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Tag: pregnant women

  • The Mothers Who Aren’t Waiting to Give Their Children Cystic-Fibrosis Drugs

    The Mothers Who Aren’t Waiting to Give Their Children Cystic-Fibrosis Drugs

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    At six months pregnant, Sonja Lee Finnegan flew from Switzerland to France to buy $20,000 worth of drugs from a person she had never met. The drug she was after, Trikafta, is legal in Switzerland and approved for cystic fibrosis, a rare genetic disease that fills the lungs with thick mucus. Finnegan could not get it from a doctor, because she herself does not have cystic fibrosis. But the baby she was carrying inside her does, and she wanted to start him on the Trikafta as early as possible—before he was even born.

    She felt so strongly because Trikafta is, without exaggeration, a miracle drug. As I wrote in the latest issue of this magazine, the daily pills have in the past five years transformed cystic fibrosis from a fatal disease into one where most patients can live an essentially normal life. Trikafta, a combination of three drugs, is not a cure, and it does not entirely reverse organ damage already caused by CF, but patients who grew up believing they would die young are instead saving for retirement. And children born with CF today can expect to live to a ripe old age, as long as they start the drugs early.

    How early is best? The drugs are officially approved for CF patients as young as 2, but a handful of enterprising mothers in the United States have gotten it prescribed off-label, to treat children diagnosed in the womb. Where doctors are more cautious, mothers are still pushing the limits of when to start the drugs. A mom in Canada sent her husband across the border to get Trikafta from someone in the United States. And Finnegan flew to France to meet a patient willing to sell their excess supply.

    Getting hold of Trikafta is in fact the hardest part. Parents told me of both insurance plans and obstetricians skeptical of a powerful new medication never tested in pregnant women—and not without reason. Trikafta has side effects, and it is new enough that not all of its ramifications are fully understood. But Finnegan pored over all the research she could find and decided that Trikafta was worth it. For $20,000, she bought a five-months supply—a relative bargain compared with Trikafta’s list price of $300,000-plus a year in the United States.

    To her, it was worth $20,000 for her son to avoid CF complications that can require major surgery at birth. It was worth $20,000 to prevent permanent damage to his organs that begins even in utero. She felt lucky she could afford it at all. Trikafta in pregnancy is not currently standard practice, but a miracle drug was out there. For her son, she would figure out a way to get it.

    The very first expecting moms on Trikafta were women with CF taking the drugs for themselves. Not long after the medication became available, in the fall of 2019, doctors noticed a baby boom in the CF community. Trikafta, it turns out, affects more than the lungs; it can also reverse the infertility common in women with CF, thought to be caused by unusually thick cervical mucus. (Most men with CF are born infertile, because the vas deferens, which carries sperm, never develops.)

    Experts worried at first about what Trikafta could do to developing fetuses. “People were like, ‘Don’t do this. We don’t know if it’s a teratogen’”—a substance that causes birth defects, says Ted Liou, the director of the adult-CF center at the University of Utah. (The CF doctors quoted in this article have all conducted clinical trials for or received speaking or consulting fees from Vertex, the manufacturer of Trikafta and several other drugs for CF.) That fear turned out to be unfounded: Hundreds of babies later, there has been, at least anecdotally, no uptick in severe birth defects.

    Read: The cystic-fibrosis breakthrough that changed everything

    Doctors started to see hints that Trikafta in utero could help babies with CF too. Of the hundreds of children born to mothers on Trikafta, only a few of the babies had CF themselves. This is because cystic fibrosis is a recessive disorder, meaning a mother with CF could have a child with CF only if the father also passed on a CF mutation. But the first documented case came to the attention of Christopher Fortner, the director of the CF center and pediatric-CF program at SUNY Upstate, who published a case report in 2021. Trikafta, he told me, made a clear difference for this baby girl.

    Cystic fibrosis is caused by an imbalance of salt and water in the body, and this affects developing organs even before birth. One in five infants with CF are born with an intestinal blockage caused by meconium—the normally sticky black stool of newborns—that has turned too thick and hard to pass. This is called meconium ileus, and in the worst cases, the intestines can rupture. Emergency surgery is necessary. Elsewhere in the body, the pancreas never forms properly with CF. “By the time they’re born, their pancreas is really not a functional organ,” Fortner said. Adults on Trikafta still have to take pancreatic enzymes with every meal, but there is some evidence that young children can gain pancreatic function if they begin the CF drugs early enough.

    When this baby girl was born, though, her meconium and her pancreas levels were normal from the very start; the standard newborn screening for CF would have never caught her. Fortner started her on enzymes as a precaution, but he stopped them after a week. She is 3 years old now and in preschool. Unlike generations of CF kids before her, she will never have to see the school nurse for enzymes every time she wants to eat. And she may never suffer the recurring lung infections that once made CF ultimately fatal. “The life she’s living,” Fortner said, “that was a whole lot like a cure to me.”

    Moms who do not have CF themselves have a much harder time getting their unborn children on Trikafta. In 2021, Yolanda Huffhines’s second child was diagnosed with CF prenatally, after a genetic test was recommended because Huffhines’s first child had cystic fibrosis. The diagnosis did not come as a shock this time, but she began to worry when the baby showed signs of meconium ileus while still in utero.

    After coming across a study in ferrets, Huffhines brought the idea of Trikafta to her doctors, who were not all enthused. Her obstetrician in particular was against it. But she found that CF doctors were more willing to weigh the well-known risks of cystic fibrosis—especially meconium ileus—against the less well-known risks of Trikafta. She asked Patrick Flume, who directs the adult-CF center at the Medical University of South Carolina, what he would do if it were his wife and child. He told her he would get Trikafta, and he agreed to help.

