Medical News

Four and a half years ago, fresh off the success of Operation Warp Speed, mRNA vaccines were widely considered—as President Donald Trump said in December 2020—a “medical miracle.” Last week, the United States government decidedly reversed that stance when Secretary of Health and Human Services Robert F. Kennedy Jr. canceled nearly half a billion dollars’ worth of grants and contracts for mRNA-vaccine research.

With Kennedy leading HHS, this about-face is easy to parse as yet another anti-vaccine move. But the assault on mRNA is also proof of another kind of animus: the COVID-revenge campaign that top officials in this administration have been pursuing for months, attacking the policies, technologies, and people that defined the U.S.’s pandemic response. As the immediacy of the COVID crisis receded, public anger about the American response to it took deeper root—perhaps most prominently among some critics who are now Trump appointees. That acrimony has become an essential tool in Kennedy’s efforts to undermine vaccines. “It is leverage,” Dorit Reiss, a vaccine-law expert at UC Law San Francisco, told me. “It is a way to justify doing things that he wouldn’t be able to get away with otherwise.”

COVID revenge has defined the second Trump administration’s health policy from the beginning. Kennedy and his allies have ousted prominent HHS officials who played key roles in the development of COVID policy, as well as scientists at the National Institutes of Health, including close colleagues of Anthony Fauci, the former director of the National Institute of Allergy and Infectious Diseases (and, according to Trump, an idiot and a “disaster”). In June, Kennedy dismissed every member of the CDC Advisory Committee on Immunization Practices (ACIP), which has helped shape COVID-vaccine recommendations, and handpicked replacements for them. HHS and ACIP are now stacked with COVID contrarians who have repeatedly criticized COVID policies and minimized the benefits of vaccines. Under pressure from Trump officials, the NIH has terminated funding for hundreds of COVID-related grants. The president and his appointees have espoused the highly disputed notion that COVID began as a leak from “an unsafe lab in Wuhan, China”—and cited the NIH’s funding of related research as a reason to restrict federal agencies’ independent grant-awarding powers.

This administration is rapidly rewriting the narrative of COVID vaccines as well. In an early executive order, Trump called for an end to COVID-19-vaccine mandates in schools, even though few remained; earlier this month, HHS rolled back a Biden-era policy that financially rewarded hospitals for reporting staff-vaccination rates, describing the policy as “coercive.” The FDA has made it harder for manufacturers to bring new COVID shots to market, narrowed who can get the Novavax shot, and approved the Moderna COVID-19 vaccines for only a limited group of children, over the objections of agency experts. For its part, the CDC softened its COVID-shot guidance for pregnant people and children, after Kennedy—who has described the shots as “the deadliest vaccine ever made”—tried to unilaterally remove it. Experts told me they fear that what access remains to the shots for children and adults could still be abolished; so could COVID-vaccine manufacturers’ current protection from liability. (Andrew Nixon, an HHS spokesperson, said in an email that the department would not comment on potential regulatory changes.)

The latest assault against mRNA vaccines, experts told me, is difficult to disentangle from the administration’s pushback on COVID shots—which, because of the pandemic, the public now views as synonymous with the technology, Jennifer Nuzzo, the director of the Pandemic Center at Brown University School of Public Health, told me. Kennedy and his team justified the mRNA cuts by citing controversial research compiled by COVID critics, and suggesting—in contrast to a wealth of evidence—that the vaccines’ risks outweigh their benefits, and that they “fail to protect effectively against upper respiratory infections like COVID and flu.” And he insisted, without proof, that mRNA vaccines prolong pandemics. Meanwhile, NIH Director Jay Bhattacharya argued that the cancellations were driven by a lack of public trust in the technology itself. In May, the Trump administration also pulled more than $700 million in funds from Moderna that had initially been awarded to develop mRNA-based flu vaccines. The mRNA funding terminated so far came from HHS’s Biomedical Advanced Research and Development Authority; multiple NIH officials told me that they anticipate that similar grant cuts will follow at their agency. (In an email, Kush Desai, a spokesperson for the White House, defended the administration’s decision as a way to prioritize funding with “the most untapped potential”; Nixon echoed that sentiment, casting the decision as “a necessary pivot in how we steward public health innovations in vaccines.”)

COVID is a politically convenient entryway to broader anti-vaccine sentiment. COVID shots are among the U.S.’s most politicized vaccines, and many Republicans have, since the outbreak’s early days, been skeptical of COVID-mitigation policies. Although most Americans remain supportive of vaccines on the whole, most Republicans—and many Democrats—say they’re no longer keen on getting more COVID shots. “People trust the COVID vaccines less,” Nuzzo told me, which makes it easy for the administration’s vaccine opponents to use attacks on those vaccines as purchase for broader assaults.

For all their COVID-centric hype, mRNA vaccines have long been under development for many unrelated diseases. And experts now worry that the blockades currently in place for certain types of mRNA vaccines could soon extend to other, similar technologies, including mRNA-based therapies in development for cancer and genetic disease, which might not make it through the approval process at Kennedy’s FDA. (Nixon said HHS would continue to invest in mRNA research for cancer and other complex diseases.) Casting doubt on COVID shots makes other vaccines that have been vetted in the same way—and found to be safe and effective, based on high-quality data—look dubious. “Once you establish that it’s okay to override something for COVID,” Reiss told me, “it’s much easier to say, ‘Well, now we’re going to unrecommend MMR.’” (Kennedy’s ACIP plans to review the entire childhood-immunization schedule and assess its cumulative effects.)

Plenty of other avenues remain for Kennedy to play on COVID discontent—fear of the shots’ side effects, distaste for mandates, declining trust in public health and medical experts—to pull back the government’s support for vaccination. He has announced, for instance, his intention to reform the Vaccine Injury Compensation Program, which helps protect manufacturers from lawsuits over illegitimate claims about a vaccine’s health effects, and his plans to find “ways to enlarge that program so that COVID-vaccine-injured people can be compensated.” Some of the experts I spoke with fear that the FDA’s Vaccines and Related Biological Products Advisory Committee—the agency’s rough equivalent of ACIP—could be remade in Kennedy’s vision. The administration has also been very willing to rescind federal funding from universities in order to forward its own ideas: Kennedy could, perhaps, threaten to withhold money from universities that require any vaccines for students.

Kennedy has also insisted that “we need to stop trusting the experts”—that Americans, for instance, shouldn’t have been discouraged from doing their own research during the pandemic. He could use COVID as an excuse to make that maxim Americans’ reality: Many public-health and infectious-disease-focused professional societies rely on at least some degree of federal funding, Nirav D. Shah, a former principal deputy director of the CDC, told me. Stripping those resources would be “a way to cut their legs off”—or, at the very least, would further delegitimize those expert bodies in the public eye. Kennedy has already barred representatives from professional societies, including the American Academy of Pediatrics and the Infectious Diseases Society of America, from participating in ACIP subcommittees after those two societies and others collectively sued HHS over its shifts in COVID policy. The public fight between medicine and government is now accelerating the nation onto a path where advice diverges over not just COVID shots but vaccines generally. (When asked about how COVID resentment was guiding the administration’s decisions, Desai said that the media had politicized science to push for pandemic-era mandates and that The Atlantic “continues to fundamentally misunderstand how the Trump administration is reversing this COVID era politicization of HHS.”)

The coronavirus pandemic began during the first Trump presidency; now its legacy is being exploited by a second one. Had the pandemic never happened, Kennedy would likely still be attacking vaccines, maybe even from the same position of power he currently commands. But without the lightning rod of COVID, Kennedy’s attacks would be less effective. Already, one clear consequence of the Trump administration’s anti-COVID campaign is that it will leave the nation less knowledgeable about and less prepared against all infectious diseases, Gregory Poland, a vaccinologist and the president of Atria Research Institute, told me. That might be the Trump administration’s ultimate act of revenge. No matter who is in charge when the U.S. meets its next crisis, those leaders may be forced into a corner carved out by Trump and Kennedy—one from which the country must fight disease without adequate vaccination, research, or public-health expertise. This current administration will have left the nation with few other options.

A not-insignificant number of TikToks aim to convince the viewer that beef-tallow moisturizer will not make your face smell like a cow. The beauty influencers who tend to appear in these videos—usually clear-skinned women rubbing tallow into their face as they detail their previous dermatological woes—describe the scent as “buttery” or “earthy” or grass-like. Many of them come to the same conclusion: Okay, even if the tallow does smell a little bit, the smooth skin it leaves behind is well worth it.

Beef tallow (as both a moisturizer and an alternative to seed oils) is one of many cow-based products that have crowded the wellness market in the past five or so years. Beef-bone broth is a grocery-store staple. Demand for raw milk has grown, despite numerous cases of illness and warnings from public-health officials that drinking it can be fatal. In certain circles, raw cow organs—heart, liver, kidney—are prized superfoods. Target and Walmart sell supplements containing bovine collagen (a protein found in cowhide and bone) and colostrum (the rich liquid that mammals produce for their newborn offspring); they promise healthier skin, a happier gut, and stronger immunity, and come in flavors such as watermelon lime, lemon sorbet, and “valiant grape.” You can buy cow-placenta pills for postpartum healing, or powdered bull testicle for testosterone support. The slightest interaction with clean-beauty Instagram can fill your feed with ads for beef-tallow lip balms, cleansing creams, sunscreen, and deodorants. (One brand even offers creamsicle-flavored beef-tallow personal lubricant, which is currently out of stock online.) Influencers praise tallow for clearing their acne and eczema—and offer discount codes so you can experience the same.

Even the government’s recent public-health messaging has veered toward the bovine. During his tenure as health secretary, Robert F. Kennedy Jr. has championed cooking in beef tallow (which he says is healthier than seed oils) and drinking raw milk (one of many items that he claims are suppressed by the FDA). Casey Means, President Donald Trump’s nominee for surgeon general, also supports raw milk; she has suggested that Americans can decide whether a given bottle is safe to drink by looking the dairy farmer in the eye and petting his cow. Means and Kennedy have largely avoided engaging with the many public-health experts who reject their views. But in May, after months of such critiques, Kennedy took shots of raw milk at the White House to celebrate the release of the “Make America Healthy Again” report.

Woo-woo, it seems, is becoming moo-moo. America has entered its cowmaxxing era.

Like most wellness offerings, cow products are marketed with vague health claims that are virtually impossible to confirm or deny, such as “deeply nourishes and supports the skin barrier,” “activate cellular health,” and “supports memory.” One of the many promises of the Ancestral Supplements Starter Pack of organ-based capsules is simply “vitality.” (The company also includes a disclaimer that the FDA has not reviewed said vitality benefits.) Advocates of these goods tend to be more specific in their praise. Raw-milk enthusiasts claim that unpasteurized milk contains bioactive chemicals that improve human health. In one video, a woman drinks raw milk that’s been in the fridge for more than a month; she claims it is safer to consume than store-bought pizza or salad and that it reduces rates of eczema, fevers, and respiratory infections. One smooth-skinned influencer, who says she hasn’t washed her face in two years, claims that beef tallow is “bioidentical” to the sebum produced by human skin. (It’s not, because it’s from cows.)

[Read: The real appeal of raw milk]

Some of these products are more likely to provide benefits than others. Bone broth is indeed rich in collagen (which, when produced by the human body, strengthens hair and skin). Whey powder, made from leftover cheese water, does contain protein. But very few studies support the idea that eating more collagen strengthens hair and skin. Whey protein can help build lean muscle, but the body can only absorb so much at a time. Some dermatologists say tallow can strengthen and hydrate the skin; others say it clogs pores and should be avoided. Other products can be downright dangerous: Just this week, Florida officials announced that 21 people fell sick after consuming contaminated raw milk.

At least part of the appeal of cowmaxxing is the cows themselves: The products evoke the pastoral ideal of a cow grazing freely in the plains, milked lovingly by human hands. It’s an image that’s been embedded in American culture for centuries. Consider how Laura Ingalls Wilder, who was no stranger to the harsh reality of farm life, described cow-raising in Little Town on the Prairie: “Warm and sweet, the scent of new milk came up from the streams hissing into the rising foam, and it mixed with the scents of springtime.” It’s enough to persuade a microbiologist to drink raw milk.

In 21st-century America, cows still summon images of fields and clover and wide blue sky, enough to trigger the human tendency to believe that what’s natural is “fundamentally good,” Courtney Lappas, a biology professor at Lebanon Valley College, told me. Her research has shown that some Americans prefer natural over man-made products even when the former is described as objectively worse—a phenomenon her colleague Brian Meier has called the “naturalness bias.” This tendency, which is prevalent across cultures, likely leads people to assume that unprocessed cow-based products are safe and healthy, she said. Tallow, some skin-care enthusiasts claim, is a healthier, safer alternative to conventional moisturizers, which supposedly contain toxic chemicals. The branding of such products, too, leans into the notion that natural is best: Fat Cow Skincare markets its tallow cosmetics as “pure skincare, powered by nature”; Heart and Soil sells capsules of “nature’s superfood” (that is, organ meats). Other brands invoke nature through the prehistoric, with names such as Primal Harvest, Primal Kitchen, Primal FX, Primal Being, and Primal Queen. Ancestral Supplements’ ad copy reads: “Putting Back In What the Modern World Left Out.”

[Read: How organ meat got into smoothies]

America’s current health landscape is the perfect setting for cowmaxxing to thrive. The naturalness bias is deeply ingrained in Kennedy’s MAHA campaign, which aims to improve public health by returning to a more natural lifestyle. In Kennedy’s view, beef tallow is superior to seed oil because it’s less processed (some people even render it at home). The carnivore and tradwife movements embody a similar message, promoting the consumption of raw cow organs and making butter from scratch. You may not know what’s in store-bought products, the thinking goes, but you do know what’s in tallow: pure, unadulterated cow fat.

