When people walk into Keri Piehl’s retro toy store in Albuquerque, N.M., their eyes light up. Wooden spinning tops, Yo-Yos, Trolls, rainbow lava lamps, scratch-and-sniff stickers—it’s like time travel, unlocked.

Some visitors make a beeline for the games and puzzles, eager to relive their glory days. “I sell a ton of jacks to grandparents,” Piehl says. “I always joke that I should have an over-50 league, because every single grandma tells me they were the best at jacks.” Others simply want to settle a score. Grandfathers, in particular, enjoy bringing up old marble-related injustices—like the time so-and-so cheated to win the game. “They’re still salty,” she laughs.

Indulging in this sort of nostalgia offers a host of wellbeing benefits, experts say. But that hasn’t always been clear. The concept has a complicated past: “Nostalgia” was coined in the 1600s by a Swiss medical student to describe homesickness among soldiers serving in European wars—essentially, the pain of longing to return to one’s native land. (“Nostos” translates to “return,” and “algos” means “pain.”) Because these feelings triggered anxiety and even physical ailments, “it was originally thought of as a brain disease,” says Clay Routledge, a psychologist who’s vice president of research and director of the Human Flourishing Lab at Archbridge Institute, a D.C.-based nonprofit research organization. “There were weird ideas like, maybe it’s demonic forces, or maybe it’s the clanging of cowbells causing damage to their inner ear.”

For centuries, scholars and medical professionals continued to assume nostalgia was detrimental. But that understanding has evolved, and more recent research, including studies led by Routledge, suggests that actually, yearning for the past has an upside: It helps us feel more connected to other people—while lowering prejudice toward “out-groups” (people who are, say, a different ethnicity or age) and increasing our ability to offer emotional support. Nostalgia can also help us find meaning in life, build self-esteem, and allow us to focus more on being true to ourselves, rather than getting caught up in extrinsic standards; plus, it can make us happier. Interestingly, it’s as much about building a better future as it is the past, experts say.

“Originally, I said, ‘OK. The best way to think about nostalgia is it’s this psychological defense mechanism—when life is uncertain and unstable, we look to the certainty and comfort of the past, and that makes us feel better,’” notes Routledge, whose book, Past Forward: How Nostalgia Can Help You Live a More Meaningful Life, will be published in December. “And that’s definitely true.” But he’s also discovered something surprising: When people share nostalgic memories, many are future-oriented. For example, someone might say: “When I was a kid, I spent summers with my grandmother; she’s no longer with us, and that makes me sad. But I cherish that time in my life, and it inspires me to create memories with my own family.” “It’s looking backwards,” Routledge says, “but it’s because you want ideas for how to move forward.”

Here, Routledge and other experts share their favorite ways to tap into nostalgia’s benefits.

1. Watch old movies.

Ask John Medina why he’s interested in nostalgia, and he’ll joke that maybe it’s because he’s 67. After age 30 or so, he says with a laugh, everyone starts looking backwards. More seriously, he’s a developmental molecular biologist who’s long been fascinated by nostalgia—and the ways it can buffer brain health by triggering the release of the feel-good hormone dopamine.

In order to reap nostalgia’s benefits, Medina aims to indulge in it for an hour a day, often watching old Disney movies that he and his mom enjoyed together when he was growing up: Fantasia, Pinocchio, Sleeping Beauty. “That’s my happy place,” he says. Follow Medina’s lead and seek out the movies that remind you of a joyful time in your life. Even better, watch them or discuss them with someone else, he recommends.

2. Dine like you did as a kid.

In need of dinner plans? Load up your plate with a cafeteria-style sloppy joe and some Pop Rocks and Pixy Sticks, and pair it with a nice glass of purple Kool-Aid. If anyone asks, call it the Nostalgia Special. “Indulge in your favorite foods from when you were a kid,” Medina echoes, with a permission-granting aside: “Even if they weren’t all that healthy for you.”

Some research shines light on the idea of food nostalgia: One study, for example, found that people seek out comfort food that reminds them of their past when they experience feelings of isolation. Scents, in particular—maybe a roast dinner, or cookies baking in the oven—can evoke nostalgia, while also increasing self-esteem, optimism, and feelings of meaning in life. So eat up—and if you have trouble recreating old staples, enlist the help of a cookbook like Betty Crocker Lost Recipes: Beloved Vintage Recipes for Today’s Kitchen.

3. Create some playlists.

Research suggests that people prefer music that was popular when they were in their teens and 20s to songs from before or after that time in their lives. Spend part of your day listening to whatever gets you grooving—or better yet, Routledge notes, make a playlist of your favorites. That’s an example of “something that requires a little more active creativity,” he says. “You’re not just listening to nostalgic music—you’re intentionally engaging with it.” 

4. Visit your local library.

When Piehl and her husband started dating, they hit the children’s section at the local library and shared their long-ago favorites with each other. (She favored James Mashall’s books, including the George and Martha series. He preferred books by Chris Van Alsburg, especially The Garden of Abdul Gaz.) “It was a really cool, fun way to learn about the other person,” she recalls. These days, her shop sells an array of nostalgia-inducing titles, including Arnold Lobel’s Days With Frog and Toad, Mad Libs, and Choose Your Own Adventure books. For an efficient shot of nostalgia, follow Piehl’s lead and go back to the picture-book basics.

5. Start a collection.

Medina often advises people to start collecting things—the earlier in life, the better. “That way, when it comes time for you to retire, you’ll have a bunch of objects you can fill a room with, and then just go and sit in as if it were a hot tub,” he says. “A hot tub for the mind.”

Objects can uniquely help conjure the past. Plus, collecting is active and social: You might find yourself combing through antique shops or flea markets, and interacting with those you encounter along the way. Brainstorm what you’re interested in—vintage Coke bottles; antique dishes; Barbies; train sets—and have fun embarking on your scavenger hunt.

6. Write your memories down—and share them with friends.

Researchers have found that when people are asked to write about a sentimental event from their past, they feel loved and supported—which helps protect against loneliness. So grab a journal (or maybe a Lisa Frank notebook for good measure), and make it a point to write regularly.

While journaling can be just for you, there’s value in sharing what you write with others, Routledge notes. “You’re the protagonist because they’re your memories, but the story is about people you care about,” he says. “When we can share them with the people we created them with, it’s a way to keep that bond alive and strengthen it.” Even if that’s not possible, he notes, nostalgia is a form of self-disclosure, so sharing your memories with new friends who didn’t experience them can help build those relationships. In other words? There’s nothing wrong, he says, with passing hours yacking about the good old days.

The costume that made Sara Reardon famous isn’t all that easy to identify, at least for a child. Her sons guessed that her beloved outfit, in which she films many of her Instagram videos for over half a million followers, was perhaps a sandwich of some sort. “They were like, ‘Mom, why are you in that hot dog costume all the time?’” She had to explain that, in fact, she was dressed as a vulva.

Acquired for $100 in 2018 to celebrate reaching 10,000 followers on Instagram, the vulva costume has become a signature of Reardon’s Instagram account “The Vagina Whisperer,” and she calls it the “best investment” she’s ever made in her business. Reardon, a physical therapist who specializes in pelvic-floor therapy, started the account in 2017, but her friends had been casually calling her the “vagina whisperer” for years. When they started getting pregnant, giving birth, and encountering common problems like leaking urine, Reardon offered them therapeutic solutions. “Pregnant friends would ask me about perineal massage or what’s the best belly support, and I thought, ‘I’m writing this email over and over again, let me just put it on Instagram,’” she says.

Pelvic-floor therapists focus on the basket of muscles at the base of the pelvis that affects peeing, pooping, menstruation, and sexual health. About one in four American women has a pelvic-floor disorder, according to the National Institutes of Health. Though women can face pelvic-floor issues across their life spans, many patients encounter problems for the first time during pregnancy and after childbirth.

“When you’re pregnant, you sign up for these emails, like, ‘Your baby is as big as a papaya.’ Well, your pelvic floor is basically the hammock stretching to support that papaya as it grows bigger and bigger,” says Reardon, 41. Women can experience complications such as pain during sex, chronic pelvic discomfort, and even pelvic organ prolapse—when a person’s internal organs collapse into her vagina. Those who do seek help often do so when these issues have progressed to an unsustainable level.

“Pregnancy and postpartum is such a huge transformation for our bodies, and we were getting zero education about how to take care of it,” Reardon says. “Every pelvic-floor therapist will tell you, patients come in and ask, ‘Why didn’t anyone tell me this sooner?’” Those conversations require intimacy and trust, something that attracted Reardon to pelvic-floor therapy in the first place.

Read More: Exhaustion, Incontinence and the Messy Reality of Returning to Work After a Baby

Instagram was the most expedient way to reach women before they encountered problems. “I was seeing a lot of women in my clinic who had these mesh surgeries for prolapse and their lives and vaginas were completely destroyed because this mesh situation went totally wrong,” Reardon says. “And I was like, ‘I don’t really want to spend my career doing damage control for people.’ There’s so much we can do to prevent this.” (In 2019, the FDA halted the sale of surgical mesh devices used in transvaginal surgeries to treat pelvic organ prolapse; mesh is still used in abdominal surgeries to treat the condition.)

Reardon has made it her mission to alert women to proactive solutions that they can start implementing even during pregnancy. She rarely uses obscure medical terminology and tries to infuse humor into her posts, whether they involve her squatting over a toilet making exaggeratedly strained faces to demonstrate what not to do or showing off kitschy knitted vulvas she ordered online. She shimmies to the latest viral pop song while explaining how to properly wash a vulva (with just water!). Her Instagram page contains a lot of basic information that can be revelatory: Busy women, she says, often rush and push to pee, unwittingly damaging their pelvic floor.

Most women assume pain and incontinence to be a natural consequence of childbirth, just one of many sacrifices mothers make when they become parents. Others are simply too embarrassed to ask for help. Women’s health is understudied and under-discussed in general, but that’s particularly true when it comes to the most intimate parts of the body.

Dr. Karen Tang, a gynecologist and gynecological surgeon, has built a large Instagram following herself talking about, among other things, chronic pelvic pain. “I actually went through an entire ob-gyn residency and didn’t learn about pelvic-floor physical therapy,” she says. “It’s kind of ridiculous.” Only once, when she was in her fellowship, did a doctor point out to her that pelvic-floor therapy could be a great, noninvasive option for many patients before turning to medication or surgery. Tang, 44, thinks things have changed a lot since she was in medical school, though she still would like to see more awareness. She now does a pelvic-floor check on anyone who comes to her complaining of chronic pain, sexual issues, or incontinence, and refers almost every patient with these concerns to pelvic-floor physical therapy.

Read More: Why There’s So Much Pregnancy Trauma on TV Right Now

The feeling that information is hidden and that patients are on their own to seek it out is widely shared by Reardon’s followers. “Wish this was discussed prior to birth!! I thought something was seriously wrong with me,” one person commented on one of Reardon’s post about peeing after childbirth. On a post about diastasis recti, when the ab muscles separate during pregnancy, a mother who gave birth three times wrote that she had this condition and “found out by coming across your page. I never knew and my doctors never looked for that after I had children.”

Sara Nicolas, a 44-year-old in Tigard, Ore., was only vaguely aware of the concept of her pelvic floor when she discovered “The Vagina Whisperer.” “When I was in my 20s, it was all the rage to just do a ton of kegels to ‘have better sex,’ and it was really eye-opening for me to look at her account and realize pelvic-floor therapists exist and physical therapy is a lot more nuanced than just kegels.” Nicolas does not have children but discovered through Reardon’s content that women who have never given birth can struggle with pelvic-floor problems too. “She is sitting there on a toilet, and it could be a situation where you can’t believe she’s putting this on the Internet, but the visual helps,” she says. “I’m a lot more comfortable talking to my gynecologist about any issues I have now.” Nicolas says her mother, who emigrated from Mexico, did not speak openly about these problems. “She grew up very poor and moved to the States, and in her generation, you just didn’t talk about these issues,” she says.

Reardon believes more women are now pushing back against this societal silence about female pain. “I think my generation of women were brought up with, ‘Here’s a book and a box of tampons. Figure it out,’” she says. “I think a younger generation of women is like, ‘F-ck this. I don’t want to end up in diapers. Help me out here.’”

Interest in exercising the pelvic floor has soared in recent years. Google Trends shows that searches for “pelvic floor therapy” have increased 244% since 2018. Celebrities like Ilana Glazer, Lena Dunham, and Meghan Trainor have brought attention to pelvic health in interviews about their own experiences with the health care system. Emily Oster, the author of hit pregnancy and parenting books like Expecting Better and Cribsheet, has boosted Reardon’s profile by citing her in her newsletter and including her in a conversation with comedian Amy Schumer.

Read More: Emily Oster Still Thinks Data Can Help Ease (Some) Parental Anxiety

Reardon attributes the rise in conversation about the pelvic floor—and the boost in her followers—in part to the pandemic. Clinics shut down. Everything went digital. TikTok blew up in the United States. Pelvic-floor therapists proliferated on the platform: Pelvic-floor therapist Alicia Jeffrey-Thomas has attracted 1 million TikTok followers with the account ThePelvicDanceFloor. U.K.-based physiotherapist Suzanne Vernazza went viral for her “squeeze along” videos, which encouraged her followers to practice kegels to trendy TikTok songs.

“Birth was a scary thing during that time,” says Reardon. “Raising babies in isolation is a hard thing. So I think people really went to Instagram for connection and information and education.” In March 2020, Reardon had 100,000 followers. Today, she has 550,000.

Tang points out that increasingly people are turning to social media to find information about their health that they’re not getting in doctors’ offices or sex-ed classes, a reflection of larger structural problems in the American health care system. She is publishing a book next year called It’s Not Hysteria about the things women are never told about their gynecological health. “You feel uncomfortable talking with friends or family or even a doctor, but you find a funny video and it seems accessible,” she says of Reardon’s content. “If you can do it in a way that is nonjudgmental and entertaining but also so honest, I think that’s what the Vagina Whisperer does so well.”

Investors, seeing the skyrocketing demand, have begun to fund femtech companies, like Bloom and Pelvic Gym, focused on pelvic-floor therapy. The Academy of Pelvic Health Physical Therapy, a nonprofit professional association with 4,032 members, says it’s seen a 21% increase in membership since 2018. Three years ago, a company called Origin launched in-person and online pelvic-floor-therapy. A representative says Origin has since treated more than 30,000 patients in all 50 states through their 20 in-person clinics as well as virtual instruction. (Glazer joined the company as an adviser last year.)

Online therapy has its drawbacks. As with all medical topics, misinformation on pelvic health proliferates on the Internet; as one pelvic-floor therapist posted earlier this year, it helps to look for accounts created by licensed pelvic-floor therapists with degrees in physical therapy rather than those who portray themselves as “trainers” or “coaches.” Tang also argues that physical examinations are needed, at least initially, to make sure patients are exercising their internal muscles correctly—though she believes virtual therapy is better than no therapy at all. These companies say they are attempting to fill a gap in our health care system. Some 40% of U.S. women who give birth do not even attend a postpartum visit with their ob-gyn, according to the American College of Obstetricians and Gynecologists.

“Health care literacy is a huge part of this,” Reardon says. “You don’t even know what you need, and then you don’t know how to get it once you need it.” Congress introduced a bipartisan bill, the Optimizing Postpartum Outcomes Act, last year that could help more women get access to pelvic-floor care after birth through Medicaid. It was revised and reintroduced in April.

In France, by contrast, postnatal pelvic-floor therapy is covered for every new mother. “I question the priorities in America. Our medical system is really based on efficiency,” she says. Doctors focus on making sure mother and baby survive birth, and that the baby is healthy, she says, but there is far less focus on the mother’s well-being once the baby is out. “How can mom be healthy? Some hospitals bring in lactation consultants to help with breastfeeding for the baby. Why not pelvic-floor therapists to help with recovery for mom?”

Read More: The Goddess Myth: Why So Many New Mothers Feel Guilt

These days Reardon spends about 30% of her time in her clinic in New Orleans and the rest making reels for social media and videos for her subscription-based platform, the V-Hive, which includes pre-recorded video courses, virtual consults, and a newsletter and has become three times as lucrative as her physical-therapy practice. For a monthly fee, you can watch Reardon demonstrate exercises and, for her pregnancy series, how to push correctly, minimize tearing, and prevent common problems like diastasis recti. She also partners with companies like Frida Mom promoting their postpartum recovery products on Instagram.

In September, Reardon announced that she is writing a book titled Floored, described on Publishers Marketplace as a “rallying cry for women’s health and a complete guide to pelvic floor care at every age and stage.” She is working on partnering with hospital systems or insurance companies to get her workout videos for pregnancy and postpartum into the hands of women who are expecting or have given birth. And someday she hopes to turn the V-Hive platform into an app with pelvic-floor-therapy information and workouts that proves as popular as—but more useful than—the ones that compare your baby to a fruit.

Reardon has found that while she tries to focus on health and biology, some view the fact that she is talking about women’s body parts as inherently political. While she posted frequently on the importance of bodily autonomy in the lead-up to the Supreme Court overturning Roe v. Wade, she’s done less of that recently. “I do find myself pulling back from commenting on reproductive rights just because people are a—holes,” she says. When online publications write about Reardon or people on social media post pictures of her in her costume, she says the comments can turn “sexist, raunchy, and trollish.” One that’s stuck with her: “The problem isn’t vaginas, it’s what they’re attached to.” “My Instagram followers who chose to follow me are so supportive, but then when I venture outside that platform, I realize sometimes that there’s still this stigma,” she says. She’s begun turning down media opportunities where an interviewer won’t allow her to say “vagina” on air.

