turner wrote, “A fairly large percentage of those who try Ketamine will consume it non-stop until their supply is exhausted.” John Lilly, a neurophysiologist and psychedelic researcher who once used LSD to investigate dolphin communication, famously abused ketamine until he believed that he was contacted by an extraterrestrial entity who removed his penis. “For anyone who is using a very significant amount of ketamine on a regular basis over a long period of time, I think there’s good reason to suspect that they could have different kinds of cognitive and psychological forms of impairment,” David Mathai, a psychiatrist who offers ketamine therapy to some of his patients in Miami, told me.

Such theoretical impairments would be concerning in any context—but especially when contemplating a person who has achieved enough power to be unironically described as co-president of the United States. To be sure, ketamine may have nothing to do with his actions. He may be simply acting in accordance with his far-right political ideology. Musk also famously brags that he rarely sleeps—never a good strategy for measured speech or actions.

[Read: Elon Musk is president]

Musk hasn’t publicly acknowledged the risks of ketamine, despite having once claimed that SSRIs, the drugs commonly used to treat depression, “zombify” patients. Other highly visible ketamine promoters tend to do the same. Dylan Beynon, the founder of the ketamine telemedicine company Mindbloom, recently wrote on X, “Ketamine is not physically addictive. SSRIs are very difficult to wean off of for many.” (Beynon’s wife, the former head of engineering at Mindbloom, now works at DOGE.) Although ketamine doesn’t lead to the same kind of physical withdrawal symptoms as opioids or alcohol, Morgan, the University of Exeter professor, said its abuse potential is widely accepted, partly because people build a tolerance to the drug very quickly. In the United Kingdom, where health data are more centralized, more than 2,000 people sought treatment for ketamine addiction in 2023. More to the point, ketamine’s most dramatic risks depend on simply how much ketamine a person takes, and for how long.

Swaths of the tech world have long been drawn to Stoic philosophy, which encourages a detachment from that which is out of your control. Stoicism offers excellent coping strategies in the face of adversity—useful in an industry where most start-ups fail—but taken to extremes, it can also be a pathway to disengagement from the world and people around you. Ketamine, similarly, can afford its users space between themselves and overwhelming despair, which might help explain how it can treat depression, Mathai, the Miami psychiatrist, said. But there are consequences for leaning into that escape for too long.

For his second presidential term, Donald Trump stacked his health team with men who disdain the medical consensus. Mehmet Oz, who awaits Senate confirmation as the head of the Centers for Medicare and Medicaid (CMS), promoted hydroxychloroquine to treat COVID-19 (it doesn’t work this way) and once faced a Senate panel over his hawking of miracle weight-loss cures (they didn’t work either). Dave Weldon, Trump’s nominee to lead the CDC, has a long history of anti-vaccine comments. So does Robert F. Kennedy Jr., now secretary of Health and Human Services.  

These perspectives are worrisome and divisive. Nonetheless, the incoming administration’s skepticism of entrenched health-care groups, if properly channeled, could help address a specific problem in the nation’s medical system: changing how Medicare pays health-care providers—in particular, specialists and primary-care physicians. In a recent executive order creating a Make America Healthy Again Commission, the president wrote of “protecting expert recommendations from inappropriate influence.” And HHS recently affirmed the administration’s aversion to outside views when it curtailed public comments on policy changes, which are often dominated by interest groups. By reexamining the priorities of doctors’ and hospitals’ groups, the Trump health team could do the miraculous: improve care and save money.

In the United States, physicians’ work is measured in relative value units (RVUs), which account for the time, technical skill, and mental effort involved in any office visit, test, or treatment. Those RVUs determine how much Medicare pays for specific services. Medicare payment also serves as the model for all other insurers, and thus influences most physician payments nationally. Doctors’ pay isn’t necessarily determined by RVUs alone, but for many physicians, compensation is closely tied to the number of RVUs someone working in their specialty is expected to generate. Even doctors who are paid a salary are often expected to meet certain RVU goals, and are paid bonuses for exceeding them.

The RVU system is biased in its very design. CMS relies on an American Medical Association committee to propose adjustments each year to RVU allocations. That committee is made up of 32 doctors—overwhelmingly specialists—and other health-care professionals. Those physicians have an inherent conflict of interest: They are in effect setting their and their colleagues’ pay. The committee estimates time spent for various types of work in part by surveying just a few dozen physicians, who, according to a 2016 report by the Urban Institute, give inflated guesstimates. CMS accepts more than 90 percent of the AMA committee’s recommendations.

As a result, surgeries, scans, and other medical procedures are consistently assigned higher RVUs than office visits or interactions in which a doctor, say,  talks to a patient about smoking or regularly taking medications for their chronic disease—so-called cognitive patient encounters. A cardiac surgeon’s time and effort for an hours-long triple-bypass operation clocks in at about 40 work RVUs. A dermatologist applying liquid nitrogen to freeze benign skin growths—a simple, low-risk procedure that takes less than five minutes—amounts to about 1.11 work RVUs. Meanwhile, a primary-care doctor spending 40 minutes with an established patient who has diabetes, kidney problems, and a heart condition generates only 1.8 work RVUs. This visit is not comparable to removing benign skin growths. And while a primary-care visit might take less time than the surgery, it is not 20 times less valuable—especially because good primary care can prevent the need for the surgery to begin with.

The AMA has made some adjustments to address these problems. In a statement, the association said that its RVU committee is working within the bounds that the government requires: For instance, its work is limited to determining the work value of different codes, not their value to patients. And the group pointed out that nine committee members have a background in primary care. The association also noted that its recommendations are nonbinding, and that its committee has worked with CMS to increase the value of cognitive patient encounters and approved those increases knowing that they would require cuts in other codes, because of Medicare’s budget-neutrality rules.      

But these adjustments are clearly insufficient, and fail to accurately reward high-value physician interventions. Indeed, the higher RVUs for specialty-related procedures mean specialists are paid more, whether or not that reflects the value of the work to patients’ overall health. A 2019 study published in JAMA found that increasing the number of primary-care physicians improved life expectancy more than increasing the same number of specialists by more than 2.5 times. It is clear that primary-care physicians deliver life-saving care—and deliver it efficiently. But their compensation does not reflect this utility. By one estimate based on tax returns, the average orthopedic surgeon or dermatologist earns roughly three times as much as the average primary-care doctor. And those pay differences mean that fewer medical students and residents will train to become primary-care physicians, which endangers Americans’ health.   

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The AMA likes to emphasize that its committee provides invaluable expertise and engages thousands of physicians in giving uncompensated advice to the government. This all may be true, but no advice is free. If the federal government disregarded the AMA committee’s advice, it could improve the system through three important reforms.

First, a committee made up of medical experts, health-policy and health-economics experts, actuaries, and others—unaffiliated with the AMA and free of conflicts of interest—could reevaluate the few hundred medical codes that account for the lion’s share of medical costs. They could reassign RVUs based not on physicians’ time, but on health benefit, cognitive skills, and difficulty, when possible. Second, if still relevant, the time that a given procedure takes could be determined by data from electronic health records, as opposed to physicians’ self-reports.

