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Becoming a public-health expert means learning how to envision humanity’s worst-case scenarios for infectious disease. For decades, though, no one in the U.S. has had to consider the full danger of some of history’s most devastating pathogens. Widespread vaccination has eliminated several diseases—among them, measles, polio, and rubella—from the country, and kept more than a dozen others under control. But in the past few years, as childhood-vaccination rates have dipped nationwide, some of infectious disease’s ugliest hypotheticals have started to seem once again plausible.

The new Trump administration has only made the outlook more tenuous. Should Robert F. Kennedy Jr., one of the nation’s most prominent anti-vaccine activists, be confirmed as the next secretary of Health and Human Services, for instance, his actions could make a future in which diseases resurge in America that much more likely. His new position would grant him substantial power over the FDA and the CDC, and he is reportedly weighing plans—including one to axe a key vaccine advisory committee—that could prompt health-care providers to offer fewer shots to kids, and inspire states to repeal mandates for immunizations in schools. (Kennedy’s press team did not respond to a request for comment.)

Kennedy’s goal, as he has said, is to offer people more choice, and many Americans likely would still enthusiastically seek out vaccines. Most Americans support childhood vaccination and vaccine requirements for schools; a KFF poll released today found, though, that even in the past year the proportion of parents who say they skipped or delayed shots for their children has risen, to one in six. The more individuals who choose to eschew vaccination, the closer those decisions would bring society’s collective defenses to cracking. The most visceral effects might not be obvious right away. For some viruses and bacteria to break through, the country’s immunization rates may need to slip quite a bit. But for others, the gap between no outbreak and outbreak is uncomfortably small. The dozen experts I spoke with for this story were confident in their pessimism about how rapidly epidemics might begin.

[Read: How America’s fire wall against disease starts to fail]

Paul Offit, a pediatrician at Children’s Hospital of Philadelphia and co-inventor of one of the two rotavirus vaccines available in the U.S., needs only to look at his own family to see the potential consequences. His parents were born into the era of the deadly airway disease diphtheria; he himself had measles, mumps, rubella, and chickenpox, and risked contracting polio. Vaccination meant that his own kids didn’t have to deal with any of these diseases. But were immunization rates to fall too far, his children’s children very well could. Unlike past outbreaks, those future epidemics would sweep across a country that, having been free of these diseases for so long, is no longer equipped to fight them.

“Yeah,” Offit said when I asked him to paint a portrait of a less vaccinated United States. “Let’s go into the abyss.”

Should vaccination rates drop across the board, one of the first diseases to be resurrected would almost certainly be measles. Experts widely regard the viral illness, which spreads through the air, as the most infectious known pathogen. Before the measles vaccine became available in 1963, the virus struck an estimated 3 million to 4 million Americans each year, about 1,000 of whom would suffer serious swelling of the brain and roughly 400 to 500 of whom would die. Many survivors had permanent brain damage. Measles can also suppress the immune system for years, leaving people susceptible to other infections.

Vaccination was key to ridding the U.S. of measles, declared eliminated here in 2000. And very high rates of immunity—about 95 percent vaccine coverage, experts estimate—are necessary to keep the virus out. “Just a slight dip in that is enough to start spurring outbreaks,” Boghuma Kabisen Titanji, an infectious-disease physician at Emory University, told me. Which has been exactly the case. Measles outbreaks do still occur in American communities where vaccination rates are particularly low, and as more kids have missed their MMR shots in recent years, the virus has found those openings. The 16 measles outbreaks documented in the U.S. in 2024 made last year one of the country’s worst for measles since the turn of the millennium.

But for all measles’ speed, “I would place a bet on whooping cough being first,” Samuel Scarpino, an infectious-disease modeler at Northeastern University, told me. The bacterial disease can trigger months of coughing fits violent enough to fracture ribs. Its severest consequences include pneumonia, convulsions, and brain damage. Although slower to transmit than measles, it has never been eliminated from the U.S., so it’s poised for rampant spread. Chickenpox poses a similar problem. Although corralled by an effective vaccine in the 1990s, the highly contagious virus still percolates at low levels through the country. Plenty of today’s parents might still remember the itchy blisters it causes as a rite of passage, but the disease’s rarer complications can be as serious as sepsis, uncontrolled bleeding, and bacterial infections known as “flesh-eating disease.” And the disease is much more serious in older adults.

Those are only some of the diseases the U.S. could have to deal with. Kids who get all of the vaccines routinely recommended in childhood are protected against 16 diseases—each of which would have some probability of making a substantial comeback, should uptake keep faltering. Perhaps rubella would return, infecting pregnant women, whose children could be born blind or with heart defects. Maybe meningococcal disease, pneumococcal disease, or Haemophilus influenzae disease, each caused by bacteria commonly found in the airway, would skyrocket, and with them rates of meningitis and pneumonia. The typical ailments of childhood—day-care colds, strep throat, winter norovirus waves—would be joined by less familiar and often far more terrifying problems: the painful, swollen necks of mumps; the parching diarrhea of rotavirus; the convulsions of tetanus. For far too many of these illnesses, “the only protection we have,” Stanley Plotkin, a vaccine expert and one of the developers of the rubella vaccine, told me, “is a vaccine.”

Exactly how and when outbreaks of these various diseases could play out—if they do at all—is impossible to predict. Vaccination rates likely wouldn’t fall uniformly across geographies and demographics. They also wouldn’t decrease linearly, or even quickly. People might more readily refuse vaccines that were developed more recently and have been politicized (think HPV or COVID shots). And existing immunity could, for a time, still buffer against an infectious deluge, especially from pathogens that remain quite rare globally. Polio, for instance, would be harder than measles to reestablish in the United States: It was declared eliminated from the Americas in the 1990s, and remains endemic to only two countries. This could lead to a false impression that declining vaccination rates have little impact.

A drop in vaccination rates, after all, doesn’t guarantee an outbreak—a pathogen must first find a vulnerable population. This type of chance meeting could take years. Then again, infiltrations might not take long in a world interconnected by travel. The population of this country is also more susceptible to disease than it has been in past decades. Americans are, on average, older; obesity rates are at a historical high. The advent of organ transplants and cancer treatments has meant that a substantial sector of the population is immunocompromised; many other Americans are chronically ill. Some of these individuals don’t mount protective responses to vaccinations at all, which leaves them reliant on immunity in others to keep dangerous diseases at bay.

If various viruses and bacteria began to recirculate in earnest, the chance of falling ill would increase even for healthy, vaccinated adults. Vaccines don’t offer comprehensive or permanent protection, and the more pathogen around, the greater its chance of breaking through any one person’s defenses. Immunity against mumps and whooping cough is incomplete, and known to wane in the years after vaccination. And although immunity generated by the measles vaccine is generally thought to be quite durable, experts can’t say for certain how durable, Bill Hanage, an infectious-disease epidemiologist at Harvard’s School of Public Health, told me: The only true measure would be to watch the virus tear through a population that hasn’t dealt with it in decades.

Perhaps the most unsettling feature of a less vaccinated future, though, is how unprepared the U.S. is to confront a resurgence of pathogens. Most health-care providers in the country no longer have the practical knowledge to diagnose and treat diseases such as measles and polio, Kathryn Edwards, a pediatrician at Vanderbilt University, told me: They haven’t needed it. Many pediatricians have never even seen chickenpox outside of a textbook.

To catch up, health-care providers would need to familiarize themselves with signs and symptoms they may have seen only in old textbooks or in photographs. Hospitals would need to use diagnostic tests that haven’t been routine in years. Some of those tools might be woefully out of date, because pathogens have evolved; antibiotic resistance could also make certain bacterial infections more difficult to expunge than in decades prior. And some protocols may feel counterintuitive, Offit said: The ultra-contagiousness of measles could warrant kids with milder cases being kept out of health-care settings, and kids with Haemophilus influenzae might need to be transported to the hospital without an ambulance, to minimize the chances that the stress and cacophony would trigger a potentially lethal spasm.