But among her devotees, Reardon’s directness is her very appeal. Reardon says it’s critical that we use correct anatomical vocabulary and applies this rule to her own home as well. She tells her 6- and 8-year-old sons, for instance, to use terms like “testicles” instead of “balls.” They know she helps patients with their pelvic floors. They’re permitted to play with the models of the female reproductive system sitting on desks and coffee tables all over her house. Just one thing is off limits: they are not allowed to touch the vulva costume with which their mom built her brand. The company that made it shut down so she’s unable to buy a backup. “It’s very precious,” says Reardon.

For those living in affluent countries, it’s easy to forget about tuberculosis, which seems like a disease of the Victorian era. In the U.S., thanks to investments in public health and TB surveillance infrastructure, less than 600 people died from the disease in 2020. Compared to COVID-19, which caused 350,000 deaths that same year, it’s understandable why it’s not at the top of the U.S. public health agenda.

But if you zoom out and look at global public health, TB gets much more scary. It is the world’s most deadly infectious disease, killing approximately 1.5 million people per year, reclaiming the top spot from COVID-19 in October 2022. Experts warn that while the spread of TB might seem confined to developing countries right now, its unchecked spread could lead to mutations which result in more drug resistant versions of the disease. That’s something that could be highly disruptive to rich countries, too. 

As a result, the world health community is mobilizing, and last week concluded the second-ever United Nations high-level meeting focused on taming the disease. In a major breakthrough, a manufacturer of testing equipment agreed to lower the price of its devices, expanding testing to millions more.

A highly contagious disease

TB is caused when the tuberculosis bacteria spreads in the lungs. Anyone can get the disease, including healthy people, but those who are malnourished, living in crowded living conditions, or are immunocompromised are most susceptible. If untreated, a person with TB will spread the disease to an average of 15 people per year. Most often, patients will first notice that they are sick when they begin experiencing a persistent cough that lasts weeks, sudden weight loss, or a high fever. Without treatment, approximately half of those with TB disease would die within five years.

“TB knows no borders,” says Dr. Lucica Ditiu, Executive Director of Stop TB Partnership, a U.N. hosted organization that aligns global funding agencies, NGOs, and civil society groups working on ending TB. “I keep telling everyone, you can eat healthy, you can be vegan or vegetarian. You can run, you can use a condom, and you can sleep under a bed net. But so long as you breathe, you can still catch TB.”

In the 20th century, multiple new antibiotics were created to cure TB disease but with each case of TB, the bacteria has the chance to continue multiplying in the body of its human host. Sometimes, during the reproduction process, some strains of the bacteria will develop traits that make it resistant to antibiotics. The most recent data suggests that 3.6% of all new tuberculosis cases today are resistant to multiple TB drugs.

Read More: How an Innovative Deal Will Give Millions Access to Cheaper Tuberculosis Drugs

Multidrug-resistant TB has a higher mortality rate, and doctors are often forced to resort to using more toxic drugs with severe side effects to treat the disease. Some have been known to cause total deafness in patients.

Two years ago, a groundbreaking study found that TB, once thought to be spread by coughing, spreads primarily through breathing. Every time an infected person exhales, they propel aerosols containing the bacteria into the air. Crowded indoor spaces, like prisons, are especially fertile breeding grounds for TB, just like COVID. TB is much less contagious than COVID, but the more it mutates, the more chances it has to acquire mutations that make it more contagious.

“There’s no biological reason that multi-drug-resistant TB can’t acquire what it takes to transmit easily,” says David Bishai, the director of the school of public health at the University of Hong Kong. “We know that ancestral TB was extremely contagious through airborne methods. And so this does represent a pandemic threat.”

On Sept. 22, the United Nations held a high-level meeting on TB, where countries reported on the progress achieved so far and revealed their plans for tackling the disease over the next five years. Currently, the international community has set a target for reducing global TB cases by 80% by the year 2030. Prominent TB activists attended the meeting as well, including writer and YouTuber John Green.

Social media pressure

Green, author of The Fault in Our Stars, has launched multiple social media campaigns aimed at getting major companies to reduce their pricing of TB tests and drugs in lower and middle income countries.

“In the 21st century, you can’t say that tuberculosis deaths are even caused by the bacteria Mycobacterium tuberculosis because we know how to kill that bacteria,” said Green. “Death from tuberculosis is caused by human choice. It’s caused by human built systems…It means we’re not doing a good job of assigning equal value to every human life. But it’s also hopeful in the sense that if we are the cause of tuberculosis, we may also be the cure.”

Last week, activists scored a major win when Danaher, a U.S. company which manufactures test cartridges that make TB testing more affordable and accurate, announced it would reduce the price of each cartridge from $9.98 to $7.97. Ditiu of the Stop TB Partnership says that this means that countries around the world will be able to provide an additional 5 million tests. Approximately one in every 13 TB tests administered comes back positive, according to Ditiu.

“Every person can infect up to 15 others per year,” says Ditiu. “If we can find people with TB as early as possible and diagnose them, we can put them on treatment and stop this chain of transmission.”

Ditiu estimates that approximately 300,000 people will be diagnosed earlier thanks to the reduced price of Danaher’s test cartridges. 

Now that it’s fall, it’s time to get updated on your COVID-19 vaccines if you want to stay protected throughout the winter, when infectious diseases flourish. But does it matter which shot you get?

For now, there are only two options—both mRNA-based vaccines, made by Moderna and Pfizer-BioNTech. The U.S. Food and Drug Administration (FDA) is still reviewing data from Novavax, which makes a different type of vaccine based on recombinant viral proteins. Both Moderna’s and Pfizer-BioNTech’s vaccines are approved for people 12 years and older, and have an emergency use authorization for children under 12.

Practically speaking, if you’re eager to get your shot soon, you’ll get an mRNA vaccine, since these are the only ones approved so far. And the sooner you get boosted, the sooner you’ll be protected against getting infected and also from getting really sick, so most health officials will probably advise you not to wait for Novavax’s shot, if and when it is authorized. While the updated mRNA shots target XBB.1.5, a different virus variant than the ones that are circulating now, studies that the manufacturers presented to health officials show that the shots still produce a strong antibody response against the newer variants like EG.5 and BA.2.86.

But if and when Novavax’s vaccine becomes available, does it make sense to switch if you’ve received mostly mRNA shots so far? Does the type of vaccine matter when it comes to how well you’ll be protected, both against infection and against serious disease?

Dr. Kirsten Lyke, professor of medicine at the University of Maryland School of Medicine, who conducted some of the earlier mix-and-match studies on previous combinations of vaccines, says she didn’t see much difference when people who were vaccinated with earlier mRNA vaccines received boosters of earlier Novavax shots. “It doesn’t look like Novavax following mRNA is any better than mRNA-mRNA,” she says. Those data, however, were based on studies that only looked at antibody levels people generated up to six months after a booster shot.

Looking more specifically at how the mRNA and recombinant protein vaccines work, Dr. Otto Yang, professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles, says there may be a difference between the two technologies in how the immune system sees SARS-CoV-2. Vaccines using the mRNA technology contain the genetic code for the virus’ spike protein, and this code instructs certain cells in the human body to make this viral protein and then present it to the immune system. Recombinant protein vaccines, like Novavax’s, skip that step and directly provide the viral protein. In theory, Yang says, that would mean that the levels of viral protein that the immune system initially sees might be higher with Novavax than with mRNA vaccines, since the amount produced by the mRNA vaccines depends on how many immune cells get the code and start producing the protein. But it’s not clear whether those potentially higher levels of protein translate into stronger immune responses in the form of antibodies.

The genetic approach of the mRNA vaccines, however, also has an advantage because it may produce a more robust T cell response. T cells and antibodies make up two of the major parts of an immune response; antibodies are the front-line defenses designed to prevent viruses from infecting cells in the first place, and T cells are then recruited to recognize and destroy infected cells, and provide protection against serious disease. But in order for the body to generate killer T cells, viral proteins need to make their way into a specific part of the immune cell, and mRNA vaccines ensure that happens. “[Viral] proteins have to be in that area of the cell to generate the killer T cell response, which has evolved to deal with problems like infected cells by killing the cells,” says Yang. “Recombinant protein vaccines are not going to access this part of the cell.”

Studies have shown that it’s likely the T cell response, which could be slightly more durable than the antibody response, that may be largely responsible for protecting vaccinated people from severe disease, since antibodies produced by any vaccine tend to wane after a few months. “Antibodies seem to be the upfront gatekeepers, and T cells seem to be the palace guard that clears out invaders once they get in,” says Yang. That may explain why, as new variants emerge, some people who are vaccinated still get infected, but they don’t end up in the hospital or die from their infections as many people did in the early days of the pandemic before vaccines were available.

Another advantage of a stronger T cell response is that T cells can also target parts of the virus that are less exposed to immune system attacks, and therefore, less prone to mutating. Experts believe T cells  may be recognizing the virus’ nucleocapsid protein, which forms the core structure of the virus, and which remains relatively similar among the various variants that have appeared so far.

Novavax says that its original vaccine also produces a good T cell response, because the vaccine is fortified with an adjuvant, or additive, that is designed to rev up the immune response and amplify it. “That adjuvant can induce the types of T cell responses that we think are more important in fighting viruses,” says Bob Walker, chief medical officer for Novavax. He says the company is currently testing its updated vaccine in people to get more specific data on the antibody and T cell responses the shot can produce.

“Personally, I think there is probably not a lot of difference between the [two types of vaccines,” says Lyke. “You get good responses with all of them. That’s why anyone who is vaccinated probably has good protection even this far out from getting severe disease.” Which means that it’s not that important which vaccine you get—but that you get one of the updated shots.

Hospitalizations for COVID-19 have been on the rise since the beginning of July. Then came the identification of the heavily mutated and possibly highly-transmissible BA.2.86 variant by the global surveillance network. Such a variant has the potential to evade our vaccine- and infection-induced antibodies and cause a surge of seasonal hospitalizations. The recommendation by the FDA’s VRBPAC in June that the Fall updated vaccine be composed of an XBB-lineage of the Omicron variant appeared to be at risk. There was mounting concern we be faced with a similar situation from last year where the virus had already mutated well beyond the BA.4/5-bivalent vaccines by the time they were rolled out.

But the landscape of the pandemic—especially the clinical disease caused by SARS-CoV-2—has significantly changed. On the front lines of the emergency department (ED), we are seeing a different virus. This is likely a combination of both high levels of population hybrid immunity and evolution of the virus itself to favor infection of the upper airway and cause less severe disease.

The CDC’s recent decision to universally recommend vaccines for everyone, while falling short of a much-needed targeted recommendation for high-risk groups, paves the way for equity of access and insurance coverage for Americans needing to top up their protection against infection. And recent preliminary studies from multiple labs on BA.2.86 has actually been reassuring.

Read More: Pandemics Don’t End. They Echo.

New hospital admissions had increased nationally by 9% in the first week of September and have been on an upward trajectory since the beginning of July driven by EG.5, FL.1.5.1, and the XBB subvariants. At 16,000 current hospitalizations, this is still far below the Omicron peak of 145,000 hospitalizations that overwhelmed our health care system in January 2022.

Hospitalizations are highest in those patients 70 and older. Compared to earlier in the pandemic when our ED and hospitals were overrun with patients suffering from hypoxia and viral pneumonia requiring various oxygen modalities, proning techniques, and ventilators—elderly patients are lately presenting to my ED with weakness, fatigue, dehydration, and electrolyte abnormalities. Even though these symptoms are caused by covid infection, they are less staff- and resource-intensive compared to years past. Management of such illness is less challenging, and patients are discharged home after a few days.

Immunologically, this is not surprising that older Americans are becoming sick with COVID as head into the fall. It’s been a year or more since many of them last had a COVID-19 infection or a vaccine dose. In fact, only 46.5% of those 75 and older ever received the most recent bivalent booster.

Even though protection against severe disease remains robust, protection against any infection has most certainly waned. For healthy individuals under 65 years, current variants are expressing a predilection for the upper respiratory tract and follow a particular pattern. Symptoms typically start with a sore throat, and progress to headache, rhinorrhea, and nasal congestion.

This tracks with what we observed from Omicron in multiple lab studies since early 2022. Omicron family variants are approximately 10-times less efficient than the Delta variants at replicating in lung tissue and mutations favor preference for upper airway tissue.

A UNIVERSAL RECOMMENDATION

Recently the CDC’s Advisory Committee on Immunizations Practice (ACIP) voted to approve the updated XBB.1.5 monovalent vaccine for everyone 6 months and older. ACIP members were likely convinced mostly by data that a universal recommendation will prevent 400,000 hospitalizations and 40,000 deaths due to COVID-19 infection.

Read More: These Are the Vaccines You Should Get

As this is the first vaccine rollout since the end of the pandemic emergency that is not financed by the federal government, a universal recommendation also paves the way for insurance coverage. For those without insurance, the CDC announced its Bridge Access Program for the 25-30 million Americans without insurance.

Some ACIP members and other front-line physicians like myself would still like to see the CDC more strongly advocate for vaccination in high-risk groups who stand to benefit the most from updated protection. The Joint Committee on Vaccination and Immunisation—the United Kingdom’s version of our ACIP—outlined such a targeted, evidence-based strategy focused on adults 65 and older and those in care homes, frontline health care staff, and those 6 months–64 years with underlying medical problems, such as chronic kidney and lung disease, and those who are immune-compromised, from chemotherapy treatment, for example. The Infectious Diseases Society of America echoed this support for a targeted strategy in its own response to the CDC decision—that certain high-risk groups are at increased risk of severe disease and should be prioritized for vaccination this fall.

Even for healthy individuals under 65, the XBB.1.5 monovalent updated vaccine is a good match for currently circulating variants and enables a top up of protection against any infection. While on the decline, the XBB family subvariants still comprises a large percentage of new infections. In addition, the widespread EG.5 variant is different from XBB.1.5 by just two new mutations, at F456L and Q52H; suggesting the updated vaccine will work well against it. And a switch back to a monovalent formulation ensures that those vaccinated receive a full undiluted dose against the most prevalent variants.

ACIP members were also likely reassured by recent preliminary pseudovirus and sera neutralization studies from four laboratories—two in the U.S. and in Sweden and China—demonstrating that BA.2.86 is likely 1) not more immune evasive than previous variants and 2) not very efficient at infecting our cells.

Most importantly, the sera of those previously infected with XBB was able to generate a significant response against BA.2.86 portending that the updated XBB-targeted vaccine will maintain its protection if BA.2.86 takes hold as the fall and winter unfolds. In the only human clinical trials to date, Moderna announced its XBB.1.5 vaccine generated an 8.7-11-fold increase in neutralizing antibodies against BA.2.86, EG.5 and FL.1.5.1 variants.

Before COVID-19, figuring out whether a sore throat, fever, and runny nose were caused by a cold, flu, or strep wasn’t a top priority. You either powered through, knowing you’d be miserable for a few days but would probably feel better soon or you visited the doctor’s office, urgent care, or emergency room where you might get a test to figure out which virus or bacteria was behind your misery, and maybe a prescription to treat it. But even doctors often don’t order tests, preferring instead to make diagnoses based on symptoms.

During the pandemic, however, it became more critical to know who was infected with SARS-CoV-2 so those people could isolate and not spread the virus. At-home test kits became household products, and most people are by now adept at squeezing out a few drops of solution onto a card, sticking a swab up their nose, swirling the swab in the testing liquid, and waiting for a result.

Tests for COVID-19

A number of companies, offer at-home test kits for COVID-19 that people can buy without a prescription. Most of these are rapid antigen tests, which pick up antigens, or substances that the SARS-CoV-2 virus makes. While they are relatively accurate, because it takes some time for levels of these antigens to build up after an infection, these tests are less reliable in the day or so immediately after exposure to the virus. That’s why doctors recommend repeating the test a couple of days apart.

Then there are PCR, or molecular, tests, that are closer to the gold standard used in laboratories, and rely on finding the smallest genetic signatures of the virus and amplifying them. Cue Health sells a palm-sized COVID-19 PCR device that people can purchase for $300 that allows for 10 at-home tests and doesn’t require a prescription. The device reads a saliva sample and provides results to a smartphone app in 20 minutes.

Other testing companies, such as Labcorp and Everlywell, also sell PCR-based tests for COVID-19, but they are technically collection kits, which means that you have to send a saliva sample into a lab to get results, which can mean critical days will pass before you get results.

Tests for seasonal flu

There is only one at-home test authorized by the FDA for influenza: Lucira, now owned by Pfizer, makes a combined flu and COVID-19 molecular test. The kit uses a PCR-related method of amplifying and reading any viral genes in a sample, providing a result in about 30 minutes. In coming months, eMed, a digital health company that sells test kits and telehealth services, plans to offer that kit, as well another that is currently being reviewed by the U.S. Food and Drug Administration. (The combined kit currently available on eMed’s website only tests for COVID-19 and provides a survey to help telemedicine professionals determine if a user likely has the flu.)

Tests for RSV

There currently aren’t at-home tests for RSV, because typically only infants and the elderly are at risk for severe illness. Doctors’ offices, hospitals, and urgent care centers can perform RSV tests that provide results in about 30 minutes.

The advantages of at-home testing

The currently cumbersome journey from symptoms to treatment rests on people making appointments with their doctors or at an urgent care center and could be contributing to the spread of viruses. Self-testing could reduce some of that risk since people are most infectious while they are waiting to get tested and receive treatment. Ideally, if someone tests themselves at home and finds they are positive for influenza or COVID-19, for example, they don’t necessarily have to physically visit their doctor or go into an urgent care or emergency room, where they could spread the virus to others. Instead, they could video conference with a doctor who could assess their symptoms and at-home test results, then write a prescription for, say, oseltamivir if it’s the flu, or Paxlovid if it’s COVID-19. “If you’re trying to minimize morbidity and mortality, and cut down on transmission, then [at-home] testing is an incredible tool to have,” says Thomas Denny, chief operating officer of the Duke University Human Vaccine Institute.

