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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.

At a press conference today, President Donald Trump dispensed one clear piece of medical advice to American parents in a rambling, repetitive monologue: Don’t. Take. Tylenol. He told pregnant women that they could help keep their children safe from autism by not taking the drug whenever they could avoid it (“fight like hell,” he instructed). He advised parents not to give Tylenol to their young children. He denounced giving the hepatitis B vaccine to infants and suggested that parents space out their children’s immunization schedule. (“They pump so much stuff into those beautiful little babies, it’s a disgrace,” he said.) He declared that children ideally should be given the measles, mumps, and rubella vaccines separately, though such individual shots are not available in the United States. “This is based on what I feel,” the president said.

Trump had been hinting at his big announcement for weeks, and it was evident that he wasn’t interested in making sure the contents had passed through the normal research process. “I don’t want to wait any longer. We don’t need anything more. And if it’s wrong—it’s not going to be wrong, but—if it is wrong, it’s fine. We have to do it,” Trump told the audience at a dinner for the American Cornerstone Institute on Saturday. Today, instead of opting for measured guidance, or urging additional research, Trump borrowed a strategy from his health secretary, Robert F. Kennedy Jr.: pushing ahead with a sensational conclusion based on a handful of disputed studies.

Researchers have been studying possible causes of autism for decades, and they generally dismiss singling out one culprit like a drug or a vaccine ingredient. (Instead, the consensus is that genetics play a large role, along with an array of environmental factors.) Some studies have found a possible association between acetaminophen and neurodevelopmental disorders. In 2015, the FDA issued a notice about a possible link between prenatal Tylenol use and ADHD, though it also mentioned that the cited studies had design flaws. Last month, Andrea Baccarelli, the dean of Harvard’s school of public health, published a review of other studies in which he and his co-authors concluded that acetaminophen use during pregnancy is associated with neurodevelopmental disorders, including autism, and that pregnant women should be advised to limit their use of the drug. (Baccarelli was invited to appear at today’s announcement but did not attend, a Harvard spokesperson told me. In a statement sent to reporters shortly before the White House announcement, he wrote that his August review suggests the “possibility of a causal relationship” between Tylenol and autism, but also noted that acetaminophen is “an important tool for pregnant patients and their physicians.”)

[Read: RFK Jr. is neglecting a legitimate autism concern]

Two recent large studies, meanwhile, challenge any connection at all. A Swedish study, published last year, analyzed the health records of more than 2 million children and found that acetaminophen use was not associated with autism. A study of more than 200,000 Japanese children, published earlier this month, likewise didn’t find any meaningful association. That paper suggested that links in other studies could be explained, at least in part, by “misclassification and other biases.” A spokesperson for Kenvue, the company that makes Tylenol, told me in an email, “We believe independent, sound science clearly shows that taking acetaminophen does not cause autism. We strongly disagree with any suggestion otherwise and are deeply concerned about the health risks and confusion this poses for expecting mothers and parents.”

None of that nuance was aired during the announcement. Instead Trump professed to feel “very certain” about the Tylenol theory, and repeatedly warned Americans off the drug. This is not how science—or public health—normally works. The president of the United States doesn’t tease that he’s figured out the cause of a disorder before the research has been done to support that conclusion. Nor does he warn the American people against a common medication or the childhood-vaccine schedule without detailed evidence of his reasoning, or the full support of his staff. “It may be stronger from me than from the group,” he said in his speech, referring to Kennedy, FDA Commissioner Marty Makary, NIH Director Jay Bhattacharya, and Mehmet Oz, his head of Medicare and Medicaid. “They are waiting for certain studies. I don’t—I just want to say it like it is.” (Trump’s spokesperson, Kush Desai, wrote in an email that “the Trump Administration does not believe popping more pills is always the answer for better health” and that “there is mounting evidence finding a connection between acetaminophen use during pregnancy and autism.” The Department of Health and Human Services did not respond to a request for comment.)