    Even with a sympathetic doctor, getting Trikafta wasn’t easy. First, Flume tried giving her a stash from a patient who no longer needed it, which was vetoed because his hospital couldn’t ensure that it had been properly stored. Then he asked the manufacturer, Vertex, which also said no. (The company told me it couldn’t provide Trikafta to anyone outside the drug’s official indications.) Finally, Flume told me, he decided to write a prescription as if the mother were his patient. When the insurance company asked if she had at least one copy of a specific CF mutation that Trikafta was developed for, he answered yes, truthfully. Because Huffhines is a carrier, she does have one copy. She started Trikafta at 32 weeks, and by the time her daughter was born, the meconium ileus had disappeared.

    Huffhines’s experience on Trikafta was not entirely smooth, though. The drugs come with some well-documented side effects, such as cataracts and liver damage, that have to be monitored, Flume told me, as with any new drug. Although Trikafta during pregnancy went fine for Huffhines, she started to experience unusual symptoms when she continued the medication so her daughter could get it through breast milk. Her usual migraines started going “through the roof,” and her scheduled blood work revealed that her liver enzymes had gone haywire—a sign of liver damage. She had to stop.

    Quitting Trikafta cold turkey could be harmful for newborns, though, which Huffines knew from studying the ferret research. (Suddenly withdrawing, Fortner told me, may cause pancreatitis.) She wondered: Was it possible to give a baby Trikafta directly? The pills would be too big, obviously, but her husband had scales for gunpowder that could weigh down to the milligram. She got a new one overnighted, and she began crushing the pills to give to her daughter—a technique that has since been taught to other moms. Her daughter did well. Huffhines’s doctors ended up publishing a case report in 2022—the first documenting a carrier of CF taking Trikafta.

    The long-term impacts of being on Trikafta in utero still need to be studied. The oldest child is still only 3. In adults, a small minority who have started Trikafta have reported sudden and severe anxiety, insomnia, depression, or other neuropsychiatric symptoms. The link is not fully proven or understood in adults, and it’s completely unexplored for fetal brain development. Elena Schneider-Futschik, a pharmacologist at the University of Melbourne, told me she is collaborating with researchers in the United Kingdom to get long-term developmental data on children exposed to Trikafta before birth. For now, she said, “we don’t know.”

    Fortner, who has heard from several pregnant mothers since his first case report, said he does not deter parents already set on getting Trikafta, but he does not, in all cases, push them toward it, either. Given the unknowns, he’s not sure that the benefits outweigh the risks. The clearest exceptions are cases of meconium ileus, in which doing nothing comes with its own costs. Flume told me about a recent patient whose baby was showing signs of an intestinal blockage and whose insurance initially denied Trikafta. The medication was eventually approved—but the mom went into labor the day she was due to start. Her baby needed emergency surgery. “This is something that did not need to happen,” he said.

    By the time Finnegan, in Switzerland, went looking for Trikafta last year, she had the earlier cases as models. Her baby wasn’t showing signs of meconium ileus, but she didn’t want to wait until he did, if he was going to end up down that path. Although her doctors were supportive, they could not get her Trikafta. That’s why she had to take unorthodox measures.

    She took her first pill in August, and her son was born in October with a working pancreas and no intestinal blockage. He is far too young for this to matter, but she hopes that the Trikafta allowed his vas deferens to develop normally too. Someday, he might want children of his own, and the impacts of getting Trikafta in utero might carry over into the next generation.

    Finnegan has been documenting her experience on social media, where she says her posts have inspired other pregnants moms to get on Trikafta for their unborn children. She knows of about 20 now, and after she got in touch with Schneider-Futschik, the researcher decided to survey these moms too. Meanwhile, Finnegan is sharing the stories of other moms as well, making note of details such as how long the mom was on Trikafta, what side effects she experienced, whether meconium ileus was resolved, and if insurance covered the drugs—a case series, of sorts, presented on Instagram. They are still few enough that every case is notable. In the future, though, all of this might become the utterly unremarkable standard of care.

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    Sarah Zhang

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  • Pregnancy Can Change Your Shoe Size Forever

    Pregnancy Can Change Your Shoe Size Forever

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    One night in July, a few weeks after my son was born, I lay awake, desperately scrolling through photos of injured feet. The mounting pain from an ingrown toenail in my right foot had become excruciating, and the internet promised to help. I could no longer deny the fact that the exorbitantly expensive Hoka sneakers I’d bought just months before—to prevent pregnancy-related foot pain—had become too small. To my horror, my feet had grown half a size. Permanently.

    Pregnancy books had informed me about the less rosy aspects of new motherhood, such as shedding hair (the baby’s and mine) and uncontrollable crying (the baby’s and mine). I was even prepared for my feet to temporarily swell through the trimesters. But no one told me they might stay that way. Unlike the rest of my body, my feet did not revert to their original size 9.5 after birth. Five months later, I am now the disgruntled guardian of a large infant—and even larger feet.

    Mom Feet is not a niche condition. Studies have found that anywhere from 44 to 61 percent of new moms experience lasting foot growth, and many seem to be surprised when it happens, just as I was. “Why does no one talk about the PERMANENT foot size changes after pregnancy?” one Reddit user lamented. My thoughts exactly.

    Temporary swelling in the feet (and hands) is a normal part of pregnancy, particularly in the third trimester. Extra fluid in the body tends to pool in “gravity-dependent areas,” causing ankles and toes to become noticeably puffy, Silvana Ribaudo, an ob-gyn at Columbia University Irving Medical Center, told me. This is not the same thing as Mom Feet, which I learned the hard way by wearing my Hokas long after they’d started to pinch.

    Foot swelling subsides after a person gives birth, but structural changes in the foot do not. Permanent foot growth, like most other disconcerting bodily changes that happen during pregnancy, can be attributed to hormones—in this case, one aptly named relaxin. It relaxes body tissue so that a growing baby can unfurl, then squiggle out. These changes are especially welcome in the pelvic region. In the feet, not so much.