Read more: What It Will Take to Avoid a Tripledemic This Winter

In addition to the altruistic public health reasons to test yourself, there are more selfish ones. Knowing what infection you have means you can get the right treatment, and hopefully avoid prolonged and serious illness. And for the first time, there are effective ways to manage all three major respiratory illnesses that dominate the winter: flu, COVID-19, and respiratory syncytial virus (RSV). Self-testing kits are especially useful for influenza and COVID-19, since antiviral treatments for both are most effective when people taken them within the first few days after their symptoms appear. (And while there aren’t treatments for RSV, new vaccines and antibody treatments can help to prevent infections and potentially serious complications in the most vulnerable.) Waiting to make an appointment to get tested at a health facility means many people could miss this small treatment window. “A lot of people are happy with the status quo, and don’t see a need for self-testing,” says Dr. Michael Mina, chief science officer at eMed.

And the availability of COVID-19 kits has set new expectations for at-home testing, leading both the public and health professionals to ask why more people can’t test for other illnesses themselves. In many cases, “we don’t need people to come into doctors’ offices,” says Dr. Howard Heller, an infectious disease specialist at Massachusetts General Hospital and Harvard Medical School. “The home testing space is evolving and snowballing.”

During the pandemic, the Biden Administration launched the Test to Treat program, which streamlined the process of getting a prescription from a doctor by making it possible for people to test themselves and then go to their local pharmacy where the pharmacist could write a prescription for COVID-19 antiviral medications if they were positive The availability of more self-tests means moving that entire process into the home, which would make testing and treating respiratory diseases more convenient and streamlined, which in turn could reduce their spread.

eMed is working with the National Institutes of Health to study what impact having more at-home tests will have in controlling spread of disease. The team is tracking the average time it takes for people who test positive using eMed’s at-home kits—combined with a telehealth visit on eMed’s platform—to get treatments compared to people who make appointments with their doctor or visit a pharmacy. NIH is funding the test kits and telehealth visits for 80,000 to 100,000 people who enroll in the study through June 2024.

Mina argues that wider testing, driven by at-home kits and telehealth, could lead more people to reach out to their health care professionals for the proper treatment, which in turn could keep spread of infectious diseases down, and lower hospital costs for those who develop complications. “A $25 home testing kit and telemedicine visit could avoid what could turn into an $8,000 hospital visit,” says Mina.

The negatives of at-home testing

There is a downside to more DIY testing, however. The results are essentially invisible to public health authorities, so they don’t have a clear picture of how many people are getting sick, and where. If at-home testing, especially for infectious diseases, continues to grow, then public health officials will have to look beyond lab-based results for alternative ways to track the ebb and flow of cases, such as relying on anonymous sampling of wastewater from communities.

The future of at-home testing

Researchers are continuing to work on improving the accuracy, convenience, and price of at-home tools to test for infections. They are developing cheaper versions of rapid antigen tests that utilize paper strips (similar those used for urinary tract infection tests) that could bring the price of these tests down from over $20 to a few dollars. These, and other rapid antigen tests, will continue to be useful for people who don’t have symptoms but want quick answers to whether they can safely visit loved ones in the hospital without putting them at risk—or, if they have symptoms, whether they should go to work or school if they aren’t feeling well. “If your kids are sick and you want to test them before sending them to school and causing a flu outbreak, you don’t need perfect tests when you’re trying to be a good citizen,” says Mina. “Rapid antigen tests that are 80% or more sensitive are amazingly important for public health.”

Read more: What to Know About the New COVID-19 Vaccine Booster

PCR-quality tests are also becoming cheaper and more effective. The FDA recently issued an emergency use authorization for a test made by Aptitude, called Metrix, that mimics PCR by relying on electrochemical signals from saliva or nasal swab samples that can pick up viral genes in about 30 minutes. The reader device, which can be reused, costs $75 and a single-use saliva test kit for COVID-19 is $48. Researchers are working on cheaper versions of these molecular tests, and some may eventually be read through devices that attach to smartphones.

“The biggest challenge continues to be price,” says Dr. Carlos del Rio, president of the board of directors of the Infectious Diseases Society of America and professor of medicine at Emory University. “We need to hopefully see the price come down like they have for some cell phones and computers.” Even the lowest-priced option, the rapid antigen tests, are currently in the range of $25 per test—which can add up, especially when families need to buy several kits to test everyone multiple times in a household.

Eventually, even PCR-based devices may become small, convenient, and cheap enough for people to have at home. Such diagnostic testing may follow the example of pregnancy testing, which for decades could only be done at a doctor’s office with blood and urine samples and can now be done at home with an inexpensive urine stick. “I truly believe that within five years we will have little molecular devices in our homes that can test for a panel of five things,” says Dr. Luis Ostrosky, chief of infectious diseases at UTHealth Houston and Memorial Hermann. “We’re living in a revolution in diagnostics.”

Over the coming months, more than 100,000 Americans will likely die, mostly unnecessarily, from respiratory infections. Yes, that is the reality we are now facing this fall and winter—and likely every fall and winter for the foreseeable future. Unless we act. Between flu, COVID-19, and RSV, we are likely looking at a very large number of Americans getting sick, ending up in the hospital, and dying. Most of these Americans will be our most vulnerable: older Americans, the youngest children, and those with chronic diseases. And that number of 100,000 may be an underestimate, given that many of these infections go undetected and can substantially increase the risk of heart attacks or strokes weeks later.

It doesn’t have to be this way. We can prevent another “tripledemic” and more—we can stop respiratory infections from harming and killing so many people.

For the first time, this fall and winter, we have highly effective, safe vaccines available to protect Americans against all three major causes of serious respiratory infections. In addition to flu shots, which should work well this year (their efficacy can vary from year to year), we now have effective RSV vaccines for people 60 years of age or older. Substantial data now show that the updated COVID-19 vaccine is effective against the latest variants.

But as the pandemic has shown many times, having tools—like vaccines and treatments—to save lives is just the beginning. We now need to provide broad and easy access to these shots for every American. Along the way, we need to rebuild trust in vaccines.

The work starts with acknowledging that for many Americans, vaccines are not a top priority amidst other pressing economic, health and safety challenges right now. To reach them in the coming weeks, we need to continue the progress we made during the pandemic in meeting people where they already are, be that at the barber shop, the fall festival or the community kitchen.   

We also need to counter the mis- and disinformation that has permeated the information landscape, bad information that discourages Americans from protecting themselves and their families through vaccinations. Around the nation, many public health communicators are trying new approaches to do just that. We know that billions of people around the world and in our country got safely vaccinated against COVID-19, and that helped end the emergency phase of the pandemic. These vaccines are safe. And they work.

Read More: Pandemics Don’t End. They Echo.

Finally, we need to help people navigate when is a good time to get the vaccine, based on their risk profile. That’s because the vaccine guidance is different for people at lower risk—younger people who are not immunocompromised without other severe medical conditions—than for those at higher risk.

People under the age of 60 who do not have an immunocompromising or other severe medical condition are, relatively speaking, at lower risk of complications from respiratory illness. They should get their annual flu and COVID shots because they will have milder infections if they are vaccinated and they are less likely to spread it to others if they get infected. They can get the shots as soon as it is convenient to do so. Getting these vaccines early in the season should provide a good degree of protection throughout the fall and winter.

For more vulnerable Americans—and there are around 100 million adults in the U.S. who are considered at higher risk—the situation is a bit different. Our strategies to protect older Americans, those with substantial chronic illnesses, and the very youngest children, need to consider three sets of factors: When do flu, COVID and RSV infections rise? When does protection from vaccines begin to wane? And when will vaccines be widely available to the people who need them the most? For high-risk Americans, timing may matter.

Over the last three winters, we have seen COVID peak in late December to mid-January. Flu generally peaks later. And RSV can be quite variable but is often earlier. For older and other vulnerable Americans, the protection from vaccines against infection and even serious illness can begin to wane within months of vaccination. This is largely due to an immune response to the vaccine that is less robust than it is for younger people.

High-risk Americans who get vaccinated in September, when flu shots are first made available, may experience some waning immunity by the time flu peaks, which typically happens between late January and early March. Given that there is no recommendation for a 2nd flu shot late in the season, it may make sense to wait on taking the flu shot until a little later. One could make the same case for COVID shots.

Given that RSV can come early, it may be reasonable to get RSV vaccines now and flu and COVID shots later in October. But getting all three shots together sometime during October, not later than Halloween, is also a reasonable option. And to be sure: the administration of multiple vaccines at one time has been extensively studied and the evidence shows that it is both safe and as effective as getting shots spaced out over time.

Around the nation, pharmacies, workplaces, and community clinics have started fall flu and COVID vaccinations. People can get both in one visit. Pharmacies, state and local health departments and the agencies and institutions that care for older Americans should work with community partners on intensive outreach in the upcoming weeks, standing up accessible clinics with convenient hours that offer all three vaccinations. Family caregivers should mark their calendars and schedule appointments.

For years, we tolerated tens of thousands of our vulnerable citizens dying each year from the flu and RSV. With the arrival of COVID, the number of Americans dying of respiratory infections has increased substantially. We can save many of these lives. All Americans are better off getting both the flu and COVID vaccines. But all of us also have an obligation to ensure that the nearly 1 in 3 Americans who are most vulnerable get these life-saving vaccines. If we do, we can break the deadly cycle of respiratory viruses and save lives, particularly those of the oldest and youngest among us.

Among the many lasting legacies of COVID-19 may be a newfound appreciation for the value of what we flush down the toilet and wash down the drain.

Wastewater can be a rich source of information about infectious diseases, like COVID-19, as well as flu, respiratory syncytial virus (RSV), mpox and polio, since pathogens like viruses are shed in feces, urine and saliva, all of which is drained into sewage treatment plants. Sampling that water is a good way to screen for certain viruses, and, as more people bypass the medical system and labs in favor of testing themselves at home for things like COVID-19, health agencies like the U.S. Centers for Disease Control and Prevention (CDC) have less data from which they can monitor the ebb and flow of infections. Wastewater, however, could change that and is quickly becoming the most reliable way to track such diseases.

Now that same system will not only screen for infectious disease agents but for opioids as well. Biobot, the first company to offer commercial wastewater surveillance, is launching a program in collaboration with the National Institutes of Health’s National Institute on Drug Abuse (NIDA) to track trends in opioid use in wastewater. In 2018, Biobot, based in Cambridge, Mass., began tracking opioids such as morphine, hydrocodone, oxycodone, codeine, heroin and fentanyl in a pilot program with several dozen cities including Cary, N.C. By highlighting areas where use of these drugs was higher, the city directed more resources to educating people about the dangers of overdose, as well as intervene with naloxone to reverse overdoses, which helped to reduce overdoses by 40% within a year.

Tracking opioids nationwide

The new NIDA-supported program, which is the first of its kind to regularly monitor opioid use in municipalities, will include 70 locations around the country, focusing on regions with high opioid overdoses. The scientists will screen for five substances, including cocaine, fentanyl, methamphetamine, and xylazine, as well as the overdose treatment naloxone.

“The idea is that these data will be shared not just to federal agencies but to local health departments to help them develop their own programming to address over doses,” says Mariana Matus, co-founder of Biobot. Having that information in as close to real-time as possible is important for making sure adequate resources such as treatment programs are in place, says Matus. “When we first founded the company in 2017, this type of information was very delayed,” she says. “We measured the consumption of prescription and street substances through wastewater, and that real-time information can be useful to public health officials to reduce overdoses.” Communities that see increasing trends in the presence of opioids in their wastewater, for example, can launch more harm reduction efforts such as education, treatment and intervention programs.

Read More: These Scientists are Sewer Diving to Detect Silent COVID-19 Outbreaks

Matt Meyer, county executive for New Castle, Del., hopes that’s the case for his county. In addition to opioids, Biobot will be screening for, among other things, tobacco to better direct smoking cessation and tobacco-free kids education efforts to parts of the county where use might be higher. Otherwise, he says, “my instinct would be to distribute resources equally to all schools for tobacco prevention to try to get kids not to smoke and vape. But if the sewer data is telling us where there is higher prevalence of tobacco, that would probably encourage us to spend more in certain school neighborhoods than in others. The same is true of cocaine and methamphetamine since sewage gives us unbiased data.” New Castle, for example, has a police behavioral unit that addresses substance-use complaints, and information about where use might be higher could redirect these teams to those regions.

Screening for pathogens and drugs

Everything starts with collecting the sample at the sewage treatment plant, with a kit Biobot provides. Once the sample arrives at the company’s labs, the process of scanning for opioids differs slightly from that behind screening for infectious disease agents. For viruses, the team uses gene-based detection methods to find and then amplify genetic signals of pathogens like SARS-CoV-2, influenza or mpox. In the case of opioids, which are chemical substances, they rely on mass spectroscopy, which breaks down compounds by their main ingredients and produces unique chemical fingerprints of things like fentanyl.

In the first phase of the program, the data will be fed back to local public health officials to better allocate resources for fighting the opioid epidemic—specifically addressing overdoses. Ultimately, however, Matus says wastewater surveillance for opioids could be used to detect changes in the substances and alert authorities if more dangerous and potentially deadly versions are beginning to make the rounds.

Public health officials are just beginning to tap into the power of wastewater surveillance, says Matus. During its partnership with the CDC on COVID-19 tracking, Biobot provided about 30% of the national data on COVID-19 cases from wastewater, and the information was useful enough for the agency to renew its wastewater surveillance efforts. The CDC has asked for submissions for a commercial partner and Matus hopes Biobot will be able to renew its collaboration with the CDC, and continue to provide data to the agency.

“Wastewater surveillance is becoming more mature and more mainstream month over month, year over year,” she says.

After the pandemic shut down Duke University’s campus in 2020, public-policy professor Nick Carnes worried about how his students would fare both educationally and emotionally. Wanting to help in whatever way he could, he added a simple message to his email signature.

“A note to students,” he wrote. “Please let me or another Duke professor know if you’re having any problems with your safety, well-being, or access to educational or other resources, or if you need to talk about anything right now, and/or if you know of another student who is having trouble. When in doubt, please reach out.”

Three years later, with campus back to pre-pandemic normal, Carnes hasn’t found a reason to delete the message. “A lot of students will probably roll their eyes,” he says. “But you want them to have so internalized your availability to help with a crisis that they find it sort of corny and laughable when you remind them of that.”

Not so long ago, it might not have been obvious that a public-policy professor would be willing to talk through his student’s stressors and struggles. But these days, with teenagers and young adults reporting mental-health issues in record numbers, Carnes is part of a growing trend.

Colleges have long offered on-campus health and counseling centers, but demand for mental-health support is surging such that many schools can’t meet it through traditional means. Rather than solely recruiting more therapists—a costly and difficult proposition, given that the U.S. behavioral-health field is short thousands of needed clinicians—colleges and universities across the U.S. are leaning on faculty, staff, and even students to help bridge the gap.

“The mental-health crisis is significantly increasing the demand for services and we have fewer people coming into the profession and a lot of people leaving the profession,” says Sarah Reives-Houston, who runs a behavioral-health program at the University of North Carolina at Chapel Hill (UNC). Expanding the availability of community support is a faster and more feasible—not to mention more affordable—approach than training up a new generation of therapists, and one that could ultimately be more effective, Reives-Houston says, because it “broadens the net.”

Training faculty, staff and students

UNC has so far coached more than 900 faculty, staff, and students in Mental Health First Aid, a research-backed program that teaches people to identify and respond to signs of mental distress in others. Participation is mostly voluntary and, perhaps unsurprisingly, Reives-Houston says demand has been highest among faculty and staff specializing in “helping professions,” such as nursing and social work. In the future, she says, the school plans to focus its recruitment in departments like business and the sciences to reach more people.

The need is clear. In a survey taken by about 7,000 U.S. college students during the 2022-2023 academic year, 41% reported recent symptoms of depression, 36% said they’d recently felt anxiety, and 14% said they’d considered suicide in the past year. Another survey from a few years prior found that 60% of students had experienced “overwhelming” anxiety and half said they’d been so depressed it was difficult to function.

Carnes, the Duke professor, admits it can be daunting to help when students reach out to talk. “I’m not a psychologist. I’m not a therapist,” he says. “There’s always a fear in my mind, ‘What if a student asks me a question I don’t know how to answer?’ But I had to get over that fear, because when students do ask things I can’t answer, I can still refer them to people who can.”

The responsibility to ensure students “not only do their best, but feel their best” can’t stop at the campus counseling center, says Sian Beilock, a cognitive scientist who recently became president of Dartmouth. During their college years, young adults are “acquiring the skills and habits that will be with [them] forever,” Beilock says. “It’s such an important time to make sure that students are equipped with the tools to help themselves.”

To that end, when Beilock took the reins at Dartmouth earlier this year, she debuted a campus well-being plan that includes training on Mental Health First Aid and suicide prevention for many faculty and staff; the creation of a new chief health and wellness officer position; and a policy that allows students to take time away from academics to tend to their mental or physical health without losing campus access and while receiving financial assistance for health insurance, if necessary.

Starting as early as elementary education, schools often act as a “de facto mental health hub,” for students, says Dr. Asha Patton-Smith, a child and adolescent psychiatrist with Kaiser Permanente in Virginia. Students go to school almost every day—or, in the case of many college students, live there 24/7. It can be easier to deliver care in this familiar and accessible environment, rather than leaving young people to navigate the traditional mental health system, with its high price tags, long waits, and inadequate supply of clinicians.