And yet most modern cows live in a decidedly unnatural environment. The majority of U.S. cattle are fed genetically modified crops, and some genetically modified cows are allowed to be sold as food. Many cow-based wellness products bear the label “grass-fed,” which suggests cows that were raised on pastures rather than feedlots. But the label is not strictly enforced, and it doesn’t necessarily prohibit farmers from giving cows antibiotics or hormones. There’s no guarantee that a cow whose colostrum is harvested to be sold by a tradwife on Instagram had a happy, bucolic existence. Not to mention that colostrum, whey, and placenta do not come out of the cow in the form of powders or pills.

The spread of science misinformation, along with legitimate concerns about the state of public health in the United States, have left many Americans understandably confused about whether conventional science and Western medicine can be trusted in 2025. Getting to the bottom of, say, the seed-oil controversy requires engaging with thorny scientific debates that reference inscrutable research papers; embracing the natural and ancestral by opting for tallow is an attractively simple-seeming alternative. “It brings with it a sense of purity or wholesomeness that is desirable right now,” Marianne Clark, a sociologist at Acadia University who studies wellness trends, told me. In this sense, cowmaxxing is not so much a health endeavor as it is a spiritual one, its promise downright biblical: Cowliness is next to godliness.

Illustration by Michael Houtz

The euthanasia conference was held at a Sheraton. Some 300 Canadian professionals, most of them clinicians, had arrived for the annual event. There were lunch buffets and complimentary tote bags; attendees could look forward to a Friday-night social outing, with a DJ, at an event space above Par-Tee Putt in downtown Vancouver. “The most important thing,” one doctor told me, “is the networking.”

Which is to say that it might have been any other convention in Canada. Over the past decade, practitioners of euthanasia have become as familiar as orthodontists or plastic surgeons are with the mundane rituals of lanyards and drink tickets and It’s been so long s outside the ballroom of a four-star hotel. The difference is that, 10 years ago, what many of the attendees here do for work would have been considered homicide.

When Canada’s Parliament in 2016 legalized the practice of euthanasia—Medical Assistance in Dying, or MAID, as it’s formally called—it launched an open-ended medical experiment. One day, administering a lethal injection to a patient was against the law; the next, it was as legitimate as a tonsillectomy, but often with less of a wait. MAID now accounts for about one in 20 deaths in Canada—more than Alzheimer’s and diabetes combined—surpassing countries where assisted dying has been legal for far longer.

It is too soon to call euthanasia a lifestyle option in Canada, but from the outset it has proved a case study in momentum. MAID began as a practice limited to gravely ill patients who were already at the end of life. The law was then expanded to include people who were suffering from serious medical conditions but not facing imminent death. In two years, MAID will be made available to those suffering only from mental illness. Parliament has also recommended granting access to minors.

At the center of the world’s fastest-growing euthanasia regime is the concept of patient autonomy. Honoring a patient’s wishes is of course a core value in medicine. But here it has become paramount, allowing Canada’s MAID advocates to push for expansion in terms that brook no argument, refracted through the language of equality, access, and compassion. As Canada contends with ever-evolving claims on the right to die, the demand for euthanasia has begun to outstrip the capacity of clinicians to provide it.

There have been unintended consequences: Some Canadians who cannot afford to manage their illness have sought doctors to end their life. In certain situations, clinicians have faced impossible ethical dilemmas. At the same time, medical professionals who decided early on to reorient their career toward assisted death no longer feel compelled to tiptoe around the full, energetic extent of their devotion to MAID. Some clinicians in Canada have euthanized hundreds of patients.

The two-day conference in Vancouver was sponsored by a professional group called the Canadian Association of MAiD Assessors and Providers. Stefanie Green, a physician on Vancouver Island and one of the organization’s founders, told me how her decades as a maternity doctor had helped equip her for this new chapter in her career. In both fields, she explained, she was guiding a patient through an “essentially natural event”—the emotional and medical choreography “of the most important days in their life.” She continued the analogy: “I thought, Well, one is like delivering life into the world, and the other feels like transitioning and delivering life out.” And so Green does not refer to her MAID deaths only as “provisions”—the term for euthanasia that most clinicians have adopted. She also calls them “deliveries.”

Gord Gubitz, a neurologist from Nova Scotia, told me that people often ask him about the “stress” and “trauma” and “strife” of his work as a MAID provider. Isn’t it so emotionally draining? In fact, for him it is just the opposite. He finds euthanasia to be “energizing”—the “most meaningful work” of his career. “It’s a happy sad, right?” he explained. “It’s really sad that you were in so much pain. It is sad that your family is racked with grief. But we’re so happy you got what you wanted.”

[From the June 2023 issue: David Brooks on how Canada’s assisted-suicide law went wrong]

Has Canada itself gotten what it wanted? Nine years after the legalization of assisted death, Canada’s leaders seem to regard MAID from a strange, almost anthropological remove: as if the future of euthanasia is no more within their control than the laws of physics; as if continued expansion is not a reality the government is choosing so much as conceding. This is the story of an ideology in motion, of what happens when a nation enshrines a right before reckoning with the totality of its logic. If autonomy in death is sacrosanct, is there anyone who shouldn’t be helped to die?

Rishad Usmani remembers the first patient he killed. She was 77 years old and a former Ice Capades skater, and she had severe spinal stenosis. Usmani, the woman’s family physician on Vancouver Island, had tried to talk her out of the decision to die. He would always do that, he told me, when patients first asked about medically assisted death, because often what he found was that people simply wanted to be comfortable, to have their pain controlled; that when they reckoned, really reckoned, with the finality of it all, they realized they didn’t actually want euthanasia. But this patient was sure: She was suffering, not just from the pain but from the pain medication too. She wanted to die.

On December 13, 2018, Usmani arrived at the woman’s home in the town of Comox, British Columbia. He was joined by a more senior physician, who would supervise the procedure, and a nurse, who would start the intravenous line. The patient lay in a hospital bed, her sister next to her, holding her hand. Usmani asked her a final time if she was sure; she said she was. He administered 10 milligrams of midazolam, a fast-acting sedative, then 40 milligrams of lidocaine to numb the vein in preparation for the 1,000 milligrams of propofol, which would induce a deep coma. Finally he injected 200 milligrams of a paralytic agent called rocuronium, which would bring an end to breathing, ultimately causing the heart to stop.

Usmani drew his stethoscope to the woman’s chest and listened. To his quiet alarm, he could hear the heart still beating. In fact, as the seconds passed, it seemed to be quickening. He glanced at his supervisor. Where had he messed up? But as soon as they locked eyes, he understood: He was listening to his own heartbeat.

Many clinicians in Canada who have provided medical assistance in dying have a story like this, about the tangle of nerves and uncertainties that attended their first case. Death itself is something every clinician knows intimately, the grief and pallor and paperwork of it. To work in medicine is to step each day into the worst days of other people’s lives. But approaching death as a procedure, as something to be scheduled over Outlook, took some getting used to. In Canada, it is no longer a novel and remarkable event. As of 2023, the last year for which data are available, some 60,300 Canadians had been legally helped to their death by clinicians. In Quebec, more than 7 percent of all deaths are by euthanasia—the highest rate of any jurisdiction in the world. “I have two or three provisions every week now, and it’s continuing to go up every year,” Claude Rivard, a family doctor in suburban Montreal, told me.

Rivard has thus far provided for more than 600 patients and helps train clinicians new to MAID. This spring, I watched from the back of a small classroom in a Vancouver hospital as Rivard led a workshop on intraosseous infusion—administering drugs directly into the bone marrow, a useful skill for MAID clinicians, Rivard explained, in the event of IV failure. Arranged on absorbent pads across the back row of tables were eight pig knuckles, bulbous and pink. After a PowerPoint presentation, the dozen or so attendees took turns with different injection devices, from the primitive (manual needles) to the modern (bone-injection guns). Hands cramped around hollow steel needles as the workshop attendees struggled to twist and drive the tools home. This was the last thing, the clinicians later agreed, that patients would want to see as they lay trying to die. Practitioners needed to learn. “Every detail matters,” Rivard told the class; he preferred the bone-injection gun himself.

The details of the assisted-death experience have become a preoccupation of Canadian life. Patients meticulously orchestrate their final moments, planning celebrations around them: weekend house parties before a Sunday-night euthanasia in the garden; a Catholic priest to deliver last rites; extended-family renditions of “Auld Lang Syne” at the bedside. For $10.99, you can design your MAID experience with the help of the Be Ceremonial app; suggested rituals include a story altar, a forgiveness ceremony, and the collecting of tears from witnesses. On the Disrupting Death podcast, hosted by an educator and a social worker in Ontario, guests share ideas on subjects such as normalizing the MAID process for children facing the death of an adult in their life—a pajama party at a funeral home; painting a coffin in a schoolyard.

Autonomy, choice, control: These are the values that found purchase with the great majority of Canadians in February 2015, when, in a case spearheaded by the British Columbia Civil Liberties Association, the supreme court of Canada unanimously overturned the country’s criminal ban on medically assisted death. For advocates, the victory had been decades in the making—the culmination of a campaign that had grown in fervor since the 1990s, when Canada’s high court narrowly ruled against physician-assisted death in a case brought by a patient with amyotrophic lateral sclerosis, or ALS. “We’re talking about a competent person making a choice about their death,” one longtime right-to-die activist said while celebrating the new ruling. “Don’t access this choice if you don’t want—but stay away from my death bed.” A year later, in June 2016, Parliament passed the first legislation officially permitting medical assistance in dying for eligible adults, placing Canada among the handful of countries (including Belgium, Switzerland, and the Netherlands) and U.S. states (Oregon, Vermont, and California, among others) that already allowed some version of the practice.

[Read: How do I make sense of my mother’s decision to die?]

The new law approved medical assistance in dying for adults who had a “grievous and irremediable medical condition” causing them “intolerable suffering,” and who faced a “reasonably foreseeable” natural death. To qualify, patients needed two clinicians to sign off on their application, and the law required a 10-day “reflection period” before the procedure could take place. Patients could choose to die either by euthanasia—having a clinician administer the drugs directly—or, alternatively, by assisted suicide, in which a patient self-administers a lethal prescription orally. (Virtually all MAID deaths in Canada have been by euthanasia.) When the procedure was set to begin, patients were required to give final consent.

The law, in other words, was premised on the concept of patient autonomy, but within narrow boundaries. Rather than force someone with, say, late-stage cancer to suffer to the very end, MAID would allow patients to depart on their own terms: to experience a “dignified death,” as proponents called it. That the threshold of eligibility for MAID would be high—and stringent—was presented to the public as self-evident, although the criteria themselves were vague when you looked closely. For instance, what constituted “reasonably foreseeable”? Two months? Two years? Canada’s Department of Justice suggested only “a period of time that is not too remote.”

Provincial health authorities were left to fill in the blanks. Following the law’s passage, doctors, nurse practitioners, pharmacists, and lawyers scrambled to draw up the regulatory fine print for a procedure that until then had been legally classified as culpable homicide. How should the assessment process work? What drugs should be used? Particularly vexing was the question of whether it should be clinicians or patients who initiated conversations about assisted death. Some argued that doctors and nurses had a professional obligation to broach the subject of MAID with potentially eligible patients, just as they would any other “treatment option.” Others feared that patients could interpret this as a recommendation—indeed, feared that talking about assisted death as a medical treatment, like Lasik surgery or a hip replacement, was dangerous in itself.

Early on, a number of health-care professionals refused to engage in any way with MAID—some because of religious beliefs, and others because, in their view, it violated a medical duty to “do no harm.” For many clinicians, the ethical and logistical challenges of MAID only compounded the stress of working within Canada’s public-health-care system, beset by years of funding cuts and staffing shortages. The median wait time for general surgery is about 22 weeks. For orthopedic surgery, it’s more than a year. For some kinds of mental-health services, the wait time can be longer.

As the first assessment requests trickled in, even many clinicians who believed strongly in the right to an assisted death were reluctant to do the actual assisting. Some told me they agreed to take on patients only after realizing that no one else—in their hospital or even their region—was willing to go first. Matt Kutcher, a physician on Prince Edward Island, was more open to MAID than others, but acknowledged the challenge of building the practice of assisted death virtually from scratch. “The reality,” he said, “is that we were all just kind of making it up as we went along, very cautiously.”

On a rainy spring evening in 2017, Kutcher drove to a farmhouse by the sea to administer the first state-sanctioned act of euthanasia in his province. The patient, Paul Couvrette, had learned about MAID from his wife, Liana Brittain, in 2015, soon after the supreme-court decision. He had just been diagnosed with lung cancer, and while processing this fact in the parking lot of the clinic had turned to his wife and announced: “I’m not going to have cancer. I’m going to kill myself.” Brittain told her husband this was a bit dramatic. “You know, dear, you don’t have to do that,” she recalls responding. “The government will do it for you, and they’ll do it for free.” Couvrette had marveled at the news, because although he was open to surgery, he had no interest in chemotherapy or radiation. MAID, Brittain told me, gave her husband the relief of a “back door.” By early 2017, the cancer had spread to Couvrette’s brain; the 72-year-old became largely bedridden. He set his MAID procedure for May 10—the couple’s wedding anniversary.

Kutcher and a nurse had agreed to come early and join the extended family—children, a granddaughter—for Couvrette’s final dinner: seafood chowder and gluten-free biscuits. Only Brittain would eventually join Couvrette in the downstairs bedroom; the rest of the family and the couple’s two dogs would wait outside on the beach. There was a shared understanding, Kutcher recalled, that “this was something none of us had experienced before, and we didn’t really know what we were in for.” What followed was a “beautiful death”—that was what the local newspaper called it, Brittain told me. Couvrette’s last words to his wife came from their wedding vows: I’ll love you forever, plus three days.

