This story was originally published by the Guardian and is reproduced here as part of the Climate Desk collaboration. High-profile studies reporting the presence of microplastics throughout the human body have been thrown into doubt by scientists who say the discoveries are probably the result of contamination and false positives. One chemist called the concerns “a bombshell.” Studies claiming to have revealed micro- and nanoplastics in the brain, testes, placentas, arteries, and elsewhere were reported by media across the world, including the Guardian and Mother Jones. There is no doubt that plastic pollution of the natural world is ubiquitous, and present in the food and drink we consume and the air we breathe. But the health damage potentially caused by microplastics and the chemicals they contain is unclear, and an explosion of research has taken off in this area in recent years. However, micro- and nanoplastic particles are tiny and at the limit of today’s analytical techniques, especially in human tissue. There is no suggestion of malpractice, but researchers told the Guardian of their concern that the race to publish results, in some cases by groups with limited analytical expertise, has led to rushed results and routine scientific checks sometimes being overlooked. > One scientist estimates there are serious doubts over “more than half of the > very high impact papers” on microplastics in biological tissue. The Guardian has identified seven studies that have been challenged by researchers publishing criticism in the respective journals, while a recent analysis listed 18 studies that it said had not considered that some human tissue can produce measurements easily confused with the signal given by common plastics. There is an increasing international focus on the need to control plastic pollution but faulty evidence on the level of microplastics in humans could lead to misguided regulations and policies, which is dangerous, researchers say. It could also help lobbyists for the plastics industry to dismiss real concerns by claiming they are unfounded. While researchers say analytical techniques are improving rapidly, the doubts over recent high-profile studies also raise the questions of what is really known today and how concerned people should be about microplastics in their bodies. “Levels of microplastics in human brains may be rapidly rising” was the shocking headline reporting a widely covered study in February. The analysis, published in a top-tier journal and covered by the Guardian, said there was a rising trend in micro- and nanoplastics (MNPs) in brain tissue from dozens of postmortems carried out between 1997 and 2024. However, by November, the study had been challenged by a group of scientists with the publication of a “Matters arising” letter in the journal. In the formal, diplomatic language of scientific publishing, the scientists said: “The study as reported appears to face methodological challenges, such as limited contamination controls and lack of validation steps, which may affect the reliability of the reported concentrations.” One of the team behind the letter was blunt. “The brain microplastic paper is a joke,” said Dr Dušan Materić, at the Helmholtz Centre for Environmental Research in Germany. “Fat is known to make false-positives for polyethylene. The brain has [approximately] 60 percent fat.” Materić and his colleagues suggested rising obesity levels could be an alternative explanation for the trend reported in the study. Materić said: “That paper is really bad, and it is very explainable why it is wrong.” He thinks there are serious doubts over “more than half of the very high impact papers” reporting microplastics in biological tissue. Matthew Campen, senior author of the brain study in question, told the Guardian: “In general, we simply find ourselves in an early period of trying to understand the potential human health impacts of MNPs and there is no recipe book for how to do this. Most of the criticism aimed at the body of work to date (ie from our lab and others) has been conjectural and not buffeted by actual data. “We have acknowledged the numerous opportunities for improvement and refinement and are trying to spend our finite resources in generating better assays and data, rather than continually engaging in a dialogue.” But the brain study is far from alone in having been challenged. One, which reported that patients with MNPs detected in carotid artery plaques had a higher risk of heart attacks and strokes than patients with no MNPs detected, was subsequently criticized for not testing blank samples taken in the operating room. Blank samples are a way of measuring how much background contamination may be present. Another study reported MNPs in human testes, “highlighting the pervasive presence of microplastics in the male reproductive system.” But other scientists took a different view: “It is our opinion that the analytical approach used is not robust enough to support these claims.” This study was by Campen and colleagues, who responded: “To steal/modify a sentiment from the television show Ted Lasso, ‘[Bioanalytical assays] are never going to be perfect. The best we can do is to keep asking for help and accepting it when you can and if you keep on doing that, you’ll always be moving toward better.’” > “This isn’t a dig…They use these techniques because we haven’t got anything > better available to us.” Further challenged studies include two reporting plastic particles in blood—in both cases the researchers contested the criticisms—and another on their detection in arteries. A study claiming to have detected 10,000 nanoplastic particles per liter of bottled water was called “fundamentally unreliable” by critics, a charge disputed by the scientists. The doubts amount to a “bombshell,” according to Roger Kuhlman, a chemist formerly at the Dow Chemical Company. “This is really forcing us to re-evaluate everything we think we know about microplastics in the body. Which, it turns out, is really not very much. Many researchers are making extraordinary claims, but not providing even ordinary evidence.” While analytical chemistry has long-established guidelines on how to accurately analyze samples, these do not yet exist specifically for MNPs, said Dr. Frederic Béen, at Vrije Universiteit Amsterdam: “But we still see quite a lot of papers where very standard good laboratory practices that should be followed have not necessarily been followed.” These include measures to exclude background contamination, blanks, repeating measurements and testing equipment with samples spiked with a known amount of MNPs. “So you cannot be assured that whatever you have found is not fully or partially derived from some of these issues,” Béen said. A key way of measuring the mass of MNPs in a sample is, perhaps counterintuitively, vaporizing it, then capturing the fumes. But this method, dubbed Py-GC-MS, has come under particular criticism. “[It] is not currently a suitable technique for identifying polyethylene or PVC due to persistent interferences,” concluded a January 2025 study led by Cassandra Rauert, an environmental chemist at the University of Queensland in Australia. “I do think it is a problem in the entire field,” Rauert told the Guardian. “I think a lot of the concentrations [of MNPs] that are being reported are completely unrealistic.” “This isn’t a dig at [other scientists],” she added. “They use these techniques because we haven’t got anything better available to us. But a lot of studies that we’ve seen coming out use the technique without really fully understanding the data that it’s giving you.” She said the failure to employ normal quality control checks was “a bit crazy.” > “It’s really the nano-size plastic particles that can cross biological > barriers,” but today’s instruments “cannot detect nano-size particles.” Py-GC-MS begins by pyrolyzing the sample—heating it until it vaporizes. The fumes are then passed through the tubes of a gas chromatograph, which separates smaller molecules from large ones. Last, a mass spectrometer uses the weights of different molecules to identify them. The problem is that some small molecules in the fumes derived from polyethylene and PVC can also be produced from fats in human tissue. Human samples are “digested” with chemicals to remove tissue before analysis, but if some remains, the result can be false positives for MNPs. Rauert’s paper lists 18 studies that did not include consideration of the risk of such false positives. Rauert also argues that studies reporting high levels of MNPs in organs are simply hard to believe: “I have not seen evidence that particles between 3 and 30 micrometers can cross into the blood stream,” she said. “From what we know about actual exposure in our everyday lives, it is not biologically plausible that that mass of plastic would actually end up in these organs.” “It’s really the nano-size plastic particles that can cross biological barriers and that we are expecting inside humans,” she said. “But the current instruments we have cannot detect nano-size particles.” Further criticism came in July, in a review study in the Deutsches Ärzteblatt, the journal of the German Medical Association. “At present, there is hardly any reliable information available on the actual distribution of microplastics in the body,” the scientists wrote. Plastic production has ballooned by 200 times since the 1950s and is set to almost triple again to more than a billion metric tons a year by 2060. As a result, plastic pollution has also soared, with 8 billion metric tons now contaminating the planet, from the top of Mount Everest to the deepest ocean trench. Less than 10 percent of plastic is recycled. An expert review published in the Lancet in August called plastics a “grave, growing and underrecognised danger” to human and planetary health. It cited harm from the extraction of the fossil fuels they are made from, to their production, use and disposal, which result in air pollution and exposure to toxic chemicals. > Insufficiently robust studies might help lobbyists for the plastics industry > downplay known risks of plastic pollution. In recent years, the infiltration of the body with MNPs has become a serious concern, and a landmark study in 2022 first reported detection in human blood. That study is one of the 18 listed in Rauert’s paper and was criticized by Kuhlman. But the study’s senior author, Marja Lamoree, at Vrije Universiteit Amsterdam, rejected suggestions of contamination. “The reason we focused on blood in the first place is that you can take blood samples freshly, without the interference of any plastics or exposure to the air,” she said. “I’m convinced we detected microplastics,” she said. “But I’ve always said that [the amount estimated] could be maybe twice lower, or 10 times higher.” In response to Kuhlman’s letter, Lamoree and colleagues said he had “incorrectly interpreted” the data. Lamoree does agree there is a wider issue. “It’s still a super-immature field and there’s not many labs that can do [these analyses well]. When it comes to solid tissue samples, then the difficulty is they are usually taken in an operating theatre that’s full of plastic.” “I think most of the, let’s say, lesser quality analytical papers come from groups that are medical doctors or metabolomics [scientists] and they’re not driven by analytical chemistry knowledge,” she said. Improving the quality of MNP measurements in the human body matters, the scientists said. Poor quality evidence is “irresponsible” and can lead to scaremongering, said Rauert: “We want to be able to get the data right so that we can properly inform our health agencies, our governments, the general population and make sure that the right regulations and policies are put in place. “We get a lot of people contacting us, very worried about how much plastics are in their bodies,” she said. “The responsibility [for scientists] is to report robust science so you are not unnecessarily scaring the general population.” > “We do have plastics in us—I think that is safe to assume.” Rauert called treatments claiming to clean microplastics from your blood “crazy”—some are advertised for £10,000 (about $13,400). “These claims have no scientific evidence,” she said, and could put more plastic into people’s blood, depending on the equipment used. Materić said insufficiently robust studies might also help lobbyists for the plastics industry downplay known risks of plastic pollution. The good news, said Béen, is that analytical work across multiple techniques is improving rapidly: “I think there is less and less doubt about the fact that MNPs are there in tissues. The challenge is still knowing exactly how many or how much. But I think we’re narrowing down this uncertainty more and more.” Prof Lamoree said: “I really think we should collaborate on a much nicer basis—with much more open communication—and don’t try to burn down other people’s results. We should all move forward instead of fighting each other.” In the meantime, should the public be worried about MNPs in their bodies? Given the very limited evidence, Lamoree said she could not say how concerned people should be: “But for sure I take some precautions myself, to be on the safe side. I really try to use less plastic materials, especially when cooking or heating food or drinking from plastic bottles. The other thing I do is ventilate my house.” “We do have plastics in us—I think that is safe to assume,” said Materić. “But real hard proof on how much is yet to come. There are also very easy things that you can do to hugely reduce intake of MNPs. If you are concerned about water, just filtering through charcoal works.” Experts also advise avoiding food or drink that has been heated in plastic containers. Rauert thinks that most of the MNPs that people ingest or breath in probably expelled by their bodies, but said it can’t hurt to reduce your plastics exposure. Furthermore, she said, it remains vital to resolve the uncertainty over what MNPs are doing to our health: “We know we’re being exposed, so we definitely want to know what happens after that and we’ll keep working at it, that’s for sure.”

