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When Robert F. Kennedy Jr. accepted his new position as health secretary, he made a big show of distancing himself from his past life. “News reports have claimed that I am anti-vaccine or anti-industry,” Kennedy, who has for decades promoted the debunked notion that vaccines cause autism and has baselessly sown doubt over the ability of the U.S. government to vet shots, said at his confirmation hearing in January. “I am neither. I am pro-safety.”

But for all Kennedy’s talk, this week, he did exactly what a person would do if they were trying to undermine the scientific consensus on vaccination in the United States. He abruptly dismissed the entire expert committee that advises the CDC on its nationwide vaccine recommendations—and began to fill the roster with like-minded people ready to cast doubt on the benefits of vaccination.

Like Kennedy, few of these new appointees to the Advisory Committee on Immunization Practice, or ACIP, have openly embraced the notion that they are anti-vaccine. But among them are individuals who have spoken out against COVID vaccines and policies, claimed vaccine injuries for their own children, and falsely linked COVID shots to deaths—or even baselessly accused those vaccines of “causing a form of acquired immunity deficiency syndrome.”

In January, I wrote that remaking the committee in exactly this way would be an especially harmful blow to Americans’ health: Perhaps more than any other body of experts in the U.S., ACIP guides the nation’s future preparedness against infectious disease. By appointing a committee that is poised to legitimize more of his own radical views, Kennedy is giving his skewed version of scientific reality the government’s imprimatur. Whether he will admit to it or not, he is serving the most core goal of the anti-vaccine movement—eroding access to, and trust in, immunization.

In an emailed statement, Health and Human Services Press Secretary Emily G. Hilliard reiterated that “Secretary Kennedy is not anti-vaccine—he is pro-safety, pro-transparency, and pro-accountability,” and added that his “evidence-based approach puts accountability and radical transparency first, which will restore trust in our public health system.” (Kennedy, notably, promised Senator Bill Cassidy during his confirmation process that he would maintain ACIP, as Cassidy put it, “without changes.”)

Since the 1960s, ACIP has lent government policy on vaccines the clout of scientific evidence. Its mandate is to convene experts across fields such as infectious disease, immunology, pediatrics, vaccinology, and public health to carefully vet the data on immunizations, weigh their risks and benefits, and vote on recommendations that guide the public on how to use them—who should get vaccines, and when. Those guidelines are then passed to the CDC director, who—with only the rarest of exceptions—accepts that advice wholesale.

“These recommendations are what states look to, what providers look to,” Rupali Limaye, an expert in vaccine behavior at the Johns Hopkins Bloomberg School of Public Health, told me. Medicare, for instance, is required to fully cover the vaccines that ACIP recommends; ACIP also determines which vaccines are covered by the Vaccines for Children Program, which provides free vaccines for children whose families cannot afford them. The experts who serve on ACIP have the opportunity, more than just about any of their scientific peers, to translate their vaccine rhetoric into reality.

So far, Kennedy has dismissed the 17 people who were serving on ACIP, and filled eight of the newly open slots. Most of the new nominees have an obvious bone to pick with at least some vaccines, especially COVID shots, and have publicly advocated for limiting their use. Among the new members, for instance, is Robert Malone, a controversial physician who has spoken at anti-vaccine events, where he has denounced COVID vaccines and, without evidence, suggested that they can worsen coronavirus infections. Another appointee is Vicky Pebsworth, who serves on the board of the National Vaccine Information Center, an anti-vaccine nonprofit previously known as Dissatisfied Parents Together. A third, Retsef Levi, a health-care-management expert, called for the administration of COVID vaccines to be halted in 2023, and has questioned the shots’ safety, despite a large body of evidence from clinical trials supporting their continued use. Overall, “this is not a list that would increase confidence in vaccine decisions,” Dorit Reiss, a vaccine-policy expert at UC San Francisco, told me. (None of these new ACIP members returned a request for comment.)

The next ACIP meeting is scheduled for the end of this month—and the agenda includes discussion about anthrax vaccines, chikungunya vaccines, COVID-19 vaccines, cytomegalovirus vaccine, the human-papillomavirus vaccine, influenza vaccines, the Lyme-disease vaccine, meningococcal vaccines, pneumococcal vaccines, and RSV vaccines. That’s a big slate of topics for a brand-new panel of members, Paul Offit, a pediatrician and a vaccine expert who has previously served on ACIP, told me: Depending on how the meeting is structured, and on the input from CDC scientists, these new committee members could substantially alter the guidelines on several immunizations—perhaps so much so that certain shots could stop being recommended to certain groups of Americans. Based on the composition of the committee so far, Offit predicts that the new ACIP will eventually push the CDC away from full-throated endorsement of many of these vaccines.

Even subtle changes in the wording of CDC recommendations—a should swapped for a may—can have big ripple effects, Limaye told me. Insurers, for instance, may be more reluctant to cover vaccines that are not actively endorsed by the CDC; some states—especially those in which vaccines have become a political battleground—may stop mandating those types of shots. If the CDC softens its recommendations, “we will likely see more partisan divides” in who opts for protection nationwide, Jason Schwartz, a vaccine-policy expert at Yale, told me. Pharmaceutical companies may, in turn, cut down production of vaccines that don’t have full CDC backing, perpetuating a cycle of reduced availability and reduced enthusiasm. And primary-care physicians, who look to the CDC’s vaccination schedule as an essential reference, may shift the language they use to describe childhood shots, nudging more parents to simply opt out.

Historically, medical and public-health associations, such as the American Academy of Pediatrics, have aligned their vaccine recommendations with ACIP’s—because those recommendations were all driven by scientific evidence. Now, though, scientific consensus and government position are beginning to diverge: Multiple groups of physicians, scientists, and public-health scholars have issued statements condemning the vaccine decisions of Kennedy and his allies; a number of prominent scientists have now banded together to form a kind of alt-ACIP, dubbing themselves the Vaccine Integrity Project. As the views of fringe vaccine groups become the government’s stance, Americans may soon have to choose between following the science and following what their nation’s leaders say.

Identifying as “anti-vaccine” has historically been taboo: In a nation where most people remain largely in favor of shots, the term is pejorative, an open acknowledgment that one’s views lie outside of the norm. But the more vaccine resistance infiltrates HHS and its advisers, the more what’s considered normal may shift toward Kennedy’s own views on vaccines; ACIP’s reputation for evidence-backed thinking could even gild those views with scientific legitimacy. Assembling one’s own team of friendly experts is an especially effective way to sanewash extremism, Reiss told me, and to overturn the system through what appear to be normal channels. If the nation’s most prominent group of vaccine advisers bends toward anti-vaccine, the term loses its extremist edge—and the scientists who argue, based on sound data, that vaccines are safe and effective risk being labeled anti-government.

Robert F. Kennedy Jr.’s warning about mitochondria slipped in between the anti-vaccine junk science and the excoriation of pharmaceutical drugs as “the No. 3 killer in our country.” He was speaking in 2023 to Joe Rogan, elaborating on the dangers of Wi-Fi—which no high-quality scientific evidence has shown to harm anyone’s health—and arguing that it causes disease by somehow opening the blood-brain barrier, and by degrading victims’ mitochondria.

The mention of mitochondria—the tiny structures that generate energy within our cells—was brief. Two years later, mitochondrial health is poised to become a pillar of the MAHA movement, already showing up in marketing for supplements and on podcasts across the “manosphere.” Casey Means, President Donald Trump’s newest nominee for surgeon general, has singled out the organelle as the main casualty of the modern American health crisis. According to Means (who has an M.D. but no active medical license), most of America’s chronic ailments can be traced to mitochondrial dysfunction. Should she be confirmed to the post of surgeon general, the American public can expect to hear a lot more about mitochondria.

Among scientists, interest and investment in mitochondria have risen notably in the past five years, Kay Macleod, a University of Chicago researcher who studies mitochondria’s role in cancer, told me. Mitochondria, after all, perform a variety of crucial functions in the human body. Beyond powering cells, they can affect gene expression, help certain enzymes function, and modulate cell death, Macleod said.

When mitochondria are defective, people do indeed suffer. Vamsi Mootha, a mitochondrial biologist based at Massachusetts General Hospital and the Broad Institute, told me that rare genetic defects (appearing in about one in 4,300 people) can cause the organelles to malfunction, leading to muscle weakness, heart abnormalities, cognitive disability, and liver and kidney problems. Evidence also suggests that defects in mitochondria directly contribute to symptoms of Parkinson’s disease, and could be both a cause and an effect of type 2 diabetes. Other conditions’ links to mitochondria are blurrier. Researchers see aberrant mitochondria in postmortem biopsies of patients with illnesses such as Alzheimer’s, cancer, and fatty-liver disease, Mootha said; whether those damaged mitochondria cause or result from such conditions is not yet clear.  

But according to Good Energy, the book Means published last year with a top MAHA adviser—her brother, Calley—mitochondrial dysfunction is a veritable plague upon the United States, responsible for both serious illness and everyday malaise. In their view, modern Western diets and lifestyles wreck countless Americans’ metabolic health: Every time you drink unfiltered water or a soda, or feel the stress of mounting phone notifications, you hurt your mitochondria, they say, triggering an immune response that in turn triggers inflammation. (Damaged mitochondria really can cause inflammation, Macleod said.) This chain of events, the Meanses claim, can be blamed for virtually every common chronic health condition: migraines, depression, infertility, heart disease, obesity, cancer, and more. (Casey Means did not respond to requests for comment; reached by email, Calley did not respond to my questions about mitochondria, but noted, “There is significant scientific evidence that healthy food, exercise and sleep have a significant impact on reversing chronic disease.”)

Good Energy follows a typical wellness playbook: using a mixture of valid and dubious research to pin a slew of common health problems on one overlooked element of health—and advertising a cure. Among the culprits for our mitochondrial ravaging, according to the Meanses, are poor sleep, medications, ultraprocessed foods, seed oils, too many calories, and too few vitamins, as well as chronically staying in comfortable ambient temperatures. The Means siblings therefore recommend eschewing refined sugar in favor of leafy greens, avoiding nicotine and alcohol, frequenting saunas and cold plunges, getting seven to eight hours of uninterrupted sleep a night, and cleansing your life of environmental toxins. Some studies indeed suggest that mitochondrial function is linked with sleep and temperature, but they’ve all been conducted on cell cultures, organoids, or mice. According to Macleod, evidence suggests that diet, too, is likely important. But only one lifestyle intervention—exercise—has been definitively shown to improve mitochondrial health in humans.

The Meanses are riding a wave of interest in mitochondrial health in the wellness world. Earlier this year, the longevity influencer Bryan Johnson and the ivermectin enthusiast Mel Gibson both endorsed the dye methylene blue for its power to improve mitochondrial respiration; Kennedy was filmed slipping something that looks a lot like methylene blue into his drink. (Kennedy did not respond to a request for comment; the FDA has approved methylene blue, but only as a treatment for the blood disease methemoglobinemia.) AG1, formerly known as Athletic Greens, formulates its drinkable vitamins for mitochondrial health. Even one laser-light skin treatment promises to “recharge failing mitochondria.” The enzyme CoQ10 is popular right now as a supplement for mitochondrial function, as is NAD, a molecule involved in mitochondria’s production of energy. NAD IV drips are especially beloved by celebrities such as Gwyneth Paltrow, Kendall Jenner, and the Biebers. These supplements are generally thought to be safe, and some preliminary research shows that NAD supplementation could help patients with Parkinson’s or other neurodegenerative diseases, and that CoQ10 could benefit people with mitochondrial disorders. Patients whose symptoms are clearly caused or made worse by deficiencies in a specific vitamin, such as thiamine, can benefit from supplementing those vitamins, Mootha said. But little research explores how these supplements might affect healthy adults.

