New Yorkers will soon enjoy a 30 percent discount on their meat, seafood, milk, and bread — so long as they shop at a city-owned store.

Mayor Zohran Mamdani touted such bargains this week at a press conference detailing his plans to launch five public grocery stores, in a bid to lower New Yorkers’ food costs. Under the proposal, the city would own each supermarket and dictate its pricing and labor practices, while private grocery companies would handle the day-to-day operations.

Mamdani’s proposal has been getting people worked up from the moment he unveiled it on the campaign trail for his 2025 mayoral run. For many progressives, state-owned supermarkets embody one of their movement’s highest ideals — the prioritization of public needs over private profits. For conservatives, meanwhile, “Mamdani Marts” represent an attack on free enterprise (if not, the first step on the road to Soviet breadlines).

While stimulating, these grand philosophical arguments have often overshadowed more banal but pressing questions: Would public grocery stores do more to advance Mamdani’s stated goals than other things the city could do with the same money? Has New York’s mayor discovered a way to sell groceries more efficiently than Costco does — or an approach to nutritional relief more effective than simply giving poor people more cash and food?

The answer to both of these questions appears to be “no.” And that should concern more than just New Yorkers. Mamdani’s vision is already inspiring imitators, with San Francisco and Boston both exploring their own public grocery store proposals. And in national discourse, the mayor’s policy is widely understood as an experiment — one testing a bold new theory of how governments can make food more affordable.

Unfortunately, although public grocers have merit in some circumstances, the theory underlying Mamdani’s specific plan is not merely unproven but incoherent.

Grocery socialism makes more sense for small-town Republicans

Public grocery stores have historically aimed to solve a problem that New York City does not have — a total absence of private supermarkets.

In 2018, the small town of Baldwin, Florida lost its only grocer. With only 1,600 residents — and a median income of $44,271 — the community no longer generated enough business to be worth the local IGA’s while. And no other national chain rushed in to fill the gap. 

So, the municipality opened its own grocery store, the Baldwin Market.

This attracted national media attention. And not without reason. A deeply conservative small-town trying its hand at socialism was a fun story. And it turned out that Baldwin wasn’t an aberration: Other aging rural communities in red America had turned to government grocers once private supermarkets had left them in the lurch.

Progressive policy thinkers took inspiration from these examples. In the ensuing years, proposals for using public grocery stores to combat urban food deserts — impoverished neighborhoods without convenient and affordable supermarkets — began to circulate. The merits of such plans can be debated. But their logic was straightforward: Where the market fails to provide residents with healthy food options, the government should step in. 

When post-COVID inflation sowed outrage over food prices, however, some on the left reconceived the purpose of public supermarkets: In their telling, such stores weren’t merely a means of eliminating food deserts, but also a way to make groceries more affordable.

Mamdani’s plan is principally animated by the latter goal. With more than 1,100 grocery stores and 10,000 bodegas, most of New York City is well-provisioned by private food vendors. And although parts of the municipality are under-served, the mayor is not actually concentrating his stores in such areas; his planned East Harlem location lies just blocks from an Aldi, Costco, and many other grocers. 

In a report detailing its policy, the mayor’s office makes clear that its primary aim is to drive down New Yorkers’ food bills. Yet there’s little reason to think that public grocery stores are a cost-effective way to do that.

New York City probably won’t provide groceries more efficiently than Costco

Without question, a government store can make groceries more affordable for its own customers: All it has to do is charge below-market prices.

And yet, if that store manages this feat by operating at a loss, then its shoppers’ savings will come at the broader city’s expense.

That might not be too troubling, if one pictures rich taxpayers footing the bill. But for a city like New York — which faces a structural budget deficit — revenue is a scarce resource. A tax dollar spent on public grocery stores is one that can’t be spent on nutritional assistance for low-income people. And all else equal, the latter will do more to enhance affordability: If you have a limited pool of food subsidies — and want to minimize the number of New Yorkers who can’t afford groceries — then you should spend your funds on the poor, not on whoever happens to show up at your city-owned store. 

Thus, for Mamdani’s supermarkets to be cost-effective, they can’t just subsidize low prices with taxpayer money. Rather, they need to deliver groceries more efficiently than private retailers do.

Public ownership can unlock efficiencies in certain contexts. For example, America’s private health insurance system generates massive administrative redundancies. By one estimate, if the US replaced its sprawling insurance industry with a single government payer, it could cut our health system’s annual administrative costs by $500 billion. In other words, a Medicare For All program could theoretically provide more healthcare-per-dollar than the current system does, by eliminating excess bureaucracy.

But there are no comparable inefficiencies in the grocery sector. True, a government retailer could generate some savings by declining to take a profit. But margins in the industry are slim; the average profit rate among food retailers was just 2.1 percent in 2025. Therefore, Mamdani’s stores can’t finance 30 percent discounts merely by dispensing with shareholder returns. 

Meanwhile, the city actually wants its stores to be less cost-efficient than private grocers in some respects. According to its policy brief, the government grocers will pay their workers higher wages than most retailers and may also favor “local and regional suppliers,” rather than automatically contracting with whichever food producers offer the best rate. 

The city suggests that its stores will have some cost advantages: Unlike private competitors, they will pay no rent or property taxes on their facilities. But these are merely additional subsidies, not actual efficiencies: By providing free real estate to its grocers, the city is forgoing revenue that it could otherwise collect and spend on nutritional assistance or other public goods. 

It is not yet clear how much money the city is prepared to lose each year on these stores. If Mamdani’s celebrity — and heavily advertised bargains — lure large masses of people to his markets, their steeply discounted goods will quickly sell out. In that circumstance, to avoid long stretches with empty shelves, or some complex rationing system, the city would need to rapidly restock money-losing items, compounding the stores’ operating losses.  

In theory, there is one way that government stores could benefit consumers throughout a city without being especially efficient enterprises in themselves: They could force other retailers to cut prices by accepting lower profits or discovering new efficiencies. But with grocery margins already thin, squeezing private markets further could lead to closures, thereby reducing shoppers’ options. Further, Mamdani himself insists that his stores will go out of their way to avoid harming private competitors (which, in New York, consist primarily of the sorts of small businesses that Mamdani has promised to help). 

In any case, five stores won’t substantially impact pricing citywide. And so long as each government grocer operates at a loss, scaling up the program will only deepen its costs — and thus, the tradeoff between funding public supermarkets and anti-hunger programs.

Aldi for all

At present, Mamdani’s grocery store experiment looks fairly cheap. The city estimates the stores will require $70 million in capital costs. As already noted, it’s unclear precisely how large each store’s annual operating budget will be. But even if each supermarket loses many millions each year, it still won’t make that big a difference, in the context of the city’s $125 billion budget.

Still, the opportunity costs of Mamdani’s policy are real. New York City currently plans to spend $3.1 million next year on a program called Get The Good Stuff (GTGS), which essentially gives SNAP recipients up to $10 off each time they purchase fruits and vegetables from 25 participating grocery stores. With the money slated for its public supermarkets, New York could dramatically expand the program, while also investing more money into its food banks. Alternatively, the city could modestly increase cash transfers to its lowest-income residents. 

To be sure, none of that would offer much benefit to middle-class shoppers. And the mayor is quite reasonably concerned with increasing grocery affordability for the typical New Yorker. But the city can advance that aim — while actually increasing its revenue — by easing zoning and permitting rules that currently make it difficult for large, low-cost retailers like Costco and Walmart to operate in many parts of the city. Happily, to Mamdani’s great credit, his administration’s paper on public grocery stores does briefly mention the need for permitting reforms.

Maybe public grocery stores are an end in themselves

All this said, there may still be a reasonable case for Mamdani’s stores or others like them. For example, a city’s residents might come to see such retailers as a kind of attraction, public amenity, or community space, akin to a park or library.

Further, public grocers could theoretically increase the public’s faith in the government. While the grocers are unlikely to be efficient in reality, they may appear to be. After all, their low prices will be far more visible to consumers than their operating costs. If Americans come to associate the public sector with cheap, ostensibly well-run supermarkets — rather than dreary DMV lines — that could aid the left’s broader efforts to expand the government’s remit. (Although, if the public grocers end up being characterized by overcrowding and empty shelves, the policy could further erode Americans’ confidence in the public sector.)

As a means of maximizing affordability, however, Mamdani’s program makes little sense. It will mostly just transfer income from the city’s broad population to the small subset of New Yorkers who happen to live near — or work at — one of its five stores.

Where private markets fail to provide any grocery options, public stores may be the best way for municipalities to meet their residents’ nutritional needs. But in other contexts, governments can make a bigger difference by simply putting more money in poor people’s pockets.

Maybe it was never a great idea to build so many golf courses in the desert. But in the 1990s, when Tiger Woods mania was at its peak, Las Vegas went on a fairway construction spree, dotting the city with dozens of pristine, water-gobbling green oases, most woven around upscale master-planned suburbs. 

One of those new fairways was the privately owned Badlands Golf Club, whose name now evokes huffs of frustration and wistful what-ifs from Las Vegans in the know. Opened in 1995 about 15 miles west of the Strip, the luxury course once wound its way around some of the city’s most opulent mansions and gated communities. 

By the time Woods crashed his car into a fire hydrant in 2009, the golf industry was in a crisis of its own. Many Americans had lost their appetite for the sport, which began hemorrhaging millions of players during the Great Recession and Woods’s fall from grace. Thousands of golf courses built during boom times shut down as a result — Badlands Golf Club among them. 

Meanwhile, Las Vegas, like many American cities, needed more homes to help alleviate its brutally high housing costs. These days, Nevada needs 120,000 additional affordable homes, but it is running out of places to build them, in part because about 85 percent of the state is federally owned, meaning there’s little room left for its cities to grow or sprawl. Shuttered golf courses — which often had the advantage of being tied into existing urban infrastructure, unlike more undeveloped land — presented ideal spots for relatively low-cost development.

Not everyone was happy about the idea. To the ire of its affluent neighbors, the precious real estate of the Badlands Golf Club was slated for a new housing development in 2015. What came next was one of the worst land disputes in Nevada history, a decade-long legal tussle waged by the city of Las Vegas at the behest of wealthy locals. Las Vegas was forced to fork over $286 million to a developer last year — one of the largest such settlements in history, and more than the city’s entire annual municipal culture and recreation budget — for illegally denying applications and permits to build atop the Badlands, which by then sat empty, an abandoned eyesore. Eleven years after the fiasco started, a new developer finally began clearing the site for a new luxury housing complex earlier this year, while Las Vegas has had to enact hiring freezes and delay municipal projects to pay off its hefty bill.         

In cities where space is tight, underused golf courses are, in theory, ideal canvases for new housing. These huge, repurposed tracts of land can fit thousands of new units — ideally, affordable ones — alongside other amenities like parks or basketball courts smack in the middle of some of the country’s most desirable and well-connected neighborhoods. This makes such developments much cheaper to build than creating a new suburb with all new roads and power lines from scratch.

Not every attempt to turn golf courses into housing lands is destined for financial calamity. Just last year, the city of Las Vegas approved a plan to convert a separate golf course, the city-owned Desert Pines Golf Club, into a 1,500-unit housing complex, the largest affordable housing project in Nevada history and a public-private partnership between the city, the Nevada State Infrastructure Bank, a private developer, and nonprofit partners. The project is a rare win for these kinds of developments, and may offer a blueprint for how they can be accomplished in the future. But even there, the challenges are still real. 

“Everyone wants more housing at a regional level. Everyone acknowledges that we need more housing,” said Nicholas Irwin, research director at the Lied Center for Real Estate at the University of Nevada, Las Vegas. “But no one wants it near them, and that’s the tricky part.” 

How to turn a golf course into housing

Desert Pines Golf Club opened in the heart of East Las Vegas in 1996, a lush, manicured 18-hole course, peppered with over 4,000 imported pine trees. Like nearly one in five fairways nationwide, Desert Pines was municipally owned, its pricey water needs subsidized by Vegas taxpayers. 

With its rolling green hills, Desert Pines was, by far, the largest contiguous green space in the mostly working-class neighborhood that surrounds it. But while golfers flocked to the course, many local residents barely even knew it was there or likely assumed it was out of their price range, said Ángeles Ramos, a local organizer with the immigrant advocacy group Make the Road Nevada. “Only the wealthy wanted it for their own purposes,” she told me in Spanish, but “what we want, what we urgently need, is more affordable housing.” 

There was a time when “we could just build anywhere and everywhere because the valley was underdeveloped,” Irwin said, but “now, we’re buttoned up against it. We are incredibly dense, because we’ve basically filled up the land we have.” Much of Nevada is undevelopable because the federal government has set it aside for other purposes like recreation, which explains the state’s bevy of tourist attractions like Lake Tahoe or Red Rock Canyon. But it also leaves the city with little space to build.  

If all 16,000 golf courses in America turned all of their land — about 2.3 million acres — into housing with the same density as Desert Pines, it would be enough space to build 22 million homes. If you applied that approach to only those courses that are, like Desert Pines was, municipally owned, then you could still build 4.3 million affordable homes, which would make an enormous dent in the nation’s current shortage of about 7.2 million affordable homes. 

That’s not to say that every golf course in every land-constrained city ought to be bulldozed to make way for new apartment buildings. Golfing, for the record, has made a bit of a comeback lately, much like its most famous star. And even if fairways were still closing at the rate they were a few years ago, there’s no way that they could solve Nevada’s housing gap alone, much less overcome the shortage nationwide. But they can still help close the gap. 

Ramos, who is among the local leaders organizing community meetings around the Desert Pines redevelopment, believes it could be transformative for the community over time. She says that in her neighborhood it’s become a luxury for many families just to live alone with their spouse and kids, rather than doubling up in cramped apartments, pooling together money each month to keep up with rising costs. 

 When the Desert Pines redevelopment opens about a decade from now, it will include not just 1,500 housing units, but also a soccer pitch, walking trails, and a job training center. In East Las Vegas, the temperature often feels more than five degrees hotter than it does in the Badlands’ affluent suburbs, where residents enjoy over nine times as much parkland per person. 

“This project brings a lot of hope,” said Ramos, who’s especially excited about the prospect of more accessible, kid-friendly green spaces. “We’re all human. We need equity, respect, and to live with dignity, and that’s why we urgently need trees too.”

As it turns out, you can do a lot with an old fairway. Even with all of those bells and whistles, the new development will still likely use less water than the golf course did. And, because the plot of land is already enmeshed within the community of East Las Vegas — close to existing sewer, water, and electricity lines — it will be much cheaper to build there than it would be to try doing so on the outskirts of the city, said Antonio Bermúdez, vice president of McCormack Baron Salazar, the developer working with the city and state government on the proposal.

“What I’ve seen so far in the state of Nevada is that the political will is there,” he said, though the question is, “how do we make this happen not just in Nevada and the city of Las Vegas, but everywhere else where affordable housing is needed.”

Not in my golfyard!

If the Badlands has become a brutal fable of bad governance and highly charged NIMBYism, then Desert Pines may prove to be the model of a golf course-to-housing project gone right.

It also enjoyed the privilege of being located in a welcoming neighborhood, filled with renters who could personally benefit from the project. By contrast, many other golf courses were instead built as a luxury perk embedded in master-planned communities, meaning they’re surrounded by homeowners who fear that losing a recreational amenity — especially if it’s replaced by less upscale housing — could affect their property value.

“Everyone wants more housing at a regional level. Everyone acknowledges that we need more housing. But no one wants it near them, and that’s the tricky part.” 

Nicholas Irwin, research director, Lied Center for Real Estate

Just across the street from the Badlands is another golf course, Angel Park Golf Club, built on federal land granted to the city of Las Vegas. If the city ever tried to build an affordable housing complex like the one it’s planning in Desert Pines, it would almost certainly fail given the outrage with which the surrounding community reacted to a proposal for other high-end housing in their backyard. 

Victoria Seaman, a former Las Vegas City council member, was elected in 2019 to represent the district that includes the Badlands, mid-lawsuit. Even the “big, beautiful two-acre lots” the developer originally envisioned for the site, she said, were not good enough for Queensbridge, an ultra-luxury gated community abutting the course that acted as a powerful lobbying bloc during the decade-long process, influencing the city’s illegal decision to block the original property owner from breaking ground. 

The city of Las Vegas is still paying off the total $286 million settlement it made over its obstruction of the Badlands project, in part through funding cuts to projects like the Desert Pines redevelopment in East Las Vegas.

“These were expensive homes with beautiful planning,” Seaman said of the project planned for the former golf course, and yet somehow, “these very big donors in Queensbridge convinced the entire [homeowners association] that the developer would ruin the neighborhood.”

The fight over fairways is really a fight over who gets to live where

The Badlands example is particularly dramatic, but it also gets at the challenges faced by similar projects across the country. Even a decade after many fairways fell into decline, there are few other examples quite like Desert Pines, and certainly none as large. While dozens of cities — including  Denver, New York, and Virginia Beach — have made overtures to turn golf courses into housing in recent years, almost all such projects have been met with upheaval and fierce resistance from locals. 

To some extent, that’s understandable. In Sparks, Nevada, hundreds of local residents have flooded community meetings in recent months to oppose a proposal to raze the Red Hawk Golf and Resort and build over 700 new homes in its place. “Promises were made to this community,” Tom Ciesynski, one of those homeowners, told me, “these lots, these very nice homes, were sold with premiums added for those that were sitting on the golf course.” Now, he says, the fairway’s owner is trying to build “tract homes that just don’t fit the character” of a neighborhood that has come to see the Red Hawk as its centerpiece, where Ciesynski regularly goes to golf, and where his wife takes her yoga and pilates classes. 

He understands that Sparks, like most of Nevada, faces a housing crunch. “Most people aren’t opposed to all new development, but there’s a right way to do it and a wrong way to do it,” he said, and there are other places within a “stone’s throw of where we live” where he thinks the developers ought to go and build instead.

He arguably has a point. Recreation spaces are important for livable cities, too, and it’s not fair that homeowners who were promised one thing when they bought their properties are now facing a new reality. 

And yet, the most troubling trade-off is not the one that leaves a homeowner golf course-less but the one that leaves families in East Las Vegas unable to afford homes at all. It may be tempting to only build affordable housing in places that won’t put up a fight, which in practice, means avoiding most golf courses, especially those in wealthy neighborhoods that want to preserve the kind of exclusivity that many fairways were built to project in the first place. But cities can no longer afford that indulgence — and in any case, they shouldn’t be digging in their heels to protect it.

When people talk about a new development not fitting the character of a neighborhood, “what they’re describing is an amorphous feeling,” said Irwin of the University of Las Vegas, “and if you make policies based on feelings and vibes, you get bad policy.”

The International Criminal Court is in the trenches right now.

Last week, its chief prosecutor, Karim Khan, was voted out of his position. In a first-of-its-kind vote, 82 member states decided that he engaged in misconduct and a serious breach of duty. The vote comes after he was accused of sexual misconduct by a female colleague at the ICC, which Khan has denied.

It’s a mess, and it’s hitting the ICC at an inopportune time. On top of this internal turmoil, US Secretary of State Marco Rubio recently launched an all-out attack on the court.

In a Wall Street Journal op-ed earlier this month, Rubio wrote that the Trump administration’s goal is to “dismantle the ICC—brick by brick, if necessary,” citing the possibility that the court could “target” American citizens, such as Border Patrol agents or US soldiers.

The US is not a member of the ICC, and has a history of wariness about the organization.

Beth Van Schaack previously served as the US ambassador-at-large for global criminal justice, a role that led her to work directly with the International Criminal Court. She spoke with Today, Explained co-host Noel King about the decades-long tumultuous relationship between the US and the ICC. And they discuss whether, if the ICC is now weaker than ever, the Trump administration can actually break it for good.

Below is an excerpt of their conversation, edited for length and clarity. There’s much more in the full podcast, so listen to Today, Explained wherever you get podcasts, including Apple Podcasts, Pandora, and Spotify.

If the International Criminal Court is charged with dealing with people who have allegedly done very bad things and then trying them, why is the United States not a member?

The United States signed the treaty in the waning days of the Clinton administration, but never submitted it for ratification to the Senate. And one of the concerns is that the final treaty allows for jurisdiction over individuals who may commit crimes on the territory of state parties. And the United States has always been concerned about that principle because we have troop commitments.

Supporters of the court have always said the United States and its personnel are vulnerable regardless of whether you join. If US personnel are committing crimes on the territory of state parties, which we saw in Afghanistan, the response is to do those cases domestically and there’ll be no occasion for the International Criminal Court to consider those matters.

There’ve been peaks and valleys in the relationship between the ICC and the United States. So we’re in a frankly pretty deep valley right now with this new campaign that Secretary Rubio announced.