Kutcher wrestled at first with the sheer strangeness of the experience—how quickly it was over, packing up his equipment at the side of a dead man who just 10 minutes earlier had been talking with him, very much alive. But he went home believing he had done the right thing for his patient.

For proponents, Couvrette epitomized the ideal MAID candidate, motivated not by an impulsive death wish but by a considered desire to reclaim control of his fate from a terminal disease. The lobbying group Dying With Dignity Canada celebrated Couvrette’s “empowering choice and journey” as part of a showcase on its website of “good deaths” made possible by the new law. There was also the surgeon in Nova Scotia with Parkinson’s who “died the same way he lived—on his own terms.” And there were the Toronto couple in their 90s who, in a “dream ending to their storybook romance,” underwent MAID together.

Such heartfelt accounts tended to center on the white, educated, financially stable patients who represented the typical MAID recipient. The stories did not precisely capture what many clinicians were discovering also to be true: that if dying by MAID was dying with dignity, some deaths felt considerably more dignified than others. Not everyone has coastal homes or children and grandchildren who can gather in love and solidarity. This was made clear to Sandy Buchman, a palliative-care physician in Toronto, during one of his early MAID cases, when a patient, “all alone,” gave final consent from a mattress on the floor of a rental apartment. Buchman recalls having to kneel next to the mattress in the otherwise empty space to administer the drugs. “It was horrible,” he told me. “You can see how challenging, how awful, things can be.”

In 2018, Buchman co-founded a nonprofit organization called MAiDHouse. The aim was to create a “third place” of sorts for people who want to die somewhere other than a hospital or at home. Finding a location proved difficult; many landlords were resistant. But by 2022, MAiDHouse had leased the space in Toronto from which it operates today. (For security reasons, the location is not public.) Tekla Hendrickson, the executive director of MAiDHouse, told me the space was designed to feel warm and familiar but also adaptable to the wishes of the person using it: furniture light enough to rearrange, bare surfaces for flowers or photos or any other personal items. “Sometimes they have champagne, sometimes they come in limos, sometimes they wear ball gowns,” Hendrickson said. The act of euthanasia itself takes place in a La-Z-Boy-like recliner, with adjacent rooms available for family and friends who may prefer not to witness the procedure. According to the MAiDHouse website, the body is then transferred to a funeral home by attendants who arrive in unmarked cars and depart “discreetly.”

Since its founding, MAiDHouse has provided space and support for more than 100 deaths. The group’s homepage displays a photograph of dandelion seeds scattering in a gentle wind. A second MAiDHouse location recently opened in Victoria, British Columbia. In the organization’s 2023 annual report, the chair of the board noted that MAiDHouse’s followers on LinkedIn had increased by 85 percent; its new Instagram profile was gaining followers too. More to the point, the number of provisions performed at MAiDHouse had doubled over the previous year—“astounding progress for such a young organization.”

In the early days of MAID, some clinicians found themselves at once surprised and conflicted by the fulfillment they experienced in helping people die. A few months after the law’s passage, Stefanie Green, whom I’d met at the conference in Vancouver, acknowledged to herself how “upbeat” she’d felt following a recent provision—“a little hyped up on adrenaline,” as she later put it in a memoir about her first year providing medical assistance in death. Green realized it was gratification she was feeling: A patient had come to her in immense pain, and she had been in a position to offer relief. In the end, she believed, she had “given a gift to a dying man.”

Green had at first been reluctant to reveal her feelings to anyone, afraid that she might be viewed, she recalled, as a “psychopath.” But she did eventually confide in a small group of fellow MAID practitioners. Green and several colleagues realized that there was a need for a formal community of professionals. In 2017, they officially launched the group whose meeting I attended.

There was a time when Madeline Li would have felt perfectly at home among the other clinicians who convened that weekend at the Sheraton. In the early years of MAID, few physicians exerted more influence over the new regime than Li. The Toronto-based cancer psychiatrist led the development of the MAID program at the University Health Network, the largest teaching-hospital system in Canada, and in 2017 saw her framework published in The New England Journal of Medicine.

It was not long into her practice, however, that Li’s confidence in the direction of her country’s MAID program began to falter. For all of her expertise, not even Li was sure what to do about a patient in his 30s whom she encountered in 2018.

The man had gone to the emergency room complaining of excruciating pain and was eventually diagnosed with cancer. The prognosis was good, a surgeon assured him, with a 65 percent chance of a cure. But the man said he didn’t want treatment; he wanted MAID. Startled, the surgeon referred him to a medical oncologist to discuss chemo; perhaps the man just didn’t want surgery. The patient proceeded to tell the medical oncologist that he didn’t want treatment of any kind; he wanted MAID. He said the same thing to a radiation oncologist, a palliative-care physician, and a psychiatrist, before finally complaining to the patient-relations department that the hospital was barring his access to MAID. Li arranged to meet with him.

Canada’s MAID law defines a “grievous and irremediable medical condition” in part as a “serious and incurable illness, disease, or disability.” As for what constitutes incurability, however, the law says nothing—and of the various textual ambiguities that caused anxiety for clinicians early on, this one ranked near the top. Did “incurable” mean a lack of any available treatment? Did it mean the likelihood of an available treatment not working? Prominent MAID advocates put forth what soon became the predominant interpretation: A medical condition was incurable if it could not be cured by means acceptable to the patient.

This had made sense to Li. If an elderly woman with chronic myelogenous leukemia had no wish to endure a highly toxic course of chemo and radiation, why should she be compelled to? But here was a young man with a likely curable cancer who nevertheless was adamant about dying. “I mean, he was so, so clear,” Li told me. “I talked to him about What if you had a 100 percent chance? Would you want treatment? And he said no.” He didn’t want to suffer through the treatment or the side effects, he explained; just having a colonoscopy had traumatized him. When Li assured the man that they could treat the side effects, he said she wasn’t understanding him: Yes, they could give him medication for the pain, but then he would have to first experience the pain. He didn’t want to experience the pain.

What was Li left with? According to prevailing standards, the man’s refusal to attempt treatment rendered his disease incurable and his natural death was reasonably foreseeable. He met the eligibility criteria as Li understood them. But the whole thing seemed wrong to her. Seeking advice, she described the basics of the case in a private email group for MAID practitioners under the heading “Eligible, but Reasonable?” “And what was very clear to me from the replies I got,” Li told me, “is that many people have no ethical or clinical qualms about this—that it’s all about a patient’s autonomy, and if a patient wants this, it’s not up to us to judge. We should provide.”

And so she did. She regretted her decision almost as soon as the man’s heart stopped beating. “What I’ve learned since is: Eligible doesn’t mean you should provide MAID,” Li told me. “You can be eligible because the law is so full of holes, but that doesn’t mean it clinically makes sense.” Li no longer interprets “incurable” as at the sole discretion of the patient. The problem, she feels, is that the law permits such a wide spectrum of interpretations to begin with. Many decisions about life and death turn on the personal values of practitioners and patients rather than on any objective medical criteria.

By 2020, Li had overseen hundreds of MAID cases, about 95 percent of which were “very straightforward,” she said. They involved people who had terminal conditions and wanted the same control in death as they’d enjoyed in life. It was the 5 percent that worried her—not just the young man, but vulnerable people more generally, whom the safeguards had possibly failed. Patients whose only “terminal condition,” really, was age. Li recalled an especially divisive early case for her team involving an elderly woman who’d fractured her hip. She understood that the rest of her life would mean becoming only weaker and enduring more falls, and she “just wasn’t going to have it.” The woman was approved for MAID on the basis of frailty.

Li had tried to understand the assessor’s reasoning. According to an actuarial table, the woman, given her age and medical circumstances, had a life expectancy of five or six more years. But what if the woman had been slightly younger and the number was closer to eight years—would the clinician have approved her then? “And they said, well, they weren’t sure, and that’s my point,” Li explained. “There’s no standard here; it’s just kind of up to you.” The concept of a “completed life, or being tired of life,” as sufficient for MAID is “controversial in Europe and theoretically not legal in Canada,” Li said. “But the truth is, it is legal in Canada. It always has been, and it’s happening in these frailty cases.”

Li supports medical assistance in dying when appropriate. What troubles her is the federal government’s deferring of responsibility in managing it—establishing principles, setting standards, enforcing boundaries. She believes most physicians in Canada share her “muddy middle” position. But that position, she said, is also “the most silent.”

In 2014, when the question of medically assisted death had come before Canada’s supreme court, Etienne Montero, a civil-law professor and at the time the president of the European Institute of Bioethics, warned in testimony that the practice of euthanasia, once legal, was impossible to control. Montero had been retained by the attorney general of Canada to discuss the experience of assisted death in Belgium—how a regime that had begun with “extremely strict” criteria had steadily evolved, through loose interpretations and lax enforcement, to accommodate many of the very patients it had once pledged to protect. When a patient’s autonomy is paramount, Montero argued, expansion is inevitable: “Sooner or later, a patient’s repeated wish will take precedence over strict statutory conditions.” In the end, the Canadian justices were unmoved; Belgium’s “permissive” system, they contended, was the “product of a very different medico-legal culture” and therefore offered “little insight into how a Canadian regime might operate.” In a sense, this was correct: It took Belgium more than 20 years to reach an assisted-death rate of 3 percent. Canada needed only five.

In retrospect, the expansion of MAID would seem to have been inevitable; Justin Trudeau, then Canada’s prime minister, said as much back in 2016, when he called his country’s newly passed MAID law “a big first step” in what would be an “evolution.” Five years later, in March 2021, the government enacted a new two-track system of eligibility, relaxing existing safeguards and extending MAID to a broader swath of Canadians. Patients approved for an assisted death under Track 1, as it was now called—meaning the original end-of-life context—were no longer required to wait 10 days before receiving MAID; they could die on the day of approval. Track 2, meanwhile, legalized MAID for adults whose deaths were not reasonably foreseeable—people suffering from chronic pain, for example, or from certain neurological disorders. Although cost savings have never been mentioned as an explicit rationale for expansion, the parliamentary budget office anticipated annual savings in health-care costs of nearly $150 million as a result of the expanded MAID regime.

The 2021 law did provide for additional safeguards unique to Track 2. Assessors had to ensure that applicants gave “serious consideration”—a phrase left undefined—to “reasonable and available means” to alleviate their suffering. In addition, they had to affirm that the patients had been directed toward such options. Track 2 assessments were also required to span at least 90 days. For any MAID assessment, clinicians must be satisfied not only that a patient’s suffering is enduring and intolerable, but that it is a function of a physical medical condition rather than mental illness, say, or financial instability. Suffering is never perfectly reducible, of course—a crisp study in cause and effect. But when a patient is already dying, the role of physical disease isn’t usually a mystery, either.

Track 2 introduced a web of moral complexities and clinical demands. For many practitioners, one major new factor was the sheer amount of time required to understand why the person before them—not terminally ill—was asking, at that particular moment, to die. Clinicians would have to untangle the physical experience of chronic illness and disability from the structural inequities and mental-health struggles that often attend it. In a system where access to social supports and medical services varies so widely, this was no small challenge, and many clinicians ultimately chose not to expand their practice to include Track 2 patients.

There is no clear official data on how many clinicians are willing to take on Track 2 cases. The government’s most recent information indicates that, in 2023, out of 2,200 MAID practitioners overall, a mere 89 were responsible for about 30 percent of all Track 2 provisions. Jonathan Reggler, a family physician on Vancouver Island, is among that small group. He openly acknowledges the challenges involved in assessing Track 2 patients, as well as the basic “discomfort” that comes with ending the life of someone who is not in fact dying. “I can think of cases that I’ve dealt with where you’re really asking yourself, Why? ” he told me. “Why now? Why is it that this cluster of problems is causing you such distress where another person wouldn’t be distressed? ”

Yet Reggler feels duty bound to move beyond his personal discomfort. As he explained it, “Once you accept that people ought to have autonomy—once you accept that life is not sacred and something that can only be taken by God, a being I don’t believe in—then, if you’re in that work, some of us have to go forward and say, ‘We’ll do it.’ ”

For some MAID practitioners, however, it took encountering an eligible patient for them to realize the true extent of their unease with Track 2. One physician, who requested anonymity because he was not authorized by his hospital to speak publicly, recalled assessing a patient in their 30s with nerve damage. The pain was such that they couldn’t go outside; even the touch of a breeze would inflame it. “They had seen every kind of specialist,” he said. The patient had tried nontraditional therapies too—acupuncture, Reiki, “everything.” As the physician saw it, the patient’s condition was serious and incurable, it was causing intolerable suffering, and the suffering could not seem to be relieved. “I went through all of the tick boxes, and by the letter of the law, they clearly met the criteria for all of these things, right? That said, I felt a little bit queasy.” The patient was young, with a condition that is not terminal and is usually treatable. But “I didn’t feel it was my place to tell them no.”

He was not comfortable doing the procedure himself, however. He recalled telling the MAID office in his region, “Look, I did the assessment. The patient meets the criteria. But I just can’t—I can’t do this.” Another clinician stepped in.

In 2023, Track 2 accounted for 622 MAID deaths in Canada—just over 4 percent of cases, up from 3.5 percent in 2022. Whether the proportion continues to rise is anyone’s guess. Some argue that primary-care providers are best positioned to negotiate the complexities of Track 2 cases, given their familiarity with the patient making the request—their family situation, medical history, social circumstances. This is how assisted death is typically approached in other countries, including Belgium and the Netherlands. But in Canada, the system largely developed around the MAID coordination centers assembled in the provinces, complete with 1-800 numbers for self-referrals. The result is that MAID assessors generally have no preexisting relationship with the patients they’re assessing.

