Medical News

Immediately after Hamas and Israel agreed to the first phase of President Donald Trump’s peace plan, food and medical supplies were supposed to start flooding into the Gaza Strip. Like other key aspects of the agreement, that influx did not go exactly as planned. Some food, fuel, medical supplies, and other resources are moving, but the flow of aid remains clogged.

The success of the Gaza cease-fire—which Trump has called perhaps “the greatest deal” of any he’s made—depends on the United States’ continued involvement. Top U.S. officials, including Vice President J. D. Vance and Secretary of State Marco Rubio, have flown to Israel, trying to shore up the cease-fire. (Israeli media, The Wall Street Journal reports, have taken to calling the visits “Bibisitting.”) On the immediate agenda is “giving people some food and medicine,” Vance said during a press conference last week.

Faced with humanitarian crises in the past, the White House could lean on USAID’s experience with global aid and its expertise in postwar recovery. But since DOGE was unleashed on the U.S. government, that agency essentially no longer exists. Work on aid in Gaza was not exempt, former and current aid workers told me: The Trump administration fired people actively working on this conflict, and the State Department now must figure out, largely on the fly, how to help aid reach Gaza.

As much as the Trump administration has undermined American aid around the world, its interest in peace between Israel and Palestine shows that the U.S. still intends to be very involved in humanitarian work in some places. Gaza is both the most high-profile test yet of Trump’s decision to slash the United States’ humanitarian capacity and the best available example of what relief work his administration is capable of when it is extremely invested.

In the first 12 days of the cease-fire, the UN’s World Food Programme brought in an average of just over 700 tons of food a day, a WFP spokesperson, Martin Penner, told me. The UN says cooking gas has also entered the Gaza Strip for the first time since March. Excluding weekends, when crossings into Gaza may be closed, enough aid trucks have entered on average to meet the minimum laid out in the cease-fire deal, according to a source with direct knowledge of State Department activities. But the World Food Programme says it would need to bring in twice as much food to reverse pockets of famine. The program’s meal distribution in northern Gaza, the epicenter of the Strip’s starvation, began only about two weeks into the cease-fire, Penner said. Twice during the cease-fire, the Israeli government has said it would restrict the flow of aid into Gaza: once in response to the slow release of deceased hostages, and then after a spate of violence. The source with direct knowledge of the State Department told me that humanitarian aid is now “widely accepted” to be a phase-two priority—still a goal, but one that follows the completed exchange of both Israelis’ and Palestinians’ remains.

At least some State Department officials key to pursuing that goal were not at work early during the cease-fire. Instead, they were furloughed by the government shutdown, according to one current and one former federal employee. (They, like other current and former aid workers I spoke with for this story, requested anonymity for fear of retribution.) During the first week of the cease-fire, the Trump administration pulled those officials back into the office, the current and former federal employees told me. The furloughed staff were able to get up to speed quickly, according to the current employee and the source with direct knowledge of events in the department.

But those workers represent just a fraction of the effort that the U.S. once put toward ensuring aid was entering Gaza. Before Trump took office, for example, a team of about 30 USAID experts in D.C. and the Middle East had been working full-time on providing humanitarian relief in the Strip, Andy Hall, a former USAID officer who worked on the Gaza response, told me. American involvement was key to aid getting in at all: As NPR has reported, almost nothing entered unless top officials called Israeli Prime Minister Benjamin Netanyahu, his adviser Ron Dermer, or his defense minister. At least one USAID official met daily with COGAT, the Israeli military agency that has controlled what aid enters Gaza, Paul Martin, a former USAID inspector general, told me.

UN agencies and other NGOs also participated in those meetings. But because the U.S. has a better working relationship with the Israeli agency than the UN does, the Americans made a difference in securing humanitarian access to Gaza, according to three sources with direct knowledge of the meetings. Eri Kaneko, a spokesperson for the UN’s Office for the Coordination of Humanitarian Affairs, told me that “it’s no secret that the UN and our partners have not always seen eye to eye” with COGAT, and that the UN would “welcome the support from the U.S. and other member states to ensure we’re able to deliver lifesaving aid swiftly.” Samantha Power, the top USAID official under Biden, said in a January interview with Politico Magazine that UN officials relied on USAID to lobby Israel to renew the visas of its staff so that they could continue working in Gaza.

Then the Trump administration fired every humanitarian expert employed by USAID, and many of those employed by the State Department. The USAID staffer detailed to Israel’s aid-coordination board was fired by early February, Martin told me. This doesn’t mean that the U.S. has abandoned the project permanently: In response to a request for comment, the White House directed me to the State Department, which told me in an email that officials have met with the Israeli military unit coordinating aid and directed me to its October 16 X post announcing that a disaster-response team, working without pay during the shutdown, was helping “surge and coordinate aid into Gaza.” (The person who responded did not provide their name. They did not say whether any American representatives kept attending the daily board meetings after USAID collapsed.)

Still, the federal government’s push to cancel foreign aid meant that it entered the cease-fire deal with a smaller team just assembled. In July, when the United Nations put out its own plan for surging food and medicine into Gaza in the event of a cease-fire, the State Department was still hiring the people currently coordinating its Gaza relief work, the current federal employee and one of their colleagues told me. “The lack of engagement by the U.S. on the response in the interim has undoubtedly affected the level of preparedness for ‘day 1’ of a peace deal,” the current federal employee told me.

The Trump administration’s approach to aid in Gaza has also weakened the UN’s work there. Without USAID to intervene, Israel has, as my colleague Franklin Foer wrote in August, pursued “a string of policies that seem intended to permanently push the UN out of Gaza.” Israel refused to renew the visas of top officials at at least three UN agencies operating in Gaza and de-registered major aid groups that had been working in Gaza for decades.

Beginning in May, after Israel halted all aid to Gaza for 11 weeks, the Gaza Humanitarian Foundation, a months-old nonprofit, became the primary food supplier in Gaza. The U.S. was directly involved in this venture: It was designed by American management consultants (along with Israeli officials and businessmen), staffed by American security contractors, and funded in part with American taxpayer dollars. Whereas the UN system once ran about 400 aid sites, GHF never ran more than four. According to food-security experts, extreme malnutrition in Gaza, already high, skyrocketed after GHF took over; according to Netanyahu, the foundation failed to prevent looting by Hamas. (In an email, a GHF spokesperson wrote that the non-profit was “the only organization that delivered aid directly to the Palestinian people including women, children and elderly.” He also noted that GHF was now down to three distribution sites, all “temporarily paused during the ongoing hostage exchange.”)

Now, though, the Trump administration is counting on the United Nations to help fulfill the cease-fire’s goals. Last month, in front of the UN’s General Assembly, the president essentially called it a coalition of paper pushers. But his cease-fire plan explicitly calls for the UN to distribute aid, alongside the Red Crescent and “other international institutions.” He’s also dispatched American troops to Israel to help ensure aid groups are allowed to do their work; American diplomats are set to join them.

