Pratik Pawar | Vox

Ozempic just got cheap enough to change the world

2026-04-07T18:30:58-04:00

Semaglutide injection pens on display at a news conference in Mumbai. After a key patent expired in March, more than 40 Indian manufacturers launched generic versions of the drug, now available for as little as $8 a month, compared to $349 in the US. | Dhiraj Singh/Bloomberg via Getty Images

By now, Ozempic needs no introduction in America. One in 8 American adults now takes a GLP-1 drug of some kind. But even as millions of people in wealthy countries have benefitted from these drugs, they have remained out of reach for most of the world.

But for a country of 1.4 billion people, this medication just got a lot more accessible.

Last month, a key patent on semaglutide — the GLP-1 sold as Ozempic, Wegovy, and Rybelsus — expired in India, a country known for making affordable drugs at scale. Within days, at least a half-dozen Indian drugmakers had launched generic semaglutide, with more than 40 expected to follow. The cheapest version costs about $14 a month. The same drug goes for as much as $349 a month in the US without insurance (where patents don’t expire until 2032).

Key takeaways

A key patent on semaglutide – the GLP-1 sold as Ozempic and Wegovy – just expired in India, and drugmakers there are already selling their own versions for as little as $14 a month. The same drug can cost up to $349 a month in the US.
These drugs are often talked about as a weight-loss drug, but their bigger promise is in treating obesity, diabetes, and heart disease risk all at once, a cluster of conditions that kills millions of Indians every year.
India is unusually well-positioned to benefit. Most diabetes care there runs through private doctors, so cheap generics can reach patients without waiting on the government.
And the stakes are huge. There are early signs that GLP-1s can improve the health of whole populations, not just individuals. If they do the same in India, it could be one of the biggest public health wins in a generation.

GLP-1s are often talked about as weight-loss drugs. But semaglutide’s bigger significance may be that it can treat a cluster of related metabolic diseases — especially obesity, diabetes, and cardiovascular risk — all at once.

That matters a lot in India. The country has one of the largest diabetic populations in the world by sheer number — more than 100 million people are estimated to be living with some form of the disease. And 350 million people there live with obesity. Heart attacks and strokes, which are lumped together under cardiovascular disease, claim 2.8 million lives a year in India, and strike nearly a decade earlier on average than in high-income countries.

Those numbers have been climbing “linearly upwards” for decades, said R.M. Anjana, a researcher-physician at the Madras Diabetes Research Foundation in Chennai who has also co-authored India’s largest national diabetes studies. And until now, no drug or policy has made much of a dent in the national numbers.

But there are early signs that GLP-1s can make a difference at the population level. In the US, adult obesity — which had only gone up since Gallup first started measuring it in 2008 — fell by nearly 3 percent between 2022 and 2025 as GLP-1 use surged. It was the first time anything in recent memory had bent that curve at a national scale.

India’s metabolic crisis is different, and much larger — which makes the moment all that much more consequential.

Two ways of seeing Ozempic

Diabetes and heart disease are often bound up with obesity in some form. And in India, there are millions who don’t have obesity by standard measures but already show signs of metabolic disease, such as high blood pressure or insulin resistance, putting them at greater risk of these diseases. Researchers have found that this group — people with lower weights who still have the metabolic issues common with obesity — is the single largest metabolic category among Indian adults, roughly 43 percent in a large national study. This is exactly the profile where semaglutide’s benefits will be the most dramatic.

“Should it be given to everyone? No, definitely not,” Anjana said. “But there’s definitely a group of people who’s going to benefit from these drugs, and making it more affordable is a good step.” Even those who develop Type 2 diabetes without obesity may see improvements on semaglutide.

And how the drug is understood popularly matters, especially in the early days. In India, as in the US, much of the public excitement around it has centered on slimming down, with weight-loss clinics popping up around the country and marketing pushing the drug’s weight-loss potential ahead of its clinical use.

That framing isn’t entirely wrong. India does have a substantial obesity burden, and reducing excess weight can have real benefits in also reducing other diseases. But this focus on one usage of the drug has created a strange distortion. Some diabetes patients who might have improved health outcomes with the drug are wary of it because they think it’s primarily cosmetic. Others, as Ambrish Mithal, an endocrinologist at Max Healthcare in New Delhi, puts it, “just want to lose three kilograms for a daughter’s wedding.”

“It’s the excitement of treating disease that is driving the doctors. It’s the excitement to lose weight that’s driving the public,” he said. “They’re looking at two different things.” In terms of tackling a massive disease burden, the ends may well be worth the different paths to get there.

In the real world

There are early signs that these drugs are already shaping public health writ large, not just individual health outcomes, such as the recent decline in national obesity rates in the US. And last week, the UK expanded semaglutide availability for roughly 1.2 million people to help prevent further heart attacks and strokes.

Both of these developments are signals of a drug’s broader public health utility. In India, where the burden of these diseases is far higher, and the price of the drugs that treat them is getting so much cheaper, they could have an even bigger public health impact.

That broader medical case is part of the reason why the World Health Organization added GLP-1 drugs to its essential medicines list last September, a model list of medicines it recommends countries make widely available through their health systems.

For now, though, semaglutide in India is available only through private doctors and pharmacies, not through government-funded care. In many countries, that would be a major barrier. It matters less in India, though, because most diabetes care already happens through private providers: about 80 percent of diabetes care is delivered that way, often paid out of pocket.

That also makes price especially important. Brand-name Ozempic and Wegovy previously cost more than $100 a month in India, putting them well out of reach for most people. In a country where the average monthly spending is between $44 and $75 a month per person, depending on where you live, that price was simply too high. Generics come in at a fraction of that price, which is, Anjana said, “a genuine boon.”

The entry of generics has also shaken the market. Recently, Novo Nordisk slashed the price of its branded Ozempic and Wegovy in India by up to 48 percent. With potentially more than 40 manufacturers soon to be competing in the marketplace, prices may fall further still, said Andrew Hill, a pharmacologist at the University of Liverpool who studies drug pricing. His latest estimate suggests that injectable semaglutide can be made for as little as $28 per person per year, leaving room for prices to dive even more.

Now for the hard part

Even at $14 a month, there are millions of Indians who can’t afford to pay out of pocket, and they’ll have to rely on the public health care system. But there’s no sign yet that the government will step in to help them. And recent experience doesn’t necessarily bode well. SGLT2 inhibitors, another class of diabetes drug, went generic in India six years ago and still haven’t made it to government clinics.

And India faces another, even more basic obstacle: diagnosis. According to the most recent round of India’s largest national health survey, one in four people with diabetes had not been diagnosed. A drug, however cheap, won’t help patients who don’t know they might need it. Still, for the hundreds of millions who do, or who will, the arrival of a $14 Ozempic will be transformative.

And India will not be the last place to test that promising development. Brazil and Canada, where patents are also expiring this year, are next in line. Plus, in roughly 150 countries, semaglutide was never patented in the first place. Together, those countries account for 69 percent of the world’s type 2 diabetics and 84 percent of people with clinical obesity.

But the stakes are arguably highest in India. Semaglutide can do something very few drugs can: lower weight, improve blood sugar, and reduce cardiovascular risk all at once. Now, for the first time, it is becoming genuinely cheap in a hugely populous country where all three conditions are widespread and rising. If it makes a dent there, it could point to one of the biggest public health breakthroughs of this generation.

The US slashed research for cancer, Alzheimer’s, mental health — and nearly everything else

2026-03-12T18:29:11-04:00

The National Institutes of Health in Bethesda, Maryland. | Mark Wilson/Newsmakers via Getty Images

Think about the disease that worries you most — the one that runs in your family. Or maybe someone you love is living with it. Whether that’s cancer, Alzheimer’s, diabetes, or depression, odds are the US government has been funding the research to treat it.

That research is a big reason we have drugs that made fatal blood cancers survivable, treatments that turned HIV from a death sentence into something people live full lives with, and a vaccine that all but prevents cervical cancer.

But last year, the US funded dramatically fewer grants to do medical research that can lead to breakthroughs like those. New data released by the NIH this week shows how the damage from those cuts broke down.

The numbers are striking across the board.

New grants for Alzheimer’s and aging research were cut in half — from 369 in 2024 to 177, all while the US population is rapidly aging. Mental health research grants fell by 47 percent. And new grants for cancer research fell by 23 percent — even as cancer rates are rising sharply among Gen X and millennial Americans. Across all areas, the NIH went from funding roughly 5,000 new research grants in 2024 to just 3,900 in 2025.

“This is the worst year I’ve ever seen, probably going back to the 1980s,” said Jeremy Berg, who led the National Institute of General Medical Sciences, one of NIH’s largest institutes, from 2003 to 2011.

The NIH’s funding system was already under strain — too many researchers were chasing too few research dollars. That has always meant that the most ambitious and most unconventional ideas struggle to get funded.

But the Trump administration’s policy decisions have made that problem dramatically worse in just a single year.

What went wrong

The NIH funds research through federal grants. Scientists across the country submit their proposals, a panel of outside experts scores and ranks them, and then each NIH institute — each focused on a different area of medicine — funds as many top-scoring proposals as its budget allows. In a normal year, about 5,000 new grants get funded.

Last year, one policy change did more to shrink that number than almost anything else.

In July 2025, the White House Office of Management and Budget required NIH to start paying the full cost of approved grants upfront — all at once, instead of paying year by year, as it has for a very long time. In principle, funding grants upfront makes them less vulnerable to future budget cuts.

But here’s the problem: When NIH funds a research project, it’s typically a commitment that stretches three to five years. That means in any given year, about 80 percent of the agency’s budget is already spoken for — paying for grants it promised in previous years. Only the remaining 20 percent of the budget is available to fund new research.

When the agency has to pay the full cost of every multiyear grant up front, that means each new grant costs several times more than it used to. Michael Lauer, who oversaw NIH’s grant-making for nearly a decade before leaving the agency in early 2025, put it simply: “Instead of funding five grants, you now only fund one, and that means four other grants that would’ve been funded don’t get funded.”

Berg, the former NIH institute director, estimates this single change wiped out roughly 1,000 new grants.

But it wasn’t the only factor. The Trump administration also terminated thousands of existing grants over the past year — something Lauer said he had seen happen only twice in his entire 18-year tenure at the agency. The leftover money from those terminations went to the US Treasury, not back to NIH. Berg estimates that roughly $500 million left the system this way.

On top of that, about 12 percent more grant applications were submitted in 2025 than in 2024, all competing for the shrinking pool of funds.

The Trump administration has been open about wanting a smaller NIH; it proposed cutting the agency’s budget for 2026 by 40 percent, though Congress has not enacted that cut. At the same time, the White House has pushed policy changes it says are aimed at restoring accountability at NIH — but the effect of those changes has been to shrink the agency.

“I think it’s pretty easy to start to wonder if there is some connection between those two things,” Carrie Wolinetz, a former senior NIH official, told STAT News.

The NIH did not respond to specific questions about the institute-level declines, or what happened to the money from terminated grants.

But isn’t the best research still getting funded?

With fewer grants to go around, you might think the system is just getting more selective — funding just the best ideas and cutting the rest. But that’s actually not how it works.

Philippe Aghion, the economist who shared last year’s Nobel Prize, found that past a certain point, more competition actually stifles innovation rather than spurs it. When NIH can only fund the top 5 or 6 percent of proposals, what survives is good but conservative science — established labs extending well-established research.

“The main thing you’re giving up there is new ideas,” Berg said.

Researchers in the UK recently discovered that people vaccinated against shingles had a roughly 20 percent lower risk of developing dementia seven years later. That finding came from a natural experiment in Wales, where people born before a certain date weren’t eligible for the vaccine and those born after were — and the group that got the vaccine had lower rates of dementia.

Understanding why a shingles vaccine works against dementia, and whether it could lead to new ways to prevent dementia, is the kind of exploratory research that would now struggle to get funded.

Katalin Karikó, who won the 2023 Nobel Prize in medicine for the mRNA work behind the Covid vaccines, had her grants repeatedly rejected long before the Trump cuts. The window for unconventional ideas was already narrow. Now it’s narrowing even further.

And much of the damage could prove permanent. When funding dries up, researchers leave — for other countries, for the private sector, for careers outside science altogether. “Researchers who leave the field or the country to work elsewhere are unlikely to return,” said Joshua Weitz, a University of Maryland professor who tracks science funding.

There are early signs that 2026 could get even worse for medical research. The White House budget office has delayed NIH from spending its 2026 funding, even after Congress approved it, and the NIH has made roughly a third as many new awards as it typically would by this point in the year.

The hardest thing to measure, Berg said, is the research that never got a chance to begin. “It’s much more like we set out across the ocean to see what we could discover and the voyage was canceled. There might be some beautiful island out there of incredibly important stuff, but we’re never going to know about it.”