How do you navigate, then, the hidden corridors of a stranger’s suffering? Claude Rivard told me about a Track 2 patient who had called to cancel his scheduled euthanasia. As a result of a motorcycle accident, the man could not walk; now blind, he was living in a long-term-care facility and rarely had visitors; he had been persistent in his request for MAID. But when his family learned that he’d applied and been approved, they started visiting him again. “And it changed everything,” Rivard said. He was in contact with his children again. He was in contact with his ex-wife again. “He decided, ‘No, I still have pleasure in life, because the family, the kids are coming; even if I can’t see them, I can touch them, and I can talk to them, so I’m changing my mind.’ ”

I asked Rivard whether this turn of events—the apparent plasticity of the man’s desire to die—had given him pause about approving the patient for MAID in the first place. Not at all, he said. “I had no control on what the family was going to do.”

Some of the opposition to MAID in Canada is religious in character. The Catholic Church condemns euthanasia, though Church influence in Canada, as elsewhere, has waned dramatically, particularly where it was once strongest, in Quebec. But from the outset there were other concerns, chief among them the worry that assisted death, originally authorized for one class of patient, would eventually become legal for a great many others too. National disability-rights groups warned that Canadians with physical and intellectual disabilities—people whose lives were already undervalued in society, and of whom 17 percent live in poverty—would be at particular risk. As assisted death became “sanitized,” one group argued, “more and more will be encouraged to choose this option, further entrenching the ‘better off dead’ message in public consciousness.”

For these critics, the “reasonably foreseeable” death requirement had been the solitary consolation in an otherwise lost constitutional battle. The elimination of that protection with the creation of Track 2 reinforced their conviction that MAID would result in Canada’s most marginalized citizens being subtly coerced into premature death. Canadian officials acknowledged these concerns—“We know that in some places in our country, it’s easier to access MAID than it is to get a wheelchair,” Carla Qualtrough, the disability-inclusion minister, admitted in 2020—but reiterated that socioeconomic suffering was not a legal basis for MAID. Justin Trudeau took pains to assure the public that patients were not being backed into assisted death because of their inability to afford proper housing, say, or get timely access to medical care. It “simply isn’t something that ends up happening,” he said.

Sathya Dhara Kovac, of Winnipeg, knew otherwise. Before dying by MAID in 2022, at the age of 44, Kovac wrote her own obituary. She explained that life with ALS had “not been easy”; it was, as far as illnesses went, a “shitty” one. But the illness itself was not the reason she wanted to die. Kovac told the local press prior to being euthanized that she had fought unsuccessfully to get adequate home-care services; she needed more than the 55 hours a week covered by the province, couldn’t afford the cost of a private agency to take care of the balance, and didn’t want to be relegated to a long-term-care facility. “Ultimately it was not a genetic disease that took me out, it was a system,” Kovac wrote. “I could have had more time if I had more help.”

Earlier this spring, I met in Vancouver with Marcia Doherty; she was approved for Track 2 MAID shortly after it was legalized, four years ago. The 57-year-old has suffered for most of her life from complex chronic illnesses, including myalgic encephalomyelitis, fibromyalgia, and Epstein-Barr virus. Her daily experience of pain is so total that it is best captured in terms of what doesn’t hurt (the tips of her ears; sometimes the tip of her nose) as opposed to all the places that do. Yet at the core of her suffering is not only the pain itself, Doherty told me; it’s that, as the years go by, she can’t afford the cost of managing it. Only a fraction of the treatments she relies on are covered by her province’s health-care plan, and with monthly disability assistance her only consistent income, she is overwhelmed with medical debt. Doherty understands that someday, the pressure may simply become too much. “I didn’t apply for MAID because I want to be dead,” she told me. “I applied for MAID on ruthless practicality.”

It is difficult to understand MAID in such circumstances as a triumphant act of autonomy—as if the state, by facilitating death where it has failed to provide adequate resources to live, has somehow given its most vulnerable citizens the dignity of choice. In January 2024, a quadriplegic man named Normand Meunier entered a Quebec hospital with a respiratory infection; after four days confined to an emergency-room stretcher, unable to secure a proper mattress despite his partner’s pleas, he developed a painful bedsore that led him to apply for MAID. “I don’t want to be a burden,” he told Radio-Canada the day before he was euthanized, that March.

[Read: Brittany Maynard and the challenge of dying with dignity]

Nearly half of all Canadians who have died by MAID viewed themselves as a burden on family and friends. For some disabled citizens, the availability of assisted death has sowed doubt about how the medical establishment itself sees them—about whether their lives are in fact considered worthy of saving. In the fall of 2022, a 49-year-old Nova Scotia woman who is physically disabled and had recently been diagnosed with breast cancer was readying for a lifesaving mastectomy when a member of her surgical team began working through a list of pre-op questions about her medications and the last time she ate—and was she familiar with medical assistance in dying? The woman told me she felt suddenly and acutely aware of her body, the tissue-thin gown that wouldn’t close. “It left me feeling like maybe I should be second-guessing my decision,” she recalled. “It was the thing I was thinking about as I went under; when I woke up, it was the first thought in my head.” Fifteen months later, when the woman returned for a second mastectomy, she was again asked if she was aware of MAID. Today she still wonders if, were she not disabled, the question would even have been asked. Gus Grant, the registrar and CEO of the College of Physicians and Surgeons of Nova Scotia, has said that the timing of the queries to this woman was “clearly inappropriate and insensitive,” but he also emphasized that “there’s a difference between raising the topic of discussing awareness about MAID, and possible eligibility, from offering MAID.”

And yet there is also a reason why, in some countries, clinicians are either expressly prohibited or generally discouraged from initiating conversations about assisted death. However sensitively the subject is broached, death never presents itself neutrally; to regard the line between an “offer” and a simple recitation of information as somehow self-evident is to ignore this fact, as well as the power imbalance that freights a health professional’s every gesture with profound meaning. Perhaps the now-suspended Veterans Affairs caseworker who, in 2022, was found by the department to have “inappropriately raised” MAID with several service members had meant no harm. But according to testimony, one combat veteran was so shaken by the exchange—he had called seeking support for his ailments and was not suicidal, but was told that MAID was preferable to “blowing your brains out”—that he left the country.

In 2023, Kathrin Mentler, who lives with concurrent mental and physical disabilities, including rheumatoid arthritis and other forms of chronic pain, arrived at Vancouver General Hospital asking for help amid a suicidal crisis. Mentler has stated in a sworn affidavit that the hospital clinician who performed the intake told her that although they could contact the on-call psychiatrist, no beds were available in the unit. The clinician then asked if Mentler had ever considered MAID, describing it as a “peaceful” process compared with her recent suicide attempt via overdose, for which she’d been hospitalized. Mentler said that she left the hospital in a “panic,” and that the encounter had validated many of her worst fears: that she was a “burden” on an overtaxed system and that it would be “reasonable” for her to want to die. (In response to press reports about Mentler’s experience, the regional health authority said that the conversation was part of a “clinical evaluation” to assess suicide risk and that staff are required to “explore all available care options” with patients.)

MAID advocates dispute the charge that disabled Canadians are being quietly or overtly pressured to consider assisted death, calling it a myth generated by what they view as sensationalized accounts in the press; in parliamentary hearings, lawmakers, citing federal data, have emphasized that “only a small number” of MAID recipients are unable to access the medical services and social supports they require. Even so, this past March, the United Nations Committee on the Rights of Persons With Disabilities formally called for the repeal of Track 2 MAID in Canada—arguing that the federal government had “fundamentally changed” the premise of assisted dying on the basis of “negative, ableist perceptions of the quality and value” of disabled lives, without addressing the systemic inequalities that amplify their perceived suffering.

Marcia Doherty agrees that it should never have come to this: her country resolving to assist her and other disabled citizens more in death than in life. She is furious that she has been “allowed to deteriorate,” despite advocating for herself before every agency and official capable of effecting change. But she is adamantly opposed to any repeal of Track 2. She expressed a sentiment I heard from others in my reporting: that the “relief” of knowing an assisted death is available to her, should the despair become unbearable, has empowered her in the fight to live.

Doherty may someday decide to access MAID. But she doesn’t want anyone ever to say she “chose” it.

Ellen Wiebe never had reservations about taking on Track 2 cases—indeed, unlike most clinicians, she never had reservations about providing MAID at all. The Vancouver-based family physician had long been comfortable with controversy, having spent the bulk of her four decades in medicine as an abortion provider. As Wiebe saw it, MAID was perfectly in keeping with her “human-rights-focused” career. Over the past nine years, she has euthanized more than 430 patients and become one of the world’s most outspoken champions of MAID. Today, while virtually all of her colleagues rely on referrals from MAID coordination centers, Wiebe regularly receives requests directly from patients. Coordinators also call her when they have a patient whose previous MAID requests were rejected. (There is no limit to how many times a person can apply for MAID.) “Because I’m me, you know, they send those down to Ellen Wiebe,” she told me. I asked her what she meant by that. “My reputation,” she replied.

In the summer of 2024, Wiebe heard from a 53-year-old woman in Alberta who was experiencing acute psychiatric distress—“the horrors,” the patient called them—compounded by her reaction to, and then withdrawal from, an antipsychotic drug she was prescribed for sleep. None of the woman’s doctors would facilitate her desire to die. This was when, according to the version of events the woman’s common-law husband would later submit to British Columbia’s supreme court, she searched online for alternatives and came across Wiebe. At the end of their first meeting, a Zoom call, Wiebe said she would approve the woman for the procedure. On her formal application, the woman gave “akathisia”—a movement disorder characterized by intense feelings of inner restlessness and an inability to sit still, commonly caused by withdrawal from antipsychotic medication—as her reason for requesting an assisted death. According to court filings, no one the woman knew was willing to witness her sign the application form, as the law requires, so Wiebe had a volunteer at her clinic do so over Zoom. And because the woman still needed another physician or nurse practitioner to declare her eligible, Wiebe arranged for Elizabeth Whynot, a fellow family physician in Vancouver, to provide the second assessment. The patient was approved for MAID after a video call, and the procedure was set for October 27, 2024, in Wiebe’s clinic.

Following the approval, detailed in the court filings, the Alberta woman had another Zoom call with Wiebe; this time, her husband joined the conversation. He had concerns, specifically as to how akathisia qualified as “irremediable.” Specialists had assured the woman that if she committed to the gradual tapering protocol they’d prescribed, she could very likely expect relief within months. The husband also worried that Wiebe hadn’t sufficiently considered his wife’s unresolved mental-health issues, and whether she was capable, in her present state, of giving truly informed consent. The day before his wife was scheduled to die, he petitioned a Vancouver judge to halt the procedure, arguing that Wiebe had negligently approved the woman on the basis of a condition that did not qualify for MAID. In a widely publicized decision, the next morning the judge issued a last-minute injunction blocking Wiebe or any other clinician from carrying out the woman’s death as scheduled. “I can only imagine the pain she has been experiencing, and I recognize that this injunction will likely only make that worse,” the judge wrote. But there was an “arguable case,” he concluded, as to whether the criteria for MAID had been “properly applied in the circumstances.” The husband did not seek a new injunction after the temporary order expired, and in January, he withdrew the lawsuit altogether. Wiebe would not comment on the case other than to say she has never violated MAID laws and does not know of any provider who has. The lawyer who had represented the husband said she could not comment on whether the woman is still alive.

A number of similar lawsuits have been filed in recent years as Canadians come to terms with the hollow oversight of MAID. Because no formal procedure exists for challenging an approval in advance of a provision, many concerned family members see little choice but to take a loved one to court to try to halt a scheduled death. What oversight does exist takes place at the provincial or territorial level, and only after the fact. Protocols differ significantly across jurisdictions. In Ontario, the chief coroner’s office oversees a system in which all Track 2 cases are automatically referred to a multidisciplinary committee for postmortem scrutiny. Since 2018, the coroner’s office has identified more than 480 compliance issues involving federal and provincial MAID policies, including clinicians failing to consult with an expert in their patient’s condition prior to approval—a key Track 2 safeguard—and using the wrong drugs in a provision. The office’s death-review committee periodically publishes summaries of particular cases, for both Track 1 and Track 2, to “generate discussion” for “practical improvement.”

There was, for example, the case of Mr. C, a man in his 70s who, in 2024, requested MAID while receiving in-hospital palliative care for metastatic cancer. It should have been a straightforward Track 1 case. But two days after his request, according to the committee’s report, the man experienced sharp cognitive decline and lost the ability to communicate, his eyes opening only in response to painful stimuli. His palliative-care team deemed him incapable of consenting to health-care decisions, including final permission for MAID. Despite that conclusion, a MAID clinician proceeded with the assessment, “vigorously” rousing the man to ask if he still wanted euthanasia (to which the man mouthed “yes”), and then withholding the man’s pain medication until he appeared “more alert.” After confirming the man’s wishes via “short verbal statements” and “head nods and blinking,” the assessor approved him for MAID; with sign-off from a second clinician, and a final consent from Mr. C mouthing “yes,” he was euthanized.

Had this patient clearly consented to his death? Finding no documentation of a “rigorous evaluation of capacity,” the death-review committee expressed “concerns” about the process. The implication would seem startling—in a regime animated at its core by patient autonomy, a man was not credibly found to have exercised his own. Yet Mr. C’s death was reduced essentially to a matter of academic inquiry, an opportunity for “lessons learned.” Of the hundreds of irregularities flagged over the years by the coroner’s office, almost all have been dealt with through an “Informal Conversation,” an “Educational Email,” or a “Notice Email,” depending on their severity. Specific sanctions are not made public. No case has ever been referred to law enforcement for investigation.

Wiebe acknowledged that several complaints have been filed against her over the years but noted that she has never been found guilty of wrongdoing. “And if a lawyer says, ‘Oh—I disagreed with some of those things,’ I’d say, ‘Well, they didn’t put lawyers in charge of this.’ ” She laughed. “We were the ones trusted with the safeguards.” And the law was clear, Wiebe said: “If the assessor”—meaning herself—“believes that they qualify, then I’m not guilty of a crime.”