Trump also went further than his deputies in calling out even fringier theories of autism. Of all the speakers at the White House today, Trump was the most explicit in blaming vaccines for poor health outcomes—a notion that has been repeatedly debunked—and he did so at length, at one point going on an extended tangent about a worker at Trump Tower whose son was supposedly “fried” by a fever following a childhood immunization. As I reported earlier this month, Kennedy has been in regular contact with a former Duke University researcher, William Parker, who believes that Tylenol given to young children is mostly responsible for autism. (Parker’s theory is such an outlier that none of the autism researchers I spoke with had heard of it, or him.) Today, Kennedy, Bhattacharya, Makary, and Oz didn’t bring up Parker’s theory, though Trump seemed to endorse it. “Don’t have your baby take Tylenol,” Trump said.

[Read: RFK Jr.’s calls with a scientist who says kids get autism from Tylenol]

Ever since Trump announced that his administration would find the cause of autism within months, researchers have feared that the team would jump to unsupported conclusions. But Trump hardly seems to care if he’s wrong. Besides, he repeatedly insisted, eschewing Tylenol during pregnancy has “no downside.” (Tylenol is considered the safest fever reducer available for pregnant women.)

During today’s announcement, Kennedy at least acknowledged the trade-offs inherent in scaring pregnant Americans off Tylenol, and allowed that, sometimes, using it is unavoidable. “The FDA also recognizes that acetaminophen is often the only tool for fevers and pain in pregnancy, as other alternatives have well-documented adverse effects,” Kennedy noted in his remarks. “HHS wants therefore to encourage clinicians to exercise their best judgment in the use of acetaminophen for fevers and pain in pregnancy by prescribing the lowest effective dose and shortest necessary duration, and only when treatment is required.” (Today, the FDA posted an even more measured notice to physicians, signed by Makary, that underscored a possible association between acetaminophen and autism is “an ongoing area of scientific debate.”) Trump, meanwhile, repeatedly instructed pregnant women to “tough it out.” Sowing doubts regarding vaccines, going all in on fringe theories, and opting for extreme positions instead of embracing nuance: At MAHA’s big reveal, Trump seemed determined to steal Kennedy’s spotlight.

Frank Charles, a pet-resort owner and former five-term mayor of St. Augustine, Florida, wanted a tattoo. He just wasn’t sure that he could take the pain. Then he started seeing advertisements for a place in Miami called Sedation Ink, which offers clients the attention of its licensed anesthesiologists. “You’ll enjoy a deep and peaceful sleep, allowing our artists to create breathtaking designs on your skin,” the studio’s website reads. “Join us and experience the future of tattooing, where pain is eliminated, and dreams become reality.”

Charles is no stranger to elective anesthesia, he told me. He’d gone under in the past for a nose job, a chin-reconstruction surgery, and hair transplants (twice). So the idea of being inked up while unconscious didn’t bother him at all. As for the actual experience, well, it’s hard to say. In photos of the operation, his face is covered with a dark and heavy cloth. (He looks a little bit like someone being waterboarded.) The only thing he can remember is a vision that he had while on the table. “I dreamed of waking up,” he said, “and the tattoo was in the wrong location.” It was not: Eight hours and $29,000 later, Charles came back to his senses with a picture of a blue-eyed, bejeweled lion on his right pectoral, which morphed into an American flag and then a bald eagle along his forearm (also part of this tattoo: the Statue of Liberty and the preamble of the U.S. Constitution).

This design may now belong to Charles and Charles alone, but the way that he received it—fully zonked on fentanyl and propofol—has been gaining popularity, especially among the young and rich. Two years ago, the Dallas Cowboys quarterback Dak Prescott went under for almost half a day, during which time multiple artists worked together on producing a full leg sleeve depicting, among other things, a Pegasus, a moose, the Dallas skyline, and a firm handshake. More athletes followed, getting very large tattoos that would otherwise have needed to be created across multiple sessions in a parlor, with bouts of healing in between—an arduous process that can take many weeks to complete. Even the singer Post Malone, one of pop culture’s most conspicuously tattooed celebrities, has gotten work done while medically unconscious.