[Read: Here’s how we know RFK Jr. is wrong about vaccines]

The learning curve would be steep, Titanji said, stymieing care for the sick. The pediatric workforce, already shrinking, might struggle to meet the onslaught, leaving kids—the most likely victims of future outbreaks—particularly susceptible, Sallie Permar, the chief pediatrician at NewYork–Presbyterian/Weill Cornell Medical Center, told me. If already overstretched health-care workers were further burdened, they’d be more likely to miss infections early on, making those cases more difficult to treat. And if epidemiologists had to keep tabs on more pathogens, they’d have less capacity to track any single infectious disease, making it easier for one to silently spread.

The larger outbreaks grow, the more difficult they are to contain. Eventually, measles could once again become endemic in the U.S. Polio could soon follow suit, imperiling the fight to eradicate the disease globally, Virginia Pitzer, an infectious-disease epidemiologist at Yale, told me. In a dire scenario—the deepest depths of the abyss—average lifespans in the U.S. could decline, as older people more often fall sick, and more children under 5 die. Rebottling many of these diseases would be a monumental task. Measles was brought to heel in the U.S. only by decades of near-comprehensive vaccination; re-eliminating it from the country would require the same. But the job this time would be different, and arguably harder—not merely coaxing people into accepting a new vaccine, but persuading them to take one that they’ve opted out of.

That future is by no means guaranteed—especially if Americans recall what is at stake. Many people in this country are too young to remember the cost these diseases exacted. But Edwards, who has been a pediatrician for 50 years, is not. As a young girl, she watched a childhood acquaintance be disabled by polio. She still vividly recalls patients she lost to meningitis decades ago. The later stages of her career have involved fewer spinal taps, fewer amputations. Because of vaccines, the job of caring for children, nowadays, simply involves far less death.

After my 20th shot of hormones, I texted my boyfriend, only half kidding, “I’m dying.” We had decided to freeze embryos, but after more than a week of drugs that made me feel like an overinflated balloon and forced me to take several secret naps a day, I no longer cared whether we froze anything. I was not doing this again.

In order to maximize the number of eggs that can be harvested from the human body, most women who undergo an egg retrieval spend two weeks, give or take, injecting themselves at home with a cocktail of drugs. The medications send the reproductive system into overdrive, encouraging the maximum number of egg-containing follicles to grow and mature at once. They can also cause itchiness, nausea, fatigue, sadness, headaches, moodiness, and severe bloating as your ovaries swell to the size of juicy lemons. Some people experience ovarian hyperstimulation, which can lead in rare cases to hospitalization. Studies have found the stress of fertility treatment to be a primary reason people stop pursuing it, even if they have insurance coverage.

Many people who continue with IVF feel that, if they want a child, they have no other choice. “Right now our treatment options are pretty binary,” Pietro Bortoletto, the director of reproductive surgery and a co-director of oncofertility at Boston IVF, told me. “Either you just put sperm inside the uterus. Or you do IVF, the full-fledged Cadillac of treatment.” But a third option is emerging, one that could reduce the cost and time that fertility patients spend at the doctor’s office and mitigate the side effects. It’s called in vitro maturation, or IVM. Whereas IVF relies on hormone injections to ripen a crop of eggs inside the body, IVM involves collecting immature eggs from the ovaries and maturing them in the lab. The first IVM baby was born in Korea in 1991, and since then, the method has generally yielded lower birth rates than IVF. Decades later, new scientific techniques are raising the possibility that IVM could be a viable alternative to IVF—at least for some patients—and free thousands of aspiring mothers from brutal protocols.

The challenge of IVM is to figure out how to make fragile, finicky human eggs mature in a dish as well as they do within the ovaries. The handful of researchers and companies leading the push to make IVM more mainstream are taking different approaches. One Texas-based company, Gameto, uses stem cells to produce something akin to an ovary in a dish, mimicking the chemical signals an egg would receive in the body. Last month, for the first time, a baby was born who was created using Gameto’s stem-cell medium, Fertilo. The fertility clinic at the University of Medicine and Pharmacy at Ho Chi Minh City, in Vietnam, uses a technique that involves first allowing the retrieved eggs to rest, then ripening them. Lavima Fertility, a company that spun out of research at the Free University of Brussels, is working on commercializing that technique.

[Read: They were made without eggs or sperm. Are they human?]

For now, these new treatments aren’t commercially available in the United States. The Food and Drug Administration hasn’t historically weighed in on the media that human embryos grow in, but it asked Gameto to seek approval to market Fertilo. Gameto is now preparing for Phase 3 clinical trials. Lavima could face similar hurdles. Older IVM methods are available in the U.S., but not widely used. Meanwhile, more than a dozen women in countries where Fertilo has been cleared for use, which include Australia, Mexico, Peru, and Argentina, are carrying Fertilo-assisted pregnancies, according to the company.

Compared with IVF, IVM is far more gentle. Harvesting immature follicles requires only one or two days of hormonal injections, or skips the process altogether. Reducing the hormone doses necessarily means fewer side effects and cases of ovarian hyperstimulation syndrome. (It may also curtail any possible long-term health effects of repeated exposure to these hormones, which have not been well studied.) Skipping or reducing the drugs can also save women thousands of dollars and many visits to a provider for blood work and monitoring. For women who live far from fertility clinics, or can’t commit to so many visits for other reasons, this protocol could make the difference between undergoing treatment and not, Bortoletto said.

Historically, IVM has generated fewer mature eggs and embryos compared with IVF. The stats are improving, but even if IVM maintains an overall lower success rate than IVF, it still could be the better option for several groups of patients. Egg donors, many of whom undergo multiple retrieval cycles, could be good candidates. So could hyper-responders—patients whose ovaries naturally develop more follicles each month, thanks to their young age or conditions such as PCOS. IVM clinicians could gather enough eggs from hyper-responders that even if a smaller number mature in the lab than might have in the ovaries, a patient would still have a good chance of pregnancy. These patients are also at the highest risk for uncomfortable or dangerous IVF side effects. IVM could be a safer choice, and an effective one. In a 2021 committee opinion, the American Society for Reproductive Medicine concluded that IVM reduced the burden of fertility treatment for these groups of patients. Some studies of hyper-responders have found a live birth rate of 40 percent or higher per IVM cycle, a number on par with that of IVF.

Many women seek IVF because they are approaching their 40s and have few eggs left; they will likely never be good IVM candidates. But IVM might work just fine for patients with blocked fallopian tubes, single and LGBTQ people, and young women who want to freeze their eggs. It could also be useful to cancer patients, many of whom don’t have time to undergo a lengthy IVF cycle before beginning cancer treatment that threatens their fertility. The University of Medicine and Pharmacy in Vietnam primarily offers IVM to women with PCOS, women who appear to have a significant reserve of eggs, and women with a condition that mutes their response to hormonal stimulation. Lan Vuong, who heads the department of obstetrics and gynecology, told me the live-birth rate with IVM there is about 35 percent.

IVM could go far in helping to reduce the physical and emotional toll that fertility treatment takes on women at a time when more people than ever are seeking it out. In some ways, IVF’s burden on women has increased: In an effort to improve birth rates, new drugs, with their attendant side effects, have been added to the standard protocols in the decades since 1978, when the first IVF baby was born. Beyond IVM, some companies are exploring new ways to reduce pain points, for instance by replacing needle injections with oral medications, some of which aim to have gentler side-effect profiles, or by having patients monitor a cycle at home instead of schlepping to the doctor every other day. Dina Radenkovic, the CEO of Gameto, told me that, within the fertility industry, there is a “growing recognition that fertility treatments must be not only effective but also more humane.”