America’s vaccine skepticism is starting to show up in health data

2026-03-09T17:16:23-04:00

A mother and her newborn at a hospital in Denver, Colorado, in 2025. A new study of 12 million newborns found that a routine birth dose vaccine is rapidly losing ground across US hospitals. | Hyoung Chang/The Denver Post via Getty Images

When a baby is born in a hospital in the US, one of the first things that happens — usually within 24 hours — is a hepatitis B shot, which prevents a virus that can cause liver cancer. The newborn shot has been a standard practice nationwide since 1991, after earlier efforts at prevention kept missing the mark. In the decades that have followed, most parents haven’t thought twice about it.

But over the past two years, more and more parents have started saying no. Because the birth dose is given inside the hospital, before the family goes home, there’s no appointment to miss, no chance of a scheduling mix-up — ways other childhood vaccines can be missed. If a newborn didn’t get this shot, in most cases, someone actively declined or delayed it.

A study published on February 23 in JAMA puts a clear number on that shift. The researchers tracked 12.4 million newborns — roughly a third of all US births — across hospitals in all 50 states that use Epic, one of the country’s largest electronic health record systems. Using years of prior data, the researchers modeled where vaccination rates should have been heading, and compared those projections to what was actually happening.

The study found that between 2023 and mid-2025, the share of newborns getting the hepatitis B birth dose fell from 83.5 percent to 73.2 percent. That translates to roughly “400,000 or more babies a year declining or delaying the hepatitis B [birth] vaccine,” said Joshua Rothman, a pediatrician at UC San Diego School of Medicine and the study’s lead author. For context, that’s roughly equivalent to the entire population of Minneapolis declining or delaying the shot every year.

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All of this happened before Robert F. Kennedy Jr. took over the nation’s health agencies. Now, he’s turned skepticism into policy. In January, the Centers for Disease Control and Prevention stopped universally recommending the hepatitis B birth dose — along with five other childhood vaccines. Parents were already walking away from the birth dose, and now the government is too.

The easiest vaccine to attack

The roots of this go back to the Covid pandemic, which reshaped how millions of Americans think about all vaccines — not just the Covid shot.

“This is a classic example of what we in the literature have come to refer to as a Covid-19 vaccine spillover effect,” said Matt Motta, a public health researcher at Boston University who studies vaccine hesitancy. Researchers have documented distrust of the Covid shot bleeding into general skepticism of flu vaccines, childhood MMR shots, even vaccination for pets. Polls have sent mixed signals about whether that skepticism is actually changing behavior — but a study like this captures what parents are doing, not what they are telling a pollster.

The rising skepticism hasn’t hit every vaccine equally, and hepatitis B has made for an unusually easy political target. Because the virus spreads through blood and sex, skeptics have a ready-made argument: Why vaccinate a newborn for a sexually transmitted disease? “It is one of the vaccines that lends itself very well to political opposition,” Motta said. Both Kennedy and Casey Means, President Donald Trump’s nominee for surgeon general, have made this case publicly. The scientific answer — that hepatitis B can also spread during birth and through close household contact in infancy — is true, but harder to fit on a bumper sticker.

None of this is entirely new. Americans have been arguing about vaccination since George Washington’s day, when they called it inoculation. But historically, that skepticism existed outside the federal agencies. What’s different now is that “America’s leading government health agencies are populated by people who are deeply skeptical of vaccination,” Motta said. “There is, in my mind, no precedent for this.”

From culture to policy

In January, the CDC made it official: The agency cut the number of vaccines it universally recommends for children from 17 to 11, moving hepatitis B and five others to what it calls “shared clinical decision-making” — essentially a case-by-case decision made by parents and doctors. The US has tried versions of this before, and there’s a reason we moved away from it.

In the 1980s, doctors tested only high-risk pregnant women for hepatitis B. But up to half of infections are asymptomatic, so they kept missing cases. In 1988, the country switched to testing every mother. That helped, but 50 to 100 infants were still getting infected each year — the result of mothers with false negatives, babies exposed after birth, and families who fell through the cracks. So in 1991, the US started vaccinating every newborn, and it worked. Annual infant infections dropped to fewer than 20.

The new recommendation is taking us back to the ’80s.

Without a uniform federal standard, which vaccines a child receives will be shaped less by scientific consensus than by the politics of the state they’re born in.

Supporters of the change, including Kennedy, have pointed to countries like Denmark that don’t universally vaccinate newborns for hepatitis B. But Motta said that comparison misses a critical difference: Denmark has universal tax-funded health coverage for all residents, a national vaccine registry, and the screening infrastructure to catch cases the vaccine would otherwise prevent. (The US does none of this reliably enough to do the same.)

“If you were to tell me the United States was going to make the type of investment that Denmark has in its health infrastructure,” Motta said, “then I would say, okay, let’s revisit. But that is not the reality we live in.”

That’s partly because in the US, vaccines have long served as a kind of substitute safety net — what David Wallace-Wells, writing in the New York Times, has called a way of “limiting the downside consequences of all of our country’s notorious shortcomings.” A hepatitis B shot at birth means it matters less whether a family member is unknowingly carrying the virus. An MMR vaccine means measles is less dangerous even for a child who is malnourished or far from a doctor.

And those shortcomings are real. More than 27 million Americans were uninsured at some point in 2024, and even within the CDC’s own perinatal hepatitis B prevention program, only 65 percent of exposed infants received the recommended follow-up blood testing. Screening-only strategies work when the system catches everyone. The US system doesn’t.

A study published in December estimated that the CDC’s changes could lead to hundreds of additional infant hepatitis B infections each year — and even that, the authors warned, is probably an undercount. Their model couldn’t factor in rising vaccine hesitancy, or the fact that babies who miss the first dose are less likely to get fully vaccinated.

And hepatitis B is just one of six childhood vaccines the CDC dropped from its recommended list, alongside rotavirus, influenza, and hepatitis A, among others.

The fallout of this change will be uneven. The American Academy of Pediatrics (AAP) has broken with the CDC and published its own vaccine schedule, keeping the hepatitis B birth dose for every newborn. Several states, including Massachusetts and New York, have said they’ll follow the AAP’s recommendations rather than the revised federal schedule. Others will likely follow the federal lead.

Polling suggests parents would follow. In a February survey by the Annenberg Public Policy Center of the University of Pennsylvania, 42 percent of Americans said they’d trust the AAP over the CDC on whether newborns should get the hepatitis B shot — just 11 percent said the CDC. A third weren’t sure — the exact group a clear federal recommendation could reach.

In just the first two months of this year, the US has recorded more than 1,000 cases of measles. The full year of 2024 had 285. And now, hepatitis B could see a similar surge. Every state with a Democratic governor has broken with the CDC guidelines and maintained the old hepatitis B vaccine recommendation, whereas most Republican-led states have not. Without a uniform federal standard, which vaccines a child receives will be shaped less by scientific consensus than by the politics of the state they’re born in.

Foreign aid is back from the dead — but it’s in the hands of the people who tried to kill it

2026-02-27T11:56:30-05:00

A patient waits at an HIV clinic at Mulago Hospital in Kampala, Uganda, in February 2025. The clinic, which depends on US funding for half its budget, faced uncertainty after the administration froze aid spending. Congress has since approved $9.4 billion for global health — but whether the money reaches clinics like this one is an open question. | Hajarah Nalwadda/Getty Images

There’s a dire shortage of good news in global health, so let me start with some.

Earlier this month, Congress passed — and President Donald Trump signed — a law to spend $9.4 billion on global health work in more than 50 countries. That’s funding for HIV treatment, childhood vaccines, malaria and TB programs, and much more — at roughly the same level as last year.

After a year in which the administration vilified and dismantled USAID, froze and refroze lifesaving health programs, and proposed slashing global health funding by more than 60 percent, this is a genuinely surprising development.

Some of the details in the new law are even more striking. Congress — including Republicans who co-wrote the bill — put $524 million toward family planning work; the administration had pushed to defund it entirely. Gavi, an international alliance that vaccinates more than half the world’s children, got $300 million despite Health Secretary Robert F. Kennedy Jr.’s vocal opposition toward it.

In the more than two decades since Congress began funding programs to fight HIV, malaria, and tuberculosis abroad, you could assume that money would actually get spent. That’s the law.

But that’s no longer a safe assumption.

Last year, Congress also appropriated billions for this work, but the administration chose not to spend more than a third of it. Some of the money meant for global health programs was used to pay for the White House budget director’s security detail, and the rest just sat there, unspent.

So now, American foreign aid — at least for lifesaving global health work — is back on paper. But whether it actually reaches the patients and programs that need it is another matter.

What happened last time

The money was on paper last year, too. According to an analysis by the Center for Global Development, US spending on global health fell by more than a third, the consequences of which have been devastating.

Consider the Global Fund, a massive international body that finances HIV, tuberculosis, and malaria programs in more than 100 countries. The US had pledged $6 billion to the fund for 2023 through 2025, and Congress approved the money to pay for it.

But the US failed to deliver on that pledge, and as of mid-2025, less than a third of that $6 billion had reached the Global Fund. Facing a shortfall driven largely by US inaction, the Global Fund had to slash $1.4 billion from grants it had already made to lifesaving programs.

These cuts came just as the administration was also terminating hundreds of PEPFAR programs that funded HIV and TB care on the ground. In Lesotho, where TB rates are among the highest in the world, the result was that clinics simply shut down. One patient visited nine HIV/TB clinics before finding one still open, an aid worker with direct knowledge of operations in the country told Vox.

What’s different this time

Under the Constitution, when Congress appropriates money, the executive branch is required by law to spend it as Congress dictates. But last year, the administration simply didn’t — and largely got away with it.

This time, Congress is trying to force the issue.

The new law sets specific funding floors for malaria, maternal and child health, tuberculosis, and nutrition, and uses unusually forceful language requiring the State Department to report its spending plans to Congress and to make quarterly payments to the Global Fund. Julianne Weis, co-founder of Aid on the Hill, which tracks foreign aid legislation, said these oversight requirements didn’t exist at this level of scrutiny before.

But laws didn’t stop the administration last year. AVAC, an HIV advocacy organization, sued the government over the unspent funds; that case is still active.

The real test is whether Congress enforces its own law. “Congress abdicated their responsibility [last year] for ensuring that the president spent what they had appropriated,” said Mitchell Warren, head of AVAC. Whether this Congress will act differently is an open question.

“There’s a huge question about the intent of the State Department to spend that money, and frankly the ability — the operational capacity — to do so,” said Jocilyn Estes, a policy expert at the Center for Global Development, a nonpartisan think tank.

That capacity problem is stark. Before USAID was gutted, its TB program alone had nearly 200 dedicated staff — 40 in DC and 150 around the world — managing about $406 million a year across 24 countries. Today, according to a person with direct knowledge of the program, two people at the State Department oversee that same portfolio. The President’s Malaria Initiative, which manages $795 million in funding, went from 66 staffers to five.

And going forward, a growing share of US global health funding is supposed to flow in a fundamentally different way. Under the administration’s “America First Global Health Strategy,” the US is abandoning the old USAID practice of working with aid organizations and is instead striking deals with foreign governments — an approach that experts say requires more specialized staff, not less.

The administration has signed 16 such deals so far — but they don’t cover key areas that Congress just funded, like family planning, which received roughly $524 million despite the administration actively working to eliminate it. Weis is skeptical that the White House will follow through, even with the law’s attempted safeguards. “There’s going to be a lot of money left over that is not spent,” she said.

Still, the new law is a sign that Republicans and Democrats in Congress are reasserting that the US should continue to do lifesaving global health work. “What this law mostly says is that Congress is back,” AVAC’s Warren told me. For decades, foreign aid has had strong bipartisan support on Capitol Hill, even when presidents have tried to reshape it.

But Warren isn’t celebrating yet. “I’ll declare victory when every dollar Congress appropriated is spent by the administration.”

The fiscal year ends in September. That’s when we’ll know.

One weird thing that’s been holding drug trials back

2026-01-21T13:29:33-05:00

The FDA released draft guidance in January 2026 encouraging the use of Bayesian statistics in clinical trials, a shift that could benefit patients with rare diseases like ALS.

Here’s something strange about how we test new drugs: Every clinical trial has to pretend that nothing like it has ever come before.

Even if clinicians have tested similar drugs for years, or if decades of research point in a certain direction, each trial must prove — independently — that the drug works based solely on what happens inside that specific study. Prior knowledge doesn’t count.

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For more than 60 years, this blank slate approach has been the Food and Drug Administration’s gold standard — and for good reason. If you let prior research formally count toward proving a drug works, drug companies might easily cherry-pick the studies that flatter their results.

Naturally, such rules have led to academic circle jerks over whether past research should factor into the final verdict on a drug. But for patients, the cost of starting from scratch every time can be high.

For people with rare diseases, where only a few hundred individuals worldwide might have a condition, running a traditional trial can be nearly impossible, because there simply aren’t enough patients to enroll. For children, it has meant re-proving what we already learned in adults. And for everyone, it has meant slower, more expensive trials that throw away useful information.

Now, the FDA is telling drug companies and researchers they don’t have to start from scratch anymore.

Last week, the agency released new guidance encouraging companies to use a statistical approach, that would usually be used on a case-by-case basis, called Bayesian methods. (We’ll get more into that later.)