But back in the Bush administration, there was also very acute concern and it stemmed from this Afghanistan investigation. The Bush administration and Congress both put in place measures that they thought would be protective of US servicemembers. So that was one valley.

Now what’s interesting is in the second term of the Bush administration, many of these measures were dismantled because the Bush administration realized that the court was doing important work in some areas where it also cared about justice — in particular, Darfur.

Then, the Obama administration announced a reset in its relationship with the court, and that’s where I entered the picture. The Obama administration directed various executive agencies to look for ways to support the court where the work that it was doing was consistent with US policy.

Then, we had the first Trump administration, which reversed course almost immediately and eventually imposed sanctions on senior figures, including the prosecutor herself and one of her key aides.

Then, we get to the Biden-Harris administration. They pulled down those sanctions and again launched a reset of the relationship. At that point, there were a number of situations where the court was working, including following the brutal war of aggression by Russia against Ukraine.

Here we saw a remarkable rise of bipartisan support for the work of the court. You had senior Republican figures in Congress supporting the court. The late Sen. Lindsey Graham (R-SC) led a resolution that was supporting justice in Ukraine. Secretary Rubio, then Sen. Rubio, joined that resolution. There was new legislation passed that made it easier for the United States to support the work of the court.

Of course, with the second Trump administration, we have reversed course again, and in particular with Rubio’s announcement.

Well, let’s talk about the reversal. Secretary of State Marco Rubio is at one point on board with the ICC, and then recently he vows to dismantle it. What happened here?

It’s not clear what the precipitating event is, to be honest. There is no existential threat at present. Obviously, there’s always the concern that this is some kind of a distraction because matters are not going well in Iran and with respect to the economy — that this is something to pull eyeballs away from those matters onto something that he can look tough in. Is this just kind of red meat for anti-multilateralism or is there something that is not made public that is happening?

Is there anything actually that Marco Rubio or anyone else in the United States at the highest level could do to the International Criminal Court to put an end to it?

The International Criminal Court is part of a larger system of the rules-based order that we’ve been trying to build since World War II. Almost all of our friends and allies are members of this court and they care deeply about its success. They are committed to seeing a system of international criminal justice. So, no is the answer. The United States alone cannot dismantle this court.

Now, it can injure the court and it has already done so. There are already eight ICC judges, including judges who hail from some of our closest allies — France, for example — who have been subjected to brutal sanctions. They can’t use credit cards that pass through New York. They can’t make reservations online because of financial sanctions. They can’t travel to the United States because of travel bans, et cetera. The chief prosecutor and two of his two deputies have been sanctioned. Non-governmental organizations that are involved in human rights in Palestine have been sanctioned and a UN figure has been sanctioned. Those measures are already in place.

What his most recent campaign seems to announce is some diplomatic move to try and convince states to leave the court or to cease their cooperation with the court. And we have seen in recent days a couple of states announcing that they were withdrawing. These are mostly states within Africa, but also Venezuela, subject to investigation by the prosecutor’s office. The United States can certainly injure the court, but there’s no way that we could dismantle the court.

Most Americans don’t spend a lot of time thinking about the International Criminal Court, but they may know it because lately, it has gotten a lot of attention that the court has issued an arrest warrant for [Israeli Prime Minister] Benjamin Netanyahu. New York City Mayor Zohran Mamdani has said he would like to see Netanyahu arrested if he comes to New York.

Mamdani has said he does not have that power. He cannot order the NYPD to do it, but he would like for it to happen. What are the chances that Benjamin Netanyahu comes to the United States and is arrested?

Pretty close to zero, if not actually zero. This is a matter of federal law and international law. And the Headquarters Agreement between the United States and the United Nations, which placed the headquarters of the UN in New York, basically gives certain privileges and immunities to individuals who are coming to New York to attend official functions.

New Yorkers are a feisty bunch. So when word is out that Benjamin Netanyahu is in New York, can you imagine the protests that would happen? Can you imagine the embarrassment that he might experience when he’s supposed to be giving his remarks at the General Assembly High-level Week where all the heads of states convene to deal with transnational issues and his motorcade is ensnarled in protests protected by the First Amendment, calling for his arrest for various international crimes? If I were his lawyer, I would say, “There’s no chance you’re going to get arrested.” But honestly, it could be a miserable visit, given all of the strong support for accountability in this matter in the United States.

This is a lot of drama for a body that for a long time seems to have avoided a ton of very public drama. So who gets hurt in all of this? Is it the court? Is it the US and its reputation? Where do you think this leads?

Unfortunately, I think everyone comes out not looking great here. The court needs to put in place measures to be able to receive those complaints by witnesses, whistleblowers, victims themselves, process them quickly, but also fairly to all parties involved. The United States looks terrible as well, launching a campaign like this against an international organization whose mandate it is to deliver justice for the worst crimes known to humankind.

Here in the U.S., we’re looking at the Iran War in terms of whether the U.S. should have started it in the first place, how it’s affecting oil prices, how it’s going to affect the midterms and a bunch of other things. But there’s another way to look at it, which is that Iran is putting on a global performance of standing head to head with the full might of the U.S. military and pulling it off. By their actions, we can see pretty clearly that the Iranian government does not fear Donald Trump. They’re not acting scared. If anything, they’re upping the rate of their provocations, as the state of war and effective stalemate transitions to a new normal of sorts.

It is fair to say that this is not actually the full might of the U.S. military in a theoretical sense. The president could order the U.S. military to mount a full scale ground invasion of Iran, occupy the country, dismantle the state’s system of command, control and repression. Those things are very likely possible, albeit at vast cost. But the real test of a military is not what it can do in some theoretical sense, the precise armaments it has and so forth but what the country which controls that military is able and/or willing to do in a specific economic, geopolitical, and political context. And the U.S. is clearly not willing to do those things. So in a practical sense — not the abstract power and capabilities of the U.S. military but the country’s ability to do those things — this is the full force of the U.S. military.

AI is the hottest thing in medical care right now — but many of us feel trepidation about it. Just one illustrative public survey sample: An October 2025 KFF poll found just 8 percent of Americans reported feeling a “great deal” of trust in AI managing their appointments or analyzing their health records, and only 32 percent said they would trust an online health tool that uses AI to access their medical records to provide personalized health information.

But many clinicians and healthcare administrators see AI as a powerful new tool that offers myriad opportunities to streamline and improve treatment. A 2026 survey found that more than 80 percent of US doctors use AI professionally — doubling the share from 2023. Physicians are excited by AI’s potential to keep more accurate notes of interactions with patients, to act as a second pair of eyes for human doctors, and to monitor people at risk of deteriorating and ending up in a dangerous situation.

The disconnect between what people and their providers want from AI could create more distrust, at a time when faith in the healthcare system and the medical profession have slid. Patients today want to feel empowered and in control. How can that be possible when these seemingly godlike machines are becoming more and more entrenched in our hospitals and doctors offices?

The answer comes in four words: “human in the loop.” It’s the principle upon which the ethical integration of AI depends and it could help to bridge the gap between lay people and the professionals on AI in medicine. In surveys, people are much more comfortable with the idea of their doctor using AI as an assistant than with AI acting on its own. And most clinicians want to use AI in that way, as a second opinion or passive monitor, not as a replacement for their judgment. There are real fears among the healthcare workforce about that possibility: A group of NYC nurses who were recently laid off claim it’s because their labor was going to be replaced by AI. “Human in the loop” appears to be a point of agreement between doctors and patients at this pivotal moment.

“Doctors…and nurses and staff always have been interested in primarily making the best decision for the people under their care — and these tools can help with that,” Alison Callahan, a research scientist at Stanford University who works on AI programs used in the university’s health system, told me. “The interest in making sure those tools are accurate is high.”

But what does “human in the loop” really mean in practice? How can you know when and how your doctor is using AI? And what is the best way to talk to your provider about the sudden influx of artificial intelligence in healthcare before a robot starts taking appointment notes or analyzing your MRI? I called some leading experts to find out. 

How AI is currently being used in medicine

Patients and providers alike are incorporating AI into healthcare. Individuals are using commercial AI chatbots to ask about their symptoms or the health metrics tracked by their Apple Watch, while large academic medical centers are developing sophisticated programs and protocols to try to improve medical care at the population level.

It starts with ChatGPT, Claude, etc. — the large language models that are available to the public. People are increasingly turning to them to try to understand what’s going on with their own bodies. Individual physicians are also consulting with large language models to answer questions or get up-to-date on the latest research as they figure out how to best care for their patients. 

Then there are ways in which hospitals and doctors offices are adopting AI at the institutional level. Many facilities are using AI as a way to take, collate, and summarize notes on a patient; in theory, it’s a more organized way to keep track of the informal interactions and observations that doctors have when checking on their own patients. Hospitals are also using AI to handle some administrative tasks, like scheduling follow-up appointments; some health systems have even started to use AI to help patients get ready for appointments — to send reminders about colonoscopy prep, for example.

And finally, you have maybe the most ambitious use of AI by health systems right now: as a diagnostic and risk prediction tool. In these cases, AI might offer a second opinion when, for example, a doctor is triaging a patient in the emergency room. It might help the ER staff figure out how to prioritize patients. Or these programs could monitor people either during a hospital stay or out in the real world (by drawing data from the person’s wearable) and make predictions about who may be at higher risk of complications and require further care. AI could recommend that somebody would benefit from seeing certain specialists or receiving a specific medicine or lab test, and generally offer proactive advice about the patient’s medical care.

But at this point, AI adoption is still “highly localized,” said Jennifer Goldsack, CEO of the Digital Medicine Society, a nonprofit that works with healthcare providers, drug makers, and government agencies on how to incorporate new tech (including AI) into clinical care. It depends on the individual doctor or health system. A lot of them are setting up their own programs and their own protocols for how to use these tools.

That is a big reason why it is so important for patients to be proactive about understanding how AI is being used for their health care. You can’t make assumptions; the only way you’re going to know for sure is to ask.

The questions you should ask your doctor about AI

By and large, experts say, patients should feel confident: Doctors and nurses want to keep a human in the loop, even as they integrate AI into their workflows.

“It will be a doctor who is going to be reading that summary or a nurse who is going to be reading that summary and then taking an action to order a lab or put a recommendation in for a follow-up appointment,” Callahan said. “There is high interest in making sure that that is the right decision for that person. That hasn’t changed.” 

Still, many patients say they’d be more comfortable with AI use if their doctor fully explained it in advance. And health systems may have their own priorities that push their facilities toward more rapid AI adoption and delegating more tasks to these AI tools, as seen in the recent NYC nurse layoffs.

So if you want to be informed on exactly where this technology is present and have the ability to consent to its use, you have every right to ask your doctor, experts say. 

“AI is new, but the trust that serves as the foundation of the physician-patient relationship is not,” Timothy Keyes, a machine learning scientist at Stanford Health Care, told me over email. “To that end, I think that conversations about medical AI use should be open, honest, and transparent — just like any other conversations about shared decision-making in the clinical environment should be.”

For some things, your doctor should be asking you proactively if you consent to AI use — note-taking, for example. At my most recent primary care appointment, my doctor asked me if it’d be okay for him to use AI to take and summarize notes from our conversation; Goldstack told me she’d experienced the same at recent physician visits. (This is probably the most common AI use that you will encounter, and Keyes said it’s worth considering giving your consent: “There is growing evidence that they reduce physician burnout and save them at least a bit of time each day writing notes.”)

There are also a number of direct questions that you can ask:

• Will AI be used in my care and how?
• How is my data being protected?
• Can I opt out of any AI services that I do not feel comfortable with? (Keyes noted that patients should be allowed to opt out of any care, AI-related or not; if opting out is not an option, ask how a human provider will be involved.)
• How is the health system or clinic making sure that any AI system they use is working as intended?

And the transparency goes both ways. If you’re asking a question because you consulted ChatGPT before your appointment, tell your doctor. If you’ve talked with a chatbot because of mental health struggles, tell your doctor. And at the same time, feel free to ask your physician how you yourself could actually use AI in a responsible and productive way to improve your health.

“This opens up the opportunity for both the physician and the patient to be humans-in-the-loop,” Keyes said, “in different parts of the loop, with different perspectives, using an AI system to better understand the bigger picture.”

In a way, the novelty of AI and its rapid adoption is an opportunity for all of us to be nosier and more inquisitive patients. What all of these questions really come down to, Callahan said, is how your doctor is making decisions about your health care. That is relevant to all of us, no matter how AI is involved or even if there is no AI being used at all. 

Callahan said she always has a list of questions for her doctor when they recommend a course of treatment: “What are the factors in my health that are informing this recommendation that you have? Would you be making this recommendation for other patients who are similar to me? What can you tell me about the outcomes that I might expect to experience if I say yes to this?”

“I actually think if they can point to the part of your health that is connected to the decision, whether or not an AI tool helped to make that connection is secondary to their ability to communicate effectively to me about it, and help me to feel engaged in making a decision about my own care,” she said.

AI is changing medicine quickly, for both patients and their doctors. The best way to stay ahead is to talk about it.

This story appeared in The Logoff, a daily newsletter that helps you stay informed about the Trump administration without letting political news take over your life. Subscribe here.

Welcome to The Logoff: The Trump administration is further limiting due process for asylum-seekers in the US.

What’s happening? On Tuesday, the administration issued a rule changing how some asylum requests are handled. Under the new policy, immigrants in more than 444,000 asylum cases could be denied the chance to speak with an asylum officer and claim asylum, which requires them to have experienced persecution, or the threat of persecution, in their home country because of their race, religion, nationality, political opinions, or another characteristic. 

Instead, those immigrants would be redirected to immigration judges — who could order their deportation without any additional process. 

The change, according to the administration, is intended to help clear a substantial backlog in the US asylum system, which has 1.4 million cases currently pending. But it fits a pattern by the Trump administration of dramatically curtailing access to asylum in the US. 

What’s the context? Under the second Trump administration, many previous immigration judges have been forced out or fired from their roles. Their replacements, as Bloomberg reported earlier this year, are minimally trained and instructed to deny most asylum claims outright. 

What’s the big picture? The Trump administration also has a long record of sending immigrants back into dangerous situations in their home countries, or even to countries to which they have no connection. 

Last year, as my colleague Ian Millhiser reported, the Supreme Court effectively allowed the administration to nullify the Convention Against Torture and send immigrants to war-torn countries like South Sudan. 

And those deportations are poised to get worse: In June, the Court also cleared the way for Trump to end temporary protected status for immigrants from Haiti and Syria, without consideration of procedural rules. Now, Immigration and Customs Enforcement is reportedly preparing to target hundreds of thousands of Haitians living in the US for deportation, even though the island nation is dealing with serious and widespread gang violence. 

With less than 100 days until the 2026 midterm elections, don’t miss my colleague Astead Herndon’s new newsletter, The Midterms, Actually. Every week, Astead breaks down the big ideas and key people behind the political shifts shaping the 2026 elections. You can subscribe here.

And with that, it’s time to log off…

Want to spend less time on social media? Here’s some excellent advice from my colleague Constance Grady, available here with a gift link. 

Thanks for reading, have a great evening, and we’ll see you back here tomorrow!

It’s tough to find any semblance of a silver lining in the humiliating implosion of Donald Trump’s foreign policy over the last year, especially after a week that has brought us another escalation of the war no one supports, a recycled trade war with Canada, an out-of-nowhere nuclear deal with a country that should never have access to nuclear weapons, and yet more threats against a small nation that poses no threat to the United States. 

But here’s the upside, just maybe: The tiny and perverse cadre of “anti-anti-Trump leftists” has been decisively silenced. If you find that phrase baffling, consider yourself fortunate. You evidently haven’t wasted any of your one wild and precious life arguing with renegade Marxists about whether the Trump-Putin alliance, in world-historical terms, was “objectively” superior to neoliberal internationalism on the Clinton-Obama model. 

If this is a safe space, I will admit here that at one time I was around one-third vulnerable to such arguments. I don’t mean the part about Trump being a force for progressive change in any sense, even if entirely by accident, since that was obviously and hilariously wrong, not to mention based on the same “enemy of my enemy” pretzel logic that produced the disastrous Nazi-Soviet pact of 1939. But on the level of a sophomore-seminar intellectual exercise, I could understand why self-appointed contrarians like Julian Assange and Glenn Greenwald saw Trump as a disruptive force who might upend the softcore imperialism of the previous three or four decades, which had led to the “forever wars” in Iraq and Afghanistan and the global hegemony of corporate capital. 

You didn’t have to be an unregenerate Leninist or an online troll or a Pat Buchanan-style paleoconservative (or all three at once!) to be momentarily seduced by Trump’s “America First” nonsense. Disgruntled Americans of all varieties voted for Trump by the millions, based in large part on his populist, isolationist rhetoric. Maureen Dowd’s notorious “Donald the Dove, Hillary the Hawk” column from 2016 should be inscribed above the gates of one of the lower circles of hell as a permanent warning to know-it-all media commentators. 

It was, of course, immensely helpful to Trump’s agenda of fabrications, exaggerations and outright lies that we experienced the failings of mainstream U.S. foreign policy all over again during the strange interregnum of Joe Biden’s presidency, with its pious invocation of a “rules-based order” — where the rules are set by America, of course — and its theological commitment to a now-entirely-imaginary “two-state solution” in the Middle East. Several things can be said in retrospect about Biden’s fateful embrace of Benjamin Netanyahu on the Tel Aviv tarmac after the Oct. 7 attacks: It was an authentic and heartfelt gesture, it was a grievous political error and it paved the way for a humanitarian catastrophe now widely perceived as genocidal. 

Trump’s return to power has, at the very least, finally confounded all the doofuses who ever took anything he said at face value, and has also dispensed with the contradictory or two-faced rhetoric of the Biden years. There’s no more talk of universal human rights or the spread of democracy. The fundamental logic of Trumpian policy is cynicism all the way down: We don’t care about any of those things and we never did. To paraphrase Stephen Miller, surely the most instrumental figure in the Trump White House, the only thing that matters is power. 

Maybe we should be grateful for the epic and reckless corruption of this administration, since Miller’s ambitious schemes to reshape America and the world as a white-supremacist wonderland are consistently undercut by the enormous levels of graft surrounding him. (Miller strikes me as a true believer whose corruption is moral rather than financial, one of many traits he appears to share with Joseph Goebbels.)

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As the Trump administration veers unsteadily into its lame-duck phase and a likely midterm wipeout, its quest for a legacy achievement becomes increasingly pathetic, not to mention increasingly dangerous. Trump’s dance of death with the Iranian regime might have a comical aspect if the lives of many thousands of people and the future of the global order were not at stake. By goading the president into restarting the war for the third time (by my count), the new roster of hardline leaders in Tehran, at least for now, have strengthened both their domestic control and their international reputation. It’s difficult to imagine, in fact, how Trump and his ludicrous cast of advisers could possibly have screwed this up worse than they did. (D.C. rumors suggest that high-testosterone “Secretary of War” Pete Hegseth will ultimately be compelled to walk the plank over this fiasco.)

Meanwhile, the search for something that can be pitched to last-ditch MAGA loyalists as a victory, no matter how petty and insignificant, continues. Trump has never given up on his dream of seizing or annexing Greenland, but it was always more like an extortion scheme or a real estate scam than a military threat. Roughly the same applies to his improvised plan to rebuild Gaza as a Trumpified new Riviera, which took even Netanyahu by surprise and was never likely to escape the uncanny valley of AI fantasy. 

I’m inclined to feel similar about this week’s reports that Seb Gorka, an unhinged far-right free radical with some sort of roving-ninja role in the Trump White House, is urging a military assault against Islamist militia groups in Mali, a West African nation with complicated internal dynamics and no relationship whatever to U.S. national security. Again, this might be amusing if real human lives weren’t at stake, and if billions in taxpayer dollars appropriated by Congress for aid to impoverished countries like Mali weren’t being diverted to right-wing nationalists, white supremacists and anti-LGBTQ groups instead of humanitarian and healthcare NGOs. (Read this ProPublica report for more on that.)

Things have truly gotten dark if we’re looking to JD Vance and Marco Rubio as the proverbial adults in the room, managing the worst impulses of their increasingly disinhibited and incapacitated boss. I don’t know which of those two geniuses signed off on the reported nuclear deal with Saudi Arabia, which may fall apart, goddess willing, under the weight of its impromptu idiocy and the fact that literally no one thinks it’s a good idea. Mohammed bin Salman, that kingdom’s journalist-murdering leader, is roughly the last person in the world who should have access to nuclear materials. If this deal goes through, it could rank among the very worst of Trump’s foreign policy blunders. Of course there’s still time for more. 