    If a pre-pregnancy foot is like an ice-cream sandwich straight out of the freezer—sturdy, structured—one relaxed by relaxin is a sandwich left out in the sun. The hormone causes the ligaments and tendons in the foot and ankle to lose their rigidity and strength, so the foot tends to spread out, Alexandra Black, a podiatrist at Foot and Ankle Specialists of Central Ohio who co-authored a recent review of pregnancy-related foot changes, told me. Throwing pregnancy weight on them only compounds the problems. “It leads to more of a flatter foot, a wider foot, and a longer foot,” Black said. According to the few small studies on the topic, pregnant feet, on average, go up by roughly half a shoe size and lengthen by 0.4 inches. It is a small consolation that this effect is most pronounced during first pregnancies, meaning that feet won’t grow indefinitely along with one’s brood.

    It would have been nice to learn this before I bought my Hokas, of course. Had I known better, I probably wouldn’t have purchased so many Nike Air Maxes in recent years, or suggested to my husband that we buy matching white Jordans at an outlet mall during our honeymoon. Now those beloved shoes, along with the Hokas, have been banished to storage, while I’ve had to pay up for new winter boots, high heels, and sandals.

    Having to buy new shoes is expensive but admittedly kind of fun. Other consequences of Mom Feet are not. Footwear is annoying, because even a small shift in foot size can lead to shoes that don’t fit. And the collapse of the arch in your feet can be especially painful. Mine used to be graceful, like the arc of a leaping gazelle. Now the gazelle has face-planted. That’s because a tendon on the inside of the ankle, which normally acts like a bungee cable stabilizing the arch, goes slack during pregnancy. Lengthening and flattening this tendon can cause “a flat-foot deformity,” Black said, “and it’s kind of hard to reverse that.” Flat feet can cause the knee and tibia to over-rotate, throwing the bones and muscles involved in walking and standing into disarray—a “major contributor to pain” in pregnancy, one review noted. Conditions such as painful heels caused by plantar fasciitis, leg cramps, bunions, and nail issues are all linked to Mom Feet.

    Had I known about Mom Feet, I might have been better prepared for it. Some pregnant people and new moms find it helpful to use compression stockings to reduce swelling and get orthotics for extra arch support, Black said. Unfortunately, none of my doctors (who I should note were very good) warned me about it. Ditto for any pregnancy book I read, such as What to Expect When You’re Expecting, which said only that swelling of the feet was “normal” and “temporary.” I am far from the only person who has been caught off guard by newly big feet. Mystified mothers abound on pregnancy forums; colleagues told me they were “not warned” and “had no idea this was A Thing.”

    Perhaps the reason it is commonly overlooked is that, in the grand scheme of things that mothers-to-be have to deal with, such as gestational diabetes and life-threatening spikes in blood pressure, foot pain is relatively inconsequential. Because foot-size changes “are not concerning for the well-being of mom or baby,” they might not be deemed worthy of discussion, Leena Nathan, an ob-gyn at UCLA Health–Westlake Village, told me.

    But perhaps Mom Feet isn’t talked about because many things about it are still unknown. Not everyone experiences pain, and although permanent changes are well documented, feet might still possibly revert to their original size eventually. “It can take several years,” Ribaudo said, but “sometimes it never goes back.”According to Nathan, it isn’t well understood why some people experience changes in foot size and others don’t. Even the true prevalence of this condition isn’t known for certain, because the few studies that have examined it were small. One thing is clear, however: There is a dearth of research on foot changes during pregnancy, because pregnant women, in general, are understudied. People are “hesitant to do research on pregnant women, because it’s a sensitive population,” Black said.

    During my pregnancy, I was often shocked at how little was known about concerns both minor and monumental: whether eating pineapple would induce contractions, for example, or when the baby would actually be born. Walking, climbing stairs, and having sex are commonly recommended to help induce labor, but “it’s difficult to establish whether they actually worked—or whether labor, coincidentally, started on its own at the same time,” notes What to Expect When You’re Expecting. Pregnancy literature is rife with these sorts of equivocations. Many times over the trimesters, I wondered why so much of pregnancy still felt so medieval, full of guessing, folklore, and hearsay. It’s 2023: Why are new moms still surprised when their feet grow? To this, I have found few satisfactory answers. But at the very least, I have found an ingrown-toenail treatment that works.

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    Yasmin Tayag

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  • A Modest Proposal to Save Mothers’ Lives

    A Modest Proposal to Save Mothers’ Lives

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    At the busy county hospital where I did my medical residency, we cared for patients with every imaginable problem. But one part of treatment was always the same: As soon as it was deemed medically safe, a physical or occupational therapist would visit each and every patient. In the intensive-care unit, a physical therapist might assist a patient into a sitting position at the edge of the bed. An occupational therapist might help her relearn how to hold a fork after weeks of being fed by a tube. On the general-medical and surgical wards, at least one or two patients could always be found walking the long hallways with a walker or cane, a strong and amiable physical therapist keeping pace beside them, casually asking crucial questions: “Are there any stairs in your home?” “Who does the laundry and cooking?” “Who will be around to help you?”

    But there was one area of the hospital where physical and occupational therapists weren’t involved in patient care: the maternity ward. In many hospitals, this is still true. Although I now work in outpatient OB-GYN care, my colleagues in Labor and Delivery confirm that PT/OT doesn’t have a large presence there. Amy Willats, a nurse-midwife in the San Francisco Bay Area, told me that she orders physical therapy for new mothers only in rare circumstances—“when someone is in so much pain, they can’t walk to the bathroom.” As for occupational therapy, she said, “it’s not even on my radar.”

    Some physical and occupational therapists want this status quo to change. They believe that everyone who gives birth should receive a PT/OT evaluation prior to discharge, with the same goal as for any other hospitalized patient: to prepare them to move around safely and comfortably at home. I remember how easily, in the chaotic world of the hospital, I could overlook the quiet work of physical and occupational therapists. But the extra layer of attention and care they provide could help millions of new mothers recover faster—and may even save lives.

    Pregnant women and new mothers are, in a sense, different from other hospitalized patients. Doctors tend to think of them as healthy young people undergoing a normal, natural process, one that should require serious medical intervention only occasionally. This is how my patients tend to see themselves too—and most of them do go on to live normal, if changed, lives. By this philosophy, what new mothers need isn’t intensive rehab, but a brief period (one or two days) of observation, some education about how to feed and care for their baby, and then a timely discharge home, with a single postpartum visit a few weeks later. Indeed, this laissez-faire approach is the standard of care in many U.S. hospitals.