Exactly how all of these pieces will fit together is unclear. Usually, civilian groups lead relief efforts and coordinate with the military for protection. In this case, roughly 200 U.S. soldiers are setting up a civil-military coordination center, which has also been given the job of facilitating the flow of humanitarian aid into Gaza. The person with inside knowledge of the State Department said that the UN will play a role in the civil-military collaboration, but American officials are still determining its precise shape. At last week’s press conference, Trump’s son-in-law Jared Kushner (a senior adviser in the first Trump administration, whom the president has said he “called in” to work on the cease-fire) said that coordination between the United Nations and Israel has so far been “surprisingly strong.”

Trump’s cease-fire has undeniably improved conditions in Gaza. But humanitarians’ job there is particularly difficult. Many of the people whom the UN is rushing to serve are starving, enough to require urgent medical treatment in addition to food. When starving people can’t trust that relief will come, they take what they can find, Tess Ingram, a UNICEF spokesperson who was in Gaza City when we spoke earlier this month, told me. Early in the cease-fire, as a convoy of trucks carrying food rolled into southern Gaza, Palestinians stripped them bare in 20 minutes mid-route, The New York Times reported: “Young men fared best. Children had to look for what openings they could.” How much better their situation gets will depend in part on how well the new American approach to aid works.

Eight Sleep—often called Silicon Valley’s favorite bed—is like a full-body Fitbit. It is a $3,050 mattress cover filled with sensors to monitor heart rate and body temperature. For people who pay $199 to $399 for an annual subscription, the cover will automatically heat and cool itself throughout the night to keep the owner at a sleep-optimal temperature. The add-on base (about $2,000) raises the angle of the bed to make reading more comfortable or to help stop snoring. Eight Sleep gently vibrates its users awake; it lulls them to sleep with “deep rest” meditations narrated by the wellness-science podcaster Andrew Huberman. To buy the Eight Sleep is to buy fully, with your whole body, into the idea that the future of sleep is technological.

On Monday, the future glitched. Eight Sleep’s features run on the AWS Cloud, so when one of Amazon Web Services’ data centers went offline at about 3 a.m. ET, the sleep system went haywire. Eight Sleep generally warms when the user is drifting off, then gets cooler as they enter deeper sleep. Santiago Lisa, a software engineer in Pittsburgh, told me he woke up because his bed was stuck in deep-sleep frigidity. He tried to warm it up using the Eight Sleep app, but no dice—the app was down. Then he tried the system’s manual buttons. No dice there, either—they also require the Cloud to function. Jordan Arnold, who works in the video-game industry in Washington State, told me that his girlfriend couldn’t sleep because her side of the bed was stuck at its highest temperature, 110 degrees Fahrenheit. She slept on the couch. Other poor souls, who had put their bed in a sitting position to read and were now stuck there, spent the night in the world’s most high-tech Barcalounger. A Jetsons vision of the 21st century did not include Mrs. Jetson stuck in an upright and locked position because her bed could not connect to a data center in Northern Virginia.

The disruption was short-lived: Eight Sleep’s products were up and running once AWS was. (The company is working to diversify its cloud setup, a spokesperson told me, and on Wednesday, it launched a backup mode that uses Bluetooth.) But that this fiasco happened at all is a sign of how much Americans’ desire to optimize their rest has grown—along with the market to sate that desire. We are being offered more and more ways to become, essentially, sleep cyborgs who depend on technology to enhance what should be a basic aspect of being alive. Those interested in “sleepmaxxing,” along with people who want to sleep better but don’t have a Silicon Valley–style term for it, have made sleep tech a $29.3 billion industry, by one measure. The value of the industry is expected to more than quadruple, to $135 billion, by 2034.

Shalini Paruthi, a physician who’s on the American Academy of Sleep Medicine committee for emerging technology, told me that she mostly sees her patients using sleep tech through meditation and bedtime-story platforms. Those with the Calm app can fall asleep to Harry Styles narrating a story called “Dream With Me,” Matthew McConaughey pontificating on “the mysteries of the universe,” or Travis Kelce’s mom talking about football. Devices have permeated all aspects of sleep, Paruthi said. Wearables such as the Oura Ring and Apple Watch track the wearer’s vitals. Red-light lamps aim to help people feel sleepier, noise machines play soundscapes as they drift off, and alarm clocks mimic sunlight to wake them up. I thought I was a little high-maintenance for using a fabric eye mask, but for north of $100, I could acquire a “smart” one that not only blocks light but also vibrates in sync with my heartbeat. For help falling asleep faster, people can buy a $350 “neurotech headband.” And those who aren’t ready to spend $3,000 on a sensor-filled mattress cover could instead opt for a $1,400 “dual zone climate control bed-making system”—a duvet connected to air hoses that pair with Alexa voice command. Notably, the Eight Sleep has aggregated much of the most popular consumer sleep equipment available into a single piece of technology.

Whether or not  these gadgets actually help with sleep is an open question. Sleep-tracking devices do a “pretty good job of figuring out when a person fell asleep and when they woke up, based on their movement and heart rates,” Shalini said. (So does looking at your clock.) But they don’t “always do the best job in between.” Patients will come to her because their wearable says they got no REM sleep, which, she said, “quite frankly, would be impossible.” At the very least, these devices can encourage better sleep hygiene: One too many bad “sleep scores,” and a person might just start going to bed earlier and leaving their phone in another room.

For those with actual sleep disorders, cyborg sleep can be a very good thing. People who have extreme nightmares from PTSD can use NightWare, a prescription-only system that comes with a preprogrammed Apple Watch and detects if the wearer is having a nightmare. It will vibrate enough to stop the bad dream but not enough to wake the user. And for those with restless legs syndrome, there is Nidra, a cuff worn around the calves that helps alleviate RLS symptoms. Even Eight Sleep can be FSA/HSA-eligible with a doctor’s note explaining why it might help a preexisting health condition.

But in general, the more technology in a sleep routine, the more possible points of failure. Our bed might not connect to the cloud and remain stuck at an incline. We might open our phone to summon the soothing voice of Matthew McConaughey and instead be spirited away by Instagram. Technology, one of the main reasons we can’t sleep, has entered the last part of our life that is usually free from it. Before Eight Sleep announced its new offline mode, some Reddit users discussed “jailbreaking” their bed so that it could function without the AWS Cloud. A simpler hack might be to let our bodies do what they’re already primed to do. Even when his Eight Sleep malfunctioned on Monday and remained at frigid temperatures, Lisa told me, “I ended up sleeping. It was just cold.”

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On a road in Aurora, Colorado, lined with used-car dealers and pawnshops sits a tan, low-rise building called Mango House. Inside, among international-food stalls and ethnic-clothing shops, is a family-medicine clinic that serves a largely refugee and immigrant community. Improbably, the clinic makes enough money to sustain itself and pay staff well without relying on grants or donations. And it does so through Medicaid.