[Read: The MAHA takeover is complete]

In Good Energy, as well as on her website and in podcast appearances, Casey Means promotes a number of supplements for mitochondrial health. She also recommends that people wear continuous glucose monitors—available from her company, Levels Health, for $184 a month—to help prevent overwhelming their mitochondria with too much glucose. (According to Macleod, glucose levels are only “a very indirect measure” of mitochondrial activity.) As with so many problems that wellness influencers harp on, the supposed solution to this one involves buying products from those exact same people.

At best, all of this attention to mitochondria could lead Americans to healthier habits. Much of the advice in Good Energy echoes health recommendations we’ve all heard for decades; getting regular exercise and plenty of fiber is good guidance, regardless of anyone’s reasons for doing so. Switching out unhealthy habits for healthy ones will likely even improve your mitochondrial health, Jaya Ganesh, a mitochondrial-disease expert at Icahn School of Medicine at Mount Sinai, told me. After all, “if you consistently beat your body up with unhealthy habits, everything is going to fall sick,” Ganesh said.

But the mitochondrial approach to wellness carries risks, too. For patients with genetically caused mitochondrial disease, lifestyle changes might marginally improve some symptoms, Ganesh said, but attempting to cure such conditions with supplements and a healthy diet alone could be dangerous. Means also calls out medications—including antibiotics, chemotherapy, antiretrovirals, statins, and high-blood-pressure drugs—for interfering with mitochondria. Macleod told me that statins really do affect mitochondria, as do some antibiotics. (The latter makes sense: Mitochondria are thought to have evolved from bacteria more than a billion years ago.) That’s no reason, though, to avoid any of these medications if a doctor has determined that you need them.

[Read: America can’t break its wellness habit]

And yet, a whole chapter of Good Energy is dedicated to the idea that readers should mistrust the motives of their doctors, who the authors say profit by keeping Americans sick. The book is less critical of the ways the wellness industry preys on people’s fears. Zooming in on mitochondria might offer a reassuringly specific and seemingly scientific explanation of the many real ills of the U.S. population, but ultimately, Means and MAHA are only helping obscure the big picture.

Updated at 10:26 a.m. on June 9, 2025

Since winning President Donald Trump’s nomination to serve as the director of the National Institutes of Health, Jay Bhattacharya—a health economist and prominent COVID contrarian who advocated for reopening society in the early months of the pandemic—has pledged himself to a culture of dissent. “Dissent is the very essence of science,” Bhattacharya said at his confirmation hearing in March. “I’ll foster a culture where NIH leadership will actively encourage different perspectives and create an environment where scientists, including early-career scientists and scientists that disagree with me, can express disagreement, respectfully.”

Two months into his tenure at the agency, hundreds of NIH officials are taking Bhattacharya at his word.

More than 300 officials, from across all of the NIH’s 27 institutes and centers, have signed and sent a letter to Bhattacharya that condemns the changes that have thrown the agency into chaos in recent months—and calls on their director to reverse some of the most damaging shifts. Since January, the agency has been forced by Trump officials to fire thousands of its workers and rescind or withhold funding from thousands of research projects. Tomorrow, Bhattacharya is set to appear before a Senate appropriations subcommittee to discuss a proposed $18 billion slash to the NIH budget—about 40 percent of the agency’s current allocation.

The letter, titled the Bethesda Declaration (a reference to the NIH’s location in Bethesda, Maryland), is modeled after the Great Barrington Declaration, an open letter published by Bhattacharya and two of his colleagues in October 2020 that criticized “the prevailing COVID-19 policies” and argued that it was safe—even beneficial—for most people to resume life as normal. The approach that the Great Barrington Declaration laid out was, at the time, widely denounced by public-health experts, including the World Health Organization and then–NIH director Francis Collins, as dangerous and scientifically unsound. The allusion in the NIH letter, officials told me, isn’t meant glibly: “We hoped he might see himself in us as we were putting those concerns forward,” Jenna Norton, a program director at the National Institute of Diabetes and Digestive and Kidney Diseases, and one of the letter’s organizers, told me.

None of the NIH officials I spoke with for this story could recall another time in their agency’s history when staff have spoken out so publicly against a director. But none of them could recall, either, ever seeing the NIH so aggressively jolted away from its core mission. “It was time enough for us to speak out,” Sarah Kobrin, a branch chief at the National Cancer Institute, who has signed her name to the letter, told me. To preserve American research, government scientists—typically focused on scrutinizing and funding the projects most likely to advance the public’s health—are now instead trying to persuade their agency’s director to help them win a political fight with the White House.

In an emailed statement, Bhattacharya said, “The Bethesda Declaration has some fundamental misconceptions about the policy directions the NIH has taken in recent months, including the continuing support of the NIH for international collaboration. Nevertheless, respectful dissent in science is productive. We all want the NIH to succeed.” A spokesperson for HHS also defended the policies the letter critiqued, arguing that the NIH is “working to remove ideological influence from the scientific process” and “enhancing the transparency, rigor, and reproducibility of NIH-funded research.”

The agency spends most of its nearly $48 billion budget powering science: It is the world’s single-largest public funder of biomedical research. But since January, the NIH has canceled thousands of grants—originally awarded on the basis of merit—for political reasons: supporting DEI programming, having ties to universities that the administration has accused of anti-Semitism, sending resources to research initiatives in other countries, advancing scientific fields that Trump officials have deemed wasteful.

Prior to 2025, grant cancellations were virtually unheard-of. But one official at the agency, who asked to remain anonymous out of fear of professional repercussions, told me that staff there now spend nearly as much time terminating grants as awarding them. And the few prominent projects that the agency has since been directed to fund appear either to be geared toward confirming the administration’s biases on specific health conditions, or to benefit NIH leaders. “We’re just becoming a weapon of the state,” another official, who signed their name anonymously to the letter, told me. “They’re using grants as a lever to punish institutions and academia, and to censor and stifle science.”

NIH officials have tried to voice their concerns in other ways. At internal meetings, leaders of the agency’s institutes and centers have questioned major grant-making policy shifts. Some prominent officials have resigned. Current and former NIH staffers have been holding weekly vigils in Bethesda, commemorating, in the words of the organizers, “the lives and knowledge lost through NIH cuts.” (Attendees are encouraged to wear black.)

But these efforts have done little to slow the torrent of changes at the agency. Ian Morgan, a postdoctoral fellow at the NIH and one of the letter’s signers, told me that the NIH fellows union, which he is part of, has sent Bhattacharya repeated requests to engage in discussion since his first week at the NIH. “All of those have been ignored,” Morgan said. By formalizing their objections and signing their names to them, officials told me, they hope that Bhattacharya will finally feel compelled to respond. (To add to the public pressure, Jeremy Berg, who led the NIH’s National Institute of General Medical Sciences until 2011, is also organizing a public letter of support for the Bethesda Declaration, in partnership with Stand Up for Science, which has organized rallies in support of research.)

Scientists elsewhere at HHS, which oversees the NIH, have become unusually public in defying political leadership, too. Last month, after Health Secretary Robert F. Kennedy Jr.—in a bizarre departure from precedent—announced on social media that he was sidestepping his own agency, the CDC, and purging COVID shots from the childhood-immunization schedule, CDC officials chose to retain the vaccines in their recommendations, under the condition of shared decision making with a health-care provider.

Many signers of the Bethesda letter are hopeful that Bhattacharya, “as a scientist, has some of the same values as us,” Benjamin Feldman, a staff scientist at the National Institute of Child Health and Human Development, told me. Perhaps, with his academic credentials and commitment to evidence, he’ll be willing to aid in the pushback against the administration’s overall attacks on science, and defend the agency’s ability to power research.

But other officials I spoke with weren’t so optimistic. Many at the NIH now feel they work in a “culture of fear,” Norton said. Since January, NIH officials have told me that they have been screamed at and bullied by HHS personnel pushing for policy changes; some of the NIH leaders who have been most outspoken against leadership have also been forcibly reassigned to irrelevant positions. At one point, Norton said, after she fought for a program focused on researcher diversity, some members of NIH leadership came to her office and cautioned her that they didn’t want to see her on the next list of mass firings. (In conversations with me, all of the named officials I spoke with emphasized that they were speaking in their personal capacity, and not for the NIH.)

Bhattacharya, who took over only two months ago, hasn’t been the Trump appointee driving most of the decisions affecting the NIH—and therefore might not have the power to reverse or overrule them. HHS officials have pressured agency leadership to defy court orders, as I’ve reported; mass cullings of grants have been overseen by DOGE. And as much as Bhattacharya might welcome dissent, he so far seems unmoved by it.

In early May, Berg emailed Bhattacharya to express alarm over the NIH’s severe slowdown in grant making, and to remind him of his responsibilities as director to responsibly shepherd the funds Congress had appropriated to the agency. The next morning, according to the exchange shared with me by Berg, Bhattacharya replied saying that, “contrary to the assertion you make in the letter,” his job was to ensure that the NIH’s money would be spent on projects that advance American health, rather than “on ideological boondoggles and on dangerous research.” And at a recent NIH town hall, Bhattacharya dismissed one staffer’s concerns that the Trump administration was purging the identifying variable of gender from scientific research. (Years of evidence back its use.) He echoed, instead, the Trump talking point that “sex is a very cleanly defined variable,” and argued that gender shouldn’t be included as “a routine question in order to make an ideological point.”

The officials I spoke with had few clear plans for what to do if their letter goes unheeded by leadership. Inside the agency, most see few levers left to pull. At the town hall, Bhattacharya also endorsed the highly contentious notion that human research started the pandemic—and noted that NIH-funded science, specifically, might have been to blame. When dozens of staffers stood and left the auditorium in protest, prompting applause that interrupted Bhattacharya, he simply smiled. “It’s nice to have free speech,” he said, before carrying right on.

After years of trying to improve his hospital in Riverton, Wyoming—first as a doctor, then as a board member and volunteer activist—­Roger Gose was ready to give up.

Gose, a Texas native, had been in Wyoming since 1978, when he saw an ad in a medical journal looking for a small-town internist. Ever since he was a kid, he had wanted to be a community doctor, the kind who made house calls and treated his neighbors from birth into adulthood. He found his calling in Riverton, a town of 10,000 people in one of the state’s poorer counties. For 35 years, he ran a private practice and worked shifts at Riverton Memorial Hospital, even serving for a time as the chief of medicine there. After retiring from his practice in 2012, he joined the hospital board, still eager to do whatever he could to help.

“You want to leave a place better than you found it,” he told me. And for a long time, he felt like he had.

But that was before LifePoint Health, one of the biggest rural-hospital chains in the country, saw his hospital as a distressed asset in need of saving through a ruthless search for efficiencies, and before executives at Apollo Global Management, a private-equity firm whose headquarters looms above the Plaza Hotel in Midtown Manhattan, began calling the shots. That was before Gose realized that, in the private-equity world, a hospital was just another widget, a tool to make money and nothing more.

In late 2018, Gose and a group of his neighbors decided that trying to save their hospital was futile. It had already lost its maternity ward, leaving pregnant people to drive nearly 30 miles to deliver a baby. Data from the Wyoming Department of Health show that the number of air-ambulance flights from the county where Riverton sits to hospitals elsewhere in the state rose from 155 in 2014 to 937 in 2019. By the time I spent several days with Gose and a dozen other Rivertonians in the spring of 2023, they didn’t even have a hospital anymore, they told me; they had a “Band-Aid station.” The only way to ensure that their town had a real hospital, they decided, was to build one themselves.