Finally, payments to physicians could be adjusted based on both quality and cost savings. For instance, Medicare could weigh physicians’ success in taking care of diabetes patients by the proportion of patients who have their blood sugars, blood pressure, and cholesterol controlled, and pass annual examinations tracking complications with their eyes and feet. Then, the program could adjust payments going forward: Physicians who achieve or maintain results above a certain threshold would be eligible for higher levels of payment. Similarly, surgeons should be bonused—or penalized—based on surgical-site infections, unexpected emergency-room visits, unscheduled post-procedure hospital admissions, and other quality metrics. These types of changes could usher in improved care, potentially in just a few years.      

In its statement to The Atlantic, the AMA said that its committee does rely on medical records to inform its work when possible, but needs those data sets to meet certain criteria. The association also underlined that it supports alternative payment models, including value-based models, if they’re voluntary for physicians. Still, under the banner of more physician autonomy without financial penalties, the AMA and other medical societies have also frequently opposed payment programs or made them impossible to evaluate because they are voluntary and thus biased.

But payment programs could help improve the nation’s health quickly, and could allow CMS—soon to be led by Oz, if he’s confirmed—to focus on chronic illnesses, particularly high blood pressure, the nation’s most common and deadly chronic disease.  Just under half of American adults have hypertension, and fewer than a quarter of them have their blood pressure controlled. We know how to treat this problem. Since the 1950s, more than 100 cheap, effective medications that lower blood pressure have been developed, and some medical systems and physicians have achieved blood-pressure control for 80 percent or more of their hypertensive patients. These systems all rely on care teams rather than the work of individual physicians, diagnose a patient in their home (where blood-pressure measurements tend to be more accurate), prescribe combination pills that contain two blood-pressure medications, encourage lifestyle changes, and have patients connect to a team member every two to four weeks.

In 2015, the AMA did launch a trademarked blood-pressure-control program—Target: BP, which shares some of these same insights. But despite all of these efforts, blood-pressure control has not improved, according to the CDC. Financial incentives could change that. Judging by previous experiments, those incentives would need to be large. For instance, Covered California, the California exchange, made blood-pressure control one of four quality measures for insurers, and penalized insurers who failed to meet targets with escalating reductions in premiums. In 2023, the first year the program ran, the penalty was a 1 percent reduction; blood-pressure control improved a remarkable 12 percent.  

Adopting this approach, CMS could make achieving a certain threshold of successful treatment of hypertension the dominant measure for the quality assessment of Medicare Advantage plans, and link that measure to bonuses. CMS could also penalize those achieving less than 50 percent control.

Faced with such reforms—which could lower hospitals’ and doctors’ bottom line—the medical lobbying groups would, no doubt, rebel. The AMA, for one, has long had an aversion to what it calls “scope creep”: proposals enabling nonphysician providers to take some clinical responsibility for patients that is essential to team-based care. The association claims that scope creep results in worse quality and more expensive care. At the same time, physicians and health-care organizations would likely claim they can’t take an approach that requires more intensive contact with patients, because they aren’t paid enough to spend the time. Plus, those threatened by penalties for their poor  performance would likely claim they have sicker and noncompliant patients.

Perhaps an administration filled with people willing to dismiss such self-interested pronouncements would be better at addressing chronic illness, as the president has said he intends to with the Make America Healthy Again Commission. If Kennedy and the rest of the administration focus on delegitimizing vaccines and defluoridating water, the nation’s health will suffer. But Trump’s Cabinet could also ignore special pleading by the medical establishment and fix physician payment and hypertension. That’s certainly a better prospect than more measles deaths.

“It’s not unusual.” That’s how Robert F. Kennedy Jr., the anti-vaccine activist and secretary of Health and Human Services, described an ongoing measles outbreak in and around Texas that has already infected more than 100 people and killed one child. This incident is, in fact, unusual. Until this week, someone hadn’t died of measles in this country since 2015, and endemic spread of the virus was declared eliminated in the United States 25 years ago. As the leader of our health-care system, Kennedy could have used his political megaphone to encourage vaccination. But he is a vocal critic of the measles shot, which has saved more than 90 million lives, and has claimed (with very modest evidence) that catching measles may reduce the risk of heart disease and certain cancers. In keeping with those views, he has passed on the opportunity.

Kennedy’s “Make America healthy again” (MAHA) movement is not content with simply ignoring the need for vaccination. It also has a habit of dismissing pediatric death and disability. Kennedy, in particular, has spent years downplaying the harms of vaccine-preventable illnesses. In a 2021 podcast appearance, he described the time when he contracted measles as a kid as “a great week.” “The treatment for measles is chicken soup and vitamin A,” he told the host. Children’s Health Defense, the anti-vaccine group that Kennedy formerly chaired, has in recent months spent its time “fact-checking” the fact that the polio vaccine has saved 20 million kids from paralysis. Last week, that organization suggested on X that the Texas measles outbreak was caused not by the virus but by the vaccine. (This is impossible.) And yesterday, Calley Means, one of Kennedy’s key advisers, complained that journalists were paying too much attention to that outbreak. “MSNBC has turned into the Measles News Network,” he wrote on X. “Does the media know children are dying from chronic diseases (not measles)?”

The school-aged child who died in Lubbock, Texas, appears to be interfering with the MAHA argument that public health focuses too much on preventing infection and too little on combatting chronic disease. The movement’s emphasis on chronic illness has generally been a political success. Deaths from COVID-19 have declined dramatically, but cancer, heart disease, diabetes, and other long-term conditions remain a scourge on the adult population. When it comes to young people, however, MAHA’s argument makes less sense. “Just 400 Americans PER YEAR died of measles before invention of the vaccine—and many of those deaths certainly tied to co-morbidities,” Means posted on X this month. “Obesity, autism and diabetes are ravaging every classroom, but no articles on that.” There are, of course, “articles on that.” And yet, even a chronic disease like diabetes, however bad it may be, kills fewer than 100 American children and teenagers per year.

(Kennedy, Means, and Children’s Health Defense did not respond to written questions about their statements on vaccines and vaccine-preventable diseases.)

It is only on account of vaccination, medical care, and sanitation that infections are no longer killing so many U.S. children. Most deaths of U.S. kids today result from external injuries—motor-vehicle crashes, firearms, drug overdoses, suffocation, and drowning. As for chronic illnesses, one of them, hepatitis B, has been nearly eliminated in American children thanks in part to an immunization that Kennedy also criticizes. Another chronic childhood condition—and the most deadly one—is cancer. So far, at least, the fight against pediatric cancers has been set back by the administration in which Kennedy is serving. Over the past 50 years, medicine has made miraculous advances in treating leukemia and other cancers affecting kids, largely due to research supported by the National Institutes of Health. Yet this month, the White House has taken several different steps to interfere with the NIH’s funding. Harold Varmus, who ran the agency for much of the 1990s, and then the National Cancer Institute during the 2010s, has predicted that if the recent political undermining of American science continues, “our envisioned future of longer, healthier lives will happen more slowly, in other countries, or not at all.”