The prevailing wisdom is that Medicaid is a losing proposition for health facilities, an insurance program so stingy that many can’t afford to take it. Some of those that do essentially segregate Medicaid patients into separate clinics. Here, Medicaid is preferred. 

Because the clinic relies so heavily on that program, I expected that the Trump administration’s upcoming Medicaid cuts might force Mango House to close or pare back. Instead, when I spoke recently with the clinic’s founder and owner, P. J. Parmar, they were far from his mind. Medicaid’s practices—and patients’ coverage—already fluctuate enough that he and his staff are used to weathering such unpredictable forces. Even if 15 percent of his patients fell off Medicaid because of the cuts, his practice would be fine, he said, showing me his calculations.

Parmar is a family physician who opened the practice—officially named Ardas Family Medicine, but now better known by its location inside Mango House—in 2012. He wanted to reengineer how a clinic could run, designing systems that maximized efficiency and ease of access. For starters, Parmar eliminated scheduled appointments, which he called “an exercise in craziness.” In theory, appointments ensure that people don’t have to wait long to see their doctor, but Parmar found scheduling to be so inherently erratic—some patients need only a few minutes, others half an hour; many don’t show up at all—that he could see more patients, while keeping wait times short, by simply having them walk in. On the Wednesday I was there, the practice hummed along. Medical assistants from Nepal, Myanmar, Somalia, and Afghanistan greeted patients; the average wait time hovered around 10 minutes. Even during the Monday-afternoon rush, Parmar said, waits rarely exceed 30 minutes.

Most days of the year (and it’s open all but five), the clinic is staffed with three clinicians—a mix of doctors and nurse practitioners—who together see about 100 patients. Each provider has a dedicated exam room arranged how they like, so they don’t waste time hunting for supplies or shuttling between spaces. They escort patients from the waiting room and perform vital signs themselves: The clinic doesn’t employ nurses. (Lower-cost medical assistants handle routine tasks such as giving shots and drawing blood.) The providers see patients in order of arrival. Of course, some patients still have favorites, so staff will mark any preferences when they check in. 

In American medicine, short appointment times are often a cause for complaint. But from what I observed at the Mango House clinic, the ease of access, rather than undue pressure on clinicians, seemed to keep many visits brief. An older woman Parmar has long cared for came in with a cough, and even as he was writing her a prescription, she asked, “Can I go now?” She told him that if she didn’t feel better in a week, she’d just walk into the clinic again. Parmar also deliberately streamlines clinic notes by encouraging his providers to avoid the common habit of copying and pasting blocks of obsolete or redundant information in favor of quick updates that can be scanned easily at subsequent visits. When I described this practice to Asaf Bitton, a Harvard professor and a primary-care researcher, he told me it likely helps clinicians see more patients without feeling overextended.

Small efficiencies add up, for both staff and patients. The morning I was there, a Nepalese man, Gam Sunuwar, chose to fill his prescription for blood-pressure medication at the clinic’s in-house pharmacy, even though he’d need to cut the pills in half. (Better to walk out with what he needed than wait hours at his neighborhood pharmacy for pills in the specific dose.) The pharmacy sometimes operates at a loss, but it helps keep patients loyal to the clinic. Clinicians also hand out dozens of over-the-counter medications and reading glasses for free. Patients sometimes ask the clinic to complete immigration paperwork; Parmar keeps the service cheap (and less tedious for clinic workers) with a computer formula he wrote that pulls vaccine data from the state website into federal immigration forms with one click.

The clinic accepts anyone, but about 70 percent of its patients are on Medicaid. Almost all of the rest are seen for free. Parmar’s two billers are very adept with Medicaid—the only insurer they have to master, unlike others juggling different health plans’ whims. (Parmar himself rattles off Medicaid billing codes like it’s second nature.) Here, private insurance is not desirable, because it can be difficult to get companies to pay up. During my visit, when one patient, a 9-year-old, was registered with a commercial insurance, Parmar pored over its payment sheet without making much sense of it. “In the amount of time we’ve looked at this, we could’ve seen the girl already,” he said. The clinic would bill her insurance, but if the insurer demanded more paperwork, which it likely would, the claim would be abandoned.

The clinic’s ethos—just take care of patients—is both an ethical imperative and a practical tactic to keep the clinic running at full speed. Medicaid patients often cycle off coverage because they forget to renew, or their paperwork never reaches them; Parmar called this “the churn of Medicaid.” Many patients have “no idea” what their insurance is, a status so common that staff use the term in the clinic’s tracking spreadsheet. The staff will try to figure it out, but at some point, it’s not worth haggling over insurance and demanding documents from patients. Pressing for payment could humiliate people, who often arrive with their extended families, Parmar explained, and in a community this close-knit, that could mean losing dozens of patients, including many of the Medicaid patients who keep the clinic afloat. 

And for a practice that relies on Medicaid, survival is ultimately a “volume game,” Parmar said. That phrase would usually sound ominous in health care: Seeing more patients often means rushed visits and burned-out staff. But the clinic does well on the state’s performance indicators and, from what I observed, is set up so that patients who need extra time get it. Tigist Desta, one of the nurse practitioners, spent the better part of an hour trying to figure out the vaccination status of a child who had just arrived from Ethiopia, for instance. 

The clinic had a few lean years in which Parmar lost money—particularly when he bought the old JCPenney building where Mango House is now located—but he has more than made it back. The practice’s profits are considerably higher than the average family physician’s: Parmar told me he puts much of the money back into Mango House. (He opened his QuickBooks for me, but asked that I not publicly share the numbers.) This year, he significantly raised staff salaries; several years ago, he added a dental practice, though it has yet to break even.

When I first heard about Mango House, I was curious whether its model could be duplicated elsewhere. For one, it seemed to offer a glimpse of the kind of health care Americans might experience if the country ever moved toward a single-payer system. I also found its operations appealing, particularly that it seemed to focus on what mattered to patients and doctors rather than to administrators. The simple fact that it’s an independent clinic may be an asset: Some studies have found that physician-owned clinics achieve greater cardiovascular outcomes while also being associated with lower burnout for staff. “More and more primary-care docs work for these big health systems, and they’re not independent business owners,” who are better at seeing more patients and recouping their work on the billing side, Ateev Mehrotra, the chair of health policy at Brown, told me. Parmar can adjust on the fly—he added an extra provider on those busy Monday afternoons, starting the week after I visited—because, as he put it, “there’s no committee looking over me.”

But independence can also seem like idiosyncrasy, or merely choosing different corners to cut. At Mango House, patients don’t change into gowns, except for intimate exams, and a patchwork of multilingual staff, family members, and neighbors handles interpretation—an approach that experts oppose because these unofficial translators might not explain medical terms properly or could compromise patient privacy. (Parmar countered that he retired his remote-interpreting service after finding that patients preferred their family and community members—who also often know details they themselves neglect to mention.)