Despite all of the questions surrounding Track 2, Canada is proceeding with the expansion of MAID to additional categories of patients while gauging public interest in even more. As early as 2016, the federal government had agreed to launch exploratory investigations into the possible future provision of MAID for people whose sole underlying medical condition is a mental disorder, as well as to “mature minors,” people younger than 18 who are “deemed to have requisite decision-making capacity.” The government also pledged to consider “advance requests”—that is, allowing people to consent now to receive MAID at some specified future point when their illness renders them incapable of making or affirming the decision to die. Meanwhile, the Quebec College of Physicians has raised the possibility of legalizing euthanasia for infants born with “severe malformations,” a rare practice currently legal only in the Netherlands, the first country to adopt it since Nazi Germany did so in 1939.

As part of Track 2 legislation in 2021, lawmakers extended eligibility—to take effect at some point in the future—to Canadians suffering from mental illness alone. This, despite the submissions of many of the nation’s top psychiatric and mental-health organizations that no evidence-based standard exists for determining whether a psychiatric condition is irremediable. A number of experts also shared concerns about whether it was possible to credibly distinguish between suicidal ideation and a desire for MAID.

After several contentious delays, MAID for mental illness is now set to take effect in 2027; authorities have been tasked in the meantime with figuring out how MAID should actually be applied in such cases. The debate has produced thousands of pages of special reports and parliamentary testimony. What all sides do agree on is that, in practice, mental disorders are already a regular feature of Canada’s MAID regime. At one hearing, Mona Gupta, a psychiatrist and the chair of an expert panel charged with recommending protocols and safeguards for psychiatric MAID, noted pointedly that “people with mental disorders are requesting and accessing MAID now.” They include patients whose requests are “largely motivated by their mental disorder but who happen to have another qualifying condition,” as well as those with “long histories of suicidality” or questionable decision-making capacity. They may also be poor and homeless and have little interaction with the health-care system. But whatever the case, Gupta said, when it comes to navigating the complex intersection of MAID and mental illness, “assessors and health-care providers already do this.”

The argument was meant to assuage concerns about clinical readiness. For critics, however, it only reinforced a belief that, in some cases, physical conditions are simply being used to bear the legal weight of a different, ineligible basis for MAID, including mental disorders. In one of Canada’s more controversial cases, a 61-year-old man named Alan Nichols, who had a history of depression and other conditions, applied for MAID in 2019 while on suicide watch at a British Columbia hospital. A few weeks later, he was euthanized on the basis of “hearing loss.”

[Read: ‘I’m the doctor who is here to help you die’]

As Canadians await the rollout of psychiatric MAID, Parliament’s Special Joint Committee on Medical Assistance in Dying has formally recommended expanding MAID access to mature minors. In the committee’s 2023 report, following a series of hearings, lawmakers acknowledged the various factors that could affect young people’s capacity to evaluate their circumstances—for one, the adolescent brain’s far from fully developed faculties for “risk assessment and decision-making.” But they noted that, according to several parliamentary witnesses, children with serious medical conditions “tend to possess an uncommon level of maturity.” The committee advised that MAID be limited (“at this stage”) to minors with reasonably foreseeable natural deaths, and endorsed a requirement for “parental consultation,” but not parental consent. As a lawyer with the College of Physicians and Surgeons of Saskatchewan told the committee, “Parents may be reluctant to consent to the death of their child.”

Whether Canadian officials will eventually add mature minors to the eligibility list remains unclear. At the moment, their attention is largely focused on a different category of expansion. Last year, the province of Quebec took the next step in what some regard as the “natural evolution” of MAID: the honoring of advance requests to be euthanized. Under the Quebec law, patients in the province with cognitive conditions such as Alzheimer’s can define a threshold they don’t wish to cross. Some people might request to die when they no longer recognize their children, for example; others might indicate incontinence as a benchmark. When the threshold seems to have been reached, perhaps after an alert from a “trusted third party,” a MAID practitioner determines whether the patient is indeed suffering intolerably according to the terms of the advance request. Since 2016, public demand for this expansion has been steady, fueled by the testimonies of those who have watched loved ones endure the full course of dementia and do not want to suffer the same fate.

In parliamentary hearings, Quebec officials have discussed the potential problem of “pleasant dementia,” acknowledging that it might be difficult for a provider to euthanize someone who “seems happy” and “absolutely doesn’t remember” consenting to an assisted death earlier in their illness. Quebec officials have also discussed the issue of resistance. The Netherlands, the only other jurisdiction where euthanizing an incapable but conscious person as a result of an advance request is legal, offers an example of what MAID in such a circumstance could look like.

In 2016, a geriatrician in the Netherlands euthanized an elderly woman with Alzheimer’s who, four years earlier, shortly after being diagnosed, had advised that she wanted to die when she was “no longer able to live at home.” Eventually, the woman was admitted to a nursing home, and her husband duly asked the facility’s geriatrician to initiate MAID. The geriatrician, along with two other doctors, agreed that the woman was “suffering hopelessly and intolerably.” On the day of the euthanasia, the geriatrician decided to add a sedative surreptitiously to the woman’s coffee; it was given to “prevent a struggle,” the doctor would later explain, and surreptitiously because the woman would have “asked questions” and “refused to take it.” But as the injections began, the woman reacted and tried to sit up. Her family helped hold her down until the procedure was over and she was dead. The case prompted the first criminal investigation under the country’s euthanasia law. The physician was acquitted by a district court in 2019, and that decision was upheld by the Dutch supreme court the following year.

In Quebec, more than 100 advance requests have been filed; according to several sources, at least one has been carried out. The law currently states that any sign of refusal “must be respected”; at the same time, if the clinician determines that expressions of resistance are “behavioural symptoms” of a patient’s illness, and not necessarily an actual objection to receiving MAID, the euthanasia can continue anyway. The Canadian Association of MAiD Assessors and Providers has stated that “pre-sedating the person with medications such as benzodiazepines may be warranted to avoid potential behaviours that may result from misunderstanding.”

Laurent Boisvert, an emergency physician in Montreal who has euthanized some 600 people since 2015, told me that he has thus far helped seven patients, recently diagnosed with Alzheimer’s, to file advance requests, and that they included clear instructions on what he is to do in the event of resistance. He is not concerned about potentially encountering happy dementia. “It doesn’t exist,” he said.

The Canadian government had tried, in the early years of MAID, to forecast the country’s demand for assisted death. The first projection, in 2018, was that Canada’s MAID rate would achieve a “steady state” of 2 percent of total deaths; then, in 2022, federal officials estimated that the rate would stabilize at 4 percent by 2033. After Canada blew past both numbers—the latter, 11 years ahead of schedule—officials simply stopped publishing predictions.

And yet it was never clear how Canadians were meant to understand their country’s assisted-death rate: whether, in the government’s view, there is such a thing as too much MAID. In parliamentary hearings, federal officials have indicated that a national rate of 7 percent—the rate already reached in Quebec—might be potentially “concerning” and “wise and prudent to look into,” but did not elaborate further. If Canadian leaders feel viscerally troubled by a certain prevalence of euthanasia, they seem reluctant to explain why.

The original assumption was that euthanasia in Canada would follow roughly the same trajectory that euthanasia had followed in Belgium and the Netherlands. But even under those permissive regimes, the law requires that patients exhaust all available treatment options before seeking euthanasia. In Canada, where ensuring access has always been paramount, such a requirement was thought to be too much of an infringement on patient autonomy. Although Track 2 requires that patients be informed of possible alternative means of alleviating their suffering, it does not require that those options actually be made available. Last year, the Quebec government announced plans to spend nearly $1 million on a study of why so many people in the province are choosing to die by euthanasia. The announcement came shortly after Michel Bureau, who heads Quebec’s MAID-oversight committee, expressed concern that assisted death is no longer viewed as an option of last resort. But had it ever been?

It doesn’t feel quite right to say that Canada slid down a slippery slope, because keeping off the slope never seems to have been the priority. But on one point Etienne Montero, the former head of the European Institute of Bioethics, was correct: When autonomy is entrenched as the guiding principle, exclusions and safeguards eventually begin to seem arbitrary and even cruel. This is the tension inherent in the euthanasia debate, the reason why the practice, once set in motion, becomes exceedingly difficult to restrain. As Canada’s former Liberal Senate leader James Cowan once put it: “How can we turn away and ignore the pleas of suffering Canadians?”

In the end, the most meaningful guardrails on MAID may well turn out to be the providers themselves. Legislative will has generally been fixed in the direction of more; public opinion flickers in response to specific issues, but so far remains largely settled. If MAID reaches a limit in Canada, it will happen only when practitioners decide what they can tolerate—morally or, in a system with a shrinking supply of providers, logistically. “You cannot ask us to provide at the rate we’re providing right now,” Claude Rivard, who has decided not to accept advance requests, told me. “The limit will always be the evaluation and the provider. It will rest with them. They will have to do the evaluation, and they will have to say, ‘No, it’s not acceptable.’”

Lori Verigin, a nurse practitioner who provides euthanasia in rural British Columbia, understands that people are concerned about their “rights”—about “not being heard.” Yet she is the person on the line when it comes to ensuring those rights. This is what is often lost in Canada’s conversation about assisted dying—about the push for expansion in the academic papers or in the rarefied halls of Parliament. It is not the lawmaker or lawyer or pundit who must administer an injection and stop a heart.

On a Thursday morning in June, I joined Verigin in her white Volkswagen as she drove to a MAID appointment near the town of Trail. I had not come to witness the provision, to be a stranger in the room. I was with Verigin because I wanted to understand the before-and-after of MAID, the clinical and emotional labor involved in helping someone die. After eight years, Verigin had developed a familiar set of rhythms. She had her preferred pharmacy, the Shoppers Drug Mart close to her home, in Castlegar. This morning she had arrived as the doors opened, prescription in hand; the pharmacist greeted her by name before placing on the counter a medium-size case resembling a tackle box. Verigin unsnapped the lid and confirmed that everything was in place: the vials of midazolam, lidocaine, propofol, and rocuronium.

Verigin had known the patient she was about to visit for some time, she told me. Roughly a year ago, the patient, suffering from metastatic cancer, had first asked about MAID; two weeks earlier, the patient had looked at her and said: “I’m just done.” Verigin sipped from a to-go cup of coffee, decaf, as she drove. “I try not to have too much caffeine before,” she said.

En route to the patient’s home, we stopped by the hospital to pick up Beth, an oncology nurse who often assists Verigin. Beth has a gift for assessing the energy of the room, Verigin told me, knowing when someone suddenly needed a hand held or a Kleenex, thus allowing Verigin to fully focus on the injections. Beth’s mother, Ruth, had also helped solve a problem Verigin had experienced early in her MAID practice—how obtrusive it felt rolling a clattering tray of syringes into the already fragile atmosphere of a patient’s home. A quilter, Ruth had designed a soft pouch with syringe inserts that rolled up like a towel. The fabric was tie-dyed and the soft bundle was secured with a Velcro strap.

We parked outside the patient’s ranch-style home, the white sun glaring in a clear sky. At exactly 10 a.m., the two clinicians walked to the door, where moments later they were greeted by one of the patient’s grown children. The door clicked faintly behind them.

I remained in the car, and for the next while watched the slow turn of other Thursdays: the neighbors across the street chatting in their sunroom, a dog lazing in front of a box fan. Then, at 11:39 a.m., a text message from Verigin: “We’re done.”

The clinicians were quiet as they slid into the car. “Things weren’t as predictable today,” Verigin said finally. Finding a vein had been unusually hard, and they worried momentarily that they might not succeed, at one point leaving the room to discuss their options. “It’s always been a challenge,” the patient had reassured Beth. “You’re very gentle. It’s not hurting.” The patient had remained calm, unfazed. “I’m sure they were doing that for the kids, to be honest,” Beth said. “And probably me too.”

Once the IV was in place, the provision had unfolded as planned: midazolam, lidocaine, propofol, rocuronium, death. Afterward, the family had thanked and hugged the clinicians. “I think the end outcome was good,” Verigin said. “I probably would be feeling different if we couldn’t fulfill the patient’s wish, because it’s also that big buildup and the anticipation.”

Verigin described a checklist of follow-up tasks, including the paperwork that has to be submitted within 72 hours. But for the rest of the day, her duties as a nurse practitioner would take priority. Only later that night, she said, would she finally have the space to reflect on the events of the morning. When the syringes and vials have been packed up, and the goodbyes to the survivors have been said, it is Lori Verigin who sits in her garden alone. “We are not just robots out there—we’re human beings,” she said. “And there has to be some respect and acknowledgment for that.” Verigin told me she never wants to feel “comfortable” providing assistance in dying. The day she did, she said, would be the day she knew to step back.

For Verigin, providing MAID to Track 1 patients and even to some Track 2 patients has “felt sensible.” She explained: “Yes, I may be nervous. Yes, I may be sad. Yes, I may have a lot of, you know, emotions around it, but I feel like it’s the right thing.” But when it comes to minors, or patients solely with mental disorders, or patients making advance requests, “I don’t know if I’ll feel that way.”

After dropping Beth off at the hospital in Trail, Verigin headed to the Shoppers Drug Mart in Castlegar to return the tackle box. Verigin told the pharmacist she would be back on June 18—the date of her next provision. The pharmacist was grateful for the notice. She would go ahead and order the propofol.

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This article appears in the September 2025 print edition with the headline “Canada Is Killing Itself.”

When gunfire pelted the Atlanta-based headquarters of the CDC yesterday, hundreds of employees were inside the campus’s buildings. The experience was terrifying. But some of the employees were not particularly shocked. “I’m actually surprised it didn’t happen sooner,” a nearly 20-year veteran of the agency told me. (She, like others I spoke with for this article, requested anonymity out of fear of losing her job.)