[Read: Inside the collapse at the NIH]

And notwithstanding Kennedy’s plan, as laid out during his presidential run, to ask the NIH to “give infectious disease a break,” infections were, in fact, recently a leading killer of children: From August 2021 to July 2022, COVID was a top-10 cause of pediatric mortality in the United States. In absolute numbers, these deaths still paled in comparison with deaths among adults, but Kennedy and his supporters tended to dismiss the problem out of hand. There is “no evidence children are at risk of serious illness,” Kennedy wrote in 2022. Means chastised the social-media account for a Sesame Street character after it promoted COVID shots. “8x more kids kill themselves than die of COVID,” he told Big Bird on X in 2021. (There is not yet a vaccine that prevents suicide.)

In this way, COVID minimizers often become de facto advocates for the virus. They excuse its harms by shifting blame to comorbidities such as obesity. Kennedy’s response to the measles outbreak, like those of others in his movement, hints that this unusual degree of apathy is likely to continue.

In a little over a month, the Trump administration has started to hollow out America’s federal health agencies. Roughly 2,000 probationary workers have been fired en masse, by virtue of the fact that they were relatively new to their jobs. But the long-term impact of those terminations could pale in comparison to a lesser-noticed spate of departures that have recently roiled the health agencies. In the past two months, the FDA, CDC, and NIH second in commands have all resigned or retired. So have several other prominent officials, including the FDA’s chief operating officer as well as the heads of both its food center and its drug center.

There is always some churn in a new White House, but it typically affects “political staff” who are appointed to serve in a specific administration. Civil servants, meanwhile, are far more likely to stay in their positions regardless of who is president. The continuity of these career officials ensures agencies can still function as their newly appointed political leaders map out their agendas. Like in any other industry, career officials—who dramatically outnumber political staff—do sometimes leave. But many of the top staffers who voluntarily abandoned their positions had previously not shown any sign of being ready to do so. Nirav Shah, the principal deputy of the CDC, is reportedly resigning tomorrow, despite telling a Politico reporter in January that he did not have any “current plans to leave government.” And Jim Jones, the head of the FDA’s food center, was just getting started on a long-term plan to revitalize that office. Shah and Jones, like all the other recently departed health officials mentioned in this story, declined to comment.

[Read: Inside the collapse at the NIH]

The level of attrition happening in the health agencies right now is unprecedented, Max Stier, the head of the Partnership for Public Service, a nonpartisan group that aims to strengthen the federal bureaucracy, told me. “We’re watching a complete  sweep of those most senior career experts,” he said. The president campaigned on a promise to “demolish” the so-called deep state that he believes is out to sabotage his agenda, and has repeatedly declared his intent to gut the health agencies. To an extraordinary degree, his administration has already succeeded.

The administration has offered plenty of incentive for government workers to head for the exit. One of the Trump administration’s first moves was offering a buyout to any federal worker willing to abruptly leave their positions. Trump has also mandated that all federal workers, including those who live more than 50 miles from their office, work in office five days a week. It’s unclear how many rank-and-file workers have quit because of these efforts, but prominent instances of attrition have not been limited to just the health agencies. A top Treasury Department official recently retired after reportedly refusing to give DOGE access to the government’s system for dolling out trillions of dollars each year. So too did 21 staffers at the United States Digital Service who had been drafted into working for DOGE.

Jones, the former director of the FDA’s food center, is instructive in understanding what is fueling the public-health exodus in particular. He joined the agency in 2023, and had spent the past several months staffing up areas of the food center that were faltering. But when 89 newly hired probationary employees were fired by the Trump administration earlier this month, he had enough. He did not want to be involved in “dismantling an organization,” he told the health publication Stat. The health agencies were upended by DOGE cuts just as Robert F. Kennedy Jr. was confirmed by the Senate as their boss. The health secretary has his own desires to fire bureaucrats. Had Jones not resigned, it is reasonable to assume that he would have been pushed out of his position: Kennedy previously implied that everyone at the center Jones ran should be given pink slips.

That’s easier said than done. Although bureaucrats on their probationary period—because they’re either newly hired or recently promoted—can be fired with relative ease, career officials generally cannot be let go without actual cause. But none of that matters if officials resign—whether as a result of their own dissatisfaction or being pressured out. Attrition is a cheat code for thinning the federal workforce. In just a month, the Trump administration’s assault on the federal workforce has managed to push even an ardent reformer like Jones to surrender.

These departures will likely be a cause célèbre for MAGA world. As I wrote in November, public-health officials historically have been the firewall against the political whims of the White House. That is what happened during Trump’s first term. Early in the pandemic, Janet Woodcock, then the head of the FDA’s drug center, reportedly sprung into action to prevent widespread distribution of the unproven COVID treatment hydroxychloroquine over the orders of top Trump officials. What makes the recent resignations so consequential is that they suggest that Trump and RFK Jr. will face less resistance from inside the agencies as they attempt to overhaul public health. Already, Jones has been replaced by Kyle Diamantas, a food and drug lawyer (and hunting buddy of Donald Trump Jr.) who has no previous experience working in the federal government.

Still, these resignations may not be to the Trump administration’s benefit. Very few individuals have the type of specialized knowledge that comes with decades in government service. “These are the people that you want to do everything possible to hold onto,” Stier, of the Partnership for Public Service, said. Consider Lawrence Tabak, the outgoing principal deputy director at the NIH. He served in that role for more than a decade, punctuated only by a short stint running the entire agency. That experience could have been channeled into delivering Kennedy’s promised reforms to the agency, like revisiting the government’s standards on conflicts of interests in research. Jones, though new to the FDA, had previously spent nearly two decades at the EPA regulating the safety of pesticides and other chemicals, which made him one of the few people prepared to deliver on Kennedy’s promise to ramp up the regulation of food chemicals. Indeed, Jones’s resignation from the FDA has shaken the agency’s staff. One employee who works at the food center described the mood to me as “pissed and scared and coping and numb and confused and demoralized.” (I agreed not to name the employee, because they’re not allowed to speak to the press.)

The federal health agencies have real problems: They’re often slow, bureaucratic, and cloistered, as Trump and Kennedy have been quick to point out. That some of the nation’s top health officials have decided to head for the exit may only make matters worse.

If you have tips about the Trump administration’s efforts to remake American science, you can contact Katherine on Signal at @katherinejwu.12.

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For decades, the National Institutes of Health has had one core function: support health research in the United States. But for the past month, the agency has been doing very little of that, despite multiple separate orders from multiple federal judges blocking the Trump administration’s freeze on federal funding. For weeks on end, as other parts of the government have restarted funding, officials at the Department of Health and Human Services, which oversees the NIH, have pressed staff at the agency to ignore court orders, according to nearly a dozen former and current NIH officials I spoke with. Even advice from NIH lawyers to resume business as usual was dismissed by the agency’s acting director, those officials said. When NIH officials have fought back, they have been told to heed the administration’s wishes—or, in some cases, have simply been pushed out.