This story was originally published by the Guardian and is reproduced here as part of the Climate Desk collaboration. One year on from the Eaton Fire, long after the vicious winds that sent embers cascading from the San Gabriel mountains and the flames that swallowed entire streets, a shadow still hangs over Altadena. Construction on new properties is under way, and families whose homes survived the fire have begun to return. But many are grappling with an urgent question: is it safe to be here? The fire upended life in this part of Los Angeles county. By the time firefighters brought it under control, 19 people were dead, tens of thousands displaced and nearly 9,500 structures destroyed, primarily in Altadena but also in Pasadena and Sierra Madre. Guardian graphic. Fire extent source: Cal Fire. Building damage source: analysis of Copernicus Sentinel-1 satellite data by Corey Scher of CUNY Graduate Center and Jamon Van Den Hoek of Oregon State University. Using building data from Oak Ridge National Laboratory and fire perimeters from NIFC/FIRIS. All times are localGuardian graphic. Fire extent source: Cal Fire. Building damage source: analysis of Copernicus Sentinel-1 satellite data by Corey Scher of CUNY Graduate Center and Jamon Van Den Hoek of Oregon State University. Using building data from Oak Ridge National Laboratory and fire perimeters from NIFC/FIRIS. Note: all times are local The flames incinerated many older homes and businesses filled with lead paint and asbestos. They showered the community with toxins, leaving tall piles of ash and unseen traces of heavy metals in the soil and along and inside standing structures. Research has indicated some hazards remain even after properties have undergone remediation, the clean-up process that is supposed to restore homes and ensure they are safe to occupy. As Altadena fights to return, residents—some eager to stay in the community and others who simply can’t afford to go anywhere else—are facing immense challenges while trying to rebuild their lives and come back home. Official information about the health risks was limited early on and those returning often only learned about the dangers as they went. Some people have developed health concerns such as migraines and respiratory issues. Many are still battling their insurance companies to fully cover their costs, and make certain their homes are habitable. Their predicament highlights the increased dangers that come with urban fires, and shows how Altadena has come to serve as a sort of living laboratory with scientists and residents learning in real time. Nicole Maccalla, a data scientist, and her family moved back into their Altadena home over the summer after their property underwent an extensive cleanup process, but their air purifiers still register high levels of particulate matter, heavy sediment appears when they vacuum and when it rains the distinctive smell from the fire returns. “The toll of displacement was really high on my family. And I just had to move home and try [to] mitigate risk and keep fighting the good fight,” she said. “There’s always that back-of-your-mind concern: Did I make the right choice? But I also don’t have other choices.” Early on in those first careening hours of the fire, as thick smoke and ash fell like snow over her yard, Dawn Fanning was sure her home would not be spared. The wind was blowing from the fire straight to the Spanish bungalow the producer shared with her adult son, and it seemed there was no way to stop it. Dawn Fanning outside her home in Pasadena, California, on December 28 2025. The interior of her home has been found to have lead and asbestos after the Eaton Fire.Stella Kalinina/Guardian Fanning’s home, miraculously, escaped the flames. But, while the stucco structure was intact—clothes still hanging undisturbed in her closet and her son’s baby photos packed carefully in bins in the garage—it hadn’t been unscathed either. Virtually nothing in Altadena was. “It’s dusty and there’s piles of ash in the windowsills and on the floor. At first glance, it doesn’t look any different,” Fanning said. “Your house looks the same—but it’s not. There’s toxicity in your attic and in your crawlspace and on your mattresses and on all the things.” Confused and frustrated with the local government’s handling of health concerns, Maccalla and Fanning joined other fire survivors to form Eaton Fire Residents United in hopes of ensuring the impacted areas recover safely. The community group is developing testing and remediation guidelines, gathered hygienic testing reports of hundreds of homes, and advocated for fire survivors and workers. > “When she awoke at 3 a.m., the blaze had formed a horseshoe shape around her > house, and smoke filled the room.” “There [have been] huge threats to the health and safety of residents, children in schools, elderly and immunocompromised, workers that are coming into this area that are being exposed to hazards in the workplace,” Maccalla said. “We’re still trying to work on that and get the protections people need.” Barely 15 miles north-east of downtown Los Angeles, Altadena at the start of last year was home to some 43,000 people, many lured by the affordable home prices, proximity to the mountains and bucolic feel. It has long been one of the most diverse cities in the region with a thriving Black community that began to grow during the great migration. In the early evening on January 7 2025, Fanning, who had lived in her home in the area for two decades, had a feeling she couldn’t shake that something could go very wrong. There were treacherous winds that forecasters warned posed a serious fire risk. Already, a fire was spreading rapidly on the other side of the county in the Pacific Palisades, where frantic residents were trying to evacuate and firefighters were clearing the area. Some 35 miles away, Fanning and her son were watching coverage of the unfolding fire while readying their property. Then came an alert—not from officials—but from a local meteorologist who was telling his followers to get out now. Fanning spotted flames several blocks away and she and her son decided it was time to leave. A few miles to the east, Rosa Robles was evacuating with her grandchild in tow, leaving her husband and adult children. She wanted them to go—but they were protecting the home. Armed with garden hoses, they tried to save the residence and the other houses on their block. Sometimes the wind was so strong it blew the water back in their faces, Robles said. Maccalla’s power had gone out that morning, and she and her children were sitting around watching the TV drama Fire Country on an iPad in the dark when they got the call about the fire. It seemed far away at the time, Maccalla recalled, and she felt prepared as a member of a community emergency response team. They got out lamps and began packing in case they needed to leave. She set alarms hourly to monitor the progress of the fire while her children slept. When she awoke at three, the blaze had formed a horseshoe shape around her house, and smoke filled the room. The family evacuated with their two dogs and two cats. Tamara Artin had returned from work to see chaos on the street, with fierce winds and billowing smoke all around the house she rented with her husband. Artin, who is Armenian by way of Iran and has lived in Los Angeles for about six years, always loved the area. She enjoyed the history and sprawling green parks, and had been excited to live here. Now the pair was quickly abandoning the home they had moved into just three months earlier, heading toward a friend’s house with their bags and passports. Fanning and her son had gone to a friend’s home too. As they stayed up late listening to the police scanner, they heard emergency responders call out addresses where flames were spreading. These were friends’ homes. She waited to hear her own. > “We were worried, of course, because we were inhaling all those chemicals > without knowing what it is.” In the first days after the fire began, the risk remained and there was little help available with firefighting resources spread across Los Angeles. Maccalla and her son soon returned to their property to try to protect their home and those of their neighbors. “I was working on removing a bunch of debris that had flown into the yard and all these dry leaves. I didn’t know at the time that I shouldn’t touch any of that,” she said.” The devastation in Altadena, as in the Palisades, was staggering. Many of the 19 people who died were older adults who hadn’t received evacuation warnings for hours after people in other areas of town, if at all. Physically, parts of Altadena were almost unrecognizable. In the immediate aftermath of the fire, bright red flame retardant streaked the hillsides. Off Woodbury Road, not far from where Robles and Artin lived, seemingly unblemished homes stood next to blackened lots where nothing remained but fireplaces and charred rubble—scorched bicycles, collapsed beds and warped ovens. The pungent smell of smoke seemed to embed itself in the nose. Robles would sometimes get lost in the place she had lived her whole life as she tried to navigate streets that had been stripped of any identifiable landmarks. Fire scorched the beloved community garden, the country club, an 80-year-old hardware store, the Bunny Museum and numerous schools and houses of worship. Artin and her husband returned to their home, which still stood, after a single night. They had no family in the area and nowhere else to go—hotels were packed across the county. For nearly two weeks they lived without water or power as they tried to clean up, throwing away most of their furniture and belongings, even shoes, and all of the food in the fridge and freezer. “We were worried, of course, because we were inhaling all those chemicals without knowing what it is, but we didn’t have a choice,” Artin recalled. As fires burn through communities, they spread particulate matter far and wide, cause intense smoke damage in standing structures and cars, and release chemicals even miles beyond the burned area. > After one round of remediation, “six out of 10 homes were still coming back > with lead and or asbestos levels that exceeded EPA safety thresholds.” When Fanning saw her home for the first time, thick piles of ash covered the floors. She was eager to return, but as she tried to figure out her next steps, reading scientific articles and guides, and joining Zoom calls with other concerned residents, it was clear she needed to learn more about precisely what was in the ash. Asbestos was found in her home, meaning all porous items, clothing and furniture, were completely ruined. “You can’t wash lead and asbestos out of your clothing. I was like, OK, this is real and I need to gather as much evidence [as I can] to find out what’s in my house.” In Altadena, more than 90 percent of homes had been built before 1975 and likely had lead-based paint and toxic asbestos, both of which the EPA has since banned, according to a report from the California Institute of Technology. All sorts of things burned along with the houses, Fanning said: plastic, electric cars, lithium batteries. “The winds were shoving this into our homes,” she said. The roof on Maccalla’s home had to be rebuilt, and significant cleanup was required for the smoke damage and layers of ash that blanketed curtains and beds. Despite these concerns, residents grew increasingly frustrated about what they viewed as a lack of official information about the safety of returning to their homes. Many also encountered pushback from their insurance providers that said additional testing for hazards, or more intensive remediation efforts recommended by experts, were unnecessary and not covered under their policies. So earlier this year a group of residents, including Fanning and Maccalla, formed Eaton Fire Residents United (EFRU). The group includes scientists and people dedicated to educating and supporting the community, ensuring there is data collection to support legislation, and assembling an expert panel to establish protocols for future fires, Fanning said. They’ve published research based on testing reports from hundreds of properties across the affected area, and advocated that homes should receive a comprehensive clearance before residents return. Research released by EFRU and headed by Maccalla, who has a doctorate in education and specializes in research methodology, found that more than half of homes that had been remediated still had levels of lead and/or asbestos that rendered them uninhabitable. “There’s still widespread contamination and that one round of remediation was not sufficient, the majority of the time. Six out of 10 homes were still coming back with lead and or asbestos levels that exceeded EPA safety thresholds,” said Maccalla, who serves as EFRU’S director of data science and educational outreach. The interior of Dawn Fanning’s home has been found to have lead and asbestos after the Eaton Fire.Stella Kalinina/The Guardian Maccalla moved back home in June after what she viewed as a decent remediation process. But she hasn’t been able to get insurance coverage for additional testing, and worries about how many people are having similar experiences. “We’re putting people back in homes without confirming that they’re free of contamination,” she said. “It feels very unethical and a very dangerous game to be playing.” She couldn’t afford not to come home, and the family couldn’t keep commuting two hours a day each way from their temporary residence to work and school or their Altadena property where Maccalla was overseeing construction. But she’s experienced headaches, her daughter’s asthma is more severe, and her pets have become sick. “I don’t think anybody that hasn’t gone through it can really comprehend what [that is like],” she said. “For everything in your environment that was so beloved to now become a threat is mentally a really hard switch,” she said. Robles settled back to the home she’s lived in for years with a few new additions. Seven of her relatives lost their homes, including her daughter who now lives with her. “I thank God there’s a place for them. That’s all that matters to me.” Nicole Maccalla with her dog, Cami, outside her home in Altadena. Stella Kalinina/The Guardian After the fire, she threw away clothes, bed sheets and pillows. The family mopped and washed the walls. Her insurance was helpful, she said, and covered the cleanup work. Robles tries not to think about the toxic contamination and chemicals that spread during the fire. “You know that saying, what you don’t know?” she said, her voice trailing off. Artin said she received some assistance from her renter’s insurance, but that her landlord hadn’t yet undertaken more thorough remediation. She’s still trying to replace some of the furniture she had to throw away. The fire had come after an already difficult year in which her husband had been laid off, and their finances were stretched. > “I don’t know if I’ll ever feel safe again.” She shudders when she recalls the early aftermath of the fire, a morning sky as dark as night. “It was hell, honestly.” Her rent was set to increase in the new year, and while she fears exposure to unseen dangers, moving isn’t an option. “We don’t have anywhere else to go. We can’t do anything,” Artin said. Fanning has been battling her insurance company to cover the work that is necessary to ensure her house is safely habitable, she said. Her provider is underplaying the amount of work that needs to be done and underbidding the costs, Fanning said. She and her son have been living in a short-term rental since late summer, and she expects they won’t be able to return home before the fall. Sometimes she wonders if she’ll be up to returning at all. Even now, when Fanning drives through the area to come get her mail or check on the house, she gets headaches. “I don’t know if I’ll ever feel safe, no matter all the things that I know and all the things that I’m gonna do. I don’t know if I’ll ever feel safe again.” In between trying to restore her home, she’s focused on advocacy with EFRU, which has become her primary job, albeit unpaid. “There are so many people that don’t have enough insurance coverage, that don’t speak English, that are renters, that don’t have access like I do … I feel it’s my duty as a human.” There’s much work to do, Fanning said, and it has to be done at every single property. “It’s a long road to recovery. And if we don’t do it right, safely, it’s never gonna be what it was before.”