This was, in one sense, the first attack of its kind on the CDC. The shooter, whom law-enforcment officials have identified as Patrick Joseph White, a 30-year-old resident of an Atlanta suburb, was reportedly fixated on the idea that the COVID-19 vaccine had made him depressed and suicidal. No employees were injured by the bullets that entered the buildings, according to a CDC representative. But an Atlanta police officer named David Rose was shot and later died from his injuries. White, too, was found dead—fatally shot—at the scene. (It is not yet clear if his wound was self-inflicted or if he was killed by police.) When he took aim at the agency on Friday afternoon, he was near a corner where a lone man stands holding anti-vaccine signs nearly every day, several CDC staffers told me.

In another sense, public-health workers have been facing escalating hostility since the early days of the pandemic. In 2020, armed protesters gathered on the Ohio Health Department director’s front lawn, and the chief health officer of Orange County, California, was met with death threats after issuing a mask mandate. She had to hire extra security and was eventually driven to resign. Anthony Fauci, who served as the director of the National Institute of Allergy and Infectious Diseases during the country’s initial COVID response, has faced regular death threats since 2020. Nearly a third of state, local, and tribal public-health workers reported facing some sort of workplace violence in a 2021 survey.

Last year, Fauci told CNN’s Kaitlan Collins that threats of violence to public-health workers correlate with verbal attacks from high-profile politicians and media personalities. “It’s like clockwork,” he said. In the second Trump administration, those attacks have become commonplace—the very selling points, even, that have helped a number of Trump’s health appointees gain their positions. In 2024, when announcing his own pick for CDC director, President Donald Trump maligned the CDC and other federal health agencies, accusing them of having “engaged in censorship, data manipulation, and misinformation.” Robert F. Kennedy Jr. was already a longtime anti-vaccine activist when he took the mantle as America’s health secretary; he has compared vaccinating children to the abuses of the Catholic church. During his own 2024 presidential run, he promised to “clean up the cesspool of corruption at CDC.”

“Normally, threats to public servants aren’t inspired from leadership of their own organization,” another CDC staffer said in a group chat among current and former employees. According to an MSNBC report, during an all-hands meeting today, CDC staff blamed the shooting at least partly on Kennedy’s combative attitude toward the agency. “We need them to stop fanning the flames of hatred against us, stop spreading misinformation,” one employee wrote in the meeting chat, naming Kennedy in the same comment. “We will not be safe until they stop their attacks against us.”

The shooter appears to have brought five guns to the scene, and at least four federal buildings were struck, by dozens of bullets overall. In the hours immediately after the shooting, while many CDC employees remained barricaded in offices and marooned in conference rooms, they heard nothing from Kennedy or Trump. Last night, Susan Monarez, the newly confirmed CDC director, issued a short statement reiterating the basic facts of the shooting. “We at CDC are heartbroken by today’s attack on our Roybal Campus,” she wrote. “Our top priority is the safety and well-being of everyone at CDC.” Late this morning, Kennedy sent an email to the entire staff of the Department of Health and Human Services offering support and prayers. In a post on X at around the same time, he wrote, “No one should face violence while working to protect the health of others.”

This evening, Monarez sent a more substantial email pledging to support the CDC during its recovery and noting its resilience. “We have faced adversity before, and we will do so again, drawing strength from our shared commitment to public health,” she wrote. The president has not yet made a statement about the attack. (The White House and HHS did not respond to requests for comment.)

To the CDC employees I spoke with, the sluggish response is the latest episode in the administration’s escalating abandonment of the agency. Since January, the Trump administration has hit the CDC with massive layoffs, proposed halving its budget, and forced changes to internal policies governing the fundamentals of its scientific work. Earlier this year, Kennedy purged the committee that advises the CDC on vaccine recommendations. Just this week, he canceled nearly $500 million in federally funded research on mRNA vaccines—widely considered among CDC employees and public-health experts to be the greatest domestic triumph of the U.S. pandemic response—stating incorrectly that they cause more risk than benefit against the flu and COVID.

For CDC staff, the wider threat does not seem to have passed. This evening, a group of CDC employees were trading tips on peeling off their old parking decals after the agency’s security office reportedly asked staff to remove them from their cars. One person suggested covering them with other stickers; another recommended loosening them with cooking oil.

Even people who have volunteered for risky missions in their public-health work are still getting used to the idea that the danger has arrived at the home front. “I’ve put my life on the line for this agency, responding to outbreaks in some of the most dangerous parts of the world,” a 13-year veteran of the agency told me. “I didn’t expect to face the same risks at the Atlanta campus as I faced in South Sudan.”

Last month, America’s top health officials gathered in downtown Washington for an ice-cream party. Health and Human Services Secretary Robert F. Kennedy Jr.—joined by Secretary of Agriculture Brooke Rollins—hunched over a cooler and served himself a scoop. Off to the side, FDA Commissioner Marty Makary licked a cone. There was a reason to celebrate: The dairy industry, like many of America’s largest food makers, had acquiesced to the “Make America Healthy Again” movement’s crackdown on synthetic food dyes. The International Dairy Foods Association, a lobbying group, announced that more than 40 major ice-cream companies would begin phasing out several dyes that RFK Jr. has blamed for a slew of chronic-health problems, especially in children. “I’m very grateful for this industry for stepping up,” Kennedy told onlookers.

By the end of 2027, Hershey’s birthday-cake ice cream won’t have Yellow 5 or Red 40, nor will its “blue moon” flavor have Blue 1. But your ice cream might still come with one particular artificial food dye: titanium dioxide, a chemical that turns food white and isn’t included in the International Dairy Foods Association’s “Ice Cream Commitment.” (Yes, the milk in ice cream already is white to begin with, but titanium dioxide helps keep some ice cream with added ingredients from looking like the muddied leftover milk in a bowl of cereal.) Titanium dioxide is added to many other foods, too, including salad dressings, low-fat milks, and soups. So far, the chemical seems to be largely surviving the food-dye purge. Many companies—including Kraft Heinz and General Mills—don’t mention titanium dioxide in their promises to replace similar dyes. (Neither company responded to multiple requests for comment.)

You might be eating more titanium dioxide than you think. Even food that isn’t white might contain it. The chemical is commonly used as a base layer—kind of like primer on a wall—to make brightly colored products pop. It’s not always named as an ingredient in foods that are made with the dye. Other synthetic dyes, such as Red 40 and Yellow 5, which are made from petroleum, must be disclosed on a product’s nutrition label. (That’s also true for several other dyes that end in a number.) The FDA, however, allows food companies to simply label titanium dioxide as an “artificial color,” given that technically titanium is a mineral.

Food makers argue that this distinction demonstrates that titanium dioxide is not like other dyes. The International Dairy Foods Association told me that it’s “focused on removing certified artificial colors” when I asked whether the group’s pledge included titanium dioxide. A spokesperson for the Consumer Brands Association, a major lobbying group that recently announced a food-dye pledge of its own, similarly said that the numbered dyes “are a unique subset.” Whether people really should fret about titanium dioxide while licking an ice-cream cone is a contentious question. In 2022, the European Union banned the dye over concerns that tiny particles in the product could build up in the body and damage DNA. But the decision wasn’t based on clear evidence that links the chemical to specific ailments. Rather, European officials identified “some data gaps and uncertainties” about the dye’s health impacts, and acted out of an abundance of caution.

The evidence against titanium dioxide isn’t much different from that against other artificial dyes. Food makers have stopped using the numbered dyes based solely on preliminary science. Prior to Kennedy’s confirmation, many of the same organizations that are now touting the food industry’s efforts to remove synthetic dyes were arguing that requests to ban these ingredients were scientifically flawed. In 2023, the Consumer Brands Association, alongside two other trade groups, argued that the FDA should not ban Red 3, because the science around its health harms was unconvincing.

Kennedy has indicated that he does want to phase out titanium dioxide along with other synthetic dyes, pointing to the European ban. Titanium dioxide is listed as a food additive of concern in a report on childhood chronic disease recently released by the Trump administration’s MAHA Commission. (“HHS takes the safety of food ingredients seriously and will continue to review available evidence and expert guidance on this and other additives,” a Health and Human Services spokesperson told me in an email.) MAHA has had some victories when it comes to titanium dioxide. At the end of last year, the food giant Mars removed the chemical from Skittles. The ice-cream company Turkey Hill, which joined the dairy industry’s dye pledge, is in the process of purging its products of titanium dioxide, a spokesperson said. (The company did not respond after I asked when that transition would be complete.) A representative for PepsiCo told me that the company is phasing out titanium dioxide in the one product it sells that includes the chemical: Muscle Milk. But many more companies that are replacing other artificial food dyes have been quiet about titanium dioxide.

The food industry is reluctant to give the chemical up for a reason. It’s remarkably efficient as a food dye—nothing else comes close to its ability to turn food white. (No wonder versions of the chemical are also used in house paint.) The main replacement is calcium carbonate, also known as chalk, which is much less opaque, and so food companies would need to use much more of it to get the same whitening effect. This could not only make products more expensive, it could impact the texture and taste of the underlying food. Some companies have successfully been able to reformulate their products: Skittles look the same as they always have. “These reformulations are not easy and can sometimes take months to years to accomplish adequately,” Dave Schoneker, a food-dye consultant, told me. “This ends up being a big investment.” Not every company will have a bench of food scientists able to spend years reformulating its products.

Without titanium dioxide, consumers may just have to get used to uglier food. At one point while working on this story, I went to the grocery store and picked up two blue-cheese dressings—one with titanium dioxide and one without. The version with the additive looked like what I expected blue-cheese dressing to look like: pearly white. The other one looked a bit like grayish-green mucus.

That’s not a proposition that excites the food industry, nor is it something that companies seem to believe Americans can handle. As California prepared to become the first state to ban several food additives in 2023, titanium dioxide was removed from the legislation at the eleventh hour amid vocal opposition from food companies. Before caving to pressure, Mars had resisted calls for the company to stop using artificial dyes in sweets; instead, the company settled on doing so just in Europe, citing that it’s where “consumers have expressed this preference.” Indeed, European consumers are “okay with muted tones,” Chari Rai, the head of innovation for  North America at Oterra, a natural-color manufacturer, told me. “I think the difference in the U.S. market is they’re just so used to seeing vibrant colors.”

If the industry is correct and Kennedy cannot persuade Americans to embrace an ugly scoop of ice cream, that would signal he’s going to have an even harder time pushing Americans away from foods containing the many other ingredients that he claims, with varying degrees of evidence, are making people sick. Food dyes are just cosmetic. (Ice cream still generally tastes the same with or without titanium dioxide.) Other food additives, such as emulsifiers and low-calorie sweeteners, serve a bigger role; ultra-processed foods, which Kennedy opposes, make up a sizable portion of the American diet. MAHA still has much bigger battles to fight.

Last week, the National Institutes of Health finally got some good news. A Senate subcommittee voted, with support from both parties, to increase the agency’s $48 billion budget—a direct rebuke to the Trump administration’s proposed budget, which would have slashed the agency’s funding some 40 percent. After the administration spent months battering the NIH with funding freezes, mass firings, and waves of grant terminations, that Senate vote was one of the only clear signals since January that at least some leaders in the U.S. government were committed to preserving the NIH’s status as the world’s largest public funder of biomedical research.

But inside the agency, officials could not wholeheartedly celebrate. Its political leadership has shredded the NIH playbook so thoroughly, current and former NIH officials told me, that even at current funding levels they are unable to perform their core work of vetting and powering some of the best scientific research around the world. One official told me many of their co-workers are worried that “even if we get the money, we won’t be allowed to spend it somehow.” (Several of the current and former NIH officials I spoke with for this story requested anonymity for fear of professional repercussions.)

At this point in the summer, NIH officials are always rushing to spend the agency’s remaining funds before the fiscal year ends on September 30. “More grants get processed during the fourth quarter than at any other time,” one former NIH official who oversaw grants told me. Usually, they make the deadline. This year, though, the Trump administration’s blocks to grant-making and cuts to staff have left those remaining so far behind that many of the agency’s 27 institutes and centers will fall far short of using up the money they’ve been allocated, several officials told me.

If those funds are unspent, the NIH will be forced to return a massive sum to the Treasury—which several current and former NIH officials are afraid could be used to justify future budget cuts. The administration “is setting them up to fail,” the former official told me. In the United States, government agencies need Congress to fund them, but the executive branch still runs them. The Trump administration is no longer allowing the NIH to function as an agency that can handle a $47 billion budget.

When reached for comment, an NIH spokesperson wrote in an email that the agency is “committed to restoring academic freedom, cutting red tape, and accelerating the delivery of grants to support rigorous, truth-based science,” and that it is “focused on empowering our workforce, removing bureaucratic obstacles, and fostering a culture of transparency and collaboration.” The officials operating under these principles see it differently: “It is an ongoing siege,” one of them told me. “We’re losing all capacity to act,” another said. “And we are losing hope.” For decades, the NIH’s primary function has been distributing billions of dollars—the bulk of its budget—to the American biomedical-research community. This year, though, the agency’s ability to get its funds out the door has faltered in ways it never has before: A STAT analysis found that, as of mid-June, the agency has awarded 12,000 fewer grants and about 30 percent less in funding—at least $4.7 billion—than it typically would have by that point in the year.

To mete out those funds, the agency pores over at least tens of thousands of grant applications every year, subjecting them to reviews from multiple panels of experts; only about 20 percent are funded, or sometimes far less. The agency then monitors researchers’ progress, disbursing funds incrementally over the course of several years. But since January, political appointees “have been successfully clogging up the system in every place it could be clogged,” Sarah Kobrin, a branch chief at the National Cancer Institute, told me. The administration has blocked the agency from notifying researchers of new funding opportunities; it has held up the meetings required for reviewing applications. It has instructed officials to scour grant applications for references to diversity, gender, climate change, and other concepts that the current political leaders want to erase from scientific inquiry, then to sideline those proposals. It has frozen payments meant to go out to researchers, essentially cutting them and their staff off from their salaries. And it has, over months, pushed the NIH to cancel grants that the agency had already awarded, at a scale NIH officials told me they’ve never experienced—thousands of grants canceled not, as in the past, for ethical violations or because logistical hurdles made the research impossible to advance, but because they conflicted with the administration’s political goals.