As Katherine Baicker, the provost and a health economist at the University of Chicago, told me, “Often things that work in one setting may not work in another.” In at least 16 other states, Medicaid pays as well or better than it does in Colorado, which could make replication feasible if clinics could get the same volume. But not every state allows medical assistants to give injections, erasing that cost savings. Other patient populations may be more litigious than those served by the clinic, which could pressure providers to order extra tests and unnecessary referrals. 

Neither Baicker nor Bitton, the Harvard professor, has studied Mango House, but both see the clinic’s strength as tailoring care to the local community. Bitton thought it probably shared features with the few “bright spots” he has studied—places defined by a “sort of radical simplicity,” he said, where clinicians essentially work within a single-payer system to serve a defined community of patients. Yet that may be exactly what makes Mango House tough to replicate. Parmar himself acknowledged that the clinic’s casual, community-like style might not jibe with every population. He doesn’t bother with satisfaction surveys, anyway; for him, the true measure is how many patients return. For now, it’s more than enough.

To eat 10,000 calories a day, you might try putting away a family-size box of Oreos, a box of packaged cakes, a pint of Ben & Jerry’s, takeout from Five Guys and McDonald’s, and many, many Reese’s cups—all between your regular three meals.

Dru Borden subsisted on this diet throughout his 20s and 30s. As a competitive bodybuilder—fans know him as Big Dru—he needed the calories. Since the mid–20th century, one of the core tenets of bodybuilding has stipulated that gaining muscle requires putting on weight, regardless of how. In Big Dru’s case, it worked: In early-career photos, he appears to have been cobbled together from boulders.

Body-composition researchers have established that a surplus of calories, plus resistance training, is required to gain muscle. The basic idea is that repetitive exercise causes muscles to break down, so the body needs energy and additional nutrients to build them back bigger and stronger. But spending months “dirty” bulking, as the ice-cream-and-burgers method is sometimes called, can also generate huge amounts of fat. Bodybuilders traditionally starved that fat off in the subsequent cutting phase, a period of caloric restriction that can last just as long as the bulk.

But these days, Big Dru and his fellow muscle-maxxing enthusiasts are embracing a new approach: moderation. At a time when celebrities, wellness influencers, and the nation’s top health officials are proclaiming the evils of processed foods, many bodybuilders—professionals like Big Dru, but also young, shirtless amateurs documenting their gains online—are leaving the old way of bulking behind.

On gym-bro social media, the hashtag #leanbulk is ubiquitous. (So is #cleanbulk, used interchangeably.) The term broadly refers to working out while consuming only slightly more calories than the body needs to maintain itself, and getting those calories from healthy sources. A typical lean-bulking TikTok features a young man showing off a comically ripped six-pack and C-cup pecs while meticulously documenting the food that fueled them: cottage cheese and eggs, sweet potatoes and tuna, berries and almonds, but never Twinkies.

[Read: Brace yourself for watery mayo and spiky ice cream]

“The paradigm has definitely shifted,” Guillermo Escalante, a kinesiology professor at California State University at San Bernardino and a competitive bodybuilder, told me. The concept of clean bulking emerged in the past decade or so, but it took off only recently, he said. The trend partly reflects the bodybuilding community catching up to the science. A 2020 review found that, for all but the most elite athletes, the body needs roughly 10 percent more calories to gain muscle than it does to maintain itself—certainly not anywhere near 10,000 calories. Beyond that point, research suggests, any extra calories are stored as fat. That not only obscures your gains but can hinder their growth: Working off fat sacrifices some lean muscle, Escalante said. Muscle growth can also be inhibited by the downstream effects of excess fat, such as insulin resistance and the release of inflammatory molecules, Brad Schoenfeld, an exercise-science professor at Lehman College, told me.

Lean bulking tends to produce big muscles more slowly, but it’s more sustainable over time. The effect of too much salty, fatty, and sugary food is the same for bodybuilders as it is for the less ripped: It disrupts the microbiome and immune system and increases blood sugar, triglycerides, and LDL cholesterol. “That’s really going to wreak havoc on your cardiovascular system long-term,” Escalante said. Around 2021, Big Dru switched to clean bulking because his previous diet gave him digestive issues, headaches, hormonal imbalances, and heartburn. (Now in his early 40s, he still looks like he’s been hewn from a monolith.)

But the rise of lean bulking seems to be primarily a product of broader shifts in American culture, not health data. For competitive bodybuilders, all that matters is how you appear on the day of an event. These days, people want to look like a bodybuilder 365 days a year, Escalante said. That makes dirty bulking—and its attendant buildup of fat—a less attractive option. In recent years, America has more aggressively embraced a chiseled aesthetic and made heroes of the supremely jacked. They fill social-media feeds: punching each other in Ultimate Fighting Championship matches, hosting popular podcasts, hanging on Taylor Swift’s arm, leading the Department of Health and Human Services. More than 90 percent of boys see online messages about body image, and 75 percent see videos specifically about muscles, according to a new report from the nonprofit Common Sense Media. Meanwhile, Robert F. Kennedy Jr.’s “Make America Healthy Again” movement has stoked Americans’ hunger for “natural,” “clean,” and minimally processed foods—all compatible with a clean bulk, but not a dirty one.

[Read: The body-positivity movement is over]

Clean bulking may be a healthier option than slamming fast food, but that doesn’t mean it’s good for you. If social media is any indication, lean bulking still commonly involves extreme dieting, which can lead to nutrition deficiencies, hormonal changes, eating disorders, and loss of muscle and bone density. “For any kind of adolescent, growing human body, I don’t like it,” Nicole Lund, a nutritionist at NYU Langone Health’s Sports Performance Center, told me. Among the athletes she treats, Lund has seen calorie deficits precede fractures and disturbances in mood, hormones, and growth. Eating disorders, which Escalante said are already a major concern in the bodybuilding community, seem to be rising faster among men and boys than women and girls. A study published this year found that muscle dysmorphia, a pathological obsession with obtaining a jacked physique that is sometimes called “bigorexia,” is more common among young men than previously thought. In a 2021 study of more than 4,000 American teenage boys, 11 percent had used muscle-building supplements, including anabolic steroids, to bulk up.

The collision of wellness culture with the age-old pursuit of a Greek-god bod makes it tempting to believe that swoleness is akin to health. Sometimes that’s true. But for all that lean bulkers profess online that their physical changes serve their health, many of them are primarily motivated by aesthetics. Bill Campbell, an exercise-science professor and the director of the Performance & Physique Enhancement Laboratory at the University of South Florida, told me that most of the questions he gets about clean bulking come from young men, and they’re asking “for cosmetic, physique reasons,” such as wanting to fill out a tight shirt. The world of amateur bulkers seems to be mirroring that of competitive bodybuilders: In the end, the muscles are for show.