This story was supported by the Pulitzer Center. It first appeared on The War Horse, an award-winning nonprofit news organization educating the public on military service. Subscribe to their newsletter. Marc Dervaes sat straight-backed in a circle of 10 men at a clinic in Tijuana, Mexico. The glass window behind him looked out on a pool deck and the Pacific Ocean beyond.  Inside, sunglasses masked his eyes, and a beard grew down to his chest. His blank expression invited no sympathy, and Dervaes had none to give.  “I’m sorry if this offends anyone,” he said at the introductory circle, “but I really don’t care about any of you. I’m here for me.” Dervaes knew the men would be curious about his amputation. He mentioned losing his right arm in Afghanistan but had no intention of sharing more.  The pool deck at one of Ambio Life Sciences’ clinics near Tijuana, Mexico. Natanya Friedheim Each man had his own reason to visit the clinic, where patients pay around $8,000 for a psychedelic treatment with little scientific backing. They all hoped suffering through a brain-bending, vomit-inducing, existential jolt would cure their ailments, which ranged from malaise to traumatic brain injury. A veteran of the Iraq and Afghanistan wars, Dervaes had one foot in the grave before contacting Ambio Life Sciences. Two months earlier, he had spent two days in a hospital back home in Colorado Springs with alcohol poisoning that he hoped would end his life.  “Peace was totally gone in this house,” said Michaela Dervaes, his wife of 26 years. Dervaes called the clinic after leaving the hospital. The earliest it could schedule him was April 2026—a nine-month wait. Dervaes told the man on the phone he would be dead by then.  Michaela and Marc Dervaes at an archery range in April 2021. Photo courtesy of Marc Dervaes Two companies operating clinics in Tijuana, Ambio Life Sciences and The Mission Within Center, say they have treated about 3,000 U.S. veterans in the last decade. Both use the psychedelics ibogaine—derived from the root of a central African shrub—and 5-MeO-DMT—a chemical secreted by the Sonoran desert toad. A common motivation among participants has emerged: The talk therapy and prescriptions offered by the Department of Veterans Affairs proved ineffective.  Every time Breanna Morgan opens the clinic’s oversized wooden door and shows patients into the foyer—where a half-dozen staffers wait to greet them—she assumes it’s the worst day of their lives. “They’re not here because they really want to be here,” Morgan, Ambio’s guest experience manager, said in an interview. “They’re here because it’s their only option.”  > “They’re not here because they really want to be here. They’re here because > it’s their only option.”  This is the story of one of those guests—a broken veteran whose ibogaine experience would put him face-to-face with everyone in his life he had ever wronged. His tears would soak through the eye mask patients wear to limit sensory input.  Back home, confronted by another tragedy, Dervaes would quickly regret his visit to the cliffside mansion and resent the clinic that took thousands of dollars from him.  Then, four months later, he would return. Breanna Morgan, Ambio’s guest experience manager, explains to patients how to mentally prepare for ibogaine.Natanya Friedheim MEDICAL RESEARCH AND COASTAL RETREATS For decades, overseas drug rehab clinics have offered ibogaine to people addicted to cocaine and opioids. The drug’s use among military veterans has surged over the last four years. Despite support from veterans, a push for more research, and efforts by advocates to legalize the psychedelic treatment in the United States, much remains unknown about the drugs’ long-term effectiveness and safety. The federal Drug Enforcement Administration considers both ibogaine and 5-MeO-DMT Schedule 1 substances, meaning the agency finds both have a high potential for abuse and no accepted medical use. A nurse checks Marc Dervaes’ blood pressure before he and nine other patients go to a backyard sweat lodge. Ibogaine can cause heart arrhythmias.Natanya Friedheim Psychedelic medicine advocates fear the expensive, decade-long process of bringing a new drug to market in the U.S. will adulterate both the drugs and the environments in which people take them.   Researchers, meanwhile, fear that the media hype and the proliferation of ceremonies replete with New Age rhetoric and dubious claims will undermine their efforts to gain FDA approval.  As debates play out at state legislatures and research conferences, it is here, in a coastal retreat center down the road from an open-air fruit stand, that veterans come in a desperate attempt to find relief.   Behind the clinic, a steep path, wide enough for trucks full of families, boogie boards, and fishing poles, leads to a beach covered in sand blackened with pollution.Natanya Friedheim ALIVE DAY  Dervaes’ journey to the clinic began more than a decade ago. It was in September 2009 in eastern Afghanistan. Corn grew 8 feet high on either side of the unpaved road outside of Jalalabad.  Dervaes clutched the passenger’s seat grab handle as the mine-resistant ambush protected vehicle rumbled along. A platoon sergeant with 15 years as an Army infantryman under his belt, Dervaes felt invincible.  He had survived a bullet to his helmet during his first deployment to Iraq. On his second, he spent 16 grinding months guarding nighttime construction crews in Baghdad.  His convoy drove in a tight pack. That day, a gap formed between his truck and the three others ahead, Dervaes said. “The enemy took full advantage.” Dervaes bent over a junction box to fiddle with a defective cord, his right arm still clutching the grab handle. When he looked up, he saw a man outside, a rocket-propelled grenade mounted on his shoulder aimed at Dervaes.   A big flash, pressure, and heat. Dervaes collapsed over the junction box. His right arm, wristwatch still attached, landed in the driver’s lap. He came to as the driver, his foot still on the gas, pulled Dervaes up by his helmet.  Another RPG shot through the passenger door and out the roof. The truck caught fire and filled with smoke. Chunks of flesh and bone covered the side of the cab. Dervaes heard screaming. “Someone else is hurt,” he thought. “Someone else in the truck is either dead or hurt.”  Before he was medevaced, Marc Dervaes pulled a camera out of his pocket to chronicle the ambush in which he lost his right arm in Afghanistan. He said the photo shows resilience.Photo courtesy of Marc Dervaes His body tingled. His vision grew blurry. A man with a belt-fed machine gun emerged from the stalks of corn. Somehow, the truck kept moving forward. “Drive. Drive. Don’t stop,” Dervaes said as bullets shattered the windshield.  He spent eight months recovering at an Army hospital in San Antonio, Texas, then returned to Fort Carson, Colorado, just as his unit got back from Afghanistan. He and the driver finally had time to look back. Dervaes longed to fill gaps in his memory.  “Who was screaming?” Dervaes remembers asking.  “It was you,” the driver said.  LIFE AFTER WAR Like so many Americans, Dervaes battled prescription opioid addiction after his surgeries. He faced a personal crisis, described by many veterans, of adapting to a civilian life that lacks the structure, urgency, and adrenaline soldiers grow accustomed to at war. He sought thrills as a U.S. Paralympic snowboarder. He and his wife began cave diving. As a volunteer for the nonprofit Team River Runner, he designed prosthetics for adaptive kayaking. He helped to launch the Colorado Springs chapter of the nonprofit Wounded Warrior Project. He instructs children with disabilities in snowboarding.  Dervaes threw himself into extreme sports after his battlefield injuries.Photo courtesy of Marc Dervaes More than a decade of athleticism landed him seven rib fractures, a concussion, a bruised lung, and three surgeries on his left arm, all between 2021 and 2025. So damaged was his left arm, his only arm, that he could hold neither a Voodoo Ranger beer can nor his basset hound puppy Ruby.  The pain led him to spiral.  Hours before traveling to Tijuana, Dervaes paced around the lobby of the Sheraton San Diego Resort. A hotel staffer asked if he was OK. The night before, his wife blocked the hotel room door to prevent Dervaes from leaving. Sober for three months, a requirement of attending the clinic, Dervaes wanted a drink. He feared the treatment, a last-ditch effort to address his deteriorating mental health and excessive drinking, would fail.   Two SUVs pulled up in front of the hotel’s entryway fountain. It was a Tuesday morning in early August. Dervaes sat alone in the back seat of one as drivers piled luggage into the trunks.  “How’s it going, man?” asked Brad Banks, a medical device salesman trying to quit drinking, as he slid next to Dervaes. Maintaining his forward gaze, Dervaes barely grunted.  The men rode in silence past the border checkpoints where Mexican officers wore rifles slung across their chests. In the beachside community of Playas de Tijuana, the SUVs turned down an unpaved road.  Across from a cluster of shanties, a concrete wall fortifies the clinic, an 11-bedroom compound where foreigners come and go each week. The entrance to one of Ambio Life Sciences’ clinics in MexicoNatanya Friedheim A stay at Ambio starts with an EKG, one of many medical tests the clinic requires to ensure patients are fit for ibogaine. The drug has a narrow therapeutic window, meaning a little more than an effective dose can be toxic. Too much can cause heart arrhythmias.  A 2022 review of literature published on ibogaine found 38 deaths and 20 medical emergencies associated with its use documented in medical literature. In most of those cases, the drug was used to treat opioid addiction. Other emergencies may have gone undocumented given ibogaine’s use in nonmedical settings.  Both ibogaine and 5-MeO-DMT can exacerbate existing mania or psychosis, according to Martín Polanco, a doctor who founded The Mission Within Center in Tijuana. Three hours after arrival, the men changed into swim trunks and crowded back into the Suburbans. Dervaes’ tough-guy veneer started melting away on the drive to a backyard sweatlodge. “I think it’s time we discuss sweat lodge etiquette,” he said from the back seat, squished beside two passengers. “No farting in the sweat lodge.”  A nurse checks Marc Dervaes’s heart with an EKG within hours of his arrival at Ambio Life Sciences. Monitoring is required to ensure patients are fit to take ibogaine. Natanya Friedheim ‘DON’T COME HERE TO GET HIGH’ Few people report enjoying their experience on ibogaine. Many have visions. Some see deceased relatives. To some patients’ chagrin, they see and feel nothing.  People who have taken ibogaine refer to the frequent vomiting during the more than 10-hour trip as “purging” and frame it as part of the healing experience.  The men sat around the large wooden dining table on Wednesday, the morning before they took ibogaine. Over French toast and chicken enchiladas, Isaac Pulido told them he could not predict how they would feel that night. “Many years of doing this and we still don’t have the power,” he said.  Pulido estimates he has overseen more than 4,000 treatments over the last 16 years. A nurse with a doctorate specializing in intensive care, he oversees treatments at all Ambio’s clinics in Mexico.  “Remember, we come here to get healed. We don’t come here to get high,” he told the men. “But if you get high, oh my God, embrace it. Enjoy it.” Intensive care nurse Isaac Pulido administers the treatments in Ambio’s Mexico clinics. Natanya Friedheim Doses at Ambio vary based on each patient’s body weight. If the person feels nothing after about two hours, they can take a booster pill.  > “Remember, we come here to get healed. We don’t come here to get high. But if > you get high, oh my God, embrace it. Enjoy it.” It’s possible that lower, nonhallucinogenic doses have benefits without cardiotoxicity, said David Olson, a professor at the University of California, Davis, and director at the UC Davis Institute for Psychedelics and Neurotherapeutics. But a lot of people who take hallucinogenic drugs want to trip out and end up disappointed if they don’t.  “They expect to see unicorns and all that shit,” Pulido said in an interview. Dervaes did not see unicorns.  The third and final dose of ibogaine is taken with honey. Natanya Friedheim DANTE’S INFERNO Around 10 p.m. that night, the men had swallowed their third pill. They collected pillows and descended stairs to the clinic’s treatment room. Twin mattresses lined the walls, each with a mirror propped in front of it. The men sat cross-legged on the edge of their mattresses like preschoolers getting ready for nap time. They shook rattles and stared in their mirrors. Over the next hour, lo-fi music gave way to a chaotic mix of plucked string instruments, traditional ceremonial Gabonese music.  Six nurses, two paramedics, and two doctors kept watch over the patients, who wore heart monitors throughout the night.  Patients wear heart monitors throughout the night as they experience the effects of ibogaine.Natanya Friedheim As Dervaes shook his rattle, his reflection showed him something evil, as he recalled 36 hours after his ibogaine trip. He tried to smile or change his expression. He slid on an eye mask and lay back to visions he feared would continue all night: wave after wave of people he had wronged. Each time he tried to apologize, a new vision appeared.  The drug exacerbated the severe tinnitus in his left ear. When he lifted his mask, Dervaes saw the room on fire with piles of bodies and people retching.  In the early afternoon the following day, as the drug’s effects waned, Dervaes looked in the mirror. His big brown eyes looked back at him. His downturned and angry brows had vanished.  Ibogaine’s effect on the brain has long puzzled pharmacologists. The drug reduces depression and anxiety and blocks drug withdrawals, said Deborah Mash, a pioneering ibogaine researcher who received FDA approval to study the drug in the mid-1990s.  While ibogaine leaves the blood within 24 hours, its metabolite noribogaine—what the liver creates after processing ibogaine—stays in the body longer. Noribogaine pumps the brain with dopamine, the neurotransmitter associated with mood and motivation. Drug abuse and depression are associated with dopamine deficiency. “You’re helping to restore dopamine homeostasis in the brain,” Mash said. “The enduring effect is a question that neuroscience hasn’t completely worked out.”  Ambio nurse Angie Serrano puts smoke from burning sage, a practice known as “smudging,” around Mark Dervaes’ body before he takes ibogaine.Natanya Friedheim THE SECOND TRIP The men ambled back to their rooms around midday Thursday. The sleepover party had ended. Many people experience hangover symptoms after the hallucinogenic effects of ibogaine wear off.  Only a few of the patients made it to breakfast the following morning. After a day of rest, the men would inhale another psychedelic, a synthetic version of 5-MeO-DMT.  The men circled up in the living room around noon on Friday. An Ambio employee’s prelude to the upcoming drug sounded like a warning: “For the people who are going to be here, waiting for their turn,” she said, “if you hear someone screaming for their lives or yelling like they’re about to die or something, don’t worry about it. It’s absolutely normal.” > “If you hear someone screaming for their lives or yelling like they’re about > to die or something, don’t worry about it. It’s absolutely normal.” Controversy exists over whether 5-MeO-DMT should be used in conjunction with ibogaine. “There’s no good medical or scientific reason for that at all,” said Albert Garcia-Romeu, an associate professor of psychiatry and behavioral sciences who studies psychedelics at the Johns Hopkins University School of Medicine. Dervaes sat in a hallway waiting his turn. He had arrived at the clinic indifferent to others. Now, he couldn’t stop thinking about a fellow patient, a young man whose bad ibogaine trip caused him to cry throughout the night.  Dervaes slipped off his sandals and relaxed in a hammock during down time at the clinic. In a few hours, he would smoke 5-MeO-DMT.Natanya Friedheim The sounds of wailing traveled down the hallway from a room where another patient, a fellow veteran, took 5-MeO-DMT.  “I have a feeling this is going to hurt,” Dervaes said. “It’s OK. I’ve got to let it go. I have to let all this go. I don’t want to carry it anymore.” When his turn came, Dervaes sat on a cluster of mattresses covered in serape blankets. He inhaled vapor from a pipe and lay back. In less than a minute, he began to cry. “Holy shit,” he said, starting to sit up before lying back down to convulsions.  Dervaes came out of the trip ready for a second dose. “How do you feel?” the woman asked after he sat up minutes later. “I feel reborn,” he said, his eyelashes wet with tears.  Five days later, back home in Colorado, Dervaes updated the group on his progress via their Signal chat.  He had gone to Costco.  “I DON’T GO TO COSTCO!” he wrote. “It was amazing, I didn’t feel like I wanted to strangle anyone! There was no anxiety, fear, or anger; I felt safe!!” Ambio nurse Angie Serrano props her head up on her hand as she waits for Dervaes to come out of his 5-MeO-DMT trip. Natanya Friedheim TRAUMA RETURNS  If patients experience stress after taking psychedelics, the drugs “can do more damage than good,” according to Gul Dolen, a professor of neuroscience at the University of California, Berkeley.  Dolen’s work found psychedelics reopen “critical periods”—windows when the brain is more sensitive to its environment and more capable of learning during early childhood and other critical periods. In the same way a person who just had open-heart surgery shouldn’t climb stairs, people who take psychedelics shouldn’t expose themselves to traumatic events. “Think of this as open-mind surgery,” Dolen said.  For Dervaes, the trauma returned less than a month after returning from Ambio. He lost a friend to suicide. The devastation ripped through his community of friends. In a Zoom call hosted by an Ambio counselor with about 30 former patients, frustration mounted. The healing stopped. Dervaes started drinking. “Regression,” he said.  Marc Dervaes looks out at the Pacific Ocean minutes after taking 5-MeO-DMT. Natanya Friedheim Suddenly, he questioned everything about his ibogaine journey: the healing, the expense, the hope. “I was angry for even going there and wasting my time and money.” Still, his wife, Michaela, noticed subtle changes. He was showing less rage on the road and making progress on letting things that upset him go. Over the next three months, he read more books than he had willingly read in his life, including A Lifetime at War, about a veteran more severely wounded than Dervaes.  “It was like: Wake the fuck up, man,” Dervaes said, “because you’re not the only one that’s out here hurting.” Instead of retreating, he would double down. In early December, as the first snow peppered Colorado Springs, Dervaes packed his bag. Like a growing number of Ambio’s patients, he was returning. Things fell into place quickly. A spot became available at the clinic. A nonprofit agreed to sponsor his trip. On the last day, Breanna Morgan presents Marc Dervaes with his rattle to take home from the clinic. Natanya Friedheim At a fireside ceremony before taking ibogaine for a second time, Dervaes vowed never to touch alcohol again. He has new goals, he said, and the tools to maneuver through life: prayer, meditation, plus treatments like magnetic e-resonance therapy for his post-traumatic stress and traumatic brain injuries. He said he might go back to Ambio again. Michaela Dervaes met her husband at the San Diego airport as he returned from his second trip to Mexico. She looked into his face. The soft eyes and smile were back. The ups and downs have left her exhausted.  “Even though everything seems wonderful right now, there could be just something happening, and it’ll go downhill,” she said. For now, she is hopeful. She sees how hard he is trying. “With this new treatment, I’m thinking we’re at peace.”    This War Horse news story was edited by Mike Frankel, fact-checked by Jess Rohan, and copy-edited by Mitchell Hansen-Dewar. Hrisanthi Pickett wrote the headlines.

On Thursday, in a rebuke to the GOP party line, the House of Representatives voted 230-196 to extend the Affordable Care Act’s enhanced premium subsidies for three more years. 17 Republicans defected to join all Democrats in voting for the legislation, after the end of the subsidies sparked the longest-ever federal government shutdown late last year. It remains to be seen whether the extension will pass the Senate, where a similar three-year extension vote failed in December—but cheers could be heard in the House chamber on C-SPAN after the vote. Rep. Nancy Pelosi (D-Calif.), the former House Speaker who played a key role in the 2010 passage of the ACA, posted on X that “today is a happy day” and that “the Senate must immediately take up this bill to ensure no American is pushed out of coverage.” > Today is a happy day. House Democrats have passed a bill to extend Affordable > Care Act tax credits so health care remains affordable and accessible for > America’s working families. > > The Senate must immediately take up this bill to ensure no American is pushed > out of coverage. > > — Nancy Pelosi (@SpeakerPelosi) January 8, 2026 At the end of last year, enhanced subsidies expired due to Republicans’ and Democrats’ inability to reach a deal on the Biden-era expansion, leaving many Americans facing record premium spikes. As I previously reported, Republican politicians have pushed for a health savings account model, which has shortcomings for people with high health care costs. It’s unclear how many fewer people signed up for ACA marketplace plans for 2026 by December 15, as the Centers for Medicare and Medicaid Services has not released data since December 5. ACA marketplace enrollment remains open through January 15. KFF estimates that the average cost of ACA marketplace plans has increased by 26 percent this year. Thursday’s vote involved sidestepping Republican House Speaker Mike Johnson (R-La.), who has shepherded GOP opposition to ACA benefits, with a vote yesterday for a discharge petition to bring the vote for a three-year extension to the floor. Nine relatively moderate Republican representatives defected from Johnson to join a party-line Democratic vote for the discharge petition. During the debate that preceded the vote, many Democrats shared stories of constituents who faced the prospect of unaffordable health care without the enhanced subsidies. Some Republicans lamented that ACA marketplace plans can include abortion coverage, and claimed that the ACA benefits insurers more than patients. If the extension passes the Senate and is signed into law by President Donald Trump, the nonpartisan Congressional Budget Office estimates that 6.2 million more people will be enrolled in ACA marketplace plans by 2029. Now, the ball is in the Senate’s court.