Many of these disruptions have been reversed, in some cases, within days or even hours. But at an agency where policy changes have typically been painstaking, heavily deliberated affairs, the onslaught of sudden shifts has left officials feeling exhausted, afraid, and hamstrung—unable to fund science at the rate they once could. “No one can function under this kind of whiplash,” Kobrin told me. “People are joking about getting neck braces.”

Last Tuesday, officials endured yet another jarring U-turn. First, news broke that the Office of Management and Budget had barred the NIH from spending its funds on anything but staff salaries and expenses—yet another blow to grant-making that effectively guaranteed that the agency’s already sluggish spending would completely stagnate. Then, hours later, senior White House officials intervened to reverse the decision. The second round of information arrived so late at night, Kobrin told me, that the next morning, several of her colleagues hadn’t yet gotten the message and were scrambling to rejigger their spending plans.

The back-and-forth over grant cancellations has been especially demoralizing. When the grant terminations began, two grants-management officials told me, officials were forbidden from communicating with researchers, even as their voicemails and inboxes flooded with panicked questions. “It was like dumping someone over text, and then blocking their number and ghosting them,” one of them said. That policy is no longer in place, but this means officials instead must tell researchers their funding has been paused or permanently severed, and struggle to explain why. After spending months cutting funds to researchers, many grants-management specialists then had to undo that work in a matter of days, after a federal judge ordered the agency to immediately reinstate hundreds of grants. And should the Supreme Court rule in the administration’s favor, “many of us figure we’re going to have to re-terminate all these grants anyway,” one grants-management official told me. That official has now helped award, terminate, then reinstate multiple grants—and may need to help terminate them again soon. In the meantime, officials are operating on two distinct sets of guidance: rules that apply to grants awarded to scientists in states subject to the recent court order, and Trump administration guidance that still holds everywhere else.

The job of “NIH official” has simply gotten much harder. New guidance arrives at odd hours, with impractical deadlines. Several upheavals have rippled through the agency via closed-door meetings and hallway rumors, instead of with clear paper trails. The guidance issued, multiple officials told me, has also felt absolutist—do this, or you’re fired—while often coming off as so vague that, at times, different institutes have diverged in their interpretation, leaving funding policies inconsistent and officials unsure if they have made career-ending mistakes. “The environment is clearly, they’re going to fire whoever they want for whatever reason they want,” one grants-management specialist told me. And looming over each new change is the possibility that officials are, once again, being asked to do something of sufficiently questionable legality that a court will quickly block it.

Many officials have quit or been fired, and every month, more are choosing to leave. One official told me that they have attended as many “un-happy” hours in recent months to say good-bye to co-workers as they had been to over the past five years. “And those are just the ones I managed to go to—I was invited to more,” the official said. “People just don’t leave that much. Or they didn’t.”

Officials still at the agency told me that the pileup of new policies, combined with staff departures, has saddled them with heavier workloads. “We have more work to do with fewer people,” one official told me. And what work remains, that official said, feels as though it’s being done in molasses. “I cannot fulfill all the duties responsibly in the time required,” Theresa Kim, a program officer at the National Institute of Aging, told me. Twenty of the grants in her portfolio were supposed to start paying out to researchers on June 1, she told me. But staffing cuts—especially losses from the grants-management team, which handles the budgetary aspect of grants—and endless back-and-forths over whether certain grants comported with new political priorities—meant that a funding process that should have taken just a couple of weeks had instead dragged on for months. As of this week, Kim said, 14 of those research teams had yet to receive their federal funds.

When I asked officials what it would take for the NIH to feel normal again, most of them didn’t bring up the agency’s budget at all. They instead described more philosophical changes. They wanted to do their work under clear guidance and a supportive director, without political interference or fear that their employment is constantly on the line. “Leave us alone,” one official told me. “Let us do our jobs.” Financially, the NIH—for now—remains intact. The Senate has also pushed back on the Trump administration’s proposal to restructure the agency entirely. But the NIH is fast losing what turns out to be its most important resource: people.

For the better part of the past century, the case against nicotine was simple: Smoking a cigarette might feel nice, but it will eventually kill you. Nearly one in five deaths in the United States is caused by complications from cigarette smoke. Chewing tobacco is less dangerous, but still deadly: It has long been associated with head and neck cancers.

But in 2025, nicotine isn’t so straightforward. Smoking is so deadly not because of nicotine, per se, but because of tobacco: Lighting a cigarette burns tobacco, releasing nicotine into the body. Chewing tobacco entails gnawing on actual tobacco leaves. Nowadays, it’s easier than ever to get a nicotine buzz without any tobacco at all: Just puff on a vape or pop a tiny nicotine pouch between your teeth and upper lip. These cigarette alternatives have been around for a while, but only recently have they gone fully mainstream. In January, the FDA officially sanctioned the sale of Zyn, among the most recognizable nicotine-pouch brands. In the past three months alone, Philip Morris International, which makes Zyn, shipped 190 million cans of the stuff to stores. And last month, the agency reversed a prior ruling and authorized Juul e-cigarettes. These products, the FDA has concluded, “generally have lower health risks than cigarettes.”

In this nicotine boom, it’s easy to see the drug as harmless, even good for you. Ads that tout the benefits of nicotine are everywhere: Zyn, for example, has been marketed as an “office essential” that also offers “relaxation on-the-go.” Nicotine somehow feels both energizing and relaxing at the same time, kind of like the buzz of a vodka Red Bull. The drug has been linked to statistically significant improvements in a number of cognitive exercises. The marketing goes further: Joe Rogan has hawked Athletic Nicotine, a nicotine-pouch brand that claims the drug can serve as an “exercise performance-enhancing tool.” Tucker Carlson—who has his own brand of nicotine pouches—recently claimed that because of nicotine, he is “never sick.”

[Read: The inconvenient truth about vaping]

But nicotine is not a wonder drug. The cognitive improvements found in studies were modest. Bethea AnnaLouise Kleykamp, an assistant professor of psychiatry at the University of Maryland who has studied nicotine, summed it up this way: The drug “might be, if you were to subtract it from the smoke, something that could help some people,” such as those who are sleep-deprived or have a cognitive disorder like ADHD. Not exactly a ringing endorsement. Moreover, there’s still a lot we don’t know about what nicotine alone does to the body.

All of this has nicotine in a strange place. Before the advent of newer products, the field of public health was united in its stance that no one should be using cigarettes, and thus nicotine. Now the message is more muddled than ever.

Some public-health experts still suggest staying away from nicotine in and of itself. After the decades-long war against smoking, they see new products as Big Tobacco’s latest gambit to hook the public. Others make a different calculation: If the health effects of nicotine alone are less concerning than those of cigarettes, what’s so bad about an adult sucking on a Zyn? Presuming people recognize that these products “may have some health risks,” Neal Benowitz, an emeritus professor of medicine at UC San Francisco, told me, “I have no problem with that.”

Such differing views stem from the unclear health effects of cigarette alternatives. Consuming nicotine via vape or pouch is surely safer than smoking a cigarette, but that isn’t saying much. No researchers I spoke with gave nicotine an unequivocal endorsement. “I would never go so far as to say that any drug is completely safe,” Jed Rose, an emeritus professor of psychiatry at Duke University who runs a research firm that has done paid research for nicotine companies, told me. “Whether nicotine contributes in any way to other diseases associated with smoking is not as firmly resolved as people like to think.”

Rose cited a study that showed nicotine accelerated tumor growth in mice. Other experts I spoke with cited data from Sweden demonstrating that smokeless products carry some cardiovascular risks. And emerging research indicates that the components inside of vapes can leach heavy metals into the mist that users inhale, potentially exposing them to increased cancer risk. For the most part, science simply hasn’t answered the question of how bad nicotine alone is for you. Most of the studies on the bodily effects of nicotine have been completed using subjects who smoke.

For now, the clearest problem with puffing on a Juul is that nicotine remains extremely addictive, whatever form it comes in. Addiction researchers have said that nicotine is just as difficult to quit as heroin. Smokeless products might be a little easier to quit than cigarettes, based on how they deliver nicotine. But it’s reasonable to assume that these new products will also worsen the problem of nicotine addiction by making the drug easier to consume. Desk workers can pop nicotine pouches without having to step away for a smoke break. Vape clouds are more readily concealed than the stench of cigarette smoke. This is part of the appeal: Rogue, a Zyn competitor, advertises its product as a way to “enjoy the nicotine you love without getting noticed, whether you’re in a marathon of meetings, perfecting your meal-prep, or just can’t step away for a smoke break.” (Rogue, like other nicotine brands, has to legally include warnings in its ads that its products are addictive.)

The effects of an addiction alone are not typically a first-order concern in the world of public health. Addictions typically come with other, more pressing consequences: For cigarettes, it’s heart attacks and cancer; for heroin, it’s overdoses. Anyone who has seen photos of smokers hooked to oxygen or revealing their lung-cancer scars can attest that public health has become expert in warning potential victims of these types of health problems. The risks of a nicotine addiction without the smoke are murkier. “There are interpersonal, intrapersonal, and economic consequences to being addicted,” Eric Donny, a neuroscience professor at Wake Forest University who studies nicotine, told me. “It’s really hard to quantify this in a way that we are used to.”

Nicotine boosters have compared the drug to caffeine—which is also addictive, but generally not a problem. (Hence the Death Before Decaf shirts, tote bags, and even tattoos.) But research suggests that nicotine addiction is more intense than a caffeine dependency, potentially taking a bigger toll on people’s lives. The financial costs alone can be onerous: Nicotine prices vary a lot from state to state, but in Washington, D.C., where I live, someone with an extreme Zyn habit may be shelling out upwards of $10 a day to feed their addiction. A Juul isn’t much cheaper. With either product, a heavy user is likely to spend several thousands of dollars a year.

Addiction can also take a psychological toll. Being hooked on nicotine means your brain is always screaming for another hit of the drug. At times, the longing can feel insatiable, and can force people to act in ways that are entirely against their own self-interest. A teen addicted to vaping might take a few puffs in the school bathroom, even if getting caught might mean a suspension. Or a longtime user may continue to pop nicotine pouches after a heart attack, despite research showing that quitting nicotine significantly reduces someone’s risk of death.

These downsides might seem minuscule compared with those of cigarettes. A rotting lung is considerably worse than a $10-a-day nicotine habit. But they shouldn’t be ignored. If cigarette-smoking rates continue their decades-long drop, it’s reasonable to assume that vaping and pouches will become the dominant ways people consume nicotine. New nicotine products might have solved the biggest problem with smoking. Many other, more subtle problems still remain.

Vinay Prasad, until Tuesday one of the country’s top medical regulators, just got a bitter taste of what it means to have real power. In recent months, the academic hematologist-oncologist, medical contrarian, and polemic podcaster had become a central figure at the U.S. Food and Drug Administration. In May, he was chosen to lead its Center for Biologics Evaluation and Research—a position that gave him authority over vaccines and gene therapies. In June, Marty Makary, who is currently the FDA commissioner, bestowed upon him an even more important role: chief medical and scientific officer of the entire agency. This week, Prasad abruptly departed.

We don’t know the exact reason behind Prasad’s departure. According to a Department of Health and Human Services spokesperson, he resigned to “spend more time with his family.” (Neither Prasad nor HHS responded to my request for comment.) Politico reports that President Donald Trump ordered his removal this week over the objections of Makary and Health and Human Services Secretary Robert F. Kennedy Jr. Whatever the particulars, Prasad’s sudden need for a better work-life balance suggests the administration is following a time-honored approach to medical regulation: Business comes first.

Prasad’s troubles began in the first weeks of his tenure at the FDA, when he overruled the agency’s own scientific reviewers by limiting the use of COVID vaccines. In doing so, he managed to anger the country’s pro- and anti-vaccine factions at the same time. While many public-health experts criticized the decision to limit access to the shots, Kennedy’s allies in the “Make America healthy again” movement felt betrayed by the fact that the government had allowed mRNA shots to remain available at all.

Prasad also faced a blitz from the pharmaceutical industry and patient-advocacy groups after the FDA tried to suspend distribution of a gene therapy for Duchenne muscular dystrophy called Elevidys, over safety concerns. For those affected by this rare, incurable condition, the move was seen as an outrageous denial of their right to weigh the drug’s risks and benefits for themselves, and an extinguishing of what had been at least a glimmer of hope. Two days later, the right-wing provocateur Laura Loomer publicly accused Prasad of “sabotaging Trump’s deregulatory agenda,” and an opinion writer for The Wall Street Journal declared him a “one-man death panel.”

I know Prasad a bit: I’ve twice been a guest on his podcast, and I’ve followed his prolific academic work and public commentary about evidence-based medicine since about 2016, when he was a young professor at Oregon Health & Science University working to identify low-value medical practices. We’ve had our disagreements over the years. But with respect to Elevidys and drugs like it, our views are in alignment. We share the worry, for example, that the FDA keeps lowering its approval standards for drugs that keep getting more expensive. “The American economy can handle a great deal of wasteful health-care spending,” Prasad told me in an interview in 2021. “But it can’t tolerate an infinite number.”

His skepticism of Elevidys, in particular, is both long-standing and well-founded. The therapy has not been conclusively shown to slow the progression of the muscle-wasting disease it targets, but it does often induce vomiting and damage patients’ livers. Worryingly, it also appears to be related to a pair of deaths. Prasad’s predecessor in his role at CBER, Peter Marks, approved the drug, which costs $3.2 million per course of treatment, in spite of his own staff’s uncertainty about its benefit. (Marks was forced out by Kennedy this spring, after the two clashed over access to vaccine-safety data.)