What that means is that, for the first time, companies can formally incorporate what they already know — from earlier studies, from related drugs, from real-world evidence — to help answer the central question of whether a drug works. The FDA’s guidance is still a draft, and details may shift over the coming months, but the policy signal is clear.

“It sounds so intuitive to just use the data that you have before to inform the next thing that you do,” said Merit Cudkowicz, a neurologist at Massachusetts General Hospital who runs a major ALS clinical trial, “instead of just having this sort of amnesia.”

Two ways of looking at the world

For a drug to get FDA approval, it has to prove it works in three phases of clinical trials. But “proving it works” can mean different things, depending on how you handle uncertainty.

The traditional approach — called frequentist statistics — asks a narrow question: If this drug doesn’t actually work, how likely is it that we’d see results this strong just by chance? If that probability is very low (typically below 5 percent), the drug passes the test. The appeal is objectivity; the trial data speaks for itself, and what you believed going in doesn’t formally enter the math.

Bayesian statistics, the new rule of the land, flips the question. It asks: Based on everything we already know, how likely is it that this drug works? Then, it updates that estimate as new trial data comes in. The result isn’t a binary pass/fail, but a probability — say, a 94 percent chance the drug is effective. That doesn’t mean anything goes, and the FDA still has to draw a line in the sand that’s pre-agreed before the trial runs.

The practical upshot is that Bayesian methods let you formally “borrow” information from other places. If you’ve already tested a drug in adults, you can use that data when evaluating it in children. If you’re running a trial with multiple drugs, data from one arm of the study can inform another. This flexibility matters most in situations where patients are hard to come by.

“The availability of prior information is why we see such use in pediatric,” said James Travis, a statistician in the FDA’s drug review division. “We pretty much always have adult information, so it’s very easy to do things like that in the pediatric space.”

But being able to bring in outside information raises one obvious concern: What is stopping researchers from cherry-picking the studies that make their drug look good?

Traditional trials have a hard threshold — the “p-value,” a measure of whether results are likely due to chance — that seems to remove human judgment out of the equation. You either hit statistical significance, or you don’t. Bayesian methods, by contrast, require researchers to choose “priors,” or assumptions about what they expect to find based on existing evidence.

But this critique assumes that traditional trials are capital-O objective, and that’s not necessarily the case; they just hide their assumptions better.

Every clinical trial involves choices: which patients to enroll, what outcomes to measure, what comparisons to make. A p-value can make it seem like the math is deciding, when, in fact, subjective judgments are baked in throughout.

Bayesian methods, proponents argue, force those assumptions into the open. You have to state your priors upfront, and justify them. And then everyone — including FDA reviewers — can see exactly what you assumed and evaluate whether it was reasonable.

Why patients care about statistics

All of this might sound like an academic statistical debate. But for people with serious diseases and their loved ones, the stakes are stark.

Consider amyotrophic lateral sclerosis (ALS), a neurodegenerative disease that kills most patients within two to five years of diagnosis. Around 5,000 Americans are diagnosed each year, according to the Centers for Disease Control and Prevention’s National ALS Registry.

But despite decades of research, drug trials kept failing. Testing one drug at a time, starting essentially from scratch each time, was painfully slow for a disease that doesn’t have much wait time.

In 2019, the FDA green-lit an unusually Bayesian trial to hunt for new ALS drugs. In the HEALEY ALS Platform Trial, researchers at Massachusetts General Hospital were able to test multiple ALS drugs at once, fast enough to matter for patients who didn’t have time to wait. Data from patients in one part of the trial — including those receiving placebos — can be used to inform drugs in other parts of the large-scale trial. This means the trial can drop drugs that aren’t working and add promising ones without starting over each time.

In the four years the trial has been running, seven drugs have been tested so far. A traditional approach might have managed just two. The new FDA statistical guidance, Cudkowicz, the neurologist who leads the study, said, should clear the path for other trials to follow this sort of model.

“The patients enrolled so fast because the patients with ALS felt that this was a patient-centered trial,” Cudkowicz said. Two of those drugs showed enough promise that they’re now advancing to final-stage trials.

“The Bayesian approach is just trying to take all of that data that participants give — and they give a lot of themselves — and use it in the most effective way,” said Melanie Quintana, a statistician at Berry Consultants, who helped design the HEALEY trials.

The catch

More flexibility also means more room for things to go wrong.

A 2018 review, co-authored by Aaron Kesselheim, a Harvard professor who studies FDA policy, examined more than 100 adaptive trials, a related approach that also allows mid-trial adjustments and often uses Bayesian methods. They found that only a third of trials used independent committees to monitor the data, and just 6 percent kept statisticians blinded when analyzing mid-trial. Without these safeguards, there’s more room for bias to creep in or for early results to mislead.

FDA officials say the safeguards for Bayesian trials will remain. Every proposal will be reviewed by agency statisticians, and companies must lock in their methods before the trial starts.

“It’s not like you get to pick the prior after you’ve seen the data,” John Scott, who oversees biostatistics at the FDA. “There’s really strict rules about that.”

But whether individual companies actually start using these methods is another question. The guidance is not yet set in stone. The proposal is open for public comment until March 13, with a final version expected in about 18 months. And with FDA facing leadership turnover and political uncertainty, companies may be even more cautious about trying something new.

“Drug companies hate uncertainty,” said Adam Kroetsch, a former FDA official who has written about the agency’s evolution. “They might decide it’s not worth the risk and just go with the traditional approach where they know there’s FDA precedent.”

But the FDA isn’t alone in this shift — the European Medicines Agency has also been exploring expanded use of Bayesian methods in drug development.

For patients with rare diseases, or for children waiting on treatments that already work in adults, the stakes of this statistical change are potentially life or death. The HEALEY trial has already shown what’s possible, and the FDA has opened the door. Now, more companies have to walk through it.

AI is uncannily good at diagnosis. Its makers just won’t say so.

2026-01-14T11:23:05-05:00

OpenAI recently launched ChatGPT Health, which lets users connect their medical records and fitness data.

How often have you asked ChatGPT for health advice? Maybe about a mysterious rash or that tightening in your right calf after a long run. I have, on both counts. ChatGPT even correctly diagnosed that mysterious rash I developed when I first experienced Boston’s winter as cold urticaria, a week before my doctor confirmed it.

More than 230 million people ask ChatGPT health-related questions every week, according to OpenAI. While people have been plugging their health anxieties into the internet since its earliest days, what’s changed now is the interface: Instead of scrolling through endless search results, you can now have what feels like a personal conversation. (Disclosure: Vox Media is one of several publishers that have signed partnership agreements with OpenAI. Our reporting remains editorially independent.)

This story was first featured in the Future Perfect newsletter.

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In the past week, two of the biggest AI companies went all-in on that reality. OpenAI launched ChatGPT Health, a dedicated space within its larger chat interface where users can connect their medical records, Apple Health data, and stats from other fitness apps to get personalized responses. (It’s currently available to a small group of users, but the company says it will eventually be open to all users.) Just days later, Anthropic announced a similar consumer-facing tool for Claude, alongside a host of others geared toward health care professionals and researchers.

Both consumer-facing AI tools come with disclaimers — not intended for diagnosis, consult a professional — that are likely crafted for liability reasons. But those warnings won’t stop the hundreds of millions already using chatbots to understand their symptoms.

However, it’s possible that these companies have it backward: AI excels at diagnosis; several studies show it’s one of the best use cases for the technology. And there are real trade-offs — around data privacy and AI’s tendency to people-please — that are worth understanding before you connect your medical records to a chatbot.

The good news (sort of)

Let’s start with what AI is actually good at: diagnosis.

Diagnosis is largely pattern-matching, which is partially how AI models are trained in the first place. All an AI model has to do is take in symptoms or data, match them to known conditions, and arrive at an answer. These are patterns doctors have validated over decades — these symptoms mean this disease, this kind of image shows that condition. AI has been trained on millions of these labeled cases, and it shows.

In a 2024 study, GPT-4 — OpenAI’s leading model at the time — achieved diagnostic accuracy above 90 percent on complex clinical cases, such as patients presenting with atypical lacy rashes. Meanwhile, human physicians using conventional resources scored around 74 percent. In a separate study published this year, top models outperformed doctors at identifying rare conditions from images — including aggressive skin cancers, birth defects, and internal bleeding — sometimes by margins of 20 percent or more.

Treatment is where things get murky. Clinicians have to consider the right drug, but also try to figure out whether the patient will actually take it. The twice-daily pill might work better, but will they remember to take both doses? Can they afford it? Do they have transportation to the infusion center? Will they follow up?

These are human questions, dependent on context that doesn’t live in training data. And of course, a large language model can’t actually prescribe you anything, nor does it have the reliable memory you’d need in longer-term case management.

“Management often has no right answers,” said Adam Rodman, a physician at Beth Israel Deaconess Medical Center in Boston and a professor at Harvard Medical School. “It’s harder to train a model to do that.”

But OpenAI and Claude aren’t marketing diagnostic tools. They’re marketing something more vague: AI as a personal health analyst. Both ChatGPT Health and Claude now let you connect Apple Health, Peloton, and other fitness trackers. The promise is that AI can analyze your sleep, movement, and heart rate over time — and surface meaningful trends out of all that disparate data.

“It’s going on vibes.”
Adam Rodman, physician at Beth Israel Deaconess Medical Center in Boston

One problem with that is that there’s no published independent research showing it can. The AI might observe that your resting heart rate is climbing or that you sleep worse on Sundays. But observing a trend isn’t the same as knowing what it means — and no one has validated which trends, if any, predict real health outcomes. “It’s going on vibes,” Rodman said.

Both companies have tested their products on internal benchmarks — OpenAI developed HealthBench, built with hundreds of physicians, which tests how models explain lab results, prepare users for appointments, and interpret wearable data.

But HealthBench relies on synthetic conversations, not real patient interactions. And it’s text-only, meaning it doesn’t test what happens when you actually upload your Apple Health data. Also, the average conversation is just 2.6 exchanges, far from the anxious back-and-forth a worried user might have over days.

This doesn’t mean ChatGPT or Claude’s new health features are useless. They might help you notice trends in your habits, the way a migraine diary helps people spot triggers. But it’s not validated science at this point, and it’s worth knowing the difference.

The real risks

The more important question is what AI can actually do with your health data, and what you’re risking when you use them.

The health conversations are stored separately, OpenAI says, and its content is not used to train models, like most other interactions with chatbots. But neither ChatGPT Health nor Claude’s consumer-facing health features are covered by HIPAA, the law that protects information you share with doctors and insurers. (OpenAI and Anthropic do offer enterprise software to hospitals and insurers that is HIPAA-compliant.)

In the case of a lawsuit or criminal investigation, the companies would have to comply with a court order. Sara Geoghegan, senior counsel at the Electronic Privacy Information Center, told The Record that sharing medical records with ChatGPT could effectively strip those records of HIPAA protection.

At a time when reproductive care and gender-affirming care are under legal threat in multiple states, that’s not an abstract worry. If you’re asking a chatbot questions about either — and connecting your medical records — you’re likely creating a data trail that could potentially be subpoenaed.

Additionally, AI models aren’t neutral stores of information. They have a documented tendency to tell you what you want to hear. If you’re anxious about a symptom — or fishing for reassurance that it’s nothing serious — the model can pick up on your tone and possibly adjust its response in a way a human doctor is trained not to do.

Both companies say they have trained their health models to explain information and flag when something warrants a doctor’s visit, rather than simply agreeing with users. Newer models are more likely to ask follow-up questions when uncertain. But it remains to be seen how they perform in real-world situations.

And sometimes the stakes are higher than a missed diagnosis.

A preprint published in December tested 31 leading AI models, including those from OpenAI and Anthropic, on real-world medical cases and found that the worst performing model made recommendations with a potential for life-threatening harm in about one out of every five scenarios. A separate study of an OpenAI-powered clinical decision support tool used in Kenyan primary care clinics found that when AI made a rare harmful suggestion (in about 8 percent of cases), clinicians adopted the bad advice nearly 60 percent of the time.

These aren’t theoretical concerns. Two years ago, a California teenager named Sam Nelson died after asking ChatGPT to help him use recreational drugs safely. Cases like his are rare, and mistakes by human physicians are real — tens of thousands of people die each year because of medical errors. But these stories show what can happen when people trust AI with high-stakes decisions.

So should you use it?

It would be easy to read all this and conclude that you should never ask a chatbot a health question. But that ignores why millions of people already do.

The average wait for a primary care appointment in the US is now 31 days — and in some cities, like Boston, it’s over two months. When you do get in, the visit lasts about 18 minutes. According to OpenAI, seven in 10 health-related ChatGPT conversations happen outside clinic hours.

Chatbots, by comparison, are available 24/7, and “they’re infinitely patient,” said Rodman. They’ll answer the same question five different ways. For a lot of people, that’s more than they get from the health care system.

So should you use these tools? There’s no single answer. But here’s a framework: AI is good at explaining things like lab results, medical terminology, or what questions to ask your doctor. It’s unproven at finding meaningful trends in your wellness data. And it’s not a substitute for a diagnosis from someone who can actually examine you.

Is NYC’s controversial $9 toll working? The data is in.