This story was originally published by Grist and is reproduced here as part of the Climate Desk collaboration. Wildfire smoke is an emerging nationwide crisis for the United States. Supercharged by climate change, blazes are swelling into monsters that consume vast landscapes and entire towns. A growing body of evidence reveals that these conflagrations are killing far more people than previously known, as smoke travels hundreds or even thousands of miles, aggravating conditions like asthma and heart disease. One study, for instance, estimated that last January’s infernos in Los Angeles didn’t kill 30 people, as the official tally reckons, but 440 or more once you factor in the smoke. Another recent study estimated that wildfire haze already kills 40,000 Americans a year, which could increase to 71,000 by 2050. Two additional studies published last month paint an even grimmer picture of the crisis in the US and elsewhere. The first finds that emissions of greenhouse gases and airborne particles from wildfires globally may be 70 percent higher than once believed. The second finds that Canada’s wildfires in 2023 significantly worsened childhood asthma across the border in Vermont. Taken together, they illustrate the desperate need to protect public health from the growing threat of wildfire smoke, like better monitoring of air quality with networks of sensors. The emissions study isn’t an indictment of previous estimates, but a revision of them based on new data. Satellites have spied on wildfires for decades, though in a somewhat limited way—they break up the landscape into squares measuring 500 meters by 500 meters, or about 1,600 feet by 1,600 feet. If a wildfire doesn’t fully fill that space, it’s not counted. This new study increases that resolution to 20 meters by 20 meters (roughly 66 feet by 66 feet) in several key fire regions, meaning it can capture multitudes of smaller fires.  Individually, tinier blazes are not producing as much smoke as the massive conflagrations that are leveling cities in the American West. But “they add up, and add up big time,” said Guido van der Werf, a wildfire researcher at Wageningen University & Research in the Netherlands and lead author of the paper. “They basically double the amount of burned area we have globally.” > Smaller fires may be less destructive then the behemoths, but they can still > be catastrophic, pouring smoke into populated areas. With the 500-meter satellite data, the previous estimate was around 400 million hectares charred each year. Adding the small fires bumps that up to 800 million hectares, roughly the size of Australia. In some parts of the world, such as Europe and Southeast Asia, burned area triples or even quadruples with this improved resolution. While scientists used to think annual wildfire emissions were around 2 gigatons of carbon, or about a fifth of what humanity produces from burning fossil fuels, that’s now more like 3.4 gigatons with this new estimate. The type of fire makes a huge difference in the emissions, too. A forest fire has a large amount of biomass to burn—brushes, grasses, trees, sometimes even part of the soil—and turn into carbon dioxide and methane and particulate matter, but a grass fire on a prairie has much less. Blazes also burn at dramatically different rates: Flames can race quickly through woodland, but carbon-rich ground known as peat can smolder for days or weeks. Peat fires are so persistent, in fact, that when they ignite in the Arctic, they can remain hidden as snow falls, then pop up again as temperatures rise and everything melts. Scientists call them zombie fires. “It really matters where you’re burning and also how intense the fire can become,” van der Werf said. But why would a fire stay small, when we’ve seen in recent years just how massive and destructive these blazes can get? It’s partly due to fragmentation of the landscape: Roads can prevent them from spreading, and firefighters stop them from reaching cities. And in general, a long history of fire suppression means they’re often quickly extinguished. (Ironically, this has also helped create some monsters, because vegetation builds up across the landscape, ready to burn. This shakes up the natural order of things, in which low-intensity fires from lightning strikes have cleared dead brush, resetting an ecosystem for new growth—which is why Indigenous tribes have long done prescribed burns.) Farmers, too, burn their waste biomass and obviously prevent the flames from getting out of hand.  Whereas in remote areas, like boreal forests in the far north, lightning strikes typically ignite fires, the study found that populated regions produce a lot of smaller fires. In general, the more people dotting the landscape, the more sources of ignition: cigarette butts, electrical equipment producing sparks, even chains dragging from trucks. Yes, these smaller fires are less destructive than the behemoths, but they can still be catastrophic in a more indirect way, by pouring smoke into populated areas. “Those small fires are not the ones that cause the most problems,” van der Werf said. “But of course they’re more frequent, close to places where people live, and that also has a health impact.” That is why the second study on asthma is so alarming. Researchers compared the extremely smoky year of 2023 in Vermont to 2022 and 2024, when skies were clearer. They were interested in PM 2.5, or particulate matter smaller than 2.5 millionths of a meter, from wildfire smoke pouring in from Quebec, Canada. “That can be especially challenging to dispel from lungs, and especially irritating to those airways,” said Anna Maassel, a doctoral student at the University of Vermont and lead author of the study. “There is research that shows that exposure to wildfire smoke can have much longer-term impacts, including development of asthma, especially for early exposure as a child.” This study, though, looked at the exacerbation of asthma symptoms in children already living with the condition. While pediatric asthma patients typically have fewer attacks in the summer because they’re not in school and constantly exposed to respiratory viruses and other indoor triggers, the data showed that their conditions were much less controlled during the summer of 2023 as huge wildfires burned. (Clinically, “asthma control” refers to milder symptoms like coughing and shortness of breath as well as severe problems like attacks. So during that summer, pediatric patients were reporting more symptoms.) At the same time, climate change is extending growing seasons, meaning plants produce more pollen, which also exacerbates that chronic disease. “All of those factors compound to really complicate what health care providers have previously understood to be a safe time of year for children with asthma,” Maassel said.  Researchers are also finding that as smoke travels through the atmosphere, it transforms. It tends to produce ozone, for instance, that irritates the lungs and triggers asthma. “There’s also the potential for increased formation of things like formaldehyde, which is also harmful to human health. It’s a hazardous air pollutant,” said Rebecca Hornbrook, who studies wildfire smoke at the National Center for Atmospheric Research, but wasn’t involved in either study, though a colleague was involved in the emissions one. (Last month, the Trump administration announced plans to dismantle NCAR, which experts say could have catastrophic effects.) As wildfires worsen, so too does the public health crisis of smoke, even in places that never had to deal with the haze before. Governments now have to work diligently to protect their people, like improving access to air purifiers, especially in schools. “This is no longer an isolated or geographically confined issue,” Maassel said. “It’s really spreading globally and to places that have never experienced it before.”

Federal health officials reduced the number of vaccines recommended for all children from 17 to 11 on Monday. According to the new schedule, some routine vaccines are now only recommended for “high-risk” children, while others, like the flu shot, can be administered through “shared clinical decision-making” that is based on individual discussions between the health care provider and the patient or guardian.  An assessment that provided the scientific basis for the decision to revise the immunization schedule states that an “increased emphasis on shared clinical decision-making would help restore trust in public health recommendations made by CDC.” It cites that from 2020 to 2024, trust in health care declined, “coinciding with school closures, other lockdowns, mandatory face masks, COVID-19 vaccination mandates with their de facto denial of infection-acquired immunity, and other public health recommendations that lacked scientific rationale.”  The Department of Health and Human Services’ announcement comes in response to a presidential order from Donald Trump last month that directed HHS Secretary Robert F. Kennedy, Jr., and Acting CDC Director Jim O’Neill to update the vaccine schedule according to “peer, developed countries.” Trump’s memo said that at the beginning of 2025, the US “was a high outlier” in the number of vaccinations it recommended.   But, as STAT News reports, “some other wealthy countries, including those consulted by U.S. officials, actually have similar recommendations.” HHS’ announcement said many of the peer nations that “recommend fewer routine vaccines achieve strong child health outcomes and maintain high vaccination rates through public trust and education rather than mandates.” “We are aligning the U.S. childhood vaccine schedule with international consensus while strengthening transparency and informed consent,” Kennedy said in the announcement. “This decision protects children, respects families, and rebuilds trust in public health.” This change to the vaccine schedule is the culmination of months of efforts by Kennedy, who has a long record of anti-vaccine activism, to alter the way vaccines are approved and recommended. CDC recommendations were also a target in Project 2025, which states, never again should CDC officials be allowed to say in their official capacity that school children ‘should be’ masked or vaccinated (through a schedule or otherwise).” Last month, a panel appointed by Kennedy, the CDC’s Advisory Committee on Immunization Practices, voted to end universal hepatitis B recommendations for newborns.  According to NPR, officials said that the revision was made without formal public comment or response from vaccine makers, evading the usual process in which bodies like the CDC’s ACIP evaluate changes. Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy, told NPR that the decision “will sow further doubt and confusion among parents and put children’s lives at risk.”

In 2023, Marlena Arjo adopted a one-eyed kitten with a penchant for destruction. She named him Otto, and over the next eight months, Otto grew into his own little chaotic personality. “ He’s laying on houseplants, he’s tearing books out of the bookshelves, ripping the calendar off the wall…I wasn’t prepared for having a criminal in my home,” Arjo joked. Within months, Otto got sick and stopped eating. Arjo rushed him to a vet and learned he had feline infectious peritonitis, better known as FIP, a disease that kills nearly all cats that contract it.  Subscribe to Mother Jones podcasts on Apple Podcasts or your favorite podcast app. The vet said there was nothing the clinic could do. But there was something Arjo could do. “I shouldn’t tell you this,” Arjo recalled the vet telling her. “But by the way, you can get drugs for this if you go to this Facebook group.” This week on Reveal, in partnership with the Hyperfixed podcast, we tell the story of the cat drug black market, why it was even necessary, and how cat lovers fought for big changes to make the black market obsolete.