The lights at the NIH are on; staff are at their desks. But since late January, the agency has issued only a fraction of its usual awards—many in haphazard spurts, as officials rushed grants through the pipeline in whatever limited windows they could manage. As of this week, some of the agency’s 27 institutes and centers are still issuing no new grants at all, one NIH official told me. Grant-management officers, who sign their name to awards, are too afraid, the official said, that violating the president’s wishes will mean losing their livelihood. (Most of the officials I spoke with requested anonymity, out of fear for their job at the agency, or—for those who have left—further professional consequences.)

[Read: The erasing of American science]

NIH lawyers have told officials at the agency that to comply with court orders, they must restart grant awards and payments. But HHS officials have handed down messages too, several current and former NIH officials told me: Hold off. Maintain the pause on grants. And the NIH’s acting director, Matthew Memoli, who until January was a relatively low-ranking flu researcher at the agency, has instructed leadership to stick to what HHS says. Memoli, HHS, and the NIH did not respond to requests for comment.

NIH officials are used to following cues from their director and from HHS. But they were also used to their own sense of the NIH’s mission—to advance the health of the American people—being aligned with their leaders’. For weeks now, though, they have been operating under an administration ready to dismantle their agency’s normal operations, and to flout court orders to achieve its own ends.

As the freeze wore on, one former NIH official told me, some people at the agency recalled a mantra that Lawrence Tabak, the NIH’s longtime principal deputy director, often repeated to colleagues: As civil servants, your role is not to call the policies, but to implement them. That is your duty, as long as you’re not doing something illegal or immoral. The NIH’s expert staff might have their own ideas about how to allocate the agency’s funds, but if political leaders chose to pour money into a pet project, that was the leaders’ right. This time, though, many at the NIH have started wondering if, in implementing the policies they were told to, they were crossing Tabak’s line. Over and over, the former NIH official told me, “We were asking ourselves: Are we there yet?”

Without the ability to issue research grants, the NIH effectively had its gas line cut. The agency employs thousands of in-house scientists, but a good 80 to 85 percent of its $47 billion budget funds outside research. Each year, researchers across the country submit grant proposals that panels of experts scrutinize over the course of months, until they agree on which are most promising and scientifically sound. The NIH funds more than 60,000 of those proposals annually, supporting more than 300,000 scientists at more than 2,500 institutions, spread across every state. This system backed the creation of mRNA-based COVID vaccines and the gene-editing technology CRISPR; it supported 99 percent of the drugs approved in the U.S. from 2010 to 2019. The agency has had a hand in “nearly all of our major medical breakthroughs over the past several decades,” Taison Bell, a critical-care specialist at UVA Health, told me.

That system ground to a halt by late January, after the Trump administration paused communications across HHS on January 21, and a memo released from the Office of Management and Budget just days later froze funding from federal agencies. The NIH stopped issuing new awards and began withholding funds from grants that had already been awarded—money that researchers had budgeted to pay staff, run experiments, and monitor study participants, including, in some cases, critically ill patients enrolled in drug trials.

Several of the agency’s top officials immediately sought advice from Tabak, who served as interim director from December 2021 to November 2023, and had long been a liaison between the agency and HHS. But Tabak openly admitted, several officials told me, that his power in this moment was limited. Although he had been the obvious choice to act as the NIH’s interim leader after Monica Bertagnolli, the most recent director, stepped down, the Trump administration hadn’t tapped him for the position. In fact, several officials said, the administration had ceased communicating with Tabak altogether. (Tabak declined to comment for this story.)

The role of acting director had instead gone to Memoli, who had no experience overseeing awards of external grants or running a large agency. But, officials said, Memoli had expressed beliefs that seemed to align with the administration’s. In 2021, he had called COVID vaccine mandates “extraordinarily problematic” in an email to Anthony Fauci (then director of the NIH’s National Institute of Allergy and Infectious Diseases) and reportedly refused the shot himself; last spring, Jay Bhattacharya, Donald Trump’s nominee to lead the NIH, praised Memoli on social media as “a brave man who stood up when it was hard.” And last year, Memoli had been deemed noncompliant with an internal review, two officials said, after he submitted a DEI statement calling the term “offensive and demeaning.”

[Read: A new kind of crisis for American universities]

From the moment of his appointment, Memoli became, as far as other NIH staff could tell, “the only person the department or the White House was speaking directly to” on a regular basis, one former official said. And the message he passed along to the rest of the agency was clear: All NIH grants were to remain on pause.

That position was at odds with a growing number of court orders that directed the federal government to resume distributing federal funds. Some of those orders included painstaking, insistent language usually reserved for defendants who seem unlikely to comply, Samuel Bagenstos, who until December served as general counsel to HHS, told me. In written correspondence with senior NIH leadership in early February, current HHS lawyers, too, interpreted the court’s instructions unambiguously: “All stop work orders or pauses should be lifted so contract or grant work can continue” and contractors and grantees could be paid. In other words, put everything back the way it was.

Government lawyers aren’t the final arbiters on what’s legal. But the National Science Foundation, for instance, unfroze its funding on February 2. And the independent lawyers I spoke with agreed with what HHS counsel advised. The continuation of the NIH freeze “is unambiguously unlawful,” David Super, an administrative law expert at Yale University and Georgetown University, told me. The money that Congress appropriates to federal agencies each year is intended to be spent. “If they’re holding it back for policy reasons,” Super said, “they’re violating the law.”

At a meeting on February 6, several of the agency’s institute and center directors demanded that Memoli explain the NIH’s continued freeze. David Lankford, the NIH’s top lawyer, said that the position of the general counsel’s office aligned with that of the courts: Grants should be “awarded as intended.”

But Memoli called for patience, officials with knowledge of the meeting told me. He was waiting for one thing in particular to restart grant funding: He had tasked Michael Lauer, the deputy director of the NIH’s Office of Extramural Research, which oversees grants, to draft a formal plan to make the agency’s funding practices consistent with Trump’s executive orders on gender, DEI, foreign aid, and environmental justice. (Lauer declined to comment for this story.)

Squaring those orders with the NIH’s mission, though, wasn’t straightforward. One sticking point, officials said, was funding for research into health disparities: If the administration’s definition of DEI included studies that acknowledged that many diseases disproportionately affect Americans from underrepresented backgrounds, complying with Trump’s orders could mean ignoring important health trends—and broad cuts in funding across many sectors of research. Cancer, for instance, disproportionately affects and kills Black Americans; men who have sex with men are the population most affected by HIV. “To pretend that entire communities don’t exist—in health, that doesn’t make sense,” Bertagnolli, the former NIH director, told me.

In several discussions that followed, officials with knowledge of those conversations said, Memoli assured NIH officials that health-disparity research could continue, as long as the inclusion of diverse populations in studies was “scientifically justifiable.” But given the administration’s disregard of scientific norms up until this point, “nobody was particularly satisfied by that explanation,” one former official told me.

Still, on February 7, Memoli yielded a bit of ground: He green-lighted the NIH to start issuing a small subset of grants for clinical trials. That allowance fell far short of Lankford and other lawyers’ recommendation to resume grant funding in full—but some officials wondered if the ice had begun to thaw.