[Read: Aspiring parents have a new DNA test to obsess over]

Knowing all this, I can’t help imagining how my own experience could have been different. My doctor eventually told me that part of the reason my cycle was so painful was that I was a hyper-responder, even at the advanced age of 37. If a gentler option had been available, I would have been a prime candidate.

Robert F. Kennedy Jr., President Donald Trump’s nominee for secretary of Health and Human Services, is a longtime conspiracy theorist and anti-vaccine activist. He thinks Anthony Fauci and Bill Gates are leaders of a “vaccine cartel” that intentionally prolonged or even started the coronavirus pandemic in order to promote “mischievous inoculations.” Kennedy also blames immunizations for autism and obesity (among other chronic diseases) in children. In the meantime, he isn’t really sure whether HIV causes AIDS, or whether vaccine-preventable diseases such as measles are actually dangerous.

As a doctor, I have spent years following—and fighting—anti-vaccine falsehoods. Along the way, I’ve learned an important lesson: Despite RFK Jr.’s fringe beliefs, he often seems to make sense. Kennedy’s defenders celebrate his fondness for, and facility with, evidence. His real talent, though, is for the clever manipulation of facts. Kennedy is not just a conspiracy theorist; he’s a very good conspiracy theorist. When his confirmation hearing starts on Wednesday, we can expect that he will do what he’s always done, which is to apply a veneer of erudition to nonsense. He may even come off as almost … reasonable.

To witness how this works, read the letter he sent to the prime minister of Samoa on behalf of the anti-vaccine nonprofit Children’s Health Defense in November 2019, during that country’s deadly measles outbreak. Kennedy offers his condolences for the tragic deaths of “precious Samoan children,” and then suggests the need to study the outbreak carefully, so as to “thoroughly understand its etiology.” What might have caused thousands of Samoans to get sick? The letter poses two possibilities: “It is critical that the Samoan Health Ministry determine, scientifically, if the outbreak was caused by inadequate vaccine coverage or alternatively, by a defective vaccine.”

At first glance, and for nonexperts, this letter may appear well reasoned and well sourced. It weaves in historical elements and biomedical data, and includes a list of peer-reviewed references at the end. The letter’s main request—that Samoan officials do nothing more than perform genetic testing on the circulating virus—sounds prudent. Prior research has indicated that vaccinated individuals may shed the virus and infect others, the letter says. Wouldn’t it be good to know if that produced the outbreak?

[Read: We’re about to find out how much Americans like vaccines]

In reality, of course, the epidemic was caused not by the vaccines but by the lack of them. (A vaccine-administration accident the year before had produced a scare that led vaccination rates to decline dramatically.) Although the letter’s implication that vaccines were to blame seemed wrong on its face, only when I dived into the cited scientific articles could I see the problems with its details. Kennedy incorrectly claims that genetic sequencing of a large measles outbreak in California from about four years prior found that at least one-third of the cases were due to the vaccine. “Alarmed CDC officials documented this emerging phenomenon,” he wrote. The referenced articles show this to be a fundamental misrepresentation. Although they do describe how the vaccine may, in rare cases, produce a dangerous case of measles, they specifically note that there is no risk of its being transmitted to another person. The genetic testing that Kennedy referenced is used, in part, to distinguish among people who have experienced mild vaccine reactions such as rash and fever from those who have true measles infections. This is important during active epidemics when public-health officials are widely immunizing people, while at the same time trying to isolate infectious individuals. (Kennedy’s press team did not respond to emailed questions about his letter to Samoa, or about other issues with his credibility that are raised in this article.)

A complete refutation of the Samoa letter would run many pages. That may be the point. With his ample, erroneous allusions to scholarship and appeals to authority, Kennedy has perfected the art of the Gish Gallop: a debate strategy in which the speaker simply overwhelms the listener with information, not all of it true. Kennedy’s skill at flooding his audiences with specious claims that sound logical or highbrow was on full display during his 2023 interview with the podcaster Joe Rogan. Over the course of three hours, Kennedy regaled the host with stories about vaccine safety, Albert Camus, Wi-Fi radiation, and the sexual health of frogs, among other subjects. He offered up a bounty of scientific arguments: The words study and studies came up 70 times during the conversation. And, as he has done elsewhere, he encouraged the audience to fact-check everything he said. “Nobody should trust my word on this,” he declared. “You know, what I say is irrelevant. What is relevant is the science.”

[Read: The new Rasputins]

Most of Rogan’s listeners—like most U.S. senators—aren’t likely to have the scientific expertise to assess each of his claims, and certainly not in real time. I caught some errors in the Rogan interview only by virtue of my medical training. For example, Kennedy criticized the inclusion of the hepatitis B shot in the childhood vaccine schedule. The virus is primarily a problem for intravenous-drug users, prostitutes, and homosexuals, he suggested. “Why would you give it to a one-day-old baby, you know, or a three-hour-old baby, and then four more times when that baby is not going to be even subject to it for 16 years?” he asked Rogan. Kennedy’s story sounds informed: He is facile with epidemiology and vaccine regulations; he can describe historical machinations that supposedly took place between Merck and the CDC. But the truth is that most chronic hepatitis B infections are contracted during early childhood, or through mother-to-child transmission. That’s why the World Health Organization recommends immunizing babies, and it’s why nearly every country has chosen to do so.

Kennedy does, at times, say true things about vaccines. He was not wrong, for example, when he told the podcaster Lex Fridman that early batches of the polio vaccine were contaminated with a virus called SV40. But he magnifies and distorts such flaws to the point of absurdity. SV40-containing vaccines did not cause an “explosion” of cancers, as he has argued. Kennedy is also right to say the MMR vaccine doesn’t always provide lifelong immunity to the mumps virus. However, his more extreme assertions—that the shot is causing mumps outbreaks in the military or that the disease is harmless in children—are wrong. (Before vaccination, service members routinely suffered from infections, and kids were at a heightened risk of developing brain inflammation and hearing loss.) Kennedy relies on scraps of truth to construct an alternative reality in which vaccines don’t work, their harms outweigh their benefits, and the diseases themselves aren’t so bad.

At his confirmation hearing, senators will ask him to defend that dangerous, alternative reality. He is likely to do so with impressive-sounding falsehoods, delivered with aplomb. Heed his own advice. No one should trust his word on this.

Over the past several years, a medication called mifepristone has been at the center of intense moral and legal fights in the United States. The pill is the only drug approved by the FDA specifically for ending pregnancies; combined with misoprostol, it makes up the country’s most common regimen for medication abortions, which accounted for more than 60 percent of terminations in the U.S. in 2023, according to the Guttmacher Institute, a research group that supports abortion rights. And yet, mifepristone is difficult or impossible to acquire legally in about half of states. Since Roe v. Wade was overturned in 2022, multiple federal lawsuits have threatened access to the pill at the national level.

Now a preliminary study suggests that using another drug in place of mifepristone may be just as effective for terminating an early pregnancy. The drug, called ulipristal acetate and sold as a 30-milligram pill under the brand name Ella, was approved by the FDA in 2010 as prescription-only emergency contraception. In a paper published today in the journal NEJM Evidence, researchers from the reproductive-rights nonprofit Gynuity Health Projects, along with partners in Mexico, reported the results of a trial in Mexico City that included more than 100 women with pregnancies up to nine weeks’ gestation. They found that medication abortion using 60 milligrams of ulipristal acetate (the equivalent of two doses of Ella) followed by misoprostol ended 97 percent of patients’ pregnancies without any additional follow-up care. (The FDA-approved regimen of mifepristone followed by misoprostol is about 95 percent effective, but because the new study did not directly compare the ulipristal acetate–misoprostol regimen to any other, researchers can’t yet say whether it’s superior or inferior to the standard regimen of mifepristone and misoprostol or misoprostol alone.)