[Read: The sanewashing of RFK Jr.]

That Prasad should take a tough line on drug regulation was perfectly in keeping with his history. He rose to prominence on that basis: To his many fans, he was a dogged and courageous industry watchdog; to his many critics, a self-righteous pharma scold. That mainstream Republicans should balk at this approach, and strive to undo it, was equally predictable. Politicians, particularly those on the right, have for years supported patients’ ability to obtain still-unproven therapies. During Trump’s first term, the president signed into law the “Right to Try Act,” which expanded access to experimental drugs. That law was championed by Republican Senator Ron Johnson, who, according to reporting from STAT, may have been instrumental in Prasad’s ouster.

One might have guessed that things were different now in Washington—that Kennedy’s eccentric philosophy had ushered in a novel form of conservative leadership, in which business interests didn’t always lead the way. Thus far, however, the MAHA movement has done little to adjust the status quo. Instead, it has mostly wallowed in its own contradictions. We’ve been told that cooking with seed oils is toxic but that treating measles with cod-liver oil is great; and that both deworming pills and microbe-laden raw milk are good for you. MAHA leaders have declared the FDA a “sock puppet of industry” from which Prasad himself would provide a “welcome reprieve,” while also championing the public’s right to choose its food and drugs (even as they interfere with the distribution of some vaccines).

[Read: How ivermectin became right-wing aspirin]

So which is it? Should people have easy access to almost any health-care intervention, or should the government protect vulnerable patients from drugs for which there isn’t rigorous evidence of benefit? For years, Prasad has been clear on where he stands in that regard. “It is not a case of patients who crave risk facing off with regulators who abhor it,” he wrote in a medical journal in 2019. Rather, the current system, in which “reliable data are inconsistently generated,” has failed patients who wish to make informed decisions about their care.

Whenever this tension has been tested in the Trump administration, MAHA leaders have almost always seemed inclined to move the other way. A recent op-ed by the FDA’s Makary and Mehmet Oz, the head of the Centers for Medicare & Medicaid Services, summed up the current regulatory approach as follows: Agency bureaucrats should cooperate with industry leaders instead of antagonizing them, and the government should favor “market solutions” over “prescriptive regulation.” Indeed, even as the news of Prasad’s firing was coming out, Makary was promoting his “national listening tour” of private interests. “Looking forward to hearing from more pharma and biotech CEOs!” he wrote on X.

Prasad himself appeared to recognize which way the wind was blowing. From the moment he took office, he was tempering his point of view. Before he became a political appointee, Prasad was dogmatic in his dismissal of evidence that did not emerge from large, randomized clinical trials. (“As readers know, my philosophy is RCT or STFU,” he wrote in his newsletter in 2023.) But Prasad seemed to back away from this idea even in his opening remarks to his new colleagues and staffers. “Randomized controlled trials are not always necessary, and when they are done, they are not always informative,” he reportedly said on May 7, his second day on the job.

Such appeasement efforts proved insufficient to protect him from rival forces in the Republican Party, if not also in the MAHA movement itself. For the moment, Prasad has been replaced at CBER by the wealthy biomedical entrepreneur George Tidmarsh. Surely that will come as a relief to a constituency that seems to hold immense sway with this administration: America’s drug companies and medical-device makers.

Police are still investigating what exactly prompted a gunman to kill four people in a Manhattan office building yesterday evening, but perhaps the clearest aspect of his motive is the condition that he evokes in a note found on his body: chronic traumatic encephalopathy.

The 27-year-old gunman, Shane Tamura, was a former high-school football player. He targeted the Midtown skyscraper that houses the National Football League, though none of the four people he shot and killed before ending his own life was an NFL employee. (According to a statement from NFL Commissioner Roger Goodell, one league employee was “seriously injured” and in stable condition at a hospital.) In his note, Tamura reportedly speculated that CTE might have been a cause of his mental illness, but it’s still too early for medical examiners to offer a diagnosis. (And even if an autopsy were to show anomalies in his brain, it could never reveal what precisely drove him to homicide.) Like at least one NFL player who died by suicide, Tamura asked that his brain be studied after he died.

Concerns about CTE and football have been mounting for more than two decades. In 2013, the NFL settled a lawsuit brought by more than 4,500 former players who claimed that the league concealed from them the risks of brain injury, including CTE. CTE is both rare and difficult to diagnose, so scientists haven’t definitively established its symptoms. They’re thought to include memory loss, personality changes, suicidality, and loss of motor control—all of which can be both devastating and caused by any number of disorders. Research overwhelmingly validates the link between the condition and professional football careers.

But the consequences of playing high-school football are not well studied—a major oversight, given that most people who play do not end up in the NFL, Eleanna Varangis, a University of Michigan professor who studies brain injury, told me. “The majority of the experience is at the youth level, and we still don’t know a lot about how those people look later in life,” she said.

Because CTE can be diagnosed only after death, whether Tamura had it is not yet known. Clearly, based on his note, something appears to have led him to suspect that he did. But two experts I spoke with about the condition—both of whom are advocates for better research and care in understanding CTE—told me that they had little reason to suspect that a person like Tamura would in fact have had the condition just because he played high-school football. (So far, a high-school teammate and a coach have told NBC News that Tamura was a talented player, but no further details have emerged about his time in the sport.) Jesse Mez, an associate professor of neurology at Boston University’s Chobanian and Avedisian School of Medicine and a co-director of clinical research at its CTE Center, has studied the risks of CTE across football careers ranging from one year up to 30—high schoolers to professional players. He found that the longer people play, the greater their risk of developing CTE. After five and a half years of playing, the relationship starts to be linear. But in careers shorter than that, “the likelihood of getting the disease is quite low,” Mez told me.

CTE is thought to be caused by repetitive blows to the head, whether or not they lead to concussions. But scientists have not been able to pin down the precise number of impacts (or concussions) that cause someone to tip over the threshold into CTE, and even if they could, the length of a player’s career is an imperfect proxy for how many times they hit their head, Kristen Dams-O’Connor, the director of Mount Sinai’s Brain Injury Research Center, told me. There is variability, too, in susceptibility: Some people might develop CTE after fewer blows to the head. Genetics may also play a role. Although research shows the chances that a high schooler would develop CTE are extraordinarily small, “it’s hard to say what small is,” Mez said.

[Read: Tua Tagovailoa’s impossible choice]

The ambiguities around diagnosing CTE are made only worse by the fact that it cannot be confirmed before death. “I think it would be a huge service to be able to diagnose it in life, even without absolute certainty,” Mez said. Some signs indicate that all of that fear and confusion has led to excessive self-diagnosis. CTE appears to be “uncommon” in professional football if you take all players into account, Dams-O’Connor told me. And yet, in a 2024 study of former NFL players, more than one-third believed they had CTE. To assume that CTE is to blame for, say, depression, just because a person played football, is “really harmful logic,” Dams-O’Connor said: It suggests that nothing can be done, that a person is doomed to a life of irreversible decline from a disease with no direct treatments. Whether or not Tamura had CTE, it’s chilling to think that his conjecture that it contributed to his mental illness may have driven him to violence.

Plenty of other factors, football-related or not, may have also caused or exacerbated Tamura’s mental illness, Mez said. Some research suggests that high-school football players may have greater risk for comorbidities that affect brain health, such as cardiovascular or cerebrovascular disease. A 2018 study found that people who start playing football before age 12 are at risk of experiencing cognitive, behavioral, and mood-related problems earlier in life than those who start playing when they’re older. And studies have shown that brain injuries (from football or any other cause) are associated with mental-health issues, including a higher risk of suicide, homicide, and criminal tendencies. New York City Police Commissioner Jessica Tisch said at a press briefing last night that the gunman had a “documented mental-health history,” and multiple outlets have reported that he was placed on psychiatric hold in both 2022 and 2024.

[Read: The future of detecting brain damage in football]

The New York City Office of the Chief Medical Examiner said in a statement today that it would examine Tamura’s brain during an autopsy—just as he wished. Perhaps the findings will add to the messy, ongoing science of CTE. Or perhaps they will prove a lesson in what happens when players are too quick to suspect it.

Americans have a long history of enduring heat waves by going outside. In a 1998 essay for The New Yorker, the author Arthur Miller described urbanites’ Depression-era coping mechanisms: People caught the breeze on open-air trolleys, climbed onto the back of ice trucks, and flocked to the beach. In the evenings, they slept in parks or dragged their mattresses onto fire escapes.

But since air conditioning went mainstream, in the 1960s, the easiest way to beat the heat has been by staying indoors—at home, the office, the mall—where cool air is a constant and blinds are often drawn to prevent homes from overheating (and electric bills from skyrocketing). For this convenience, Americans sacrifice the benefits of sunshine and the opportunities for fun it creates. As climate change turns up the temperature, summers in America are coming down to a choice between enduring the heat and avoiding it—both of which might, in their own ways, be making people sick.

In cities across the country, summers are, on average, 2.6 degrees hotter than they were some 50 years ago. In Phoenix, where a 95-degree day is a relief, schedules are arranged around the darkness; Jeffrey Gibson, an accountant who works from home, takes his eight-month-old daughter out for walks before 6:30 a.m.; after that, it’s so hot that she flushes bright red if they venture outside. He spends the rest of his day indoors unless leaving is absolutely necessary. It’s like this from April to October. Gibson recently told his wife, “Man, I think I’m a little depressed.”

Josef A. Von Isser, a therapist in Tucson, Arizona, told me that feeling low in the summer comes up a lot with his clients. Some feel that the heat affects them directly; others struggle with its indirect effects, such as fewer opportunities to socialize and be somewhere other than home or the office. All of them, he suspects, might be experiencing seasonal affective disorder.

The DSM-5 categorizes SAD as a type of major depression with a seasonal pattern, with symptoms such as sadness, feelings of worthlessness, and low energy. Usually, it presents in the winter, though scientists don’t agree on why. Some suspect that it’s because a lack of sun exposure may contribute to decreased levels of serotonin, a hormone that regulates mood, as well as vitamin D, which helps stimulate serotonin activity. Another theory links low exposure to sunlight with unusually high levels of melatonin, a hormone that helps regulate sleep.

[Read: The surprising truth about seasonal depression]

Summer SAD is generally accepted as a variety of the disorder, but it’s much rarer than the winter form; one study from earlier this year puts its prevalence at about 0.6 percent. That makes summer SAD especially hard to study. “It’s clearly a different kind of illness,” Paul Desan, a psychiatry professor at Yale, told me, but “it’s not in their imagination.” Unlike the winter form, which comes with a tendency to overeat, oversleep, and withdraw from society, summer SAD involves reduced appetite, insomnia, and restlessness—all of which can also be effects of heat. The scientific literature shows that heat is associated with mood disorders, anxiety, aggression, and reduced cognitive abilities. Uncomfortably hot nights, longer periods of daylight, and extended stretches of time spent indoors all disrupt sleep, which can in turn fuel mood disorders, Amruta Nori-Sarma, an environmental-health professor at Harvard, told me. Extreme heat can also be an obstacle to exercising, spending time in nature, and socializing, all of which can make people feel good and also double as important coping mechanisms for emotional distress.

Taking comfort in air conditioning when it’s too hot out is a natural human response. But air-conditioned spaces can be stifling in their own way. Staying home where it’s cool also means socializing less; some offices and homes hardly let in a wink of sunlight all day. It’s plausible that in the summer, people experience SAD symptoms not only from excessive heat but also because they spend all of their time avoiding the sun, Kim Meidenbauer, a psychology professor at Washington State University, told me. “It does make sense to me that you’d have, potentially, an analogous pattern of effects” to winter SAD, she said. The link between indoor time and summer SAD hasn’t been studied, but plenty of Americans, even if they don’t meet the DSM-5 criteria, are noticing that summer is starting to feel a lot like winter. Reddit abounds with users who lament that being forced indoors by the heat gives them “summer depression.”

America’s summer quandary—suffer inside or out?—will become only more persistent as climate change intensifies. In the United States, heat waves have grown more frequent and intense every decade since the 1960s. During a single heat wave last month, people in 29 states were warned to stay inside to avoid dangerously high temperatures. All of the experts I spoke with expressed concerns about the impacts of escalating heat on mental health. “I am not optimistic,” Ayman Fanous, a psychiatry professor at the University of Arizona, told me, noting that heat also has a well-established link with suicide risk and can exacerbate mental-health conditions such as schizophrenia, bipolar disorder, depression, and substance abuse. Many Americans don’t have access to air conditioning, or they work jobs that require them to be outside in the heat. Those who can stay cool inside may avoid the most severe consequences but still end up miserable for half of the year.

[Read: Earth’s new gilded era]

As long as summer SAD remains poorly understood, the options for addressing it will be limited. Treatment for winter SAD usually involves exposure to light boxes that mimic sunlight, but these aren’t recommended for summer SAD, because it might have a different neurobiological basis, Fanous said. For now, the first-line treatments are SSRIs such as Prozac—which can make people even more sensitive to heat.

For those with the means, the best strategy for beating summer SAD might be to move somewhere cooler. After eight years in Phoenix, Gibson has had enough of hiding from the heat for six months at a time and is ready to leave behind what he believes is his own summer SAD. Later this year, he plans to move his family to Colorado, where he hopes to be able to bring his daughter out during daylight hours. Yet Colorado summers, too, are becoming uncomfortably hot—and the same goes around the country. Last month, Alaska issued its first-ever heat advisory. As summer temperatures continue to rise, perhaps Americans will start to look back with envy on the ways our forebears beat the heat. The hotter summer nights get, the more sleeping on the fire escape starts to sound like a luxury.