That afternoon, Memoli acknowledged to other NIH officials that he understood what the agency’s lawyers were telling him, an official with knowledge of the meeting told me. But then, he offered an alternative justification for holding back the agency’s funds. What if, he said, the halt was continuing, not because the agency was adhering to the president’s executive orders, but because it was pursuing a new agenda—a new way of thinking about how it wanted to fund research? Such shifts take time; surely, the agency couldn’t continue its work until it had reoriented itself.

The lawyers were unmoved. At best, they said, that argument came off as a thinly veiled attempt to disregard court orders. Memoli contemplated this. He had no choice, he insisted: He was following the directions of three HHS officials—Dorothy Fink, then the acting secretary; Heather Flick Melanson, chief of staff; and Hannah Anderson, deputy chief of staff of policy—who had told him, in no uncertain terms, that the pause was to continue, save for the few award subtypes he’d already okayed. In other words, the Trump administration’s political leadership at HHS wanted funding to stay frozen, and that overruled any legal concerns.

And, as officials learned later that day, HHS officials had been planning new ways to limit NIH funding. That afternoon, they foisted a new policy on the NIH that would abruptly cap the amount of funding that could be allocated to cover researchers’ and universities’ overhead. The first Trump administration had tried to cut those “indirect cost” rates in 2017; in response, Congress had made clear that altering them requires legislative approval. And so within days, yet another temporary restraining order had blocked the cap.

[Read: The NIH memo that undercut universities came directly from Trump officials]

By this point, NIH lawyers were grim in their prognosis. If the agency moved forward with slashing indirect cost rates, they explained, individual staff members could be prosecuted for failing to comply with a congressional directive. On February 10, Sean R. Keveney, HHS’s acting general counsel, sent a memo to Flick Melanson that included a directive in bold, italicized font: All payments that are due under existing grants and contracts should be un-paused immediately.

Two days later, Lauer, the extramural-research director, issued a memo authorizing his colleagues to resume issuing awards—what should have been the agency’s final all-clear to return to normalcy.

Even then, the staff remained divided on how to proceed. Some institutes immediately began sending out awards: Lauer’s email spurred one institute, a current official told me, to process 100 grants in a single afternoon. Others, though, still held back. “They’re scared out of their minds,” the official told me. Some worry that, despite what Memoli has said, they’ll be held accountable for somehow violating the president’s wishes, and be terminated.

So far, at least 1,200 federal workers—many of them on probationary status—have been fired from the NIH; a new OMB memo released yesterday indicates that more layoffs are ahead. On February 11, HHS also attempted to unceremoniously reassign Tabak, the deputy director, to an essentially meaningless senior advisory position to the acting HHS secretary, with an office in another city, far from the laboratory he ran at the agency—a demotion that several NIH officials described to me as an insult. Tabak chose instead to retire that same day, abruptly ending his 25-year stint at the agency; Lauer, who had worked closely with Tabak for years, announced his own resignation that same week.

Their departures left many at the agency shocked and unmoored, several former and current officials told me: If Tabak and Lauer were out, was anyone’s position safe? And because Lauer left immediately after clearing his colleagues to issue grants, who would ensure that the agency’s core business would continue? “We’re all still terrified for our jobs,” one current official told me. Agency hallways, where colleagues once chatted and laughed, have sunk under an uncomfortable silence: “No one knows who they can trust.”

The administration has also kept up its attempts to block NIH grants. Even after Lauer’s memo went out, HHS continued to bar agency officials from posting to the Federal Register, the government journal that publishes, among other things, the public notices required by law for meetings in which experts review NIH grant applications and issue funds, one official told me. The NIH might have been allowed to award grants, but logistically, it was still unable to. Finally, on Monday, Memoli announced in a leadership meeting that the agency could resume submitting to the Federal Register. But there were limits: Although officials could post notice of some meetings to review grant proposals, meetings to finalize funding recommendations were still off the table—meaning the NIH would still be in a grant backlog. “We can’t go crazy and put all our meetings on,” Memoli told his colleagues. But if agency personnel responded to this new allowance reasonably, he said, they’d be granted more liberty.

[Read: Grad school is in trouble ]

To Super, the administrative lawyer, curtailing posting to the Federal Register constituted yet another strategy intended to circumvent court orders. “These aren’t legitimate workarounds,” he said. “This is contempt of court.” The NIH’s developing plan to align the agency’s strategies with the president’s executive orders—which, officials told me, is still awaiting formal HHS approval—may end up being a legal battleground too: On Friday, a federal judge declared Trump’s executive order attacking DEI programming a potential violation of the First Amendment.

The longer the pause on NIH funding has dragged on, the more the American research community has descended into disarray. Universities have considered pausing graduate-student admissions; leaders of laboratories have mulled firing staff. Diane Simeone, who directs UC San Diego’s cancer center, told me that, should the pause continue for just a few more weeks, dozens of clinical trials for cancer patients—sometimes “a patient’s best chance for cure, and long-term survival,” she told me—could be at risk of shutting down.

Even if courts ultimately nullify every action that the Trump administration has taken, the NIH—at least in its current form—may remain in jeopardy. Robert F. Kennedy Jr., now the leader of HHS, has said that he wants to shift the agency’s focus away from infectious disease and downsize the staff. Some Republicans have been pressing for years to slash the number of institutes and centers at the agency, which depends on Congress for its budget, or to disburse its funding to the states as block grants—a change, Bertagnolli told me, that could mean biomedical research in America “as we know it would end.”

At a meeting with NIH leadership on February 13, Memoli explained to officials that “we are going to have to accept priorities are changing.” He didn’t say what those changing priorities might be, but previewed an era of “radical transparency,” language that would headline an executive order from Trump just days later. In this moment, federal judges were “hampering us” from moving forward, into the agency’s future, Memoli said. But the path before them remained the same: The NIH would do as the nation’s leaders wished.

It’s a stressful time to be a psychiatrist in America. Not a day seems to go by without a panicked patient or friend asking me how to stay grounded in the face of the political chaos that has suddenly taken hold of the nation. One patient, a 38-year-old scientist, worries that his research will soon be defunded, ending his career. A good friend, a professor in her 60s, fears that the United States is sliding into autocracy. How, they want to know, can they make themselves feel better?

They haven’t liked the answer I’ve had to give them. This is a hard thing for a psychiatrist to say, but if you’re alarmed by Donald Trump’s hoarding of executive power and efforts to dismantle the federal government, then maybe you should be.

Plenty of Americans may cheer the disruptive effects of Trump’s flood of executive orders. But being inundated with unpredictable change over such a short period of time undermines people’s sense of security and control. It’s bound to provoke intense anxiety. Even some of Trump’s supporters appear to be reeling from the chaos: Recent polling suggests that more Americans believe that Trump has exceeded his presidential powers than not. (My patients, who are predominantly based in New York City, lean Democratic, but even some of my Republican patients have told me they are having second thoughts.)