To a certain type of person, the appeal of these procedures is self-evident: Getting a needle jabbed into your skin hurts. But for another type of person—one who feels personally, professionally, or even ideologically invested in the culture and traditions of tattooing—this trend will be unnerving. Blasphemous, even.

Getting tattooed is a way of “teaching you something about what you’re capable of,” Don Ritson, an artist based in Winnipeg, Canada, told me. “In this postmodern world where we don’t have these same feats of strength, it gives us an opportunity to prove to ourselves that we’re capable on some level.” As someone with a few dozen tattoos, each of which was at least a little painful to receive, I appreciate that argument. But I also balk at the idea that having a doodle dug into your body is a measure of your prowess. I don’t think anyone would take a look at my tattoo referencing a joke from the sitcom Frasier and think, Wow. What a strong guy. I wonder what feats of strength he’s capable of? Even the outward projection of physical strength—something I also value, and work to maintain with waffling levels of commitment—seems preposterous in a world of pricey gyms and personal trainers.

For Ritson, who delivered a recent TEDx Talk called “Marked Without Feeling: What Tattooing Loses Under Anesthesia,” the experience of pain is a stamp of one’s personal resolve, and without it, tattooing risks losing whatever remaining connections it has to various underground subcultures. The anesthetized tattoo is “tied to these athletes or actors, people who have money, but they don’t have time,” he told me. “They kind of want to skip the line a little bit. They want the thing, but they can’t actually commit to doing what it takes to get the thing.”

Tattoo culture has in many other ways been normalized and gentrified over the past few decades. Once the province of bikers and sailors and scumbags, tattoos now appear on nearly one-third of all Americans. Modern shops look less like punk bars than pricey hair salons or smartphone showrooms. But tattoos like Frank Charles’s, produced in an operating theater at much higher cost, would seem to be the culmination of this trend. If a standard tattoo parlor might refuse service only when a customer is clearly underage or way too drunk, or both at once, the people who come into Sedation Ink in Miami are screened as if they’re getting rhinoplasty or some other cosmetic procedure. They need “a full medical clearance from a physician,” Noel Pace, a health-care attorney who works with the studio, told me. “It’s like going into a surgery.” Indeed, Sedation’s customers are described not as clients but as “patients.”

For “Sweet” Dave O’Connor, a tattoo artist in Hamilton, Ontario, who has done a number of my tattoos, the transformation of a parlor into a medical clinic negates its social meaning. O’Connor works in what’s called the “traditional” style, characterized by bold outlines, a crisp color palette, and familiar tattoo-shop imagery: anchors and horseshoes and vipers and clipper ships and jaguar heads and whatnot. His thinking about the enterprise is similarly old-school. The move toward tattooing under anesthesia is “the complete end-game of the ‘Customer is always right’ attitude,” he told me. “The one common thread through every tattoo, regardless of the size, shape, style, the person getting it, is that there’s pain involved. It’s the one thing that unifies all tattoos. And if you take that out of it, then what is there? You didn’t do anything for it. Other than pay for it. And take a nap.”

[Read: The new meaning of tattoos]

Other tattooers aren’t quite so ruffled by the practice. The L.A.-based artist Romeo Lacoste has tattooed celebrities including Kendrick Lamar, Ariana Grande, and Justin Bieber. He has tattooed backstage at concerts. He has even tattooed on a private jet. He told me that he regards tattooing in a surgical room with the aid of anesthetic as just another step in the evolution of his art. There are practical benefits too. Without sensitive patients squirming under the buzz of the needle, he said, he’s able to get cleaner work done more efficiently. He also enjoys collaborating with other artists on a single, large piece of art. “A lot of those guys want to complain now,” he told me, but their fixation on the old way of doing things will soon be left behind. “The mentality that you have to earn your pain is just going to get more watered down. Eventually, I don’t even think that mentality will exist anymore.”