As Andrea Baccarelli, the dean of Harvard’s School of Public Health, prepared to open a virtual town hall earlier this month, members of the university’s graduate-student union gathered for a watch party with “Baccarelli Bingo” cards. The game boards were filled with phrases the dean was expected to use: “these are difficult times”; “i know it’s not a satisfying answer but we don’t know”; “… which is why we must be innovative!” At the center of the grid was a free space, bedazzled with emojis, that read, “no meaningful commitments made.”

Baccarelli’s stated goal was to provide an update on the school’s financial crisis. Of Harvard’s schools, HSPH has been by far the most reliant on government grants—and so was the hardest hit by the Trump administration’s cuts to federal research funding. In the spring, essentially overnight, the school lost about $200 million in support. Although a federal judge has ruled that those grant terminations were illegal, the school’s future relationship with the federal government remains uncertain. Long-term survival for HSPH would require dramatic change, Baccarelli said at the town hall: It needed to become less dependent on federal funds. In the process, it would have to cut $30 million in operations costs by mid-2027 and potentially slash up to half of its scientific research. HSPH is one of the most consequential public-health institutions in America: The school once contributed to the eradication of smallpox and the development of the polio vaccine, led breakthroughs linking air pollution to lung and heart disease, and helped demonstrate the harms of trans fats. If the Trump administration’s aim has been to upend American science, HSPH is a prime example of what that looks like.

But the school’s dean, too, has become something of an emblem—of how unprepared many scientists are to face this new political reality. At the town hall, Baccarelli had to address his controversial work linking acetaminophen—Tylenol—to autism and answer for how he’d communicated with the Trump administration about it. (Another Baccarelli Bingo square: “acetaminophen mentioned.”) At a press conference in late September, Donald Trump and several of his top officials announced that they would update Tylenol’s labeling to discourage its use during pregnancy, leaning heavily on Baccarelli’s research on the subject and on expert witness testimony he’d given. “To quote the dean of the Harvard School of Public Health,” FDA Commissioner Marty Makary said, “‘There is a causal relationship between prenatal acetaminophen use and neurodevelopmental disorders of ADHD and autism spectrum disorder.’”

Plenty of the school’s faculty were taken aback to hear Trump officials warmly referencing their dean, especially given that Tylenol’s connection to autism—a complex condition with many contributing factors—is shaky at best. Karen Emmons, an interim co-chair of HSPH’s department of social and behavioral sciences, told me she almost crashed her car when she heard Makary quoting Baccarelli on the radio. Many were also surprised to learn, from press reports, that Baccarelli had fielded calls about his research from Health and Human Services Secretary Robert F. Kennedy Jr. and National Institutes of Health Director Jay Bhattacharya earlier in September.

The dean’s interactions with the administration quickly became a new vulnerability for the school. As other experts criticized the methodology of Baccarelli’s work on Tylenol and called his claims about causality unfounded, Baccarelli began to look like a biased researcher, allied with the same political leaders “who are starving us of our funding and basically killing the school,” Erica Kenney, a nutrition researcher at the school, told me. In the view of many faculty members, Baccarelli had undermined the public position Harvard spent months cultivating—as a beacon of academic integrity, unwilling to bend to the administration’s political pressure. (Baccarelli declined interview requests for this story and answered a series of in-depth questions with a brief statement saying that he looked forward to “continuing the work of building a sustainable future” for the public-health school.)

At the town hall, Baccarelli seemed to recognize these consequences. “I’m really sorry about the impact this has had on our school,” he said. But he was also defensive, describing himself as a researcher who wanted to explain the value of his work and help set evidence-based policy. He had spoken with the administration as a scientist, not as a Harvard dean, he said, and hadn’t anticipated that Trump officials would focus so pointedly on his affiliation with the school. His instinct, in other words, was to treat science as severed from politics. He seemed unaware of how unrealistic that split now is for American scientists.

Some nine months into the Trump administration’s assault on academic science, Harvard’s public-health school has just about everything going against it that an American academic institution can. It is part of Harvard, which the administration has accused of failing to protect students from anti-Semitism. It has excelled in several fields that the administration has declared unworthy of federal funds: infectious disease, health equity, climate change, global health. About half of the school’s faculty contributes in some way to international research, which the administration has also taken a stand against. Many HSPH researchers are themselves from other countries—including roughly 40 percent of the school’s students—and their ability to stay here is uncertain under the Trump administration’s immigration policies.

Historically, nearly half of HSPH’s revenue and 70 percent of its research funding have come from federal grants. And unlike academics supported largely by tuition or endowments, HSPH researchers typically have had to bring in nearly all of their own research funds, including to cover their own salaries and those of staff and trainees. “Faculty members essentially function as a small business,” Jorge Chavarro, HSPH’s dean for academic affairs, told me. When researchers’ federal income dried up, they had to shrink those businesses. David Christiani, a cancer researcher, laid off four staff members; to pay the rest of his people, he told me, he’s blown through nearly half of the roughly $900,000 in discretionary funds that he’s accumulated since the 1990s. Roger Shapiro, an infectious-disease researcher, fired half of a research team in Botswana that has been studying the use of HIV antiretroviral drugs during pregnancy. Erica Kenney’s team will likely shrink from about a dozen people to three. And the school’s incoming cohort of Ph.D. students this year was half its usual size. (In 2018, I earned a Ph.D. in microbiology from Harvard’s Graduate School of Arts and Sciences. My thesis adviser, Eric Rubin, holds an appointment at the public-health school.)

When the funding crisis hit, Harvard distributed emergency funding across its schools. But what reached HSPH faculty offered little relief—in Christiani’s case, it was “too small to have kept anything going other than literally the freezers and some data management,” he told me. (The office of the Harvard University president did not respond to a request for comment.) The public-health school has put limits on the amount of discretionary funds that faculty can spend to keep their research going, to ensure the longevity of those resources during the crisis. “This is supposed to be the most flexible amount of money you have, so people try to save it for as long as possible,” one faculty member, who requested anonymity because they are not a U.S. citizen, told me. To plug the gaps, faculty have been frantically applying for nonfederal sources of money. But whereas grants from the NIH could total millions of dollars, many foundation grants come in the tens of thousands, not even enough to sustain a single postdoctoral fellow for a year.

As their professional world fell apart, many staff, students, and faculty waited for Baccarelli to articulate a clear path forward. He left the task of divvying up emergency funds to HSPH’s nine department chairs, and many researchers grew frustrated as different parts of the school scrambled to make ends meet in different ways. In one department, at least one faculty member has used personal funds to cover trainees’ travel expenses; the biostatistics department has pushed at least 10 Ph.D. students to do data-analysis externships in exchange for coverage of stipends. Across the school, three senior lecturers and three tenure-track junior faculty members have been notified that they will likely be terminated in 12 months, unless they secure alternative funding.