The post Trump’s foreign policy enters its decadent, desperate end stage appeared first on Salon.com.

Last week, the Food and Drug Administration (FDA) approved a small pill called enlicitide. It is a tablet you swallow once a day on an empty stomach with a sip of black coffee, water, or tea. But it does something that until now took a needle and a specialist’s prescription: It lowers the most dangerous kind of cholesterol by nearly 60 percent, about as much as the strongest injectable drugs on the market.

If that sounds less innovative than some of the medical advances I sometimes cover here — there’s no AI or gene editing involved — you’re missing the story. Enlicitide is just the latest example of how medicine has been quietly making progress against the deadliest thing in the modern world.

That thing is heart disease. It has been the leading cause of death in the United States for essentially a century, and in 2025 it killed 694,708 Americans — about one in five deaths — more than every form of cancer combined. Around the world, cardiovascular disease kills roughly 20 million people a year, the biggest cause of death on the planet.

But today, our enemy is on the retreat. In the US, the age-adjusted death rate from cardiovascular disease has fallen about three-quarters since 1950. In plain terms: A 60-year-old today is roughly four times less likely to die of heart disease this year than a 60-year-old was when Harry Truman was president. As I wrote last year, deaths specifically from heart attacks are down 89 percent since 1970.

That progress comes down to a single number. Low-density lipoprotein, or LDL, aka the “bad” cholesterol your doctor always wants you to lower. Until recently, a high LDL score was all but inescapable, something you could nudge lower with a better diet and willpower but struggle to really fix. What has changed is that we can now lower LDL for nearly anyone who needs it — further, more easily, and earlier in life than before.

A lifesaving genetic mutation

It’s a story that goes back 20 years. In the early 2000s, two geneticists at University of Texas Southwestern, Helen Hobbs and Jonathan Cohen, wanted to solve a medical mystery: Why did some individuals have striking low cholesterol levels? They combed the Dallas Heart Study for an answer. They found a handful — many of them Black Americans — carrying a broken copy of a gene called PCSK9. Their bodies cleared LDL from the blood with unusual efficiency, and the payoff was staggering: carriers of the strongest variant had about 28 percent lower LDL and roughly 88 percent lower risk of heart disease than people who did not carry the mutation.

That finding proved lowering LDL prevents heart attacks, and it handed drugmakers a target: copy that gene. Every PCSK9 drug since — including the new enlicitide — imitates a mutation a few people in Dallas were simply born with.

Millions of Americans still take the old cholesterol-lowering workhorses, statins, and they’ve proven highly effective at reducing heart disease for most people. But not everyone: Some people can’t tolerate the muscle aches; others take them faithfully and still don’t get their LDL low enough. Enlicitide is built for exactly those people: a pill as cholesterol-lowering as an injection but without the needle, and a drug that spares them the statin muscle aches.

Closing the loop

If the pill is today, gene editing is tomorrow — and it may be the answer to a problem no pill can reliably solve: getting people to keep taking their medicine.

About half of patients on statins quit them within a year, and a daily pill, however potent, only helps the people who actually take it. So that demands a fix you can’t forget. A company called Verve Therapeutics, now owned by Eli Lilly, has been testing a treatment that makes a single-letter edit to the PCSK9 gene in the liver — one infusion, in theory for life. In its first human trial, published over the spring in the New England Journal of Medicine, a single dose cut LDL by as much as 62 percent, and held it there for more than a year. Instead of a pill mimicking the effects of the genetic mutation that protected those people in Dallas, gene editing just switches off the gene.

As important as it is, cholesterol isn’t the whole story when it comes to heart disease. There’s smoking, which declined from about 40 percent of US adults in the 1960s to under 15 percent today, sparing countless arteries. High blood pressure — the silent condition that killed President Franklin D. Roosevelt at 63 in 1945, when doctors had few effective ways to treat it — can now be caught early and treated with cheap generic pills.

And then there are the GLP-1s. More than one in 10 US adults say they are currently on an anti-obesity drug, and whatever else you may think of them, they’ll make a significant dent in heart disease. In one major trial semaglutide cut cardiovascular events by 20 percent.

The war continues

Still, the war on heart disease won’t be easy to win.

Just because a pill like enlicitide has been proven to lower a lab value does not mean it’s yet proven to lower deaths. They should — the injectable versions of these drugs cut heart attacks and strokes by about 20 percent in long trials. But enlicitide’s own outcomes study won’t conclude for years.

Precisely because the condition itself so widespread, treatments for heart disease will only be effective if they are equally widespread.

Heart disease is shifting, too. The same research showing heart-attack deaths down 89 percent found deaths from other heart conditions — heart failure, arrhythmias, hypertensive disease — up 81 percent since 1970, though because heart attacks were killing several times as many people, overall heart-disease deaths have still dropped by about two-thirds since 1970.  Some of that shift is perversely the result of success: people who might have died of an initial heart attack now live long enough for the heart to wear out in other ways. And some of this is the reverse of progress: As smoking and cholesterol fell, obesity climbed to about 40 percent of US adults, pulling diabetes and high blood pressure with it.

And then there’s perhaps the biggest problem in medicine: access. A 60 percent drop in cholesterol helps only the people who can actually get the drug. Half of patients abandon cheap statins within a year. Enlicitide arrives at about $300 a month with uncertain insurance coverage. The gene edit, whenever it becomes available, will certainly cost far more, and at first will reach only the sickest.

More than 60 percent of US adults are projected to have some form of heart disease over the course of their life. Precisely because the condition itself so widespread, treatments for heart disease will only be effective if they are equally widespread.

Which brings us back to that unassuming little pill. It’s just a tablet, doing what a generation of scientists spent their careers trying to do: turning one of the deadliest numbers in medicine into one you can change. It’s the kind of progress that’s too easy to miss — until it saves your life.

A version of this story originally appeared in the Good News newsletter. Sign up here!

Abdul El-Sayed is among America’s most prominent proponents of Medicare-for-all. 

The frontrunner in Michigan’s Democratic Senate primary literally wrote the book on that policy (or at least, a book on it). In El-Sayed’s view, Medicare should cover “all necessary healthcare” for every American — without co-pays, premiums, or deductibles — and be “accepted everywhere.”

Alas, despite his many years of advocacy, El-Sayed has seemingly failed to persuade his wife of that last point: According to a recent report from the Washington Free Beacon, El-Sayed’s partner, the psychiatrist Sarah Jukaku, does not accept Medicare as a form of payment at her private practice.

This bit of gossip is of little importance, in and of itself. The Free Beacon’s story does nothing to refute the case for El-Sayed’s candidacy or his healthcare plan (his wife’s business is, well, her business). As hit pieces go, it’s weak tea.

Nevertheless, the tension between El-Sayed’s healthcare proposals and his wife’s business practices is real. And it is illustrative of a major challenge facing anyone who wishes to reform our nation’s misbegotten healthcare system: To meet the medical needs of all Americans, reformers will need to defy the interests of most doctors — and in many cases reduce their compensation. 

And that won’t be easy. Few people feel a deep fondness for insurance companies. But El-Sayed is far from the only American who loves a physician.

The biggest obstacle to Medicare-for-all

To understand why Medicare-for-all would be bad news for many doctors — and how the Free Beacon’s story illustrates that point — we must first dwell on one fundamental fact about America’s healthcare system: It’s a rip-off. 

The US spends about twice as much per person on medical goods and services as other wealthy countries. And yet, all that money does not actually buy us much more care. Compared to our peers abroad, Americans are less likely to see a doctor, secure a long hospital stay, or access a timely appointment for medical treatment. On the other hand, we do have the privilege of paying radically higher healthcare prices.

To take just one telling example: In the United States, a coronary bypass surgery will typically cost more than $89,000; in Australia, it costs just $17,741.

Such exorbitant prices are the chief obstacle to any version of universal healthcare. Even with one-third of working-age Americans uninsured or underinsured — and thus, consuming too little medical care — the bill for America’s health sector ran to $5.7 trillion in 2025. 

In El-Sayed’s vision, Americans would consume vastly more medical services than they do today: The uninsured would suddenly have access to every doctor in the country, while everyone else would see their co-pays and deductibles drop to zero, encouraging them to schedule far more doctors’ visits.

This would be a costly proposition in any country. At America’s current healthcare prices, it would be prohibitively expensive. There is simply no way to realize anything approaching the left’s healthcare ambitions without slashing the amount of money that Americans pay per medical service. 

Doctors will pay a price for universal healthcare

Medicare-for-all advocates are aware of this fact. And they’re typically eager to talk about one source of America’s high healthcare prices: The inefficiencies of our private health insurance model. 

In America’s byzantine system, each insurer needs its own teams of auditors, claims reviewers, and myriad other specialists, while every major healthcare provider needs a horde of administrators to navigate the idiosyncratic rules of all these different insurance companies. Americans pay dearly for this bureaucratic bloat. By one estimate, our system’s administrative costs are $500 billion higher than they would be if the insurance industry was consolidated into a single public insurer. 

And yet, as large as that figure may seem, it still represents a fraction of America’s excess healthcare costs. The primary cause of our nation’s exorbitant medical prices is simpler than administrative redundancies: our healthcare providers charge exceptionally high rates.

Hospitals are the biggest culprits on this front. But physicians are also part of the problem.

According to a 2026 study from economists at the University of Chicago, Stanford, and the US Census Bureau, American physicians earn about twice as much as Canadian ones — and four times as much as Swedish doctors. 

Critically, this does not merely reflect America’s greater wealth or wage inequality. It is true that educated professionals of all kinds — financial analysts, lawyers, software engineers, etc. — earn more in the US than they do in other rich countries. But American doctors don’t just earn unusually high absolute incomes — they also occupy an atypically rarified place within their own country’s class hierarchy. About 42 percent of American specialty physicians are in the top 1 percent of their nation’s income earners. Among Canadian specialists, that figure is just 27 percent; for Swedish ones, it is 7 percent.

The main driver of these disparities is straightforward: America imposes fewer price controls on its healthcare sector than other nations do. 

And this is where Jukaku’s practice reenters the picture. 

The public parts of America’s insurance system — Medicare and Medicaid — pay rates that are only modestly above international norms. It is when American doctors bill private insurers — or the rich consumers of boutique medicine — that they really make bank.

As a result, top clinicians like Jukaku often decline to take Medicare. If you’ve got affluent patients beating down your door, accepting Uncle Sam’s rates just doesn’t pay.

Unless the government forces doctors and hospitals to swallow steep pay cuts, however, Medicare-for-all won’t pencil out. According to a widely cited 2018 analysis by the economist Charles Blahous, if a single-payer system kept provider payments constant, national health spending would rise by $3.25 trillion over a decade, even with administrative savings taken into account. By contrast, if all providers were forced to accept Medicare’s rates, health spending would actually fall by $2.05 trillion over the same period.

Soaking physicians is tough politics

Thus, there is a clear conflict between progressives’ healthcare ambitions and medical providers’ material interests. 

Yet the left is often reluctant to acknowledge this reality. El-Sayed tends to portray insurers as the sole economic beneficiaries — and political defenders — of America’s inequitable healthcare system. The fact that hospitals and doctors also profit off the status quo’s dysfunctions does not feature prominently in his rhetoric. To the contrary, El-Sayed suggested in 2020 that doctors like his wife are actually underpaid, even though American psychiatrists earn far higher salaries than their counterparts abroad. 

To be fair, progressives aren’t alone in eliding providers’ culpability. Virtually all Democratic politicians do the same. And not without reason. Politically speaking, it is one thing to denounce the greed of private insurers — the faceless bureaucracies standing between Americans and their desired treatments. It’s quite another to call for reducing the wages of doctors, men and women who perform laudatory work and enjoy widespread admiration. 

Precisely for this reason, however, reformers must grapple with healthcare providers’ investment in the current system. The American Medical Association (AMA), the lobby representing our nation’s physicians, was instrumental in killing past attempts to move toward single-payer. And at least some segments of the medical profession would surely mobilize against any contemporary Medicare-for-all bill that imposed substantial cost controls on the healthcare sector. What’s more, in doing so, they would be able to draw on a resource the private insurance industry lacks — the public’s trust.

How to make healthcare less expensive right now

There is no easy answer to the problems all this presents. But part of the solution is to chip away at providers’ payment rates where progressives already have the power to do so. This would not only help drive down costs for existing healthcare in the short term, an urgent priority all its own, but also would smooth the path to universal coverage in the long run.

That project can take many forms. One would be state-level payment regulations. In Maryland, hospitals receive the same rates, no matter whether their patients pay with Medicare, private insurance, or cash. And their budgets are also fixed, so that they aren’t able to milk fees out of unnecessary care. Rhode Island, meanwhile, caps the growth of its hospital reimbursement rates at the pace of overall inflation. Other states could follow their lead. 

But policymakers should also address the supply constraints that undergird American doctors’ high salaries. US physicians’ ability to command high pay doesn’t just reflect America’s weak cost controls but also a persistent shortage of working doctors. The US has roughly 2.7 physicians for every 1,000 of its residents; the average among comparable countries is 3.9, according to a Kaiser Family Foundation analysis.

In this context, forcing down doctors’ pay might seem perilous. After all, doing so would reduce young people’s incentive to pursue a medical career, potentially deepening the shortage. 

In reality, however, there is no dearth of qualified people who want to practice medicine in the US. We just don’t let many of them do so.

This is partly because American policymakers consciously sought to restrict the number of doctors in the country, beginning in the 1980s. As Robert Orr of the Niskanen Center explains, the US government issued a report in 1981 warning of an imminent “physician surplus” and recommending “immediate action to curtail both the domestic training of physicians as well as the admittance of those trained outside of the country.”

The report’s argument rested on false premises; it failed to anticipate that Americans’ demand for healthcare would rise sharply as they grew wealthier. Nonetheless, its recommendations were largely implemented: Federal support for medical-school scholarships was pared back while funding for residencies has been capped since 1997. 

At the same time, policymakers maintained high barriers to the immigration of fully-trained foreign doctors: Even physicians with years of experience, and credentials in nations with high medical standards, are typically required to complete a multi-year residency before being able to practice in the US.

Ending the federal freeze on residency funding will require congressional action. But states can immediately make it easier for foreign doctors to practice within their borders. In fact, Tennessee established a pathway for such physicians to ply their trade in the state, without having to repeat a residency, in 2023. And many states subsequently enacted similar reforms.

Removing the bottlenecks on America’s doctor supply won’t eliminate the political hurdles to Medicare-for-all. But it would put downward pressure on doctors’ salaries, reduce the risks of capping physician pay, and make the left’s vision of healthcare abundance more feasible. After all, you can’t actually eliminate the care rationing that so many Americans resent by extending insurance coverage or enacting price controls alone. No matter how we pay for our medical services, we can only deliver as much care as our health sector’s resources allow. 

Don’t hate the doctor, love the sick

In saying all this, I don’t mean to convey disdain for the medical profession. Like El-Sayed, some of my best friends are doctors! In fact, my mother, father, brother, and sister-in-law are all physicians. And they all have contributed far more to American society than I ever will. My brother spends his workdays providing lifesaving treatments to cancer patients; I often spend mine sitting at a desk in my pajamas, arguing about politics on the internet. 

Physicians deserve to be well-paid for their strenuous labor. But if we want healthcare in America to be universally affordable and widely accessible, we will need to pay many of them a bit less.

What caused the ongoing outbreak of cyclospora, the diarrhea-causing parasite currently spreading across the United States? Michigan officials have been saying for weeks that they believed the outbreak may be linked to bagged salad or salad kits. What we were waiting to learn was the specific brands and specific products in question. 

And late last week, it looked like we finally had the answer — but then things quickly got cloudy. 

On July 16, the Washington Post reported, citing anonymous sources, that the outbreak had been linked to shredded iceberg lettuce supplied to Taco Bell by Taylor Farms. A day later, Taylor Farms said it was withdrawing products from US stores and restaurants based on information from the FDA.

But then on July 19, per NBC News, the FDA said that there had been a false positive for cyclospora when testing a sample of Taylor Farms iceberg lettuce; Taylor Farms said in its own statement that the FDA had “apologized” for the mix-up. The next day, the company and the federal government were stuck in a semantic argument: Per NOTUS, the FDA insisted it did not “officially apologize” to Taylor Farms but “explain[ed] factually the issues” with the false positive. 

So where does that leave us right now? Officials still believe that Taylor Farms iceberg lettuce was the source of the Michigan outbreak. But whether those are the only products driving the outbreak remains unclear, with almost every state now reporting at least one cyclospora case in 2026. And on Thursday afternoon, the FDA announced that it was tracking a second outbreak linked to other unspecific products, though details were otherwise scarce.

Any outbreak of food-borne illness requires careful public communication. Officials need to tell people how to avoid contaminated food without scaring them away from eating fresh fruits and vegetables altogether.

But instead, many Americans have been left wondering what, exactly, they’re supposed to do. As one frustrated Reddit user put it: “So is the damn lettuce bad or not????” (If you need some advice on what foods are safe and what foods to be cautious about, we have a story for you.)

It may sound like a funny question, but it’s a profoundly serious one. The problem isn’t just that people are confused about their lettuce. The Trump administration’s handling of the cyclospora outbreak — from its conflicting public messages to accusations of political favoritism — has left many Americans even more confused about whether they can trust anything they’re hearing from the government. That’s a dangerous place to be during any public health emergency.

The cyclospora outbreak has become a communications nightmare

We are approaching 10,000 cyclosporiasis cases across the US this year: Michigan alone has recorded 7,664 as of this morning, Ohio has seen more than 1,200, and more than 40 states have now reported at least one case in 2026. The country usually sees a few hundred cases at most in a given year. Cyclosporiasis, the disease caused by the cyclospora parasite, leads to what public health experts describe as “watery” and “frequently explosive” diarrhea. While it isn’t typically life-threatening, it can cause serious complications: 160 people have been hospitalized in Michigan since the outbreak began.

And so for those of us who very much hope to eat fresh produce but do not want diarrhea, there’s a bit of urgency to figure out where the cyclospora is coming from. Food-borne illness investigations are already inherently difficult because of how globalized our food supply has become: Produce can travel all over the country and the world before it comes to your grocery shelf, and the process of government health workers interviewing the people who get sick and cross-checking to identify the shared foods that they might have in common is laborious.

Once investigators find a source, the information has to be shared clearly and responsibly. That is where the Trump administration has tripped up this week. 

Trump — and Health Secretary Robert F. Kennedy Jr. in particular — came into office criticizing the public health establishment. They accused officials of misleading the public about the novel coronavirus and the vaccines developed to fight it, while failing to convey the nuances of the pandemic. But now, as they grapple with the incomplete picture of the cyclospora emergency, they are making many of the same mistakes.

“They’re very similar problems, even if on the outside, they don’t look quite the same,” said Michael Mackert, director of the Center for Health Communication at the University of Texas at Austin. “The underlying commonality is very much that we are dealing with imperfect information all the time.”

In any outbreak, some uncertainty is to be expected. Investigators have struggled to identify the source of earlier cyclosporiasis outbreaks too. And the FDA maintains that the likely source of the outbreak is Taylor Farms iceberg lettuce, based on the information they have gathered from sick patients and other sources, no matter the false positive result that has sparked so much confusion.

“The epidemiological evidence is so strong that the lack of a positive test is almost meaningless,” said Francisco Diez-Gonzalez, director of the Center for Food Safety at the University of Georgia. 

But the mistake that the Trump administration made was in sharing preliminary results and then having to issue a seemingly contradictory statement shortly afterward.

“FDA should have waited for confirmation of the presumptive results before going public,” Diez-Gonzalez said.

The larger stakes of the Trump administration’s poor communication

Investigations like these are hard enough — but when you add in the public health funding cuts of the past 18 months and the casual and widespread corruption characteristic of the Trump administration, trust in the government’s public health apparatus has sunk even lower.

It’s created just the conditions for conspiracies to bloom. “Unfortunately our FDA is compromised,” wrote one top commenter on Reddit. “I would not trust what comes out of it during this administration.” 

Several news outlets and influential social media accounts noted that Taylor Farms had donated $1 million to Trump’s MAGA super PAC and, in the middle of the controversy, received a private White House meeting. According to the New York Times, Taylor Farm officials used that meeting to dispute the findings that their products were responsible for the outbreak — and shortly thereafter, the FDA made its “false positive” announcement.

The administration insists that their decision-making is being guided by science, but even the appearance of impropriety has become a common theme in the press coverage. The broader uncertainty and distrust may help to explain why it’s not only Taco Bell and Taylor Farms taking a hit right now: According to Market Watch, Chipotle and the fast-casual salad chain Chopt have also seen a decline in traffic in recent weeks.