    But as the U.S. faces a surging maternal-mortality rate, with more than half of maternal deaths occurring after delivery, physicians are now in wide agreement that the standard of care needs to change. Pregnant women in the U.S. are not as young as they once were. Pregnancy and childbirth can present grave dangers—particularly when a woman already has underlying health conditions. A vaginal delivery is an intense physiological event that involves the rapid expansion and then contraction of the musculoskeletal system, along with dramatic shifts in hormones, blood volume, and heart rate. A Cesarean section is a major surgery that involves cutting through layers of skin, fascia, and muscle—and that’s if everything goes perfectly.

    Read: The mothers who can’t escape the trauma of childbirth

    Rebeca Segraves, a Washington State–based doctor of physical therapy specializing in women’s health, told me she was struck early in her career by the realization that women undergoing a C-section did not receive routine postoperative PT. She was used to performing inpatient evaluations for patients recovering from relatively minor illnesses and surgeries, such as pneumonia, gallbladder removal, and prostatectomy. But after a C-section, she says, a PT evaluation “just wasn’t the culture.” She set out to change that.

    For most people, if the phrase postpartum physical therapy calls to mind anything at all, it’s pelvic-floor PT. In the early 2010s, American women living abroad introduced U.S. audiences to the French practice of perineal “reeducation,” a comprehensive exercise regimen prescribed for every postpartum mother and subsidized by the French government, designed to retrain the muscles of the pelvic floor after birth. Since then, U.S. researchers and the popular press have documented the widespread and devastating effects of urinary incontinence, pelvic-organ prolapse, and chronic pelvic pain—issues that can be overlooked or dismissed at the postpartum visit.

    But Segraves is arguing for postpartum PT/OT that goes beyond the pelvic floor. Segraves has developed an approach called “enhanced recovery after delivery” (ERAD), essentially a training program for OB-GYN departments and hospital-based PT/OT staff that encourages an evaluation for every woman after childbirth. ERAD includes an assessment of body mechanics and cardiopulmonary function, gait retraining, infant lifting and lowering techniques, and (in the case of C-section) incision-protection training. Crucially, a therapist also monitors the woman’s bodily responses—such as pain and vital signs—while she practices these simple home activities in the hospital.

    Segraves believes that these interventions could be lifesaving. Warning signs of the major postpartum killers—including preeclampsia, stroke, hemorrhage, and infection—sometimes manifest right away, but in many cases they don’t appear until a woman returns home, where they may go unrecognized. The more attention paid to new mothers in the hospital—particularly while they’re moving around, Segraves argues—the more likely providers are to catch these warning signs.

    Read: An awkward evolutionary theory for one of pregnancy’s biggest complications

    As an example, Segraves told me about a patient she met a few years ago who had suffered a third-degree perineal laceration (a particularly severe birth injury) during a vaginal delivery. At the time, Segraves was primarily focused on providing physical therapy after C-sections, but her team advocated for this woman to receive a PT evaluation prior to discharge. When the woman tried to stand and walk, her blood pressure shot to a dangerously high level. Ultimately, the patient was transferred to the ICU and diagnosed with severe preeclampsia.

    Anecdotes like these make a powerful case for universal PT/OT for new mothers. But as yet, there’s no proof that it could affect postpartum outcomes on a large scale. To get this kind of evidence, Segraves will need a clinical trial. So far, she told me, she’s gotten a grant to study physicians’ and therapists’ attitudes toward routine postpartum PT/OT.

    Her research is in the early stages, but my conversations with maternal-care specialists suggest that attitudes are mixed. Olga Ramm, a urogynecologist in the San Francisco Bay Area, told me she worries that PT/OT for all pregnant women could be hard to implement universally, “because so much of it really depends on that interpersonal relationship and connection between the patient and the therapist.” Funding is an issue too: Physical and occupational therapists are licensed professionals whose services aren’t cheap, and many hospitals are already strapped for cash and staff. Adding a PT/OT evaluation for every hospitalized patient “seems like a fairly expensive way” to bolster postpartum services, Ramm said. Willats, the nurse-midwife, agreed. “The way we educate people should change,” she said. “We don’t necessarily need a different group of people to do that education.”

    Then again, physical and occupational therapists may be uniquely positioned to do this work. Unlike doctors, who are usually trained to think about patients as sick or healthy, PTs and OTs are interested in how a person’s body serves her in her daily life—what Segraves calls “roles and routines.” This means seeing a new mother as someone who is about to return home in a changed body, who will need to lift, rock, and soothe a newborn; perform heavy chores such as cleaning and laundry; and perhaps breastfeed that newborn, whose kicking feet land right on a fresh C-section scar. PT/OT is about helping her adapt to all of these changes with intention and care.

    Read: A surprising side effect of giving birth  

    Doctors and patients tend to think of physical therapy as primarily a set of rehab exercises that help a patient recover from an injury. But another way to view PT and OT is as an opportunity, inside the overwhelming world of the hospital, for a skilled professional to see and treat the patient as a whole person. Segraves told me the story of a young woman with a high-risk pregnancy and a prolonged hospital stay, during which baby gifts from friends and family piled up around the room. After several agonizing weeks, she delivered a stillbirth by C-section. A few days later, Segraves watched as an occupational therapist sat by the patient’s side, helping her fold all of those tiny newborn clothes, tucking them neatly back into gift bags for her to take home. At that moment, Segraves said with a touch of awe in her voice, the young woman was “more functional than any of us had seen her up to that point.”

    When I consider this story, I can’t help but recall the therapists strolling the hallways of my residency hospital, asking my patients questions I’d never bothered to address—about their home, their life, their “roles and routines.” Really, the questions they were asking were much deeper—and exactly the ones that are central to new motherhood: How will you manage in this new body, this new life? Who will you be?