Humans have a powerful instinct to protect ourselves from psychic pain by denying or minimizing the potential seriousness of the threats we encounter. Studies have shown, for example, that the brain selectively attends to positive information, and that people tend to discount negative predictions in order to maintain an optimistic bias. The urge is unavoidable. Several weeks after Trump’s inauguration, a close friend told me she was still on “a break” from the news. She hadn’t yet heard about the president’s proposal to turn Gaza into the “Riviera of the Middle East,” among other things.

[Read: The people who don’t read political news]

An information blackout might temporarily spare you such discomfort, but denial can be its own source of anxiety. A lack of knowledge about the environment around you increases uncertainty, which psychological studies have shown to be very stressful. For example, in one 2015 study, people who failed the California bar exam were more anxious the day before they received the news than afterward. (However, they felt more negative emotions immediately following the news.) Certainty, by contrast, allows us to activate coping strategies. That’s why we can adjust to good news or even bad news—both are clear and unambiguous—but we cannot reconcile with the unknown.

Many therapists are trained to identify the exaggerated emotional responses and distortions of reality that beset their patients, and to help them understand that things are not as bad as they imagine. But when the situation really is as dire as a patient believes, soothing reassurance that one’s distress is misplaced would be malpractice. No one can say exactly where Trump is taking the country, but those who worry about the breakdown of essential public services, the spilling of national-security secrets, and national paralysis in the face of natural disasters are empirically grounded in their concerns. Think of it this way: If your house is in danger of catching fire, the last thing you should do is disable the alarm.

Optimism relaxes us, robbing us of the drive to take action. But angst, like a smoke detector, is a powerful motivating force—one that can impel people to help bring about the very changes they need to feel better. Worrying about missing an important deadline at work might, for example, rouse you to work faster or cancel other plans that would delay your task. The solution to a constitutional crisis is less clearly defined—unless you’re a lawmaker or member of the executive branch, there’s little you personally can do to stop the erosion of democratic norms—but getting involved in local politics and community organizations can both help to shore up your corner of the world. Speaking up in defense of democratic values is also powerful, especially when many individuals are willing to do so at once.

[Read: ‘Constitutional crisis’ is an understatement]

Research suggests that you’re less likely to take such action if you insist on pretending that things will be fine. For example, in a pioneering study published in 2011, college students who were instructed to imagine that the following week would be terrific felt significantly less motivated and energetic—and were academically less productive—than their peers who were told to visualize all the problems that might take place during the coming week. In difficult times, inappropriate optimism can disarm and relax us—and substitute for actions that could actually bring about that sunny imagined future.

None of this is to suggest that abject despair is the appropriate response to the rise of authoritarianism in America. If you’re feeling anxious or hopeless, try to focus on the basics: Exercise, get enough sleep, eat a healthy diet, and talk about your distress with friends and loved ones. These tried-and-true strategies help us tolerate adversity.

Even better is a technique called mental contrasting, co-developed by the psychologist Gabriele Oettingen, who led the study on college students. The idea is to visualize an attainable goal (such as getting involved in local politics or running a mile), then think about all the obstacles that might get in your way (such as failing to find people who share your political vision, or shin splints). Mental contrasting has been shown to help people improve their relationships and recover from chronic pain, possibly because it undercuts the complacency brought about by unrealistic optimism. Crucially, the technique works only for goals you have a chance of achieving; in other words, mental contrasting may not be what allows you, personally, to defeat the global creep of authoritarianism. But it’s more likely to help you, say, identify five ways you can meaningfully improve your local community, then execute on them, which is likely to make you feel at least a little better.

[Anne Applebaum: The new propaganda war]

During this challenging time, maintaining one’s peace of mind—or at least a reasonable sense of hope—is a commendable goal. But first, Americans have to see the world as it is, even if it’s upsetting to many.

Jennie Bromberg was somehow still exuberant last weekend about her future career in public health. In January, she interviewed for a competitive Ph.D. program in epidemiology at the University of Washington, one of several to which she has applied. “I loved them. It was amazing,” she told me by phone while on a walk with her Australian shepherd. But the email that arrived from UW shortly after she got home was not the acceptance letter that she’d hoped for. Nor was it even a rejection. Instead, it said that she’d been placed in grad-school purgatory. All new offers of admission were being put on hold “in response to the uncertainty we are facing because of the rapidly changing financial landscape.” The email finished: “We appreciate your patience as we navigate through these uncertainties and disruption.”

Those words euphemize a cascade of traumas that have befallen higher education since Inauguration Day. The Trump administration has frozen, slashed, threatened, and otherwise obstructed the tens of billions of dollars in funding that universities receive from the government, and then found ways around the court orders that were meant to stop or delay such efforts. In the meantime, new proposals to raise the tax on endowment income could further eat away at annual budgets. And all of this is happening at just the time when graduate admissions are in progress. Future researchers such as Jennie Bromberg are caught in the middle.

The University of Washington is not alone in putting things on hold. The University of Pennsylvania, the University of Pittsburgh, and the University of Southern California have also paused or cut their graduate admissions, at least temporarily. Ilya Levental, a biophysicist at the University of Virginia, told me that his program in biomedical sciences reduced the size of its incoming class by 30 percent. In other words, grad school is in trouble. And because grad school trains the next generation of academics—those who will be teaching students, discovering knowledge, and translating science into practice—this means the future of the university itself is in trouble too.

Doctoral students typically do not pay for their advanced degrees. Instead, they work in research groups or labs, or sometimes as classroom instructors. In exchange for this work, universities usually pay them a modest salary and waive or cover their tuition. In engineering, the sciences, and medicine, the cost of that support comes mostly from faculty research that is in turn paid for by grants received from the federal government.

[Read: A new kind of crisis for American universities]

Once it became clear, in recent weeks, that this grant money was in jeopardy, schools began gaming out contingencies. Reducing the number of graduate students they will have to pay next year is one way to lower near-term risk. It’s also an act that universities would want to take right now, before their offers of admission are sent out. “People are trying to be conservative, because the worst outcome is very bad here,” Aaron Meyer, an associate bioengineering professor at UCLA, told me. “A commitment to a Ph.D. student in the sciences is easily half a million dollars, over many years.”

Administrators’ choices on admissions are made even more complicated by a weird dynamic in play across higher ed. No one wants to overreact and cut new students without good reason, but they also have to hedge against the risk of others’ cuts. The situation is structured like a prisoner’s dilemma: If lots of programs start reducing their admissions, that means fewer total spots for applicants, which in turn could lead to greater “yields”—that is, a higher proportion of each school’s offers gets accepted. No school wants to end up with too many students, so if one expects a growing yield, it may decide to cut admissions offers on that basis—and thus exacerbate the larger trend.

The administration has also called for tightened scrutiny on visas of all kinds, including student visas. This could further muddy grad-school yields by making some applicants unable to accept their offers of admissions or enroll. Graduate-student unions, which now represent more than 150,000 students nationwide, add another layer of uncertainty. Organizing has allowed grad students, who can barely afford to live in many cities, to advocate for better pay and labor practices. But it also increased the cost of graduate education in a way that worried administrators even before the grant and overhead cuts arrived. Schools sometimes take graduate tuition, and normally pay student stipends, from the same grants that are now at risk. And some grants have already been canceled, leading to a scramble for money to cover current students. The whole system has been thrown out of whack.

