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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[Read: When PTSD is contagious]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[Read: Healing a wounded sense of morality]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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