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  • The End Is Coming for Trump’s GOP Rivals

    The End Is Coming for Trump’s GOP Rivals

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    The arctic chill that upended the final weekend of the Iowa Republican caucus provided a fitting end to a contest that has seemed frozen in place for months.

    This caucus has felt unusually lifeless, not only because former President Donald Trump has maintained an imposing and seemingly unshakable lead in the polls. That advantage was confirmed late Saturday night when the Des Moines Register, NBC, and Mediacom Iowa released their highly anticipated final pre-caucus poll showing Trump at 48 percent and, in a distant battle for second place, Nikki Haley at 20 percent and Ron DeSantis at 16 percent.

    The caucus has also lacked energy because Trump’s shrinking field of rivals has never appeared to have the heart for making an all-out case against him. “I think there was actually a decent electorate that had supported Trump in the past but were interested in looking for somebody else,” Douglas Gross, a longtime GOP activist who chaired Mitt Romney’s 2012 campaign in Iowa, told me. But neither DeSantis nor Haley, he adds, found a message that dislodged nearly enough of them from the front-runner. “Trump has run as an incumbent, if you will, and dominated the media so skillfully that it took a lot of the energy out of the race,” Gross said.

    In retrospect, the constrictive boundaries for the GOP race were established when the candidates gathered for their first debate last August (without Trump, who has refused to attend any debate). The crucial moment came when Bret Baier, from Fox News Channel, asked the contenders whether they would support Trump as the nominee even if he was convicted of a crime “in a court of law.” All the contenders onstage raised their hand to indicate they would, except for Chris Christie and Asa Hutchinson, two long shots at the periphery of the race. With that declaration, the candidates effectively placed the question of whether Trump is fit to be president again—the most important issue facing Republicans in 2024—out of bounds.

    That collective failure led to Christie’s withering moral judgment on the field when he quit the race last week: “Anyone who is unwilling to say that he is unfit to be president of the United States is unfit themselves to be president of the United States.” But even in practical political terms, the choice not to directly address Trump’s fitness left his principal rivals scrambling to find an alternative way to contrast with the front-runner.

    Over time, DeSantis has built a coherent critique of Trump, though a very idiosyncratic one. DeSantis runs at Trump from the right, insisting that the man who devised and articulated the “America First” agenda can no longer be trusted to advance it. In his final appearances across Iowa, his CNN debate with Haley last week, and a Fox town hall, DeSantis criticized Trump’s presidential record and 2024 agenda as insufficiently conservative on abortion, LGBTQ rights, federal spending, confronting the bureaucracy, and shutting down the country during the pandemic. He has even accused Trump of failing to deport enough undocumented immigrants and failing to construct enough of his signature border wall.

    Read: Trump is coming for Obamacare again

    On issues where politicians in the center or left charge Trump with extremism, DeSantis inverts the accusation: The problem, he argues, is that Trump wasn’t extreme enough. The moment that best encapsulated DeSantis’s approach came in last week’s CNN debate. At one point, the moderators asked him about the claim from Trump’s lawyer that he cannot be prosecuted for any presidential action—including ordering the assassination of a political rival—unless he was first impeached and convicted. DeSantis insisted the problem was that in office, Trump was too restrained in using unilateral presidential authority. He complained that Trump failed to call in the National Guard over the objections of local officials to squelch civil unrest in the Black Lives Matter protests following the 2020 murder of George Floyd. When DeSantis visited campaign volunteers last Friday, he indignantly complained “it’s just not true” that he has gone easy on Trump in these final days. “If you watched the debate,” DeSantis told reporters, “I hit on BLM, not building the wall, the debt, not draining the swamp, Fauci, all those things.”

    Perhaps the prospect of impending defeat has concentrated the mind, but DeSantis in his closing trek across Iowa has offered perceptive explanations for why these attacks against Trump have sputtered. One is that Trump stifled the debates by refusing to participate in them. “It’s different for me to just be doing that to a camera versus him being right there,” DeSantis told reporters. “When you have a clash, then you guys have to cover it, and it becomes something that people start to talk about.” The other problem, he maintained, was that conservative media like Fox News act as “a praetorian guard” that suppresses criticism of Trump, even from the right.