Public health requires public confidence. Perceived influence from special interests is a problem, even if the interactions didn’t alter the FDA or CDC’s actions.

Kennedy, who helms our government’s health department, should understand this well: His Make America Healthy Again movement made restoring public trust a central part of its message while accusing the existing public health establishment as being in league with special interests. 

The cyclospora outbreak has revealed how difficult that is to do in practice. 

In trying to communicate nuanced information during an active outbreak — while consulting interested parties like Taylor Farms itself — the administration has instead fueled doubts about the credibility of its messaging

Even before cyclospora turned eating salad into a leap of faith, Trump had a poor track record: His administration has slashed CDC staff, brought on vaccine skeptics to set vaccine policy, and clashed with the scientific establishment on a number of high-profile issues, like the time Trump held a televised press conference to argue a disproven theory that Tylenol can cause autism.

“Unfortunately, this is another example of a missed opportunity to establish credible and trusted communications to prepare the public to understand the real risks from the pathogen and confidence in the food safety and information from the FDA,” Scott Ratzan, editor-in-chief of the Journal of Health Communication: International Perspectives, told me. “Faith in our institutions continues to erode. We could do better.”

We are lucky cyclospora is not a deadly disease. Next time, the stakes for these miscues could be much higher.

There was an unintentionally revealing moment in acting Attorney General Todd Blanche’s confirmation hearing last week. After Sen. John Kennedy (R-LA) asked Blanche whether he and President Donald Trump are friends, the leader of the United States Department of Justice replied, “I’m his lawyer,” before correcting himself and saying he “was his lawyer.”

Blanche previously defended Trump in three criminal cases brought while the president was out of office, but he is emphatically not supposed to be Trump’s lawyer right now. As acting attorney general — Blanche currently leads the DOJ because the attorney general’s job is vacant and Blanche is the Senate-confirmed deputy attorney general (DAG) — Blanche’s client is the United States, not the person who happens to occupy the White House. 

But it’s easy to see why he misspoke: Blanche has largely acted as Trump’s hammer since he was confirmed as the DOJ’s No. 2 official, overseeing numerous prosecutions of Trump’s perceived enemies. Now Trump wants to promote him to the DOJ’s top job — a sign of Trump’s confidence in his former criminal defense lawyer turned personal enforcer.

It’s unusual for a president to put his own defense lawyer in such a powerful position — indeed, it’s unusual for a president to have a criminal defense lawyer at all. But Trump has a long string of attorneys who’ve defended him and his companies against an equally long string of criminal allegations ranging from tax fraud, to falsifying business records, to illegally taking classified documents, to charges arising from his failed attempt to steal the 2020 presidential election. 

And he’s put at least five of those criminal defense lawyers in top federal jobs. 

Trump’s decision to turn much of his criminal legal team into powerful government officials matters for two big reasons. The first is that two members of that team, Blanche and Solicitor General John Sauer, are leaders within the Justice Department. Next to the military, there is no more fearsome government institution than the DOJ, which has the power to arrest people and try them for federal crimes. 

The DOJ is supposed to exercise this authority with restraint — and often with restraints imposed by the Constitution itself — but Blanche has used the Justice Department’s power against Trump’s political enemies who appear to have committed no crime and removed constraints on Trump and his Justice Department, all while Sauer has worked consistently to convince the Supreme Court to remove other constraints on Trump.

Meanwhile, three of Trump’s former criminal lawyers, Emil Bove, Justin Smith, and Matthew Schwartz, now have lifetime appointments as US Court of Appeals judges, placing them one rung on the judicial ladder down from the Supreme Court. The judiciary, of course, is the branch of government that is supposed to prevent the president from breaking the law, so every Trump loyalist appointed to this branch weakens the remaining legal constraints on Trump and his administration.

Trump, of course, isn’t the only president to place close confidants in the Justice Department or the federal bench. President John F. Kennedy famously named his brother attorney general. President Lyndon B. Johnson appointed Abe Fortas, who represented him in a 1948 election dispute, to the Supreme Court in 1965.

But Trump’s decision to place someone willing to pursue his personal vendettas in charge of the Justice Department is, at the very least, a break with post-Watergate norms established to prevent the DOJ from becoming a political weapon. And Fortas, who resigned in disgrace after fewer than four years on the bench, is more of a cautionary tale than a model of good governance.

Although the current Supreme Court is dominated by conservative Republicans, some of these justices do break with Trump on questions that divide the Republican Party — such as whether Trump should unilaterally impose high tariffs on many nations. But if Trump gets to turn his personal cronies into justices, that could change quickly. A judiciary controlled by MAGA loyalists means that all remaining checks on Trump’s authority could end. Many of his former-lawyers-turned-appointees are already working to make an unchecked Trump administration a reality.

How are Trump’s former personal lawyers already reshaping American legal norms?

Smith, who worked on the Trump v. United States immunity case, was confirmed last month. And Schwartz, who worked on the false documents case that led to Trump’s conviction, joined the bench last week. So there’s not much to say about these two men’s record in federal office — yet.

But Blanche, Bove, and Sauer have all displayed ruthless cunning in their efforts to advance Trump and his causes.

Blanche has been DAG since March 2025, a role that oversees the federal government’s criminal prosecutions and its 93 regional US attorneys’ offices. He’s led the entire Justice Department since April, after former Attorney General Pam Bondi — another of Trump’s former personal lawyers — left office.

So Blanche oversaw several dubious federal prosecutions targeting people Trump perceives as enemies, including criminal proceedings targeting former FBI Director James Comey and current New York Attorney General Letitia James. There’s also evidence that Blanche has played an unusually direct role in the Justice Department’s decision to bring meritless charges against prominent Democrats.

In May 2025, for example, Newark Mayor Ras Baraka, a Democrat, showed up at an ICE detention facility in his New Jersey city and asked to tour it. He was briefly let inside the gate, where he was confronted by about a dozen law enforcement officers and asked to leave, which he did.

But then one of these officers received a phone call. A video, later submitted to a federal court, shows the officer turning to his colleagues after the call and announcing, “We are arresting the mayor right now, per the deputy attorney general of the United States.” That deputy attorney general, of course, was Blanche. (In a September court filing, DOJ confirmed that officers arrested Baraka “after consulting with the Deputy Attorney General.”)

Yet, despite Blanche’s apparent decision to personally order Baraka’s arrest, the DAG forgot to check whether Baraka had actually done something that could support criminal charges. The mayor was only charged with misdemeanor trespassing, and those charges were dismissed two weeks later. At the court hearing formally dropping these charges, a federal magistrate judge admonished prosecutors for “using the immense power of the government to pursue weak cases or to make examples without sufficient cause.”

Blanche also unsuccessfully attempted to establish Trump’s $1.776 billion “anti-weaponization fund,” which would have been used to distribute money to Trump’s allies — including, potentially, Trump supporters who participated in the January 6 attack on the US Capitol. Although the fund appears dead after it received bipartisan pushback in Congress, a DOJ press release announcing the fund said it was “established” by the attorney general, a role performed by Blanche, and that the fund would be administered by five people chosen by Blanche.

Before Trump took office, Bove was Blanche’s law partner. Shortly before Bove joined the bench, he briefly served as principal associate deputy attorney general — essentially the DAG’s top deputy, which meant that Bove was Blanche’s right-hand man. In that role, he was often described as Trump’s “enforcer.” 

Bove spent only about half a year as Blanche’s lieutenant, but he managed to spark a mini-revolt in one of the Justice Department’s most prestigious offices during his short tenure. After Bove ordered the DOJ to dismiss corruption charges against then-New York City Mayor Eric Adams “without prejudice,” a maneuver that would allow the charges to be reinstated if Adams did not cooperate with the Trump administration’s immigration crackdown, seven federal prosecutors resigned rather than comply with Bove’s order. 

One was Danielle Sassoon, a former law clerk to Justice Antonin Scalia, a conservative icon. Another, Hagan Scotten, wrote in his resignation letter to Bove that “I expect you will eventually find someone who is enough of a fool, or enough of a coward, to file your motion. But it was never going to be me.” Scotten clerked for Republican Chief Justice John Roberts and for future Republican Justice Brett Kavanaugh.

Meanwhile, a whistleblower complaint by another former DOJ lawyer claims that Bove said, in a meeting about a court decision halting some deportations, “that D.O.J. would need to consider telling the courts ‘fuck you’ and ignore any such order.”

Trump appointed Bove to the US Court of Appeals for the Third Circuit last September. Federal appeals courts typically spend months deciding cases, so his tenure on the Third Circuit has thus far been less eventful than his time at the DOJ. But there are early signs that he remains loyal to Trump even after moving into an independent branch of government. Bove attended a Trump rally in December, a highly unusual move for judges who are supposed to remain nonpartisan. And the background image on his iPhone is reportedly an image of a defiant Trump raising a fist, or at least it was months after he joined the bench.

That leaves Sauer, who, as solicitor general, is tasked with defending federal government programs in the Supreme Court. That includes the Trump tariffs that the Supreme Court struck down last winter, and Trump’s unconstitutional attempt to strip many newborn Americans of their citizenship.

Despite these losses, Sauer has an impressive winning record before the Supreme Court, largely because the Court is controlled by six Republicans who are highly sympathetic to Trump and his agenda. This is, after all, the same Court that said that Trump may use the powers of the presidency to commit crimes, after Sauer argued as much. 

Sauer has been particularly effective in persuading the Republican justices to block lower court rulings against Trump on the Court’s “shadow docket,” a once rarely used mix of emergency motions and other matters that became a routine part of Supreme Court litigation during Trump’s first term.

So Trump has taken several of his personal lawyers and transformed them into some of the most well-credentialed — and in some cases, the most powerful — figures in the legal profession. Thus far, the evidence suggests that these individuals remain loyal to Trump, even when they move into jobs that are supposed to be nonpartisan. Three of them already have lifetime appointments. 

Any nation governed by the rule of law must have government officials who will obey whatever constraints the law imposes — whether they be federal agency leaders who follow the law out of a sense of duty, or judges who rein in executive branch leaders who refuse to do so. Institutions like the Department of Justice also depend on informal norms, many of which are a response to similar abuses of power during the Nixon administration, that have long constrained federal prosecutors.

But Trump’s DOJ is often actively hostile to these norms, and the growing legal power of Trump’s personal lawyers is just the latest example. Their steady reshaping of the judiciary clears the way for a federal government that is not constrained by anything.

In January 2025, Linda-Gail Bekker stood inside a vaccine manufacturing plant and allowed herself to believe that the first HIV vaccine candidate conceived through African science and led by Africans might finally become a reality.

The vaccine would be built on mRNA technology, the same platform that had helped tame the Covid-19 pandemic. Bekker hoped it might finally crack the puzzle that had frustrated HIV researchers for more than four decades.

No virus has proved more evasive. Hundreds of HIV vaccines have entered testing; none has succeeded at providing durable protection against infection. And the need remains vast: In 2025, roughly 1.2 million new HIV infections were reported; anti-retroviral treatments have turned it into more of a survivable disease, but more than half a million people died from AIDS-related causes the same year. There is still no known cure.

So researchers like Bekker, an infectious disease specialist at the University of Cape Town, have more hope now, in part because there is finally a clearer idea of what an effective vaccine needs to do. It must coax the immune system into producing a particular type of protective antibody, a rare class of defender, capable of recognizing and disabling HIV despite the virus’s extraordinary diversity and rapid ability to mutate.

No one yet knows how to reliably do that. But mRNA is uniquely suited to the task of finding out, vaccinologists say. Thanks to the platform’s speed and flexibility, researchers can iterate rapidly through the otherwise laborious process of designing, testing, and refining the series of vaccine components needed to guide the body toward making those essential antibodies.

At the start of last year, Bekker and her colleagues were ready to put that strategy to the test. The clinical trial for their new mRNA-based HIV vaccine was just on the verge of enrolling its first participants. But the project depended on the same backing that had sustained HIV vaccine research for decades: US government funding. Washington had long supplied roughly 90 percent of the world’s investment in the field. Then President Donald Trump returned to office.

Within hours of his inauguration, Trump signed an executive order freezing foreign aid. The $45 million contract from the US Agency for International Development (USAID) that was supposed to fund clinical trials like Bekker’s disappeared, as did a web of other funds, many routed through the National Institutes of Health (NIH), that had helped fuel the field’s progress for years.

The timing could hardly be more cruel. After 40-odd years of chasing a shape-shifting foe, scientists believe they now know what kind of immune response an HIV vaccine must generate — and have in mRNA a powerful new tool for pursuing it. But just as many researchers have finally glimpsed a path to victory, the United States and much of the funding has pulled away from the fight. 

Pushing the envelope

From the outset, the target for preventing HIV was clear. Within a year of identifying the virus as the cause of AIDS in 1983, researchers had zeroed in on its envelope protein as the most promising point of attack for a vaccine.

Protruding from the virus’s surface in knobby clusters, the envelope protein acts like a molecular grappling hook, latching onto immune cells before pulling the virus itself inside. Without this feature, HIV cannot infect a cell.

Much as the coronavirus spike protein would later become the basis for Covid vaccines, this protein on the surface of HIV seemed an obvious bullseye. But identifying the target didn’t mean researchers could hit it. Most of what the immune system sees of the envelope protein is actually just a decoy. The parts that stick out and draw the strongest immune response are also its most changeable, differing from one strain to the next and mutating freely whenever antibodies close in, leaving the body to waste its firepower on a target that keeps slipping away.

Candidate vaccines kept making the same mistake. They would elicit plenty of antibodies, but not the kind that could keep up with the virus. Time and again, promising candidate vaccines generated excitement in the laboratory, only to come up empty when it mattered most in large-scale clinical testing.

The field’s fortunes started to change in the late 2000s when researchers began studying the small fraction of people living with HIV who developed antibodies capable of recognizing the virus’s concealed, conserved features. Though these hard-won antibodies came too late to protect their makers, they gave scientists a molecular blueprint for the defenses a vaccine would need to build.

As the field came to learn, these “broadly neutralizing antibodies” do not appear overnight but rather after years of battle with the virus. 

The challenge, then, was to design a vaccine that would not just trigger an immune response but guide a person’s immune system through the same evolutionary journey. This would require a succession of vaccine components to prompt a carefully choreographed process within the body, rather than the single, fixed target that suffices for shots against measles or hepatitis B.

It was a strategy rooted in rational design but dependent on trial and error. Progress would come through a steady stream of small proof-of-concept studies, each informing the next generation of vaccine candidates. Ordinarily, it would take at least a year — often longer — to manufacture and prepare each vaccine iteration before it could be tested in people. 

But then the Covid pandemic rocketed mRNA into the spotlight.

The mRNA advantage

mRNA technology upends the old recipe of vaccine development. Conventional shots work by showing the immune system a mugshot of the enemy: a killed or weakened germ, or one of its proteins, grown batch by batch in vats of cells or eggs. An mRNA vaccine takes a different route. Rather than supplying the mugshot, it supplies the instructions to draw one: a short, lab-printed strip of messenger RNA, the molecule cells normally use to ferry genetic directions from DNA to their protein-making machinery.

Inject the right sequence, and it will program the body’s own cells to become tiny factories, producing the target protein and presenting it to the immune system as if it were the real intruder. Because it is all just code, refining a design means editing text, not rebuilding a factory — the work of days, not months.

“We’ve been able to design vaccines in real time,” said University of Pennsylvania Perelman School of Medicine assistant professor Ted Kreider, who is a specialist in infectious diseases.

To HIV researchers, the appeal was obvious. HIV’s greatest weapon was its ability to shift and adapt. Now, at last, a vaccine could, too. 

The timing was ideal. Just as researchers were beginning to map the path to an effective vaccine, mRNA offered a way to move down that path at speed. With vaccine designs no longer bottlenecked by design and manufacturing, what once might have taken decades of stepwise vaccine development could, thanks to mRNA, be compressed into years.

Across a growing number of clinical trials, researchers are now testing different vaccine components, different sequences, and different delivery platforms, searching for the combination that most effectively nudges the immune system toward a truly HIV-thwarting response.

A paper published last month in Nature offered one such path forward, showing in monkeys that a painstaking sequence of eight shots could coax the immune system into producing potent antibodies capable of neutralizing a broad range of HIV strains. But even the study’s authors see a catch. “It’s still too many [shots] to be practical in humans,” said Dennis Burton, a professor of immunology and microbiology at Scripps Research who worked on the project.

Whether mRNA ultimately becomes the vaccine itself — or simply the tool that helps researchers discover it — remains an open question.

The fundamental challenge for now, after all, is vaccine design, notes Mark Feinberg, president and CEO of IAVI, a nonprofit research organization focused on developing vaccines against HIV. And for that task, he says, “the most obvious advantage of mRNA is simply the speed of getting an idea from the laboratory to the clinic.”

But if the technology reaches the finish line, researchers say it could offer other advantages as well. Because the protein is made inside the body’s own cells rather than in a lab, it folds and displays itself much as it would on the real virus, giving the immune system a more faithful target to train against. That way, when the real virus arrives, the body already knows its true face.

It also gives vaccine designers an unusual number of knobs to turn, notes Kristie Bloom, an mRNA vaccine researcher and molecular biologist at the University of Witwatersrand in South Africa. By altering the vaccine’s formulation, dose, or genetic design, researchers can shape not just the magnitude of the immune response but also its balance: favoring antibody-producing B cells, virus-killing T cells, or some mix of the two.

With mRNA, “there’s quite a bit of flexibility,” she said.

Not so fast

For all the putative upsides, however, mRNA does carry some baggage. There are concerns about public acceptance given the intense backlash and misinformation campaigns that followed the rollout of Covid-19 vaccines. And though those shots ultimately proved remarkably safe, with very low rates of serious side effects, a peculiar skin problem has emerged in early-stage trials of mRNA vaccine candidates for HIV specifically. 

In two separate trials reported last year, around one in 12 participants who received mRNA-based HIV vaccines manufactured by Moderna developed chronic urticaria, a form of persistent hives that in some cases endured for years. The vaccines encoded different portions of HIV’s envelope protein, yet both produced the same unexpected side effect.

The fact that the reactions appeared across distinct vaccine designs — but never before in Moderna’s other mRNA vaccine programs — has fueled suspicion that something about HIV’s envelope protein itself may be involved. Even so, no clear explanation has emerged. 

“We’ve ruled a bunch of things out,” said William Schief, a professor at Scripps Research’s department of immunology and microbiology who doubles as vice president for protein design at Moderna, “but there’s no smoking gun.”

Schief is continuing to investigate the source of the immune reactions. But not wanting an unresolved safety signal to bring the program to a halt, he and his collaborators have pressed ahead with lower-dose versions of the vaccine, betting that the hives will fade while the desired immune response remains intact. 

That strategy is now being evaluated in an IAVI-backed trial led by Bekker in South Africa. Known as IAVI G004, it has yielded encouraging early results. (Unlike the African-developed vaccine whose launch was derailed by the USAID funding freeze, this study is testing a different mRNA vaccine candidate, manufactured by Moderna.)

At the lowest dose tested, just one-tenth of the amount used in the original studies, the hives that had troubled earlier trials never materialized, Bekker said. Her team has since moved on to a somewhat higher dose, seeking the sweet spot between safety and immune potency. 

All of these discoveries and challenges along the way have helped map a path forward. “We know what we need to do,” said Barton Haynes, director of the Human Vaccine Institute at the Duke University School of Medicine. The task for them now is to move through the necessary iterations as quickly as the science — and the funding and political landscape — allow.

“A black hole”

When Bekker and her team learned about the sudden funding cut that would halt their African-designed, USAID-funded vaccine study in January 2025, they were already in Tanzania to prepare its launch. They immediately had to stop work on the project, which had been years in the making. “It was like falling into a black hole of depression,” she said. 

And the setbacks kept coming. With prominent vaccine critic Robert F. Kennedy Jr. overseeing US health policy, the federal government moved to undermine both vaccine science broadly and mRNA technology in particular.

The NIH, in addition to terminating dozens of smaller HIV-related grants, began winding down its flagship Consortia for HIV/AIDS Vaccine Development (CHAVD) program, which has long served as a cornerstone of global HIV vaccine research, while other federal agencies curtailed support for mRNA vaccine projects across multiple disease areas.

At the same time, South Africa, the continent’s leading center for biomedical research, found itself in the Trump administration’s crosshairs over allegations of anti-white discrimination. New federal research grants were no longer permitted to support collaborations with South African scientists, severing ties that had underpinned years of international HIV research.