The new study is small and did not include a control group. But the findings raise the provocative possibility that a drug already marketed as a contraceptive could also serve, at a higher dose, as a medication for abortion—a potential substitute for mifepristone, subject to fewer restrictions, wherever the latter is banned or difficult to get. The American abortion landscape, already fragmented, just got even more complicated.

Ulipristal acetate is a chemical relative of mifepristone and the most effective emergency-contraceptive pill available in the United States. When taken within five days of unprotected sex, it delays ovulation, which in turn prevents fertilization of an egg. Studies show that Ella works better than morning-after pills containing levonorgestrel, such as Plan B One-Step, and is more effective for a longer period of time after sex. Ella may also be more effective than other morning-after pills in people with a BMI above 26, which includes most American women over the age of 20. Although Ella’s 30-milligram dose is enough to prevent pregnancy, previous studies have suggested that the amount is highly unlikely to help end pregnancy as mifepristone does, by blocking a fertilized egg from implanting in the womb or disrupting the uterine lining.

Some experts have long suspected that a higher dose of ulipristal acetate could yield a different result. But the field has been generally reluctant to pursue research on the drug as a possible abortifacient out of concern for its role as an emergency contraceptive. Studies have repeatedly shown that a lower dose of mifepristone can act as an effective emergency contraceptive when taken soon after unprotected sex, with few side effects. It’s sold that way in a handful of countries where abortion is legal and widely available—but in the U.S., it was never approved for emergency contraception, and reproductive-rights advocates have not pushed for it. “Our idea, when we developed ulipristal acetate, was precisely to get away from abortion,” says André Ulmann, the founder and former chair of HRA Pharma, the drug’s original manufacturer. He and his colleagues worried, he told me, that any association with abortion would endanger their ability to market the drug for emergency contraception.

[Read: The other abortion pill]

The new study may very well validate Ulmann’s old fears. If further research confirms its findings, Americans seeking abortions may soon have a safe and effective workaround in places where mifepristone is restricted—and American abortion opponents will have a big new target. In an NEJM Evidence editorial accompanying the Gynuity study, Daniel Grossman, a professor of obstetrics, gynecology, and reproductive sciences at UC San Francisco, argued as much, writing, “There is a risk that the findings of this study could be misapplied and used by politicians to try to restrict ulipristal for emergency contraception.” Beverly Winikoff, the president and founder of Gynuity Health Projects and a co-author of the study, told me that she knew the stakes when she and her colleagues began their research. But part of Gynuity’s mission is to safeguard abortion care. In Winikoff’s view, another potential option for medication abortion in the U.S. was too important to ignore.

In 2022, a coalition of groups that oppose abortion sued the FDA in an effort to pull mifepristone off the market. In June, the Supreme Court unanimously struck down the challenge, ruling that the anti-abortion groups lacked standing. But in October, three states filed an updated version of the same suit in federal court; last week, a federal judge ruled that the case can proceed. Currently, 14 states have a near-total ban on medication abortion, and more than a dozen others limit how the drugs can be distributed, with requirements such as an in-person visit, an ultrasound examination, and a 24-hour waiting period. More restrictions may be on the way: Project 2025, the conservative-policy plan developed by the Heritage Foundation for an incoming GOP administration, calls for the FDA to entirely withdraw the drug’s approval. President Donald Trump, however, has been inconsistent, saying that he doesn’t plan to block access to the abortion pills while simultaneously refusing to rule out the possibility.

In light of the new study, it’s hard to imagine that anti-abortion groups won’t seek similar restrictions on Ella, threatening its availability as an emergency contraceptive. Anti-abortion activists and Republican lawmakers have repeatedly sought to blur the line between abortion and contraception by reasoning that pregnancy begins not, as federal law states, after a fertilized egg has implanted in the uterus, but at the moment when egg and sperm meet. Students for Life of America claims, for example, that all forms of hormonal birth control are abortifacients. “Abortion advocates have long denied Ella’s potential to end an embryo’s life, but this study contradicts that narrative,” Donna Harrison, the director of research for the American Association of Pro-Life Obstetricians and Gynecologists—which was a plaintiff in last year’s Supreme Court case—told me in a statement. “Women deserve to be fully informed about how this drug works, as well as its risks.” (Until now, no evidence had indicated the drug’s abortifacient potential; at the dose approved for emergency contraception, there is still no evidence that Ella can disrupt an established pregnancy.)

[Read: Abortion pills have changed the post-Roe calculus]

The Gynuity study points to a possible role for ulipristal acetate as part of an abortion regimen, Kelly Cleland, the executive director of the American Society for Emergency Contraception, told me. But it doesn’t change what we know about its use for emergency contraception. For now, Ella remains on the market as just that.

For more than 60 years, vaccination in the United States has been largely shaped by an obscure committee tasked with advising the federal government. In almost every case, the nation’s leaders have accepted in full the group’s advice on who should get vaccines and when. Experts I asked could recall only two exceptions. Following 9/11, the Bush administration expanded the group who’d be given smallpox vaccinations in preparation for the possibility of a bioterrorism attack, and at the height of the coronavirus pandemic, in 2021, the Biden administration added high-risk workers to the groups urged to receive a booster shot. Otherwise, what the Advisory Committee on Immunization Practices (ACIP) has recommended has effectively become the country’s unified vaccination policy.

This might soon change. Robert F. Kennedy Jr., one of the nation’s most prominent anti-vaccine activists and the likely next secretary of Health and Human Services, has said that he would not “take away” any vaccines. But Kennedy, if confirmed, would have the power to entirely remake ACIP, and he has made clear that he wants to reshape how America approaches immunity. Gregory Poland, the president of the Atria Academy of Science and Medicine and a former ACIP member, told me that if he were out to do just that, one of the first things he’d do is “get rid of or substantially change” the committee.

Over the years, the anti-vaccine movement has vehemently criticized ACIP’s recommendations and accused its members of conflicts of interest. NBC News has reported that, in a 2017 address, Kennedy himself said, “The people who are on ACIP are not public-health advocates … They work for the vaccine industry.” Kennedy has not publicly laid out explicit plans to reshuffle the makeup or charter of ACIP, and his press team did not return a request for comment. But should he repopulate ACIP with members whose views hew closer to his own, those alterations will be a bellwether for this country’s future preparedness—or lack thereof—against the world’s greatest infectious threats.

[Read: ‘Make America Healthy Again’ sounds good until you start asking questions]

Before ACIP existed, the task of urging the public to get vaccinated was largely left to professional organizations, such as the American Academy of Pediatrics, or ad hoc groups that evaluated one immunization at a time. By the 1960s, though, so many new vaccines had become available that the federal government saw the benefit of establishing a permanent advisory group. Today, the committee includes up to 19 voting members who are experts drawn from fields such as vaccinology, pediatrics, virology, and public health, serving four-year terms. The CDC solicits nominations for new members, but the HHS secretary, who oversees the CDC and numerous other health-related agencies, ultimately selects the committee; the secretary can also remove members at their discretion. The committee “is intended to be a scientific body, not a political body,” Grace Lee, who chaired ACIP through the end of 2023, told me. ACIP’s charter explicitly states that committee members cannot be employed by vaccine manufacturers, and must disclose real and perceived conflicts of interest.