    Those are compelling observations, but incomplete as an explanation. DeSantis’s larger problem may be that the universe of voters that wants Trumpism but doesn’t think Trump can be relied on to deliver it is much smaller than the Florida governor had hoped. One top Trump adviser told me that the fights Trump engaged in as president make it almost impossible to convince conservatives he’s not really one of them. Bob Vander Plaats, a prominent Iowa evangelical leader who has endorsed DeSantis, likewise told me that amid all of Trump’s battles with the left, it’s easier to try to convince evangelical conservatives that the former president can’t win in November than that he has abandoned their causes.

    The analogy I’ve used for DeSantis’s strategy is that Trump is like a Mack truck barreling down the far-right lane of American politics, and that rather than trying to pass in all the space he’s left in the center of the road, DeSantis has tried to squeeze past him on the right shoulder. There’s just not a lot of room there.

    Even so, DeSantis’s complaints about Trump look like a closing argument from Perry Mason compared with the muffled, gauzy case that Haley has presented against him. DeSantis’s choice to run to Trump’s right created a vacuum that Haley, largely through effective performances at the early debates, has filled with the elements of the GOP coalition that have always been most dubious of Trump: moderates, suburbanites, college-educated voters. But that isn’t a coalition nearly big enough to win. And she has walked on eggshells in trying to reach beyond that universe to the Republican voters who are generally favorable toward Trump but began the race possibly open to an alternative—what the veteran GOP pollster Whit Ayres calls the “maybe Trump” constituency.

    The most notable thing in how Haley talks about Trump is that she almost always avoids value judgments. It’s time for generational change, she will say, or I will be a stronger general-election candidate who will sweep in more Republican candidates up and down the ballot.

    Read: The real reason Republicans couldn’t kill Obamacare

    At last week’s CNN debate, Haley turned up the dial when she that said of course Trump lost the 2020 election; that January 6 was a “terrible day”; and that Trump’s claims of absolute immunity were “ridiculous.” Those pointed comments probably offered a momentary glimpse of what she actually thinks about him. But in the crucial days before the caucus, Haley has reverted to her careful, values-free dissents. At one town hall conducted over telephone late last week, she said the “hard truths” Republicans had to face were that, although “President Trump was the right president at the right time” and “I agree with a lot of his policies,” the fact remained that “rightly or wrongly, chaos follows him.” Talk about taking off the gloves.

    Jennifer Horn, the former Republican Party chair in New Hampshire who has become a fierce Trump critic, told me, “There’s no moral or ethical judgment against Trump from her. From anyone, really, but we’re talking about her. She says chaos follows him ‘rightly or wrongly.’ Who cares? Nobody cares about chaos. That’s not the issue with Trump. He’s crooked; he’s criminal; he incited an insurrection. That’s the case against Trump. And if his so-called strongest opponent won’t make the case against Trump, why should voters?”

    Gross, the longtime GOP activist, is supporting Haley, but even he is perplexed by her reluctance to articulate a stronger critique of the front-runner. “I don’t know what her argument is,” Gross told me. “I guess it’s: Get rid of the chaos. She’s got to make a strong case about why she’s the alternative, and it’s got to include some element of judgment.”

    The reluctance of DeSantis and Haley to fully confront the former president has created an utterly asymmetrical campaign battlefield because Trump has displayed no hesitation about attacking either of them. The super PAC associated with Trump’s campaign spent months pounding DeSantis on issues including supporting statehood for Puerto Rico and backing cuts in Social Security, and in recent weeks, Trump’s camp has run ads accusing Haley of raising taxes and being weak on immigration. In response, DeSantis and Haley have spent significantly more money attacking each other than criticizing, or even rebutting, Trump. Rob Pyers, an analyst with the nonpartisan California Target Book, has calculated that the principal super PAC supporting Trump has spent $32 million combined in ads against Haley and DeSantis; they have pummeled each other with a combined $38 million in negative ads from the super PACs associated with their campaigns. Meanwhile, the Haley and DeSantis super PACs have spent only a little more than $1 million in ads targeting Trump, who is leading them by as much as 50 points in national polls.