“That’s a perfect storm to prevent us from building on the most exciting science HIV vaccines have had in 45 years,” said Mitchell Warren, executive director of AVAC, a nonprofit dedicated to HIV prevention access and policy. 

Yet for all the financial and political disruption, the scientific momentum hasn’t stopped. Philanthropic organizations and governments elsewhere have stepped up to help fill the funding gap, allowing key trials to move forward, although in scaled-down forms with more modest ambitions. 

The Africa-led effort that Bekker had dreamed of was salvaged, with emergency backing from the South African Medical Research Council, albeit in diminished form and built, in the end, on the same protein-based technology that mRNA was meant to leapfrog.

The only mRNA-based HIV vaccine study that is actually underway in Africa is IAVI G004: a program designed by US scientists, not by locals, and funded largely by the Gates Foundation.

A longtime backer of HIV research, that foundation is estimated to invest around $70 million annually — with $64 million being invested in 2022, and $70 million in 2026 — across a global portfolio of HIV vaccine programs. That’s a substantial sum, though only a fraction of the hundreds of millions of dollars once provided by the NIH, USAID, and other federal agencies. 

For now, some of that funding continues to flow. But even what remains is far from assured. The Trump administration’s proposed 2026 budget would slash the National Institute of Allergy and Infectious Diseases — the NIH institute that has long anchored HIV vaccine science — along with the Office of AIDS Research that coordinates HIV research across the entire NIH, leaving the field’s longer-term future in doubt.

“We’re not going to be able to fill the gap that’s been left by the US government,” said Nina Russell, director of TB & HIV research and development at the Gates Foundation. Still, she says, the foundation remains determined to keep the most promising vaccine programs moving forward: “We are super committed to it.”

All of these changes have left the research field daunted, but not hopeless. “It’s been a very disruptive time,” said Burton, who leads one of the CHAVD research hubs. But he remains convinced the field is on the right track. “The pieces of the puzzle are in place,” he said. “It’s obviously been a long, long journey, but you can begin to see the end.”

A higher bar

The funding crisis and political challenges are not the only forces reshaping HIV vaccine development.

For much of the HIV epidemic, which has killed over 40 million people worldwide, even a partially effective vaccine might have been enough to transform the course of HIV. Today, however, vaccine researchers are also competing against long-acting preventive drugs that can protect people for months at a time with just two injections. 

These drugs are an enormous step forward for HIV protection, but they also raise the standard the vaccine field must meet, Warren said. “The bar for a licensed vaccine that is going to have a public health impact has gotten much higher,” he said.

But these prophylactic drugs, which began as daily pills and have evolved into long-acting injectables, are only as good as the systems that deliver them. Cost, stigma, and the need for regular clinic visits have limited access in many countries with the highest HIV burdens. A vaccine, by contrast, that provided years of protection after a handful of doses could overcome many of those barriers.

That is precisely why many scientists view the current retreat of the US government with such alarm. After decades of disappointments and billions of dollars in investment, the field finally believes it has a coherent strategy for building an effective HIV vaccine. The fear is that momentum could stall just as researchers have begun to see a path across the finish line. As a result, what once seemed like a scientific problem increasingly looks like a political one.

For Bekker, the current moment feels all too familiar. In the early 2000s, South Africa’s government embraced AIDS denialism, delaying the rollout of lifesaving treatments and forcing researchers and clinicians to battle both the virus and the state. A quarter-century later, she says, the political opponent has merely changed address to Washington, DC, threatening once again to undermine the fight against HIV and cost countless lives.

“When politics interferes in science,” Bekker said, “that is the death of scientific progress.”

Bekker still does not know whether the vaccine she watched being manufactured last year will ever reach the people it was designed to protect. She and her colleagues still hope to carry out the made-in-Africa mRNA vaccine trial they spent years designing — if they can find a way to pay for it. But Bekker remains convinced that the scientific strategy behind it is the right one, and that mRNA may yet do for HIV what it did for Covid-19, rapidly transforming decades of scientific groundwork into an effective shot.

She only hopes politics does not succeed where HIV itself has failed in slowing the field’s progress. “We should only be fighting the virus,” Bekker said. “But we’re fighting the administration and its policies, and that is a waste of our energy.”

The Democratic Socialists of America say they are fighting for “a government by, for, and of the working class.” 

Yet the organization’s membership and candidates consist largely of educated professionals. As of 2021, 80 percent of DSA members over 25 were college-educated, while 28 percent earned more than $100,000 a year (putting them in roughly the top 15 percent of America’s income distribution), according to a DSA internal survey. Among the group’s most prominent politicians, meanwhile, is an Ivy League graduate student, a lawyer, and the well-educated son of a Hollywood director and famous academic. 

In recent weeks, as the DSA has racked up victories in Democratic primary elections, the apparent tension between the group’s self-conception and demographics has attracted critical scrutiny.

In the New York Times, Thomas Edsall argues that most of the DSA’s members and supporters in the electorate are “in no way working class.” The libertarian commentator Robby Soave, right-wing pundit Batya Ungar-Sargon, and liberal economics writer Noah Smith have all voiced similar sentiments. 

There are many cogent ways for socialists to respond to such criticism. One would be to note that an organization doesn’t need to have a uniformly working-class membership in order to fight for working-class interests. Another would be to observe that not all college graduates are well-heeled professionals, even as pundits often use educational attainment as a stand-in for class in political analysis. 

But some socialists prefer a simpler retort: The DSA’s critics are simply mistaken; in reality, the group’s membership is more or less entirely “working class” — because that term describes everyone who must sell their labor in order to meet their needs. 

This conception of the “working class” has deep roots on the left. As Jacobin’s Ben Burgis explains, orthodox socialists subscribe to a “two-class map of capitalist society,” in which “Some people are capitalists who own their own ‘means of production’ (like factories, farms, offices, or grocery stores) and other people work for the capitalists.”

Many contemporary socialists (including Burgis) find this dichotomy reductive, and endorse more nuanced portraits of America’s class structure. But the orthodox, “two-class” model informs a great deal of the modern left’s rhetoric, among both socialists and progressives. And the notion that lawyers and day laborers both belong to the “working class” is widely held among anti-capitalists. 

There’s something to be said for this idea. Educated professionals and manual workers surely do have some shared interests, due to their common status as laborers. For example, both benefit from the existence of a well-funded unemployment insurance system, in a way that the Elon Musks of the world do not. 

For the most part though, orthodox socialism’s “map” is badly out of date. And its expansive conception of “the working class” does less to illuminate modern America’s economic divisions than to obscure them.  

The long afterlife of Marx’s failed prophesies

Karl Marx and Frederich Engels laid the foundations for the modern left’s conception of class in The Communist Manifesto of 1848. 

In that book, the claim that there were just two important classes under capitalism — capitalists and workers — rested on a set of grim predictions about where industrialization was headed. 

According to Marx’s analysis, technological progress was in the process of obliterating “all distinctions” between different strata of working people, as automation was driving virtually everyone’s wages down to “the same low level.” The middle class of small manufacturers and shopkeepers, meanwhile, was poised to “decay and finally disappear,” as more productive, large-scale enterprises left them in the dust.

Society was therefore splitting into “two great hostile camps” — the capitalist and working classes, whose interests were impossible to reconcile. 

Under these conditions, a binary conception of class makes perfect sense. If all workers will soon be condemned to low wages, then there’s little point in dwelling on the (temporary) distinctions between them. Likewise, if shopkeepers and small-time capitalists have gone the way of the triceratops, one can more comfortably cast all business owners as members of the ruling elite.

You can’t navigate modern capitalism with a 19th-century map

But we don’t live in the future that Marx foresaw. 

Rather than melting all workers into a uniform proletariat, capitalism cultivated a kaleidoscopically diverse laborforce — one segmented by countless fine-grained distinctions of pay and prestige. And instead of immiserating ordinary people, industrial development brought unprecedented mass prosperity (albeit, with the aid of many socialistic reforms). 

As a result, old-school socialists’ “two-class map” makes for a poor guide to modern capitalism’s terrain. And anyone trying to impose Marx’s cartography onto the landscape will encounter several problems.

For one, in a world where some workers earn as much in a year as others do in a lifetime, the idea that there is only one fundamental class division — that between laborers and capitalists — becomes unconvincing. 

In the United States, some convenience store owners make $70,000 a year, while many surgeons earn upward of $600,000. It would be odd to say that the former are members of society’s dominant class (since they live off business income), while the latter belong to its subordinate one (since they live off salaries). After all, the minimart owner and Musk do not have especially similar material interests. Nor, for that matter, do the impoverished farmworker and high-earning neurosurgeon (much less, the superstar athlete with a $40 million salary). Yet this is what orthodox socialism’s binary would suggest. 

Ultimately, in a modern capitalist society, it makes a lot more sense to see class as a multidimensional continuum than as a binary.

A second, related difficulty is that the border between labor and capital has grown fuzzier since Marx’s time. Today, American workers often own both a home and some share of their nation’s financial assets, like a 401(k) filled with stock from major corporations. Many billionaires, meanwhile, choose to work. 

Socialists are well aware of this reality, which is why they define a person’s class status by their dependence on labor: The typical white-collar worker may own a little stock, but not enough to quit her job and live off dividends. Unlike a billionaire CEO, such a professional must work in order to meet her needs. 

This is a sound distinction. But it does not actually resolve the challenge of distinguishing the working class from the ruling one. This is because, in an advanced economy, whether someone “needs” to work is partly subjective. Millions of Americans survive on less than $25,000 a year in market income. If upper-middle-class families were willing to accept a similarly austere living standard, many would be able to live entirely off their investments.

Of course, Americans shouldn’t be content to live in poverty. But it is harder to say precisely what standard of living qualifies as “enough.” In Marx’s time, a relatively good life for a wage worker might have meant reliable access to food and shelter for one’s family and a little time and money left for simple leisure. Today, the list includes high-quality education for one’s children, access to advanced medical treatments, modern home appliances for cooking and cleaning, Internet-connected devices for entertainment, and often personal transportation, like a car — all of which are typically (and justifiably) treated as basic necessities.

This raises the question: At what level of wealth does a person stop needing to work — even if they must keep clocking in to achieve their desired lifestyle? The socialist writer Matt Bruenig has proposed drawing the line at about $1.4 million (or roughly 20 times America’s average wage): Once you’ve accrued that much in housing and financial assets, your decision to sell your labor becomes voluntary and you cease to be working-class. 

This is a reasonable cut-off. But it’s still fairly arbitrary. Ask an American with a net worth of $1.4 million whether they need to work, and they’re liable to say yes. And typically, they will be correct — at least, in the sense that they could not sustain their way of life without earning a paycheck. You could say that their present lifestyle is too lavish — and that $1.4 million in assets is all that’s required to generate the amount of income one truly needs. But it’s not obvious why this threshold doesn’t actually lie at $1.6 million, or $800,000, or $500,000.

As a result, the only way to draw the upper boundary on who “needs” to work — without making arbitrary judgments about what standard of living is necessary — is to place it extremely far up the class hierarchy: The superrich generally don’t need to choose between sustaining their lifestyles and abstaining from work. But once your definition of “working class” becomes capacious enough to include low-end multimillionaires, it loses all plausibility. 

Ultimately, in a modern capitalist society, it makes a lot more sense to see class as a multidimensional continuum than as a binary. An individual’s degree of economic freedom and power is determined by a host of factors — above all, their household incomes and net worths, but also the market value of their skills (which shapes their future earning prospects) and familial wealth and connections. Even one’s eligibility for social welfare benefits can matter; after all, the largest group of Americans who don’t need to work to meet their needs are Social Security recipients.

Precisely how we should weigh these different sources of advantage is a tricky question. And implicit disagreements over it shapes our discourse about “the working class.” 

Take Graham Platner, the former Democratic Senate candidate in Maine. To his champions, Platner was a working-class candidate, due to his lack of a college diploma, years of service in the military, and low-income, physically demanding job farming oysters (along with his gravelly voice and tattoos). To his detractors, meanwhile, Platner was a pseudo-proletarian due to his upper-middle-class childhood, prep school education, and receipt of steady financial help from his father and mother, a lawyer and entrepreneur. Meanwhile, Platner probably would not qualify as “working class” under the orthodox socialist definition for multiple reasons: For one, he does not need to work in order to get by, thanks to his disability benefits and family support. For another, he is the owner of his oyster business, rather than a salaried worker who answers to a boss. 

In any event, whichever factors one emphasizes, it’s clear that a person’s class privilege increases continuously as their income, net worth, familial wealth, and “human capital” rises. There is no single point on any of these scales past which a person’s class position is abruptly transformed. The gap between “the 99 percent” and the billionaire class matters — but so does that between the top 15 percent and the working poor.

Of course, in ordinary political discourse, we inevitably need to boil down reality’s intricacies into rough categories. No politician will ever promise to fight for the “bottom six deciles in combined SES score, nor will any labor activists ever chant, “The 30th to 60th percentiles in household income, united, will never be defeated.” 

But a taxonomy of classes with several subcategories (such as “the poor,” “the working class,” “the middle class,” “the upper-middle class,” “the rich,” and “the superrich”) will capture a bit more of reality than a taxonomy with only two. 

“Working-class” rhetoric can camouflage professional-class interests

All this said, even if orthodox socialism’s “two-class map” is analytically flawed, it could still be politically beneficial. Perhaps, when affluent professionals decide that they belong to the same class as the working poor, they become more inclined to fight for the latter’s interests. 

Some of the DSA’s own activities lend credence to this theory: Despite its largely white-collar membership, the organization advocates for many policies that would principally benefit America’s most disadvantaged. More broadly, in the wake of Occupy Wall Street, many college-educated millennials came to identify with “the 99 percent.” And as this cohort has grown more influential in Blue America, the Democratic Party has embraced more ambitious anti-poverty policies, such as a guaranteed monthly income for working-class families. 

The main fiscal barrier to American social democracy is that our middle class in general — and upper middle-class in particular — pays much lower taxes than their peers in Western Europe.

And yet, socialists’ expansive conception of “the working class” can be put to more dubious uses. Specifically, it can help relatively well-off professionals disguise their class’s particular interests as those of all working people.  

The left’s push to cancel all graduate student debt is arguably a case in point. During Joe Biden’s presidency, the DSA criticized the White House for attempting to forgive only $10,000 of most borrowers’ student loans (a plan that was ultimately blocked by the Supreme Court). Instead, the socialists called on Biden to cancel all student debt, including the balances accrued by the graduates of elite medical schools and MBA programs. 

On its face, the idea that the US government should transfer tens of thousands of dollars to young doctors and Harvard MBAs would seem wildly regressive. The median US physician can expect to earn more than $6.5 million over the course of their lifetime, while the median graduate of a top-five business school can expect to earn more than $8 million. Virtually all Americans have worse prospects than this. And in the inflationary conditions of the Biden era, increasing young professionals’ disposable income was liable to push up prices for everyone else. In other words, blanket student debt forgiveness would have likely transferred purchasing power from low-income workers to early-career physicians and management consultants.

Many socialists would struggle to defend such a policy, were it presented in these terms. But by eliding the class distinctions between low- and high-income borrowers,  the DSA was able to convince itself (if not the public) that across-the-board forgiveness was in the interest of “the working class.”

The socialist framework is similarly unhelpful in the realm of tax policy. 

In recent years, as socialist and progressive politicians have grown more dependent on professional class support, they’ve become more averse to endorsing broad-based tax increases.

From Zohran Mamdani to Chris Van Hollen, the Democratic left tends to reserve its tax hike proposals for the superrich. And yet, the reason that America lacks a comprehensive welfare state is not that our billionaires pay unusually little in taxes; to the contrary, our top rates are comparable to those of some Scandinavian countries. The main fiscal barrier to American social democracy is that our middle class in general — and upper middle-class in particular — pays much lower taxes than their peers in Western Europe. Simply maintaining our existing programs, like Social Security, will likely require a major tax increase on higher-end salaried workers. 

In this context, binary conceptions of America’s class structure — which pit an undifferentiated “working class” against the capitalist elite, or the 99 percent against the 1 percent — can help educated professionals evade responsibility for bankrolling a more egalitarian economic system.

Check your class privilege

Ultimately, the DSA’s ability to serve working-class interests hinges less on its own demographics than its policies and politics. When an organization mistakes the preferences of its most privileged members for those of all working people, however, its campaigning and policymaking is liable to suffer. 

Perhaps, before this century’s end, AI will bring about the calamity that Marx prophesied — and Ivy League lawyers and delivery drivers will find their skills equally devalued by an all-powerful ownership class. Until the robot apocalypse, however, educated professionals and low-wage workers will live in very different circumstances — and harbor distinct economic interests. To safeguard the wellbeing of the disadvantaged, well-off egalitarians need to mind these gaps, not paper over them with obsolete class categories. 

For a man who considers himself the greatest builder the world has ever known — move over, Pharaoh Khufu! — Donald Trump has managed vanishingly little of it in either of his presidential terms. What his administrations have done is show an impressive talent for tearing things down. 

From the East Wing of the White House to the United States Agency for International Development (USAID) and public health, Trump has demonstrated a clear aptitude for demolition. Among his most successful accomplishments has been his assault on the international institutions that were created in response to the worst catastrophes of the 20th century. 

During his first campaign and administration, Trump constantly attacked NATO, the military and political alliance formed in 1949 in response to Soviet aggression that operates on the principle of collective security. He also withdrew from the Paris Climate Accords and ripped up the Iran nuclear agreement, cornerstones of Barack Obama’s foreign policy. But Trump didn’t stop there. He withdrew from the United Nations Framework Convention on Climate Change, the Intermediate-Range Nuclear Forces Treaty, the World Health Organization, UNESCO, the Trans-Pacific Partnership and the U.N. Human Rights Council. Since he returned to office in January 2025, he has continued to attacks on NATO and signed an executive order withdrawing from 66 additional international organizations. 

To be fair, Republicans have never really trusted international institutions. This tendency stretches back at least a century to the League of Nations. While the GOP has tended to back alliances like NATO, which they felt they could control, the party has been deeply suspicious of organizations like the United Nations, which they believe threaten national sovereignty — and impede America’s ability to act with impunity anywhere in the world. Since 1998, this has especially included the International Criminal Court, which is now coming under assault by Secretary of State Marco Rubio on behalf of the Trump administration.

Since its creation, the I.C.C. has been the bête noire of the American right. At first glance, one might have thought such an organization would have been championed by the U.S. After all, the country pioneered the idea of such a tribunal after World War II when it ran the Nuremberg trials to hold Nazi leaders accountable for crimes against humanity, while also pointedly declaring that waging a war of aggression is “the supreme international crime,” containing within itself “the accumulated evil of the whole.” The idea of holding individuals responsible for such violations was forged in that process and became the basis of international criminal law. 

In 1998, the Rome Statute of the International Criminal Court was adopted and established four crimes over which it could take jurisdiction if the party state refused use its own legal system: genocide, crimes against humanity, war crimes and the crime of aggression. The statute was immediately decried by Republicans (and some conservative Democrats) as a threat to U.S. sovereignty on the basis that Americans could be subject to political prosecutions. But that wasn’t all of the story. It’s clear they also wanted to maintain the impunity conferred by America’s superpower status. 

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One hundred twenty-five countries are parties to the agreement. The U.S., under Bill Clinton, was a signatory to the treaty, but it was never ratified, and in 2002 it was officially withdrawn by George W. Bush. Israel, Sudan, Burundi, the Philippines and Russia have also withdrawn. 29 countries have signed but not ratified the agreement, while 41 others, including China and India, have neither signed nor acceded to it. 

Since then, the I.C.C. has tried war criminals and has a number of active cases, although few leaders have faced charges while in office. In November 2024, Israel Prime Minister Benjamin Netanyahu became an exception for his conduct in Israel’s war against Gaza following the attacks by Hamas on Oct. 7, 2023, joining the likes of Russian President Vladimir Putin and former Sudanese President Omar Hassan al-Bashir. 

Even after Bush withdrew from the treaty, it was assumed the I.C.C. could grow its legitimacy among the holdouts — including the U.S., which has used the body itself when it was advantageous. But that is not to be. 

Project 2025, the plan for a MAGA overhaul of the entire federal government produced by the right-wing Heritage Foundation, explicitly demanded that the U.S. to “must end blind support for international organizations,” only using them to the extent that they help the country achieve its own goals regardless of the effect on other nations.

Now, in his quest to be the frontrunner for the 2028 Republican presidential nomination, Rubio has launched a full-blown assault on the I.C.C. with the support of Trump. The move is part of a variety of crusades the secretary is leading to establish his MAGA bona fides, and comes in addition to his international “far left terrorist crusade,” which I recently chronicled. Not content just to refuse to participate in the process and pledge to rely on our own justice system, as Republicans have done in the past, Rubio wants the I.C.C. destroyed completely. 