The staff of Mother Jones is, once again, rounding up the heroes and monsters of the past year. This is a non-exhaustive and totally subjective list, giving our reporters a chance to write about something that brought joy, discontent, or curiosity. Happy holidays. My Instagram algorithm has decided that I am a woman, and, therefore, I must want to lose weight. In 2025, that meant it was impossible for me to scroll through my feed without being visually assaulted by ingratiating marketing campaigns, encouraging me to shed those last few pesky pounds via drugs, specifically off-label GLP-1. > For a brief moment, companies found it profitable to showcase physical > diversity and promote the idea of loving your body just the way it is. Not so > anymore. In one ad, I am being pitched “looser jeans.” In another, I am being patronized by a cake: “PSA for the girls,” states shoddily Photoshopped frosting. “You don’t need to be obese to start a GLP-1.” In practice, though, you do—at least according to the US Food and Drug Administration, which has only approved GLP-1 drugs for people with clinical obesity or Type 2 diabetes and for people who are overweight with weight-related comorbidities. The companies that manufacture the name-brand GLP-1s like Ozempic, Zepbound, and Wegovy haven’t meaningfully tested the drugs on people with BMIs lower than 27. The sponsored ads that bombard my feeds, from telehealth companies like Willow, Noom, Fridays, EllieMD, and Midi Health, are technically promoting another product: compounded GLP-1 injections and tablets. These are not FDA-approved; they are custom-made by pharmacists and usually include small doses of semaglutide, the active ingredient in Ozempic, along with other ingredients. EllieMD, for example, offers a “longevity microdose” that includes B12. The FDA has been clear on this. “Compounded drugs should only be used in patients whose medical needs cannot be met by an FDA-approved drug,” states an FDA release warning against the use of unapproved GLP-1 drugs for weight loss. But the ads I’ve seen overwhelmingly focus on cosmetic changes, not improved health. Some discuss quickly dropping a handful of pounds before a big event, like a wedding. To obtain a prescription, you still need to talk to a doctor, who is tasked with assessing your medical history and needs. Willow’s website is explicit about the end game here: “Proven medicine that powers fast cosmetic weight loss.” Willow, Noom, Fridays, and EllieMD did not respond to requests for comment. Midi Health told me it takes a medically focused, clinician-led approach to prescribing GLP-1 medications. “When our clinicians prescribe these therapies, it is because there is a clear medical benefit and as part of a comprehensive care plan focused on a woman’s overall health. GLP-1s have FDA-approved indications beyond obesity, including diabetes, sleep apnea, and long-term weight maintenance…We also recognize that BMI is an imperfect tool designed for research, not individualized medical care,” said Midi Health. To be fair, it isn’t just the off-label drugs that are getting backed by an aggressive marketing push. In 2023, when Ozempic went mainstream, more than 4,000 semaglutide ad campaigns flooded the internet. That same year, print ads for “a weekly shot to lose weight” swept the New York City subways. Ro, the company behind that campaign, now has a series of video ads with Serena Williams. It was depressing to have my TV-watching experience interrupted by a close-up shot of the indomitable tennis star injecting a drug that can cause muscle loss and fatigue. All these ads are nauseating because they traffic in the assumption that weight loss is a universal goal; the question is just whether you’d like to lose 5, 10, or 50 pounds. But I do not want to lose weight. I have spent more than half of my life trying to squash my urge to lose weight—and be free of the deeply inscribed messaging that thinner is a better, more desirable form. It’s been many years since I’ve restricted calories or purged after a meal, habits I picked up before I was even through puberty. Still, sometimes I falter. I’ll find myself redownloading MyFitnessPal or using my finite attention to perform caloric mental math, calculating the damage done by a tablespoon of cooking oil or the splash of milk added to my morning coffee. This disordered history probably makes me the perfect demographic for receiving targeted GLP-1 ads. It’s very possible that my attention lingers, subconsciously, when I come across them on my feed. And if that’s the case, the algorithm has almost certainly noticed, and taken it as an invitation to send me more—despite all of the times I’ve clicked “not interested.” To research this piece, I decided to see if I’d actually be eligible to microdose the GLP-1 being promoted to me. I filled out two online quizzes from the companies Noom and Hers. I lied about past eating disorder history by checking a box. Hers—a women’s telehealth company that launched in 2018 with a focus on sexual wellness and skincare and has since become better known for offering weight loss drugs—warned me that my prescription would not be “evaluated for safety, effectiveness, or quality by the FDA.” It asked me harrowing questions such as, “How disruptive would vomiting, constipation, and diarrhea be to your daily life?” And then, thank God, Hers told me I didn’t qualify. Noom let me right in. After it thanked me for taking the “important (and hard) first step” of sharing my current weight, it prompted me to buy my “personalized plan” for shedding 10 pounds in seven weeks. There’s still a lot we don’t know about the long-term side effects of GLP-1 drugs, but they do appear to be beneficial for those who medically need them. I am not one of those people. And as the multibillion-dollar semaglutide market explodes across the globe, it’s disappointing to see it stamp out the last remaining shreds of the mid-2010s “body positivity” movement. For a brief moment, companies found it profitable to showcase physical diversity and promote the idea of loving your body just the way it is. Not so anymore. The resounding message—on social media, on TV, in the goddamn subways—is that thin is back in. And companies are doing what they’ve always done best: exploiting our insecurities to cash out.

There may be hope for millions of Americans whose health insurance premiums are set to skyrocket in the new year, but not before Congress gets back from its two-week holiday vacation. Four moderate Republicans signed on to a Democratic petition to extend Affordable Care Act subsidies for three years on Wednesday, effectively giving Democrats the numbers they needed to force a floor vote in Congress. Minority Leader Hakeem Jeffries (D-NY) led the petition, which allows a majority of House members (218 votes) to force a bill to a floor vote. The petition received support from all 214 Democrats and four Republicans who defied GOP leadership in signing —Reps. Brian Fitzpatrick (R-Pa.), Mike Lawler (R-NY), Rob Bresnahan (R-Pa.), and Ryan Mackenzie (R-Pa.). The subsidies date back to 2010, when Congress passed the Affordable Care Act. The effort was a signature achievement of President Barack Obama’s first term, and became colloquially known as “Obamacare.” The law effectively created marketplaces where people could buy health insurance if they weren’t covered by their employers, Medicare, or Medicaid. Buyers were incentivized with tax credits, a type of subsidy. Those subsidies got a big boost in government funding under President Joe Biden in 2021 as part of the Inflation Reduction Act, and many more people became eligible for them. But the credit extended only through 2025. ACA marketplace enrollment was 24.3 million people in 2025, hitting a record-high for the fourth consecutive year. Now, unless Congress extends them again, many enrollees will experience dramatic spikes in their premium costs. According to Kaiser Family Foundation, a nonpartisan healthcare policy group, subsidized enrollees are estimated to pay more than double for premiums. They found that the average cost of $888 in 2025 would increase to $1,904 in 2026.  Even though House Speaker Mike Johnson (R-La.) acknowledged at a Tuesday press conference that around a dozen Republicans were working to reduce health care costs for their constituents, “many of them did not want to vote on this ObamaCare COVID-era subsidy the Democrats created.”  Rep. Fitzpatrick said he voted with Democrats because GOP leadership rejected compromise after he spent months offering ideas and amendments.  “The only policy that is worse than a clean three-year extension without any reforms, is a policy of complete expiration without any bridge,” Fitzpatrick said in a statement on Wednesday. “Unfortunately, it is House leadership themselves that have forced this outcome.” Fitzpatrick is one of several Republicans who face competitive challenges in their electoral districts in 2026. But all of this may be too little, too late. The ACA funding bill is not expected to go to the floor before the end-of-the-year deadline unless Johnson decides to speed up the vote, which doesn’t seem likely. House rules state a bill can only go to a floor vote at least seven legislative days after a discharge petition. The House will only be in session until Friday before a two-week holiday. House members come back on January 6, so a floor vote will most likely take place in the second week of January.

This story was originally published by ProPublica, a nonprofit newsroom that investigates abuses of power. Sign up for ProPublica’s Big Story as soon as they’re published. On the one-month anniversary of President Donald Trump’s inauguration earlier this year, a group of his appointed aides gathered to celebrate. For four weeks, they had been working overtime to dismantle the US Agency for International Development, freezing thousands of programs, including ones that provided food, water and medicine around the world. They’d culled USAID’s staff and abandoned its former headquarters in the stately Ronald Reagan Building, shunting the remnants of the agency to what was once an overflow space in a glass-walled commercial office above Nordstrom Rack and a bank.  > A cast of Trump’s lesser-known political appointees and DOGE operatives cut > programs in ways that guaranteed widespread harm and death in some of the > world’s most desperate situations. There, the crew of newly minted political figures told the office manager to create a moat of 90 empty desks around them so no one could hear them talk. They ignored questions and advice from career staff with decades of experience in the field. Despite the steps to insulate themselves, dire warnings poured in from diplomats and government experts around the world. The cuts would cost countless lives, Secretary of State Marco Rubio and the other Trump officials were told repeatedly. The team of aides pressed on, galvanized by two men who did little to hide their disdain for the agency: first Peter Marocco, a blunt-spoken Marine veteran, and then 28-year-old Jeremy Lewin, who, despite having no government or aid experience, often personally decided which programs should be axed.  By the third week in February, they were on track to wipe out 90 percent of USAID’s work. Created in 1961 to foster global stability and help advance American interests, USAID was the largest humanitarian donor in the world. In just a month’s time, the small band of appointees had set in motion its destruction. In a corner conference room, it was time to party. They traded congratulatory speeches and cut into a sheet cake. Days later, on a remote patch of land in South Sudan, a 38-year-old man named Tor Top gathered with his neighbors outside the local health clinic. Surrounded by floodwaters, their hamlet of thatch and mud homes had been battling a massive outbreak of cholera, a deadly disease spread by poor sanitation. Around the country, it had infected 36,000 people in three months, killing more than 600, many of them babies. Top’s family lived in the epicenter. The clinic, one of 12 in the area run by the Christian, Maryland-based humanitarian organization World Relief and funded by USAID, provided a key weapon in the fight: IV bags to stave off dehydration and death. The bags cost just 62 cents each, and in three months, the clinics had helped save more than 500 people.  Now, Top, who lived with his wife, children and mother in a one-room house less than 50 feet from the clinic, listened as World Relief staff shared grim news: The Trump administration had stopped USAID’s funding to World Relief. Their clinic, their lifeline, was closing. Top’s usual gentle demeanor broke down. Why would the US just cut off their medical care in the middle of a deadly outbreak? By now the broad story of USAID’s ruin has been widely told: The decree handed down by Trump; Elon Musk, who led the new Department of Government Efficiency; and Russell Vought, who holds the purse strings for the administration as the head of the Office of Management and Budget, to scuttle the agency and undo decades of humanitarian work in the name of austerity. Publicly, the administration tried to temper international backlash by promising to keep or restore critical lifesaving programs.  But that promise was not kept. Instead, a cast of Trump’s lesser-known political appointees and DOGE operatives cut programs in ways that guaranteed widespread harm and death in some of the world’s most desperate situations, according to an examination by ProPublica based on previously unreported episodes inside the government as well on-the-ground reporting in South Sudan. In some cases, they abandoned vital operations by clicking through a spreadsheet or ignoring requests in their inboxes.  