Some faculty members took those notices as a clear indication of HSPH’s more cutthroat future. One, who requested anonymity to speak about the school’s strategies, felt relatively secure because the school would “forfeit about $900,000 of overhead if they got rid of me,” they said. “When you become a financial liability, they cut you loose.” (Stephanie Simon, the school’s dean for communications and strategic initiatives, told me that prospects for future federal funding don’t motivate potential terminations, but also that grant reinstatements could prompt the school to rescind the notices for the tenure-track faculty.)

Baccarelli has repeatedly declined to say how many people the school has laid off this year, a common point of frustration among the HSPH scientists I spoke with. “So many of us have left, and you can’t tell us the impact?” said Matthew Lee, a former HSPH postdoctoral fellow who lost his position this summer because of the funding crisis. At the town hall, Baccarelli said that the university had asked him not to share those details. But he did share that HSPH had already cut $16 million from its operations budget, $7 million of which accounted for losses in personnel.

This was the path forward. In the brief statement he sent in response to my questions,  Baccarelli said that he had “developed and communicated a strong vision for the future of the school.” The statement linked to a strategic vision on the HSPH website, which acknowledged that the school “cannot maintain the status quo” but asserted that it would emerge as “a focused, resilient, and unambiguously world-class school of public health.” Left unsaid was that it would almost certainly be a smaller, less enterprising one.

In many ways, Baccarelli, who assumed the deanship at the start of 2024, has limited power: He can’t force the Trump administration to relinquish funds, or raid the pool of money that Harvard University holds centrally. Still, for months, many trainees and faculty have been calling for their dean to “stand up more forcefully” to the administration’s siege on science and defend his school’s most vulnerable researchers, Sudipta Saha, a Ph.D. student at HSPH and the vice president of Harvard’s graduate-student union, told me. Before the town hall, the school’s faculty council conducted a poll—unlike anything they’d seen before, several faculty told me—about the dean’s ability to do his job and the impact that the Tylenol debacle will have on the school. (The results have not been made public, but at the town hall, Baccarelli described the feedback as “very direct.”) Several of the faculty I spoke with defended the dean. “He did nothing wrong,” David Christiani told me; Karen Emmons and Erica Kenney emphasized that they were sympathetic to his plight. But most HSPH researchers I spoke with said they were deeply frustrated with him.

To his critics, Baccarelli’s recent actions have revealed how willing he is to play fast and loose with scientific certainty, at a time when much of the scientific establishment has denounced the Trump administration for doing exactly that. Baccarelli’s research focuses on topics such as air pollution and aging, but for years he has had a side interest in Tylenol use during pregnancy. In 2023, he gave expert-witness testimony on behalf of plaintiffs suing the maker of Tylenol, for which he was paid about $150,000 and spent some 200 hours preparing. In that testimony, Baccarelli asserted that taking the drug during pregnancy was not just linked to neurodevelopmental conditions such as autism but probably caused them. Neither his own research nor others’ has demonstrated such a strong conclusion, and the presiding judge picked up on that. Although Bacarelli was “the plaintiffs’ lead expert on causation,” she noted, he had co-authored a study in 2022 arguing that more research was needed before changing recommendations for using Tylenol during pregnancy. She ultimately excluded his testimony.

Baccarelli later seemed concerned about how he’d come off in the case, Beate Ritz, an epidemiologist at UCLA who studies neurodevelopmental conditions, told The Atlantic. According to Ritz, Baccarelli approached her at a conference and explained that he wanted to write a paper to clarify why he’d concluded that Tylenol should be used cautiously: He had been accused of being in it for money, and hoped to set the record straight. Ritz agreed to collaborate with Baccarelli. Their resulting manuscript, published in August, stopped short of saying that Tylenol use during pregnancy caused autism, but argued for a strong link between the two. Since the Trump administration thrust the study into the limelight, several other scientists have lambasted it, saying it overemphasizes evidence that supports the authors’ preset biases. (Ritz told The Atlantic that she asked Baccarelli and her other co-authors to correct an early version of the paper because it gave undue weight to lower-quality studies. But she stands behind the final version.)

When Kennedy called, Baccarelli wanted to promote his findings as any other researcher would, he said at the town hall: “As a scientist, I felt it was my responsibility to answer his questions.” He said he had not discussed the school’s financial situation with the administration. He also declined to attend the press conference on autism; instead, he released a statement that day noting that further research was needed to determine a causal relationship between the drug and autism, but advising “caution about acetaminophen use during pregnancy.” (Andrew G. Nixon, the director of communications for the Department of Health and Human Services, did not answer my questions about the administration’s association with Baccarelli, but acknowledged that some recent studies other than Baccarelli’s “show no association” between Tylenol and autism. The administration’s current guidance “reflects a more cautious approach while the science is debated,” he wrote.)

Baccarelli’s intentions were understandable, Emmons told me: “He doesn’t want to give up his science.” At the same time, though, “when you’re a dean, you’re always a dean.” Baccarelli’s assumption that he could selectively cleave himself from his role at the school, several HSPH researchers told me, was at best clueless and politically unsavvy. At worst, it represented reckless neglect of his duty as the primary steward of his school’s reputation and future. Even in a less politically charged climate, Baccarelli’s controversial paper and overzealous witness testimony might have blemished his reputation. Under current conditions, they cut against his own vision of leading a world-class institution—which requires proving to other parts of the research enterprise that the school has maintained its commitment to scientific rigor.

Prior to this year, many HSPH researchers saw the school’s reliance on federal funds as a strength. Government support was exceptionally stable, and HSPH researchers were exceptionally good at winning it. By Harvard’s standards, the school’s endowment was not its primary boasting point—public-health alumni don’t tend to become billionaires —and in times of wider financial turmoil, HSPH remained well insulated, Amanda Spickard, the associate dean for research strategy and external affairs, told me. Now, for the first time, the school is confronting the risks of sourcing half of its operating budget from a single entity.

The government was public health’s ideal funder in part because it could play science’s long game: funding research that might not be immediately profitable or even beneficial. That pact is now broken, and as the school seeks alternative routes, several researchers worry that some of the most important science will be the fastest to fall by the wayside. If, as some faculty suspect, more commercializable research is likelier to survive at the school, HSPH also risks abandoning a core public-health mission—meeting the needs of the underserved—and detracting from Baccarelli’s own strategic vision of building “a world where everyone can thrive.”

I asked multiple faculty members in top leadership roles how HSPH planned to deal with these imbalances. None of them delivered satisfying answers. Spickard and Jorge Chavarro both mentioned getting faculty to think more creatively about pursuing funding. Both also acknowledged that some faculty will lose out more than others. (Emmons, the interim department co-chair, suggested that making research more interdisciplinary could appeal to funders across a wider range of fields.) Chavarro also said that HSPH leadership planned to clarify which of the school’s decisions are temporary, emergency measures versus actions that will guide the school long-term. But when I asked for examples from each of those categories, he hesitated, and ultimately named only emergency actions.