The administration has already sanctioned eight of the court’s judges, including its chief prosecutor, banning their travel to the U.S. On July 13, Rubio took to the pages of the Wall Street Journal to declare that the I.C.C. “threatens every aspect of our political and legal system.” Using the usual sophomoric language of the MAGA movement, such as referring to “smug globalists,” he declared that the U.S. will now lead a “diplomatic campaign” against the Court, which will include penalties on countries that continue to cooperate with it, including by withdrawing foreign assistance. This is a tried and true Trump tactic that the president has even deployed on the home front against blue states that disagree with him. Now, it looks like the GOP establishment, of which Rubio has long been a representative, has signed on to the president’s mob-like coercion tactics against all rivals foreign and domestic.

According to Stewart Patrick of the Carnegie Endowment for Peace, the administration’s goal is to destroy multilateralism altogether using what he called “four basic behaviors: defection, rebellion, substitution, and conditional cooperation.” Trump has quit some institutions, attempted to sabotage others and even tried to establish his own, such as the “Board of Peace” and the “Shield of the Americas,” both of which the administration believes it can dominate — and no doubt profit from. It has reengaged with others, such as the World Bank and the G20, but on a conditional basis: They are expected to do as they are told. But, as Patrick observed, “the administration’s campaign to dismantle the ICC is a campaign of pure destruction, a coercive attempt to impose the United States’s will on the rest of the world.”

The world has reacted in horror to Rubio’s moves, as we might expect. Patrick wrote, “Given the voluble reaction from America’s closest allies, the full-bore attempt by the administration to destroy the ICC would seem to be both imprudent and futile, an effort in symbolic politics that will further cement the reputation of the United States as an unhinged, domineering hegemon, rather than a benevolent and farsighted global leader.”

I’m afraid that ship has sailed.

This policy is Marco Rubio’s baby. He owns it. The secretary has established himself as the would-be statesman who took Donald Trump’s wrecking ball and made it his own. In doing so, his remake of himself in the Dear Leader’s image is complete.

The post Marco Rubio’s quest to destroy the International Criminal Court appeared first on Salon.com.

Physicists have longed for a theory of everything, a single framework that would explain every force in the universe. After the better part of a century, they’re still looking. But social science, improbably, may have beaten them to it.

In 2021, three British writers — John Myers, Sam Bowman, and Ben Southwood — published an essay in the progress-minded site Works in Progress arguing that a startling share of what ails the modern West comes down to one thing: too few homes built where people want to live. Slow growth. Widening inequality. Falling fertility. Obesity. Even climate change. They look like separate problems with separate causes, until you notice that each one gets worse when housing gets scarce. The authors called it “the housing theory of everything,” and five years on, the case has only gotten stronger.

The mechanism is simple: where you can afford to live determines your job, your commute, your family size, your neighbors, your politics. Make homes scarce where opportunity is, and every one of those suffers. 

As I wrote back in 2022, once you begin to understand the housing theory of everything, you start to see it everywhere. One estimate from the essay puts the cost of building restrictions in just three cities — New York, San Francisco, and San Jose — at 8.9 percent of US GDP, about $8,775 per American worker per year. And today a record 22.6 million renter households, or half of all renters, now spend more than 30 percent of their income on housing.

It’s not supposed to be this way. Since the 1970s, nearly everything material in American life has gotten cheaper measured in hours of work — a television fell from 60 hours of labor to 7 — while the house you put it in went the other way. If you’ve ever wondered why decades of genuine progress don’t feel like progress — a major obsession of this newsletter — housing is a big part of the answer. The gains are real, but our rents and mortgages are eating them. 

That’s the bad news. Here’s the good news.

A new law for our single biggest problem

What made all this feel so depressingly unfixable is that no one seemed positioned to fix it. Zoning is controlled by thousands of city councils and planning boards, each answerable to neighbors with a vested interest in scarcity, since for most American homeowners, the housing shortage bolsters their net worth. And Congress had simply left the field, going roughly 30 years without passing a major housing law. 

Then, over about three weeks this summer, lawmakers acted. On June 22, the Senate passed the 21st Century ROAD to Housing Act 85-5. The House followed a day later, 358-32, and after President Donald Trump chose not to veto it, the bill automatically became law on July 11. The ROAD Act is the most significant housing legislation in decades, and the first built squarely on a basic YIMBY premise that cuts to the heart of the housing theory of everything: Homes are expensive because America made them too hard to build.

The act stitches together more than 60 separate bills, 36 of them bipartisan, negotiated by Sen. Tim Scott (R-SC) and Sen. Elizabeth Warren (D-MA) along with Rep. French Hill (R-AR) and Rep. Maxine Waters (D-CA). Its centerpiece, the Build Now provision, ties federal block-grant money to results: cities that add homes get more, cities that block them get less, and a $200 million annual innovation fund rewards measurable increases in supply.

The rest of the bill takes scissors to the red tape strangling housing. The law streamlines federal environmental review for housing the federal government itself helps fund. It directs the Department of Housing and Urban Development to write guidelines for single-stair apartment buildings up to six stories — a small-sounding change that my colleague Rachel Cohen Booth has called “a deceptively simple reform that could unlock more housing.” And it ends a 1970s-era rule requiring factory-built homes to sit on a permanent wheeled chassis, a mandate that added thousands of dollars per unit and helped keep the cheapest form of American housing out of most neighborhoods.

What’s revolutionary here isn’t the elements of the bill — which are still largely small-bore compared to the scale of the problem — but the acceptance of the basic YIMBY idea that, as Republican Sen. John Kennedy of Louisiana said, “If we had more housing, the price would go down.” Ben Metcalf of UC Berkeley’s Terner Center told the New York Times the law was “catch-up on 30 years of policy,” while Laura Foote, executive director of YIMBY Action, put it more simply: the law is a triumph “simply because it exists.”

The states ran the experiment first

Congress may be late to these YIMBY ideas, but it has the benefit of knowing they have been tested. One of the best examples is in Auckland, New Zealand, which upzoned three-quarters of its single-family land in 2016, rewriting the rules so those lots could hold apartments, not just one house each. Construction roughly doubled within five years, and a study published last year estimates Auckland rents are now about 23 percent lower than they would have been without the reform.

The American version of Auckland — with better tacos — is Austin, which spent a decade legalizing apartments, killing parking minimums, and shrinking minimum lot sizes. The Texas city added 120,000 homes between 2015 and 2024, growing its housing stock by 30 percent. As my colleague Marina Bolotnikova reported this spring, Austin rents fell 6 percent in a single year, more than any other large US metro, with the fastest declines in older, cheaper buildings — exactly where relief matters most. 

Other states have noticed. California exempted most urban infill housing from its famously litigious environmental review law. Montana passed its “Montana Miracle” package, legalizing duplexes and backyard apartments on land that had allowed only single houses. Texas legalized homes in commercial zones statewide. 

Red states and blue states are coming to the same diagnosis about solving the housing problem: build more. The new federal law mostly just tells them to keep going.

Why your rent won’t drop tomorrow

It’s a sign of just how terrible federal housing policy has been for so long that what is ultimately a pretty modest law is being greeted so rapturously. 

The ROAD Act notably contains almost no new money — its final section is literally titled “No Additional Funds Authorized.” Zoning, which can make or break housing, remains a local power. The law mandates nothing; it nudges with grant formulas, which a determined city council can shrug off. The New York Times’ Conor Dougherty, one of the top reporters on housing, judged it “unlikely to do much to blunt the high cost of rent and ownership in America anytime soon.” Mortgage rates have been stuck above 6 percent since 2022 — as I could show you from my own mortgage statements. National homebuilding has barely moved, and forecasters expect little change this year.

Experience shows that a problem big enough to be a viable theory of everything is going to need more than one reform. Minneapolis famously ended single-family zoning in 2018, and only got a modest building response, because a dozen other rules still stood in the way. What worked in Auckland and Austin was the full stack — density plus permitting plus parking plus lot sizes. Housing, as advocates put it, is a door with many deadbolts; this law unlocks the federal ones and hands the states a better set of keys. The others are still bolted.

Usually with this newsletter I like to point at progress that has already arrived but gone unnoticed. Housing is the opposite case: The problem is exactly as bad as everyone feels it is, and what arrived this month is agreement about why. America spent 40 years treating expensive housing like the weather: unfortunate, unchangeable, nobody’s fault. It has taken five years for that diagnosis published on a magazine website to become a universally praised act of Congress.

The ROAD Act won’t pour a single foundation. What it did do was build the consensus upon which the next few million of them will be built. And consensus, in American politics, is the material that takes the longest to set.

A version of this story originally appeared in the Good News newsletter. Sign up here!

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Defense Secretary Pete Hegseth announced this week that the Pentagon would begin testing the testosterone levels of all military members over the age of 30 as part of their regular, annual physical exams. And — if their levels are low — service members could choose to receive testosterone replacement therapy.

“It’s not about artificial enhancement,” Hegseth said. “It’s about restoring and optimizing your natural capabilities, protecting your longevity, and ensuring you have the biological foundation required to sustain the fight.”

The High-T Department of War. pic.twitter.com/hlAUq3j2cD

— Secretary of War Pete Hegseth (@SecWar) July 15, 2026

It’s another example of the performative masculinity that has defined Hegseth’s time atop the US military. He has sought to rebrand the Department of Defense as the Department of “War,” preached a “warrior” ethos, rolled back DEI initiatives while blocking promotions for women, and taken an unusual interest in the beard-grooming standards of service members.

The testosterone obsession is just one of several ways that the military is having a Make America Healthy Again movement. Hegseth announced over the spring that service members would no longer be required to get an annual flu vaccine. (The military later reinstated the mandate for new recruits, after a major flu outbreak at a boot camp.) And also this week, he launched a new investigation into the Defense Department’s decision in 2021 to mandate the Covid-19 vaccine — shades of the efforts being made by Robert F. Kennedy Jr. at the US Department of Health and Human Services.

Go a little deeper

The “T” trend is not just a fixation of Kennedy’s, who has said that he takes testosterone supplements, and Hegseth. More Americans of every age group are taking testosterone. By one count, prescriptions grew from 7.3 million in 2019 to more than 11 million in 2024.

So, is getting more people to take supplemental testosterone actually a good idea? Should everybody be screened, as Hegseth is suggesting for service members over 30?

The Endocrine Society said in a statement after Hegseth’s announcement that there was “insufficient evidence” to support testosterone-level screening for asymptomatic Americans. Previous research suggests that, if anything, testosterone is already overprescribed in the US; only 12 percent of men receiving a prescription had received appropriate diagnostic testing.

Testosterone levels indeed fall as men age, and there has been a general decline in testosterone among men today compared to men of the past. But what’s not clear is whether widespread testosterone testing and supplementation is the solution. 

For one, distinguishing between a natural decline in testosterone and a decline that warrants clinical intervention is the subject of ongoing debate among doctors. Low T can also be a sign of other chronic health conditions that it would be better to treat. If your T is dropping because of obesity, for example, it would be better to lose weight (or take a GLP-1 drug instead of a testosterone supplement). The evidence is mixed on how much taking T actually improves things like mood, energy, sexual performance — or military effectiveness — and taking too much testosterone could come with its own health risks.

The dialogue around T supplements is still evolving. Doctors used to worry that extra testosterone could cause cardiovascular problems, but more recent research has allayed those fears, leading  proponents in the Trump administration to call for more prescribing. But the evidence right now does not appear to support the widespread T testing and supplementation that the military’s new program would suggest.

One link for later

How to keep your cool on a bad day: As a parent of three children, I’m always on the lookout for better ways to manage my stress — and took heart in the four strategies suggested by Vox’s Allie Volpe in her piece this week. If we can take the time to acknowledge how we’re feeling and really reflect on what has led us to feel that way, we might be able to avoid a full-blown meltdown. That’s news you can really use.

Before you go…

• Did you know: Prediction markets correctly guess the winner of reality TV shows upward of 90 percent of the time? It’s a trend that raises questions about insiders using insider knowledge to make a buck — and risks ruining the fun of following these shows.
• Today’s trivia: What is a Russian name meaning “holy”? (You can find this and other brain puzzles in Vox’s daily crossword. Look for the answer in Monday’s edition.)
• Yesterday’s trivia: Yesterday, we asked you what animal can be as narrow as a few millimeters or as wide as 13 feet. That would be crabs, the various species of which can range from tiny and adorable to monstrously terrifying.

Much like its indifference toward soccer, America’s aversion to public transport has made it a global anomaly, an oddity encapsulated by the nation’s sacred pregame pastime: the tailgate. 

Here in the US, celebrating sports means driving your big car to a colossal suburban gridiron football stadium, where you’ll grill, baby, grill until the smoky scents of burgers and bratwurst float across vast plains of asphalt. So entrenched is the nation’s car culture that the average American spends about half a month sitting behind the wheel every year. In fact, while the US has tens of millions more cars than it has people to drive them, even its largest cities have far fewer trains or buses per capita than our global peers. 

As a result, Americans are more than twice as likely to die in a car accident as Europeans, and nearly five times as likely to die in a car crash as someone in train-happy Germany. While many transit projects carry similar price tags, the US still boasts many dozens more college football stadiums than it does rapid transit systems or subway networks.

So, it’s no wonder that critics doubted that US cities hosting this year’s World Cup, the largest single sporting event in human history, could effectively find ways to schlep visiting fans around. After abandoning its initial pledges to shepherd fans for free, New Jersey earned scorn for trying to sell $150 round-trip train tickets to MetLife Stadium, prompting journalists to test how difficult it would be to reach it by foot, bike, or canoe. Kansas City’s shiny new pop-up World Cup buses got caught in hours of ensnarled traffic on their way to their city’s very first game between Algeria and Argentina. 

And yet, on the precipice of the tournament’s final stage, the nation’s widely expected World Cup public transit meltdown has simply not materialized. To the surprise of pretty much everyone, US cities have managed to absorb the influx of fans with relative ease, even under the pressure of record ridership en route to stadiums, watch parties, and fan zones. 

Eli Lipmen, executive director of the advocacy group MoveLA, said that he had “actually been pleasantly surprised and quite impressed” with how the Los Angeles transit system performed amid the World Cup. As he explained, that notoriously gridlocked city is in the midst of a “major cultural shift” around public transit. As Angelenos spend less time in their cars, the city has gotten quieter, he said. “People are happier. There’s more of a sense of community,” Lipmen said.

A renewed commitment to public transit infrastructure has played a part in that shift — and not just in Southern California. In the lead-up to the World Cup and the 2028 Olympics, Los Angeles unveiled three new subway stations in May, its first new stations to open in over two decades. Meanwhile, Seattle’s Sound Transit shuttled a record-shattering 309,000 riders when Team USA faced Team Belgium, thanks in part to its completion of a light rail extension that had been in the works for nearly two decades. Atlanta overhauled its bus network, Miami made use of a new rapid transit line, and Kansas City spent millions to expand its tram service and rolled out pop-up shuttles. 

As it turns out, US cities can build new buses, trams, and trains much faster than they may think. The harder question now is whether they can keep up that momentum when it serves locals, and not just visitors. Just hours after Kansas City’s final World Cup match — Argentina 3, Switzerland 2 — its cash-strapped transit authority shut down its extended tram service with plans to slash a quarter of its regular bus routes by the end of this summer. 

Many host cities “are still not building [transit] as a serious modal shift” away from cars, said Eric Goldwyn, director of the NYU Marron Institute of Urban Management. “They’re building it as a cutesy-patootsie complement.”

Americans learned to love soccer. Can they learn to love transit too?

LA is among the exceptions, and not only because of its looming Olympics host gig. The city has made a concerted effort over the past couple of years to invest in and rebrand its transit system, which had long had a reputation for grime and danger. “If you’d spoken to me two and a half years ago, this conversation would be about safety and security on the metro system,” said Lipmen, referencing a bus that was taken hostage in 2024, one of several “really horrible, very high-profile incidents” that left many Angelenos feeling unsafe on the system. “Now, the conversation is about joy and celebration.”

What changed? 

LA began investing heavily in building more trains, buses, and subway stations, and overhauled its public safety approach, which led to a 6.7 percent drop in violent crime on transit and a 33 percent drop in incidents like drug use and weapons possession. For Lipmen, the real shift came when the metro system opened its three new stations along the D line in May, and released a raunchy “Ride the D” shirt to celebrate it. Almost immediately, the Metro’s cheeky merchandise sold out, and would continue to sell out every time it was restocked for months to follow. 

It might sound silly, but the hype genuinely helped dull some of the stigma associated with taking the train. “People who were quietly riding transit all of a sudden felt comfortable in their own skin as a transit-rider, and proud to be a transit-rider,” Lipmen said. 

Overall, LA’s big bet appears to be slowly working. “LA is a transit city,” Jennifer Vides, Metro Los Angeles’s chief customer experience officer, told the Associated Press last week. “People want to try to say that it’s not. Obviously, we have a lot more expansion to do and we’re working on it. But people really want transit.”

Beyond adding new train lines or bus fleets, normalizing public transit requires “a dramatic recast of how people get around and travel,” Goldwyn said. Cities need a vision that ensures that there is an actual “destination on the other end” of their new transit line, like offices or the kind of housing California’s new bill aims to get built near transit hubs. Most cities will need a mixture of “carrots and sticks” to help people who are used to driving everywhere see the value in hopping on a bus or tram as part of their everyday commute, not just to get to the airport or the stadium. “If your transit is not connecting you to places you want to go, you’re not going to use it,” Goldwyn said. 

A single tournament, like a single train line, will never be enough to change how Americans move. But if this nation of football fans can learn to love soccer, then surely they can learn to love the train a little bit more too. At the very least, with LA28 precisely two years away, Los Angeles just got closer to making its car-free summer Olympic dreams come true.

As if we needed one more thing to worry about so soon after the hantavirus scare, there is a new public health threat for Americans to contend with: a rapidly escalating outbreak of, of all things, diarrhea.

It’s a parasite-borne illness called cyclosporiasis. It can cause explosive and watery bowel movements — and it is wreaking havoc across the United States this summer.

How bad exactly? As of July 15, Michigan’s health department is reporting 3,762 cyclosporiasis cases, up from 1,500 late last week. Forty-four people have been hospitalized as of July 9. To put that number in context, the state normally sees about 50 cases in a year. To the south, at least 364 people have been infected in Ohio. According to a USA Today compilation of state health department data, almost every state has reported at least one cyclosporiasis case this year. 

This is not our first bout with a cyclosporiasis outbreak. In 2013, the US saw more than 600 cases, and more than 500 people were sickened across the country by contaminated McDonald’s salad meals in 2018. Cyclosporiasis is caused by the parasite cyclospora, which can infect people when it is attached to fresh produce and then consumed. It does not, fortunately, spread from person to person. We do know some likely culprits: Bagged salads, basil, cilantro, peas, and berries have been linked to prior outbreaks. 

Watery diarrhea — described by public health authorities as “frequent” and “sometimes explosive” — is the most common symptom. People can also experience cramping, bloating, nausea, and vomiting. Symptoms can start anywhere between two days and two weeks after a person eats tainted food. No one has died, and thankfully, cyclosporiasis is rarely fatal. But it is an extremely unpleasant experience that could last for up to a month without treatment, and certain people, such as folks who are immunocompromised, are at higher risk of more serious complications.

There are steps that everyone can take to protect themselves from cyclosporiasis (more on that in a moment). But the current situation is challenging, because, right now, officials don’t actually know which products are causing the outbreak. “At this time, no specific produce grower, supplier, or type of produce has been identified as the source,” Laina Stebbins, a spokesperson for the Michigan Department of Health and Human Services, said in a statement to Vox on Friday. On Monday, Michigan officials said they believed lettuce or bagged salad products were to blame, but still had not identified specific brands or items that could be linked to the growing outbreak.

It’s a public health mystery, one that results from both the sneaky nature of the parasite itself and our increasingly globalized food supply. It could be a while before we learn the answer. But, in the meantime, if you’ve found yourself spooked by some of the recent headlines, here’s what you actually need to know.

Why cyclosporiasis outbreaks are so hard to trace

Cyclosporiasis makes itself hard to find. Scientists don’t know exactly how much of the parasite a person needs to be exposed to to become infected — one of many unknowns about the basic features of the bug. The foods carrying this pathogen may not be contaminated with much of it at all, which makes any preemptive testing a challenge.

And, on top of that, there can be a long gap between the parasite being introduced to the food supply and when a person actually gets sick, which further complicates any efforts to trace the outbreak’s origins. A fruit or vegetable could be contaminated in one of the various tropical or subtropical regions of the world where cyclosporiasis is more common, well before it lands in your grocery store in the United States. 