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The conventional wisdom about rural hospitals in the 21st century is that they are, in a word, screwed. Young people move away; older residents left behind need more expensive care and are less likely than urban and suburban residents to have private insurance, which is more lucrative for providers than Medicare and Medicaid. A 2018 report from the U.S. Government Accountability Office found that twice as many rural hospitals closed from 2013 to 2017 than in the five years prior, and the ones that remained were in much worse financial shape than their nonrural counterparts. Emergency funding during the coronavirus pandemic improved the financial health of rural hospitals, but after that ­funding dried up, many were left facing labor shortages and supply-chain problems that increased prices. House Republicans’ proposed cuts to Medicaid could drive even more hospitals out of business, the American Hospital Association argued in a letter to congressional leaders this April.

The ability to stave off closure has been the chief value proposition that private-equity firms offer to rural hospitals. In my reporting on private equity’s growing dominance in health care, I heard versions of the story that LifePoint and Apollo told Riverton residents again and again: Without us, you will be left with no hospital at all. Yours is running out of money, and our ability to consolidate and find efficiencies across our ever-­growing system is the only thing that can keep it alive. Your community is too small and poor to support an obstetrics department, or general surgery, or mental-health services, so you won’t have those anymore, but isn’t something better than nothing?

Accepting that private equity is the only option for rural hospitals, though, requires accepting that rural Americans deserve less access to care than their urban and suburban counterparts, and that the care they do receive will be measurably worse. A landmark 2023 study found that in the three years after a private-equity acquisition, the rate of serious preventable medical complications increased significantly. (LifePoint hospitals were not included in the study, which focused on acquisitions made before 2018.) Patients were more likely to fall in the hospital and more likely to acquire infections at the site of a surgical incision. The number of central-line infections, which often result from improper insertion or cleaning, rose 38 percent. Though the study didn’t delve into the reasons for the increases, the implication was clear: Focusing on short-­term profits was leading to cost cutting that could be dangerous for patients.

In Riverton, the hospital’s owner was cutting costs aggressively, while also raising prices. In 2014, LifePoint formally merged the hospital with one in wealthier Lander, a town 25 miles away, and renamed them SageWest Riverton and SageWest Lander. In 2017, the year before Apollo bought LifePoint, researchers examined hospital data for 14 individual Wyoming facilities and found that SageWest charged the highest relative prices; data from 2020 show that SageWest maintained the largest price disparity of any general hospital in the state after the Apollo acquisition. (LifePoint referred questions about the Riverton and Lander hospitals to SageWest; SageWest leaders did not respond to several requests for comment.)

At the same time, the Riverton hospital was shrinking. In quick succession, SageWest suspended its obstetrics services, closed its inpatient mental-health unit, and shrank other basic services. By 2022, the last year for which Centers for Medicare and Medicaid Services data are available, SageWest employed 227 people across its two campuses, nearly 40 percent fewer than before the Riverton-Lander merger. According to Gose, the number of physicians based in Riverton had dwindled from 20-something to just seven.

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If they were going to build a new hospital, Gose and his neighbors first needed to know whether it could theoretically be financially viable. By 2018, they had formed a nonprofit, Riverton Medical District, and one of the board members, Vivian Watkins—the former head of commercial lending for U.S. Bank’s 14 branches across Wyoming, and the kind of person who can’t leave the grocery store without stopping four times to ask about someone’s kids or their neighborhood drama—began cold-calling hospital CEOs across Wyoming, looking for advice on where to start. One told her that she should go straight to Stroudwater Associates, a Maine-based consultancy with a specialty in rural-health-care finances.

                       

The Riverton nonprofit was not Stroudwater Associates’ typical client. The company’s chairman, Eric Shell, and his team usually work directly with rural hospitals, or occasionally with a larger chain looking for system-­wide strategic planning. Gose, Watkins, and their allies didn’t have a hospital, didn’t have concrete plans for a hospital, didn’t even have any money for a hospital. Still, Shell was intrigued by the brazenness of what they were dreaming up.

After nearly 30 years working with rural hospitals, Shell believed that rural hospitals could survive, but that too few hospital executives think creatively about solutions. Over and over, he’s seen cuts damage a hospital’s business further: “You win the battle, but you lose the war,” he told me. Instead of cutting costs by “doing more with less” (to use the corporate jargon for layoffs and overworking employees), making rural hospitals run in the 21st century means increasing profits by expanding a hospital’s business.

One of Shell’s go-­to examples is Mahaska Health in Oskaloosa, Iowa, a nonprofit hospital in a city slightly bigger than Riverton. When the pandemic hit in 2020, hospitals across the country were overwhelmed with critically ill COVID patients, but also saw a decline in other types of cases. The result was a huge, unexpected loss of revenue for many hospitals, and a correspondingly huge number of layoffs: 1.4 million health-care workers lost their jobs in April 2020 alone. At Mahaska, though, CEO Kevin DeRonde—­a former NFL linebacker—­ran in the opposite direction: He hired many of the providers who had been laid off from other area hospitals, Shell said. His hospital took a short-­term financial hit, but DeRonde wagered that patient volume would recover once the worst of the pandemic eased up.

The bet paid off. After the drop in 2020, the number of non-­COVID patients skyrocketed. Now many hospitals were understaffed, but not Mahaska. The hospital hadn’t been doing well even before the pandemic, losing more than $5 million in 2017. By 2023, it made $7.5 million in net income, according to Shell and Mahaska Health officials.

Growth, though, is more difficult at hospitals owned by private-equity firms, because of the need to keep shareholders happy through quick returns. “When I look at what they’re doing in Lander and Riverton, I shake my head and say, ‘That’s not the way I’d be running the company,’” Shell told me. “But I’m not running the company, and they’re driven by an external force. If they’re not beating the market rate of compensation for their investors, their investors are going to walk.”

Shell agreed to conduct a feasibility study for Riverton Medical District, and Stroudwater spent months digging into every aspect of Riverton’s economy, population, and existing health-care options. Just 44 percent of Medicare recipients in the area who needed hospital treatment got it at either Riverton or its sister hospital, leaving an opening for a new hospital to quickly capture market share. The presence of the Wind River Reservation, which surrounds Riverton, boosted the financial case: The Eastern Shoshone and Northern Arapaho Tribes, which share the reservation, both provide private insurance to their members. In June 2019, Shell’s firm handed over its report. Its takeaway: The area had the ability to “support a financially viable rural health system with a range of medical, surgical, and specialty services.”

The Riverton Medical District team had the answer they wanted, from a company with real bona fides in the rural health-care world. Gose and Watkins were jubilant. They were going to build a hospital—if they could find the money, that is.

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Friends and neighbors had banded together to cover the $150,000 Stroudwater study, but a whole new hospital was going to cost tens of millions.

Shell didn’t think they could pull it off. He told them so outright. He’s an accountant, which means always assuming the worst. He couldn’t fathom why a bank or a government would give Riverton Medical District a loan, considering the competition risk. The group, though, was unanimous: Shell’s fears weren’t going to stop them. They were the ones who lived there; they were the ones who, in Gose’s words, felt an obligation to leave Riverton better than they found it.

After months of looking into every other source of funding they could think of, Riverton Medical District turned to what the group considered the “lender of last resort”—the U.S. Department of Agriculture, the primary government funder of projects affecting rural Americans. A community hospital in an underserved rural area fit the portfolio, which could qualify Riverton Medical District for low-­interest loans.

Applying for government money, however, required navigating government bureaucracy. In an email exchange that stretched over months, the USDA rural-development regional director for Wyoming, Lorraine Werner, was encouraging but exacting. Every time Werner needed more documents, including a third-­party audit that cost an additional $50,000, the group would scramble to get them to her. Then she would ask for even more. It took Riverton Medical District more than a year to have its application accepted—­not for funding, just for consideration.

Yet somehow, Riverton residents never seemed to grow tired of what looked to many outsiders like a quixotic scheme. To house the hospital, the Eastern Shoshone Tribe agreed to sell eight acres on the north end of town and donated four more acres outright. People kept handing over money, frequently $5 or $10 at a time.

Finally, after an application process that took nearly two years, USDA announced its ruling. The federal government agreed that a new hospital in Riverton could be financially viable, committing to fund the lion’s share of the costs—more than $37 million. It was the largest USDA rural-development loan ever awarded in the state of Wyoming.

The money would fund a hospital offering every routine service Rivertonians had lost. It would have 13 inpatient beds, a full surgical department, two labor-and-delivery rooms, two rooms equipped for intensive care, and space for physical and speech therapy. It would be staffed to perform surgery and deliver babies 24 hours a day. And the building would be designed to accommodate future growth, with the potential to add 11 new patient rooms, additional surgery space, and more parking, board members told me.

In its report, USDA was more bullish than Shell and Stroudwater had been; the agency’s official assessment of the project barely referenced the threat of competition from the existing hospitals. Citing numbers provided by the Riverton Medical District board, USDA found that the hospital could break even with just 30 percent market share, far less than SageWest’s 44 percent.

The Riverton Medical District project, evaluators wrote, had generated a remarkable level of local support; the agency noted donations from individuals and businesses that added up to more than $1 million, and more than 200 letters of support. Several of the letters said that without a new hospital, they would move out of Riverton. Multiple business owners wrote that the lack of a fully functioning hospital left them unable to recruit and retain workers. Most of the USDA report was written in bureaucracy-­speak, but at one point the author slipped into first person: “The applicant started a true grassroots movement to bring back essential services to the community and has exhibited a level of community support, both monetarily and otherwise, that is unseen in my experience.”

In December 2024, just before the soil froze for the season, work crews broke ground on Riverton’s new community hospital. In early June, 400 people turned out for a community celebration, cheering for state-government officials and Riverton Medical District board members and signing a beam that will be installed into the new facility.

Building a new, locally owned hospital isn’t a scalable way to help every community where hospitals owned by private-equity firms are providing less health care. The particular combination of ingredients in Riverton Medical District’s recipe baked into something resembling a miracle. But to Gose’s mind, following Riverton’s example doesn’t require building a community hospital in every rural county in the country. What it requires is people with knowledge of, and investment in, one specific community making decisions for that community—the exact opposite of the private-equity ethos of consolidation at all costs.

“Often you’ll see a lot of people get excited and involved in something for two or three months or six or whatever, but then they get disillusioned and quit,” Gose told me. “And I think that’s what LifePoint thought we were doing. And they underestimated that failure was not an option.”

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This article has been adapted from Megan Greenwell’s forthcoming book, Bad Company: Private Equity and the Death of the American Dream.

Every Monday and Wednesday, students at Channelview High School, outside Houston, are treated to Domino’s for lunch. Delivery drivers from a local branch of the fast-food chain arrive at the school with dozens of pizzas fresh out of the oven, served in Domino’s-branded cardboard boxes. Children can be picky eaters, but few foods are more universally enticing than freshly cooked pizza—let alone from a restaurant students are almost certainly already familiar with. “For kids to be able to see Oh, they’re serving Domino’s, I think it makes a huge difference,” Tanya Edwards, the district’s director of nutrition, told me.

The deliveries are part of Domino’s “Smart Slice” initiative, which sends pizzas to school districts around the country—often at little or no cost to students themselves. “Smart Slice” is part of the national school-lunch program, so taxpayers foot a portion of the bill to guarantee that every kid has lunch to eat. Despite kids’ enthusiasm, you can see the problem: Students munching on free fast food might seem to embody everything wrong with the American diet. If school cafeterias can be thought of as classrooms where kids learn about food, giving them Domino’s would be akin to teaching driver’s-ed students how to drive by letting them play Grand Theft Auto.