The abrupt moves left aid workers and communities with no time to find other sources of funding, food or medicine. Borrowing from a phrase used to describe the US’ overwhelming military campaign during the Iraq War, political appointee Tim Meisburger told senior USAID staff that the strategy was “shock and awe.” (Meisburger declined to comment.) Tibor Nagy, a veteran diplomat who was Trump’s acting undersecretary of state for management until April, has long been a critic of the vast networks of nonprofit organizations funded by American taxpayers. But he told ProPublica the administration never cared to differentiate between the “fluff” and vital humanitarian programs. “It was the most harebrained operation I’d seen in my 38 years with the US government,” Nagy said, referring to the methods used this year. “Who knows how much damage was done.” In public statements and congressional testimony, Rubio has repeatedly insisted that no one died because of cuts to US foreign aid and that his staff had reinstated lifesaving operations. But ProPublica found that those claims were a charade: Lifesaving programs remained on the books, but the flow of money didn’t restart for months, if at all. Lewin blocked funding requests for programs like tuberculosis treatment in Tajikistan and emergency earthquake response in Myanmar, records show.  This meant that dozens of supposedly “active” operations were dormant throughout most of the year. Rubio’s advisers let other critical programs, which typically run on one-year grants, expire without renewing them.  Few places were hit harder than South Sudan, the youngest and poorest country in the world, as well as one of the most dependent on American aid.  After Trump’s inauguration, career USAID and State Department staff spent months warning top officials that the funding cuts would exacerbate a historic cholera epidemic ripping through the country. They needed less than $20 million to fund lifesaving health programs, including cholera response efforts, for three months at the beginning of the year—an eighth of what Trump recently approved to buy private jets for one cabinet secretary and just 3 percent of USAID’s budget in South Sudan last year. But Rubio, Marocco and Lewin failed to heed their own agencies’ assessments, according to internal records and interviews.  As a result, people in South Sudan died. By denying and delaying those funds for months, Trump’s appointees incapacitated the fragile nation’s emergency response systems at the very moment when doctors and aid workers were scrambling to contain cholera’s spread. “We had to start rationing lifesaving interventions,” said Lanre Williams-Ayedun, the senior vice president of international programs for World Relief. “To have something like this happen in a place like this, where there aren’t mechanisms for backup, just means people are going to die.” Villages and towns that had been reining in the outbreak suddenly lost essential services. Cholera came roaring back. “The trend was going down,” said a former US official. “When we stopped the funding, it just surged.” This summer, ProPublica journalists hiked and boated across Rubkona County, the epicenter of South Sudan’s outbreak and home to the country’s largest refugee camp, to interview families that the US cut off from help. We collected medical files, diaries, meeting notes and photographs documenting cholera’s devastation after essential services stopped. ProPublica also interviewed more than 100 government and aid officials and reviewed enormous caches of previously unreported memos, correspondence and other documents from inside the Trump administration. Many were granted anonymity due to fears of reprisal. In response to a detailed list of questions, a senior State Department official said fast, drastic changes to foreign aid were necessary to reform a “calcified system.” The world, especially US interests, will be better for it in the long run, the official said, despite “some disruptions in the short term.” The official also said that Rubio was the final decision-maker for all aid programs. They also contended that they had a limited budget to work with, “which required some tradeoffs on what programs to continue,” saying OMB has ultimate control over new humanitarian funds.  The official maintained that nobody died as a result of the funding cuts. “That’s a disgusting framing,” the official said. “There are people who are dying in horrible situations all around the world, all of the time.”  “Who is responsible for the suffering of the people of South Sudan?” the official added. “The South Sudanese [government leaders] who take their oil revenues and buy private jets and fancy watches and don’t see to their own people? Or the United States? Are we responsible for every poor person all around the world?” > “It was the most harebrained operation I’d seen in my 38 years with the US > government.” Officially, the death count in South Sudan is nearly 1,600, making it the worst cholera epidemic in the country’s history. But that toll is a dramatic undercount. ProPublica found newly dug, unmarked graves alongside roads and in backyards. In one town, community leaders showed reporters an informal cemetery with at least three dozen people who they said did not make it to medical facilities in time.  Tor Top’s mother, Nyarietna, was one of the uncounted. In March, the clinic doors had been padlocked for two weeks when she developed vomiting and diarrhea. Top bundled her into a rented canoe and began paddling toward the nearest hospital, eight hours away. Less than halfway into the journey, long after they had stopped reassuring one another that she would be OK, Nyarietna died.  Top turned the canoe around and made his way back home, where he buried his mom in their backyard. Now he alone tends the small garden where she grew corn and okra for their family. “If there was medicine here,” he said later, “maybe her life would have been saved.” AID TO SOUTH SUDAN For years, Sudan’s Arab-led central government waged a campaign of brutal violence against its Christian minority in the south. Their persecution became a cause celebre of the American Evangelical movement, which convinced President George W. Bush’s administration to help broker a peace agreement that led to independence 15 years ago. Since then, the US has given the fledgling nation nearly $10 billion in aid, according to federal data. That money subsidized virtually every corner of the health care system, among other institutions. Still, South Sudan remains undeveloped. Political instability, corruption and dysfunction are rampant. The transitional government hasn’t paid public employees’ salaries for most of the last two years. US officials had long been on alert to South Sudanese aid workers siphoning resources. Deadly political violence—left over from the civil war and threatening a new one—besets much of the country.  Well before Trump took office this year, the international community had broadly agreed that it was necessary to end the nation’s dependence on foreign aid, and US officials were working on strategies to force its leaders to take responsibility for its citizens. Some of the most vulnerable among them live in Rubkona County, an oil and cattle hub larger than Rhode Island near Sudan’s border. There, a refugee camp formed in 2014 during the nation’s civil war when thousands of people fled behind a United Nations peacekeeping mission to escape a massacre in the nearby town of Bentiu. As South Sudan’s political turmoil continued to spiral, tens of thousands more fled to the camp. In 2020, Rubkona was hit by a series of catastrophic floods that submerged the majority of the county. Generations of people are now essentially trapped there with nowhere else to go. THE MAN-MADE ISLAND OF TRAPPED REFUGEES After the U.N. lost its US funding to maintain dikes, canals and latrines, the Bentiu refugee camp turned into an open sewer that helped spread cholera. More than 110,000 displaced people live in dark, single-room homes made of corrugated metal and tarps on a square mile of land surrounded by floodwaters. Previously, USAID gave the U.N.’s International Organization for Migration $36 million for work in South Sudan, which included keeping the Bentiu camp habitable and making critical repairs to the dikes that surround the camp and hold back the rising floodwaters. The group maintained the drainage system and paid people to pick up garbage and clean the latrines—essentially performing sanitation services for 110,000 people. Despite those efforts, cholera began spreading late last year as new refugees poured in from neighboring Sudan. Rubkona County quickly became the outbreak’s epicenter. In a matter of days, hundreds of infections turned to thousands and the death toll mounted. US-funded organizations raced to set up treatment units in the camp and surrounding communities.  The situation was dire, and people had few viable options to leave Bentiu, US Ambassador Michael Adler reported back to Washington after USAID staff visited the camp to assess the outbreak in early December. The US-funded cholera clinics and other programs were necessary given the “explosivity” of the illness’ spread, he wrote. It was the kind of routine crisis response that USAID was renowned for handling. The last cholera outbreak in Rubkona, in 2022, lasted seven months, and government statistics say that just one person died while about 420 were sickened. An aggressive sanitation campaign, largely funded by the US, was crucial to containing the disease. Now faced with a new outbreak, the embassy’s staff rushed to get the aid organizations in Rubkona more money, according to the organizations and former officials. By early January, humanitarians were preparing to expand operations. World Relief planned to expand its mobile clinics, Williams-Ayedun said. USAID told Solidarités International, which repaired water pipes, provided sanitation services and distributed soap, to aggressively spend the money it had to combat cholera, with the understanding that the agency would immediately review a proposal for more funds, according to two former officials. An additional $30 million for the U.N.’s migration office—which planned to use the money to continue maintaining the refugee camps—was already committed. Then Trump took office, signing an executive order on day one to freeze all foreign aid pending a review of whether it aligned with the administration’s stated values. “JUST THROW THEM IN THE POT” Days later, Rubio issued sweeping stop-work orders to aid programs worldwide. Musk declared that his DOGE team had fed USAID “into the woodchipper.” After a swift backlash from aid organizations, foreign governments and US ambassadors overseas, Rubio announced that lifesaving operations would continue during his review. Marocco told lawmakers as much during briefings.   It wasn’t true. Behind the scenes, Marocco and his lieutenants repeatedly obstructed USAID’s Africa, humanitarian aid and global health bureaus from restarting programs critical for responding to disease outbreaks, according to interviews and memos obtained by ProPublica. The money aid organizations in South Sudan were expecting by February didn’t come. Meanwhile, the appointees suspended nearly all of USAID’s staff, and those remaining said their bosses blocked payments even for approved programs. Marocco was meant to be “the destroyer, and then someone else would come in to rebuild,” one former official said a senior political appointee had told her. “I guess the one thing happened, but not the other.” (Marocco did not respond to multiple requests for comment.)  The cuts were so frenetic that, for a brief time, the US government stopped paying for the fuel that ran the electricity for the American embassy in Juba, including the security compound, just as violence was surging throughout South Sudan, according to former senior officials. In response to questions about the episode in Juba, the senior State Department official denied it was a mistake or that Rubio’s review wasn’t careful. “Going back and looking at things again doesn’t mean that you’ve made a mistake,” the senior official said.  At one point in February, Marocco tried ordering the immediate return of foreign service officers stationed abroad. Several senior USAID officials protested, citing safety and logistical concerns for staff in war zones. During one meeting that month, Lewin responded, “You don’t want to get to know the lobsters. Just throw them in the pot,” according to an attendee and meeting notes.  Lewin joined the government via Musk’s DOGE and later took over for Marocco. He seldom came to the USAID office or met with his own staff experts, officials said. Publicly, he called the agency an “unaccountable independent institution” where secrets leak so quickly “we have to hand-walk memos around like we’re in the ’40s.” In the weeks that followed, DOGE and Trump appointees forbade those who remained at USAID from communicating with aid groups and discouraged discussion internally, telling staff abroad not to approach ambassadors to advocate for programs, emails show.  Senior staffers said they were prohibited from meeting with congressional delegations to share basic information, which was critical to Congress’ oversight capabilities. The government’s health experts feared that taking any action to save lives could be a fireable offense.  Still, some spoke out.  “The consequences on lives lost and funding squandered will grow exponentially and irreversibly in many cases,” Nicholas Enrich, then an acting assistant administrator at USAID, warned in a Feb. 8 email to agency leaders, including Joel Borkert, the chief of staff, and Meisburger, who led the humanitarian affairs bureau. They did not respond to his plea, and Enrich was later put on administrative leave.  