“Oftentimes when we see these outbreaks, what happens is that somewhere in the world, a contamination event occurs, and then that produce is then shipped throughout the area and it could go anywhere in the world,” Dr. Kathleen Linder, the hospital epidemiologist at the Veterans Affairs hospital in Ann Arbor, Michigan, told Vox. 

Sometimes, the source can be closer to home: A 2020 outbreak appeared to be linked to produce grown in Florida and shipped to a plant in Illinois that produced bagged salad kits. But, as if to demonstrate the difficulty of doing this work, the FDA said it could not conclusively prove those farms were the source of the outbreak.

The point is: We have a food production supply chain that sources produce and combines ingredients from all over the country and the globe — providing more opportunities for a parasite like this to find its way in.

“We’re relying more and more on produce coming from other countries so that we can have raspberries all year round,” Joseph Eisenberg, a professor of epidemiology and global public health at the University of Michigan, told Vox. “That kind of luxury only happens when we centralize our food distribution system.”

Even once an outbreak is underway, it can be hard to pinpoint the source. Symptoms may not occur for up to two weeks after a person eats contaminated food. 

“I can barely remember what I had for dinner a couple nights ago; there’s no way I’m going to be able to remember a week ago,” Linder told me. “It takes a lot of time and a lot of manpower to get all that information collected.”

As with any outbreak under the Trump administration, the Centers for Disease Control and Prevention is responding with significantly fewer workers and resources than it used to have. To be clear: This cyclosporiasis outbreak could have happened either way. This parasite has sparked widespread infections before. But Linder said that because the CDC has rolled back some of its national reporting programs, it’s been left to the states to take the lead — and that has made it harder to pull together a complete picture of the outbreak.

“It has been very hard to get updated information,” Linder said. “The information is lagging a little bit behind because it’s being done at the state level.”

What you can do to reduce your risk of cyclosporiasis

For scientists, the work ahead involves better understanding the properties of the pathogen itself and developing surveillance tools and techniques that allow us to catch contaminated food before it reaches people. But what can the rest of us do right now, during an active outbreak?

According to various public health authorities, the short version is to cook the produce that you can — heat is the absolute best option for eliminating cyclosporiasis — and to clean your raw fruits, vegetables and herbs as thoroughly as possible. 

Wash everything with running water before eating or preparing it. Scrub the firmer fruits, like melons and cucumbers, with a produce brush if you have one. If you see damaged or bruised areas on your fruit or lettuce, cut them away. Even if a food’s package says it’s prewashed, Linder said she advises people to rewash it just to be sure.

Previous outbreaks have specifically been linked to bagged lettuce and salads, so you might consider buying whole heads of lettuce instead. If you do that, cut away the outer layers and then separate the inner leaves to wash them. For green onions, you should cut away the bulby root and the outer layer and then wash them thoroughly. Raspberries were associated with one of the first US outbreaks in the 1990s, and they are particularly tricky to clean given their bumpy surfaces; you may want to consider eating them only after cooking (to prepare a jam or compote, for example) or opt for frozen raspberries for the time being. (Freezing is believed to reduce, if not completely eliminate, the parasite.) And be careful with leftovers: You should refrigerate any unused foods that you plan to eat later within two hours. 

You could also consider buying locally sourced foods, Linder said, because cyclosporiasis is more common in food sourced from other parts of the world.

If you do start to experience extreme diarrhea, make sure to hydrate very well to avoid dehydration. Linder told me that if somebody experiences dizziness, they can’t keep fluids down, or they have very dark urine, then they should seek immediate medical attention. And anybody experiencing those symptoms should get in touch with their health care providers and their local health department. 

Sooner or later, experts will probably figure out what caused the current outbreak, whether it’s one source or several. But cyclosporiasis will still be a concern in the future; it’s a byproduct of the food system we have built. It serves as a potent reminder about the importance of good food hygiene. A little extra effort to wash your food before you eat it could save you a lot of pain later.

Update, July 15, 2026, 11:45 am ET: This story, first published July 10, has been updated with current case numbers and products linked to the outbreak.

This story was originally published in The Highlight. To get access to member-exclusive stories like this every month, become a Vox Member today.

America’s housing supply was built for a world we no longer live in. But what will replace it? 

As the nation turns 250, that is one of the most important questions we face in the coming decades. Building enough homes, of the right kind, and in the right places is a prerequisite for economic opportunity and growth. Our crippling housing shortage is upstream of many of the problems that ail the US, from our cost of living and increasingly zero-sum politics to our seemingly intractable national bad mood. 

The root of the problem is that the United States governs housing under a nearly century-old paradigm that’s been cracking under growing strain. Since the end of the Great Depression and World War II, when the baby boom massively increased the country’s population and millions of Americans sought relief from derelict urban housing, suburbia has been the country’s default blueprint for development. Big single-family homes, two-car garages, and giant strip malls were not merely consumer preferences. They were also written into law by rigid zoning codes — the rules that dictate what kinds of things can be built where — incentivized by midcentury lending standards, and absorbed into the professional common sense of planners and builders. 

The system shaped not just the suburbs, but also many cities, and has kept homes scarce, expensive, and sprawling, resulting in a housing affordability crisis that has come to dominate politics. And in the decades ahead, this pattern will become even more misaligned with the reality of American life. Households are getting smaller, and Americans are getting older. If today’s low immigration rates continue, the US Census Bureau projects the country in 2076 will have fewer families with children and working-age adults, and far more seniors — the inverse of the demographic transition that drove the great suburbanization. Climate change and new technology, such as driverless cars, will also force cities and suburbs and populations to adapt.

US history offers reasons for optimism, showing repeatedly that we can reorganize ourselves with extraordinary dynamism when the occasion calls for it. Our cities have already lived many lives, growing from tiny outposts into world-leading metropolises, before receding again in the wake of suburbanization and de-industrialization, and then more recently gaining new life with influxes of younger generations.

The transformations ahead may not be as physically dramatic as those of the American past, but they call for equally monumental cultural and political shifts in our approach to housing. We’re already making progress: The ascendant “yes in my backyard” (YIMBY) movement has persuaded states and localities to roll back restrictive policies that make it essentially impossible to build enough homes. The effects of those reforms are slowly making themselves felt in more affordable neighborhoods. 

But there is still far more to do. Housing reformers will need to turn their attention not just to removing bad regulations like single-family zoning and minimum lot sizes, but also toward reviving a role for government in shaping our communities through real, big-picture planning. Doing so would supply a missing piece in America’s housing agenda — making US cities and suburbs not just more affordable, but more vibrant and livable and helping us better use our existing infrastructure. That will matter even more as a shrinking working-age population makes endless outward sprawl harder to sustain.

A more abundant, more varied, and even more fun housing future is not inevitable, but it is decisively within reach. Here is what the future could look like by America’s 300th birthday, if we commit to making ourselves anew. 

Suburban retrofit abundance

Arthur Nelson, a professor emeritus of urban planning and real estate development at the University of Arizona, has a few words of warning for anyone trying to report on what cities might look like in a half-century: “You’re not going to be right.” 

Urban planners tend not to project many decades into the future because what that future will look like invariably hinges on factors we couldn’t possibly imagine today. The most important unknown for our future population and housing needs will be whether the US opens its doors to many more immigrants, as it has done at times in the past. Assuming immigration rates remain low, however, US population is projected to peak somewhere around the mid-21st century and fall thereafter; by 2076, it will have dropped back to today’s size, on the way to declining further. 

Despite that uncertainty, many of the housing abundance advocates, policy experts, and urban planners I spoke to for this piece expressed striking optimism that the future of housing will be better than the present, and enthused about how much can be transformed in 50 years. Start with the suburb, where the majority of Americans live today, and where the future of American housing will be decided. 

Imagine that, in 2076, you’re walking through a residential neighborhood in La Mirada, California, a midcentury, southeastern suburb of Los Angeles, one of the regions at the epicenter of today’s housing crisis. The bones look much like the suburbs we know today — gently curving streets, sun-baked yards, low-slung buildings set back from the sidewalk — but the old single-family monoculture in many neighborhoods has loosened: Houses built during the region’s mid-20th-century building boom now have small cottages, also known as accessory dwelling units (ADUs), tucked beside them. Some bigger houses have been subdivided into two homes. Other lots now hold triplexes, fourplexes, and small apartment buildings that sit comfortably among single-family homes. A few houses have become shared homes for seniors who want support and companionship without being cordoned off into a retirement community. (In 50 years, that will include people born in the 1980s, 1990s, and ’00s — me, and perhaps you, too.)

Even as the overall US population has plateaued, this late-21st century Greater Los Angeles might be home to millions more people than today, but it has not had to push all of them farther into the arid desert or the fire-prone hills. Because as many as two to three times more people are living on each acre of land, housing costs have eased. Many people rely on shared driverless cars, freeing up the space that would be needed for car storage, so land that had been parking can be put to better uses.

Perhaps most strikingly different from today’s suburbia, the hard wall between home and commerce — which is near-universally mandated by local zoning codes today — has softened. Near the neighborhood’s edge, where local streets meet a larger main road, a neighborhood grocery and clinic have opened on what used to be strictly residential lots. And, yes: That is a donut shop running out of a neighbor’s garage. A few doors down, an old three-bedroom has become a small co-working space, and a converted garage houses a bicycle repair shop. Housing has not only become more affordable, but with more of the rituals of daily life mixed in, the suburb has gained a richer, more connected public sphere. There are simply more people around — walking, talking, and lingering. 

Could we get there? Some experts I consulted predicted that simply easing regulations on what can be built in these neighborhoods will unlock a long-suppressed capacity for creative adaptation, allowing suburban areas to evolve in precisely this way. In the suburbs of superstar cities like LA, San Francisco, and Boston, land values are so high that property owners have strong incentives to redevelop single-family lots into more economically valuable uses, like multiple housing units. They just need to be legally allowed to do so. 

The YIMBY movement’s recent legislative successes have already put much of the country on that path. More than a dozen states, including California, have passed laws to allow building ADUs on residential home lots, and many others have new laws allowing denser housing, like townhomes and small apartment buildings in these areas too.

“I suspect it’s just a matter [of time] before the rest do the same,” M. Nolan Gray, senior director of legislation and research for the advocacy group California YIMBY, told me in an email. The upshot for the far future of housing is that “detached single-family zoning is dead,” predicts Gray, who is also an urban planner by trade. “I think the typical lot in a (non-HOA) suburb of a typical US city in 2076 will have at least a second unit; perhaps a manufactured ADU plopped in the back, perhaps a McMansion that has been converted into a duplex.” 

Such reforms also offer important tools for a graying population. As Nelson has argued, the number of senior households in the US is already growing faster than younger ones, and without zoning flexibility to redevelop single-family homes into smaller units or adapt them to the changing market in some other way, older homeowners would face the prospect of being stuck with large, hard-to-maintain houses. 

Even more dramatic suburban retrofits might come in commercial districts — think aging, abandoned malls, strip malls, and “power centers” built around big box stores and even bigger parking lots. As Vox’s Rachel Cohen Booth has written, there is a growing movement to turn those sites into housing. 

An increasing number of states have started allowing apartments in commercial districts, where building multifamily housing is an easier sell politically than allowing it in residential areas where neighbors might resist. 

Meanwhile, Gray added, communities across the country have been very rapidly repealing parking minimums — the fixed number of parking spots required at every residence and business. As minimums are phased out, parking lots can be redeveloped  into housing and other uses better than acres of underused, heat-trapping asphalt.

“I expect most of today’s strip malls and shopping malls will gradually be converted into mixed-use pocket neighborhoods,” Gray predicts — a distinctly American version of a much older human pattern of development, where homes, shops, services, and public life are allowed to coexist. 

Maybe we need an urban planning revival

Despite early signs these reforms are nudging American housing toward a better future, the national rate of new home construction has barely moved, and forecasters expect little change in 2026. That owes less to the reforms than to the broader economy: mortgage rates largely stuck above 6 percent since 2022, which raise borrowing costs for builders and freeze existing owners in place; rising material and labor costs; and a thinning construction workforce worsened by President Trump’s immigration policies. Where YIMBYs have passed new laws, many local governments prove adept at finding ways to flout them. Housing advocates will have to commit themselves to a long fight, until change exists not only on paper, but also in the real world.

Even then, unleashing the free market alone won’t solve every problem with how American cities and suburbs are built and organized, or how they feel to live in.

Those failures are visible everywhere: Have you ever wondered why so many residential streets wind around in aimless, circuitous patterns, disconnected from the town around them? Or why you are forced to endure a nightmare commute to drive just 10 miles? These are all failures not just of too much regulation in the form of rigid zoning, but also of an absence of coherent urban planning. 

Robert Goodspeed, an associate professor of urban planning at the University of Michigan, points to good planning as an essential missing element in today’s housing reform movement. “I think that the YIMBY movement has completely missed the importance of planning,” he told me. “Even if we repealed all zoning, it still doesn’t realize a well-designed, well-planned community that has high quality of life.”

The zoning approach works so poorly because it micromanages what can or cannot be built on any given parcel of land. It’s a set of prohibitions on what the private market is allowed to do (made without regard for how people actually want to live): No apartments can be built on this street, even if there’s an enormous amount of demand to live there; no coffee shop may be opened on that corner, even if it would fill up with neighbors delighted to make it part of their daily routine.

Urban planning, on the other hand, at its best is concerned with the public realm. It oversees the larger body of a city or area and provides the connective tissue of its infrastructure — roads, transit, parks, sewers, and other utilities — that links up the space, something the private sector can’t provide. It allows cities to function as a cohesive whole and has the potential to give the public access to what a community has to offer. 

In the late 19th and early 20th centuries, American planners were animated by real civic ambition, laying out future-minded street grids that could continue to grow and connect the residential and the commercial. One reason more recent development has been so poorly designed, Gray argues, is that planners have become so bogged down enforcing the tedious minutiae of zoning codes. “Zoning has utterly consumed planning, to the point that many city planning departments now do little that would resemble what a normal person might think of as planning,” he writes in his book Arbitrary Lines. Gray calls for abolishing zoning altogether, and freeing up municipal planning offices for more useful work that can accommodate the changes we know we need to make to our housing stock. 

Easier said than done, of course. The US comprises thousands of individual cities and suburbs, each with its own zoning code, and they will not surrender that authority willingly. 

But it’s not crazy to imagine that, in 50 years, planning in the US looks very different from today. Local governments derive their authority to zone from states, Gray points out. And just over the last few years, states from Montana to Maine to Oregon have been wresting certain zoning powers away from cities and suburbs. That shift could provide the seeds for a future where planning is run on a more unified, regional level, much like it is in peer countries like France and Japan. Local planners might then be empowered to focus on what matters — facilitating humane growth in places that people want to move to, and creatively solving the challenges that will arise from retrofitting a built environment that was not designed to accommodate that sort of evolution. 

Could we just…start over with all-new cities? 

One of the country’s most audacious attempts to revive American urban planning is unfolding in Solano County, California, roughly an hour north of San Francisco. There, a controversial, billionaire-backed company is advocating an iconoclastic solution to the Bay Area’s housing affordability crisis. 

Instead of fighting through red tape to get permission to add a few homes in Palo Alto or Marin County, the startup California Forever wants to build a new city from scratch. Forty years after construction begins, the company hopes, it would be more populous than the St. Louis, Orlando, or New Orleans of today, providing homes to around 400,000 people and jobs in advanced manufacturing, shipbuilding, and other industries. 

The project has not yet broken ground, and, ironically enough, likely won’t be able to for several more years, as it moves through environmental review and other required regulatory steps. But it eventually hopes to prove that it’s still possible to build physical things in the world’s tech capital, the place that has transformed everyday life at extraordinary speed but still struggles with the elemental task of making room for people to live. The project has won support from many prominent housing reform advocates, who welcome it as a bracing challenge to an untenable status quo that has meaningfully damaged the US economy. (According to one widely cited study, restrictive housing policies in superstar metro areas, including San Francisco and San Jose, lowered overall American GDP growth by around 36 percent between 1964 and 2009 because they prevented more people from moving to those highly productive cities.)

Despite its Silicon Valley provenance, California Forever’s most interesting ambition is less futuristic than throwback. It hopes not merely to add a mass of badly needed housing stock to the Bay Area, but to deliver it in the form of a pedestrian-centered city of the kind that hasn’t been built in the US in a hundred years. Its architectural renderings show handsome mid-rise townhomes, apartments, and single-family homes along shaded, walkable streets with a bus rapid transit system, all organized around a traditional grid network of streets. Gabriel Metcalf, the head of planning for California Forever, told me he predicts the city will eventually have the lowest per capita rate of car travel anywhere in the US other than New York City.

Of course, the project in its full form might not get past regulatory hurdles. Even if it does, it could end up being too expensive for the people who work in its schools, grocery stores, and coffee shops to live in, especially with California’s high labor costs, environmental review, and other expenses baked in. It’s also very difficult to build a successful city from the top-down. 

But whatever becomes of this movement to build entirely new cities, it is tapping into a real gap that already exists in the US housing market: Despite our reputation for being car-loving suburbanites, many Americans want something different. A 2026 Pew Research Center survey, for example, found that 44 percent of respondents say they prefer to live in a walkable area — even if the homes are smaller (other estimates actually put the number higher). The surest prospect for making that a reality might not be new cities, but repairing existing ones. 

Alicia Pederson, a Chicago-based writer, researcher, and founder of the organization Courtyard Urbanist, predicts that, with good urban planning, we could in 50 years see a “golden age of American city-building.” With a graying and eventually shrinking national population, many cities will have to work harder to attract and retain residents by offering a better quality of life, she told me in an email. That might mean providing better housing options that make vibrant, walkable life accessible to more Americans without sacrificing the benefits of suburban single-family homes: spacious, sunny housing units and abundant green space. The kind of courtyard blocks common in some European cities offer one elegant solution: They occupy an entire city block, with a perimeter of mid-rise buildings and an interior yard. And they can accommodate homes in a range of sizes, which are more flexible and easier for aging people to maintain than detached houses. 

The future is still up for grabs

It’s entirely possible that sheer inertia keeps the US on its current sprawling trajectory as it approaches its 300th birthday, with reforms producing only a scattering of ADUs and boxy apartment buildings often derided as “gentrification buildings,” rather than any deeper transformation of the American built environment. 

Arpit Gupta, an associate professor of finance at New York University who I consulted because of his talent for poking holes in urbanist orthodoxies, predicted that the US by 2076 will actually see “a dramatic increase in sprawl” thanks to the future adoption of autonomous vehicles. That’s because he and many other transportation researchers believe many people would be willing to tolerate longer commutes in self-driving cars than they do in cars they have to drive themselves, providing one more reason to push housing ever outward. Minus the self-driving cars, that’s what’s happening in the hyper-sprawling and still growing Sunbelt, where new housing continues to be built farther and farther from city centers. 

But there are many other paths we might take. Domestic migration may begin shifting northward in the coming decades, amid a warming climate and water scarcity in the Southwest. Many Midwestern cities are showing signs of renewed growth (may I recommend moving to Madison, Wisconsin?), offering a chance to build more and better housing on the region’s extensive pre-war urban bones. And it’s much too early to assume that AVs will massively increase the amount we drive, Michael Manville, a professor of urban planning at UCLA, cautioned me. Different policy choices could lead to shared self-driving systems that encourage less car ownership and more density.

The future won’t vindicate every utopian blueprint — nor should it. Our housing system ought to be open and capacious enough to accommodate the country’s diverse and evolving preferences. The way we’ve organized housing for much of the last century has given us not only pervasive unaffordability, but also too few choices, too few versions of the American dream. That very scarcity is part of why Americans today are so angry at one another: It feeds the sense that we’re fighting over scraps. 

But if we make room for more ways of living together and think big about how to get there, we may find ourselves less trapped by the failures of the present than we think. Cities often surprise us: Fifty years ago, who could have predicted that places like New York City and Boston, then battered by population loss and disorder, would recover so dramatically? 

The trajectory we take in another 50 years will surely confound our predictions, too. And that’s reason enough to build something less brittle than what we inherited — a housing approach with enough room, variety, and imagination to enable American life to change again.

This story was originally published in The Highlight. To get access to member-exclusive stories like this every month, become a Vox Member today.

Emily Hoffman was walking home from lunch in the Pittsburgh neighborhood of Squirrel Hill in February 2023, when a driver turning left struck her on the crosswalk.