    Haley’s sharpest retort to any of Trump’s attacks has been to say he’s misrepresenting her record. During the CNN debate, Haley metronomically touted a website called DeSantislies.com, but if she has a similar page up about Trump, she hasn’t mentioned it. (Her campaign didn’t respond to a query about whether it plans to establish such a site.)

    “Calling him a liar right now is her strongest pushback, but I just don’t think GOP voters care about liars,” Horn told me. “If she engaged in a real battle with him for these last days [before New Hampshire], that would be fascinating to see. The fact that she’s not pushing back, the fact that she’s not running the strongest possible campaign as she’s coming down the stretch here, makes me wonder if she is as uncertain of her ability to win as I am.”

    Some Republican strategists are sympathetic to this careful approach to Trump, especially from Haley. A former top aide to one of Trump’s main rivals in the 2016 race told me that “nobody has found a message you can put on TV that makes Republicans like Trump less.” Some other veterans of earlier GOP contests believe that Haley and DeSantis were justified in initially trying to eclipse the other and create a one-on-one race with Trump. And for Haley, there’s also at least some argument for preserving her strongest case against Trump for the January 23 New Hampshire primary, where a more moderate electorate may be more receptive than the conservative, heavily evangelical population that usually turns out for the caucus.

    “She has to draw much sharper contrasts,” Gross told me. “And to be fair to her, once she gets out of here, maybe she will. What she strikes me as is incredibly disciplined and calculating. So, I do think you’re going to see modulation.”

    DeSantis has the most to lose in Iowa, because a poor showing will almost certainly end his campaign, even if he tries to insist otherwise for a few weeks. For Haley, the results aren’t as important because whatever happens here, she will have another opportunity to create momentum in New Hampshire, where polls have shown her rising even as DeSantis craters. Still, if Haley is unable or unwilling to deliver a more persuasive argument against Trump, she too will quickly find herself with no realistic hope of overtaking the front-runner, whose lead in national polls of Republican voters continues to grow. That’s one thing common to winter in both Iowa and New Hampshire: It gets dark early.

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    Ronald Brownstein

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  • Please Don’t Call My Cervix Incompetent

    Please Don’t Call My Cervix Incompetent

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    If you haven’t been pregnant, you’d be forgiven for thinking the language of pregnancy is all baby bumps, bundles of joy, and comparisons to variously sized fruits. But in the doctor’s office, it’s a different story. The medical lexicon for moms-to-be can be downright harsh. Case in point: the phrase geriatric pregnancy, which, until recently, was used to refer to anyone pregnant after their 35th birthday.

    This unfortunate term is thought to stem from a concept that dates back to the 1970s, when amniocentesis, a procedure to screen for genetic abnormalities, was becoming routine. That year, the National Institutes of Health identified 35 as the age at which the risk that the test would harm the fetus was roughly equal to the chance of a fetus being born with Down’s syndrome. In the four-plus decades since, advancements in screening technology have made that calculation essentially obsolete—and the idea that your 35th birthday is some sort of cliff-of-no-return absurd. Moms, for their part, always hated the phrase: When Jamila Larson, a 49-year-old mother of two in Hyattsville, Maryland, was called “geriatric” by a midwife in 2011, “it felt like a gut punch,” she told me.

    Though you’ll still hear it occasionally, this term has (thankfully) been on its way out for a while. One reason is changing demographics. As more and more women give birth after turning 35—in 2020, about one in five babies in the United States was born to a mom who had passed that birthday—labeling them as particularly “old” no longer makes sense. Last August, the American College of Obstetricians and Gynecologists (ACOG) announced that its preferred terminology is now “pregnancy at age 35 years or older”—or, even better, that doctors and researchers should simply indicate patients’ age in five-year increments starting from the age of 35.

    This is how progress works: When a medical term outlasts its usefulness, we thank it for its service and move on. So it may surprise you to learn that a litany of dubiously appropriate and medically inaccurate words are still used to describe pregnancy and childbirth. Over the past decade, the field of medicine has acknowledged that language has the power to perpetuate bias among doctors, and worked to scrub its vocabulary of such terms, including schizophrenic (which reduces a person to a stigmatized disease), drug abuser (which reduces a person to their addiction), and sickler (a derogatory term for someone with sickle-cell disease). And yet, doctors continue to describe women’s bodies using charged terms such as hostile uterus, incompetent cervix, and habitual aborter—words that arguably sound worse than the now-shunned geriatric pregnancy. Why do some words evolve, while others insist on haunting moms’ medical charts like ghosts of medicine past?