2026-01-06T18:26:58-05:00

E-ZPass readers and license plate-scanning cameras over Park Avenue in New York, on April 24, 2025. | Michael Nagle/Bloomberg via Getty Images

Could a $9 toll change notorious traffic? New York became the first American city to find out.

A year ago, it began charging drivers for entering Manhattan’s busiest central neighborhoods during peak hours. Critics called it a cash grab, and President Donald Trump even vowed to kill it.

But a year in, congestion pricing has largely proved to be a success, according to new data released by the Metropolitan Transportation Authority — the agency that runs New York’s massive network of subways, buses, and commuter rails.

Since tolling began, 21 million fewer vehicles have entered the toll zone, an 11 percent drop from what was projected without it. And average vehicle speeds improved by 23 percent. That’s the difference between a one-hour crawl and a 45-minute commute.

But the real gains came at the entry points. At the Holland Tunnel, for example, morning rush hour speeds jumped from 10.8 to 16.2 miles per hour — a 51 percent improvement. A separate analysis that used anonymized Google Maps data found these improvements spilled over to regional roads, meaning even drivers outside the zone got faster commutes.

Public transit riders benefited, too. After years of steady decline, average bus speeds in the zone ticked up 2.3 percent, reversing the trend seen in 2023 and 2024. Subway and bus ridership is up too, carrying more than 400,000 riders every day compared to 2024.

It’s easy to dismiss traffic as just a nuisance, but sitting in it is linked to higher stress, lost productivity, and worse air quality for everyone. Getting people out of cars and onto transit helps on all three fronts.

Streets got safer. Crashes involving trucks in the zone dropped by 21 percent compared to the previous year.

The MTA made money. Net revenue exceeded the MTA’s initial projections. That cash is earmarked for transit upgrades, including modern subway signals, 56 new elevators for accessibility, and the Second Avenue Subway extension.

The one place the jury is still out is on air quality. It’s worth watching because air pollution is a quiet killer. In New York City alone, fine particulate matter contributes to roughly 2,000 deaths and over 5,000 hospitalizations each year — and traffic is a major source of those pollutants.

A recent study from Cornell found a 22 percent decline in one kind of particulate matter after congestion pricing went into effect, while another analysis found little effect. The MTA’s own analysis showed no significant change in pollution levels. If London and Stockholm are any guide, it’ll take a few years of data before congestion pricing’s effects on air quality becomes clear.

There’s also the question of drivers who, looking to dodge the toll, might reroute through Queens or other neighborhoods outside the zone. The MTA has anticipated that and earmarked $100 million to offset potential air quality impacts in those neighborhoods: funding school air filters near highways and swapping out diesel equipment for electric.

The vocal opposition that greeted the program’s launch has largely died down, similar to what happened elsewhere. When Stockholm launched its congestion pricing in 2006, two-thirds of residents opposed it. After a six-month pilot, they held a referendum. More than half voted to keep it.

New York seems to be on the same arc. Gov. Kathy Hochul, who delayed the program in 2024, now touts it as an “unprecedented success.” And other cities are paying attention. Officials in Los Angeles have already reached out to New York for advice on their own potential pilot project, according to Gothamist.

Turns out, if you charge people to drive, fewer people drive. Who knew.

26 things we think will happen in 2026

2026-01-06T15:26:47-05:00

For the seventh year in a row, the Future Perfect staff — plus assorted other experts from around Vox — convened near the end of the year to make forecasts about major events in 2026.

Perhaps in keeping with the year we just experienced, the prognostication had grim overtones. Will the US remain an electoral democracy? Will the country fall into a recession? Will there be war in Taiwan? Will more states ban lab-cultivated meat? Will a Category 5 hurricane make landfall in the US? Will Beyoncé release a rock album? (Which is maybe just grim to me — there are so many better options!)

As always, we try to avoid random guessing. Each prediction comes with a probability attached. That’s meant to give you a sense of our confidence in our forecasts. The idea here is to exemplify epistemic honesty — being as transparent as we can about what we know we know, what we know we don’t, and what we don’t know, we don’t know.

As we have every year, we’ll check back at the end of the year and provide a report card on how we did, whether our accuracy ends up being Nostradamus level, or more like a band of blindfolded monkeys throwing darts at a board. You can check out how we did in 2025 here. We hope you enjoy reading — and don’t forget to update your priors. —Bryan Walsh

The United States

The US falls from the ranks of liberal democracies in the leading V-DEM index, but remains an electoral democracy (60 percent)

Entering 2026, assessing the health of American democracy is a bit of a puzzle.

There is no doubt that, in the first year of Donald Trump’s second presidency, American democracy has weakened significantly. He has smashed through constitutional constraints on his power, targeted his political opponents for repression, and run roughshod over civil liberties protections. It’s bad enough that three of the world’s top scholars of comparative democracy — Steven Levitsky, Daniel Ziblatt, and Lucan Way — have concluded that the United States has crossed the line into a form of authoritarianism.

On the other hand, there is little indication that Trump has been able to create a lock on power — or even significantly compromise the fairness of elections. Democrats dominated elections in 2025, anti-government activists operate freely, and the media is (mostly) as independent and critical as it was before Inauguration Day. When I spoke to Levitsky in December, he told me that Trump was failing “at consolidating autocratic power.”

For this reason, my own view is that the United States is still best classified as democracy, albeit a much weakened one. V-DEM, the leading academic metric of democracy, distinguishes between two classes of democracy — the stronger liberal democracy and weaker electoral democracy. When V-Dem releases its ratings for the past year, I expect the United States will fall from the former into the latter.

However, my confidence is low. What’s happening in the US is unprecedented for the world’s hegemon, and there is at least some credible evidence of bias in global democracy ratings — making the ultimate outcome a bit tricky to say for sure. —Zack Beauchamp

Democrats will take back at least one house of Congress (95 percent)

If the last one was tricky, this one is straightforward. There are at least five clear reasons to believe Democrats are headed for a midterm romp.

Point 1: In modern American politics, the president’s party almost always performs poorly in midterms.

Point 2: The Democratic Party is increasingly strong with college-educated voters, who tend to turn out more reliably in midterms than non-college voters — meaning the party has a structural leg up in those contests.

Point 3: Trump is an especially unpopular incumbent. The only 21st-century president with equivalently bad numbers at this point in his term was Trump himself, who experienced a massive electoral wipeout in the 2018 midterms. And there is real evidence Trump’s coalition is fraying from the inside.

Point 4: Democrats have dominated 2025 elections so consistently that it has become a meaningful indication of 2026 performance.

Point 5: Voter dissatisfaction is driven by a combination of affordability and concerns about his extreme policies in areas like immigration, and the White House seems either unable or unwilling to change in response to these concerns.

For all these reasons, Democrats are basically a lock to take back the House — barring hard-to-pull-off election tampering or some kind of unforeseen event that transforms the political environment. The Senate map is unfavorable, making it a much tougher fight, but they’re still competitive given the fundamentals. —ZB

At least one major function remains at the Education Department (70 percent)

The dismantling of the Education Department was one of the biggest stories in the early days of Trump’s second term, as the administration fired hundreds of staffers and Education Secretary Linda McMahon promised to lead the department on its “historic final mission.”

The president can’t actually dissolve the department without an act of Congress, but his administration has been moving bits of it to other agencies since the spring. In November, the White House announced perhaps the biggest shift yet, moving programs supporting K-12 students to the Labor Department, with other functions parceled out to the Departments of Health and Human Services, Interior, and State.

However, experts have long warned that other departments don’t have the expertise to take over Education staffers’ work, and the moves that have already occurred have reportedly been plagued with problems. Now Republican lawmakers are starting to voice concerns about what happens if the administration tries to transfer special education programs to another department, a move it has not yet made but hasn’t ruled out.

The Trump administration has already done lasting damage to the department, experts say. But getting rid of an agency is a lot harder in practice than in theory, and with Republicans starting to throw up warning signs, it’s more likely than not that at least one function of the department will remain through the end of next year. —Anna North

The Supreme Court will rule against Trump in the tariffs cases currently before the Court (70 percent)

To date, at least three federal courts have ruled that President Donald Trump exceeded his power under the International Emergency Economic Powers Act (IEEPA), when he imposed a broad range of constantly shifting tariffs on foreign imports. The Supreme Court is likely to join these three courts before the close of its current term.

For the most part, this Supreme Court’s Republican supermajority has been extraordinarily loyal to Trump. This is, after all, the same Court that held that Trump may use the powers of the presidency to commit crimes. But the Republican justices do sometimes break with Trump on issues that divide Republicans, and especially on issues that divide conservative legal elites.

The tariffs cases are just such an issue. At least some of the lawsuits challenging the tariffs were brought by right-leaning legal shops that hew to the GOP’s more traditional, libertarian views on foreign trade. Numerous Republican luminaries have joined briefs opposing the tariffs,

Including former Sen. John Danforth (R-MO), an early mentor to Justice Clarence Thomas. Over the spring, at a conference hosted by the conservative Federalist Society, a number of speakers criticized the tariffs and questioned their legality.

At the Supreme Court argument on the tariffs in November, the Court’s Republicans did, indeed, appear divided on whether to back Trump. While some members of the Court defended the tariffs, Chief Justice John Roberts and Justices Neil Gorsuch and Amy Coney Barrett — all Republicans — asked very skeptical questions of Trump’s lawyer.

It is always dangerous business to predict that this Supreme Court will break with a Republican president, which is why I still think there is a 30 percent chance that Trump prevails. And even if Trump does lose this round of litigation, he is likely to attempt to reinstate at least some of his tariffs by invoking other statutes. But my prediction will come true if the Court rules that Trump exceeded his authority under the IEEPA when he imposed his tariffs on imports. —Ian Millhiser

Trump will replace at least one member of the Supreme Court by the end of 2026 (75 percent)

Trump is unpopular — a recent Associated Press poll pegs his approval rating at 36 percent — and his party just got hosed in the 2025 elections. Republicans are still favored to hold onto the Senate after the 2026 midterms, largely because the Senate is malapportioned to favor small states that tend to vote for the GOP, but the Republican Party is in a deep enough hole that it could lose both houses of Congress.

And if the Democrats do take the Senate, they can prevent Trump from ever confirming another federal judge again. Which brings us to 75-year-old Justice Samuel Alito.

Alito is the Court’s most unapologetic partisan. If you want a full rundown of Alito’s history of rulings favoring the Republican Party, I encourage you to read my profile of him entitled “The Republican Party’s man inside the Supreme Court.” The short of it is that he’s often willing to embrace arguments that even his fellow Republican justices find embarrassing, at least when those arguments favor the GOP or its preferred policy outcomes.

If Alito retires while Republicans still control the Senate, he can be confident that his replacement will be a Republican who shares his views on the overwhelming majority of issues. He might even be replaced by one of his former law clerks.

If Alito does not retire, by contrast, he risks losing his last chance to retire under a Republican president and a Republican Senate. In the worst case scenario (from Alito’s perspective), he could die after Democrats regain both the White House and the Senate, ensuring that he will be replaced by his ideological opposite.

There’s also a chance that a different justice could either retire or die. Thomas is 77. Justice Sonia Sotomayor is 71. Roberts is 70. If any justice leaves the Court in 2026, a Republican Senate will almost certainly confirm Trump’s nominee to replace them.

That said, there is a chance that Alito and his fellow Republican justices are enjoying the power that comes with being part of a six-justice supermajority so much that they won’t want to give it up. But Alito has been such a reliable partisan during his time on the bench that it would be surprising if he denied his party its best chance to replace him with a younger version of himself. —IM

The world

Benjamin Netanyahu will not be the prime minister of Israel by the end of the year (65 percent)

Netanyahu has led the Israeli government for 15 of the last 16 years. He has weathered indictments, a criminal trial, coalition fractures, and of course the horrors of the Gaza war. Why would anyone bet against him in the 2026 elections (currently scheduled for October)?

The answer, I think, is that he has been living on borrowed time since October 7, 2023.

After that day’s atrocities, Netanyahu’s poll numbers collapsed — with most Israelis blaming him and his government for Hamas’s successful attack. His survival since then has had nothing to do with voters, and everything to do with coalition management: He has managed to prevent his far-right coalition partners from defecting and triggering early elections. But in 2026, there will be elections — and all indications are that his coalition doesn’t have the votes.

“The Netanyahu government has not been able to win a majority in any credible survey,” Dahlia Scheindlin, a leading Israeli pollster, told me last year.

That said, you really do not want to count Netanyahu out. And there are easy-to-imagine scenarios where he survives despite his obvious problems.

Currently, the best-polling opposition party is led by former Prime Minister Naftali Bennett. While Bennett is strongly anti-Netanyahu, he is also a right-winger — and to form an anti-Netanyahu government, polls suggest he’d likely need support from a broad coalition, including the left and even an Arab party. You can easily imagine Bennett failing to overcome the opposition’s ideological divisions and striking some kind of deal with Netanyahu instead. Or you could imagine protracted coalition negotiations that leave Netanyahu in power for months after the October elections, even if he is deposed in 2027.