At the very least, that mentality will face commercial pressure to adapt. In July, shortly after the heavy-metal singer Ozzy Osbourne’s passing, I went into a small tattoo shop around the corner from my house. Since I was a teenager, I’ve told myself that I’d get a tattoo of his name when he died. Hellbent on making good on the dopey promise of my younger self, I forked over $50 to have the letters OZZY inked onto my forearm. During the (very brief) session, I asked the artist what he thought about the entry of anesthetics into tattoo culture. He said he had compunctions—in theory. But he also copped to the fact that he’d be glad to take the daily rate of $10,000 that one gets to do that kind of work.

[Read: Tattoos do odd things to the immune system]

The allure—for artists and their clients alike—is clear enough, even if the new approach carries certain hazards. Earlier this year, a 45-year-old Brazilian social-media star named Ricardo Godoi went into a private hospital for a full-back tattoo while sedated and intubated. Near the start of the procedure, he went into cardiac arrest and died. Although dozens of cases of death from anesthesia are recorded every year in the U.S., the risk to any individual is very low: Fewer than one anesthesia-related mortality occurs for every 100,000 procedures, according to a 2018 study. And the notable tattoo parlors that offer this procedure—Sedation Ink, as well as The California Dream Tattoo and Ganga Tattoo in Los Angeles—tend to operate more like medical centers than studios. At some studios, artists dress in surgical scrubs and are overseen by a board-certified anesthesiologist.

But maybe even just that teeny-tiny chance of death can make the anesthetized tattoo a test of mettle, too, in the way that Ritson meant: The added risk becomes a counterbalance for the loss of pain, on some kind of toughness scale. Or perhaps the rise of sedation-assisted tattoos will serve to raise the floor for every other form of body art, no matter how routine, if it comes without the benefit of propofol. Sure, you may have gotten a pencil-thin etch of a wheat sheaf inked into your arm at a shop that looks like an Apple store. But at least you were there. At least it felt like something. At least it hurt.

As far as sticker price goes, the recommended vaccines for kids in the United States do not come cheap. The hepatitis-B shot, given within the first hours of life, can be purchased for about $30. The rotavirus vaccine costs $102 to $147 a dose. A full course of the vaccine that protects against pneumonia and meningitis runs about $1,000.

Virtually all children receive these shots for free. The federal government legally requires most insurance to cover the roughly 30 different shots for kids, without a co-pay. Kids who are on Medicaid or who don’t have insurance coverage can get free shots as well, thanks to a CDC program known as Vaccines for Children. Among public-health experts, VFC, as it’s commonly known, is widely seen as an unmitigated success. After the program was created in 1994, “disease went down, and life was a lot simpler for the families,” Anne Schuchat, a former top CDC official, told me. Roughly half of American children are eligible to receive vaccines through VFC.

That ease and simplicity may be about to change. This week, the CDC’s Advisory Committee on Immunization Practices (ACIP)—which guides America’s vaccine policy—convened for just the second time since Robert F. Kennedy Jr. fired the entire panel and appointed new members, some of whom lack vaccine expertise or have expressed anti-vaccine views (or both). The meeting was chaotic, contentious, and plagued by indecision. But the votes it got through are starting to point toward a shifting, more fractured landscape for kids’ access to vaccines.   

Yesterday, ACIP voted to remove the joint measles-mumps-rubella-varicella (MMRV) vaccine from the childhood-immunization schedule for children under 4, and instead recommended that kids get two separate shots: one for measles, mumps, and rubella, and another for varicella. This morning, the panel also voted to remove the combination shot from the VFC program. Both votes were motivated by a concern about the safety of the vaccine, including an elevated risk of febrile seizures. (As the CDC’s website points out, these seizures can be stressful for families, though most children fully recover.)