The days of school Domino’s—and school pizza in general—are numbered. Health and Human Services Secretary Robert F. Kennedy Jr. and his supporters are on a mission to overhaul school lunch. Late last month, the Trump administration’s Make America Healthy Again Commission released a highly anticipated report on children’s health that pointed to school meals as one venue where ultra-processed foods are offered to kids unabated, contributing to obesity and other kinds of chronic disease. Unless cafeteria workers make school pizza from scratch, nearly every kind contains industrial ingredients that qualify the meal as an ultra-processed food. In effect, ridding school lunch of ultra-processed foods means the end of pizza day as we know it.

Many of the food reforms pushed by RFK Jr.’s movement are popular. Doing away with artificial food dyes, for example, is far more sensible than Kennedy’s conspiracist views about vaccines. But in the case of banning most school pizza, RFK Jr. could be facing a tougher sell. MAHA’s vision for food is about to run headfirst into a bunch of hungry kids in a school cafeteria.

Even though Domino’s school pizza is delivered by Domino’s drivers carrying Domino’s pizza boxes, the company’s Smart Slice is different from what would arrive at your door should you order a pie for dinner tonight. Cafeteria pizza has to abide by nutrition standards for school meals that the Obama administration spearheaded in 2010. The overly cheesy rectangular pizza with a cracker-like crust that you might have eaten in school no longer cuts it. Consider Domino’s Smart Slice pepperoni pizza: It’s made with mostly whole-wheat flour, low-fat cheese, and pepperoni that has half as much sodium than typical Domino’s pepperoni. It’s not a green salad by any means, but school Domino’s is far from the worst thing kids could eat.

Other common cafeteria offerings—such as mini corndogs, mozzarella sticks, and chicken tenders—are also now more nutritious than in decades past. Those standards could still be improved (and we’re still talking about corndogs, mozzarella sticks, and chicken tenders), but they have led companies to sell slightly healthier versions of their foods in schools. Research has shown that, on average, school meals are now the healthiest things kids eat in a day.

In an email, HHS Press Secretary Vianca N. Rodriguez Feliciano said that “while some of these products may technically meet outdated federal guidelines, they are still heavily engineered, nutritionally weak, and designed for corporate profit, not for the health of our kids.” Indeed, school lunch starts to look considerably less healthy if you account for the growing concern over ultra-processed foods. Many school lunches are made in factories with chemicals such as emulsifiers and flavor enhancers you wouldn’t find in a home kitchen. Eating lots of ultra-processed foods is associated with a range of maladies, including Type 2 diabetes and heart disease, though nutritionists are deeply divided on just how much we should be fretting over these industrial ingredients.

To some degree, whether school pizza should be avoided because it’s ultra-processed is beside the point. By allowing Domino’s into school cafeterias, the government also is essentially giving the company carte blanche to advertise its pizza. Serving Smart Slice out of a typical Domino’s box gives “the false impression to children and parents that the less-healthy products served in their restaurants are healthy choices,” Jennifer Harris, a food-marketing expert, told me in an email.

Kennedy has called for schools to serve “real food, whole food, farm-fresh food,” instead of anything ultra-processed. It would, of course, be better for school cafeterias to swap out the pepperoni pizza with salad and chicken breast. But for many kids, school lunch subsidized by the government may be their only real meal of the day. At Channelview, where such a large portion of students are eligible for public assistance that everyone eats for free, simply getting food in kids’ bellies is top of mind. “I can make a fancy little sweet-potato black-bean bowl, but I don’t think my kids are going to eat it,” Tanya Edwards said. “Instead, they are going to go home hungry, and I don’t really know what they have at home.”

The concern isn’t theoretical. Evidence shows that when school meals are too healthy, a sizable portion of kids simply get off the lunch line. In the early 2010s, when the Los Angeles Unified School District overhauled its lunch offerings—an effort that included removing pizza from the menu—schools reported that massive amounts of food were landing in the trash. (The district later brought back pizza, and pepperoni pizza is now the district’s most popular item, a spokesperson said.) Food waste is a perennial issue in school meal programs. A Department of Agriculture study of more than 100 schools found that an average of 31 percent of the vegetables included on observed school lunch trays were wasted. Pizza, however, was among the least wasted food, along with breaded and fried chicken patties and nuggets.

Even advocates for healthier school meals admit that there’s a limit to how much students will tolerate healthier offerings. “We definitely need to harness school food to educate kids about healthy eating, but I don’t think that means no pizza,” Janet Poppendieck, a professor emerita at Hunter College who wrote a book on fixing school meals, told me. “We need to include healthy versions of kids’ favorite foods; otherwise, I don’t think they’ll eat.” In part to ensure that kids actually eat lunch, many school districts seem to have pizza day at least once a week. A spokesperson for Florida’s Hillsborough County Public Schools, the seventh-largest district in the country, told me that its first, second, fifth, and seventh most popular entrees are all in the pizza family (No. 5 is mini calzones; No. 7 is pizza sticks). All told, the district has doled out nearly 3 million servings this school year.

If it wanted to, the Trump administration could simply force kids to suck it up and literally eat their vegetables. Technically the responsibility of overseeing the school-meal program falls to the USDA—which isn’t under Kennedy’s purview—but Secretary of Agriculture Brooke Rollins has signaled that she is onboard with MAHA-ing school lunch. Still, any attempt to enact a ban would likely invite significant backlash. In 2023, when the federal government floated the idea of banning the sale of sugary chocolate milk in elementary and middle schools, many parents flooded the government with complaints. So did some students: Ben, a fourth grader who left only his first name, wrote in an official comment to the USDA that it should abandon the proposal “because students are super MAD.” Members of Congress also put pressure on regulators to stop the reform. The USDA later abandoned the chocolate-milk ban. In 2011, after the Obama administration released its new guidelines for school lunch, Republicans in Congress tried to fight back against healthier pizza by classifying the dish as a vegetable.

It’s no wonder why MAHA has a problem with school pizza. Kennedy has pointed to corporate malfeasance as a leading source of America’s diet problems. You don’t have to be a fan of his to feel uneasy that Domino’s, a fast-food company that sells philly-cheese-steak-loaded tater tots, is participating in a taxpayer-funded program meant to feed kids nutritious meals. But Kennedy’s favored approach to food and, well, everything—big proposals and dramatic overhauls—isn’t well suited to school meals. The health secretary might dream of kids eating from a salad bar stocked with seed-oil-free dressings five days a week, but ending school pizza day won’t automatically make that happen. Telling kids what to eat is one thing; getting them to eat it is another.

Gambling has swallowed American sports culture whole. Until early 2018, sports betting was illegal under federal law; today, it’s legal in 39 states and Washington, D.C. (and easy enough to access through backdoor channels even in the states where it isn’t). During NFL games, gambling commercials air more often than ads for beer. Commentators analyze not just whether a team can win, but if they might win by at least the number of points by which they’re favored on betting apps. Nearly half of men younger than 50 now have an account with an online sports book, and Americans spent about $150 billion on sports wagers last year. I regularly get ads on my phone offering me a complimentary $200 in sports bets, as long as I gamble $5 first.

As betting has overrun American sports, other forms of gambling are also on the rise. According to industry data, American casinos are more popular now than at any point on record. The age of their average patron had been crawling upward for years, but since sports betting was legalized at the federal level, it has plummeted by nearly a decade, to approximately 42. Some signs point to gambling problems increasing, too. No centralized entity tracks gambling addiction, but if its scale comes even close to matching the new scale of sports betting, the United States is unequipped to deal with it.

In its power to ruin and even end lives, gambling addiction is remarkably similar to drug dependency. Imaging studies show that pathological gamblers and people with substance addictions share patterns of brain activity. They are more likely to experience liver disease, heart disease, and sleep deprivation, whether it originates in the anxiety of concealing a gambling addiction or because someone is up wagering on contests, such as cricket and table tennis, that happen in faraway time zones. The best national survey available, which dates to well before the rise of sports betting, found that 2 million to 4 million Americans will experience a gambling disorder at some point in their life; one in six people with a gambling disorder attempts suicide. Even if their death certificate says differently, “I’ve had several patients who died because of the emotional pain from their gambling disorder,” Timothy Fong, a psychiatrist specializing in addiction treatment and a co-director of UCLA’s gambling-studies program, told me.

Fong, like the other researchers I spoke with, said that rapid forms of gambling, especially those that allow you to place multiple bets at one time, tend to be especially addictive. For decades, sports betting mostly involved wagers on who’d win a match, by how much, and total points scored—outcomes resolved over the course of hours. Now apps offer endless in-game bets decided in seconds. Last year, I watched the Super Bowl with a friend who bet on the national anthem lasting less than 90.5 seconds—the smart money, according to the analysts. He lost when Reba McEntire belted the song’s last words twice.

The ability to place one bet after another encourages a hallmark behavior of problem gamblers—when deep in the red, instead of walking away, they bet bigger. “Viewing sports gambling as a way to make money is likely to end badly,” Joshua Grubbs, a gambling researcher at the University of New Mexico, told me. “Gamblers that think that gambling is a way toward economic success or financial payouts almost always have far more problem-gambling symptoms.” And some apps actively blur the already hazy line between betting and other financial activities. For instance, the financial platform Robinhood, where millions of people trade meme stocks and manage their retirement accounts, began offering online sports “events contracts” (a type of investment whose payout depends on traders’ correctly predicting the outcome of a specified event) during March Madness this year through a partnership with the financial exchange Kalshi. (A Robinhood spokesperson told me this “emergent asset class” differs significantly from sports betting because users, not the house, set the prices, and can more easily exit their positions. But the experience of “investing” in an events contract is virtually indistinguishable from betting.) Financial markets have recently started offering services like this even in states where sports betting is illegal. State gambling regulators have called foul, but the federal government has so far made no move to stop the companies. As the courts sort out whether any of this is legal, Robinhood decided to let customers trade on the Indy 500 and the French Open.

Several recent trends suggest that problem gambling might be on the rise in the U.S. Calls to state gambling helplines have increased. (This might be partly explained by advocacy groups marketing their helplines more aggressively than ever; gambling companies also tack the numbers onto their ubiquitous ads.) Fong said that he was recently invited to speak to a consortium of family lawyers, whose divorce clients have started asking, “How do I protect my children from the damage of their father’s gambling?” Researchers and counselors are especially worried about single young men who play in fantasy sports leagues, bet on sports, day trade, and consider gambling a good way to make money. Gamblers Anonymous is rolling out groups for young people. “I’m treating guys who would never be caught dead in a casino,” James Whelan, a clinical psychologist who runs treatment clinics for gambling addiction in Tennessee, told me.

[Read: How casinos enable gambling addicts]

These imperfect proxy measures, along with incomplete data trickling out of a few states, are the best indicators that researchers have about the extent of gambling addiction. Experts are also unsure how long any increase in problem gambling might last: Some studies suggest that the prevalence of gambling problems tends to equalize after a spike, but those findings are usually limited to physical casinos and remain debated within the field. According to researchers I spoke with, no study has established the prevalence of gambling addiction in the U.S. since sports betting became widespread. Federal agencies dedicated to alcoholism and substance abuse allocate billions of research dollars to American universities every year. Yet for decades, the federal government—the largest funder of American research—has earmarked zero dollars for research on gambling activity or addiction specifically, despite collecting millions annually from gambling taxes. (The Substance Abuse and Mental Health Services Administration, which collects national data on behavioral health and funds research into it, declined to comment.)