Read More: Why College Is a Risky Time For Students’ Mental Health

Studies show this approach works at various levels of schooling. Among adolescents, school-based health programs can improve well-being and reduce suicidal ideation, drug use, and risky sexual behavior, according to the U.S. Centers for Disease Control and Prevention. On college campuses, meanwhile, there’s evidence to support programs that teach coping skills and mindfulness, as well as regular screenings for mental-health issues, according to a report from the American Council on Education (ACE).

But the ACE report also notes that programs meant to train non-professionals in mental-health support aren’t universally shown to be effective in studies. After training, participants typically report more knowledge about mental health and more confidence about the idea of intervening if someone is in need—but that doesn’t always translate to actually intervening, nor does it mean the person who is struggling goes on to receive formal care. “We are not recommending the complete abandonment” of these programs, the authors write in the ACE report, but they shouldn’t be a campus’ only solution.

Peer support is one approach that can augment these programs—and one in use at schools like Washington University in St. Louis, which operates Uncle Joe’s Peer Counseling and Resource Center, a hotline through which students can talk with trained peer counselors 24/7. In-person office hours are also available from the college-student-friendly hours of 10 p.m. to 1 a.m., and the programs’ volunteers can connect students with other resources on campus or in the community if necessary.

Receiving help from peers

“Unlike traditional counseling where you might have a counselor who’s 20 or 30 years older than you, we’re at a similar spot in life,” says Mallory Leff, a senior who co-directs the program. “Being able to talk to someone who seems closer to a friend than an adult is an easier step for people to take.”

Bringing peers together is the cornerstone of nonprofit Radical Hope’s program, too. The group trains students at dozens of colleges across the country—including New York University, Northeastern University, and Delaware State University—to lead a free four-week curriculum designed to help their peers learn self-care, social-connection, and coping skills. The idea, says CEO Liz Feld, is to help students improve well-being and build resilience before they reach a crisis point.

“A lot of the issues that they’re dealing with are not issues that should ever rise to the level of needing clinical help,” Feld says. “What they really need is to talk to people who’ve had similar experiences, who share their thoughts and fears and anxieties and excitement about this chapter in their lives.”

That rings true for Delaney Dardet, who co-directs Uncle Joe’s with Leff in St. Louis. “We can’t have the same experiences as someone else,” she says. “But just to know that there’s another voice and ear on campus that you can talk to” can make all the difference.

WASHINGTON — The Biden administration announced Wednesday that it is providing $600 million in funding to produce new at-home COVID-19 tests and is restarting a website allowing Americans to again order up to four free tests per household — aiming to prevent possible shortages during a rise in coronavirus cases that has typically come during colder months.

The Department of Health and Human Services says orders can be placed at COVIDTests.gov starting Sept. 25, and that no-cost tests will be delivered for free by the United States Postal Service.

Twelve manufacturers that employ hundreds of people in seven states have been awarded funding and will produce 200 million over-the-counter tests to replenish federal stockpiles for government use, in addition to producing enough tests to meet demand for tests ordered online, the department said. Federal officials said that will help guard against supply chain issues that sparked some shortages of at-home COVID tests made overseas during past surges in coronavirus cases.

Dawn O’Connell, assistant secretary for preparedness and response at HHS, said the website will remain functional to receive orders through the holidays and “we reserve the right to keep it open even longer if we’re starting to see an increase in cases.”

“If there is a demand for these tests, we want to make sure that they’re made available to the American people for free in this way,” O’Connell said. “But, at this point, our focus is getting through the holidays and making sure folks can take a test if they’re going to see Grandma for Thanksgiving.”

The tests are designed to detect COVID variants currently circulating, and are intended for use by the end of the year. But they will include instructions on how to verify extended expiration dates, the department said.

The initiative follows four previous rounds where federal officials and the U.S. Postal Service provided more than 755 million tests for free to homes nationwide.

It is also meant to complement ongoing federal efforts to provide free COVID tests to long-term care facilities, schools, low-income senior housing, uninsured individuals and underserved communities which are already distributing 4 million per week and have distributed 500 million tests to date, the department said.

O’Connell said manufacturers would be able to spread out the 200 million tests they will produce for federal use over 18 months. That means that, as demand for home tests rises via the website or at U.S. retailers when COVID cases increase around the country, producers can focus on meeting those orders — but that they will then have an additional outlet for the tests they produce during period when demand declines.

“We’ve seen every winter, as people move indoors into heated spaces, away from the outside that, over each of the seasons that COVID’s been a concern, that we have seen cases go up,” O’Connell said.

She added that also “there’s always an opportunity or chance for another variant to come” but “we’re not anticipating that.”

“That’s not why we’re doing this,” O’Connell said. “We’re doing this for the fall and winter season ahead and the potential for an increase in cases as a result.”

HHS Secretary Xavier Becerra said that the “Biden-Harris Administration, in partnership with domestic manufacturers, has made great strides in addressing vulnerabilities in the U.S. supply chain by reducing our reliance on overseas manufacturing.”

“These critical investments will strengthen our nation’s production levels of domestic at-home COVID-19 rapid tests and help mitigate the spread of the virus,” Becerra said in a statement.

We are in the midst of a new psychedelic renaissance. Drugs like MDMA and psilocybin are being ushered into mainstream medicine, promoted as miracle cures for a host of psychiatric woes. But as psychedelics come to be seen as treatments for various types of psychological suffering, we are overlooking one of their most precious offerings: the potential for play.

“Neuroplasticity” is the word many mental health professionals are now using to describe the positive effect of psychedelics; a process in which the brain sort of loosens up, becoming flexible and open to learning (Children’s brains, for instance, are highly plastic.) Plasticity is why researchers believe psychedelics show promise in helping individuals who are suffering from psychological complaints related to obsessiveness, ruminations, and habits—what professionals diagnose as “depression,” “anxiety,” and “addiction.” And it’s one reason psychedelics help people in general, moving them from a sense of repetitiveness in their lives to a more expansive, awakened encounter with the world.

Neuroplasticity primarily focuses on cognition, emphasizing the role of thinking. But that’s where the idea of a more flexible brain misses the most interesting and most human element in psychedelics: Experience, not just thinking, has always been the central way psychonauts talk about the effects of these medicines, especially in regard to mystical experiences: When we “open the doors of perception,” we’re not just thinking differently, we’re experiencing differently; encountering the world in a new or altered way through our thoughts, yes, but just as importantly, through our feelings, perceptions, intuition and gut instincts.

Read More: Psychedelics May Be Part of U.S. Medicine Sooner Than You Think

In our increasingly data-driven society, where the measurable and visible aspects of life often receive higher validation and credibility, the significance of subjective experience—the sentient (experiencing) “you” that interacts with the world—is diminishing. That’s a problem, since you really can’t describe a soul or a self without starting with the idea that they are, at base, sites of experience. Things get soulless fast when we define people as merely thinkers.

In this sense, it is no coincidence that prominent researchers are studying the transformative effects of psychedelics consider mystical experiences as the core therapeutic component of these substances. Neuroplasticity fails to encapsulate this crucial aspect in any shape or form. On the other hand, play, its more profound, engaging, and spiritual cousin, does.

Play has been given too “fun” a rap in our culture. For children and adults alike, play can obviously involve fun and amusement. But play is so much more than that, and is very serious business.

To understand what I mean by play, imagine a lump of clay in your hand. It exists independently of you. Yet here you are, able to mold it. That’s the first thing to understand about play: It’s the act of taking something into your hands or mind and experiencing it as pliable.

Play is most awesome and even magical in its ability to make us see possibility and malleability in things that, unlike wet clay, appear completely inert. Think about a child playing with their toys. These toys are manufactured by others, and thus exist in an external world to the child, and they can be as solid as a wood block. Yet the child playing with them experiences their toys as if they are as compliant, as ready for possibility, as wet mud in their hands. When we adults play with ideas, we’re doing something very similar, looking at all angles of some theory or concept that may seem like settled law. That’s what places this mindset at the center of psychological change, which depends on our ability to take a more flexible and innovative approach to old narratives about ourselves, and to see possibility in revisions to those stories that often motivate us to alter our lives and change our relationship to our suffering.

In many ways, proponents of psychedelic-induced plasticity seek precisely this quality—a departure from habitual thoughts and behaviors through a more flexible worldview. However, they fall short by limiting their focus to thinking.

Back to the clay: you shape it, forming something entirely unique. Whatever you make from it, this clay will become a creation: something from you that exists independently of you.

That’s the next thing to understand about play: Through it, the invisible landscapes of our inner lives merge with the visible world we all perceive in our own unique ways. When we play, we always play with someone or something: it’s always a relationship, an encounter between the “me” of our original, creative impulses and a “not-me” of a world that goes on without us, as the great psychoanalyst D.W. Winnicott called it in his seminal 1971 book Playing and Reality. Play thus acts as an antidote to the isolation and disconnection inherent in psychological suffering—it is inherently collaborative and connective.

Read More: What MDMA Taught Me About Human Connection

Think, for a moment, about listening to your favorite song. While you may have had nothing to do with the creation of this cherished gift from the land that is not-you, what you gain from listening to it is tremendously dependent on your own unique being: You chose the song, the song means something to you, it reflects your particular taste in music and it might be your favorite because it resonates so powerfully with your own memories and experiences. In fact, it’s nothing to you without your “me.”  It’s also nothing if it were never written or played by the “not-me” of musicians. The whole event is a collaboration between the ineffable space of your unique soul and a world made by others; and the end result is a one-of-a-kind encounter.    

Winnicott called the in-betweenness generated in play transitional meaning a sort of experiential space and a particular state of mind you enter when you play, created between (a subjective) you and the (objective) world. Not unlike a psychedelic trip in this way, with its sense of interconnectedness, a loss of a solid ego state, and a deep feeling of being related to everything. “The sensation that the partition between ‘here’ and ‘there’ has become very thin is constantly with me,” wrote Bill W., the founder of AA, about his psychedelic journey, capturing well the “here” of “me,” and the “there” of “not me,” and a thinning of the barrier between the two.

When you’re in this transitional space, you experience what Winnicott called “going-on-being”: a sense of life coursing through you, your soul stirring, and a self emerging alive here on earth. “It is in playing and only in playing,” wrote Winnicott. “that the individual child or adult is able to be creative and to use the whole personality, and it is only in being creative that the individual discovers the self.” So here’s another important aspect of play: it conjures you to life.

Play also evokes our perception of life within other living beings. As you mold the clay, you perceive it as imbued with vitality. If that sounds a little far out, recall the child playing with her toys: an intrinsic element of her play is her summoning of life to those toys, seeing them as animated.

This, too, is a central element of the psychedelic experience—the recognition that the world around us is alive, vivid, animated, its vitality extending beyond our individual existence. Remarkable, when you think about it—how play performs two really important tasks that are both central elements of religion (especially early religions) and central themes in psychedelic experiences: stirring souls to a feeling of greater aliveness and animating the world around us.

None of us always vibrantly experiences the relationship between the outer world and our inner life. We sometimes feel lonely, isolated, dislocated and empty inside. These feelings (and lack of feelings) come up when we’ve not been able to enter into a playful mindset.  Play is always about being in relationship, since play is always an act of playing with something else, whether that be other people and beings, toys, ideas, imagination, words, tools, instruments.

Through play, we also encounter the vitality within the space between ourselves and the external world. While the idea that this middle space has a life of its own seems a little mystical, I’ll bet you know the experience of an “us” that has its own spirit and character. Think of a great night out with friends. Do you think back on one friend making that night great, or do you think about the group, and a sort of unique spirit to that group?  If you chose the latter, that is what I’m writing about: a sense of an unseen party to your party, the unique space you formed by relating.

Because we live in ecologies, life is something that flows between us. Play gives us access to this living middle element since it’s an inherently collaborative and relational activity.  As do psychedelic experiences, by the way.

Psychedelics are not magic bullets, but they do hold great magic. In the religious realm, they are the substances people have been taking for centuries as a way to reach the divine, and the encounters people experience today with deities can’t be swept under the rug as mere drug-induced states. Psychedelics also offer access to deep secular magic: a conjuring of life in one’s being and in others, an alertness to the strange and beautiful novelty of the world around us, an experiencing of one’s connection to this world, and the ability to take what seems solid within us and mold it like clay.

In other words, to do the thing we are already equipped to do, since it is the most human thing to do: play. 

In a neat little neighborhood in Venice, Calif., there’s a block of squat, similar homes, filled with mortals spending their finite days on the planet eating pizza with friends, blowing out candles on birthday cakes, and binging late-night television. Halfway down the street, there’s a cavernous black modern box. This is where Bryan Johnson is working on what he calls “the most significant revolution in the history of Homo sapiens.” 

Johnson, 46, is a centimillionaire tech entrepreneur who has spent most of the last three years in pursuit of a singular goal: don’t die. During that time, he’s spent more than $4 million developing a life-extension system called Blueprint, in which he outsources every decision involving his body to a team of doctors, who use data to develop a strict health regimen to reduce what Johnson calls his “biological age.” That system includes downing 111 pills every day, wearing a baseball cap that shoots red light into his scalp, collecting his own stool samples, and sleeping with a tiny jet pack attached to his penis to monitor his nighttime erections. Johnson thinks of any act that accelerates aging—like eating a cookie, or getting less than eight hours of sleep—as an “act of violence.” 

Johnson is not the only ultra-rich middle-aged man trying to vanquish the ravages of time. Jeff Bezos and Peter Thiel were both early investors in Unity Biotechnology, a company devoted to developing therapeutics to slow or reverse diseases associated with aging. Elite athletes employ therapies to keep their bodies young, from hyperbaric and cryotherapy chambers to  “recovery sleepwear.” But Johnson’s quest is not just about staying rested or maintaining muscle tone. It’s about turning his whole body over to an anti-aging algorithm. He believes death is optional. He plans never to do it. 

Outsourcing the management of his body means defeating what Johnson calls his “rascal mind”—the part of us that wants to eat ice cream after dinner, or have sex at 1 a.m., or drink beer with friends. The goal is to get his 46-year-old organs to look and act like 18-year-old organs. Johnson says the data compiled by his doctors suggests that Blueprint has so far given him the bones of a 30-year-old, and the heart of a 37-year-old. The experiment has “proven a competent system is better at managing me than a human can,” Johnson says, a breakthrough that he says is “reframing what it means to be human.” He describes his intense diet and exercise regime as falling somewhere between the Italian Renaissance and the invention of calculus in the pantheon of human achievement. Michelangelo had the Sistine Chapel; Johnson has his special green juice. 

But when I showed up at Johnson’s house one Monday in August, I wasn’t really there to figure out if his elaborate age-defying strategies actually worked. I assumed that given my family history of cancer and personal fondness for pepperoni pizza, I probably won’t live long enough to find out. Instead, I spent three days observing Johnson to learn what a life run by an algorithm would look like, and whether the “next evolution of being human” would have any real humanity at all. If living like Johnson meant you could live forever—a big if!—would it even be worth it?

Kate Tolo opens the door to Johnson’s house and welcomes me inside. Tolo, a 27-year-old former fashion strategist who is originally from Australia, is Johnson’s chief marketing officer and most loyal disciple. Two months ago, she became the first person aside from Johnson to commit to Blueprint, making her the first test of how Blueprint works on a female body. Tolo is known as “Blueprint XX.”

The home is beautiful and devoid of clutter, with floor-to-ceiling windows looking out on the pool and lush greenery outside. It reminds me of an Apple Store in a jungle. Tolo offers me a little bowl of special chocolate, which had been “un-dutched,” stripped of heavy metals, and sourced only from regions with high polyphenol density. It tastes like a foot. She also makes me a juice-like concoction that contains chlorella powder with spermidine, amino complex, creatine, collagen peptides, cocoa flavanols, and ceylon cinnamon. Tolo and Johnson call it the Green Giant, but it looks almost black, like the stuff that washes off a duck after an oil spill. She manages to mix it without getting any of the dark sludge on her immaculate white jumpsuit. “It moves through some people’s digestive system faster than others,” she chirps, gesturing to the nearby bathroom. I take a tentative sip. It tastes like Gatorade, but sandy.

Johnson walks into the room, wearing a green T-shirt and tiny white shorts. He has the body of an 18-year-old and the face of someone who had spent millions attempting to look like an 18-year-old. His skin is pale and glowing, which is partly because of the multiple laser treatments he’s done, and partly because he had no hair on his entire body. The hair on his head is “not dyed,” Johnson says, but he does use a “gray-hair-reversal concoction” which includes “an herbal extract” that colors the hair a darkish brown. He gestures to my Green Giant, and then toward the bathroom. “Did you warn her?” he asks Tolo. I pretend to take another sip.

The next day, Johnson walks me through his morning routine, step-by-step. He woke up at 4:53 a.m, but delayed most of his routine until I arrive at 7 a.m. to observe him. His bedroom has almost nothing in it: no photos, no books, no television, no glass of water, no phone charger, no chair with piled-up clothes he tried on once, no dry cleaning he meant to put away, no towels, no mirror, no nothing. “I only sleep in here,” he says. “No work, no reading.” The only two objects in the room besides his bed are a laser face-shield he uses for collagen growth and wrinkle reduction, and the device he wears on his penis while he sleeps to measure his nighttime erections. “I have, on average, two hours and 12 minutes each night of erection of a certain quality,” he says. “To be age 18, it would be three hours and 30 minutes.” Nighttime erections, he says, are “a biological age marker for your sexual function,” one that also has implications for cardiovascular fitness. The erection tracker looks like a little AirPods case with a turquoise strap, like a purse worn by a penis. (No penises were viewed in the reporting of this article.)