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    Christine Henneberg

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  • We Can Finally Do Something About the Third ‘Tripledemic’ Virus

    We Can Finally Do Something About the Third ‘Tripledemic’ Virus

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    Every fall, when the air turns chilly and the leaves red, pediatric ICUs begin preparing for the onslaught of the virus known as RSV. Not flu, not COVID, but RSV, or respiratory syncytial virus, is the No. 1 reason babies are hospitalized, year after year. Their tiny airways can become inflamed, and the sickest ones struggle to breathe. RSV is deadly on the other end of the age spectrum too, killing 6,000 to 10,000 elderly Americans every year.

    For decades though, there was no way to stop the virus’s seasonal tide. The quest for a vaccine always came up short. And then suddenly, the vaccines started working.

    This year, doctors have not just one but multiple new shots to prevent RSV. Three gained FDA approval in rapid succession in recent months: an antibody shot for infants called nirsevimab, a form of passive immunization for babies too young to get proper vaccines; a vaccine from Pfizer for both adults over 60 and pregnant mothers, who can pass the immunity on to their babies; and finally, a vaccine from GlaxoSmithKline also aimed at adults older than 60. Together, these herald a new era for RSV.

    That these three new RSV shots are coming out at once is no coincidence. They succeed where others failed because they all target a specific weak spot in the virus, first identified in 2013. This strategy of finding a virus’s most vulnerable points applies to other pathogens too, and experts say it can revolutionize the design of vaccines for other diseases. In fact, it was quietly used to make the COVID vaccines from Pfizer and Moderna. Scientists had originally perfected the idea with RSV, only to repurpose it for the COVID vaccine, which raced ahead, given the urgency of the pandemic. This year, though, the shots are coming for RSV.

    “We’re in a really good position, finally, after more than 65 years,” says Asunción Mejías, an infectious-diseases doctor at St. Jude Children’s Research Hospital.

    The first attempts to make an RSV vaccine began not long after the virus’s discovery, in 1956, but an early trial ended so catastrophically that it had a chilling effect for decades.

    It had started off with promise. The early vaccine was modeled after a successful one for polio, in which the virus is inactivated with a chemical called formalin. But when infants given the early RSV vaccine later caught the virus, a whopping 80 percent had to be hospitalized—compared with only 5 percent in the control group. Two of the babies died, their lungs ravaged. The vaccine did worse than offer no protection; it made the disease more severe. “It was such a disaster,” says Ann Falsey, an infectious-diseases doctor at the University of Rochester. Scientists spent years piecing together why—the vaccine riled up the wrong part of the immune system in very young babies—but they got no closer to making a vaccine that worked. The field was stuck.

    Then, in 2008, a serendipitous meeting led to an eventual breakthrough. A young, freshly minted Ph.D. named Jason McLellan, who studies the structure of proteins, began a new job at the National Institutes of Health to work on HIV vaccines. The lab he had joined, on the fourth floor, had run out of room, though, so he got put in another, on the second. There, he ran into Barney Graham, a virologist who had been trying to solve the puzzle of RSV since the 1980s. He convinced McLellan that this virus was worth a look too.

    By then, scientists had at least homed in on a plausible vaccine target. Much as COVID uses spike protein to infect cells, RSV uses a protein—called F for “fusion”—to physically fuse the virus particle to a human cell. F comes in two forms, though: an extremely unstable prefusion state and a far more stable postfusion state. And once it switches to the postfusion state—which can also happen spontaneously— “it can’t come back,” McLellan told me.

    When RSV vaccines are manufactured, all the F protein eventually switches to the postfusion state. But the antibodies against postfusion F weren’t very effective. McLellan soon figured out why. He found that extremely potent neutralizing antibodies bind to a specific site—the very tip of the prefusion F—that is lost when the protein rearranges into its postfusion form. With that, Graham told me, “you lose ten- to 1,000-fold potency.” An effective RSV vaccine would need to target the prefusion F.

    The team knew what to do, but had a practical dilemma: How to stabilize F in its prefusion form, so the team could put it in a vaccine? McLellan rejiggered the protein slightly, adding molecular “staples” and filling a hole in the protein structure. These changes froze F in its prefusion shape. When the team tested this version of the vaccine in mice, the results could not have been clearer. The vaccine induced the highest levels of neutralizing antibodies Graham had ever seen in his three decades of studying RSV. “This is it,” McLellan remembers thinking.

    Soon, pharmaceutical companies came calling, and the race was on. (The experts in this article—like nearly everyone who works on RSV vaccines—have all received research grants, consulted for, or worked in some other way with one or more of the companies developing shots for RSV.) Today, Pfizer’s and GlaxoSmithKline’s newly approved RSV vaccines target the prefusion F protein, as does nirsevimab, the antibody shot for infants from AstraZeneca and Sanofi. Both the vaccines and the antibody shot trigger immunity against RSV: Vaccines stimulate the immune system to make its own antibodies, and nirsevimab is a direct infusion of antibodies.

    Trials for all three shots were already under way when the coronavirus pandemic hit. But because RSV nearly disappeared during social distancing, the trials got delayed. Meanwhile, McLellan and Graham devised a similar molecular trick to stabilize COVID’s spike protein, which Pfizer and Moderna later used in their vaccines. (The stabilization wasn’t make-or-break for COVID, as it was for RSV, though—AstraZeneca’s COVID vaccine was effective despite not having this modification.) But unstable fusion proteins are found in many different classes of viruses beyond RSV. McLellan, now at the University of Texas at Austin, is working on shots against the prefusion structure of other stubborn viruses such as cytomegalovirus and Crimean-Congo hemorrhagic fever. (Graham is now a professor at Morehouse School of Medicine.) This approach—called structure-based vaccine design—could unlock new ways of targeting once-elusive viruses.