Gambling-addiction treatment is “50 years behind where we are with drugs or alcohol or any other substance,” Michael Sciandra, the executive director of the Nebraska Council on Problem Gambling, told me. Doctors and therapists, even those who specialize in treating addiction, rarely screen for issues with gambling, he said. Among the handful of dedicated gambling-addiction treatment providers around the country, many deploy cognitive behavioral therapy, which studies suggest can at least temporarily improve patients’ quality of life and reduce the severity of their gambling problem. But discrepancies in treatment approaches and tiny trial sizes make it difficult to say exactly how many patients the therapy helps. Two medications used to treat alcoholism and opioid addiction have also been found to reduce the severity of gambling addiction across a handful of small clinical trials. But the evidence needed for FDA approval would require large and expensive clinical trials that no one seems eager to fund, Marc Potenza, the director of Yale’s Center of Excellence in Gambling Research, told me.

Because the federal government doesn’t fund gambling-addiction treatment, each state decides what resources to make available. A Tennessee caller to the national helpline 1-800-GAMBLER might be put through to their state’s helpline and then connected to the network of government-subsidized clinics Whelan runs across the state. But in states with bare-bones offerings, workers typically refer callers to peer-support groups such as Gamblers Anonymous, or to online resources on budgeting, says Cole Wogoman, a director at the National Council on Problem Gambling, which runs the helpline. Studies have found that each of these strategies is less effective than therapy.

[Charles Fain Lehman: Legalizing sports gambling was a huge mistake]

Texas could be an example of how unprepared the U.S. is to deal with any increase in problem gamblers. The state’s gambling laws are among the strictest in the country, and yet it still sends the second-highest number of callers (behind California) to 1-800-GAMBLER. This November, Texans might vote on a constitutional amendment to allow sports betting. The state of more than 30 million has no funding for gambling treatment and only three certified gambling counselors, according to Carol Ann Maner, who is one of them. The state’s official hub for gambling help, which Maner leads, was founded just this spring.

Once they find the money, Maner and her colleagues plan to finally set up the state’s own helpline. But first, they need to recruit and train more therapists for a job that, thanks to a lack of state and federal funding, might require turning away uninsured clients. That’s a daunting task. Finding the apps Texans can use to get around gambling restrictions is easy.

It was a travesty—two travesties, actually, separate but inextricably linked. In May 1953, Edmund Hillary and Tenzing Norgay became the first people to reach the summit of Mount Everest, a challenge that had killed more than a dozen people in the preceding decades and that scientists had once declared impossible. The catch: They breathed canisters of pure oxygen, an aid that the Everest pioneer George Mallory—one of those who died on the mountain—had once dismissed as “a damnable heresy.”

A month later, a young British medical trainee named Roger Bannister just missed running the first sub-four-minute mile, another long-standing barrier sometimes dubbed “Everest on the track.” But he did it in a race where his training partner let himself be lapped in order to pace Bannister all the way to the finish line, violating rules about fair play due to the advantages of pacing. Bannister’s American rival, Wes Santee, was unimpressed. “Maybe I could run a four-minute mile behind one of my father’s ranch horses,” he said, “if that’s what you want.”

Funny how history repeats itself. Fast-forward to a couple of weeks ago: A controversy erupted in the world of mountaineering, when four British climbers summited Everest just five days after jetting to Nepal from the United Kingdom. To skip the usual weeks or months spent gradually adjusting to high altitude, they paid a reported $153,000 each for a bespoke protocol that included inhaling xenon gas to help them adjust more rapidly. Meanwhile, on the track, Kenya’s three-time Olympic champion, Faith Kipyegon, is preparing for a carefully choreographed, Nike-sponsored attempt to become the first woman to run a mile in under four minutes. It’s slated for June 26 in Paris and will almost certainly violate the same pacing rules that Bannister’s run did.

Both initiatives are, by any measure, remarkable feats of human ingenuity and endurance. They’re also making people very angry.  

The xenon-fueled expedition was organized by an Austrian guide named Lukas Furtenbach, who is known for his tech-focused approach to expeditions. He has previously had clients sleep in altitude tents at home for weeks to pre-acclimatize them to the thin mountain air. What made the new ascent different is that, in addition to sleeping in altitude tents, the four British climbers visited a clinic in Germany where they inhaled xenon gas, whose oxygen-boosting potential has been rumored for years. The World Anti-Doping Agency banned xenon in 2014 after allegations that Russian athletes used it for that year’s Winter Olympics. But subsequent studies on its athletic effects have produced mixed results. Other research in animals has hinted at the possibility that it could offer protection from potentially fatal forms of altitude illness, which can occur when climbers ascend too rapidly. For now, the strongest evidence that it helps high-altitude mountaineers comes from Furtenbach’s own self-experimentation over the past few years.

When news of Furtenbach’s plans emerged earlier this year, the International Climbing and Mountaineering Federation’s medical commission put out a statement arguing that xenon probably doesn’t work and could be dangerous because of its sedative effects. Other critics have pointed out that shorter expeditions mean less paying work for the Sherpa guides in the region. But these criticisms can feel like post hoc justifications for the fact that many mountaineers simply have a gut-level aversion to what seems like a shortcut to the summit. Their objection isn’t to xenon itself but to the idea of making Everest easier.

That’s the same problem many runners have with Kipyegon’s sub-four-minute-mile attempt. Women have made extraordinary progress in the event since Diane Leather notched the first sub-five in 1954, but under conventional racing conditions, no one expects a sub-four anytime soon. Kipyegon is the fastest female miler in history: Her current world record, set in 2023, is 4:07.64, which leaves her more than 50 yards behind four-minute pace—an enormous deficit to overcome in a sport where, at the professional level, progress is measured in fractions of a second. Nike has promised “a holistic system of support that optimizes every aspect of her attempt,” including “footwear, apparel, aerodynamics, physiology and mind science,” but hasn’t revealed any details of what that support might look like. That means critics—and there are many—don’t yet have any specific innovation to object to; they just have the tautological sense that any intervention capable of instantly making a miler 7.7 seconds faster must by definition be unfair. (I reached out to Nike for further specifics about the attempt, but the company declined to comment.)

It’s a safe bet that new shoes will be involved. Kipyegon’s effort, dubbed Breaking4 by Nike, is a sequel to the company’s Breaking2 marathon in 2017, in which Kipyegon’s fellow Kenyan Eliud Kipchoge came within 25 seconds of breaking two hours at a time when the official world record was 2:02:57. Kipchoge’s feat was made possible in part by a new type of running shoe featuring a stiff carbon-fiber plate embedded in a thick and bouncy foam midsole, an innovation that has since revolutionized the sport. But the reason his time didn’t count as a world record was that, like Bannister, he had a squad of pacers who rotated in and out to block the wind for him all the way to the finish line. That’s also likely to be a key for Kipyegon. In fact, scientists published an analysis earlier this year suggesting that a similar drafting approach would be enough to take Kipyegon all the way from 4:07 to 3:59 without any other aids.

Bannister’s paced-time trial in 1953 was ruled ineligible for records because, per the British Amateur Athletic Board, it wasn’t “a bona fide competition according to the rules.” Still, the effort had served its purpose. “Only two painful seconds now separated me from the four-minute mile,” Bannister later wrote, “and I was certain that I could cut down the time.” Sure enough, less than a year later, Bannister entered the history books with a record-legal 3:59.4. Similarly, Kipchoge went on to break two hours in another exhibition race in 2019, and Nike’s official line is that it hopes that feat will pave the way for a record-legal sub-two in the future. (It’s certainly getting closer: The world record now stands at 2:00:35.) In 1978, a quarter century after Hillary and Norgay’s historic ascent, Reinhold Messner and Peter Habeler climbed Everest without supplemental oxygen.

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One view of innovation in sports, advanced by the bioethicist Thomas Murray, is that people’s perceptions are shaped by how new ideas and techniques are introduced. The status quo always seems reasonable: Of course we play tennis with graphite rackets rather than wooden ones, use the head-first Fosbury flop to clear high-jump bars, and climb mountains with the slightly stretchable kernmantle ropes developed in the 1950s. But many of these same innovations seem more troublesome during the transition periods, especially if only some people have access to them.

When Bannister finally broke the four-minute barrier, he was once again paced by his training partners, but only for about the first three-quarters of the race. This form of pacing remained highly controversial, but because none of the pacemakers had deliberately allowed himself to be lapped, the record was allowed to stand. These days, such pacing is so routine that there are runners who make a living doing nothing but pacing races for others, always dropping out before the finish. The full-race pacing that Kipyegon will likely use in Breaking4 remains verboten; the slightly different pacing that leads runners almost all the way through the race but forces them to run the last lap alone is simply business as usual. Oxygen in a can is good; xenon in a can is bad. These are subtle distinctions.

Sports are, in at least some respects, a zero-sum game: When one person wins a race or sets a record, it unavoidably means that someone else doesn’t. Even at the recreational level, if everyone decides to run marathons in carbon-plated shoes that make them five minutes faster, the standards needed to qualify for the Boston Marathon get five minutes faster. “Once an effective technology gets adopted in a sport, it becomes tyrannical,” Murray told me several years ago, when I was writing about athletes experimenting with electric brain stimulation. “You have to use it.” In the ’50s, a version of that rationale seemed to help the British expedition that included Hillary and Norgay overcome the long-standing objections of British climbers to using oxygen—the French had an Everest expedition planned for 1954 and the Swiss for 1955, and both were expected to use oxygen.

Less clear, though, is why this rationale should apply to the modern world of recreational mountaineering in which Furtenbach operates. What does anyone—other than perhaps the climbers themselves, if you think journeys trump destinations—lose when people huff xenon in order to check Everest off their list with maximal efficiency? Maybe they’re making the mountain more crowded, but you could also argue that they’re making it less crowded by getting up and down more quickly. And it’s hard to imagine that Furtenbach’s critics are truly lying awake at night worrying about the long-term health of his clients.

Something else is going on here, and I’d venture that it has to do with human psychology. A Dutch economist named Adriaan Kalwij has a theory that much of modern life is shaped by people’s somewhat pathological tendency to view everything as a competition. “Both by nature and through institutional design, competitions are an integral part of human lives,” Kalwij writes, “from college entrance exams and scholarship applications to jobs, promotions, contracts, and awards.” The same ethos seems to color the way we see dating, leisure travel, hobbies, and so on: There’s no escape from the zero-sum dichotomy of winners and losers.

Kalwij’s smoking gun is a phenomenon that sociologists call the “SES-health gradient,” which refers to the disparities in health between people of high and low socioeconomic status. Despite the rise of welfare supports such as pensions and health care, the SES-health gradient has been widening around the world—even, Kalwij has found, among Olympic athletes. There used to be no difference in longevity among Dutch Olympians based on their occupation. But among the most recent cohort, born between 1920 and 1947, athletes in high-SES jobs, such as lawyers, tend to outlive athletes in low-SES jobs by an average of 11 years. As Kalwij interprets it, making an Olympic team is a life-defining win, but getting stuck in a poorly paying dead-end job is a loss that begets an endless series of other losses: driving a beater, living in a lousy apartment, flying economy. These losses have cumulative psychological and physiological consequences.

Some things in life really are competitions, of course. Track and field is one of them, and so we should police attempts to bend its rules with vigilance. Other things, such as being guided up Everest, are not—or at least they shouldn’t be. The people who seem most upset about the idea of rich bros crushing Everest in a week are those who have climbed it in six or eight or 12 weeks, whose place in the cosmic pecking order has been downgraded by an infinitesimal notch. But I, too, was annoyed when I read about it, despite the fact that I’ve never strapped on a crampon. Their win, in some convoluted way, felt like my loss.