The point is that there’s a lot of uncertainty here. But I’m going to bet on the most consistent thing: Polls showing that a clear majority of Israelis are done with Bibi. —ZB

There will not be a ceasefire, agreed to by both Ukraine and Russia and observed for at least 30 days, by December 31, 2026 (60 percent)

A salon damaged by Russian bombing in Kostiantynivka, Ukraine, December 28, 2025.

| Diego Herrera Carcedo/Anadolu via Getty Images" data-portal-copyright="Diego Herrera Carcedo/Anadolu via Getty Images" />

The Trump administration has been pushing hard for a ceasefire deal in recent weeks and there was some optimism it might end before Christmas. But the underlying dynamics of the conflict are still the same and still make an end to the war in the coming months more unlikely.

Despite the heavy casualties Russia is taking, the damage to its economy inflicted by sanctions, and the slow pace of progress on the battlefield, Russian President Vladimir Putin believes he is winning the war and is unlikely to be satisfied with any deal that does not severely curtail Ukraine’s sovereignty. It’s not even clear if the 28-point plan cooked up by his envoys Steve Witkoff and Jared Kushner in November, which was heavily tilted toward Russian interests, would have been enough to satisfy him.

On the other side, Ukrainian leaders mostly accept at this point that they’re unlikely to regain all of the territory currently held by Russia by military force. But they are just as unlikely to accept Trump’s recent demands that they cede the so-called fortress belt of heavily defended positions in eastern Ukraine, something that would be suicidal fairly likely event that Russia restarts its war in a few years. And while NATO membership may be off the table at this point, Ukraine is likely to insist on security guarantees from NATO countries that will probably be unacceptable to the Russian side.

While US support for Ukraine gives it significant leverage, European countries are now the primary economic and military backers of the Ukrainian war effort and Ukrainians are making far more weapons of their own, including the ubiquitous drones that are playing such a vital role on the battlefield.

For all Trump’s public attacks on Ukraine, the United States is still providing intelligence support to the Ukrainian military and selling the country for weapons (in many cases, paid for by Europe). And if the past year’s back and forth is any indication, Trump’s current pro-Moscow tilt could shift.

Trump’s success with the Gaza ceasefire showed that these deals can come together much more quickly than many expect, but for a variety of reasons, the combatants in Ukraine are less susceptible to American pressure and less willing to call off the fighting. Most likely, Ukraine is facing a fifth year of devastating and brutal war. —Joshua Keating

Between January 1 and December 31, 2026, China does not impose a full blockade of Taiwan or launch a declared invasion (75 percent)

In 2021, Adm. Phil Davidson, then the head of Indo-Pacific Command, told Congress he believed China would likely seek to achieve its ambition of taking control of Taiwan “in the next six years.” We’re now approaching the later end of what has become known in defense circles as the “Davidson window.” But for the moment, war — or something close to it — still seems unlikely. The biggest question mark around a military scenario in Taiwan is whether the US would intervene directly to defend the island. And the best case for the argument that China will move soon is that President Donald Trump’s words and actions have given little reason to believe he would do that. But an amphibious invasion of a mountainous and densely populated island with a hostile population is still a daunting prospect even if the US doesn’t get involved.

A blockade or quarantine might be more likely, something Taiwan’s economy is vulnerable to, but the island’s importance to the global tech economy means the fallout from a blockade would be both massive and widespread. (One analysis predicted a blockade of Taiwan would cost the world $2 trillion in lost economic activity.) And the US is not the only country that might come to Taiwan’s aid: Japan’s new prime minister recently enraged Beijing by suggesting a Taiwan crisis would be a survival threatening situation for Japan, meaning it would have legal justification to deploy its military.

To put it bluntly, at the moment, Xi Jinping has a good thing going with Trump, who is seeking better trade relations with China and has even gone so far as to agree to sell advanced microchips that the Chinese never even asked for. China may also be holding out for the possibility of “peaceful reunification.” The island’s major opposition party, the Kuomintang, now favors much closer relations with Beijing.

We should absolutely expect more economic pressure on Taiwan and its supporters abroad, more moves to block diplomatic contacts between Taiwan and the outside world, more influence campaigns and propaganda directed at the Taiwanese public, and even possible “gray zone” attacks targeting Taiwan’s infrastructure, such as undersea communications cables.

Putin’s decision to invade Ukraine showed that sometimes autocratic leaders can make risky moves that seem to make little sense from the outside, but assuming Xi is a bit more level-headed, he’s unlikely to gamble it all on an invasion or blockade in the coming year. —JK

Economy

At least two more states will pass laws effectively ending apartment bans (single-family-only zoning) in most residential areas statewide (45 percent)

The last few years have seen the birth of a new paradigm in how housing in the United States is regulated and built. Ever since the widespread adoption of zoning codes over the last century, it’s been local governments — cities, suburbs, small towns — that decide what’s allowed to be built, usually to an extreme degree of prescriptiveness. Most residential land across the country is zoned exclusively for detached single-family homes — no duplexes, triplexes, or apartment buildings allowed. That is, as I wrote about last year, what’s fundamentally at the root of the great American housing shortage and housing affordability crisis.

But those rules are steadily, if slowly and unevenly, starting to change. Many states have passed legislation that begins to unwind the morass of local obstacles to building homes, with single-family-exclusive zoning being a frequent target. While this trend is technically a form of centralization, I think it’s better to think of it as a kind of deregulation that gives power back to people to create things in their communities. California, Maine, Montana, Oregon, Vermont, and Washington all now have laws requiring local governments to allow at least duplexes, and in some cases even more homes, on lots zoned for single-family homes in many residential areas. Several other states are considering similar bills, and more will probably be introduced this year.

These state-level zoning preemption laws are, in reality, usually enormously complex and often include carveouts and exceptions that were needed to get the legislation over the finish line because local opposition to new housing can be fierce. So while I think we’re extremely likely to see more states pass housing liberalization laws in 2026, I think the chances that two more states pass laws with my exact criteria — ending single-family zoning in the residential areas that cover most of the state’s population — are just under 50-50. —Marina Bolotnikova

Total billionaire wealth will exceed $17 trillion, as calculated by the UBS Billionaire Ambitions report (85 percent)

The grass is green. The sky is blue. The rich get richer.

Some things are just common sense. But actually, the wealth of the very wealthiest people does not always get bigger year after year. Take 2022, for example, when stock market woes made the world’s billionaires about $2 trillion poorer than they were the year before. Womp, womp.

But ever since then, the ultra-rich have indeed only gotten richer. A new billionaire was born every 37 hours of 2025, lifting the total number of billionaires to nearly 3,000 and their collective wealth to a record-shattering $15.8 trillion, according to the UBS Billionaire Ambitions report. Many have gotten rich off the AI boom, while others are heirs and heiresses, whose inheritances grew by a collective $297.8 billion last year as part of a giant wealth transfer that’s just getting started.

As long as nobody bursts their bubble, the ultra-rich will probably just get richer in 2026. And if their wealth keeps growing at the rate it has been, they’ll very likely be sitting on over $17 trillion by the time UBS publishes its report next winter. —Sara Herschander

The US will experience a recession in 2026 (55 percent)

Even in “good” times, the US economy is a balancing act between consumer spending, business investment, financial conditions, and policy choices.

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Recession forecasts are the meteorology of economics: Everyone complains when you’re wrong, and nobody sends thank you notes when you’re right. Still, the reason I’m slightly over 50 percent is simple: Late-cycle economic risk is real, and the list of plausible triggers — the AI bubble popping, trade policy finally hitting home, a major international crisis — is long.

Even in “good” times, the US economy is a balancing act between consumer spending, business investment, financial conditions, and whatever policy choices Washington makes in a given week. It doesn’t take a Great Depression-level shock to tip that balance — sometimes it’s just interest rates staying tighter longer than expected, a confidence shock, or a geopolitical event that hits energy and trade. And if 2020 taught us anything, it’s that the economy can fall down the stairs faster than it can climb them.

For scoring, I’d define “recession” as a National Bureau of Economic Research-dated recession that begins in calendar year 2026. If the NBER hasn’t ruled by the time we do our year-end grading (they are not known for sprinting), we’ll use a proxy: two consecutive quarters of negative real GDP growth in 2026.

Why only 55 percent? Because the US has a stubborn capacity to muddle through — until it doesn’t. —BW

Animals

The share of cage-free eggs in the US will not surpass 50 percent in 2026 (60 percent)

At the end of 2024, cage-free eggs accounted for 38.7 percent of the US egg supply. By September 2025 — the most recent data available — that figure hit 45.3 percent. It was a major shift for such a short period, and equates to millions of egg-laying hens no longer spending their entire lives in tiny cages.

I think that in 2026, this trend will continue, but not fast enough for the US egg supply to reach 50 percent cage-free by the end of September. And that’s because a few big events occurred in 2025 that spurred this momentum that won’t occur next year.

The first is that laws in three states — Arizona, Colorado, and Michigan — that require eggs sold to be cage-free went into effect in 2025 (though Arizona quickly delayed its implementation by years). No new laws will go into effect next year.

Additionally, over the last decade, hundreds of food companies pledged to source cage-free eggs, and many set a 2025 deadline. While a lot of them have not followed through on their pledge, a lot inched closer during this deadline year.

I could be — and hope I will be — wrong, and there are two reasons why I might lose this prediction. The first is that animal advocacy groups are now focused on pressuring grocery chains to meet their cage-free pledges, and if they’re successful in 2026, that could quickly tip the scales, since grocery stores account for where most eggs are sold. Second, there’s bird flu — if the virus were to disproportionately hit cage farms this winter and spring, that would affect the ratio of cage-free to cage eggs for much of 2026.

The food industry’s rapid move away from cages for egg-laying hens is a major success story for the modern animal rights movement, and hitting 50 percent of the US egg supply will be an important milestone. I think it’ll happen soon — let’s say by March 1, 2027 — but I don’t think it’s in the cards by the end of September, 2026. —Kenny Torrella

At least one US state will ban lab-grown meat in 2026 (60 percent)

In 2024, Florida and Alabama banned the production and sale of lab-grown, or cell-cultivated, meat. They represented unabashed protectionism — favoring livestock farmers over startup food companies — and hollow, conspiratorial culture war posturing (when he signed the bill into law, Florida Gov. Ron DeSantis implied this was a contest between real Floridians and globalist elites).

Even though many ranchers and farming groups have opposed the bans, arguing that it looks bad to outlaw your competition, five more states passed similar laws in 2025 — three with full-on bans (Mississippi, Montana, and Nebraska), and two with two-year bans (Texas and Indiana). In many other states, lawmakers introduced similar bills that failed, and I figure at least one will succeed next year (for the purpose of accuracy, I’ll count a temporary ban as a ban).

I’m not particularly confident, however, because some states seemed to have settled on strict, unfavorable labeling requirements for cell-cultivated meat producers as opposed to banning the product altogether. And in some states, the bills have proven controversial (for example, many ranchers in Wyoming were opposed to a ban on libertarian grounds).

At this moment, the bans mean little in practical terms — only a few restaurants around the country serve cell-cultivated meat, and in small quantities. But the bans could pose a problem for the industry down the road if they figure out how to affordably produce cell-cultivated meat at scale. —KT

The US will authorize mass bird flu vaccination for at least one major US poultry category — egg-laying hens, broiler chickens, or turkeys (35 percent)

The US is entering its fifth year of a truly ghastly bird flu outbreak. It’s caused dozens of human bird flu cases across the country, it’s sparked an outbreak in dairy cows, it’s sent egg prices soaring, and it’s been catastrophic for the tens of millions of chickens and turkeys who’ve died horrible deaths on infected farms. And all this is happening despite the fact that we already have vaccines that could dramatically blunt the damage.

So why, four years into this outbreak, have we managed to do so little to get avian flu under control?

It has more to do with bureaucracy and economic interests than scientific capacity. The American chicken meat industry exports a significant share of its product abroad, and the fear is that our trading partners would reject US chicken because of the challenge of determining whether a poultry bird is infected with avian flu or simply has antibodies from vaccination. So instead of vaccinating, the US has resorted to mass killing chickens and turkeys — quite painfully — in a mostly unsuccessful attempt to control the spread.

As the outbreak stretches on, and egg and turkey producers complain that they aren’t allowed to vaccinate because of the chicken industry’s trade concerns, pressure has mounted for US regulators to approve a plan to start vaccinating poultry birds across the country — something that ought to be a no-brainer given that, as Vox’s Kenny Torrella has pointed out, the costs of managing the outbreak have been much higher than the value of the chicken industry’s exports. As of last summer, the US Department of Agriculture was reportedly working on such a plan.

Will we start routinely vaccinating in 2026? We’re closer than we have been in any previous year, but securing assurances from trade partners is hard, long work, as is devising a plan for vaccine rollout that satisfies those partners, and all indications are that we’re not close yet. If we start to see more severe bird flu spread in 2026 and sustained spikes in egg prices, the USDA’s calculus might change. But for now, I think we’re less likely than not to see the agency authorize vaccination as part of a standard avian flu control program in poultry birds (rather than just as part of limited pilots or experimental uses). —MB

Climate

Global data center electricity demand will stay below 3 percent of total electricity in 2026 (80 percent)

A sign on a rural Michigan road opposes a planned $7 billion data center on southeast Michigan farm land. Opponents say the Data Center could raise residential electricity rates and endanger the water supply.