HHS Secretaries typically do not meddle extensively with ACIP membership or its necessarily nerdy deliberations, Jason Schwartz, a vaccine-policy expert at Yale, told me. The committee’s job is to rigorously evaluate vaccine performance and safety, in public view, then use that information to help the CDC make recommendations for how those immunizations should be used. Functionally, that means meeting for hours at a time to pore over bar graphs and pie charts and debate the minutiae of immunization efficacy. Those decisions, though, have major implications for the country’s defense against disease. ACIP is the primary reason the United States has, since the 1990s, had an immunization schedule that physicians across the country treat as a playbook for maintaining the health of both adults and kids, and that states use to guide school vaccine mandates.

The committee’s decisions have, over the years, turned the tide against a slew of diseases. ACIP steered the U.S. toward giving a second dose of the MMR vaccine to children before elementary school, rather than delaying it until early adolescence, in order to optimally protect kids from a trifecta of debilitating viruses. (Measles was declared eliminated in the U.S. in 2000.) The committee spurred the CDC’s recommendation for a Tdap booster during the third trimester of pregnancy, which has guarded newborn babies against whooping cough. It pushed the country to switch to an inactivated polio vaccine at the turn of the millennium, helping to prevent the virus from reestablishing itself in the country.

[Read: We’re about to find out how much Americans like vaccines]

I reached out to both current ACIP members and the Department of Health and Human Services to ask about Kenndy’s pending influence over the committee. ACIP Chair Helen K. Talbot and other current ACIP members emphasized the group’s importance to keeping the U.S. vaccinated, but declined to comment about politically motivated changes to its membership. The Department of Health and Human Services did not return a request for comment.

Should ACIP end up stacked with experts whose views mirror Kennedy’s, “it’s hard not to imagine our vaccination schedules looking different over the next few years,” Schwartz told me. Altered recommendations might make health-care providers more willing to administer shots to children on a delayed schedule, or hesitate to offer certain shots to families at all. Changes to ACIP could also have consequences for vaccine availability. Pharmaceutical companies might be less motivated to manufacture new shots for diseases that jurisdictions or health-care providers are no longer as eager to vaccinate against. Children on Medicaid receive free vaccines based on an ACIP-generated list, and taking a particular shot off that roster might mean that those kids will no longer receive that immunization at all.

At one extreme, the new administration could, in theory, simply disband the committee altogether, Schwartz told me, and have the government unilaterally lay down the country’s vaccination policies. At another, the CDC director, who has never been beholden to the committee’s advice, could begin ignoring it more often. (Trump’s choice to lead the CDC, the physician and former Florida congressman Dave Weldon, has been a critic of the agency and its vaccine program.) Most likely, though, the nation’s new health leaders will choose to reshape the committee into one whose viewpoints would seem to legitimize their own. The effects of these choices might not be obvious at first, but a committee that has less academic expertise, spends less time digging into scientific data, and is less inclined to recommend any vaccines could, over time, erode America’s defenses—inviting more disease, and more death, all of it preventable.

Dale Carnegie, the self-made titan of self-help, swore by the social power of names. Saying someone’s name, he wrote in How to Win Friends and Influence People, was like a magic spell, the key to closing deals, amassing political favors, and generally being likable. According to Carnegie, Franklin D. Roosevelt won the presidency partly because his campaign manager addressed voters by their names. The Steel King, Andrew Carnegie (no relation), reportedly secured business deals by naming companies after at least one competitor and a would-be buyer, and maintained employee morale by calling his factory workers by their first name. “If you don’t do this,” Dale Carnegie warned his readers, “you are headed for trouble.”

By Carnegie’s measure, plenty of people are in serious jeopardy. It’s not that they don’t remember what their friends and acquaintances are called; rather, saying names makes them feel anxious, nauseated, or simply awkward. In 2023, a group of psychologists dubbed this phenomenon alexinomia. People who feel it most severely might avoid addressing anyone by their name under any circumstance. For others, alexinomia is strongest around those they are closest to. For example, I don’t have trouble with most names, but when my sister and I are alone together, saying her name can feel odd and embarrassing, as if I’m spilling a secret, even though I’ve been saying her name for nearly 25 years. Some people can’t bring themselves to say the name of their wife or boyfriend or best friend—it can feel too vulnerable, too formal, or too plain awkward. Dale Carnegie was onto something: Names have a kind of power. How we use or avoid them can be a surprising window into the nature of our relationships and how we try to shape them.

The social function of names in Western society is, in many ways, an outlier. In many cultures, saying someone else’s given name is disrespectful, especially if they have higher status than you. Even your siblings, parents, and spouse might never utter your name to you. Opting for relationship terms (auntie) or unrelated nicknames (little cabbage) is the default. Meanwhile, American salespeople are trained to say customers’ names over and over again. It’s also a common tactic for building rapport in business pitches, during telemarketing calls, and on first dates.

Western norms can make sidestepping names a source of distress. For years, Thomas Ditye, a psychologist at Sigmund Freud Private University, in Vienna, and his colleague Lisa Welleschik listened as their clients described their struggles to say others’ names. In the 2023 study that coined the term alexinomia, Ditye and his colleagues interviewed 13 German-speaking women who found the phenomenon relatable. One woman told him that she couldn’t say her classmates’ names when she was younger, and after she met her husband, the issue became more pronounced. “Even to this day, it’s still difficult for me to address him by name; I always say ‘you’ or ‘hey,’ things like that,” she said. In a study published last year, Ditye and his colleagues searched online English-language discussion forums and found hundreds of posts in which men and women from around the world described how saying names made them feel weird. The team has also created an alexinomia questionnaire, with prompts that include “Saying the name of someone I like makes me feel exposed” and “I prefer using nicknames with my friends and family in order to avoid using names.”

[From the April 2023 issue: An ode to nicknames]

Names are a special feature of conversation in part because they’re almost always optional. When an element of a conversation isn’t grammatically necessary, its use is likely socially meaningful, Steven Clayman, a sociology professor at UCLA, told me. Clayman has studied broadcast-news journalists’ use of names in interviews, and found that saying someone’s name could signal—without saying so directly—that you’re speaking from the heart. But the implications of name-saying can shift depending on what’s happening at the moment someone says a name and who’s saying it; we all know that if your mom uses your name, it usually means you’re in trouble. Even changing where in the sentence the name falls can emphasize disagreement or make a statement more adversarial. “Shayla, you need to take a look at this” can sound much friendlier than “You need to take a look at this, Shayla.” And, of course, when someone says your name excessively, they sound like an alien pretending to be a human. “It may be that folks with alexinomia have this gut intuition, which is correct, that to use a name is to take a stand, to do something—and maybe something you didn’t intend,” Clayman said. Another person could misinterpret you saying their name as a sign of closeness or hostility. Why not just avoid the issue?

In his case studies and review of internet forums, Ditye noticed that many people mentioned tripping up on the names of those they were most intimate with—like me, with my sister. This might sound counterintuitive, but saying the names of people already close to us can feel “too personal, too emotional, to a degree that it’s unpleasant,” Ditye told me, even more so than saying the name of a stranger. Perhaps the stakes are higher with those we love, or the intimacy is exaggerated. People on the forums agreed that avoiding loved ones’ names was a way to manage closeness, but sometimes in the opposite way. “I think this is pretty common among close couples,” one person wrote. “It’s a good thing.” Using a name with your nearest and dearest can feel impersonal, like you’re a used car salesman trying to close a deal. If I say my boyfriend’s name, it does seem both too formal and too revealing. But if I use his nickname—Squint—I feel less awkward.

[Read: Why we speak more weirdly at home]

Alexinomia is a mostly harmless quirk of the human experience. (It can cause problems in rare cases, Ditye told me, if, say, you can’t call out a loved one’s name when they’re walking into traffic.) Still, if you avoid saying the names of those closest to you, it can skew their perception of how you feel about them. One of Ditye’s study participants shared that her husband was upset by her inability to say his name. It made him feel unloved.