Crucially, even when USAID’s new bosses did approve organizations to resume lifesaving work, they at times denied requests for the money that would allow them to do so, internal records show. Other proposals to fund existing grants or reverse terminations languished in limbo. The official responding on behalf of the State Department said Trump’s OMB ultimately has more control over approving new grants and extensions, but that it was never the administration’s intention to keep all of the lifesaving programs forever.  When ProPublica asked about the funding delays and the State Department’s explanation, OMB communications director Rachel Cauley said in an email, “That’s absolutely false. And that’s not even how this process works.” She did not clarify what was false, and the State Department did not address when Lewin sought funds from OMB for South Sudan’s cholera response.  In early February, embassy staff in South Sudan provided Adler, the ambassador, with a list of the most critical operations there, warning that funds had not been released and lifesaving programs would cease when their money ran out.  A career foreign service officer appointed to his post by the Biden administration, Adler had long been critical of the government of South Sudan for ongoing violence and deserting its own people, according to embassy cables and interviews with people familiar with his thinking. Still, early on he appeared to recognize that without US intervention, the most vulnerable people in the country did not stand a chance against cholera. In a Feb. 14 memo addressed to the leadership of the State Department’s Africa bureau, Adler asked the administration to release money to keep people alive.  “Lifesaving medicine and medical care, as well as emergency water and sanitation services, play a critical role in controlling disease outbreaks,” the embassy wrote, “notably a severe cholera outbreak in South Sudan’s border regions hosting the greatest number of refugees.” Adler declined to meet with ProPublica in South Sudan and did not respond to a detailed list of questions.  DEATH BY SPREADSHEET As humanitarian groups racked up unpaid bills, they began to file lawsuits challenging the foreign aid freeze. A federal judge ordered the administration to reimburse the organizations. But on Feb. 26, the Supreme Court temporarily paused the lower court’s order.  In a meeting with senior agency staff the next day, Lewin, who at that time was not yet in charge of USAID programs, indicated that he interpreted the recent legal decisions as a potential license to dispense with one of the key review processes for unfreezing operations, according to two attendees and meeting notes. One of those attendees took Lewin’s remarks to mean that “he had no intention to review contracts or implement lifesaving programs.” In response, the senior State Department official told ProPublica, “No one meant that or said that.” The next night, a Friday, staff at the Bureau of Humanitarian Assistance, the division of USAID that dealt with emergencies and ran nearly all of the programs in South Sudan, were working late, scrambling to keep emergency programs operational. Suddenly, they noticed Borkert making changes to a key spreadsheet.  To create the spreadsheet, DOGE had sidestepped career staff, pulling information from databases made for project management. It was so rudimentary that it was often impossible to tell what a program did from descriptions as vague as “extension No. 4” or “allocation of funds,” according to people who saw the spreadsheet. Rubio and his aides had already terminated hundreds of programs in preceding days. Staff were bracing for another round of cuts, but many of the line items remaining in the file were for programs that provided food, clean water or essential medicines. Veteran USAID officials watched as Borkert scrolled down the spreadsheet, turning rows red, yellow or green every few seconds, never asking a single question. Realizing the red programs were slated to be cut, they frantically started editing descriptions so that Borkert would at least know what those programs did. Within minutes, he’d flagged dozens of them for termination. (Borkert declined to comment.) A senior staff member in the group raced upstairs and begged Borkert to reinstate them, according to two officials familiar with the episode. He relented on several. But the next day, Marocco and Lewin told the group they’d kept far too many programs, emails show. Lewin ordered 151 additional awards terminated, writing that he would “have strong objections to these awards being turned on.” Marocco followed up by email at 11:30 p.m. saying the reactivations were “far too broad,” indicating several more line numbers and writing “sound like terminations,” next to them, ultimately canceling even more programs. On March 10, Rubio announced on X that the review was over. In response to lawsuits, Trump officials told the courts that the review was a careful examination of USAID’s operations. More than 5,000 programs had been canceled, and fewer than 1,000 remained — a figure that many officials told ProPublica was arbitrary but binding. In reality, the administration still wasn’t releasing money and many of the surviving programs had no funds, according to interviews with humanitarian groups and government officials, as well as memos and spreadsheets documenting those decisions. When asked about the current status of the 1,000, the senior State Department official criticized USAID’s former vetting procedures and said the administration is in the process of creating new programs.  Soon after the review ended, the cholera response in South Sudan came crashing down. “GOD IS WITH US” Rebecca Nyariaka and Koang Kai were shrouded in grief throughout the upheaval in Washington. Their only child, 4-year-old son Geer, had been one of the first victims when cholera inundated the Bentiu camp in December.  The couple met in secondary school at a refugee camp in Kenya and got married after they’d both returned to their homeland in 2013. After violence broke out, they fled to Bentiu, finding occasional jobs working with health clinics.  Now, in early March, they prodded one another to stay hopeful: 28-year-old Nyariaka was once again pregnant. In the refugee camp, the couple could see the signs of the funding cuts everywhere. Uncollected garbage barricaded the drainage ditches that encased their neighborhood. Human waste spilled out of the overflowing communal latrines near Nyariaka’s house and into the fetid water filling the culverts. Toilets crawling with rats, maggots and flies became so noxious that neighbors began defecating on the surrounding dirt roads. The stench was overwhelming. “Those who washed the latrines have gone,” Kai said. “And we are left here all alone.” The U.N.’s new sanitation contract had been committed before Trump took office, but it hadn’t received any money since last year. On March 12, USAID staff in the region sent Washington field notes about the conditions in the camp, where health services faced “closure or severe cutbacks” because of the funding shortfall. Officials at the organization pleaded behind the scenes as well. They repeatedly called and met with embassy leaders to request help, to no avail. “What we have now is survival of the fittest,” one U.N. official told ProPublica. When Nyariaka gave birth to a healthy baby boy, cholera was rampant throughout the camp. Neighbors were dying around them, and Kai was worried for his wife and new baby. “When cholera enters your home, you know the chances of survival are very low. Very few people survive it,” he said later.  Nyariaka named the baby Kuothethin, “God is with us.” In her first days back from the hospital, her body still healing, the new mom used the bathroom frequently, teetering back and forth to the overflowing latrines close to her house. She soon developed violent vomiting and diarrhea, the hallmark symptoms of cholera.  Kai, tall and muscular, picked her up in his arms and raced to the camp hospital, but it was too late. Nyariaka died just after they arrived. She had been nowhere except her house and the latrines since coming home from the hospital, Kai said. He’s certain the toilets are to blame for her death. Depressed and unable to care for their newborn, he sent the baby across the floodwaters to live with his mother-in-law on another side of the state. Kai and Nyariaka had been best friends for years before they started dating, their lives intertwined for nearly two decades. “Her whole way of life was good. She loved our children and cared for them,” Kai said. “I am heartbroken.” As the disease ripped through the camp, more services shut down, including transportation for the dead. Kai’s neighbor, John Gai, lost his father to cholera. Gai had to take him to the cemetery himself in a wheelbarrow, his father’s head bobbing at his knees. “Nobody should have to carry a dead body among the living,” Gai said. “GROSS NEGLECT” On March 28, Rubio notified Congress that he was officially shuttering most USAID operations and transferring programs that survived his review, including several in South Sudan, to the State Department.  Staffers spent the next weeks repeatedly appealing to Lewin—who by then had replaced Marocco as Rubio’s top foreign aid official—for authority to perform the mundane tasks needed to keep the programs operating. In late April, the agency’s humanitarian bureau submitted a blanket request to fund grants that Lewin had already approved. Lewin refused, records show, and the humanitarian bureau had to submit country-specific proposals for consideration. That process dragged on for months. In June, just before USAID was shut down for good, Lewin finally approved some of the funding the staff had advocated for. But by then it was too late. The officials had run out of time to transfer money already appropriated by Congress to remaining programs.   On June 26, R. Clark Pearson, a supervisory contracting officer at USAID, sent a scathing email to USAID offices around the world in response to an email from the top procurement officer for the agency listing the hundreds of programs that were meant to be active. He said there was no one who could manage the awards, which he called “gross neglect on an astonishing level.”  “In a time of unimaginable hubris, gross incompetence and failures of leadership across the Agency, this has to be one of the most delusional emails I have seen to date,” Pearson wrote. “Lives depend on these awards and for the [US government] to simply not manage them because of an arbitrary deadline is inexcusable.” That same day, a senior humanitarian adviser informed Adler that payment extensions for several programs, with the exception of food aid, weren’t processed because the “approval was received late.”  In September, the Supreme Court issued another emergency ruling that let the administration withhold nearly $4 billion that Congress earmarked for foreign aid.  Later that month, OMB released some new foreign aid funds. That’s when World Relief finally began to receive funding, allowing the clinic in Tor Top’s community to reopen, even though the administration claimed the program had been “active” for almost seven months.  The U.N.’s migration program has not received a new South Sudan grant.  The organization will run out of money for dike maintenance in Bentiu by February, after months of some of the most severe flooding in years. A spokesperson for the U.N.’s migration program said the organization was still in discussion with the State Department and “continues to engage with donors about the critical humanitarian needs in South Sudan.” THE UNCOUNTED  During the first months of the cholera outbreak, a mobile health team run by the International Rescue Committee, a US-based nonprofit that works in crisis zones around the world, visited Nyajime Duop’s remote village on the edges of Rubkona County twice weekly. The team brought soap and transported sick people to IRC’s nearby clinic for care.  At 27, Duop’s youthful face belied a life marked by war and poverty. She had arrived just a few months earlier, fleeing violence in Khartoum, Sudan, with an infant and toddler in tow, when Trump officials terminated IRC’s $5.5 million grant.  The IRC suspended its operations in the village in the spring. When Duop’s 1-year-old baby, Nyagoa, fell ill with cholera in July, on a day IRC would have visited, there was no one to help her. By the morning, Nyagoa was unconscious. She died that day, the Fourth of July. Cholera has spread to nearly every corner of South Sudan, infected at least 100,000 people and killed 1,600, though cases began abating this fall. The true death toll is impossible to know, in part because clinics that would have cared for people and counted the dead were shuttered. The Trump administration also cut funding to the World Health Organization, which helped the South Sudanese government gather accurate data on the outbreak.  In a pasture a short walk from IRC’s clinic, ProPublica found at least three dozen mounds covered in sticks—the makeshift graves, village leaders said, of those who died of cholera before reaching the clinic. The clinic’s security guard told reporters he saw one man collapse and die just yards from the front gate. “There are many more cases,” said Kray Ndong, then acting minister of health for the area, “many more deaths.” The Trump administration recently announced a new era of foreign aid, where the US will prioritize “trade over aid.” South Sudan, with a gross domestic product one-tenth the size of Vermont’s, has little to offer.  “The administration says they are committed to humanitarian needs,” one aid official in South Sudan said. “But we don’t know what that means, only that it will be transactional.”