Jim West/UCG/Universal Images Group via Getty Images

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Per the International Energy Agency, data centers consumed 1.5 percent of the world’s electricity in 2024, around 415 terawatt-hours. Though these massive, energy-hungry facilities are proliferating at a rapid pace, they’re still a small fraction of humanity’s energy use.

Tech companies say they need many more of them, particularly to run their AI products, but data centers have an image problem. They are starting to wear out their welcome in some communities and are being thoroughly shunned in others. Only 44 percent of Americans say they would want one of these giant humming boxes near them. Speculation around their energy demand is already starting to raise electricity prices for consumers in some markets.

Now some environmental groups and activists are already calling for a moratorium on new data center construction, not just voting down individual projects, and at least one community has officially imposed a pause.

There are also strains on the global supply chain for data center components, so even places ready to go on a construction spree will have to wait for parts to catch up. Additionally, more power generators are continuing to come online, so the percentage share that goes to data centers won’t rise as quickly. —Umair Irfan

At least one Category 5 hurricane makes landfall in the continental US, as defined by the National Hurricane Center (10 percent)

The United States lucked out in 2025 with no major hurricane hitting the mainland. However, it’s only a matter of time before one does so again. The question is how strong it will be. There are typically 14 storms strong enough to be given a name in any year, but only 45 were ever known to have reached Category 5 strength, with sustained winds at 158 miles per hour. Fewer still maintained their full strength as they reached the shore.

The last Category 5 hurricane to hammer the continental US was Hurricane Michael in 2018, so baseline chances of this happening again next year are fairly low. The year 2026 is poised to start as a La Niña year, where the surface of the Pacific Ocean cools to below-average temperatures. That tends to create more favorable conditions for hurricanes in the Atlantic Ocean. The pattern is then lonely to shift into a neutral phase that has minimal effects on cyclones in the Atlantic. The other key variable is how much heat is in the Atlantic Ocean. Hurricanes run on warm water, and the fever of record-high temperatures broke in the Atlantic Ocean this year.

Add to that the variability in how hurricanes travel and you have a fairly low chance of the most powerful type of hurricane hitting the continental US at maximum power next year. —UI

Science and technology

At least one state-of-the-art AI system can complete a task that takes humans 16 hours, succeeding on at least half of its attempts (75 percent)

One of the past year’s most striking AI-related visuals was a graph showing that the length of tasks AI can do is doubling every seven months. This may seem a bit in the weeds, but it’s actually really important, because it speaks to AI’s growing ability to work autonomously. According to METR, the research group that made this graph, Claude Opus 4.5 has already hit four hours and 49 minutes, which means that the chatbot is expected to succeed at least 50 percent of the time on tasks that took humans that long. Extrapolating from this graph, I predict that at least one AI model will hit at least 16 hours by the end of 2026. I’m making this prediction with 75 percent confidence.

I could go higher, but I won’t, because a few variables could still change the trajectory. For example, if compute growth slows, we could see substantial delays in capability milestones. I also want to emphasize that you shouldn’t take this to mean that AI will put you out of work by the end of 2026: What’s being measured here is AI’s ability to succeed at very particular tasks, not its ability to generalize to the whole of what you can do. — Sigal Samuel

Congress will not pass, and Trump will not sign, any comprehensive federal legislation primarily focused on AI safety (90 percent)

The White House has come out strongly against state-level AI regulation, releasing an executive order in December saying that the “Administration must act with the Congress to ensure that there is a minimally burdensome national standard — not 50 discordant State ones.”

But it’s very unlikely that we’ll see comprehensive federal legislation in 2026 requiring AI companies to implement safety plans. For one thing, there is no consensus on what shape such a national framework should take. For another, the White House’s attempt to ban state-level regulation (with the idea of putting in a national framework instead) has proven extremely unpopular, including among Republicans. Plus, with so much tech lobbying aimed at relaxing regulation rather than entrenching it, there’s little incentive for the White House to push through comprehensive federal legislation on safety.

Taken together, all this leads me to think that while Congress may pass more specific AI provisions in 2026 (for example, related to national defense), it won’t pass a comprehensive national standard when it comes to actually keeping us safe from AI. —SS

At least one primarily AI-generated song reaches No. 1 on the Billboard Hot 100 chart (60 percent)

This is the kind of prediction that sounds silly right up until it’s not. Wholly AI-generated music has already crossed one major threshold, when the country track “Walk My Walk,” by the AI band Breaking Rust, topped Billboard’s Country Digital Song Sales chart. One survey found that 60 million people were using AI tools to make music, while the streaming platform Deezer reported that a third of the tracks uploaded each day were AI generated.

The remaining barrier to AI music colonizing your ears isn’t capability so much as distribution: You don’t hit No. 1 because you made a great song — you hit No. 1 because the machinery of attention (TikTok, streaming playlists, fandoms, and labels) decides to make your song unavoidable. And I could see the sheer novelty factor pushing at least one AI generated song to the top of the pops.

So what counts as “primarily AI-generated” here? For scoring purposes, I’d define it narrowly: The core musical content (melody/arrangement and a substantial share of the vocals or instrumentation) must be generated by an AI system, and that fact has to be publicly acknowledged by the creators or credibly reported: “AI was used in mastering” or “a producer used AI for a synth patch” — aka AI as a means to supplement human-made work doesn’t count. If it’s essentially an AI-made track with human polishing, it qualifies.

Why 60 percent? Because the incentives of novelty, speed and cost all line up. The big uncertainty is backlash: legal, cultural, or platform-level. But history suggests that if something can go viral, it eventually will. —BW

Elon Musk will exit the Giving Pledge (55 percent)

Musk is on track to become history’s first trillionaire. His fortune is already so gargantuan that if he wanted to, he could end world hunger and subsidize a free national preschool program and still have hundreds of billions of dollars to spare.

But don’t bet on it, because the world’s richest man may soon become the first person ever to go take-backsies on the Giving Pledge, a promise by the ultra-wealthy to donate half of their wealth in their lifetime or upon their death.

To be fair, plenty of other signatories have quietly died without fulfilling their pledge. But Musk has also drifted far away politically from who he was when he signed in 2012, and his qualms about philanthropy — including that of his fellow pledgers — are no secret. He thinks it is “extremely difficult” to give money well. MacKenzie Scott is “concerning.” Nonprofits are “money laundering” schemes. Philanthropy is “bullshit.” And the pledge’s founder Bill Gates, Musk told his biographer Walter Isaacson, is “categorically insane (and an asshole to the core).”

Oh, and his good friend Peter Thiel has been openly encouraging Musk — whose charitable foundation has regularly failed to meet the minimum legal giving requirements anyway — to unsign. Altogether, it’s become more likely than not that Musk will publicly bow out of the Giving Pledge before December 31, 2026. It could come in the form of a quiet delisting on GivingPledge.org, but chances are we’ll find out on X before anywhere else. —SH

There will be a satellite collision in low Earth orbit (75 percent)

Space is getting awfully crowded.

About 15,000 satellites currently orbit Earth. That number has risen exponentially in recent years due to megaconstellations, large satellite networks launched by private companies like SpaceX and Amazon to provide broadband internet access around the world. Most of these satellites are in low earth orbit (LEO), or 1,200 miles or less above the planet’s surface. As of late October, there were at least 12,000 active satellites in LEO — and just over 66 percent are a part of SpaceX’s Starlink constellation, which aims to eventually have up to 42,000 satellites.

We’ve launched more satellites to LEO in the last four years than we have in the previous 70 years combined. By 2040, we should expect to see more than 560,000 satellites in orbit based on planned launches. It’s hard to predict exactly how many satellites we’ll have by the end of 2026, but we know that Starlink and other megaconstellations will continue to grow.

The more satellites we have, the greater the chance that they will collide into one another or “space junk” — debris from human-made objects like defunct satellites, bits of spacecrafts, and old rocket parts. Various countries have space traffic management systems to protect against this, but they certainly aren’t fail-safe, especially given the rate at which new satellites are being launched into orbit and the increasing risk of collisions that comes with that.

On December 9, a Starlink satellite narrowly avoided colliding with a Chinese satellite. Space X claimed that the Chinese operator didn’t share its location data. Starlink satellites can automatically change course to avoid objects, but they have to know they’re there for this to work. In the first half of 2025, Starlink performed more than 144,000 avoidance maneuvers. So yes, collisions are inevitable — they’re just a question of when. I’d say 2026. —Shayna Korol

Health

The US will approve at least one fully synthetic, small-molecule oral GLP-1 receptor agonist for obesity and/or Type 2 diabetes treatment (70 percent)

GLP-1 drugs like Ozempic and Wegovy are all the rage, but high demand has meant serious shortages. That’s partly because these drugs are complex peptides grown from living cells, a process that’s hard to scale. But that won’t be the case for long.

Eli Lilly, an American pharmaceutical company, has developed an oral GLP-1 pill that works like the injections but is structurally very different, more similar to an aspirin. A pill like that would be much cheaper, won’t require cold storage, and can be pressed into pills by the billions. In pivotal trials, the drug showed weight loss rivaling the injections.

Lilly is submitting for FDA approval by year’s end, and the drug has been selected for the FDA’s new priority voucher program, which can cut review times from 10 months to as little as two. The government has already struck a deal with Lilly capping Medicare patients’ costs at $50 a month if approved. And CEO Dave Ricks told CNBC he expects a global launch “this time next year.”

Already in late December, the FDA approved a pill version of Novo Nordisk’s Wegovy. But that’s still a semaglutide, or peptide — not what I’m covering with this prediction. But if Lily’s approval goes through, we’ll be in a true era of GLP-1 abundance. —Pratik Pawar

Robert F. Kennedy Jr. is still serving as health secretary by the end of the year (60 percent)

RFK Jr. has never been a natural fit for the Trump administration. A longtime Democrat with a history of environmental advocacy, he was initially useful to Trump largely because he brought in voters supportive of his Make America Healthy Again movement. But his anti-vaccine advocacy has gotten him into trouble with Republican senators and occasionally put him out of step with Trump, who said in September that “you have some vaccines that are very amazing.”

Indeed, if I’d been making this prediction in the fall, I might have given Kennedy less than even odds of staying in his position through 2026. However, he has scored wins lately, like rolling back the federal recommendation that infants receive the hepatitis B vaccine at birth (to be clear, experts say getting rid of the recommendation is dangerous and could lead to unnecessary deaths). He has also managed to avoid real political fallout around the release of Olivia Nuzzi’s memoir about their alleged affair. Vaccine skeptics are reportedly excited about their recent victories and looking forward to more.

Neither vaccine opposition nor MAHA more generally are truly core to Trump’s governing project, to the extent that he has one, and it’s possible to imagine a post-midterm shakeup of the US Department of Health and Human Services. For now, however, the odds favor Kennedy keeping his job. —AN

The World Health Organization will officially withdraw the United States’s measles elimination status (75 percent)

The United States earned measles elimination status from the WHO in 2000, after decades of a successful vaccination campaign. More than 90 percent of children received the measles vaccine — and Americans widely agreed on its value. In the following years, with rare exceptions, the only cases in the US were brought here from other parts of the world where measles was still more widespread.

Not anymore.

Measles vaccination rates have been sliding for years, and 2025 brought the biggest single outbreak in more than three decades, seeded in West Texas among a religious community that is skeptical of vaccinations. Even as that outbreak petered out over the summer, after more than 700 cases and three deaths, local outbreaks have persisted in Utah and South Carolina.

The WHO’s criteria for revoking measles elimination status is 12 months of continuous transmission. Considering the same strain of the measles virus that was present in Texas in January was still circulating as of November, it doesn’t look good.

It seems to me that only a massive effort from the federal government could stamp out the disease in time — but that appears far less likely than the Kennedy-led health department limiting access to the measles vaccine next year. Instead, it looks like a pretty safe bet that one of the most contagious viruses known to humanity will continue spreading long enough to undo one of the US’s signature public health wins. —Dylan Scott

Culture

Beyoncé will release a rock album (55 percent)

Will Beyoncé release a rock album in 2026?

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Not many of my colleagues know this about me, but I’m a huge Beyoncé fan — and how could one not be? She has a voice like honeyed velvet, she can belt like no one else alive, and she can tear through choreo in six-inch heels like she’s just getting warmed up. Her creative instincts have made her one of America’s most consistently admired stars for over two decades, and she’s nothing if not incredibly versatile.

It’s already widely speculated that the third album in Beyoncé’s Renaissance trilogy (the first two being 2022’s Renaissance and 2024’s Cowboy Carter) will be rock ’n’ roll-adjacent, with many reports citing the rock songs she’s already released on Lemonade and her most recent album, plus the numerous rock-coded Easter eggs she’s been dropping over the last year. But she’s also been manifesting a bigger rock project ever since her jaw-dropping backbend set to electric guitar at a 2009 performance of “Freakum Dress,” and probably for even longer.