When Johnson wakes up and removes the device, he weighs himself on a scale that uses “electrical impedance” to measure his weight, body-mass index, hydration level, body fat, and something called “pulse wave velocity,” which he explained but I didn’t quite grasp. “I’m in the top 1% of ideal muscle fat,” he says. Then he turns on his light-therapy lamp (which mimics sun exposure) for two to three minutes to reset his circadian rhythm. He takes his inner-ear temperature to monitor changes in his body, and starts off with two pills of ferritin to boost his iron, along with some vitamin C. He washes his face, uses a cream to prevent wrinkles, and puts on a laser light mask for five minutes, with red and blue lights designed to stimulate collagen growth and control blemishes. By this time, it’s typically about 6 a.m., and Johnson walks downstairs to start his day. 

The Blueprint supplement regimen is arranged on Johnson’s kitchen counter, organized from left to right. He begins with eye drops for his pre-cataracts, then uses a little vibrating device against the side of his nose to stimulate a nerve that apparently helps his eyes create tears. Johnson makes his Green Giant, then starts taking more pills in between sips of dark-green sludge. “It’s what my body has asked for,” he says. Does he ever miss coffee, even a little? “I love coffee, it’s so fun,” he says. “It’s an addictive escalation drug for me.”

At this point, he begins doing special exercises to increase his grip strength. Then he heads to his home gym—decorated with a floor-to-ceiling wallpaper photograph of a forest—and starts an hour-long routine. Johnson can leg-press 800 lbs., but his daily workout isn’t much more advanced than something you’d see from a very enthusiastic guy at the gym: a series of weights, planks, and stretches. He does this seven days a week; he adds on a high-intensity workout three days a week. Occasionally, during these high-intensity workouts, he’ll wear a plastic mask to measure his VO2 max, or the maximum rate of oxygen consumption during physical exercise. Johnson’s VO2 Max is in the top 1.5% of 18-year-olds, he says.

After his workout, Johnson eats a meal of steamed vegetables and lentils that have been blended until they resemble a mush the color of a sea lion. He and Tolo don’t name their meals “breakfast,” “lunch,” or “dinner.” They call them “first meal,” “second meal,” and so on. This is first meal. He offers me some “nutty pudding,” which is made from macadamia-nut milk, ground macadamia and walnuts, chia seed, flaxseed, Brazil nuts, sunflower lecithin, ceylon cinnamon, and pomegranate juice. It’s the color of a pencil eraser and tastes a little dusty, but it’s not too different from a vegan yogurt, if you like that sort of thing. 

Johnson insists all this is about something much bigger than getting ripped and maintaining a youthful glow. “Most people assume death is inevitable. We’re just basically trying to prolong the time we have before we die,” he says. Until now, he adds, “I don’t think there’s been any time in history where Homo sapiens could say with a straight face that death may not be inevitable.”

Experts strongly disagree. “Death is not optional; it’s written into our genes,” says Dr. Pinchas Cohen, dean of the Leonard Davis School of Gerontology at the University of Southern California. Cohen emphasizes that living longer in the future is certainly possible: over the course of the 20th century, human life expectancy rose from around 50 to more than 80. But living forever is not. “There’s absolutely no evidence that it’s possible,” Cohen says, “and there’s absolutely no technology right now that even suggests that we’re heading that way.”

“If you want immortality, you should go to a church,” adds Dr. Eric Verdin, CEO of the Buck Institute for Research on Aging. “If I believed even a little bit that it would be possible, I would be excited. It’s a pipe dream.” Verdin isn’t just skeptical of Johnson’s claims that he can achieve immortality; he’s skeptical of his claims of age-reversal altogether. “He professes to make everything transparent, but as a scientist it’s really impossible to understand the tools he’s using to assess his age,” Verdin says, adding that the Buck Institute reached out to Johnson to collaborate on some research, but never heard back. Johnson’s lack of interest in collaboration with independent scientists made Dr. Verdin even more skeptical. “I think if he wants to convince all of us that what he’s doing is valid, then he’s going to have to accept being challenged by colleagues,” he says. (Johnson doesn’t remember ignoring Verdin’s invitation, and says that he and Verdin have recently exchanged friendly emails.)

Some scientists do believe that limited age-reversal is possible. In still controversial and contested work, researchers at Harvard Medical School have claimed they’ve rejuvenated older mice, and are currently testing whether the aging clock can be turned back in human skin and eye cells. But those experiments are being done according to established scientific conventions. Johnson, in contrast, has made himself a human guinea pig, adopting nearly every age-related treatment at once and seeing what works.

It’s not just that medical professionals are skeptical of Blueprint’s ability to achieve immortality. They’re not even convinced Johnson’s routine is particularly healthy. Dr. Nir Barzilai, the director of the Institute for Aging Research at the Albert Einstein College of Medicine in New York City, met Johnson in May, at the annual retreat for the Academy for Health & Lifespan Research. Barzilai recalls that when Johnson showed up, the doctors present were concerned. “He looked sick. He was pale. I don’t know what he did with his face,” Dr. Barzilai says, adding that he was alarmed by Johnson’s lack of fat, which plays an important role in the body. “All these MDs, we all kind of agreed that he didn’t look so great.”

Barzilai also has serious reservations about Johnson taking so many supplements and treatments at once, warning that all the different pills could interact with one another in dangerous ways. “What he’s doing hasn’t proven to be safe, because some of the treatments he’s taking are actually antagonizing to each other,” he says, adding that doctors normally research the effects of one drug at a time, rather than the cumulative effects of more than 100 pills at once. “Even if it works for him, how do you know it works for you?” Barzilai says. Blueprint, he adds, is “not an experiment that we accept as scientists or doctors.” 

Johnson did not make his own doctors available for an interview, nor did he provide details about his team. But he intends to bring Blueprint to the masses. Johnson puts all of his biological measurements online—from his resting heart rate to his plaque index to images of his intestines taken with a “small bowel camera”—and his YouTube videos about his exercise regimen and therapeutic experiments have been viewed by millions of people. Roughly 180,000 people signed up for his newsletter in the first five months, Tolo says. Blueprint’s first commercial product, sold on his website, is an allegedly cholesterol-reducing olive oil, sold in a black box emblazoned with a red-lit photo of Johnson and the slogan “Build your autonomous self.” Fifteen percent of Johnson’s daily diet consists of this olive oil. Two 25 oz. bottles cost $75. Tolo says they’ve sold out.

As Johnson, Tolo and I settle in to eat our “first meal” on his massive rust-colored couch, Johnson gestures to a bookshelf full of biographies: Ben Franklin, Harry Truman, Winston Churchill, Napoleon. “I have a relationship with the 25th century more than I have a relationship with the 21st century,” he says. “I don’t really care what people in our time and place think of me. I really care about what the 25th century thinks.”

Artificial intelligence “is clearly the most significant event in this part of the galaxy,” he says. “What is the equivalent response for humans to have to AI?” Given the looming AI revolution, Johnson argues that outsourcing the management of the body to an algorithm is the ultimate form of human-AI “alignment.” If everything from marketing to legal research to retail will soon be optimized by algorithms, why shouldn’t algorithms run our bodies as well? Johnson argues that automating the physical body is a form of evolutionary adaptation to what he believes is an inevitable, AI-dominated future.

But all this talk about the scope of history, and the march of technology, and the benefits of un-dutched chocolate seemed to be missing something, I say. Aren’t humans more than just brains and meat? Isn’t there some other ineffable element that makes us human: the feeling of watching your toddler play in a lake, the joy of popcorn with girlfriends at the movie theater, the grief of losing a family member, the frustration at a lost earring? Surely, there must be more to living than simply maintaining adequate oxygen in your spleen. 

He doesn’t see it that way. “Whether we’re talking about falling in love, or having sex, or going to the baseball game, you’re talking about biochemical states in the body,” Johnson says. “You can remove everything and just say, ‘I’m experiencing this kind of electrical activity in my body and these kinds of hormones.’ We have a whole bunch of ideas about what it means to exist, we have all these ideas about what is happiness, and other things. We’re walking into a future where we no longer have control,” he continues. Which means “we are willing to divorce ourselves from all human custom. Everything: all philosophy, all ethics, all morals, all happiness.” 

I try another approach. Let’s say you’re right, I ask Johnson. What if you do live forever? That means you’d outlive everybody you’d ever known on the planet. You’d watch your children and grandchildren and all your friends die before you. What would that be like? Is a life without the people you love worth living?

Johnson says that question reminds him of “senior night” before graduating from high school. “We say goodbye, we have been together all these years, and we’re probably not going to see each other again,” he says. “At every stage in life, we move through these transition states of relationships and new experiences,” he continues. “And at every stage, you could certainly pose that question, because the circumstances are going to change. Is it worth it to carry on?”

It strikes me as a weird way to answer a question about watching his own children die, but I turn to Tolo, who was silently eating her nutty pudding in a different corner of the couch. I ask her what she thought about the possibility of watching everyone she loves die before she does. It doesn’t seem like she’s considered this. “Hopefully they wouldn’t,” she says. “I really hope that as many people as possible can come along that journey.” 

Johnson chimes in again. “I think your question reflects Homo sapiens for the 21st century,” he says. “The underlying assumption is, they have roughly 70 years of life. That’s their starting frame: I’m going to die soon, and I can’t do anything about it. So I’m optimizing in this window of time… If you change the frame, and death is not inevitable, none of the previous practiced thought patterns work.”

My 21st century Homo sapien brain was not convinced. Johnson seemed to suggest that for humans to survive in an AI-aligned future, they may need to sacrifice part of what makes them human in the first place. I thought of Tuck Everlasting, the 1975 children’s novel about an immortal family whose inability to age sets them apart from the world, adrift from the life of everyone they meet, forever alone.

I left Johnson’s house and drove to the DoubleTree hotel in Marina Del Rey. The woman at the front desk handed me a chocolate chip cookie, as they usually do at DoubleTrees (which is why I stay there). My rascal brain wanted it. But it was an act of violence that would accelerate my inevitable death. I abandoned it on the counter and took my Blueprint-approved dinner—steamed broccoli, cauliflower, and lentils, with $75 dollar olive oil and absolutely no flavor—up to my room.

Johnson wasn’t always like this. He grew up in a small Mormon community in Utah. His grandfather owned a farm with horses, and Johnson and his four siblings spent most of their time outside, helping to harvest alfalfa and corn. Johnson served his Mormon mission in Ecuador, then went to Brigham Young University, followed by business school at the University of Chicago. He got married, had three children, and in 2007 he founded Braintree, a payment-processing company. Braintree acquired Venmo five years later. In 2013, the combined entity was sold to PayPal for roughly $800 million. Johnson walked away with more than $300 million.

Despite his financial success, Johnson recalls this as a painful time. He says he fell into a deep depression in 2004 and stayed there for 10 years. He was overwhelmed by building his company while raising three young children. Medication and therapy didn’t help. He was 50 pounds overweight and miserable, he says.

Within a year of selling his company, Johnson ended his marriage and left the Mormon church. In 2014, he plowed $100 million into the creation of the OS Fund, which invests in companies working in what Johnson calls the “programmable physical world”—his term for companies that use AI and machine learning to develop new technologies for therapeutics, diagnostics, and synthetic biology. In 2016, Johnson founded Kernel, a neurotechnology company that uses a specially designed helmet to measure brain activity. Its goal is to detect cognitive impairment at the earliest stages; for now, the company is looking for biomarkers for psychiatric conditions. It can also be used, as a fun side hobby, to measure the age of his brain. 

One day during my visit, we drive to the company’s offices, which are about 20 minutes from Johnson’s home. Even though his mission in life is to “not die,” he still drives himself around LA in an electric Audi. (Extremely slowly.) Before he pulls out of his driveway, he utters his pre-driving mantra to himself: “Driving is the most dangerous thing we do.” Johnson is aware that his singular focus on living forever might make an accidental death somewhat embarrassing.  “What would be more beautiful irony than me getting hit by a bus and dying?” he says. 

In Kernel’s open-plan office, I’m brought into a small room, where a technician fits my head with what looks like a ski helmet with dozens of circular probes inside. I’m instructed to sit and watch a screensaver-type video of soft crystalline shapes morphing into each other. Later that day, my results appear in my email. It tells me that although I am 34, my brain age is 30.5.

On the way home, Johnson utters his pre-driving mantra again before inching through the streets of LA at about 16 m.p.h. As he’s explaining again why Blueprint is “the most significant revolution in the history of Homo sapiens,” a black Chevy truck pulls out of a Trader Joe’s parking lot. He swerves to avoid it, barely taking a breath before returning to comparing himself to Magellan and Lewis and Clark. “I’m not a biohacker. I’m not an optimization person,” he tells me. “I’m an explorer, about the future of being human.” 

Even futuristic humans were mere mortals once. Tolo first reached out to Johnson in 2016, when she was working in fashion in New York City. The AI revolution was beginning to come into view. “I felt so strongly that the only way we could proceed as species would be to kind of latch ourselves onto AI,” she says. She saw a quote from Johnson in a tech newsletter, advocating for humans to “merge with AI,” and decided she wanted to work for him. After years of entreaties, a job finally opened up, and Tolo took a title and pay cut to become Johnson’s assistant at Kernel. “We’d spend hours in his office, just chatting about the future of humanity,” she says.

When she first started working for Johnson, Tolo was a typical twentysomething. She drank alcohol and milky lattes, ate fast food, and stayed up too late dancing with her friends. But early this year, she and Johnson began discussing whether she should try Blueprint as well, to see how the routine would affect a female body. Before committing, Tolo requested a 30-day trial period. That trial included committing to a rigorous sleep routine, adopting Johnson’s exact diet protocol, taking more than 60 pills a day, and doing 13 minutes of intense exercise and 39 minutes of moderate exercise every day. She also measured her ovulation and her menstrual cycle.

“When I was in my trial period, I would go out to brunch with friends, and I would bring my Blueprint food, and there is a bit of sadness,” Tolo says. “Because everyone else at the table is like, ‘Oh my God, this breakfast burrito is so good.’” Ultimately Tolo decided to commit to Blueprint for good. She concluded the health benefits outweighed the lifestyle costs. Tolo says her friends have adjusted to her Blueprint lifestyle. She’s moved her social life earlier in the day to protect her sleep schedule, and they’ve gotten used to her habit of bringing her own vegetable mush to restaurants. The decision, once made, was permanent. “It would also be the final decision in a way,” she says. “It’s like, I’m deciding to no longer decide again.”

Now, as Blueprint XX, she has given up “all the things that I’ve come to cherish in small ways about my life,” she says. She and Johnson think of themselves as a sort of futuristic Adam and Eve. They had even planned an Adam-and-Eve themed photoshoot to help people understand that they’re “talking about a revolution on the scale of the whole human race,” Johnson says. Even though Tolo is apparently as important to the future of humanity as Eve herself, she plated and served all the meals I ate on my visit, and, at least while I was there, seemed to do most of the dishes.

Johnson is currently single. His older son is serving a mission for the Mormon church, and his younger daughter is 13 and lives with her mother. So Johnson spends much of his time with his 18-year-old middle son, Talmage, who commits to the Blueprint diet, rest, and exercise routines, but skips the anti-aging therapies. He briefly donated blood plasma to Johnson in order to test whether it had a measurable impact on his father’s aging, but stopped once Johnson decided it didn’t work. Talmage, who is about to start his freshman year of college, says that he’s adopted many of his dad’s attitudes towards lifestyle and life extension. “The idea of having pizza is more painful than pleasurable for me,” he says.

Johnson says his lifestyle makes it very difficult for him to date, rattling off what he calls the “10 reasons why [women] will literally hate me.” The reasons include: eating dinner at 11:30 a.m., no sunny vacations, bed at 8:30pm, no small talk, always sleeping alone, and, of course, “they’re not my number one priority.”

Throughout my visit with Johnson, I could feel my rascal brain buzzing to life. Johnson venerates what he calls “the emergent self,” which is driven “more by computational guidance and less by human want.” And yet wanting, I thought, is what humans do. There is almost no experience more human than the experience of want. As I watched Johnson drink his immortality gruel and explain his religious commitment to bedtime, I was wondering: What did he want? Did he miss eating birthday cake? Staying up late dancing? Baseball games that stretch into long nights filled with hot dogs and beer? Johnson wanted an eternal life. But what is life without wanting?

There were so many things I wanted to do, even if I knew that each indulgence could bring me closer to death. I wanted to meet a friend for cocktails in Santa Monica. I wanted to snuggle into my hotel bed and watch And Just Like That, and I wanted to stay up too late texting my friends about it. I wanted to FaceTime my daughter, the one who had caused me to gain 30 happy pounds when I ate only butter pasta and cheese pizza for most of my pregnancy. I wanted to take the first plane home, even if it meant landing at 1 a.m. and getting four hours of sleep, so that I could be there when she wakes up and says “Up!” with the force of a commanding officer. I wanted eggs and bacon for breakfast. I didn’t want to stop wanting. Life’s too short.

With reporting by Leslie Dickstein

While most of the video series and programs available on the popular “holistic wellness”/fitness site Alo Moves—owned by the trendy activewear line Alo Yoga—are run by solitary instructors, the company’s newest offering is marked by photos and videos of a group of four women pulled close up against one another and roaming Hawaiian beaches.

It’s a clearly symbolic presentation of the company’s new SYNCD program, a collection of 24 videos designed to guide users through self-care and fitness activities customized for each of the four phases of the menstrual cycle. The program, which launched in late August, is the latest—and likely not the last—in a wave of offerings from fitness and wellness purveyors looking to latch onto the recent popularity of a workout method known as “cycle syncing.” Unlike the push-through-the-pain approach of training during menstruation women athletes have adopted for decades, cycle syncing invites those same people to instead allow their exercise—and often, other lifestyle elements—to be dictated by not only their periods, but their entire menstrual cycles. The four instructors leading SYNCD’s classes, Alo Moves says, are all enthusiastic practitioners of the strategy.