As Dale Carnegie wrote, “a person’s name is to that person the sweetest and most important sound in any language.” Pushing through the discomfort and simply saying their name every now and then can remind your loved ones that you care. By saying someone else’s name, even when it’s awkward, you’ll be offering a bit of yourself at the same time.

When my family returned to our home in Santa Monica last Sunday night, we breathed a sigh of relief. Our house was fine, and the air quality was in the “good” category. Schools would reopen the next day. But as we unpacked, I noticed what looked like salt-and-pepper snow delicately dancing over the street. Ash from the Palisades Fire, burning just five miles north of us, was descending all around, coating the car we had left behind. In the backyard, it gathered over the small patch of turf we played on and in small clusters all across the garden, where my kids had recently planted carrots.

The next morning, we walked to school, talking about the blue sky. My 8-year-old pointed out the piles of windblown ash by the curb. That day, the kids would stay inside so the school could clean the debris from the playground equipment and yard.

As I walked the four blocks back home, a city-owned street sweeper buzzed past. When the truck’s bristles hit the pockets of ash, they kicked up car-size clouds of dust, sending all the debris back into the air. I clutched my N95 mask tighter against my face, pulled down my sunglasses, and jogged away. I closed the door tightly behind me.

That night, a local bookstore and mediation space held a ceremony to “call in the rain for a land devastated by fire.” Rain would help keep more fires from starting, and it would also help wash the ash away. For now, we’re left to deal with it on our own, swabbing surfaces, clearing streets, wondering what we’re breathing in and what it will do to the waterways that absorb it.

On Tuesday, the debris was continuing to fall, so the school held a “walking-only” recess. When I saw gardeners arriving armed with leaf blowers, my heart sank. (Los Angeles County has temporarily banned their use because they throw up so much dust.) But no one knew exactly the right way to clean up the mess. One neighbor was vacuuming their steps with a Shop-Vac.

With smoke, the hazards are clear: You can see it and smell it, and get out of the way. Our phones have been vibrating with air-quality indexes, which measure pollution in the air, but not ash. With ash circling like toxic feathers, it’s hard to know what is safe. The residue from house fires contains far more toxins than that of brush fires. The PVC pipes, lithium-ion car batteries, plastic siding, flooring, and everything else that evaporated in the blazes launched a soup of chemicals—nickel, chromium, arsenic, mercury—into the air. Older homes can contain lead and asbestos. Until Wednesday, the day after walking-only recess, L.A. County had an ash advisory in place, which recommended staying inside and wearing a mask and goggles when leaving the house.

But our lives in Los Angeles are largely outside: This is a city that dines outdoors all year long, where winter temperatures hover in the 60s and surfers are in the water in January. With no rain in the forecast, how long will our lives be coated in a fine layer of toxic dust? Maybe a very long time: A webinar put on by California Communities Against Toxics warned that the amount of ash that the fires had generated would take years to excavate, and created public-health risks.

The prospect of continued exposure to airborne chemicals sounds ominous, but Thomas Borch, a professor of environmental and agricultural chemistry at Colorado State University, was more sanguine. After the 2021 Marshall Fire tore through towns in the foothills of the Rocky Mountains, Borch studied contaminants in the soil at houses near the fire. Some of the properties had elevated levels of heavy metals, but most were still below levels of concern. And although living among clouds of fine debris might feel apocalyptic, Borch told me that the wind could be helping to dilute the contamination in my neighborhood. “A lot of these ashes spread out over a much bigger area,” he said, which helps mitigate their health impacts.

Once ash and soot creep inside homes—through doors and windows, on shoes and clothes—“it’s a lot harder to actually get rid of,” he added. Cleaning can reinvigorate pollution inside the home, so it has to be done carefully. Borch advised that we vacuum with a HEPA filter and wet-mop surfaces to keep pollution from building up inside the house.

But the real questions regarding human health and ash are still open. Researchers have only recently started to investigate how the ash from structural fires differs from that of wildfires. In Los Angeles, Borch’s colleagues have set up 10 coffee-bag-size samplers around the fires (as close as they were allowed to go). They also plan to collect ash from within the burn areas and from windblown dust to compare the different toxins in smoke and ash, as well as their concentrations in the weeks and months following the fires.

If rain does arrive, it will wash out much of the debris, and the city will feel clear again. But that rain could also carry contaminants into streams, reservoirs used for drinking water, or the Pacific Ocean. Perhaps by then the wind will have blown most of the ash away, or in places, such as my neighborhood, outside of the fire’s direct path—we will have cleared the ash on our own. (Clearing ash in fire zones is a regulated process.) My family is still waiting to pull up the vegetables in our yard, but I’m no longer worried about bouncing balls and biking. We’ve been slowly wetting down our stone patio and stairs and trying to gently sweep up the ash, while making sure we’re protected by gloves, goggles, and masks. Half of the neighbors are wearing masks outside. We’re still swirling around like ash from the crisis, waiting for the rains to put everything back in place.

No drug is quite like nicotine. When it hits your bloodstream, you’re sent on a ride of double euphoria: an immediate jolt of adrenaline, like a strong cup of coffee injected directly into your brain, along with the calming effect of a beer. Nicotine is what gets people hooked on cigarettes, despite their health risks and putrid smell. It is, in essence, what cigarette companies are selling, and what they’ve always been selling. Without nicotine, a cigarette is just smoldering leaves wrapped in some fancy paper.

But if the Biden administration gets its way, that’s essentially all cigarettes will be. Today, regulators at the FDA announced that they are pushing forward with a rule that would dramatically limit how much nicotine can go in a cigarette. The average cigarette nowadays is estimated to have roughly 17 milligrams of the drug. Under the new regulation, that would fall to less than one milligram. If enacted—still a big if—it would decimate the demand for cigarettes more effectively than any public-service announcement ever could.

The idea behind the proposal is to make cigarettes nonaddictive. One study found that some young people begin feeling the symptoms of nicotine addiction within a matter of days after starting to smoke. In 2022, roughly half of adult smokers tried to quit, but fewer than 10 percent were ultimately successful.

For that reason, the rule could permanently change smoking in America. The FDA insists that the proposal isn’t a ban per se. But in the rule’s intended effect, ban may indeed be an apt term. The FDA estimates that nearly 13 million people—more than 40 percent of current adult smokers—would quit smoking within one year of the rule taking effect. After all, why inhale cancerous fumes without even the promise of a buzz? By the end of the century, the FDA predicts, 4.3 million fewer people would die because of cigarettes. The agency’s move, therefore, should be wonderful news for just about everyone except tobacco executives. (Luis Pinto, a vice president at Reynolds American, which makes Camel and Newport cigarettes, told me in an email that the policy “would effectively eliminate legal cigarettes and fuel an already massive illicit nicotine market.”)

Still, there’s no telling whether the FDA’s idea will actually come to fruition. The regulation released today is just a proposal. For the next eight months, the public—including tobacco companies—will have the opportunity to comment on the proposal. Then the Trump administration can decide whether to finalize the regulation as is, make changes, or scrap it entirely. Donald Trump has not signaled what he will do, and his relationship to cigarettes is complicated. In 2017, his FDA commissioner put the idea of cutting the nicotine in cigarettes to nonaddictive levels on the agency’s agenda. But the tobacco industry has recently attempted to cozy up to the president-elect. A subsidiary of Reynolds donated $10 million to a super PAC backing Trump. Even if the Trump administration finalizes the rule, the FDA plans to give tobacco companies two years to comply, meaning that the earliest cigarettes would actually change would be fall 2027.