Another detail in Kalwij’s research sticks in my mind. Among American Olympians, silver medalists tend to die a few years earlier than either gold or bronze medalists. Kalwij theorizes that these results, too, are related to people’s outlook. Gold medalists are thrilled to win, and bronze medalists are thrilled to make the podium; silver medalists see themselves as “the No. 1 loser,” as Jerry Seinfeld once put it. With that in mind, I’ve tried to reframe my attitude about the xenon controversy. Let the annual Everest frenzy continue, with or without xenon, and let its allure continue to draw the most hard-edged and deep-pocketed summit baggers. Meanwhile, leave the other, lesser-known mountains for the rest of us to enjoy in tranquility. I’d call that a win.

The morning of April 28, 2004, started like the rest of Jeff Turner’s mornings in Iraq. Breakfast in the chow hall, a walk across the grounds to his station. The same sun, the same palm trees, the same desert. But the two distant thumps Turner heard as he left the hall were unusual. Boy, that sounds like mortars, he thought.

The hall exploded first. Shards of its metal frame shot into his flesh. The second bomb erupted in the sand nearby, encircling him in smoke. Turner dove between two parked mail vans. There, he began to register the screams from the chow hall. A soldier who had been chasing Turner down found him soaked in blood. “You’ve got a problem, sergeant,” the soldier told him.

The mortar had ripped through the hall’s canvas roof and sprayed shrapnel in every direction. Compared to others, Turner was lucky. He walked away from the attack with wounds deep in his leg and under the wristband of his watch. The next day, he was back at work.

But he knew something was off. He soon found his heart pounding throughout mundane tasks. Loud noises sent him leaping into bunkers. What little sleep he got was plagued with nightmares; waking launched him into a state of panic. Some of these symptoms persisted for years. A decade after the explosion, the flashbacks began. Vivid memories of war would flood his vision, freezing him in place. He didn’t know what was happening at first, but he eventually noticed certain triggers: the bang of a dump truck, the scent of wet canvas. “It would bring me back, just like that,” Turner told me. “I would be stuck.”

Flashbacks, along with nightmares, sleeplessness, and a heightened sense of fear, are hallmark symptoms of post-traumatic stress disorder. Without treatment, some people with PTSD begin to notice distortions in their behavior and mood. They feel like they are in constant danger, because the past keeps barging in on the present. The fear makes them avoidant, and they withdraw into isolation. Shame, guilt, and anger fester; depression and a dramatically higher risk of suicide can follow. Turner received his diagnosis when his tour ended in 2005. At home, he snapped at his wife and kids. He kept misplacing his keys and losing his hat. Rage consumed him at all times, except when he was drunk. “I was a completely different person,” he said.

Treating PTSD revolves around a central question: How do you get a person to leave the past in the past? Researchers work on ways to distance patients from the intense feelings a recollection of a traumatic moment can evoke. Since PTSD was first recognized by the medical field more than 40 years ago, the prevailing psychotherapeutic treatment has entailed facing the trauma head-on. In prolonged-exposure therapy, patients revisit their trauma in weekly sessions with therapists in the hope that repetition will extinguish their fears. The idea is, essentially, to face your demons, to look terror in the eye. And it works. Prolonged exposure, which has been extensively studied and is endorsed by the National Center for PTSD, the leading PTSD-research center housed in the Department of Veterans Affairs, has been found to help nearly 70 percent of patients who complete treatment. The past recedes; life can move forward again.

The problem with prolonged exposure, however, is that it can be incredibly hard to get through. Charging right toward trauma invites immense pain. It can be so harrowing that people drop out of treatment. Fewer than half of patients actually complete it, according to the largest-ever study of psychotherapy treatment for PTSD in veterans.

PTSD is more common among veterans than civilians. It’s also deadlier. Among people with current or past diagnoses, the risk of death by suicide for veterans is roughly double that of civilians. The urgency of the situation has led researchers to develop alternative therapies for PTSD: medications, new forms of talk therapy, regimens involving virtual reality, and, most controversially, psychedelics. After years rotating through a jumble of medications and therapies with limited effects, in 2023, Turner took an even less conventional route. He landed on a little-known treatment called Reconsolidation of Traumatic Memories.

RTM comes with a big, perhaps even fantastical claim: that treating PTSD can be painless. Turner was skeptical but figured he had nothing to lose. To his surprise, the treatment seemed to be the only thing that worked. After just five sessions, he told me, his flashbacks disappeared. “It was the weirdest thing,” he said. “When I did it, it was done.” The treatment, he told me, was “a bit of a miracle.”

With an unorthodox approach and apparently dramatic results, RTM invites—and demands—scrutiny. Many researchers look at it suspiciously, if they’ve heard about it at all. Most I spoke with for this article hadn’t. Michael Roy, a retired Army colonel who has spent decades researching PTSD, is the exception. In 2017, RTM proponents presented anecdotes of the treatment’s purportedly miraculous effects at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, where Roy is a professor of medicine. He listened dubiously. “At first, I was kind of skeptical of the whole thing,” he told me. But after he conferred with a colleague, his doubt gave way to curiosity. RTM might be worth researching, he thought, if it could be studied in a rigorous way.

The treatment intrigued Roy because it attempts a softer, gentler way of confronting past trauma. If prolonged exposure plunges headfirst into a painful memory, RTM dips a toe in, testing the waters. Instead of talking openly about a difficult memory, RTM patients reimagine their trauma through a series of specific mental exercises meant to fade its emotional charge. Like other types of psychotherapy, RTM uses movies as a metaphor for replaying a traumatic memory. But where RTM differs is the extreme—even comical—regimentation it employs to achieve its desired effect.

[Read: When PTSD is contagious]

The therapy follows a manualized 89-step protocol. First, you’re asked to imagine yourself seated in a movie theater that you associate with happy memories, taking in the sensory details: the scent of popcorn, the plush seats. Next, you detach from your body—floating up, then backward toward the projection booth. Suddenly, you become the projectionist and hit “Play.” As a minute-long, black-and-white clip of your trauma rolls, you watch your seated self watching the screen.

Meanwhile, the therapist observes your reactions. The subtlest flicker—a shift in posture, a clenched jaw—prompts the therapist to bring you back to the present, redirecting your attention, say, by asking you to spell your name backwards. Once you’ve calmed down, you return to the theater. Only this time, you’re told to tweak the film in any way that makes it easier to watch: You might change the camera angle, move the screen back 20 feet, or replace everyone with stick figures. You replay the clip in your mind. If it’s still distressing, you adjust it again and again, until you can repeatedly “watch” it from start to finish without reacting. The point is to make the trauma mundane. Ideally, the experience leaves you bored.

When you can consistently watch the clip without reacting, the second phase of RTM begins. You return to the theater, but this time you walk up to the movie screen and step inside the film’s final frame. Now the scene is in vivid color and detail. The therapist tells you to let the memory play out backwards, as if being rapidly rewound. The whole scene whizzes by in about two seconds. This, too, you must learn to withstand without reacting. Then the final phase, “rescripting,” begins. The therapist asks you to invent an alternate version of the memory in which the trauma never happens, and to tell that story aloud. In this timeline, anything goes: A person who was sexually assaulted in their dorm might imagine that they left for a party instead, or that the window opened and a unicorn took them out of the room. Doing so should be easy, even fun, for patients, according to Roy. Sometimes, he told me, “they’re smiling; they’re laughing.”

The approach is based on a theory of how memories can be reworked. Reconsolidation—the R in RTM—is a neurological process in which a long-term memory is retrieved, altered, then stored in its new form, like a digital document that is edited and saved. Reconsolidation is thought to alter the physical structure of a memory itself in a person’s brain, though the exact mechanics of how this would happen remain hypothetical. RTM’s bizarre sequence of steps is supposed to be a means to control the process: The idea is not to trick the person into thinking they never experienced trauma, but rather to soften the intense emotions attached to the memory.

Critics of RTM point out that reconsolidation isn’t as well established as the paradigms that other PTSD treatments are based on. Extinction, the foundation of prolonged exposure, was famously demonstrated by the Russian scientist Ivan Pavlov nearly a century ago: He conditioned dogs to salivate at the sound of a metronome—and then gradually taught them to unlearn the response by no longer giving them food after each tick. But RTM’s proponents argue: Why not try something new? The dearth of palatable treatment options means that many people are not addressing their trauma at all. Besides the relative ease for patients, they say, RTM offers other benefits over more common treatments: It’s quick, usually lasting no more than four 90-minute sessions. And because it doesn’t involve directly probing a person’s worst memories, administering treatment is less excruciating for therapists, too.

RTM was created two decades ago by Frank Bourke, a clinical and research psychologist. Bourke positions himself as an academic underdog whose scientific contributions have been unjustly overlooked. After getting his Ph.D. in psychology, he lectured briefly at Cornell University before starting his own clinical practice, where he created the prototype for RTM. Its basis, he told me, is neurolinguistic programming, or NLP, a 1970s-era idea bridging cognition, language, and behavior that has widely been dismissed as pseudoscience. He developed an NLP-based treatment that he says helped 400 or so people who had experienced the horror of the September 11 attacks. This treatment evolved into RTM. In his own research on the therapy, he reports that a mind-boggling 90 percent of PTSD patients saw improvements in their condition. He currently leads the Research and Recognition Project, a nonprofit that promotes the use of RTM.

Last fall, I spoke with Bourke over a video call from his home in upstate New York. For someone in his 80s, he is unexpectedly forceful, like a cable-TV pastor. He fumed about the treatment not being more widely used. Given the staggering suicide rate among veterans, he said, “how the hell can I not get this thing into play?” Right now, RTM’s most prominent supporters are not scientists. They include the cartoonist Garry Trudeau—who has praised RTM in his long-running comic strip Doonesbury, which often focuses on veterans issues—and Montel Williams, the talk-show host and retired naval officer.

[Read: The self-help that no one needs right now]

Researchers acquainted with RTM, meanwhile, are largely skeptical of it. Only one clinical trial on RTM has been published independently of Bourke’s group, and its lead author, based in the United Kingdom, declined to speak with me for this story. Four small clinical trials by Bourke and his team, though published in peer-reviewed journals, weren’t done particularly well. They compared RTM patients only with people who received no treatment at all—that any form of treatment would be better than nothing is unsurprising. In this context, even a 90 percent improvement doesn’t mean much. Elizabeth Hembree, a prolonged-exposure expert at the University of Pennsylvania, told me that further research on RTM would be worthwhile, “but in trials that are actually, you know, good.” The methodology raises suspicions about RTM in general. It seems like it’s “going to work like magic, and that gets my hackles up,” Andrew Cooper, a psychiatry professor at the University of Toronto at Scarborough, told me. Even Roy felt similarly when he first heard about it. “It sort of seemed too good to be true,” he told me.

When I asked Bourke over email about the criticisms of his studies, he said they were done “in order to attract the interest, support and funding from prestigious university laboratories and researchers.” Bourke maintains ties to Roy, who has sought to give RTM the more rigorous scientific shakeout it needs. In 2019, Roy began the first large-scale clinical trial of RTM, investigating its effectiveness compared with prolonged exposure. He completed it last year. His early data, which he has presented at conferences but aren’t published yet, make a compelling case for RTM. In every metric measured, RTM modestly outperformed its competitor: 89 percent of patients completed RTM, compared with a 73 percent completion rate for prolonged exposure; after treatment, nearly 70 percent of RTM patients no longer met the criteria for a PTSD diagnosis, compared with 61 percent of prolonged-exposure patients. RTM treatment required an average of 8.2 sessions versus 8.9, and afterward patients scored lower than prolonged-exposure patients on the PCL-5, a standard measure of PTSD severity.