Cycle syncing is one of the biggest topics in women’s health right now. Since the release of a Nike cycle-syncing program via their Training Club app in 2022, Google searches for the term have more than tripled. The last six months have seen an explosion of at-home programs and apps, including offerings from big players like the period-tracking app Flo, the activity-tracker WHOOP, and the at-home fitness company Tonal. On TikTok and Instagram, some personal fitness creators offer their own plans online for a fee, designed for followers to use alongside a period-tracking app. If your own favorite lifestyle or exercise brand doesn’t yet encourage cycle syncing, chances are high that they’ve got something in the works.

In theory, such an approach sounds like a welcome change, given that women have historically been excluded from sports science; in practice, experts say that these programs can be overly generous in their interpretations of a limited amount of research about the physical and emotional effects of the menstrual cycle. Where content creators and the companies behind new programs say cycle syncing can help people better attune to their bodies, critics worry that the technique could promote a harmfully reductive and narrow vision of how the menstruating body works.

The specificity of these programs simply can’t apply to everyone, says Tory Eisenlohr-Moul, a clinical psychiatrist at the University of Illinois at Chicago. “Given what we know about how differently people react to the cycle … you’re contributing to this misogynist idea that all females are driven by their hormones.”

Hormones throughout the cycle

Cycle syncing taps into the wellness world’s current obsession with hormones, the chemical messengers that drive key physiological functions of the body. A central idea promoted by the fitness and nutrition influencers who first made cycle syncing popular online is the idea that a healthy body is one in which unspecified hormones are “balanced.” Their goal is to regulate the body’s regulators, which in a healthy person fluctuate as needed in order to do things like maintain your core temperature and put you to sleep after a long day.

Unlike hormone balancing efforts, however, cycle syncing is about indulging, rather than controlling, the natural ebbs and flows of certain hormones. The menstrual cycle is operated by specific hormones, like follicle-stimulating and luteinizing hormones, and causes near-constant fluctuations in others, including estrogen, progesterone, and testosterone. We know a lot about what these patterns look like and some of their more standard effects on the body that appear throughout the four phases of a cycle. During the late luteal phase, for instance, which occurs just before menstruation, progesterone plummets, which can have a destabilizing effect on mood. In serious cases, this is recognized as premenstrual dysphoric disorder (PMDD), but nearly anyone who’s been a teenage girl or lived with one has experienced some of progesterone’s mental effects. Similarly well-documented peaks and valleys in libido, thermoregulation, skin health, and taste perception, are all possible, but vary from person to person.

While different syncing apps have different approaches—some are more geared for exercise fanatics, others have a more New Age vibe—they’re all pretty much the same when stripped down to their fitness plans. During the menstrual cycle, suggested exercises are simple activities along the lines of gentle yoga and pilates, though Nike suggests high-intensity interval training, or HIIT, for those who have the energy. HIIT tends to be recommended for the follicular phase, which occurs for roughly a week and a half following menstruation, when users are told to expect abundances of speed, power, and creativity. The much-shorter ovulatory phase is similarly high-octane, while in the luteal phase users are encouraged to embrace the natural energy letdown by focusing on flexibility exercises and other low-impact movement.

“Based on my experiences, and my knowledge about anatomy, and physiology, and the menstrual cycle, I think there’s some merit to it,” says Amy Tremback-Ball, a professor of physical therapy at Misericordia University who’s studied the menstrual cycle’s effect on college athletes. “For those who might be training for something and knowing that they’re going to push—like bumping up two miles or four miles in a run—I think there is a better time to do that to avoid injury.” Tremback-Ball, formerly an ultramarathoner, says that her most serious running injuries occurred during her luteal phase, when connective tissue can weaken.

However, none of the programs address the unique hormonal landscapes of the growing number of people who use any form of hormonal birth control, including pills, patches, and IUDs, as well as those who are pregnant, menopausal, suffering from endocrinological disorders, or using any sort of hormone therapy. While future products may address these populations, for now cycle-syncing apps remain exclusively focused on those with unaltered menstruation.

What does the research say?

Cycle-syncing programs frequently claim they’re designed using the latest research on athletic performance throughout the cycle, but often neglect to mention that just about all of that research has been done on elite female athletes, who aren’t representative of the typical customer of these programs. What’s more, the research is still less than a decade old, and the flurry of preliminary studies in recent years are still raising more questions than they answer. Among their findings include the possibility that building muscle could be easier during certain parts of the cycle and that there is a connection between the higher rates of orthopedic injuries in female athletes and looser, more injury-prone joints during the ovulatory phase, when the body is prepared for potential implantation. They’re groundbreaking findings, but it could be years before any universal real-world application materializes.

The preliminary studies most relied on by cycle-syncing programs are survey-based, and reiterate what people who menstruate have so often been told to ignore—that it can suck to exercise on your period. Researchers asking menstruating athletes including professional rugby and soccer players to report the effects of their cycle have all found that over 90% of respondents cite the menstrual phase as a time when they’re lower energy or feel less physically and mentally powerful. It’s the underlying, less-technical message of these types of studies—that the body can no longer simply be ignored—that cycle-syncing programs have latched onto.

Menstruation is just one piece of the puzzle

Eisenlohr-Moul, who studies menstrual hormones in the brain, says cycle-syncing programs seem to be predicated on the assumption that menstrual hormones are the most powerful forces in determining your mood and energy at any given moment. But it ignores the multitude of other physiological and mental factors that play a role in how someone feels. “Exercise is so much about the brain and your ability to make yourself do things that are sometimes physically uncomfortable,” she says. For those without PMDD and similar serious hormonal problems, factors like how much stress they’re under at work or how many hours they slept the night before can easily overshadow cyclical changes in mood or energy.

Be aware, too, Eisenlohr-Moul says, of what any new fitness program may be asking of you outside the gym. Alo Moves’s SYNCD includes not just workouts and meditation sessions, but guidance on making a turmeric tea for ovulatory pain and dry brushing the skin to promote general detoxification and decrease water retention. Though they may have value as enjoyable rituals, neither of these practices are backed by empirical evidence. They’re easy to skip, but “if you’re a person who kind of tends to spiral into a compulsive place with those kind of rules, then you might want to back off,” says Eisenlohr-Moul.

Tremback-Ball and Eisenlohr-Moul agree that cycle syncing should be viewed as more of a learning experience than a strict regimen, simply because the variety in how individuals experience their menstrual cycles can’t possibly be captured by a single program. In an ideal world, says Tremback-Ball, everyone who wanted to learn about cycle syncing for their own body would have an informed coach to help them develop an individualized program. 

Eisenlohr-Moul recommends trying a program for a month or two if you’re interested, and to pay close attention to whether or not it actually makes you feel any better, or if it’s taking more effort than it’s worth.

“If your workout is not making you happy because it’s being dictated by something,” says Tremback-Ball, throw it out and “do what makes you happy.” Your hormones will be just fine.

The night before my first book came out, I lay awake envisioning all the ways it could ruin my life. What if I get sued because I made a mistake? What if I get harassed online? What if I get such bad reviews I never work in journalism again?

I’d spent the past 18 months obsessing over the project, thinking about it on a loop. I often struggled to sleep, ruminating over all the ways it might fall short. I started seeing a therapist for the first time in my life. My career was at its high point, and I had accomplished a dream so big I’d never actually thought it would come true, but my mental health had never been worse.

The fact that I was also living through and writing about the first years of the COVID-19 pandemic certainly didn’t help, but it was the stress of the book that really had me spiraling. By the time it was published in mid-2021, I was mentally and physically exhausted. I longed to do less, to forget about work and productivity and self-promotion and just…be.

As it turns out, I had—and have—plenty of company. Around the time my book came out, so many people were quitting their jobs the media began calling it the “Great Resignation.” Then people started “quiet quitting,” proudly doing the bare minimum at work without actually resigning. Now, lots of people want a “lazy-girl job” that’s low-stress and high-pay. That’s hardly an unprecedented desire, but it now seems to be pervasive. Federal data show that preference for part-time work is rising and, at least according to one 2022 study, the pandemic ushered in a “sharp decline” in the number of hours U.S. adults want to work. The idea of a four-day work week is gaining mainstream credibility, too. Increasingly, it seems, people are rejecting the stress and burnout traditionally baked into U.S. work culture in favor of a slower, more peaceful life.

These trends hit me on a core level. During all those sleepless nights leading up to my book’s publication, I began to reevaluate my relationship with ambition and what I want from my work and life. And the truth I came to is this: mediocrity is a far better fate than misery.

American ambition

Embracing mediocrity goes against everything Americans are taught to believe. Hard work has been valued throughout U.S. history, dating back to the Puritans who built New England on the belief that labor was inextricably linked with salvation. The idea that anyone can succeed with enough hard work forms the backbone of the “American Dream,” a phrase popularized in the 1930s. The concept of the American Dream has evolved over time—until the mid-1900s, the phrase was associated not with material wealth but with furthering the common good—but it has always placed a premium on progress, on striving to be better as both individuals and a people. In more recent decades, the American Dream has become closely aligned with the kind of economic prosperity required to own a big home, a nice car, and the latest iPhone, with cash to spare for a glamorous vacation every summer.

To pursue that prosperity in a deeply capitalist society, anyone not born into immense wealth has to work for it. So it’s perhaps no surprise that U.S. culture lionizes hard work and looks down on leisure, that we’re raised to earn and do and achieve as much as we can, to shoot for the moon and settle for landing among the stars. We are taught, from an early age, that we can be anything we want to be, that with enough elbow grease we can accomplish big things. The subtext being that we should accomplish big things, no matter what it takes to get there.

For a long time, I bought into that mindset. I was the straight-A high school student, the summa cum laude college graduate, the magazine intern happy to give up my personal time to write articles for free if it meant advancing my nascent career. It was only once I achieved the big thing and watched it tank my mental health that I realized what this mindset had cost not just me, but also others who subscribe to it.

As of 2023, more than three-quarters of U.S. adults report feeling stressed at work, almost 60% experience elements of burnout, and almost 20% feel they work in a “toxic” environment, according to the American Psychological Association. We often normalize these problems, turning them into topics for happy-hour venting sessions, but they are not trivial. Countless studies show that chronic stress is bad for the body and mind, and burnout is linked to everything from depression to premature death, research shows. Last year, the U.S. Surgeon General declared improving workplace mental health and well-being “a critical priority for public health.”

Some companies have responded to these warnings with anti-burnout programs and extra vacation time. But the solution, as I see it, requires a broader rejection of the ceaseless pursuit of greatness that often leaves our health and happiness in its wake.

How striving affects well-being

In 1922, a group of more than 1,500 high-ability U.S. children were enrolled in a study through which researchers would track them for years on end. Ninety years later, a pair of researchers used some of the resulting data to assess how ambition had affected the participants over the course of seven decades.

Perhaps unsurprisingly, people who self-identified (and were described by loved ones) as ambitious achieved more lucrative and prestigious careers. But when it came to life satisfaction and longevity, the researchers didn’t find a strong connection to ambition. In spite of their professional accomplishments and cushy salaries, go-getters were not significantly happier or healthier than less-ambitious people, although they weren’t significantly unhappier either.

Similar conclusions come up often in scientific studies. Researchers have found that countries with shorter average working hours tend to have happier populations; achieving a huge career goal may not bring lasting satisfaction; and traits that frequently accompany ambition, like perfectionism and desire for power, can predispose people to burnout, anxiety, and depression.

Meanwhile, things that reliably boost happiness and well-being—community, time in nature, movement, mindfulness, personal growth, and learning—are often seen as unserious pursuits for which only underachievers have time. Research suggests that, in work-obsessed modern society, busy people are regarded as higher-status than people with lots of leisure time, a reversal from previous eras when only the rich had time to relax. When busyness and productivity are brandished as badges of honor, it is daring to prioritize activities that result only in rest or relaxation or joy.

But these things, so often skipped or squeezed into our 48 hours away from the office each week, are what make life feel manageable and rewarding. “Feeling good within yourself is about way more than ambition and striving forward,” says Emma Bradshaw, who researches the relationship between aspiration and well-being at Australian Catholic University. “Sometimes sitting in place is perfectly healthy.”

Bradshaw’s work is guided by a school of thought called self-determination theory (SDT), which holds people have three key psychological needs: a feeling of choice and control over their actions, connection with others, and a sense of competence and achievement. But the type of achievement matters.

SDT research, including Bradshaw’s, suggests that people who are motivated by internal, or “intrinsic,” goals are more likely to feel fulfilled than people who are striving toward external, or “extrinsic,” markers of success. “Things like building quality relationships with other people, growing and learning new things about the world and about ourselves, contributing positively to the community…tend to be better for you, as opposed to things like wanting lots of money and wanting to be really beautiful and wanting to be popular,” Bradshaw says.

That’s not to say everyone who is successful, wealthy, or popular is unhappy, or even that ambition is inherently bad. Lots of successful people, Bradshaw says, tap into intrinsic motivation in their work, pursuing new projects because they genuinely enjoy the process or have a higher motivation for doing so. The problem is that we often chase promotions and raises and awards by default, even if those things are unlikely to bring lasting fulfillment or satisfaction without a deeper purpose.

Trying to obtain these external trappings of success can feel like forever chasing moving goalposts. “It’s infinite, how much money you could try to earn,” says Sheri Johnson, a psychology professor at the University of California, Berkeley, who has researched the relationship between ambition and mental health. “You may be stuck in that striving state without satisfaction.”

Who gets to be mediocre?

But giving it all up isn’t so simple, as scholar Avram Alpert learned when he wrote his recent book, The Good-Enough Life, which explores how the pursuit of greatness harms individuals, communities, and society at large. Initially, Alpert says, he wanted to focus on how learning to be pleased with “good” instead of “great” might affect individuals’ happiness and well-being. But it felt impossible to say with a straight face that people should “chill out and be good enough” in the face of huge societal barriers like wealth inequality, racism, and sexism.

“If you say, ‘I’m going to be good enough. I’m not going to be overly ambitious and I’m not going to pursue every last award and every last degree and I’m not going to try to rise to the top of the pyramid,’ and then you find you’re doing that but society isn’t respecting that,” Alpert wondered, where does that leave you?

Checking out of the greatness grind often requires a safety net that millions of Americans living paycheck to paycheck or in poverty simply don’t have. It is one thing to tell someone who is already financially comfortable that money can’t buy happiness. But what about someone struggling to pay the rent or put food on the table? How could anyone tell them to be content with less?

“We shouldn’t have layers of society where people have to work that hard and live in those dire conditions,” Alpert says. But since we do, choosing mediocrity is perhaps the greatest privilege of all—and one that historically has available only to white people, says Michael Harriot, author of Black AF History: The Un-Whitewashed Story of America.

“A Black person has to work twice as hard as a white person to get half as far,” Harriot says. That means choosing to be average often isn’t an option for people of color, just as it isn’t for others who have to swim against the current of discrimination every day, including those who are not able-bodied, cisgender, or heterosexual.

But, at the same time, “we can’t expend all of our energy and work ourselves to death trying to accomplish things that are unachievable because of systemic issues,” Harriot says. He bristles against the narrative that “rugged individualism and hard work is how [people of color] get ahead in America, when we know that’s not true.” Individuals can’t fight against centuries of systemic oppression on their own.

It was that realization that led Amil Niazi to write a viral 2022 essay about renouncing ambition, which she is now adapting into a book. Niazi felt for a long time that being exceptional was her only choice. “I’m an immigrant. I grew up very poor. I’m a woman of color,” Niazi says. “I was never able to be mediocre. I would not be able to be where I am today if I had just sat back and said, ‘It’s okay for me to be average.’”

But even decades of striving didn’t prevent Niazi from being passed over for professional opportunities and promotions, which she says often went to people—predominantly white men—who could relate to her bosses in ways she couldn’t. After years of burning out trying to play their game, Niazi decided to quit and start her own, leaving her job in media to freelance and create her own definition of success.

Accepting “good enough” in a world that wants great

Even as an objectively privileged white woman, I’m nervous to attach my name to an essay with anything positive to say about mediocrity. As much as I craved it in the depths of my pre-publication stress, I do not actually want—nor can I afford—to torpedo my career. Numerous times as I wrote this essay, I wondered, Do I really want to be known as the mediocrity girl? And if I feel uneasy, how could I expect anyone without my advantages to embrace this concept?

That fear says a lot about the culture we live in. It should not be controversial to say that life exists beyond work and achievement, that the ways we’ve been taught to strive are hurting us—all of us, but particularly those who are marginalized by systems of power. And yet it’s a scary thing to put in writing.

So how can I, and everyone, live a good-enough life when the world isn’t there yet? Alpert thinks it’s about applying the philosophy of good-enoughness to whichever “pockets” of your life you can, whether that’s sometimes taking on a behind-the-scenes role rather than seeking credit; adopting a hobby just for fun; or trying to remember that, as he puts it, “the things we find most meaningful and wonderful and purposeful,” like being with loved ones, are not lazy or frivolous, but vital.

Dr. Gordon Parker, a psychiatrist and founder of the Black Dog Institute, an Australian research organization focused on mental health, believes that aiming for a 20% more laidback lifestyle can enhance well-being, particularly for the kind of type-A people who are prone to perfectionism. In other words: you don’t have to reject the system in its entirety. Sometimes it’s about trying to do just a little bit less, and becoming okay with that.

That’s been the case for Kathleen Newman-Bremang, who has written about embracing mediocrity as a Black woman. Newman-Bremang was raised to believe she had to be excellent, always, to succeed in a system that wanted her to fail. But that constant pursuit left her exhausted and disillusioned. Eventually, Newman-Bremang realized the far more “radical act” was to embrace mediocrity, even with all the negative baggage that word carries.