If Trump goes through with the rule, it may be the end of cigarettes. But although cigarettes might be inseparable from nicotine, nicotine is not inseparable from cigarettes. These days, people looking to consume the drug can pop a coffee-flavored Zyn in their upper lip or puff on a banana-ice-flavored e-cigarette. These products are generally safer than cigarettes because they do not burn tobacco, and it is tobacco smoke, not nicotine, that causes most of the harmful effects of cigarettes. FDA estimates that should cigarettes lose their nicotine, roughly half of current smokers would transition to other, safer products to get their fix, Brian King, the head of the FDA’s tobacco center, told me.

Whether nicotine’s staying power is a good thing is still unclear. Few people—even in the tobacco industry—will argue with a straight face that cigarettes are safe. Nicotine defenders, however, are far more common. In my time covering nicotine, I have spoken with plenty of people who emphatically believe that the drug helps them get through their day, and that their habit is no more shameful or harmful than an addiction to caffeine. There is clearly a market for these products. Just ask Philip Morris International, which earlier this year invested $600 million to build a new factory to meet surging demand for Zyn. But it’s true, too, that nicotine is addictive, regardless of how it’s consumed. There isn’t much data looking at long-term impacts of these new nicotine-delivery devices, but the effects of nicotine, such as increased heart rate and blood pressure, are enough to give cardiologists pause.

I promised my parents—both smokers during my childhood—that I’d never pick up a cigarette. I kept that promise. But about a year ago, I started to wonder just how bad safer forms of nicotine could actually be. (Mom, if you’re reading this, I’m sorry.) I found myself experimenting with Zyn. Doing so gave me a window into why my parents craved cigarettes, but it also quickly gave me a firsthand look at why it was always so hard for them to quit. My one-Zyn-a-day habit quickly became two, and two became four. And yet, each time the pouch hit my lip, that burst of dopamine seemed to get more and more lackluster. Soon enough, I was reaching for nicotine without even thinking about it. The FDA’s new proposal, if finalized, will mean that misguided teens (or, in my case, 33-year-olds) prone to experimentation won’t do so with deadly cigarettes. But that will be far from the end of America’s relationship with nicotine.

The first time Jamie Cassidy was pregnant, the fetus had a genetic mutation so devastating that she and her husband, Brennan, decided to terminate in the second trimester. The next time they tried for a baby, they weren’t taking chances: They would use IVF and screen their embryos’ DNA. They wanted to avoid transferring any embryos with the single-gene mutation that had doomed their first pregnancy. And then they started wondering what other ailments they could save their future son or daughter from.

The Cassidys’ doctor told them about a company, Genomic Prediction, that could assess their potential children’s odds of developing conditions that aren’t tied to a single gene, such as heart disease, diabetes, and schizophrenia. The test wouldn’t be any more invasive than screening for a single gene—all the company needed was an embryo biopsy. The science is still in its early stages, but the Cassidys didn’t mind. Brennan has Type 1 diabetes and didn’t want to pass that condition on, either. “If I can forecast that my baby is going to have less chance to have Type 1 diabetes than I did, I want that,” he told me. “I’d burn all my money to know that.”

Thanks to more sophisticated genetic-testing techniques, IVF—an expensive, invasive treatment originally developed to help people with fertility troubles—is becoming a tool for optimizing health. A handful of companies offer screening for diseases and disorders that range from life-threatening (cancer) to life-altering (celiac disease). In many cases, these conditions’ genetic links are poorly understood or weak, just one factor of many that determine whether a person develops a particular condition. But bringing another human being into the universe can be a terrifying-enough prospect that some parents are turning to extensive genetic testing to help pick their future offspring.

Genetic screening has been a crucial part of IVF—and pregnancy—for decades. Medical guidelines recommend that any aspiring mother should be given the option to test her own DNA and find out whether she risks passing on dangerous genes, a practice known as carrier screening. If both parents carry a particular mutation, doctors will likely suggest IVF and embryo screening. These measures are traditionally limited to conditions linked to single-gene mutations, such as Huntington’s disease, most of which are exceedingly rare and seriously affect a child’s quality of life. During IVF, embryos are also typically screened for chromosomal abnormalities to help avoid miscarriages, and generally nonheritable conditions such as Down syndrome.

[Read: Genetic discrimination is coming for us all]

As the scientific understanding of the genome has progressed, companies including Genomic Prediction and a competitor called Orchid have begun offering a test that promises a more comprehensive investigation of the risks lurking in an embryo’s genes, using what’s known as a polygenic risk score. Most common ailments aren’t connected to a single gene; polygenic risk scores aim to predict the lifetime likelihood of conditions, such as diabetes, in which many genes contribute to a person’s risk. Consumer DNA-testing companies such as 23andMe use these scores to tell customers whether they have, say, a slightly above-average likelihood of developing celiac disease, along with a disclaimer that lifestyle and other factors can also influence their chances. These risk scores could theoretically help identify customers who, say, need a colonoscopy earlier in life, or who need to double down on that New Year’s resolution to eat healthier. But the current scientific consensus is that polygenic risk scores can’t yet provide useful insights into a person’s health, if indeed they ever will.  

Analyzing an embryo’s DNA to predict its chances of developing genetically complex conditions such as diabetes is an even thornier issue. The tests, which can run thousands of dollars and are typically not covered by insurance, involve sending a small sample of the embryos to the companies’ labs. In the United States, such tests don’t need to be approved by the FDA. Genomic Prediction even offers customers an assessment of which embryos are “healthiest” overall. But the control these services offer is an illusion, like promising to predict the weather a year in advance, Robert Klitzman, a Columbia University bioethicist and the author of the book Designing Babies, told me. A spokesperson for the American Society for Reproductive Medicine told me there aren’t enough quality data to even take a position on whether such tests are useful. And last year, the American College of Medical Genetics and Genomics published a lengthy position statement concluding that the benefits of screening embryos for polygenic risk were “unproven” and that the tests “should not be offered as a clinical service.” The statement raised the possibility that people might undergo extra, unnecessary rounds of IVF in search of ever healthier embryos.

Genomic Prediction published a rebuttal to the ACMG that cited, among other research, several studies led by company researchers that concluded that among siblings, those with a lower risk score were significantly less likely to have a given condition. The truth is, though, the effect of screening embryos for polygenic risk won’t be clear until the embryos chosen to develop into fetuses are born, grow up, and either develop diabetes or don’t. Genomic Prediction and Orchid both told me that humanity shouldn’t have to wait that long for the insights their tests provide. Polygenic risk scores are “one of the most valuable pieces of information that you can get,” Orchid’s founder and CEO, Noor Siddiqui, told me. Nathan Treff, Genomic Prediction’s chief science officer, was similarly bullish. “Everybody has some kind of family history of diabetes, cancer, and heart disease. So we really don’t have a situation where there’s no reason for testing,” he told me.

Many of the experts I spoke with about these tests are concerned that people might opt into IVF because they’re chasing certainty that companies can’t really promise. A study last year found both high interest and approval among Americans when it comes to screening embryos for polygenic risk. For now, most of the customers I interviewed used advanced tests that included polygenic risk because they were going through IVF anyway. Many of Genomic Prediction’s customers using the scores are participants in a clinical trial. But Tara Harandi-Zadeh, an investor in Orchid, told me she planned to do IVF even though she and her husband have no fertility issues or history of genetic disease. Harandi-Zadeh is especially worried about de novo mutations—genetic changes that occur spontaneously, without any hereditary link. She wants to screen her embryos to weed out monogenic diseases and plan for the risks of polygenic ones. “If I have that information, I can help my child at the stages of life to be able to get treatment or tests or just prepare for it,” she said. Treff told me that people like Harandi-Zadeh make up a small percentage of Genomic Prediction’s customers, but their numbers are growing.