    For RSV, this fall and winter will be a test of how well the shots fare in the real world. As the adage goes, vaccines don’t save lives; vaccinations do. Falsey, the University of Rochester doctor, specializes in studying RSV in the elderly, and she worries that too few Americans over 60 will get the new vaccines this year. A CDC advisory panel decided that elderly Americans can get the vaccines through “shared clinical decision-making” with their doctors but did not go as far as to fully recommend vaccination, which would have triggered private insurers to cover the shots under the Affordable Care Act. Out of pocket, they can cost more than $300. The vaccine for pregnant women, meanwhile, has FDA approval, but the same CDC panel is voting today on whether to recommend it. The panel will likely scrutinize a possible link to premature births, which has shown up before with RSV vaccines.

    Nirsevimab, the antibody shot for infants, has gotten a full-throated endorsement, though, and it’s poised to have the biggest impact this season. It replaces an existing RSV-antibody shot called palivizumab, which is not widely used. Palivizumab targets a less potent site that is on both the pre- and postfusion F, and it needs to be administered up to five times a season (compared with once for nirsevimab), at a cost of some $1,500 a dose. For these reasons, it’s been reserved for the highest-risk babies, such as preemies with underdeveloped lungs. But most babies who end up hospitalized were healthy to begin with, says St. Jude’s Mejías, so the older shot didn’t put much of a dent in overall hospitalizations.

    Nirsevimab is meant to be more widely used: The shot is approved for all infants in their first RSV season. “It’s going to change the way we manage and treat RSV,” Mejías told me. It should be available for babies starting in October. And if all goes according to plan, pediatric ICUs could be a little quieter this winter.

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    Sarah Zhang

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  • A Genetic Snapshot Could Predict Preterm Birth

    A Genetic Snapshot Could Predict Preterm Birth

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    This article was originally published by Knowable Magazine.

    For expectant parents, pregnancy can be a time filled with joyful anticipation: hearing the beating of a tiny heart, watching the fetus wiggling through the black-and-white blur of an ultrasound, feeling the jostling of a little being in the belly as it swells.

    But for many, pregnancy also comes with serious health issues that can endanger both parent and child. In May, for example, the U.S. Olympic sprinter Tori Bowie died while in labor in her eighth month of pregnancy. Potential factors contributing to her death included complications of preeclampsia, a pregnancy-specific disorder associated with high blood pressure. Preeclampsia occurs in an estimated 4.6 percent of pregnancies globally. Left untreated, it can lead to serious problems such as seizures, coma, and organ damage.

    Preeclampsia and preterm birth are relatively common conditions that can put both the mother and her baby at risk of health issues before and after birth. But doctors don’t have a good way to determine whether an individual will develop one of these complications, says Thomas McElrath, an ob-gyn at Brigham and Women’s Hospital, in Boston. Currently, physicians primarily look to a woman’s prior pregnancies, medical history, and factors such as age and ethnicity to determine her risk. These measures are useful but limited, and may fail to identify problems early enough to enable effective treatment, McElrath says. “They’re not as precise as I think most of us, as clinicians, would really want.”

    That may soon change. Scientists are learning that free-floating bits of genetic material found in a pregnant person’s blood may offer a way to detect complications such as preeclampsia and preterm birth—although some experts caution that it’s too early to determine how useful these tests will be in the clinic. In the meantime, the tests are providing researchers with a new way to unravel the underlying biology of these inscrutable ailments.

    All of us carry bits of our own genetic material—both DNA and its more evanescent cousin, RNA—around in our bloodstreams. During pregnancy, these free-floating fragments, known as cell-free DNA and RNA, are also released from the developing fetus into the mother’s blood, primarily via the placenta. For more than a decade, clinicians have used cell-free DNA from blood to screen the fetus for genetic abnormalities.

    But DNA provides a largely static view of the genetic content within our cells. RNA gives a snapshot of which genes are turned on or off at a specific point in time. Because gene activity varies across cells and over time, researchers realized that they could use RNA to glean a more dynamic view of the changes that occur within the mother’s body during pregnancy. RNA enables scientists to look beyond the fixed genotype to factors that change over the course of pregnancy such as prenatal complications, says Mira Moufarrej, a postdoctoral researcher at Stanford University who co-authored a paper in the 2023 Annual Review of Biomedical Data Science on noninvasive prenatal testing with circulating RNA and DNA.

    Read: The pregnancy risk that doctors won’t mention

    To screen for possible complications, scientists have been looking at cell-free RNA in pregnant women’s blood that originates from both mother and child. Some of the earliest studies of this kind emerged in the early 2000s. In 2003, for example, Dennis Lo, a chemical pathologist at the Chinese University of Hong Kong, and his colleagues reported that in a study of 22 pregnant women, a specific RNA released from the placenta was much more abundant during the third trimester in those who had preeclampsia than in those who did not. Over the years, Lo’s group and others have looked at broader changes in RNA during pregnancy in larger groups of people.

    In a 2018 study, Moufarrej, who was then a doctoral student; her adviser Stephen Quake, a biophysicist at Stanford University; and colleagues reported that cell-free RNA could help determine when labor would occur. The researchers recruited 38 pregnant women in the United States known to be at risk of preterm birth, and then drew a blood sample from each. By comparing cell-free RNA in those who eventually delivered prematurely with that in those who gave birth at full term, they were able to identify a set of RNAs that appeared up to two months prior to labor that could pinpoint about 80 percent of premature births.

    That proof-of-concept investigation spurred the researchers to look further and examine whether cell-free RNA could also predict preeclampsia. Other groups had previously reported RNA-based signatures of preeclampsia—in 2020, for instance, scientists working with the California-based biotech company Illumina reported dozens of RNA transcripts that were unique to a small cohort of pregnant women with the condition. But Moufarrej, Quake, and their colleagues wanted to track RNA changes throughout pregnancy to see whether it might be possible to identify people at risk of preeclampsia during early pregnancy, before symptoms began.