“Maybe my worth is not weighed by my weariness. Maybe my worth is not what kind of worker I am,” she says. “If I am just mediocre professionally, that’s okay. That can still mean that I am a good person, a good friend, a good wife, a good dog owner.”

That mindset shift is a work in progress, Newman-Bremang says. She still has to remind herself to rest and take breaks. But she no longer believes that excellence is the only option.

I, like Newman-Bremang, have tried to embody that philosophy through a hundred tiny revolutions against capitalist culture. I do my work as well as I can, but I take my lunch breaks, I use my vacation time, I resist the urge to check email on weekends. These are privileges of secure white-collar work, to be sure, and I am grateful for them. But also: they should not be as revolutionary as they feel to me, and I remind myself of that when my inner voice tells me to do more, achieve more, produce more.

Bradshaw, the SDT researcher, also gave me a piece of advice that struck a chord. When you are presented with a decision, she told me, think about why you would agree to it. Is it because you genuinely want or need to do the thing, or because you think it will make you look good?

This, too, is perhaps not so revolutionary, but it felt that way to me. So much of what I’ve done in my life has been to appear impressive, to get my foot in the door so that someday I could step all the way through. But I’ve been through the door, now, and the room inside wasn’t all I imagined it to be.

“Tripledemic“ jumped into our vocabulary and lives last year, referring to the winter surges of three respiratory viruses—RSV (respiratory syncytial virus), flu (influenza), and COVID-19. The tripledemic of 2022 infected millions, overwhelmed hospital systems, and killed more than 100,000 people in the U.S. over the 4-month peak span of these viruses.

As much as we hoped that respiratory illness would fade with the COVID-19 public health emergency ending, we must recognize that these viruses will continue to impact us for years. As the school year begins, we already see short-term school closures due to respiratory illness. We are seeing new variants of COVID-19 that may also contribute to increased cases of disease. 

However, the severe impact of the anticipated wave of respiratory illness this winter can be very different from last year. We can reduce the levels of severe viral disease seen over recent years, thanks to the remarkable development of new vaccines and therapeutics against these viruses. We can achieve this goal of preventing hospitalization and death by ensuring that individuals at the most significant risk for severe disease are vaccinated against each of these viruses before the late fall and winter months and receive prompt antiviral treatment when ill.      

RSV, flu, and COVID-19 are respiratory pathogens spread by the breath, spoken word, and cough. As with most pathogens, some individuals are more vulnerable than others to these infections. RSV and influenza take their most significant toll on those less than one year and older than 65 years and in people with serious underlying medical conditions. COVID-19 also exerts its most severe impact on older people and those with underlying medical problems. Although less frequent than in adults, COVID-19 can also result in severe disease in children, more than 50% of whom have no underlying medical conditions, which is why COVID-19 vaccines are recommended for children six months and older by the American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC).

During the respiratory season of 2022-2023, it was estimated that 100,000-200,000 people were hospitalized with RSV, 300,000-650,00 with flu, and 700,000 with COVID-19. During that surge, 6,000-10,000 people died from RSV, 19,000-58,000 from flu, and 75,000 from COVID-19. These numbers of deaths due to RSV were greater than the levels seen over the several years before the pandemic. It was remarkable that RSV and flu-related illnesses fell over the first two years of the COVID-19 pandemic, partly due to the mitigation measures against COVID-19, which also slowed the spread of these other respiratory viruses. Yet, with the relaxing of masking and other anti-COVID-19 mitigation measures, RSV and flu cases rebounded to exceed pre-pandemic levels. It is difficult to predict the patterns of RSV, flu, and COVID-19 over the coming months. But we can expect a rise in the activity of these viruses as population immunity from last year’s infections and vaccinations wanes and new viral forms appear.

This past year heralded important developments in the prevention of RSV. RSV infection among children under five years, which resulted in 58,000-80,000 hospitalizations and 100-300 deaths last year, can be prevented in several ways. If a pregnant individual is vaccinated against RSV, the transfer of immune protection from the parent to the fetus will protect the infant after birth, and such vaccines have recently been approved. If parents are not immunized against RSV during pregnancy, infants can receive a long-acting monoclonal antibody by injections to protect against severe disease for up to 6 months. This FDA-approved medication, Beyfortis, is now available through the Vaccines for Children (VFC) program and through pediatric care providers. The drug is approved for neonates and infants born during or entering their first RSV season and in children up to 24 months of age who remain vulnerable to severe RSV disease through their second RSV season. RSV vaccines for those 60 years and older have also been approved, dramatically reducing cases in older people.

The influenza vaccine is modified yearly in anticipation of the expected flu strain and is recommended for those six months and older. The flu vaccine, with doses specific for children and adults, becomes available in the fall and comes in forms administered by injection or a nasal spray. This year’s vaccine is designed to target several different flu strains. In addition to vaccines, several anti-flu medications, including Tamiflu, effectively reduce flu severity if started within a few days of illness onset.

Although cases, hospitalizations, and deaths due to COVID-19 are much lower now than over the previous three years, this virus remains a serious public health threat, with more than 100,000 deaths over the current year. COVID-19 will also be a top-five cause of death for adults and a top-ten cause of death for children. As with RSV and flu, severe disease due to COVID-19 is preventable through vaccination.

For individuals who develop COVID-19 infections, disease severity can also be markedly reduced by oral antiviral agents, including Paxlovid and Mulnupiravir. More than 80% of adults in the US have received at least one dose of a COVID-19 vaccine, and 70% have completed the primary series. Because the protection from these vaccines phase after about six months, booster shots are recommended, but only 17% of the US population has a current booster shot. Like the flu vaccine, booster vaccinations are adapted to the anticipated circulating virus type, the Omicron variant. On September 12, 2023, the CDC recently recommended that everyone six months and older get updated COVID-19 vaccines from Moderna and Pfizer-BioNTech that better match the current circulating virus strains. These new vaccines will be available within a week of the announcement.

More than 700 million doses of COVID-19 vaccine have been administered in the U.S., and data clearly show that COVID-19 vaccines are very effective in reducing severe disease risk and have an excellent safety record, as shown in very recently presented data. Notably, the risk of myocarditis following last fall’s updated COVID-19 vaccine was minimal, with two confirmed myocarditis out of about 650,000 doses, which is lower than after the primary series.

There is recent discussion has been about when to get flu or COVID-19 booster shots. Because the effectiveness of the flu and COVID-19 vaccines can wear off after six, it makes the most sense to get these vaccines in late October or November before the anticipated peak of illness during wintertime. Until there is a combination respiratory pathogen vaccine, these vaccines need to be administered separately. Flu and COVID-19 vaccines can be given simultaneously. Still, since the RSV vaccine is new, it has been recommended to wait two weeks after the RSV vaccine before other immunizations until more data are available.

Common sense public health measures also play a role in combatting the tripledemic, as we can spread viruses to others when we are infected. First, we must avoid others, especially those with vulnerabilities, when ill. We also now have home testing available to diagnose each virus separately or in combination. This can lead to prescribing antiviral medication and treating symptoms when coupled with telemedicine or in-person office visits. Mask use may also be considered in high-risk settings, especially for those who are medically vulnerable.

As part of this discussion of tripledemic action, we also need to recognize that issues related to COVID-19 have become politically polarized to the point where facts about the disease, its impact, its treatment, and its prevention are ignored. But we also need to recognize that COVID-19 now takes its place among the other common respiratory pathogens, and we have strong medical tools to address tripledemic viruses.

With all the amazing preventative tools and treatments we now have, we can look forward to saying, “tripledemic severe disease, no more.”

The psychedelic drug MDMA can reduce symptoms of post-traumatic stress disorder, researchers reported in a new study published Thursday.

The company sponsoring the research said it plans later this year to seek U.S. approval to market the drug, also known as ecstasy, as a PTSD treatment when combined with talk therapy.

“It’s the first innovation in PTSD treatment in more than two decades. And it’s significant because I think it will also open up other innovation,” said Amy Emerson, CEO of MAPS Public Benefit Corporation, the research sponsor.

Earlier this year, Australia became the first country to allow psychiatrists to prescribe MDMA and psilocybin, the psychoactive ingredient in psychedelic mushrooms. The drugs are gaining wider cultural acceptance in the U.S. in part because of efforts by the nonprofit advocacy group Multidisciplinary Association for Psychedelic Studies.

Read more: Psychedelics May Be Part of U.S. Medicine Sooner Than You Think

For the new study, researchers measured symptoms in 104 people with PTSD who were randomly assigned to get either MDMA or a dummy pill during three sessions, one month apart. Both groups received talk therapy.

Common side effects in the MDMA group were muscle tightness, nausea, decreased appetite and sweating. But only one person in the MDMA group dropped out of the study.

After treatment, 86% of the MDMA group improved on a standard PTSD assessment compared to 69% of the placebo group. The assessment measures symptoms such as nightmares, flashbacks and insomnia.

By the study’s end, 72% of people in the MDMA group no longer met the diagnostic criteria for PTSD, compared to about 48% of the placebo group.

Read more: Psychedelics Could Revolutionize Couples Therapy

“The results that they got are very exciting,” said Barbara Rothbaum, who directs the Emory Healthcare Veterans Program in Atlanta. She was not involved in the research, which was published in the journal Nature Medicine.

PTSD also can be treated with other medications or talk therapy.

“They are very effective, but nothing is 100% effective,” Rothbaum said. “So we absolutely need more options for treatment.”

Before MDMA could be prescribed in the U.S., the Food and Drug Administration would need to approve it and the Drug Enforcement Administration would need to change its classification. MDMA is currently classified as Schedule 1, on par with heroin and deemed to have “no currently accepted medical use and a high potential for abuse.”

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

It’s easy to understand how a medicine like phenylephrine got onto pharmacy shelves in the first place. The common decongestant, used most often as an ingredient in multidrug cold medications like DayQuil and Sudafed PE, was initially designated as “safe and effective” by the Food and Drug Administration (FDA) in 1976, when the agency was newly—and less stringently than today—greenlighting drugs that had been on the market for years before the agency had established any efficacy standards. After a full review of 14 studies (12 unpublished and two published) from pharmaceutical companies—a fair body of evidence for the time—the panel of experts assigned to evaluate over-the-counter allergy medications ruled that phenylephrine was effective.

Except phenylephrine has never worked. What’s puzzling, then, is how it stayed on those shelves for 50 years without a challenge. That changed on Sep. 12, when a different FDA advisory committee looking in part at that same early research voted 16-0 that the common oral form of phenylephrine is ineffective, opening the door for products claiming it works as a decongestant to be pulled from stores altogether. Though a final decision by agency authorities could take months and face legal challenges, the panel vote alone could be a death blow to the medication, which appears in products that together account for nearly $1.8 billion in U.S. spending each year.

Experts agree that an over-the-counter medication shouldn’t easily be able to go half a century without being reevaluated against new scientific standards. The FDA has since the late 1960s required that over-the-counter medications meet formal standards for both safety and efficacy, but since its initial market purge of medications that didn’t meet those criteria in the early 1970s, such approvals have really only been called into question over safety concerns. “In 50 years, I don’t ever remember a drug being removed from the market because it wasn’t effective,” says Leslie Hendeles, a professor emeritus at the University of Florida’s College of Pharmacy and an FDA consultant. In other words, if it isn’t broken, the FDA usually doesn’t have the bandwidth to fix it. The story of phenylephrine, then, isn’t just an example of the agency’s past oversights, but could be what Hendeles calls the “poster child” of a new effort to clean them up in every aisle. 

Though it’s popular now, phenylephrine became the main over-the-counter decongestant through a sort of process of elimination. The 1976 panel that allowed it to stay on the market after the FDA updated its standards also approved two other decongestants: pseudoephedrine and phenylpropanolamine. The studies that formed the basis for phenylephrine’s approval were shaky by today’s standards; Hendeles says that the results are riddled with statistical anomalies, and that “some even had fraudulent data.”

At the time, phenylephrine was the least common of the three. Around the turn of the century, however, large studies began to demonstrate an association between phenylpropanolamine and deadly brain bleeds, and so the market for phenylephrine and pseudoephedrine increased. 

Most manufacturers who used phenylpropanolamine switched to pseudoephedrine around 2000, Hendeles says—the most popular allergy medications at the time, including Claritin D, which led the market, all contained pseudoephedrine along with the standard antihistamines, which fight allergy symptoms triggered by the immune system, like itchiness and swelling. But pseudoephedrine at the time was also the easiest-to-acquire form of one potential key ingredient in the production crystal meth, and with the passage of the Combat Methamphetamine Epidemic Act of 2005, any medication containing it could no longer be sold on shelves; you didn’t need a prescription, but it was only accessible by pharmacists and all sales were tracked. “Companies didn’t want to lose the income from sales in front of the counter,” Hendeles says, “and phenylephrine could be purchased in grocery stores, convenience stores, airports, cruise ships—everywhere.” Reformulations and new options with phenylephrine proliferated. Today, there are 261 over-the-counter products containing the drug.

Read More: Common Nasal Decongestant Doesn’t Actually Work, According to FDA Advisors

But not all manufacturers made the switch. Schering-Plough (since bought out by Merck), the maker of Claritin D, was hesitant, says Hendeles. “They were effective, and they didn’t want to make the switch unless it was going to give them the same efficacy,” he says. Internally, the company ran some of the first studies of phenylephrine since the 1970s, and sure enough, they showed that the last over-the-counter option was ineffective. So they chose to keep making Claritin D with pseudoephedrine, even though it meant the drug would have to go behind the counter. The makers of Zyrtec and Allegra followed suit with their pseudoephedrine products. 

Around the same time, in 2007, Hendeles’s University of Florida colleague Randy Hatton filed a public records request that granted him access to the dozen original studies on phenylephrine that the FDA had initially looked at decades earlier. Together, the two researchers concluded that the evidence showed oral phenylephrine at the allowed dose was no better than a placebo, and immediately filed a citizen’s petition asking the FDA to require pharmaceutical companies to test doses higher than the maximum allowed 10 mg of phenylephrine. In response, the agency assembled the Non-Prescription Drug Advisory Committee (NDAC) to address Schering-Plough’s findings and the concerns raised by Hendeles and Hatton.

Amid conflicting presentations and interpretations of research given by the petitioners, manufacturers, and the Consumer Healthcare Products Association, which represents the industry, the NDAC ultimately voted “yes” on a resolution that the evidence on phenylephrine was “suggestive of efficacy.”

Hendeles didn’t agree then, and today claims that the meeting was far from thorough and fair. “The head of the [NDAC] said that the ideal outcome of this meeting would be for the committee to say that it’s effective and didn’t need additional studies,” he says. “He said, ‘that way, we won’t have to change the monograph’”—referencing, Hendeles says, the established rule sheet for a family of drugs. According to Hendeles, a chronically understaffed and underfunded FDA may have simply not been able to give the issue the attention it deserved at the time.

In the FDA’s own recounting of the 2007 meetings, the agency suggests that some consultants present were likely swayed by the fact that studies have actually shown that phenylephrine can be an effective nasal decongestant. Of course, what the NDAC was supposed to be assessing in this case was its efficacy as an oral decongestant, processed in the gut. That the body metabolizes a drug differently based on method of administration isn’t unusual, but can certainly make specifying its usage more confusing. 

Following those meetings, the FDA also asked companies manufacturing oral phenylephrine test higher-dosage versions of their drugs, as Hendeles had requested. But two extensive studies by Merck found that even 40 mg of phenylephrine—a whopping four times the largest dosage being sold in Claritin pills in stores—was no more effective than a placebo. In 2015, “when we saw the results of this dose ranging study, Dr. Hatton and I went and submitted another petition” to the FDA, Hendeles says. “This time that petition was actually to remove the drug from the marketplace.”

Though it took another half decade, that second petition, and its support from groups including the American Pharmacy Association, is a big part of what finally got the FDA to take its most recent look at phenylephrine. Another reason for the FDA’s recent move was the Coronavirus Aid, Relief, and Economic Security Act, passed in 2020, which enabled the agency to more easily revise over-the-counter approvals and recommendations.

If the FDA does decide to take phenylephrine off the market, it may signal to the market that more medications might be subject to new regulatory scrutiny. In the allergy aisle alone, Hendeles has a few other products in his crosshairs, including the cough suppressant dextromethorphan, found in Robitussin, and the mucus thinner guaifenesin, found in Mucinex. “The data that’s in the literature suggests that neither of those two are effective,” he says. 

For now, with no given timeline for a final decision from the FDA, phenylephrine is still on the market. Still, with flu season coming, a word to the wise and congested: It’s time to get comfortable with nasal spray.

BOSTON (AP) — Boston firefighter Daniel Ranahan had heard about colleagues getting cancer but he was stunned when doctors discovered a tumor in his chest.

He was only 30 and had been in the Boston Fire Department less than a decade. But as he investigated his diagnosis of Hodgkin’s lymphoma in October 2020 and sought successful treatment, he learned he and others wore gear that contained the toxic industrial compound PFAS.

“You always hear about the dangers. You just never think it’s going be you,” said Ranahan, who stopped working due to the cancer and is among thousands of firefighters nationwide who sued PFAS manufacturers and companies that make firefighting gear and foam, seeking damages for their exposure.

“These guys put this on day in and day out to protect neighborhoods and wherever they are working,” he said. The Associated Press was not given access to his doctors due to the ongoing litigation, making it difficult to independently verify his claims.

The multi-layered coats and pants worn by firefighters have become the latest battleground over PFAS, or per-and polyfluoroalkyl substances. It’s found in everything from food packaging to clothing and is associated with health problems including several types of cancer. In March, the Environmental Protection Agency for the first time proposed limits on the chemicals in drinking water.