Choosing to take fewer students forestalls or even ends the careers of future scientists. It also makes research harder. In most science, engineering, and medicine programs, students get accepted into specific labs or groups led by the faculty whose grants also fund those students. These faculty members take on students to help them carry out their research. “Ph.D. students make up the bulk of the academic-research workforce,” Levental told me. Without their labor, work on already awarded grants can’t be done—assuming the funds to carry out those grants continue flowing in the first place.

[Read: The chaos in higher ed is only getting started]

The situation could deteriorate if current doctoral students start jumping ship. A Ph.D. student might make $35,000 a year, a sum they tolerate because “they are investing in themselves and are dedicated to the cause,” as Levental put it. But that investment might start to look foolish. Dallas McCulloch, a doctoral student who studies health and illness at Wayne State University with four years of supposedly guaranteed funding, told me that he is thinking of quitting and moving abroad to pursue his degree, because of “the grim prospects of any future funding, including for my dissertation.” McCulloch, an American who also holds a German passport, said he is worried that if he doesn’t act soon, he’ll end up competing with a “mass exodus” of researchers seeking to leave the United States.

Universities could decide to cover shortfalls in science and engineering by reallocating funds for graduate education from elsewhere. Some faculty and administrators I spoke with are worried that the humanities might become a casualty of such reapportionment. There, graduate students are typically paid for teaching, not research. Knock-on cuts to their admissions could follow, the effects of which might then reverberate into undergraduate education. If grad school in the sciences falters, the effects will not be contained.

For the moment, though, the whole system is in limbo. UW’s “pause” on graduate admissions was set to last at least two weeks, according to the email that was sent to Bromberg two weeks ago. No news was promised either way—and no news is what Bromberg has received so far. Given the chaotic and aggressive rush of new directives from the federal government, universities have no idea whether their financial outlooks will improve or worsen in the coming months. They don’t even know when they’re likely to find out. Over the weekend, Carolyn Ibberson, a microbiologist at the University of Tennessee at Knoxville, created a shared spreadsheet to track the latest news. Its title sounds definitive, “Graduate Reductions Across Biomedical Sciences (2025),” but much of the information there is cited to private conversations and internal emails. In other words, academics face uncertainty about how universities are handling uncertainty.

Bromberg can only take things as they come. She lives in Columbus, Ohio, but plans to attend, at her own expense, Washington’s on-campus open house for prospective graduate students and is still waiting to hear back from other schools. She told me that she understands the pressures that administrators are feeling at the moment: “I just feel so bad for people who have to make these decisions.” And if Bromberg doesn’t get into a doctoral program—or if the research career she hopes the degree will unlock becomes unviable—she’ll just have to think of something else. Like McCulloch, she has wondered if she could flee to Europe. Even before the Irish journalist Fintan O’Toole urged his government to steal American scientists, Bromberg had already researched the cost of moving Gatsby, her 70-pound dog, from Columbus to Dublin: $8,000, or about one-quarter of a typical annual graduate salary. “I’ll be devastated if this is the end of everything I’ve worked for in my career,” Bromberg said. “But what am I going to do? I have to start looking into these things.”

In the early, uncertain days of the coronavirus pandemic, scientists delivered one comforting pronouncement: The virus that caused COVID mutates rather slowly. If that remained true, the virus would not change much to become more dangerous soon, and any vaccine could provide years of durable protection.

What actually happened was that SARS-CoV-2 began mutating quickly, first to be more transmissible and then to evade our immunity, causing breakthrough infections and reinfections. Five years and an alphanumeric soup of variants later, most of us have gotten COVID at least once. The vaccine is still being updated to match new circulating variants. And the virus itself is still changing.

In truth, scientists were both right and wrong about the speed at which SARS-CoV-2 mutates. The rate of mutations as this virus jumps from person to person is indeed unimpressive. But scientists were not aware of a second, accelerated evolutionary track: When SARS-CoV-2 infects a single immunocompromised patient, it can persist for months, accumulating countless mutations in that time.

And if we are unlucky, that highly mutated virus might spread to others. This is the likely origin of Omicron, which appeared in fall 2021 with more than 50 mutations—an astounding evolutionary leap. Omicron looked like it had achieved four or five years’ worth of expected evolution in just months, Jesse Bloom, who studies viral evolution at the Fred Hutchinson Cancer Center, told me at the time. These mutations enabled Omicron to cause a massive wave of infections even among the vaccinated.

Scientists now believe that chronic infections in immunocompromised patients are a key driver of variants in Omicron and beyond. Even as COVID surveillance has faded in urgency, researchers are watching chronic infections for signs of what’s to come.

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In retrospect, clues were there from the beginning. At the start of the pandemic, researchers in New York, including Harm van Bakel, a geneticist at the Icahn School of Medicine at Mount Sinai, began sequencing viruses from cancer patients who tested positive for SARS-CoV-2 in March and April 2020—and then kept testing positive for up to two months. The patients couldn’t clear the virus because their immune systems had been weakened by disease and by cancer treatments they received. The study, published in December 2020, concluded that immunocompromised patients with COVID might need long isolation periods, lest they unwittingly spread the virus. (These chronic infections in people who are immunocompromised are distinct from long COVID, which doesn’t necessarily involve continual shedding of virus.)

That same month, a preprint from a group led by Ravindra Gupta in the U.K. connected more of the dots. Gupta and his colleagues had found an immunocompromised patient with a lingering infection who was treated with antibodies from COVID survivors, only for the virus to acquire curious new mutations. Two mutations in particular gave the virus a slight edge in infectivity and antibody evasion. An immunocompromised host, the authors suggested, could provide the ideal viral training ground: A weakened immune system cannot wipe out the virus but can put up just enough defense for the virus to learn its tricks. In this case, the infused antibodies from COVID survivors likely contributed to whatever defenses the patient himself had, but even together they were not enough to completely clear the infection.

The virus from that particular patient probably didn’t spread far, if at all; most do not. But countless chronic infections all around the world subjecting the virus to similar immune defenses could ultimately lead to the same battle-tested mutations showing up over and over again. Indeed, mutations similar to the two in the U.K. patient soon showed up in variants such as Alpha and Omicron that did sweep around the world, Gupta told me recently. And in 2021, multiple alarming variants were found to have a different mutation that researchers in New York first observed in immunocompromised patients way back at the beginning of the pandemic. (Researchers at Mount Sinai, led by van Bakel and Viviana Simon, did match a minor variant from an immunocompromised patient to other infections in the New York City area, though it didn’t seem to spread much beyond that.)