The effect of the move away from the combination vaccine will be limited, because most children in America already receive the separate shots. However, one group would bear the brunt of the changes more than others: children on VFC. Some parents opt for the convenience of a single shot, and those who are covered by private insurance may still be able to get it. Although private insurers will no longer be required to cover the joint MMRV vaccine free of charge, they are already pledging to continue with business as usual: On Tuesday, AHIP, a lobbying group that represents the health-insurance industry, announced that its members will continue to cover shots under the pre-ACIP vaccine schedule until the end of 2026. (A spokesperson for AHIP declined to comment on what happens after that.) Parents could, hypothetically, also pay for these vaccines out of pocket. The disproportionately poor children covered by VFC do not have the same kind of wiggle room. What shots they can get for free from the program, and when, are directly tied to ACIP’s recommendations. (A Department of Health and Human Services spokesperson told me that the move will not increase vaccine inequality but did not explain further.)

Mainly, the changes that ACIP is currently considering would create inconveniences for poor families—more trips to the doctor, more needle pricks. But as my colleagues Tom Bartlett and Katherine J. Wu wrote yesterday, the change to the MMRV policy, while minor, can send the message that vaccines are dispensable. The committee also discussed delaying when kids should get the hepatitis-B shot but ultimately decided to table an anticipated vote on whether they would recommend the delay. (Kennedy has intimated that the hepatitis-B vaccine may cause autism, despite the lack of data showing a link between the two.) If the hepatitis-B vaccine or another shot is removed entirely from the schedule, that will immediately hit kids served by VFC.

Beyond potentially serious disparities, more alterations to childhood vaccines would likely cause more confusion. Kennedy’s recent changes to COVID-vaccine policy, which narrowed the approval for COVID shots so that they are recommended only for people over 65 or who have certain underlying conditions, left many Americans unsure about if and how they could get one. (Today, ACIP also voted that every person should consult with a clinician before receiving a COVID shot.) Americans who rely on VFC may soon have to similarly figure out what shots they can get, and where. The confusion over COVID shots “is a small glimpse of what may happen” if ACIP moves forward with changes to the childhood-vaccine schedule, Schuchat told me.

In the event that a vaccine is removed from the schedule, the experts I spoke with remain hopeful that some entity, such as a state health department, a community health center, or philanthropy, would step in to provide uninsured kids with free shots. But who or what, besides the federal government, could provide vaccines at the necessary scale is an open question. “It’s going to require some sort of extraordinary effort to provide that access,” Richard Hughes IV, a professorial lecturer in law at the George Washington University Law School, told me. VFC works so well not only because it provides vaccines free of charge but also because it is designed to ensure that doctors always have a supply of vaccines on hand—the CDC purchases vaccines and then provides them for free to doctors, who then dole them out to children in need.

Medicaid could still provide some backstop for the poorest children, experts told me, but a likely scenario seems to be a system in which private insurers continue to cover vaccines, while poor children are left behind. Such a scenario is “the definition of a health-care disparity,” Christoph Diasio, a pediatrician in North Carolina, told me.

America has seen this type of vaccine inequity before. Beginning in 1989, measles tore through several cities—including Los Angeles, Houston, and Chicago—precisely because many low-income children were unable to access the vaccine. “A big part of the problem was, kids were in the doctor’s office, but because they weren’t insured, the doctors were referring the family to the health department,” Schuchat told me. “That extra visit was something that was not easy for parents to find the time to get to.” Researchers estimated that nonwhite preschoolers were seven to 10 times more likely to contract the virus than white children. It was this outbreak that led to the formation of the VFC program in the first place.

In his time as secretary of Health and Human Services, Kennedy has claimed that reforms to Medicaid would improve the program, despite projections from the Congressional Budget Office that the change would kick millions off of the safety-net program. He has decimated minority-health offices in his department in the name of government efficiency. And he has said that vaccine changes will be made in line with the latest science, despite overwhelming evidence to the contrary. Now, in the name of following the science, Kennedy is on the cusp of creating a two-tiered vaccine system.