Her Renaissance trilogy, so far, has explored the Black musical roots of modern pop music, with each release encompassing not a fixed genre but a sonic world with porous borders. So while rock is a narratively satisfying guess for Beyoncé’s next act, there’s also a great deal of uncertainty — she’s rarely straightforward or predictable.

Nevertheless, I’ll place my bets that she’ll have an album out this year with rock or a rock subfield as its primary genre, as defined by at least one major music chart or streaming platform (Billboard, Apple Music, or AllMusic), or as defined by album reviews in a majority of the following outlets: Pitchfork, Rolling Stone, the New York Times, The Guardian, and Vulture. A tad overconfident? Perhaps. But we could all use a hard cultural pivot from the last few years of country music and aesthetics, and I can’t wait to see what Beyoncé will do as rock frontwoman. —MB

Jacob Elordi will be nominated for an Oscar for Best Supporting Actor for his portrayal of the creature in Frankenstein (70 percent)

Oh, Mr. Kissing Booth. I didn’t think you had it in you, but your sorrowful, baby doe eyes as the creature has endeared me!

I went to see Frankenstein in IMAX with one of my friends, and I knew that I was going to walk into a monster-sympathetic adaptation. (It’s Guillermo del Toro we’re talking about, he of Pan’s Labyrinth and The Shape of Water.) I’m a big fan of the book, and was eager to see how Elordi would interpret the creature’s curiosity, rage, and desire for love. Elordi’s creature was more than I could have ever hoped for. Elegant, childlike, and grotesque, all wrapped into one lanky 6-foot-6-inch body — a beautiful foil to Oscar Isaac’s impetuous Victor. I entirely forgot this is Nate from Euphoria! And apparently so did everyone at Cannes.

He will be nominated for Best Supporting Actor, but the odds he wins are lower, depending on who from One Battle After Another is nominated, either Benicio del Toro or Sean Penn. If it’s both, Elordi is cooked. —Izzie Ramirez

The biggest mosquito-borne disease in the world has a cure. There’s just one problem.

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In a children's ward for dengue in Bangladesh's capital, patients are squeezed two to a bed as cases rise well after the usual season for the potentially deadly mosquito-borne virus. | Abdul Goni/AFP via Getty Images

There’s a reason dengue infections are also called “breakbone fever.”

Along with a mild fever, symptoms of the mosquito-borne illness include bone-deep, aching pain in the joints and behind the eyes. In severe cases, blood vessels begin to leak. And in the worst cases, that can lead to organ failure.

More than 14 million people contracted dengue last year, and the real number is likely several times higher. While it remains most common in South Asia and Latin America, it’s no longer just a tropical disease. Warming temperatures are pushing dengue into southern Europe and the United States. Last year, Texas saw its highest case count in two decades, including locally acquired infections, meaning the virus is now circulating here, not just arriving with travelers.

Key takeaways

Dengue has no treatment. Doctors can manage the pain and keep you hydrated, but there’s nothing that actually fights the virus.
But, a new pill called mosnodenvir just proved it can stop the virus, the first time any drug has been shown to have effectiveness against dengue.
However, Johnson & Johnson, the company behind mosnodenvir, already walked away from developing it, joining a long line of drug makers chasing better money in cancer and obesity drugs.
The disease is now spreading to new parts of the world. The drug is stuck in limbo, and the gap between what we need and what the market will fund keeps growing.

The public health tools we have — the dengue vaccines, bed nets, fogging campaigns, public awareness to drain standing water — are all aimed at keeping mosquitos at bay and preventing infections in the first place. There’s nothing for after: no antivirals — nothing like Paxlovid for Covid, or Tamiflu for the flu, or artemisinin for malaria. Once you’re sick, the strategy is just supportive care and hope.

Earlier this month, though, that changed.

A new antiviral pill for dengue called mosnodenvir showed promising results in early phase 2 trials. In a study where volunteers were deliberately exposed to dengue, roughly half of those who received the highest dose never got sick at all. For a field that has struggled for decades to find an effective antiviral, it’s the clearest evidence yet that a drug can prevent dengue — and researchers believe the same pill could eventually treat people who are already infected.

But, even before the results were published, Johnson & Johnson, the American pharmaceutical giant that developed mosnodenvir, had already abandoned any efforts to bring the drug to market.

Last year J&J announced it would wind down its dengue antiviral work, with a “strategic reprioritization” of its research toward non-communicable diseases like cancer and obesity. What this means is that one of the most promising dengue drugs ever tested is now without a pharma sponsor, waiting for someone else to carry it forward.

André Siqueira, who heads the dengue program at the Drugs for Neglected Diseases Initiative (DNDi), said mosnodenvir is “very, very promising” and said he wants to see it pushed into further trials “as quickly as possible.”

But why — if the drug shows much promise — would its maker walk away?

J&J’s exit isn’t an outlier; it’s part of a broader retreat from infectious disease research across the pharmaceutical industry, as companies shift toward drugs for wealthier markets: cancer, obesity, autoimmune disorders.

Dengue already kills thousands every year, and it’s getting worse. By 2080, climate models suggest, nearly 60 percent of the world’s population could be living in areas where dengue spreads.

And, in this new world, watching the first antiviral pill that works against dengue get abandoned — while the disease spreads to new continents — reveals the gap between the drugs we need and the drugs the market will deliver.

| MD Abu Sufian Jewel/NurPhoto via Getty Images" data-portal-copyright="MD Abu Sufian Jewel/NurPhoto via Getty Images" />

What the pill actually proved

To test whether mosnodenvir actually works, researchers did something uncommon: They deliberately infected people with dengue.

Over the past three years, 31 volunteers in Baltimore and Vermont, in what’s called a challenge trial, agreed to take a pill for several days and then get injected with a weakened dengue virus. It’s a faster way to get answers than waiting for people to get sick naturally, but it requires volunteers willing to sign up for a controlled case of dengue.

Among people who got the highest dose of mosnodenvir, 6 out of 10 never developed an infection at all. The other four had much lower levels of virus in their blood and milder symptoms than the placebo group, where everyone got sick. At lower doses, the drug delayed infection but didn’t prevent it — a clear signal that the higher dose was doing something real.

“It’s one of the most beautiful dose-response results I’ve seen,” Anna Durbin, the Johns Hopkins researcher who led the study, told Science last month.

Then, there’s the field data. In 2023, J&J launched a trial across more than 30 sites in South America and Asia to test whether the drug could protect people in the same household who are at high risk of getting bitten by the same mosquitoes. Among 265 people who received the highest dose, not a single person developed symptomatic dengue. In the placebo group, 60 percent did. (This data hasn’t been formally peer-reviewed yet, but it’s posted publicly.)

For Neelika Malavige, a prominent dengue researcher at the University of Sri Jayewardenepura in Sri Lanka, the significance goes beyond the numbers. “It’s a huge scientific breakthrough just doing the study,” she said, referring to the design of the challenge trial itself, which had never been done for a dengue antiviral before. For a disease with no approved treatment, this is as close to proof of concept as it gets.

“The dengue community may be closer than ever to a long-awaited treatment,” Xuping Xie of the University of Texas Medical Branch wrote in a commentary accompanying the paper.

But, there are some caveats

The trial proved that mosnodenvir can prevent infection, a first for any dengue drug. But prevention isn’t what dengue doctors need most. What they need is a treatment, something to give patients who are already sick to keep them from getting worse.

That’s what makes an antiviral so valuable. Prevention strategies have a ceiling; you can reduce mosquito populations, but you can’t eliminate them, and warming temperatures keep pushing them into new territory. A drug that works after exposure would be the first tool that doesn’t depend on stopping the mosquito first.

The hope is that the same drug could do both. Mosnodenvir works by blocking the virus from replicating, and, in theory, that should help whether you take it before you’re infected or shortly after. The question is timing.

That’s where dengue gets tricky. Unlike malaria, where the parasite lingers, and you can kill it with drugs, the dengue virus moves through the body notoriously fast. By the time a patient feels sick enough to see a doctor — usually a few days into the fever — the virus is often already on its way out. The brutal symptoms that follow, the blood vessel leakage and organ damage, are driven largely by the body’s own immune response, not the virus itself.

Why I wrote this

As a global health reporter, this story felt grimly familiar. The things we pay attention to get solved, and so-called neglected tropical diseases have become something that just happens elsewhere. It’s the reason why tuberculosis is still the deadliest infectious disease and why it took 35 years to develop the first malaria vaccine.

This line from a 2004 article captures this quite well: “Probably the worst thing that ever happened to malaria in poor nations was its eradication in rich ones.”

I grew up in Mumbai, where dengue was a regular occurrence every monsoon season. But the disease isn’t staying there anymore. It’s spreading — into southern Europe, into the United States — and the question of who develops drugs for it is no longer someone else’s problem.

This is why antivirals have been so hard to develop for dengue. The window to intervene can be narrow, and for many patients, it’s already closing by the time they show up.

The scientists who developed mosnodenvir believe it could work as a treatment. “If you reduce the amount of replicating virus, you will also reduce the likelihood that the patient evolves towards severe disease,” said Johan Neyts, a virologist at KU Leuven whose lab co-discovered the drug. The logic is in line with how antivirals for, say Covid, work, but this hypothesis hasn’t been tested in humans. Treatment trials were planned in Singapore, but the Covid pandemic made them impossible. By the time restrictions lifted, J&J had already decided to exit.

The dream, Malavige said, is simple, “You go to the doctor, get yourself tested, the test is positive, you’re given an antiviral, and that’s the end of the story.” The question is whether patients can get there early enough — and whether mosnodenvir can work.

There’s also the question of resistance. In the human challenge trial, genetic mutations emerged in the virus among nearly all the participants who took mosnodenvir — mutations that could, in theory, make the drug less effective over time. And some dengue strains already circulating in nature appear to be harder to treat with this type of drug.

This is a real limitation. Mosnodenvir alone probably isn’t a long-term solution, because, eventually, the virus might adapt. But that problem is a familiar one for drug makers. HIV and malaria both evolved resistance to early drugs, and the answer was combination therapy: multiple drugs that attack the virus in different ways, making it far harder to escape all of them at once.

For that strategy to work with dengue, though, we need more drugs to combine. Mosnodenvir may not be the whole puzzle, but it could be the first piece. “If people stopped at the first sign of seeing trouble,” Malavige said, “then the world will not progress.”

Could Mosnodenvir…get adopted?

Johnson & Johnson’s exit follows a well-worn path for big pharma.

Over the past two decades, Bristol Myers Squibb, Novartis, AstraZeneca, and other major drugmakers have all scaled back or abandoned infectious disease research, judging that these drugs simply couldn’t compete with cancer and obesity blockbusters. A recent op-ed in the Financial Times called it a “textbook market failure.” The public health impact is massive, but the financial returns for addressing them aren’t.

After J&J’s exit, ownership of mosnodenvir is being transferred back to KU Leuven, the Belgian university where the drug was first discovered before J&J licensed it for development. “We will do all we can to make sure that mosnodenvir is further developed in clinical trials as soon as possible,” said Patrick Chaltin, who directs the university’s drug discovery center. To do that, the university is working with the Wellcome Trust, a major global health funder, to find new partners and funding.

And fortunately, mosnodenvir isn’t the only dengue drug that the pharmaceutical industry is looking into. The Swiss drug maker Novartis is running a phase 2 treatment trial for a different antiviral, and the Serum Institute in India is testing a monoclonal antibody.

Drug development is expensive and uncertain, and the people who need dengue treatments most are not the people who can pay the most. But these steps are encouraging.

In countries where dengue has always circulated — India, Brazil, the Philippines, Sri Lanka — people have learned to live around it, says Malavige. Life bends around when the mosquitoes are biting, and then bends back.

But dengue isn’t locked in those places anymore. Warmer temperatures are carrying the mosquitoes — and the virus — somewhere new every year. And there’s no sign that this expansion is slowing down.

Want to help save the most lives possible? Here’s where to give money.

2025-12-01T09:58:09-05:00

Saving lives with donations is possible. | Lorena Spurio for Vox

If you want to help human beings alive right now, there are few better places to give than global health.

Diseases that have been largely eradicated in the US still claim hundreds of thousands of lives abroad. In 2022, the most recent year for which there’s data, ten Americans died of malaria; all acquired it abroad. But the World Health Organization estimates that worldwide, 600,000 people died of it that year, most of them children in Africa.

If you don’t want to think about individual charities at all, the simplest move is to give to GiveWell Top Charities Fund.

You can stop reading here and feel very good about it.

If you want to see how the sausage is made — and what other high-impact options exist — keep going. Check out the following causes:

Fighting malaria
Giving kids vitamin A
Backing vaccinations
Supporting local NGOs
Aid to Sudan
Surveillance to find the next pandemic
Ending lead poisoning
Combatting superbugs

For a long time, the world was slowly pushing those numbers down. That progress is now at real risk.