Although more than a month has passed since a federal judge declared the grant terminations at Harvard illegal, money is only just starting to trickle back to the public-health school, and several faculty told me they still don’t have access to their funds. (An internal communication sent by Baccarelli last week indicated that the university was still “in the process of reconciling the payments.”) HSPH has also been cautious about lifting spending limits on its faculty, in part because Harvard worries that the administration will continue to appeal the judge’s decision, or otherwise renew or escalate its attacks, Christiani told me. Late last month, HHS referred Harvard for debarment, which would block the institution from receiving any federal funds in the future.

Many HSPH scientists expect that this is far from the end of the most difficult era of their career. A few pointed toward William Mair, who studies the links between metabolic dysfunction and aging, as one scientist already stretching to do the kind of interdisciplinary work that might help the school survive. In recent months, Mair has been reaching out to colleagues across the school to collaborate on a healthy-aging initiative that will draw on multiple public-health fields. But Mair, too, has had to whittle his lab down to just five people and shelved many of the team’s more ambitious experiments. Originally from the United Kingdom, he came to the U.S. nearly 20 years ago for his postdoctoral fellowship, then stayed in the country that he felt was the best in the world at supporting science. (He became a citizen earlier this year.) “I don’t want to leave this community,” he told me. “But every minute I stay here at Harvard is currently detrimental to my own science career.” The university that once promised to buoy scientific aspirations now feels like a deadweight.

Tom Bartlett contributed reporting.

Politicians sometimes do silly things to draw attention to their favorite issues. In 2015, then-Senator Jim Inhofe famously brought a snowball onto the floor of Congress to argue against the existence of climate change. Representative Marjorie Taylor Greene toted a balloon to the 2023 State of the Union to mock the Biden administration’s handling of a Chinese spy craft. But in terms of sheer spectacle, few can top Jared Polis and his “forbidden” feast.

In 2015, Polis, then a Democratic congressman from Colorado, dined on hemp scones and washed them down with a glass of raw milk. The point was to highlight the purported absurdity of the government’s rules for what people can and cannot eat. He was pushing Congress to pass the Milk Freedom Act, a bill that aimed to make unpasteurized dairy easier for Americans to buy. At the time, the beverage was a delicacy for hippies in cities like Boulder, not a rallying cry for Robert F. Kennedy Jr. and the “Make America Healthy Again” movement. In May, the health secretary, who has said he drinks only raw milk, downed a shot of the stuff during a podcast taping in the White House.

Polis, now the governor of Colorado, still speaks fondly of his stunt. “Raw milk is relatively low-risk compared to many things that people choose to do in their everyday lives,” he told me recently. “We should lean into freedom,” he said, and allow “people to make their own decisions on what to eat.” (For the record, raw milk can lead to serious cases of foodborne illness.) I spoke with Polis not just to ask him about unsafe milk. Few prominent Democratic politicians want anything to do with RFK Jr. and his agenda to remake American health; Polis is the exception.

From the moment last year that Kennedy was picked to lead the Department of Health and Human Services, Polis has taken a different route than the rest of his party. Many quickly came out and said that Kennedy’s past anti-vaccine activism disqualified him from the position. “I’m excited by the news that the President-Elect will appoint @RobertKennedyJr,” Polis posted on X. “He helped us defeat vaccine mandates in Colorado in 2019 and will help make America healthy again.” During Polis’s first year as governor, in 2019, he allied with Kennedy in opposing a bill that would have made it more difficult for parents to get vaccine exemptions for their kids. Since Kennedy’s confirmation, Polis has worked directly with the Trump administration. In August, he got permission from Washington to ban the purchase of soda using food stamps in Colorado, a controversial policy that Kennedy has repeatedly held up as one of his priorities. So far, 12 states have signed on to test the idea—Colorado is the only one that is run by a Democrat.

[Read: Republicans are right about soda]

When I asked Polis why he supports RFK Jr.’s soda agenda, his response was scattered. He told me that if people really want to drink soda, they still can, just like how Coloradans are free to buy marijuana or alcohol. “People with their own money can make whatever decisions they want,” he said. But the government “shouldn’t be subsidizing cavities and diabetes,” he added. He also claimed that banning soda from being purchased with food stamps was an act of “moral integrity.” The food-stamps program—formally the Supplemental Nutrition Assistance Program—is supposed to support nutrition, he said, and “soda has zero nutritional content.”

The response underscores the eclectic nature of Polis’s politics. While in Congress, he was at one point the only Democratic member of the House Liberty Caucus—a home of staunch libertarianism—but he also sat on the Congressional Progressive Caucus. As governor, he has taken a decidedly populist, and at times combative, approach to reforming the health-care industry; within a month in office, he set up an aptly named Office of Saving People Money on Healthcare. Polis’s varied political beliefs make him a lot like Kennedy, who was a Democrat until 2023. Kennedy has managed to bridge three specific tendencies—toward fiscal conservatism, social liberalism, and a belief that improving societal health is a moral imperative—and present them as one overarching ideology. During his confirmation hearing in January, Kennedy struck a similar tone in explaining the MAHA agenda. “This is not just an economic issue. It is not just a national-security issue. It is a spiritual issue, and it is a moral issue,” Kennedy said. “We cannot live up to our role as an exemplary nation, as a moral authority around the world, when we are writing off an entire generation of kids.” (An HHS spokesperson did not respond to a request for comment.)

Polis, in other words, may be the closest thing there is to a MAHA Democrat. When I asked him what he thought of that title, he pushed back, noting that MAHA is a bit too close to MAGA. “Unfortunately it’s only one letter away from an acronym that is something I’m staunchly opposed to,” he said. The governor also went out of his way to distance himself from Kennedy’s recent moves to roll back vaccine access. Kennedy’s decisions—namely his push to narrow approval of COVID vaccines—have “slanted the field against individual choice,” he explained. Although Polis opposes vaccine mandates, he is not an anti-vaxxer. Last month, the governor bucked Kennedy by signing an order allowing pharmacists to continue giving COVID shots without a prescription. “We will not allow unnecessary red tape or decisions from Washington to keep Coloradans from accessing life-saving vaccines,” he wrote on X at the time. Yesterday, Polis joined more than a dozen other Democratic governors to form a public-health alliance to counter RFK Jr.

Polis’s positioning seems politically savvy. Kennedy’s focus on tackling obesity and chronic disease by overhauling the American diet is popular—much more so than his policies limiting vaccines. (According to one poll by Healthier Colorado, a nonpartisan group, residents in the state support banning the purchase of soda with SNAP benefits—albeit by a narrow margin.) And by not openly identifying with MAHA, Polis avoids alienating himself from Colorado’s Democratic voters. “They think of it as Trump’s label,” Celinda Lake, a Democratic pollster who has surveyed voters on the topic, told me about MAHA. “If you put Trump in front of Cheez-Its, Democrats wouldn’t like it.”