[Emi Nietfeld: America’s IVF failure]

Scientists just don’t understand enough about the genome to confidently predict what any single embryo will be like should it go on to become a person. Most genes influence many facets of our being—our health, our physical traits, our personality—and only a fraction of those interactions have been investigated. “You don’t know the full package,” Klitzman said. “Bipolar disorder is associated with creativity. So if you screen out bipolar disorder, you may also be screening out genes for creativity, for instance.” Because no embryo is completely risk-free, future parents might also have to decide whether they think, say, a risk of diabetes or a risk of heart disease sounds worse. A paper out last week put it this way: “The expected reductions in disease risk are modest, at best—even if the clinical, ethical and social concerns are dismissed.”

Those concerns are significant. More and more people are already turning to IVF for reasons other than infertility. Some select their children based on sex. Jeffrey Steinberg, a fertility doctor with clinics in the U.S. and internationally, offers eye color selection and told me he is working on height. Orchid assesses genetic risk for some autism-spectrum disorders, and Genomic Prediction plans to add a similar screening to its catalog. A paper published last week argued that editing embryos—not just testing them—could mitigate genetic risk for a variety of conditions, while also acknowledging it could “deepen health inequalities.” (In the U.S., clinical trials of embryo editing cannot be approved by the FDA, and public funds cannot be used for research in which embryos are edited.) Critics say that even if technology could cut the prevalence of diseases like diabetes, doing so could drive discrimination against those born with such “undesirable” traits. Social services and support for people with those conditions could also erode—similar concerns have been raised, for example, in Iceland, where pregnancy screenings have all but eliminated Down-syndrome births.

[From the December 2020 issue: The last children of Down syndrome]

Even if the science does catch up to the ambitions of companies like Genomic Prediction, genetics will never guarantee a child a healthy life. “Of the 100 things that could go wrong with your baby, 90 percent of them or more are not genetic,” Hank Greely, the director of the Center for Law and the Biosciences at Stanford University, told me. That’s partly why the Cassidys decided to ignore most of their screening results and simply select the embryo that didn’t have the monogenic mutation that Jamie carried, and had the lowest risk of diabetes. “We’re not trying to have a kid that’s 6 foot 2 and blond hair and blue eyes and going to go to Harvard. We just want a healthy baby,” Brennan told me.

Their son was born in 2023 and so far has been at the top of the curve for every developmental marker: He’s big and tall; he talked and walked early. It will be years, probably, before they know whether or not he’s diabetic. But it’s hard, they said, not to feel that they picked the right embryo.

Influenza cases have been surging. RSV activity is “very high.” Signs of COVID have been mounting in sewer water, and norovirus, too, is spawning outbreaks like we haven’t seen for at least a dozen years. You might even say that America is in the midst of a “quad-demic,” although I really hope you don’t, because “quad-demic” is not a word that anyone should say.

With that in mind, here are The Atlantic’s tips and tricks for steering clear of any illness during this year’s terrible quad-demic. What are The Atlantic’s tips and tricks? They are soap.

Consider the norovirus, a real terror of a pathogen, just a couple dozen nanometers in length, with its invasive acids tucked inside a protein coat. Exposure to fewer than 100 particles of norovirus can leave you with several days’ worth of vomiting and diarrhea. Those particles are very, very hard to kill.

Douse them in a squirt of alcohol, and, chances are, they’ll come through just fine. One study looked at a spate of norovirus outbreaks at nursing homes in New England during the winter of 2006–07, and found that locations where staff made regular use of hand sanitizers were at much greater risk of experiencing an outbreak than others in the study. Why? Because those other nursing homes were equipped with something better.

They had soap.

Research finds that soap is good at cleaning things. At least 4,000 years of history suggest the same. Soap works because its structure mixes well with water on one end and with oils on the other. The latter, hydrophobic side can hook into, and then destroy, the membranes that surround some microbes (though norovirus isn’t one of them). Molecules of soap also cluster up in little balls that can surround and trap some germy grime before it’s flushed away beneath the tap. And soap, being sudsy, makes washing hands more fun.

Not everyone endorses washing hands. Pete Hegseth, whose good judgment will be judged today in his confirmation hearing for secretary of defense, once said that he hadn’t washed his hands in 10 years. He later said this was a joke. After that, he started hawking bars of soap shaped like grenades. The man who picked him is, of course, more than avid in his washing-up; Donald Trump is known to use his Irish Spring down to the sliver.

For all his love of soap, Trump also seems attached to hand sanitizer: His first administration kept Purell supplied just outside the Oval Office, per Politico. This would have helped keep him free of certain pathogens, but not all of them. When scientists compare different means of removing norovirus from fingertips, they find that none is all that good, and some are extra bad. Commercial hand sanitizers hardly work. The same is true for quaternary ammonium cations, also known as QACs or “quats,” which are found in many standard disinfecting products for the home. My local gym dispenses antiseptic wipes for cleaning the equipment; these are tissues soaked in benzalkonium chloride, a QAC. Quats may work for killing off the germs that lead to COVID or the flu, but studies hint they might be flat-out useless against norovirus.

[Read: Can’t we at least give prisoners soap?]

The science of disinfecting stuff is subtle. And a lot of what we thought we knew about killing off norovirus has turned out to be misguided. It’s very hard to grow a norovirus in the lab, so for a while, scientists used another virus from the same family—feline calicivirus, which can give a cat a cold—as a stand-in for their experiments. This was not a good idea. “Feline calicivirus is a wimp compared to human norovirus,” Lee-Ann Jaykus, an expert on food virology at North Carolina State University, told me. Her work has shown, for example, that bleach works pretty well at disinfecting feline virus in the lab, and that the same is true for a mouse norovirus that is often used in these experiments. But when she and colleagues tested human-norovirus samples drawn from patients’ fecal specimens, the particles seemed far more resistant.

You know what works better than hand sanitizers or QACs at getting rid of actual human norovirus? I’ll bet you do! It’s soap.

Or maybe one should say, it’s washing up with soap. A letter published in The Journal of Hospital Infection in 2015 by a team of German hygienists followed up on earlier work comparing hand sanitizers with soap and water, and argued that the benefits of the latter were mechanical in nature, by which the hygienists meant that simply rubbing one’s hands together under running water could produce an analogous effect. (They also argued that some kinds of hand sanitizer can inactivate a norovirus in a way that soap and water can’t.) Jaykus’s team has also found that the hand-rubbing part of hand-washing contributes the lion’s share of disinfecting. “It’s not an inactivation step; it’s a removal step,” she told me. As for soap, its role may be secondary to that of all the rubbing and the water: “We use the soap to make your hands slippery,” Jaykus said. “It makes it easier to wash your hands, and it also loosens up any debris.”

[Read: Wash your hands and pray you don’t get sick]

This is faint praise for soap, but it’s hardly damning. If washing at the sink disinfects your hands, and soap facilitates that process, then great. And soap may even work in cases where the soap itself is grimy—a bathroom situation known (to me) as “the dirty-bar conundrum.” Some research finds that washing up with soap and contaminated water is beneficial too. Soap: It really works!

But only to a point. I asked Jaykus how she might proceed if she had a case of norovirus in her household. Would she wash her hands and wipe down surfaces with soap, or would she opt for something stronger?

She said that if her household were affected, she’d be sure to wash her hands, and she might try to do some cleaning with chlorine. But even so, she’d expect the worst to happen. Norovirus is so contagious, its chance of marching through a given house—especially one with kids—is very high. “I would pretty much call my boss and say I’m going to be out for four days,” Jaykus told me. “I’m sorry to say that I would give up.”

Maybe we should add that to our list of tips and tricks for getting by in January: soap, for sure, but also, when your time has come, cheerful acquiescence.