In 2025, the Trump administration effectively dismantled USAID, canceling or gutting thousands of health programs and shifting a skeleton of its staff into the State Department. Other governments around the world have pulled back their funding, too. A conservative real-time tracker attributes roughly 600,000 deaths so far to the collapse of USAID, with modelling suggesting that if cuts on this scale continues, they could lead to more than 14 million additional deaths by 2030 from diseases like malaria, tuberculosis, diarrhea, and respiratory infections.

The weird, hopeful part is that global health interventions are fairly cheap. that’s how the US and other rich countries succeeded in stamping out these diseases. That is an opportunity for people seeking to give and make others’ lives better: It means that saving a life in a relatively poor country is possible at relatively low cost.

GiveWell, our favorite evaluator of global health charities, estimates that the groups it recommends can save a life for $3,500 to $5,500. Put another way, giving $300 a month for a year could be enough to save someone’s life. There are gym memberships that cost more than that. And there’s never been a better time to make a difference as an individual donor to the health and well-being of people around the world.

So if you want to donate to improve global health, where should you start? There are too many good causes to list here, but hopefully, the ones below give you some ideas.

Fighting malaria

GiveWell, the charity evaluator, currently lists four groups on its “top charities” list. Two of them focus on malaria: Against Malaria Foundation and the Malaria Consortium.

The two groups take two different approaches to preventing malaria transmission, both of which are extremely cost-effective. Against Malaria focuses on funding and distributing insecticide-treated nets, which people in malarial regions (largely sub-Saharan Africa but also parts of South Asia) can sleep under and protect themselves from bites by malaria-carrying mosquitos.

The Vox guide to giving

The holiday season is giving season. This year, Vox is exploring every element of charitable giving — from making the case for donating 10 percent of your income, to recommending specific charities for specific causes, to explaining what you can do to make a difference beyond donations. You can find all of our giving guide stories here.

The nets themselves are incredibly cheap. GiveWell estimates that Against Malaria can provide a net for 6 each. You may have heard in the news that bednets are sometimes used for other purposes, like fishing. That’s true. GiveWell estimates, based on past studies and their own research, that about 75 percent of nets distributed will be used as intended. And the intervention is still incredibly cost-effective. A meta-analysis looking at five randomized studies of bednets found that mortality from any cause fell by 17 percent among children targeted for bednet distribution (whether they used the nets or not); they were 45 percent less likely to get malaria. The effect on children actually using the nets is, of course, much greater.

The other program GiveWell recommends donating to is the Malaria Consortium’s Seasonal Malaria Chemoprevention initiative, which uses another approach to prevent malaria infections. “Chemoprevention” means giving antimalarial medications to at-risk people before they’re bitten by a mosquito, in hopes of preventing a malaria infection. The campaigns are seasonal because in many malarial regions, malaria-carrying mosquitos only thrive and transmit the disease in certain seasons, often during a summer rainy season where there’s more water for mosquitos to breed in.

Seasonal chemoprevention is a newer approach than bednets, but there’s very strong evidence that it’s effective at stopping malaria transmission. GiveWell cites a Cochrane Collaboration review of six randomized studies that found that malaria cases among young children fall by 73 percent due to seasonal chemoprevention campaigns. GiveWell itself extended that review to add two newer studies, and drop an older one that they thought less relevant, and got a similar number: 79 percent less malaria among young children.

A year of chemoprevention costs very little per person, about $7 on average. Combining that low cost with that degree of effectiveness makes it a very inexpensive way to save someone’s life.

Giving kids vitamin A

It’s pretty easy to get enough vitamin A if you’re in a rich country and can easily access leafy greens like spinach or lettuce, or other vegetables like carrots. But in many poor countries, vitamin A deficiency is a serious problem, which in children can lead to stunting, blindness, or even death.

Thankfully, there’s a simple way to fight vitamin A deficiency: Give people vitamin A. Helen Keller International, a charity founded in 1915 by Keller, the noted deaf-blind writer and activist, is one of the world’s leading groups supporting vitamin A supplementation campaigns, and one of GiveWell’s top recommended charities. It subsidizes governments in affected countries and provides technical support for mass campaigns to distribute vitamin A capsules (about $1 each to deliver) to households with children.

GiveWell recommends Helen Keller because vitamin A supplementation, in their view, significantly reduces child mortality, by about 4 to 12 percent. They base this, as with their malaria judgments, on a Cochrane meta-analysis, which, depending on assumptions used, concluded that vitamin A supplementation reduces mortality by between 12 and 24 percent. That said, the largest study included there produced a much smaller estimate (4 percent). GiveWell leans conservative, assuming that, over time, with better global nutrition, the impact is likely on the lower end of that spectrum.

But even a 4 percent drop in mortality for $1 is a stunningly good deal. What’s more, vitamin A supplementation has other benefits.

It can prevent blindness and stunting, helping children grow up with healthy vision and to healthy heights and weights, which could translate into higher incomes and other benefits as an adult. Though the evidence here is less voluminous than on mortality, it’s important to remember that there’s more to global health than just preventing deaths. Vitamin A can prevent deaths, but it also makes the lives it saves easier and more fulfilling.

Backing vaccinations

A landmark 2024 study from the WHO suggested that in the past fifty years, vaccines have saved 154 million lives, the vast majority of children under 5. Yet vaccine-preventable illnesses like hepatitis A and B or streptococcus pneumoniae still kill millions every year. Expanding access to the vaccines we already have can be as important as developing new ones.

But reaching the so-called last mile of hard-to-reach populations not currently being vaccinated can be difficult. New Incentives, the fourth and final charity recommended by GiveWell, tries a simple method to reach them: offering money. It gives cash incentives of around $5-8 to parents and other adults in northern Nigeria as an incentive to get vaccinated against against measles, pneumococcal disease, tuberculosis, and the five diseases the pentavalent vaccine protects against (diphtheria, tetanus, pertussis, hepatitis B, and Hib).

A randomized trial of New Incentives’s programs released in 2020 found that overall, children targeted by the program were 22 percentage points more likely to be vaccinated: 36 percent of children in the control group were immunized, compared to 58 percent in the group receiving incentives. And the program has rapidly scaled. By 2023, New Incentives had enrolled over 1.5 million infants.

Even if you suspect the actual impact isn’t quite that significant, the program is extremely cost-effective; roughly 9 to 18 percentage points according to GiveWell’s estimates. And that cost-effectiveness has actually improved. Due to the devaluation of the Nigerian currency Naira in 2024 and 2025, a US dollar now funds significantly more incentives than before.

Supporting local NGOs

Empowering and funding local, community-based organizations — as opposed to large, global agencies such as the World Health Organization or the Red Cross — helps create a more nimble, sustainable, and culturally relevant aid environment. Local organizations not only have a better understanding of local needs, but they can respond faster to emergencies.

But in late 2025, this has become more complicated. For years, agencies like USAID pledged to shift 25 percent of their funding to local partners. With the dissolution of USAID and the retreat of major Western donors this year, those pledges have evaporated. The agencies are gone, leaving local groups as the primary — and often only — safety net for their communities.

Here are some local NGOs working to address challenges from health care and gender-based violence to unemployment and social development:

Taimaka is a Nigerian nonprofit in the Gombe State that treats children with severe malnutrition through community health workers, shifting care from crowded hospitals. They use a simple app to diagnose and track kids in their villages, treating a child for roughly $94 — less than half what standard programs cost — and early estimates suggest that it saves lives at around the same cost as the best-known malaria charities. My colleague Sigal Samuel wrote more about their work here.
For 19 years, Rwanda Men’s Resource Centre has worked to teach healthy masculinity, promote gender equality, and reduce gender-based violence. For the past five years, gender-based violence has been steadily rising in the east African country. According to 2020 survey data, almost 40 percent of girls and women aged 15–49 years have experienced physical, sexual, or psychological violence. The NGO has a variety of training programs and community engagement events that teach couples and young people how to resolve conflict and cohabitate peacefully, improve communication and joint decision-making, and to leverage new tools to improve financial instability.
Afya Research Africa is a Kenyan NGO working toward universal health coverage by providing affordable primary care in rural communities. The organization funds door-to-door health services and supports brick-and-mortar health clinics and pharmacies. Afya also provides rare funding for its clinicians to conduct locally relevant research.

Aid to Sudan

Sudan continues to face the most devastating humanitarian crisis in the world. For more than a year, the country has been embroiled in a civil war that has displaced nearly 12 millions people, pushed entire communities into famine, and crippled the national banking, health care, and telecommunications systems.

And yet, the conflict remains one of the most neglected in the world. As of November, the United Nations has received only about a third of the humanitarian funding it requested earlier this year — leaving a gap of nearly $2.8 billion.

Meanwhile, staff from international aid and human rights groups have repeatedly faced challenges accessing the most fragile parts of the country while other organizations have been forced to lay off local aid workers due to insecurity and budgetary constraints. These local and international NGOs are still working to fill critical gaps across Sudan and in neighboring countries hosting refugees from Sudan:

Doctors Without Borders (MSF) provides health services to thousands of people across Sudan despite recurrent attacks against health care workers and health clinics. MSF doctors and nurses have treated tens of thousands of people facing malnutrition to avert famine-related deaths. The NGO is also working to quell a cholera outbreak and to ramp up care for malnutritioned children and expecting mothers who are dying from preventable infectious diseases. In many places, MSF clinics are the only functioning health care facilities still caring for people.
The Sudanese American Physicians Association (SAPA) is a lifeline for the country’s collapsing health system. This diaspora-led group uses its network to fund and supply hospitals that have been abandoned by the state. They provide salaries for local doctors who haven’t been paid in years and source critical supplies for surgeries and maternity care.
Alight is a local group providing health care across five Sudanese states. Currently, the organization runs 42 primary health clinics, a field hospital, and four mobile health facilities. The NGO recently launched a program to feed mothers who give birth in severely resource-limited refugee camps.

Surveillance to find the next pandemic

Most years, the deadliest infectious disease in the world is tuberculosis, a brutal bacterium that’s also frustratingly expensive to eradicate (which is why none of GiveWell’s top charities target it). But in 2020, 2021, and 2022, there was a new deadliest-disease, and you can probably guess its name: Covid-19.

All told, the Sars-Cov-2 virus has killed over 7 million people, with estimates of “excess deaths” (including deaths due to disruptions to the economy and health care access, and ones due to Covid but not reported as such) reaching into 20 to 30 million. The world spent untold trillions to fight the pandemic. It would have been much more humane, and cheaper, to have prevented it in the first place.

Ultimately, pandemic monitoring and prevention is the job of governments rather than charities, but there are nonetheless some valuable groups working to prevent a repeat of the Covid experience. One is the Nucleic Acid Observatory, a project developing ways to surveil wastewater and other sources and notice when novel pathogens start showing up. The technologies they’re helping to build could help us catch things like Covid weeks or months earlier, and give us time to squash them before they become full-fledged pandemics.

Ending lead poisoning

Lead poisoning has, historically, been a major blind spot in the global health world. The extent of the problem is enormous: A landmark study found that about half of children in poor countries are exposed to very high levels of lead. At least 1.5 million people die annually from cardiovascular diseases (like heart disease) caused by lead poisoning, imposing a global economic cost of about $6 trillion a year.

But the resources devoted to preventing lead poisoning were minimal. One estimate in 2021 found that charities and nongovernmental organizations were spending between $6 and 10 million a year on the problem. That’s less than two cents per child poisoned by lead.

While there are several worthwhile charities working on this issue, I (Dylan) recommend in particular Pure Earth, which has been a leader on lead and metal contamination for decades; the Lead Exposure Elimination Project, which has been influential in fighting lead paint specifically in developing countries; and the Center for Global Development, which has become the center of lead policy in the global health world and helped make the issue a bigger priority in recent years.

Combatting superbugs

Researchers estimated that more than 1 million people died globally from antibiotic-resistant infections in 2019. Despite the emerging crisis, antibiotic research and development has long stalled. No large US or European pharmaceutical company is working to develop new antibiotics.

Fortunately, a small but growing group of researchers and clinicians has been working to revive a decades-old treatment for drug-resistant infections: bacteriophages, viruses that target and kill bacteria. Phage therapy is starting to make inroads in the US and Europe, though clinicians still have to request emergency use authorization from the Food and Drug Administration, or equivalent agencies, before the treatment can be used. Today, there are some 80 clinical trials for phage therapy in the US alone.

But while phage therapy is gaining ground in developed countries, many developing countries in Africa and Asia are falling behind, even though the burden of drug-resistant infections is highest in these countries. A lack of regulatory agencies to review and approve the treatment is one major barrier. Another is an absence of local manufacturing infrastructure, which has hindered local drug development in developing countries for years.

Researchers consistently demonstrate that phage therapy is safe and effective for treating drug-resistant infections, even those caused by bacteria that no known antibiotics can treat. What is needed now is for the phage therapy technology and expertise to be transferred to developing countries.

That is the mission of Phages for Global Health, an NGO run by Tobi Nagel and an international team of physician researchers. The organization trains laboratory technologists in Africa and Asia to study phages in their labs and partners with institutes to conduct research and develop new phage products that can be used, for instance, to prevent and quell cholera outbreaks and decontaminate poultry products to prevent foodborne illness.