Polis is not the only Democrat trying to do a similar dance. Jesse Gabriel, a Democratic state lawmaker in California who spearheaded the state’s recent effort to phase out ultra-processed foods in schools—another Kennedy priority—has sought to draw distinctions between his efforts and those of the administration. “Here in California, we are actually doing the work to protect our kids’ health, and we’ve been doing it since well before anyone had ever heard of the MAHA movement,” Gabriel said in a recent press conference.

Before RFK Jr. came along, Democrats were indeed the party of healthier diets. As my colleague Tom Bartlett recently wrote, “Let’s Move,” Michelle Obama’s campaign to reduce childhood obesity, has a lot of similarities with MAHA. Kennedy has pressured companies to stop using synthetic food dyes, prompting red states to pass food-dye regulations of their own. They are following in the footsteps of California, which was the first state to ban a dye, Red 3, back in 2023.

[Read: RFK Jr. is repeating Michelle Obama’s mistakes]

The GOP’s embrace of these food policies has put Democrats in an odd position. The party hasn’t quite figured out how to interact with the MAHA movement. Democrats might be serious about tackling chronic disease, but they’ve ceded that issue to Kennedy in recent months, likely because of trepidation about being seen as allies of the secretary. Democratic strategists I spoke with emphasized that their party needs to figure out a message that demonstrates it is more serious than the Trump administration in attacking these issues—especially one that can appeal to certain groups (namely suburban moms) that are gravitating to the MAHA message.

Even Polis, who is willing to go further than most other Democrats in aligning himself with RFK Jr., has struggled to articulate his own alternative to MAHA. (When I asked how he’d like his record as governor to be remembered, if not as one of a MAHA Democrat, he simply said, “Effective.”) As we spoke, it often felt like Polis and I were talking past each other. When I asked him why other Democratic governors weren’t pursuing a ban on buying soda using food stamps, he talked about his own opposition to Republicans’ recent cuts to SNAP. For the most part, Polis didn’t want to talk about Kennedy; he wanted to talk about his health-care achievements. Therein lies the predicament for Polis, and other members of his party: RFK Jr. has so quickly laid claim to issues of food and nutrition that it’s difficult to talk about them at all without invoking the health secretary.

It was a strange weekend for employees of the Centers for Disease Control and Prevention, to say the least. On Friday, hundreds of workers at the agency, many of whom have been furloughed since the federal government shut down on October 1, found out they were being fired as part of widespread layoffs across federal agencies. Less than a day later, a curt follow-up email landed in many of their inboxes informing them that they weren’t being let go after all. No explanation, no apology.

Staffers spent the weekend trading calls and texts, trying to piece together who had been axed, who had been spared, and, most puzzling, why. “There’s really no strategy that they’re using, no real approach—at least any thoughtful approach—to how they are doing these cuts,” Daniel Jernigan, who directed the National Center for Emerging and Zoonotic Infectious Diseases before he resigned in August, told me.

I spoke with half a dozen current and former CDC officials, and foremost on their mind was what they described as the ineptitude of the botched downsizing. For example, almost all editors of the “Morbidity and Mortality Weekly Report,” which the CDC has published since 1960, were among those notified on Friday night that their work was “unnecessary or virtually identical to duties being performed elsewhere in the agency.” By Saturday, several CDC sources told me, they had their jobs back.

Andrew Nixon, the communications director for Health and Human Services, wrote in an email that “the employees who received incorrect notifications were never separated from the agency and have all been notified that they are not subject to the reduction in force.” He declined to answer specific questions about layoffs.

Many of the cuts that have stuck so far seem to conflict with the administration’s stated aims. A branch of the National Center for Health Statistics that coordinates an annual survey of the dietary habits of Americans—a topic presumably of interest to those attempting to make America healthy again—was eliminated, according to its former chief, David Woodwell. Secretary of Health and Human Services Robert F. Kennedy Jr. has accused the agency’s vaccine advisory board of being “plagued with persistent conflicts of interest” and insisted that such conflicts must be eliminated in order to restore Americans’ trust in the CDC. And yet, the agency’s human-resources office—which handled ethics issues—has been scrapped, according to Alt CDC, a team of anonymous public-health officials that has been crowdsourcing updates on the firings. “I would think, if you are monitoring for conflicts of interest, particularly when you’ve accused the agency of having them, you would want to have an office to do that,” Debra Houry, who was the CDC’s chief medical officer until she resigned in August, told me.

One veteran researcher who still has his job (and, like other public-health workers I spoke with for this story, requested anonymity for fear of losing it) told me he believes that Kennedy’s ultimate goal is to “silence the scientific voice of career CDC scientists.” And indeed, perhaps the clearest result of the firings is that they appear to consolidate Kennedy’s power over the agency. Every member of the CDC’s Washington office, which serves as a conduit between the agency’s Atlanta headquarters and Capitol Hill, was fired; barring a second round of reversals, that office appears to be closed. The person managing Alt CDC’s Bluesky feed yesterday, who identified herself as an epidemiologist in a state health department, told me she’d heard that CDC personnel who normally share information with state officials during outbreaks have been eliminated. “So the only contact they have is going to HHS—is going to RFK,” the epidemiologist told me.

For CDC scientists who received layoff notices, the past few days have been disorienting. I spoke with one longtime scientist at the agency who learned on Friday that she would lose her job but then, on Saturday, received an email with the subject line “Rescission of Previous Notice of Reduction in Force.” In other words, her job—deemed redundant the day before—was again apparently necessary. She told me that her short-lived firing “felt like the culmination of eight months of abuse” under the Trump administration. She was particularly distressed by Kennedy’s June decision to fire the entire vaccine advisory board and stack it with his allies, but recent months have offered even more opportunities for stress and indignation. In August, a gunman who blamed COVID vaccines for his depression opened fire on the agency’s Atlanta campus, killing a police officer. (The veteran scientist told me she shopped online for a bulletproof vest to wear to work, though she ended up not buying one.) Weeks later, Kennedy pushed out the agency’s newly confirmed director, Susan Monarez. Three top CDC officials—Houry, Jernigan, and Demetre Daskalakis, the former director of the National Center for Immunization and Respiratory Diseases—subsequently resigned in protest.

[Read: ‘It feels like the CDC is over’]

On Friday, hours before layoff notices went out, Jim O’Neill, who took over as acting CDC director after Monarez’s ouster, posted two photos on X of what appeared to be a bald eagle soaring over the Capitol building. His message: “Good morning we are going to win.” For the people I spoke with who remain at the CDC, what exactly the acting director hopes to win—and for whom—isn’t clear, in part because they haven’t heard anything else from O’Neill. On Friday, instead of discussing the growing turmoil at the agency he oversees, Kennedy posted on X congratulating President Donald Trump for his new drug-pricing deal and defending comments he made at a recent Cabinet meeting linking autism with the use of Tylenol after circumcision. As of this evening, he still hadn’t addressed the firing about-face.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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