Hoffman was 34. By the time paramedics arrived on the scene, she had gone into a traumatic cardiac arrest. They strapped her onto a machine that delivered automated chest compressions and rushed her to UPMC Presbyterian, a major trauma hospital in Pittsburgh.

Over the next several days, doctors performed multiple surgeries, kept Hoffman on a ventilator, and waited until she was stable enough for an MRI. The scans showed multiple strokes and severe traumatic brain injury. She was alive, but her family understood that she was not going to make a meaningful recovery to a life she would have wanted.

The next Thursday, a week after the crash, Emily’s parents and her sister Beth Hoffman met with the care team and decided to remove ventilator support to allow her to die naturally. Organ donation came up only afterward. Emily was already a registered donor, and Beth knew it was what her sister wanted.

For most of the short history of organ transplantation, Emily would not have been the usual kind of organ donor.

Almost all transplanted organs once came from patients who died in one specific and rare way called brain death, in which the brain has irreversibly stopped functioning, even as machines keep the heart beating and the organs supplied with oxygen. Brain death is extraordinarily rare,  but it happens often enough to create a workable — though far from sufficient — supply of life-saving organs.

But Emily was not one of the brain-death donors. Even after the strokes and brain injury, she still had some reflexes. She was dying, but not brain dead.

Her donation followed a different path, one that has transformed American transplantation in the last decade. It is called donation after circulatory death, or DCD. Instead of death being declared because the brain has stopped functioning, in DCD, death is declared after circulation ceases and the heart stops beating. Many more people die this way than by brain death.

Death by circulatory criteria has been legally recognized since the 1980s, but for decades, doctors rarely recovered organs this way, because, once blood stops moving through the body, organs begin to deteriorate within minutes. In recent years, however, new machines and surgical techniques have helped change that, giving doctors the ability to preserve organs outside the body, making DCD far more viable.

↗ Explore the interactive version of this chart.

Hoffman’s donation is hardly an outlier anymore. In the last decade, DCD has gone from a rare practice to something that now accounts for nearly half of all organ donors who have died in the United States. In 2000, DCD donors supplied just 219 organs (kidneys, livers, lungs, hearts, and pancreas combined) to the transplantation system in the US. In 2025, DCD brought in close to 17,000 organs. (Most transplanted organs, about 85 percent, come from dead donors, though some organs, most often kidneys, can also come from living donors.)

That growth has saved lives, but it has also pushed transplant medicine into an unusually sensitive moment: the time after a family has decided to let their loved one die but before death has actually occurred.

In brain-death donation, a patient has already been declared dead before the possibility of donation is raised with the family. Because most brain-dead donors are on ventilators, with machines supplying oxygenated blood to their organs, transplant teams can take their time with the donation process.

DCD doesn’t offer that same cushion. Because organs deteriorate so quickly after circulation ceases, the work of donation — the testing, matching, surgical teams flying in — has to be set in motion once the family has decided to withdraw life support but before the patient has died.

This is where the tension in DCD begins. The process pushes transplantation into the narrow interval between that decision to let someone die and the moment death occurs. It creates a situation with almost no parallel in medicine: one set of hands caring for the dying, even as another prepares to recover and transplant their organs.

The medical system tries to manage that complexity with a strict procedural sequence. First, hospital doctors and family conclude that no treatment will bring the patient back to a life they would have wanted. Only then, and only from a separate team, does the word donation come up. The firewall is in place so that the need for organs never shapes the decision to let someone die. 

“Ethically, you want to make sure that those two are uncoupled,” said Wade Smith, director of the Neurovascular Service at the University of California San Francisco.

But as DCD has scaled up, more weight is put on that narrow interval. What was once a rare event is now routine in hospitals across the country, carried out by teams with different levels of experience and overseen through rules that can vary from one place to another. At the same time, the organizations that handle organ donations are under new federal pressure to acquire and distribute more organs from eligible donors.

DCD has saved thousands of lives by making donations possible from patients who once wouldn’t have been donors. Hoffman’s donation improved several lives at once: Her kidneys went to two men, her liver to a third recipient, and her corneas helped give sight to a nine-month-old baby. 

But its growth has also made the fragile period before death more consequential: how families are told, which steps can be taken while the patient is still alive, how consistently hospitals and organ donation teams follow safeguards, and who has the authority to stop the process if something feels wrong.

When DCD was still rare, these questions stayed at the edges of transplantation. Now, they are moving towards its center, as a lifesaving practice becomes a routine part of how Americans die and donate.

The breakthrough

Modern transplantation is a relatively young field, only about 70 years old. And from the beginning, transplantation has depended on the novel medical achievement of keeping organs functional after a person had been declared dead.

The mechanical ventilator, developed in the 1950s, made that possible. It could keep a body breathing, and its heart beating, even after the brain had stopped for good. That created, for the first time, a situation where patients were deceased by every older measure, even as their organs were still functional.

Surgeons were initially wary of recovering organs, largely because the legal lines between life and death had never been clearly drawn. Then, in 1968, a Harvard committee proposed a definition of brain death. By 1981, a model law gave states the language to recognize two ways of legal death. Your heart and lungs could stop for good (circulatory death) or your entire brain could (brain death). Today, every state recognizes some version of that framework.

With those lines in place, transplant teams could work with more confidence, and brain death turned out to be close to ideal for them. Because a ventilator kept the heart beating and blood moving through the organs, even after death, there was no ticking clock to race against. The hospital staff had time to evaluate the organs, sometimes convince families to donate them, find the right recipients, and bring in surgical teams before recovery began.

The problem was always with the math. Brain death is rare — only about three in 1,000 deaths happen in a way that leaves organs usable for transplant. That puts a hard biological ceiling on how many ideal donors there could ever be.

But demand for the organs had no such ceiling. Nearly a million Americans are diagnosed with heart failure each year, while surgeons performed just 4,636 heart transplants in 2024, after DCD became a widely used part of transplantation, up 81.5 percent from 2013. There are “just not enough organs to go around,” said Ashish Shah, chief of cardiac surgery at Vanderbilt University. The kidney numbers are even bleaker. Over 500,000 people are on dialysis in the US, but only a fraction will ever reach the waiting list, and even among those who do, many will die before receiving a transplant offer, said Dorry Segev, a transplant surgeon and researcher at NYU Langone.

The modern DCD boom grew out of this desperation, presenting the possibility of donation in far more common cases of death that transplantation surgeons had rarely been able to draw on before: catastrophic strokes, car crashes, cardiac arrests, and other injuries that left patients with no meaningful chance of recovery but short of brain death. But with DCD, the clock suddenly became a factor. Once circulation stopped, the organs deteriorated fast, and, in many cases, they were ruined before surgeons could recover them. 

Because of those challenges, DCD stayed marginal for decades, at well under a tenth of all donations. Those numbers ultimately spiked because of several things that happened almost simultaneously.

The first was technological. New machines, like TransMedics’ Organ Care Systems — which were first used in 2015 in the UK — could keep a recovered organ alive outside the body, pumping it with warm, oxygenated blood instead of packing it in ice, allowing a heart to beat and function as normal inside a box. This meant that even if there was delay in recovering an organ, that damage could be limited, even reversed, once the organ was put in the machine. 

Other teams found ways to use machines originally developed to support failing hearts and lungs to restart circulation inside the bodies of donors after death had been declared. Transplant teams in Spain and the UK began adapting that technology before American programs picked it up for DCD hearts around 2019. Both approaches helped extend the time to successfully perform DCD.

“As soon as the results were good, the big American centers took it on,” said John Dimarakis, a cardiac transplant surgeon at the University of Washington.

Policy changes also helped push DCD further. In Hoffman’s case, the donation process was coordinated by CORE, the nonprofit responsible for organ donation in the Pittsburgh region. Organ procurement organizations, or OPOs, cover a particular region in the US, and they work with hospitals in that region to evaluate potential donors, speak with families, arrange testing, and offer organs to transplant centers. There are 54 such OPOs in the US, which are certified and regulated by the Centers for Medicare and Medicaid Services (CMS). 

For years, critics argued that OPOs were judged according to weakly defined standards based on numbers they reported themselves, and poor performers were rarely penalized. But in 2020, new federal rules began ranking them against one another, with a mechanism to strip the worst performers of their territory. Facing the threat of losing their monopolies, many OPOs began pursuing harder cases they would’ve earlier passed over, according to Greg Segal, who founded patient advocacy group Organize. A larger share of those more complicated donors were DCD.

Still, no single force explains the speed of DCD’s rise. “Technology plays a big role in it,” said Nader Moazami, a cardiac surgeon at NYU Langone who helped pioneer one of the new techniques. “But it doesn’t explain how suddenly 50 percent of our donors are DCD.” In 2000, there were only 118 DCD donors in the United States. By 2025, there were 8,137. Brain death donation grew over that same period but far more slowly — from 5,867 donors a year to 8,416.

↗ Explore the interactive version of this chart.

Whatever the mix, it’s clear that DCD has led to more organs, shorter waits, and saved thousands of lives that otherwise would have ended on a list. “People who have been waiting now wait less,” Dimarakis said.

On a chart, it looks like an unambiguous triumph — until you step into a hospital room.

The passage

Beth Hoffman remembers her sister Emily’s last morning. She read aloud an email from Bradley Whitford, Emily’s favorite actor from the TV drama The West Wing, who had written after hearing what had happened. Then, a playlist of Emily’s favorite songs played as the breathing tube came out. Within about 10 minutes, while “For Good” from Wicked filled the room, her sister was gone.

What Beth mostly didn’t see was the second sequence unfolding around her: the referrals, tests, calls, and scheduling that would turn Emily from a dying patient into an organ donor. 

Federal rules require every hospital to alert their organ procurement organization whenever a person may be nearing death. The OPO screens those referrals, and most go nowhere. Alexandra Glazier, who runs the OPO that covers most of New England, says hers get about 50,000 such referrals a year. Only 2 or 3 percent turn out to have any medical possibility of donation at all. 

Emily was one such possible case for her Pittsburgh hospital’s OPO. The organization had to reach out to her family; explain what DCD would involve; and, then, start the work that had to happen while she was still alive: reviewing her medical history, testing whether her organs could be used, matching them to recipients, and arranging the surgical teams who might fly in to recover them.

Most families never see much of that work, but some do. Smith, the UCSF neurologist, watched a family agree to withdraw life support and donate, set a time, and gather relatives for a final goodbye, only to learn that the withdrawal had to wait because the OPO still needed more tests. Some families, after being told their dying relative must stay on machines longer for donation’s sake, walk away.

For the Hoffmans, things proceeded more quietly. When the time came, Emily was wheeled into the operating room, and the breathing tube was removed there. The surgeons who would recover her organs were kept away from the withdrawal and death declaration. They often fly in from their own hospitals — sometimes several at once for different organs — but they’re walled off from everything that comes before. “We are not involved in that process,” said Dimarakis, the cardiac transplant surgeon at the University of Washington, “because it’s not ethical for us to be involved.”

That separation is the line DCD depends on. One team cares for the dying patient, withdraws support, and declares death. The other waits outside that decision and recovers the organs only after. The OPO stands between them, coordinating the donation without letting the firewall be breached.

Then comes the waiting. Once the ventilator is out, the clock starts ticking. If the heart doesn’t stop within a window — often about two hours — the organ recovery may be called off, and the patient is returned to end-of-life care. But when circulation does stop, as it did for Emily, the team counts exactly five more minutes to make sure it won’t restart on its own. Only then can a hospital physician declare death, and only then can the transplant surgeons begin.

DCD rests on a simple promise: The need for organs never causes the death. The death is already coming, and donation only changes what can come from it. 

But a new frontier in DCD complicates that promise.

The reversal

Normally, after death is declared, most DCD organs are removed and preserved outside the body, either on ice or on machines that circulate oxygenated fluid or blood. The goal is to slow the damage that begins the moment circulation stops.

Then, around the mid-2010s, transplant teams in Spain and the UK began using a newer technique that restores circulation inside the dead donor’s body, before the organs are removed. It’s called normothermic regional perfusion, or NRP.

In one version of NRP, called abdominal NRP, blood is meant to be restored only below the diaphragm to preserve organs such as the kidneys and liver. In a more controversial version called thoracoabdominal NRP, it runs through the chest, as well, and the heart starts beating again.

For the transplant team, especially heart surgeons, the appeal is clear. Kidneys and livers can survive a stretch without circulation, but a heart is harder to preserve. Once it has stopped, there’s no easy way to know whether it will beat reliably again. NRP helps answer that question by restarting it inside the donor’s body after death has been declared, where surgeons can watch it work before deciding whether to recover it.

Shah, the Vanderbilt cardiac surgeon, says the technique lets doctors take hearts from donors who otherwise would not be able to yield a workable one.

But this kind of NRP is unsettling for the very reason that it is useful. If a death is declared because the heart has stopped, what does it mean to start it again inside a donor’s body, often only minutes later? Is that still death? Or something else?

The controversy isn’t simply that the heart beats again. A beating heart is not, by itself, the same as a living person. The heart of a brain-dead patient can beat, too, can be kept going by machines, and that doesn’t mean the person is alive. The deeper concern is whether restored circulation in the body could reach the brain, which could potentially restore consciousness.

To prevent blood from reaching the brain, surgeons clamp or cut the vessels that carry blood to the head before circulation is restored. That distinction is central to the defense of NRP, and it lets surgeons say they are restoring circulation and restarting the heart, not the person. 

But those safeguards haven’t always worked. In a safety notice last November, the Organ Procurement & Transplantation Network (OPTN), the federal system that oversees transplant policy and data, said it had received “verified reports” that blood had unintentionally reached the brain and brainstem during NRP. Such events are extremely rare, the notice said, but can occur when a clamp fails or blood reaches the head through an unrecognized route. The notice asked transplant programs using either form of NRP to strengthen their safeguards and report any failures. But those recommendations were not national requirements and as of May 2026, the OPTN was still developing formal standards for NRP. For Claire Morgan, a transplant surgeon from North Carolina who has criticized NRP’s rollout, that is a central weakness. “It’s a bulletin. It’s not a policy,” she said. “There’s no punishment for not reporting.”

But even if blood never reaches the brain, NRP can still introduce deeper ambiguity into our understanding of circulatory death. In the first few minutes after a heart stops, it can often be brought back, an event that happens every day in a busy emergency department. In conventional DCD, however, doctors don’t try to restart the heart, because a patient or family has already decided against being revived. It is that decision, not just the stopped heart itself, that turns the moment into a death. The same goes for anyone who dies under a do-not-resuscitate order.

NRP puts pressure on that logic. The circulation declared permanently gone is deliberately brought back. “There’s a misalignment between NRP practices and the legal standard for how death is defined,” said Glazier. You cannot, critics argue, pronounce someone dead because the circulation will never return — and then return it.

Robert Truog, professor of Medical Ethics, Anaesthesia, & Pediatrics at Harvard Medical School, supports NRP but thinks the possibility of blood returning to the brain is the issue that matters most. “The only questions are, is there a risk of pain or suffering in the procurement of the organs?” he said. And there’s a possibility of that if the circulation is restarted in the brain.

None of this is settled, which is why some hospitals refuse to perform NRP at all. Moazami pioneered the NRP heart technique in the US and practices it at NYU Langone. “But you cannot do it at Columbia,” he said, “just five miles away.” Glazier’s OPO, one of the country’s largest, said her organization has done roughly 650 NRP cases since adopting the practice — but only the abdominal kind, holding off on the heart version until the national protocols are better standardized.

Claire Morgan, a transplant surgeon from North Carolina who has criticized the rollout of NRP, is more worried about what happens if something goes wrong. The donor cannot complain, families may never know if there was a concern, and clinicians who speak up may have limited protection if they challenge what happened in the operating room. 

All of that matters, because NRP is already far from marginal. The Organ Procurement & Transplantation Network (OPTN), the federal system that oversees transplant policy and data, only began collecting data on whether NRP was used in a DCD recovery in October 2025. In the first five months of that reporting, from October 1, 2025, through February 28, 2026, 3,463 DCD donors were recovered nationally, according to data shared by the OPTN with Vox. More than half of those involved NRP; though, OPTN doesn’t collect data on which kind.

Vox’s analysis also found that NRP cases were concentrated among some organ procurement organizations. The top 10 OPOs accounted for 47 percent of all DCD recoveries that used NRP.

The patchwork

The core safeguard in DCD — that the decision to withdraw life support must come before questions about donation — is widely accepted. But many of the details around that sequence that shape a family’s experience, or a patient’s protection, are still handled differently from hospital to hospital, OPO to OPO.

“The entire process of DCD or donor withdrawal is not very standardized across the United States or even within states, even within different hospitals in the same city,” Moazami said.

That can mean differences in what families are told about the donation process, what medications are considered appropriate before death, whether NRP is allowed and how it is performed, and who has the clear authority to pause or stop the process if someone believes something is wrong.

That unevenness matters more now, because the transplant system has been trying, with good reason, to recover more organs. For years, many in the field, and those who depended on it, argued that the organ procurement organizations were leaving transplantable organs on the table. Greg Segal, whose advocacy group Organize helped push for stronger OPO accountability, compared the old system to a canvassing campaign where you only knock on the easiest doors. “The problem with OPOs is they were only doing the much easier ones,” he said.

A 2020 rule from the Centers for Medicare & Medicaid Services, the federal agency that oversees OPOs, was meant to change that. It ranked OPOs against one another and created a path to penalize low performers by stripping them of their territories. That policy appears to have had some impact, but it is hard to separate from other forces driving DCD’s rise including new preservation technology, like NRP and broader clinical adoption. Jeffrey Trageser and Charles Strom from the Association of Organ Procurement Organizations, the trade group that represents OPOs, argued that the metrics are too broad, evaluating OPOs partly on whether transplant centers ultimately accept organs and not fully accounting for regional differences such as age of potential donors, local rates of cancer, or how far organs must travel to reach transplant centers.

This pressure to recover more organs has also made some OPOs seem more aggressive to the clinicians working besides them. “Some people view them as vultures, which is horrible,” said Smith, the UCSF neurologist who has experienced the tension from the hospital side. “They’re trying to do their job.” Still, he added, “when you impose that [pressure], then it changes how aggressive they are.”

Both things can be true. The old system needed pressure to perform better. And pressure can create risks, or perceived risks, in a process that depends on careful judgement around a dying patient.

And the safety question isn’t a theoretical concern either. A March 2025 investigation from the Health Resources and Services Administration (HRSA), the federal agency that oversees the national transplant system, documented what can happen when those safeguards fail. In a review of attempted DCD cases at Kentucky Organ Donor Affiliates, an OPO that covered Kentucky and parts of Ohio and West Virginia, HRSA found recurring problems about staff missing vital signs in patients that raised concerns, failed to work collaboratively with hospital medical teams, failed to respect family decision-making, and documented medical data poorly. HRSA said the pattern suggested “organizational dysfunction” and a weak safety culture.

One OPO’s failure does not prove that DCD is broadly unsafe or that OPOs across the country behave the same way. But the Kentucky review showed how badly things can go when the line between patient care and organ recovery is not honored.

Since then, federal officials have been trying to close some of the gaps. HRSA has pushed for clearer family education around DCD and more standardized reporting on ventilated patients referred to OPOs, as well as opened up a reporting channel that sends misconduct concerns directly to HRSA. In a separate case, the Department of Health and Human Services also moved to shut down an OPO in South Florida after finding unsafe practices, underperformance, and paperwork errors.

Organ donation is a touchy subject, because it relies so much on the goodwill and the trust of the people who agree to give their organs so they can live on in others. But the procedural issues also matter, because there are lives at stake on both sides of the process. 

Around 13 people die each day in the US waiting for organs. In that desperate landscape, the rise in DCD has led to many lives saved and helped several more live better, fuller lives. The dearth of organs even compelled my former Future Perfect colleague Dylan Matthews to sign up as a living donor and donate his kidney to a complete stranger. (You can read his story here).

And the value of the donation is not just measured in recipients saved. For the Hoffmans, the knowledge that Emily’s organs helped others offered a solace they had not expected. Emily “gave the gift of life in her death,” Beth told me.

That is the highest ideal organ donation — and DCD – can achieve: a death already coming that still changes the lives of others in need. The case for DCD is clear, but its future depends on its proponents’ ability to protect both patients and public trust.

Clarification, July 1, 6 pm ET: A previous version of this post described how the NRP process intends to stop blood from reaching the brain, but did not acknowledge cases where that does not go according to plan. The post has been updated to include a safety notice from the Organ Procurement & Transplantation Network, which said it had received “verified reports” that blood had unintentionally reached the brain and brainstem during NRP. The post has also been updated to clarify that Dorry Segev and Nader Moazami are doctors at NYU Langone.