    [Read: The culture war over ‘pregnant people’]

    Geriatric pregnancy got a spurt of publicity in 2021, when the makers of the fertility and motherhood app Peanut turned their attention to the minefield of pregnancy language. After a video of a distraught woman whose doctor told her she would be “geriatric” if she were to get pregnant garnered attention on the app, Peanut launched a campaign to come up with more neutral-sounding alternatives to existing medical language. That April, they released a glossary of proposed replacements. Still, more attention from the public doesn’t always translate into institutional action: Although 20,000 people have downloaded Peanut’s glossary, there hasn’t been any official movement within medicine to do away with the original terms.

    Across the U.S., doctors are still doling out diagnoses that sound not only archaic, but downright weird. Many of these terms are enshrined in the global catalog of diseases that doctors use to report procedures to insurance companies, known as the ICD-11. The latest version of that glossary, released in 2022, still includes the phrase elderly primigravida, which is basically a synonym for geriatric pregnancy. In 2016, during her second pregnancy, Larson’s notes read “elderly multigravida”—meaning she was both over 35 and had been pregnant before.

    Or consider incompetent cervix, a term that is in both the ACOG dictionary and the ICD-11. Really, it means a pregnant person’s cervix has dilated before the pregnancy is complete, which can lead to premature birth or miscarriage. Meena Khandelwal, an ob-gyn and the director of research for obstetrics and gynecology at Cooper University Health Care in Camden, New Jersey, told me she avoids using the phrase in front of patients (she sometimes uses weak cervix instead, though she isn’t sure that it’s much better). But because incompetent cervix is entrenched in insurance codes and her hospital’s record-keeping system, the phrase is likely to show up in patients’ notes anyway.

    [Read: She got pregnant. His body changed too.]

    To be sure, communicating that the cervix has opened early is crucial; it prompts doctors to monitor the situation using ultrasound, to temporarily sew the cervix closed, or to try another treatment. Providers need to be able to inform one another about patients quickly and clearly; one could argue that is a much more important function of medical jargon than protecting patients’ feelings. The point of language evolution is not to make words so gentle that they become meaningless.

    But in many cases, the existing language is less clear and precise than gentler alternatives. For example, failure to progress—a general term meaning that labor has lasted longer than expected—says nothing about the reason the labor is slow. And calling a patient “geriatric” offers less information than simply stating whether she is in her 30s, 40s, or 50s. The outdated words even have the potential to worsen patient outcomes: a 2018 study on physician bias found that when doctors read stigmatizing language in a patient’s charts, they tended to have more negative attitudes toward the patient and treat their pain less aggressively. Besides, “incompetent” is a strange way to describe whether a cervix is open or closed. It makes it sound like this organ should be worried about its next annual review.

    This odd quality unites many pregnancy-related terms: They make it sound as if the pregnant person, or their body part, could have chosen a different path. When you are told your uterus is being “hostile” or are accused of “failure to progress,” it’s hard not to feel like you’ve somehow failed the assignment. “It sends a message of ‘You could be normal, but you’re not. You’re not working with us here,’” says Kristen Syrett, an associate professor of linguistics at Rutgers University. Even geriatric pregnancy, which doesn’t explicitly apply blame, seems to suggest that a mom-to-be has knowingly brought more risk upon her unborn child by choosing pregnancy “later” in life.

    [Janice Wolly: My first pregnancy]

    Many moms told Peanut that the most devastating label they encountered was habitual aborter. That term usually refers to someone who experiences multiple miscarriages before 20 weeks of pregnancy, a condition that affects 1 to 2 percent of women. (Its cousin is spontaneous abortion, which means such a miscarriage has happened once). From a purely medical perspective, abortion refers to any procedure that terminates a pregnancy, and includes procedures to empty the womb after a miscarriage. But in layman’s terms, it has come to mean a chosen termination of a pregnancy. That, plus the implication that aborting is a bad habit you can’t seem to break, made the term feel particularly inappropriate. “It’s really horrific if you think about it,” says Somi Javaid, an ob-gyn and the founder of the health-care company HerMD, who consulted on the Peanut project.