    In a study published in 2022, the researchers recruited several dozen mothers at heightened risk of preeclampsia and drew blood from them four times: at or before 12 weeks, in weeks 13 to 20, at or after 23 weeks, and after birth. Afterward, the researchers compared cell-free RNA for women who indeed developed preeclampsia against that of those who did not. The team identified RNAs corresponding to 544 genes whose activity differed in those who developed preeclampsia and those who did not. (The study did not differentiate between maternal and fetal RNA, but because the majority of cell-free RNA in a pregnant person’s blood is their own, Moufarrej says that most of these RNAs are likely maternal in origin.)

    Then, using a computer algorithm, the researchers developed a test based on 18 genes measured prior to 16 weeks of pregnancy that could be used to predict a woman’s risk of developing preeclampsia months later. The test correctly identified all of the women who would later develop preeclampsia—and, equally important, all of the women who the test predicted wouldn’t develop preeclampsia did in fact escape the disease. (About a quarter of the women who were predicted to develop preeclampsia did not get the disease.) The same 18-gene panel also correctly predicted most cases of preeclampsia in two other groups totaling 118 women.

    The team also took a closer look at which tissues the RNA of interest originated from. This included the usual suspects, such as the lining of the blood vessels (also known as the endothelium), which scientists already know is associated with preeclampsia, as well as other, more unexpected sources, such as the nervous and muscular systems. The authors note that, in the future, this information could be used both to understand how preeclampsia affects different parts of the body and to assess which organs are at highest risk of damage in a particular patient.

    According to Quake, studies like these from both his team and others are starting to reveal the diversity of changes throughout the body that contribute to pregnancy complications—and providing evidence for something that clinicians and researchers have long suspected: that both preeclampsia and preterm birth are conditions with a range of underlying causes and outcomes. “There are now strong indications that you should be defining multiple subtypes of preeclampsia and preterm birth with molecular signatures,” says Quake. “That could really transform the way physicians approach the disease.”

    Research teams elsewhere are also looking at other pregnancy complications such as reduced fetal growth, which can cause infants to be at higher risk of problems such as low blood sugar and a reduced ability to fight infections. Some of these tests are now being validated in large studies, while others are still in the early days of development.

    RNA-based tests for both preeclampsia and preterm-birth risk are inching their way toward the clinic. Mirvie, a company co-founded by Quake in South San Francisco, is focused on developing both. Last year, the company published a study of a preterm-birth test with hundreds of pregnant individuals as well as one on a preeclampsia test with samples from more than 1,000 women. Both studies had promising results. The company is now in the middle of an even larger study of the preeclampsia test that will include 10,000 pregnancies, Quake says. (Quake and Moufarrej are both shareholders of Mirvie.)

    Cell-free RNA-based tests for preeclampsia are leading the way, says McElrath, likely because preterm birth has more subtypes and more potential causes—including carrying multiples, chronic health conditions such as diabetes, and preeclampsia—which make it a more complicated issue to address. (McElrath is involved in validating Mirvie’s tests; he serves as a scientific adviser to the company and has a financial stake in it.)

    Read: Childbirth is no fun. But an extremely fast birth can be worse.

    Still, questions about these tests remain. An important next step, says Moufarrej, is determining what’s behind the RNA changes associated with a heightened risk for these pregnancy complications. All of the studies conducted to date have been correlative—linking patterns in RNA with risk—but to provide effective treatment, it will be important to determine the cause of these changes, she adds. Another open question is how important maternal versus fetal RNAs are to determining the risk of pregnancy complications. To date, most studies have not distinguished between these two sources. “This remains an active area of investigation,” McElrath says.

    Erik Sistermans, a human geneticist at Amsterdam UMC, says that although  researchers can learn a lot from cell-free RNA, it’s still too early to judge what the power of these RNA-based tests will be in clinical practice. He notes that he and other researchers are also investigating the possibility of using cell-free DNA to determine the risk of pregnancy complications such as preeclampsia. For example, some groups are looking at chemical modifications to DNA known as epigenetic changes, which occur in response to age, environment, and other factors.

    Yalda Afshar, a maternal- and fetal-medicine physician at UCLA, agrees that it’s still unclear whether these tests will provide benefits not available from existing screening methods such as looking for the presence of risk factors. For these screening tests to truly benefit patients, clinicians will first need to understand the underlying biology of these complications—and have effective treatments to offer patients found to be at risk, she adds. (Afshar is an unpaid consultant for Mirvie.)

    There are also ethical questions to consider. Screening tests provide only an estimate of risk, not a definitive diagnosis, Sistermans notes. Before these tests are rolled out to the public, it will be crucial to consider how best to communicate test results, and what next steps to take for individuals who are identified as being in a high-risk category, he says. For preeclampsia, low-dose aspirin can help prevent or delay its onset, while the hormone progesterone may help prevent some cases of preterm birth. But every additional test added to a prenatal screen makes decisions more complicated and potentially stressful for pregnant women. “You shouldn’t underestimate the amount of anxiety these kinds of tests may cause,” Sistermans says.

    Still, researchers are optimistic about the future of cell-free RNA-based tests. The tests for preeclampsia are already more accurate than currently available tests for the condition, according to McElrath. And if researchers succeed in predicting other complications, he adds, future patients will benefit not just from additional information about their pregnancies, but also from the opportunity to receive more personalized care. “Once we start to see success in early preeclampsia prediction,” McElrath says, “it will quickly spread out from there.”

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    Diana Kwon

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  • Abortion Could Matter Even More in 2024

    Abortion Could Matter Even More in 2024

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    Last month, during a meeting of Democrats in rural southwestern Iowa, a man raised his hand. “What are three noncontroversial issues that Democrats should be talking about right now?” he asked the evening’s speaker, Rob Sand, Iowa’s state auditor and a minor state celebrity.

    I watched from the side of the room as Sand answered quickly. The first two issues Democrats should talk about are new state laws dealing with democracy and education, he told the man. And then they should talk about their support for abortion rights. “People in the Iowa Republican Party and their activist base” want to “criminalize abortion,” Sand said.

    I registered this response with a surprised blink. Noncontroversial? Democrats in competitive states, and especially committed centrists like Sand, aren’t usually so eager to foreground abortion on the campaign trail. This seemed new.