The news that PFAS compounds are in their gear — primarily meant to repel water and contaminants like oil and prevent moisture-related burns — is worrisome to firefighters.

The International Association of Fire Fighters or IAFF says that cancer has replaced heart disease as the biggest cause of line-of duty deaths. Firefighters have been shown to be at higher risk than the general population of getting several types of cancer.

Firefighters are exposed to a laundry list of carcinogens coming from fires burning hotter and faster than ever before — often due to increased petroleum products in homes. But as they learn more about PFAS, firefighters have grown suspicious that their personal protective equipment or PPE is sickening them.

“We had no idea that the gear that we were putting on every day was essentially loaded with PFAS,” said IAFF General President Edward Kelly, who was elected in 2021 on a campaign in part to address dangers of PFAS in gear.

Sam Dillon, president of Boston Firefighters, Local 718, said the union had to act.

“When we break it down, the problem to us becomes very simple,” he said. “There is proven science that PFAS is a known carcinogen. There is also proven science that PFAS is in protective gear that firefighters wear. So when its brought to our attention that there is a known carcinogen in the protective ensemble that our members wear, it is grave concern to the union and it’s our job to address that issue.”

One defendant in the lawsuits, 3M Co., said in a statement that it “manufactures a variety of personal protective equipment products that meet nationally recognized standards to help protect first responders facing high-hazard environments.” Last year, the company announced it would stop manufacturing PFAS by the end of 2025 and would work to discontinue using the chemicals in its products.

Another defendant, W. L. Gore & Associates, says the PFAS compound PTFE used in its clothing is nontoxic and safe.

“Based on the body of available and reliable science, Gore concludes its firefighting products are not the cause of cancers impacting firefighters, who by the nature of their important work are sometimes exposed to cancer-causing chemicals from fires,” said company spokesperson Amy Calhoun.

The American Chemistry Council said in a statement that “PFAS-based materials are the only viable options for some key equipment that meet the vital performance properties required for firefighting gear.”

Heightened concerns about gear

The PFAS has been in the gear for decades. But the wife of retired Worcester, Massachusetts fire lieutenant Paul Cotter who had cancer raised concerns about PFAS in gear in 2016. Until then, many firefighters had not heard of PFAS or did not know it was in their gear.

Gear makers told Diane Cotter there were only trace amounts of PFAS and it was safe. “I was attacked by firefighters when discussing the idea that chemicals in the gear could be causing cancer,” she said.

Cotter sent patches of gear to Graham Peaslee, a University of Notre Dame professor who studies PFAS, for testing.

“It was loaded with PFAS. That was the first eye opening moment that there may be more than just trace amounts,” said Peaslee, who also found the chemicals on gloves and in firehouse dust.

“They come off and they pose risks,” he said.

Courtney Carignan, an exposure scientist and epidemiologist at Michigan State University, said she found PFAS at twice the levels of the general population in the blood of more than half of the 18 firefighters she tested in Nantucket and Fall River, Massachusetts. She also found PFAS in gear was transferred to the skin of firefighters.

But Carignan is still investigating how much the gear contributed to increased levels of PFAS in the blood and whether PFAS exposure may be causing or contributing to cancer.

“Even though we know PFAS is in the gear, we still don’t know how much exposure that is,” she said.

Firefighters take action

The revelation of PFAS in the gear sparked a campaign by firefighters to find safer alternatives and to hold companies responsible.

Lawsuits on behalf of firefighters argue they were exposed to significant PFAS levels and companies knew the gear contained PFAS and that it can cause serious health problems. The suits also allege companies misrepresented their products as safe.

The IAFF, which represents more than 340,000 U.S. and Canadian firefighters, decided in 2021 to no longer accept sponsorships or advertising from the chemical industry and to oppose PFAS in turnout gear. A Congressional bill introduced in July would accelerate the search for safer alternatives and support firefighter training to reduce exposure from existing gear.

Seven states including Washington, New Hampshire and New York passed bills requiring companies to disclose PFAS in their gear, according to Safer States, a coalition of environmental health groups. Several more states introduced or enacted bills this year that provide funds to purchase PFAS-free gear or prohibit manufacture or sale of gear containing the chemicals, according to Emily Sampson, an environment policy analyst at the National Conference of State Legislatures.

No easy fix

For most fire departments, there is no easy fix. Replacing gear is expensive — one set can cost upwards of $4,000 — and finding alternatives has proven challenging. Some companies are promoting a PFAS-free outer layer but that doesn’t solve the problem because the other two layers still contain PFAS, the IAFF said.

Among the hurdles, according to a IAFF lawsuit filed in March, is that the National Fire Protection Association or NFPA standard for gear can only be met with PFAS-infused material. The suit accuses the NFPA of working with several gear makers to maintain that requirement. It seeks damages and an end to the standard.

Chris Dubay, NFPA vice president and chief engineer, said in a statement that the standard “does not specify or require the use of any particular materials, chemicals or treatments for that gear.” He said the group has no “special agreements or relationships with any company or organization” in development of standards.

“The manufacturers who are producing this gear owe it to the fire service to come up with an alternative,” Brockton Fire Chief Brian Nardelli, who has heard of companies promoting gear with less PFAS but is reluctant to buy it for his 231-member department without more proof.

Instead, his department tries to limit firefighter exposure to gear that’s been integral to firefighter identity. They would take it everywhere, including charity events. Now, Brockton discourages firefighters from wearing turnout gear in living quarters and encourages them to wash it after fires. It’s stored on trucks and is only to be worn for serious calls like fires and car accidents.

“Guys have seen everyone who has gotten cancer, guys dying from cancer,” said William Hill, the president of the Brockton Fire Fighters Local 144 who was successfully treated for testicular cancer. “Being told that PFAS is in the gear, guys don’t want to take the chance of being overexposed.”

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Associated Press climate and environmental coverage receives support from several private foundations. See more about AP’s climate initiative here. The AP is solely responsible for all content.

As Americans fend off a late summer COVID-19 spike and prepare for a fresh vaccine rollout, Republicans are raising familiar fears that government-issued lockdowns and mask mandates are next.

It’s been a favorite topic among some of the GOP’s top presidential contenders. Florida Gov. Ron DeSantis told reporters that people are “lurching toward” COVID-19 restrictions and “there needs to be pushback.” South Carolina Sen. Tim Scott posted online that the “radical Left” seeks to bring back school closures and mandates. And former President Donald Trump urged congressional Republicans to stop the Biden administration from bringing back COVID-19 “mandates, lockdowns or restrictions of any kind.”

“The radical Democrats are trying hard to restart COVID hysteria,” Trump told supporters in Rapid City, South Dakota, during a recent campaign stop. “I wonder why. Is there an election coming up by any chance?”

While some individual schools and colleges have implemented temporary mask requirements, there is no sign that anyone in federal or state leadership is considering widespread COVID-19 restrictions, requirements or mask mandates. The administrations of several Democratic governors denied that any such moves are even under discussion. The overriding sentiment is to leave the decisions to individuals.

“No COVID-19 public health restrictions or mask requirements are being considered by the Murphy administration,” said Christi Peace, spokesperson for New Jersey Gov. Phil Murphy.

“There are no impending mass lockdowns or mask mandates for New Mexico,” said Jodi McGinnis Porter, spokeswoman for the New Mexico Department of Public Health.

It was largely the same message from Democratic governors’ offices in several other states that responded to an inquiry about whether any COVID-19 mandates were under consideration. That included Connecticut, Kansas, Louisiana, Massachusetts, Michigan and Oregon.

Pennsylvania Gov. Josh Shapiro, a Democrat, made clear his opposition to COVID-19 lockdowns as well as mask and vaccine mandates when he was campaigning for office last year: “This is an area where I think folks got it wrong,” he said of school and business shutdowns. His office echoed the same sentiment in its response to the AP this week, saying, “The administration’s view is that there is no need to impose restrictions.”

In the two most populous Democratic-led states, California and New York, the state health departments recommend getting the updated vaccine, but have no requirements for the shot or mask wearing. New York Gov. Kathy Hochul was asked during a news conference Wednesday about whether she would consider mask or vaccine mandates: “We are in a place where we’re seeing low numbers; not requiring such actions today,” she said.

Elisabeth Shepard, spokesperson for Oregon’s Democratic governor, Tina Kotek, noted that the federal public health emergency for the virus outbreak ended in May.

“Currently, COVID-19 lockdowns and mask mandates are not being discussed and the governor has no plans to institute these measures,” she said.

Still, the misleading narrative has proven a convenient scare tactic for Republicans in their efforts to woo voters who see Democrats as oppressive leaders targeting their freedoms.

The GOP presidential hopefuls hammering this message in the last week join a chorus of conservative lawmakers and far-right pundits who have spent the last month warning that tyrannical COVID-19 measures are looming.

In August, conspiracy theorist Alex Jones claimed an anonymous “high-level manager in the TSA” and an unnamed “Border Patrol-connected” source told him that Transportation Security Administration workers would soon need to wear masks and that COVID-19 lockdowns would return in December.

The U.S. Centers for Disease Control and Prevention said the claims were “utterly false,” but they still were amplified by influential Republicans, including Rep. Lauren Boebert of Colorado, who posted on X that she wrote to the TSA demanding answers.

Later last month, when a Black liberal arts college in Atlanta announced it had reinstated a temporary mask mandate in response to student infections, Rep. Marjorie Taylor Greene, a Republican from Georgia, posted on X that “Americans have had enough COVID hysteria. WE WILL NOT COMPLY!”

The school, Morris Brown College, has since lifted the requirement but is keeping in place other policies, including contact tracing and temperature checks on campus.

Some of the outcry from conservatives has been in response to President Joe Biden’s comments last month on COVID-19’s recent uptick, which has led to an increase in hospitalizations and deaths nationwide — though a fraction of what the country saw in past surges.

“As a matter of fact, I signed off this morning on a proposal we have to present to the Congress a request for additional funding for a new vaccine that is necessary — that works,” Biden told reporters during a visit to South Lake Tahoe. “And tentatively — not decided finally yet — tentatively, it is recommended that, it will likely be recommended that everybody get it no matter whether they’ve gotten it before or not.”

The CDC on Tuesday endorsed those new shots for everyone 6 months and older, and the vaccines will be available at pharmacies, health centers and some doctor offices as soon as this week. But a new federal vaccine mandate is not under consideration, according to a White House official who requested anonymity to discuss the administration’s thinking.

A federal mask mandate is also not on the table.

“To be clear, the rumors of a federal mask mandate are not true,” said Jeff Nesbit, assistant secretary for public affairs for Health and Human Services. “We now have a range of tools for people to protect themselves from the impact of COVID-19, including vaccines, at-home testing and treatments. Masking is one of several steps people may choose to take to protect themselves if they wish.”

Reinstated mask requirements across the country have so far been limited to a handful of local schools and businesses. One example is a Maryland elementary school that required students who were exposed in a classroom’s outbreak to wear masks at school for 10 days.

But these isolated measures have sparked outrage from conservatives who have used them to energize their supporters.

Sen. J.D. Vance of Ohio last week unveiled the “Freedom to Breathe Act,” a bill that would block the federal government from imposing mask mandates for domestic flights, public transit and schools. His call for unanimous passage of the bill failed, with Democratic Sen. Ed Markey of Massachusetts calling it a “red herring” meant to deflect from the GOP’s prioritization of “gimmicks over people.”

Greene, the Republican from Georgia, introduced a companion bill in the House. She has said she won’t vote to avoid a government shutdown unless the government ends coronavirus mandates, which have already largely been reversed.

Misinformation experts say there’s a strategy to Republicans’ foreboding claims about impending mandates: They remind voters of the negative feelings they had early in the pandemic — and associate those with Democrats.

“Wearing a mask doesn’t have to be connected to anxiety, fear, anger and other strong emotions, but for many people it is,” said Lisa Fazio, a Vanderbilt University psychology professor who studies the spread of false claims. “No one wants to go back to those feelings, so Republicans are trying to tie those negative feelings and memories to their political opponents.”

Meanwhile, some of the Republican-led states where state leaders are railing against COVID-19 measures have been the hardest hit by the recent surge. Data shows Mississippi had the highest COVID-19 death rate per 10,000 people in the last week of August.

Early that week, the state’s Republican governor, Tate Reeves, pledged to block any widespread restrictions, posting online that the state would “live in self-determination, not top-down fear.”

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Associated Press data journalist Nicky Forster and writers Joey Cappelletti, Mike Catalini, Sara Cline, Jill Colvin, John Hanna, Susan Haigh, Maysoon Khan, Seung Min Kim, Steve LeBlanc, Morgan Lee, Marc Levy, Lisa Mascaro and Andrew Selsky contributed to this report.

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The Associated Press receives support from several private foundations to enhance its explanatory coverage of elections and democracy. See more about AP’s democracy initiative here. The AP is solely responsible for all content.

In a long-awaited update to the COVID-19 vaccine schedule, the U.S. Centers for Disease Control (CDC)’s vaccine committee recommended that everyone six months or older should get another booster shot.

In a long-awaited update to the COVID-19 vaccine schedule, the U.S. Centers for Disease Control (CDC) recommended on Sept. 12 that everyone six months or older should get another booster shot. CDC director Dr. Mandy Cohen endorsed the recommendation made by the agency’s committee of outside vaccine experts.

That shot will be the newest vaccine greenlit by the Food and Drug Administration (FDA) just a day earlier. The FDA approved mRNA vaccines made by Moderna and Pfizer-BioNTech that target the XBB.1.5 variant for everyone 12 years or older, and issued an emergency use authorization for mRNA vaccines for children six months to 11 years. The FDA’s actions also mean that the updated vaccine is the only one authorized or approved against COVID-19; the previous booster, against BA.4/5 is no longer authorized.

In a 13-1 vote, the CDC’s panel of vaccine experts decided that near-universal vaccination for everyone six months or older would provide the best protection against another serious surge in infections this fall and winter. Hospitalizations due to COVID-19 have been increasing since mid-July, CDC scientists reported, and while most of those have involved young children and older people, half of the children under five who have been hospitalized did not have underlying health conditions, a reminder that even otherwise healthy people can experience serious COVID-19 illness.

Despite the near unanimous vote in favor of recommending the vaccine for most people, committee members raised several concerns. First, the new vaccines target the XBB.1.5 variant—which is no longer the virus causing the most infections in the U.S., but was the dominant virus earlier in the summer, when the FDA made the decision to switch to a new vaccine. At the time, the agency advised manufacturers to start producing shots targeting that variant. But XBB.1.5 has since been replaced by a handful of new strains, including EG.5.1 and BA.2.86. Moderna, Pfizer, and Novavax all presented data to the committee showing that their XBB-targeted vaccines generated good antibody responses against these new variants as well, but only Moderna’s data involved human cells while Pfizer and Novavax provided data from animal studies. (Novavax has not yet submitted a request to the FDA to authorize its XBB vaccine, but expects to do so soon when its studies are complete.)

Some members  questioned whether the updated vaccine should be recommended for most people, or just for those at highest risk of COVID-19 complications, such as the very young, the elderly, and those with compromised immune systems. Dr. Matt Daley, senior investigator at the Institute for Health Research at Kaiser Permanente Colorado, and the head of the CDC’s work group that reviewed the vaccine safety and effectiveness data, said that when the group began discussions earlier this summer, they did not assume that the updated vaccine would be recommended for everyone. “We viewed this as an opportunity to re-evaluate the vaccination program, and started from a blank slate,” he said. The work group therefore asked the CDC for more detailed data on who was being hospitalized, who was experiencing more severe disease, and who was dying from COVID-19, so it could better understand if certain populations were more vulnerable to complications and could benefit from vaccination. What they saw was that “Disease burden does vary greatly by age, but serious illness occurred across all age groups including among those without underlying medical conditions,” Daley said. “That was the most persuasive argument for me for universal vaccination.”

Those data, coupled with the fact that many people did not get the most recent booster, means that overall immunity against SARS-CoV-2 is dropping, said Dr. Sandra Fryhoffer, associate professor of medicine at Emory University who was representing the American Medical Association at the meeting. “We are all more susceptible.”

Most of the committee members agreed, but Dr. Pablo Sanchez, professor of pediatrics at Ohio State University-Nationwide Children’s Hospital, was the only member to vote against the recommendation. “I think we need to let the public know that the data on children is not there,” said Sanchez. “We need to level with our patients and say what is known and what is unknown rather than make a blanket recommendation, especially for groups for whom there isn’t data.” Sanchez argued for a recommendation that focused on the most vulnerable groups, such as people over 65 years, the immunocompromised, and pregnant people, and encouraged other groups to make individual decisions about getting vaccinated after discussing their risks and benefits with their doctors.

Some committee members shared Sanchez’s concerns about the lack of data, but also pointed out that without a universal recommendation, current inequities in vaccine access would only deepen since those without access to health care would not benefit from individual discussions about their need for a vaccine.

The updated vaccine will be the first COVID-19 shot to be distributed in the way most vaccines have in the past, prior to the pandemic, on the commercial market for around $120-$130 per dose, rather than purchased and provided for by the government. That means that pharmacies and doctors’ offices will purchase the vaccines at their own cost and get reimbursed for the shots. Most insurers, including Medicare and private companies, will continue to cover the vaccine, without co-pays, since it is recommended by the CDC. 

The Vaccines for Children program will provide shots for uninsured and underinsured younger kids. For older children and adults without adequate insurance coverage, the CDC announced that it will purchase shots and make them available at state and local health departments, as well as through retail pharmacies that participate in the Bridge Access Program until 2024. To sustain the program beyond that for adults, the agency hopes to secure additional funding to launch a permanent Vaccines for Adults program and extend the shots it provides beyond COVID-19 vaccines.