    This sense of blame becomes more acute when you consider that for many people, reproductive organs are intimately tied to a sense of identity and self-worth—at least compared with, say, the kidneys. In the context of wanting a child, it’s difficult to hear that your uterus is “hostile” or your cervix is “incompetent” without thinking that those terms apply to your whole self. Even physicians can be taken aback: When Javaid was in her 20s, her own doctor deemed her “infertile” in her notes on account of her “old” uterus—meaning that its lining had thinned, a side effect from a fertility medication she was taking. “It felt like being slapped in the face,” she told me. “The impact of the word was not muted by my knowledge at all.”

    Medical terms can, and do, change. But usually the field is responding to larger shifts in the culture, rather than leading the charge. That’s what happened with the phrase pregnant women, which organizations including the ACLU and the CDC have been incrementally phasing out in favor of pregnant people, a term that has sparked vigorous debate about inclusive language and feminism. Last February, ACOG followed suit, announcing that it would “move beyond the exclusive use of gendered language” to better encompass the fact that people of all genders can become pregnant.

    [Helen Lewis: Why I’ll keep saying ‘pregnant women’]

    With geriatric pregnancy, the change was likely more bottom-up, starting with doctors themselves. After all, for many, it was personal: The length and intensity of medical training increases the odds that doctors will have children later than other women—that they will be, in their own language, geriatric moms, says Monica Lypson, a vice dean at Columbia University’s medical school who researches equity and inclusion. Lypson was deemed “geriatric” when she was pregnant at age 36—a choice of words she found “jarring” as a patient.

    Perhaps because incompetent cervix, habitual aborter, and the like refer to conditions that aren’t so common, many providers don’t realize just how hurtful they can be. Ariel Lefkowitz, an internal-medicine physician who cares for patients with pregnancy complications in Toronto, told me that he used to think of failure to progress the same way as he thought of kidney failure or heart failure. He didn’t notice the negative connotations until his wife, Sarah Friedlander, started training to be a birth educator and pointed them out. Now he sees that “it’s a lot more loaded, it’s a lot more personal,” he said.

    That realization pushed him to think harder about the bias embedded in medical language in other fields, such as failure to cope. “We’re so medicalized and supposedly neutral and in this clinical environment,” said Lefkowitz, who in 2021 co-wrote an editorial in the journal Obstetric Medicine on the importance of inclusive language in obstetrics. “It’s very easy to become numb to the ridiculous ways in which we speak.”

    The outdated terms that are currently stuck in the ICD-11, doctors’ offices, and the pages of medical journals may yet change. More doctors are recognizing that how patients perceive their words can have real impacts on health outcomes, says Julia Raney, a primary-care provider for adolescents who has created workshops on using mindful language in clinical settings. Accordingly, medicine is moving toward more person-centered care, including a focus on concrete risks rather than on blame and stereotypes. For instance, in her work with teens, Raney will note that they have a BMI in the 95th percentile rather than refer to them as simply “obese.” The goal is not to shield the patient from reality, but to better define their medical needs. Like ACOG’s move to designate moms as “35–39” or “40–44” rather than “of advanced maternal age,” this has the double benefit of being both less judgmental and more medically precise.

    [Anya E. R. Prince: I tried to keep my pregnancy secret]

    Doctors also have new reasons to be careful with their language. Since April 2021, an “open notes” law has given patients the right to freely and electronically access just about everything their doctors write about them. While the rule is still largely unknown to patients, open notes can make doctors more conscious (and, sometimes, anxious) about how what they write could affect their patients. “I think we’re all aware of that when we write anything,” Steve Lapinsky, an editor in chief of the journal Obstetric Medicine, told me. This increased transparency, he said, might just be the kick medicine needs to accelerate the pace of language change and do away with terms like incompetent cervix once and for all.

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    Rachel E. Gross

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