Roy’s results aren’t nearly as eye-popping as those from Bourke’s studies. But they are still impressive. And they carry much more weight. His study comprises more than 100 active or former service members, and unlike the previous studies, it compares RTM head-to-head with an active competitor—“a good step,” Hembree told me. Given Roy’s affiliation with the Army and federal funding for his work, Roy’s study, which he hopes to publish within a year, may be what it takes to propel RTM into academic relevance.

Last fall, I traveled to Boston to line up early outside a Marriott meeting room, hoping to snag a seat in what I assumed would be a packed house. Roy was presenting his completed findings on RTM at the annual International Society for Traumatic Stress Studies conference, the largest gathering of researchers in the field. In 2022, the last time he spoke about RTM to this crowd, the preliminary results from his then-ongoing study were so positive that they caused an uproar from skeptics. Now Roy was back, and I was sure that the crowd would return for more drama.

Only they didn’t. A sparse crowd listened politely as Roy, who is in his early 60s, took the podium at the end of a fluorescently lit room. His graying curls were offset by his boyish demeanor. With a click, he pulled up his first slide. It featured a quote from the Argentine writer José Narosky: “In war, there are no unwounded soldiers.” Another slide referenced the study showing that fewer than half of patients complete prolonged-exposure therapy. “That sucks,” Roy said.

Taking on an intervention as unorthodox as RTM risks damaging Roy’s academic reputation. But it could also crown his decades-long career in PTSD research. While he was an internal-medicine resident at Walter Reed in the early ’90s, war broke out in the Middle East. “I saw hundreds and hundreds of Gulf War veterans, and it was fairly obvious that PTSD was a huge issue,” Roy told me. The treatment programs he developed incorporated many types of therapy—psychiatric, physical, recreational, art—and are still used at Walter Reed today. But they’re far too labor-intensive to scale. “If we could do that for everybody, that’d be great. But, obviously, that’s not too realistic,” Roy said. In his view, to treat the growing number of veterans with PTSD, the standard treatments must evolve.

[Read: Healing a wounded sense of morality]

In some ways, RTM is a radical departure from those treatments. Prolonged exposure is based on weakening the link between memories and emotions through the phenomenon of extinction, not actively changing them. Psychologists initially believed that a memory was like wet cement: malleable until it became permanently set, or “consolidated,” David Riccio, a professor emeritus of psychology at Kent State University, told me. But in the late ’60s, researchers showed in animals that old memories could be altered and then stored away in their updated form. Hence, reconsolidation.

Reactivating a difficult memory—loosening the cement, so to speak—requires just a fleeting recollection. Because RTM is supposed to work quickly, patients can address multiple traumas during treatment—an important factor for veterans, whose traumas tend to stack up. A therapist in Roy’s study told me that RTM patients addressed up to four traumas in 10 sessions. If the data bear out RTM’s effects, “it could end up surpassing those others that are first-line treatments now,” Roy said.

That remains a big if. RTM is still novel enough that it could go nowhere. Promising trials are shelved all the time, sometimes for reasons beyond their results. And the Trump administration’s massive funding cuts to a Department of Defense–led research-grants program will undoubtedly hamper PTSD research more broadly. Cost, logistics, and financial interests can doom research. So can ideological differences. The basic goal of RTM—remedying PTSD without the pain—conflicts with the prevailing paradigm of trauma treatment. When a person is afraid of elevators, they “understand implicitly that I need to get into an elevator at some point to get over this,” Barbara Rothbaum, a psychiatry professor at Emory University who has researched prolonged exposure for decades, told me. In this view, RTM is ineffective at best, and, at worst, it’s cheating, like merely peeking at the elevator from around a corner down the hall. Recalling a trauma, but backing off before becoming too emotional, could be seen by some exposure experts as avoidance, Hembree said—the very thing that keeps people with PTSD stuck in the past.

After a subdued question-and-answer period in the Marriott conference room, the symposium faded to an end. A few attendees milled around outside the room, looking bemused. Birgit Kleim, a scientist from the University of Zurich who studies reconsolidation, laughed when I asked her thoughts on RTM. The data are so good that I “don’t believe it,” she said. Later, she shared a sentiment that is so often meant to strengthen emerging science but can also thwart it: It’s promising, but more research is needed.

Over sushi in Boston, Roy told me about his history of pursuing unconventional research. Not all of it worked out. A previous idea he studied—treating brain injury with music composed from patients’ own brain waves—turned out to be “garbage,” he said. Research is always a gamble. A fringe idea with real potential could turn out to be groundbreaking, but chances are, it’ll be a dud. Roy shrugged: That’s just how science goes.

The next morning, as I waited in a dark ballroom for one of the keynote addresses of the conference to begin, hundreds of researchers had turned out to hear a discussion on using psychedelics to treat PTSD, itself uncharted territory. Spotlights on an elevated stage illuminated six leaders of PTSD research, imposing against a royal-blue backdrop. Among them was Paula Schnurr, who is widely regarded as the most influential person in the field. Psychedelics were promising because research on new PTSD treatments has “hit a wall,” Schnurr said. Yet even psychedelics are still combined with old therapies such as prolonged exposure, noted another panelist, Amy Lehrner. “Are we about developing and studying new options for veterans? Or are we about closing down inquiry and just sticking with what we already have?” Lehrner said.

Consider the “PTSD Clinical Practice Guideline,” a document produced jointly by the Defense Department and the VA that profoundly shapes treatment and research. The most recent version, released in 2023, recommends just three therapies, down from seven in previous iterations. These three options are sometimes disparagingly referred to as “the trinity”: In addition to prolonged exposure, they include cognitive processing therapy and eye-movement desensitization and processing, which are newer treatments. Over the past decade, a number of researchers have denounced the field’s reliance on these approaches.

RTM’s chances of finding a foothold in this landscape are slim. Prolonged exposure was one of the first therapy treatments for PTSD. As such, it is both well studied and widely used despite its drawbacks, Maria Steenkamp, an NYU psychiatry professor who has critiqued the dominance of prolonged exposure, told me. The narrative that it is the best treatment “took on a life of its own over time,” Steenkamp said.

This story has dramatically influenced the field. Most funding for research on new treatments comes from the Department of Defense and the VA, which is currently bracing for the Trump administration to cut more than 80,000 jobs. Under normal circumstances, the VA awards funding on the basis of several factors, including plausibility, preliminary evidence, a sound investigation plan, and the researcher’s track record. As a result, well-established treatments have continued to be studied and refined over time. “The folks who were best positioned to compete for funding were individuals who already had a track record of conducting clinical trials in PE and CBT,” Charles Hoge, a senior scientist at the office of the Army Surgeon General who has criticized the recent “Clinical Practice Guideline,” told me. As a result, “relatively small amounts of funding are going into novel treatment approaches.” The field, it seems, is not so much stuck but looped into an ouroboros.

Everyone I spoke with told me that Schnurr was the person to ask about the future of new treatments. I was warned that she would be difficult to get an audience with. As the executive director of the National Center for PTSD, she oversees the Clinical Practice Guideline. She ran the study indicating prolonged exposure’s 55.8 percent dropout rate that is so often cited by its critics—the finding that Roy said “sucks.” After weeks of emailing with the VA’s press officers, I finally got through to her. She defended prolonged exposure by explaining that even patients who drop out of treatment still reap some of its benefits, and that condensing sessions into a shorter time frame—weeks rather than months—significantly reduces the dropout rate. The VA is constantly seeking new treatments, but it only backs those with a solid evidence base, she said. That’s why the list of recommended treatments has been pared down.

How might a little-studied but promising therapy such as RTM get the VA’s attention? Schnurr’s answer was as I expected: More research is needed, preferably not by the treatment developer. If you’re a scientist pitching new research to the VA, you have to “make a good case as to why you think a particular treatment should work, and provide preliminary evidence if you have it,” Miriam Smyth, a director in the VA’s research office, told me. Other than Bourke, the only scientists who have studied RTM are Roy and the British group that declined to speak with me; most haven’t looked into it. “My guess would be that they find that other treatments look more promising,” Schnurr said.

RTM’s fiercest advocates argue that no one with PTSD has time to wait around. Whether or not RTM truly is the treatment they’ve dreamed of, they’re correct about the urgency. After Turner, the Iraq veteran, tried RTM, his flashbacks vanished, but the anger that has coursed through him for two decades has never abated, he told me. Near the end of our interview, his brusque exterior cracked. Through sobs, he said that nobody but a veteran could understand how it feels. He has largely been able to move on from his past, but the damage it caused is always present, walling him off from the rest of the world. “I just don’t think or feel the same,” Turner said. “And I feel that everywhere.”

Updated at 3:38 p.m. ET on May 31, 2025

Solving HIV vaccination—a puzzle that scientists have been tackling for decades without success—could be like cracking the code to a safe. The key, they now think, may be delivering a series of different shots in a specific sequence, iteratively training the body to produce a strong, broad immune response that will endure against the fast-mutating virus, ideally for a lifetime.

Figuring out which ingredients to include in those shots, and in which order, is one of the trickiest immunological conundrums that researchers have ever faced. But mRNA, the fast, flexible technology that delivered two of the world’s first COVID-19 vaccines in record time, is ideal for that kind of brute-force tinkering, and may be the most important tool for getting an effective HIV vaccine, Julie McElrath, the head of the Vaccine and Infectious Disease Division at Fred Hutchinson Cancer Center, in Seattle, told me. Multiple mRNA-based HIV vaccines are now in clinical trials, and early data suggest that they’re prompting the type of immune responses that researchers think are essential to keeping HIV at bay—and that other vaccine candidates have struggled to elicit at all.

But recently, several promising mRNA HIV-vaccine candidates have slammed up against a technical roadblock. In two small clinical trials, 7 to 18 percent of participants developed rashes and other skin reactions after getting the shots—including multiple cases of chronic hives that troubled volunteers for months after they were immunized. All of the vaccines were manufactured by Moderna.

The rashes aren’t life-threatening; they’re also readily treatable. Still, they can be debilitating and distressing. “I’ve had patients who literally can’t go to work,” Kimberly Blumenthal, an allergist and immunologist at Massachusetts General Hospital, who has treated people with chronic hives, told me. The rate at which they’re occurring in the trials is also out of the norm, and no one has an explanation yet for the root cause. To prioritize patient safety, mRNA HIV-vaccine research in people has slowed as researchers try to suss out the cause of the hives, William Schief, the Scripps Research Institute biophysicist who helped design the vaccines, told me. (Schief also holds titles at Moderna and at IAVI, the nonprofit that sponsored some of the HIV-vaccine work.)

At any time, a side effect this uncomfortable and prolonged would give researchers pause. But in 2025, a setback for a high-profile mRNA vaccine trial—focused on HIV, no less—could more fundamentally upend potentially lifesaving research.

Secretary of Health and Human Services Robert F. Kennedy Jr., a longtime and prominent anti-vaccine activist, has repeatedly questioned the safety of mRNA COVID vaccines. He and agency leaders are already recommending that fewer Americans take vaccines and creating new hurdles to vaccine approval. Since January, the National Institutes of Health, under HHS’s direction, has also terminated funding for hundreds of research projects related to HIV and vaccines. This week, the department canceled Moderna’s nearly $600 million contract to develop mRNA-based flu vaccines.

The HIV-vaccine studies that detected the skin reactions were also supported by NIH funding, and the researchers involved collaborated directly with NIH scientists. But those partnerships have since been terminated, and the NIH is now telling several agency-supported researchers working on HIV vaccines that the government is not planning to continue funding their work, according to several researchers I talked with.