None of the more notorious COVID variants has been directly traced to a single immunocompromised patient. But indirect evidence has accumulated over time that many variants do develop this way. Chronic infections, scientists have now observed over and over, create a distinct pattern of mutations: an overabundance of changes in the spike protein (which helps penetrate human cells) but not in the rest of the virus. This pattern is clearly found in both BA.1 and BA.2 versions of Omicron, as well as the variant that gave rise to JN.1, which drove last winter’s COVID surge. Bloom now says he has “very high confidence” that these variants came from chronic infections. The evidence is not as clear with other variants, he told me, but they could very well have evolved in the same way.

Long before COVID, Bloom had tracked the evolution of influenza during chronic infections in four immunocompromised patients; some mutations in these patients eventually showed up in the seasonal flu. I wrote about the study when it was published in 2017, intrigued by the possibility that chronic infections could predict changes in flu from year to year. At the time, this was quite a novel idea.

Flu and COVID evolution do differ in important ways, but chronic COVID infections, too, are now being examined as harbingers of the future. “Those will actually teach us a lot about the future tricks SARS-CoV-2 will come up with,” says Simon, a microbiologist at the Icahn School of Medicine at Mount Sinai. To discover what those might be, she and van Bakel are now leading a research project to create better tools for sequencing chronic infections and to better understand which immunocompromised patients are most at risk for carrying them. What they find could be a preview for the future of COVID.

Americans have plenty to worry about these days when it comes to infectious-disease outbreaks. This is the worst flu season in 15 years, there’s a serious measles outbreak roiling Texas, and the threat of bird flu isn’t going away. “The house is on fire,” Denis Nash, an epidemiologist at CUNY School of Public Health, told me. The more America is pummeled by disease, the greater the chance of widespread outbreaks and even another pandemic.

As of this week, the federal government may be less equipped to deal with these threats. Elon Musk’s efforts to shrink the federal workforce have hit public-health agencies, including the CDC, NIH, and FDA. The Trump administration has not released details on the layoffs, but the cuts appear to be more than trivial. The CDC lost an estimated 700 people, according to the Associated Press. Meanwhile, more than 1,000 NIH staffers reportedly lost their jobs.

Perhaps as notable as who was laid off is who wasn’t. The Trump administration initially seemed likely to target the CDC’s Epidemic Intelligence Service, a cohort of doctors, scientists, nurses, and even veterinarians who investigate and respond to disease outbreaks around the world. Throughout the program’s history, EIS officers have been the first line of defense against anthrax, Ebola, smallpox, polio, E. coli, and, yes, bird flu. Four recent CDC directors have been part of the program.

The layoffs were mostly based on workers’ probationary status. (Most federal employees are considered probationary in their first year or two on the job, and recently promoted staffers can also count as probationary.) EIS fellows typically serve two-year stints, which makes them probationary and thus natural targets for the most recent purge. EIS fellows told me they were bracing to be let go last Friday afternoon, but the pink slips never came. Exactly why remains unclear. In response to backlash about the planned firings, Musk posted on X on Monday that EIS is “not canceled” and that those suggesting otherwise should “stop saying bullshit.” A spokesperson for DOGE did not respond to multiple requests for comment.

This doesn’t mean EIS is safe. Both DOGE and Robert F. Kennedy Jr., Donald Trump’s newly confirmed health secretary, are just getting started. More layoffs could still be coming, and significant cuts to EIS would send a clear message that the administration does not believe that investigating infectious-disease outbreaks is a good use of tax dollars. In that way, the future of EIS is a barometer of how seriously the Trump administration takes the task of protecting public health.

Trump and his advisers have made it abundantly clear that, after the pandemic shutdowns in 2020, they want a more hands-off approach to dealing with outbreaks. Both Trump and Kennedy have repeatedly downplayed the destruction caused by COVID. But so far, the second Trump administration’s approach to public health has been confusing. Last year, Trump said he would close the White House’s pandemic office; now he is reportedly picking a highly qualified expert to lead it. The president hasn’t laid out a bird-flu plan, but amid soaring egg prices, the head of his National Economic Council recently said that the plan is coming. Kennedy has also previously said that he wants to give infectious-disease research a “break” and focus on chronic illness; in a written testimony during his confirmation hearings, he claimed that he wouldn’t actually do anything to reduce America’s capacity to respond to outbreaks.

The decision to spare EIS, at least for now, only adds to the confusion. (Nor is it the sole murky aspect of the layoffs: Several USDA workers responding to bird flu were also targeted, although the USDA told me that those cuts were made in error and that it is working to “rectify the situation.”) On paper, EIS might look like a relatively inconsequential training program that would be apt for DOGEing. In reality, the program is less like a cushy internship and more akin to public health’s version of the CIA.

Fellows are deployed around the world to investigate, and hopefully stop, some of the world’s most dangerous pathogens. The actual work of an EIS officer varies depending on where they’re deployed, though the program’s approach is often described as “shoe-leather epidemiology”—going door to door or village to village probing the cause of an illness in the way a New York City detective might investigate a stabbing on the subway. Fellows are highly credentialed experts, but the process provides hands-on training in how to conduct an outbreak investigation, according to Nash, the CUNY professor, who took part in the program. Nash entered EIS with a Ph.D. in epidemiology, but “none of our training could prepare us for the kinds of things we would learn through EIS,” he said.

In many cases, EIS officials are on the ground investigating before most people even know there’s a potential problem. An EIS officer investigated and recorded the United States’ first COVID case back in January 2020, when the virus was still known as 2019-nCoV. It would be another month before the CDC warned that the virus would cause widespread disruption to American life.

More recently, in October, EIS officers were on the ground in Washington when the state was hit with its first human cases of bird flu, Roberto Bonaccorso, a spokesperson with the Washington State Department of Health, wrote to me. “Every single outbreak in the United States and Washington State requires deployment of our current EIS officers,” Bonaccorso said.

EIS is hardly the only tool the federal government uses to protect the country against public-health threats. Managing an outbreak requires coordination across an alphabet soup of agencies and programs; an EIS fellow may have investigated the first COVID case, but that of course didn’t stop the pandemic from happening. Other vital parts of how America responds to infectious diseases were not spared by the DOGE layoffs. Two training programs with missions similar to that of EIS were affected by the cuts, according to a CDC employee whom I agreed not to identify by name because the staffer is not authorized to talk to the press.

The DOGE website boasts of saving nearly $4 million on the National Immunization Surveys, collectively one of the nation’s key tools for tracking how many Americans, particularly children, are fully vaccinated. What those cuts will ultimately mean for the future of the surveys is unknown. A spokesperson for the research group that runs the surveys, the National Opinion Research Center, declined to comment and directed all questions to the CDC.

And more cuts to the nation’s public-health infrastructure, including EIS, could be around the corner. RFK Jr. has already warned that certain FDA workers should pack their bags. Kennedy has repeatedly claimed that public-health officials inflate the risks of infectious disease threats to bolster their importance with the public; EIS fellows are the first responders who hit the ground often before public officials are even sounding the alarm bells.

Ironically, the work of the EIS is poised to become especially pressing during Trump’s second term. If measles, bird flu, or any other infectious disease begins spreading through America unabated after we have fired the public-health workforce, undermined vaccines, or halted key research, it will be the job of EIS fellows to figure out what went wrong.