When reached for comment, Emily Hilliard, HHS’s press secretary, wrote in an email, “The reality is that mRNA technology remains under-tested, and we are not going to spend taxpayer dollars repeating the mistakes of the last administration, which concealed legitimate safety concerns from the public”—referencing the mRNA-based COVID-19 vaccines, which were rigorously tested in clinical trials, and billions of doses of which have been safely administered people around the world.

Under normal circumstances, detecting rashes in a small vaccine-safety study would represent a routine scientific setback, and prove that the trials served their intended purpose. But the administration’s anti-vaccine stances have created a culture of fear among scientists: Several of the researchers I contacted for this story declined to comment, for fear of publicly tying their name or institution to reporting on mRNA vaccines and losing funding for their research. Science requires resources and open discussion—in torpedoing both, the Trump administration is rapidly undoing decades of progress toward ending the HIV pandemic.

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Researchers running the mRNA HIV-vaccine trials first took note of the rashes in 2022, shortly after studies began. But as they started to publicly discuss the side effect, and media reports of them began to emerge, many scientists in the field weren’t quite sure what to make of the initial findings. The trial in which it had been reported had enrolled only 60 people, and it wasn’t set up to rigorously look at a mysterious side effect. “The sort of feeling was, Yeah, that’s a bit weird, God knows what happened,” John Moore, an HIV researcher and vaccinologist at Cornell, told me. This April and May, though, researchers independently published two papers describing the rashes, for four separate vaccines, in two separate trials: one for the IAVI-backed vaccine and another run by the HIV Vaccine Trials Network. Now, the side effect is “real, confirmed, generalizable,” Moore said. “And we don’t know why it’s happening.”

The vaccines in question target slightly different parts of the virus. But all of them rely on a Moderna-manufactured mRNA backbone, and all of them triggered, in up to about 10 percent of participants, chronic hives that emerged a few days or weeks after vaccination and in many cases lasted for months. That’s a long time to be battling itching and discomfort—and it threatens to be a major deterrent to completing the series of vaccines, or potentially starting at all, Genevieve Fouda, an immunologist and HIV researcher at Cornell, told me.

Delayed, chronic hives have long been known as a rare side effect of vaccines, including mRNA-based COVID vaccines. But the rates are generally very low—usually well under 1 percent, and often detectable only in massive studies of thousands of people. To see these rashes crop up in two small safety studies—one of 60 people, the other of 108—is a significant departure from precedent, scientists told me. And working out why they’re appearing at such high rates will take time. Although researchers understand that the reactions are a kind of autoimmunity—in which the body inadvertently learns to attack itself—they don’t know exactly why rashes occur after certain immunizations or infections, Blumenthal told me.

In this case, the data so far do point to the specific combination of mRNA and HIV as a root cause. Other mRNA vaccines, including Moderna’s, haven’t had this issue to anywhere near this degree; neither have other HIV vaccines that have made it into people. And several researchers pointed out to me that, so far, the only trials that they’re aware of in which these hives have turned up at this frequency have involved a Moderna-manufactured product. None of the other vaccines being tested by the HIV Vaccine Trials Network, for instance, has seen rashes at that rate—including other, non-Moderna mRNA HIV vaccines, Jim Kublin, the director of HVTN, told me. (Barton Haynes, the Duke immunologist leading work on one of the non-Moderna vaccines, told me he and his colleagues have not encountered the same skin-reaction problem.) Hives also appear to have been a more common side effect of the Moderna COVID vaccines than of the Pfizer ones, though still overall rare. “This is truly an outlier in terms of what we’ve seen,” Robert Paris, a vice president at Moderna, told me.

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A persistent mRNA problem would be a major blow to HIV-vaccine development. When the technology emerged, it sped progress like nothing else: “Things that originally took us about three years, we could do them in maybe three and a half months or so,” Mark Feinberg, the head of IAVI, told me. The early results for these vaccines have also been very promising, and before the hives were detected, researchers were well on their way to testing even more iterations of mRNA-based HIV vaccines, to crack the final immunization code. But for the moment, “there’s no appetite to say, ‘Let’s try all these different immunogens and see what happens,’” Schief, the Scripps researcher who helped design the vaccines, told me.

Still, most of the researchers I spoke with insisted that they’ll find a solution soon. The mRNA vaccines for HIV “are not at all dead in the water,” Kublin told me. If needed, scientists could tweak the vaccine recipe, or combine the mRNA approach with another technology. The fix may be as simple as lowering the vaccine dose, a strategy that Schief and Feinberg are working to test in a new trial based in South Africa. (Moderna’s COVID vaccine also contained more than three times as much mRNA as Pfizer’s—and one study found that lowering the Moderna dose seemed to reduce the rate of certain skin reactions.)

Successful HIV vaccination may require a balancing act—minimizing hives, while still delivering enough mRNA to rile up the immune system. But researchers may not be able to drive the rates of skin reactions down to zero: HIV is especially adept at cloaking itself from the immune system, and there may be few ways to force the body to attack the virus without producing collateral damage. And Schief and others couldn’t say what rate of hives would be acceptably low. The virus is so infectious and deadly that some minor side effects may be worth the risk, if the vaccine is effective at generating the right immune response. But even a perfect, immunity-inducing shot won’t do the world any good if people are afraid to take it.

Still, if a rash can dissuade someone from vaccination, so, too, can misinformation, or an official’s decision to stop recommending a shot. No vaccine progress will be made if the federal government doesn’t want it to happen: Paris, of Moderna, told me that earlier this spring, the NIH terminated its partnership with the researchers developing these mRNA HIV vaccines, forcing the scientists to seek alternate sources of support. And yesterday, Schief and Haynes were told that their groups at Scripps and Duke would not have the opportunity to renew funding for the two HIV-vaccine-focused research consortia that their institutions lead—millions of dollars that the researchers had been told to expect they would receive, and that have been powering the development of their mRNA shots. The rationale, Haynes told me, as it was described to him, was “due to the desire to go with currently available approaches to eliminate HIV.” Currently available approaches include community education and preventive drugs, but notably, no vaccine. (HHS did not respond to questions about these funding shifts.)

“Unless we can find a substitute source of support, this work won’t go forward,” Haynes told me. If the project of HIV vaccination looks less promising right now than it has in years, that’s not about science or technology, or about any single side effect: It’s about politics.

In contrast to his aging predecessor, President Trump appears robust and energetic. Yet, like Joe Biden, Donald Trump is an elderly man, and he will become the oldest sitting president in U.S. history by the end of his second term. In light of recent revelations about Biden’s declining health, as a doctor and an expert in aging, I have been thinking about the responsibilities of Trump’s doctors to him and to the American public. If the way we care for elderly people is distinct because their bodies and risks are distinct, perhaps the care of an elderly president should be, too.

Presidents are getting older—which is to be expected, given the doubling of the average human lifespan across the 20th century. As we age, the likelihood of disease goes up significantly each decade (which makes sense because human mortality is holding steady at 100 percent). An elevated risk of disease shouldn’t exclude a person from any job—even one as important as the U.S. presidency—but in elderhood, certain diseases become more prevalent, such as heart disease and cancer, the leading causes of death for adults. After age 70, a person is also at increased risk for one or more health conditions in a category unique to old age, the so-called geriatric syndromes, which include cognitive impairment, functional decline, falls, and frailty.

On the surface, Trump seems stronger and less vulnerable than Biden did. Yet looks do not necessarily reflect risk for illness and disability. A hallmark of advanced age is its variability: One person may be physically powerful but have dementia; another might have hearing loss but no cognitive changes; a third could have heart disease, diabetes, high blood pressure, and high cholesterol—physiologic time bombs that increase a person’s risk of major events such as heart attacks, strokes, and death.

And Donald Trump has lived in a way that raises his risk for heart and other serious diseases as he ages. For years, he has been overweight or obese, as measured by his BMI—which doesn’t distinguish between lean, muscular weight, and fat, meaning he is likely even less healthy than his abnormal BMI suggests. His gait, though better than Biden’s, demonstrates the same weakness of many lower extremity muscle groups, and his history of eschewing formal, particularly muscle-building, exercise means that his risk for falls and frailty is increasing more quickly than they would with resistance and balance training—recent signs that he might be adopting healthier habits notwithstanding. Equally important, fat on a body indicates fat in and around the body’s critical organs and blood vessels, including the brain and heart.

To truly understand our current president’s health, as a doctor I would want to know and follow not just his BMI but also his percentages of fat and muscle, and to track his strength, hand grip, and walking speed. His doctors should be discussing those predictive measures with him, as well as the negative effects his lifestyle might have on his heart health and cancer risk.

That would be true for any older patient, but the president’s crucial role may well change which additional tests his doctors should consider. For example, routine screening for prostate cancer—which Biden reportedly did not undergo—is not recommended for men over age 70 because most, even if they develop prostate cancer, will die of something else. But these tests might make sense for a president over age 70 because the risks of a serious form of the cancer would affect not just the man but the country and the wider world. Other tests that fall into this category might include functional heart and brain scans, additional cancer screenings beyond usual age cutoffs, and certain biomarkers.

More aggressive screening would still have trade-offs for both the president and the nation. It could subject the president to unnecessary procedures and psychological stress. Opponents might use even a clinically insignificant diagnosis to their advantage. But more aggressive screening might also enable earlier diagnosis or, if a potentially disabling or lethal condition is found, succession planning.

Because the risk of adverse health events increases throughout the last third of life, we geriatricians recommend discussing what’s known as “goals of care” with each patient—to get a sense of their values and their fears. We ask about what matters most to them in their life, which situations seem worth some suffering and which do not, and how they have handled and experienced past health events. Programs proven to help people clarify their priorities and plan ahead can help patients, families, and doctors choose a course most consistent with their values and goals.

For a president, such conversations are even more essential. First, they could help the president, as an individual, think through how to separate political pressures from personal needs and family responsibilities. Second, having a plan that protects the country should be a core responsibility for anyone in high office, and an elderly president in particular should think ahead of time about how to best serve the United States in the event of a majorly debilitating health event or general decline.

Goals-of-care conversations are difficult for some people—and some doctors. If Trump’s doctors are not skilled at this sort of conversation, they should engage a consultant who is able to push him to reflect on how his answers to these questions would affect his ability to do his job, or the functioning of the country. Just as it’s the president’s responsibility to answer these difficult questions, so too is it his doctors’ responsibility to pose them.

When asked to comment, the White House did not address questions about Trump’s risk, mitigation strategies, or contingency planning, but Liz Huston, a spokesperson, said over email that Trump “receives the highest-quality medical care” from his doctors and “is in great health as evidenced by the results of his comprehensive annual physical exam.” (Huston also said the White House was not going to accept the unsolicited advice of “an activist Democrat doctor,” referencing a 2023 article on aging politicians in which I wrote, based on what reporters had told me, that journalists decades younger than Nancy Pelosi had trouble keeping up with her.)

Trump’s physicians face another challenge that most clinicians do not: Which information about their patient’s health should they share with the public? In both Trump terms, many physicians have struggled to believe the information provided by the president’s medical team and have suspected that his risks are being substantially downplayed. And now we know the problem exists in both major political parties. Biden’s team seemingly withheld information that would have made clear that he did not have the physical or cognitive ability to govern for a second term. Surely, with such high stakes, the president’s health is an exception to the usual rules of patient privacy. When a person signs up for “public office,” by definition they forfeit some of the privacy protections the rest of us are entitled to by law. Their health and ability to do their job affect hundreds of millions of lives.

The U.S. could consider imposing a maximum age limit on the presidency. But that one-size-fits-all approach risks eliminating potentially fit and favored candidates. In its absence, the person leading the country should receive station-specific, evidence-based, and person-centered care—that attends to their role, medical conditions, functional abilities, and preferences. And the American public deserves transparency about the president’s health.