    Read: The most dangerous Democrat in Iowa

    Ascribing a narrative to some elections is easy. The past two midterm cycles are a case in point. The Democrats’ 2018 blue wave, for example, will go down as a woman-led backlash to a grab-’em-by-the-groin president. In 2022, Democrats performed better than expected, according to many analysts, because abortion rights were on the ballot. Now, a year after the Supreme Court overturned Roe v. Wade, Democrats want to do it again.

    They’re betting that they can re-create and even supercharge their successes last year by centering abortion rights in their platform once again in the lead-up to 2024. They want all of their elected officials—even state auditors—talking about the issue. “If we can do all that, we’re gonna be telling the same story in December 2024 that we told in 2022,” Yasmin Radjy, the executive director of the progressive political group Swing Left, told me.

    But this time, Republicans might be better prepared for the fight.

    After the leaked draft opinion before the Dobbs decision last May, many in Washington assumed that abortion would fade from voters’ minds by the time November rolled around. “As we get further away from the shock of that event, of Roe being overturned, you don’t think that … people will sort of lose interest?” CNN’s Don Lemon asked the Democratic political strategist Tom Bonier in September 2022. People did not. Two months later, Democrats celebrated better-than-expected results—avoiding not only the kind of “shellacking” that Barack Obama’s party had suffered in 2010, but the widely predicted red wave. The Democrats narrowly lost the House but retained control of the Senate, flipping Pennsylvania in the process. Abortion-rights campaigners won ballot measures in six states.

    “The lesson has been well learned,” Bonier told me last week. “This is an issue that is incredibly effective, both for mobilizing voters but also for winning over swing voters.”

    Read: Is Gen Z coming for the GOP?

    The latest polling suggests that the issue is very much alive. A record-high number of registered U.S. voters say that abortion is the most important factor in their decision about whom to vote for, and most of those voters support abortion rights, according to Gallup. Rather than growing less salient over time, abortion may even have gained potency: Roughly a quarter of Americans say that recent state efforts to block abortion access have made them more supportive of abortion rights, not less, according to a USA Today poll last week. Not only that, but recent data suggest that demand for abortion has not been much deterred, despite post-Dobbs efforts to restrict it.

    Americans have watched as Republicans in 20 states restricted or banned abortion outright, and activists took aim at interstate travel for abortions and the pill mifepristone. Stories about pregnant women at risk of bleeding out or becoming septic after being denied abortions have lit up the internet for months. All of this attention and sentiment seem unlikely to dissipate by November 2024.

    “Republicans ran races on this issue for decades,” the Democratic strategist Lis Smith told me. “You’re gonna see Democrats run on this issue for decades to come as well.”

    Already, Democratic activists plan to engage swing voters by forcing the issue in as many states as possible. So far, legislators in New York and Maryland have introduced abortion-related ballot measures for 2024. Similar efforts are under way in other states, including Florida, Arizona, Missouri, South Dakota, and Iowa.

    Smith and her fellow party operatives are confident that they’ve landed on a message that works—especially in purple states where candidates need to win over at least a few moderates and independents. The most successful Democrats last year anchored their abortion messages around the concept of personal liberty, Swing Left’s Radjy told me, because it was “the single issue that is equally popular among far left, far right, center left, and center right.” Radjy shared with me a research report that concluded: “With limited attention and resources, [candidates should] lead with the freedom to decide. Freedom is resonating with the base and conflicted supporters, as well as Soft Biden and Soft Trump women.”

    Smith echoed this reframing. “Republican politicians want to insert themselves into women’s personal medical decisions,” she said, by way of exemplifying the message. “They want to take away this critical freedom from you.” In her view, that gives Democratic candidates a decisive advantage: They don’t even have to say the word abortion; they only have to use the language of freedom for people to be receptive.

    Joe Biden has never been the most comfortable or natural messenger on abortion. But even he is giving the so-called freedom framework a try. Freedom is the first word in the president’s reelection-announcement ad. Republicans, he says in a voice-over, are “dictating what health-care decisions women can make”; they are “banning books, and telling people who they can love.”

    Read: The new pro-life movement has a plan to end abortion

    It’s helpful, Democratic strategists told me, that the Republicans jockeying for the presidential nomination have been murky at best on the issue. Former South Carolina Governor Nikki Haley held a press conference in April to explain that she sees a federal role in restricting abortion, but wouldn’t say what. Senator Tim Scott of South Carolina was foggy on his own commitments in interviews before appearing to support a 15-week national ban. Florida Governor Ron DeSantis, who recently signed a six-week limit on abortion, talks about that ban selectively. The leader of the primary pack, Donald Trump, has said that abortion laws should be left to the states, but told a reporter recently that he, too, is “looking at” a 15-week restriction.

    Trump clearly wants to appease the primary base while keeping some room to maneuver in the general election. But if he’s the nominee, Democrats say, he’ll have to answer for the end of Roe, as well as the anti-abortion positions advocated by other Republicans. “When I worked for Obama in 2012, as rapid-response director, we tied Mitt Romney to the most extreme positions in his party,” Smith told me. If Trump is the abortion-banning GOP’s nominee, they will “hang that around his neck like a millstone.”

    I found it difficult to locate Republican strategists willing to talk with me about abortion, and even fewer who see it as a winning issue for their party. One exception was the Republican pollster and former Trump adviser Kellyanne Conway, who says that Republicans can be successful in campaigning on abortion—if they talk about it the right way. At a press conference celebrating the anniversary of the Dobbs decision, hosted by the anti-abortion group Susan B. Anthony List, Conway seemed to take a swipe at the former president—and the rest of the wishy-washy primary field. “If you’re running to be president of the United States, it should be easy to have a 15-minimum-week standard,” she said.

    To win on abortion is to frame your opponent as more extreme, and Democrats have made that easy, says Conway, who also acts as an adviser to the Republican National Committee. Broad federal legislation put forward by Democratic lawmakers last year, in response to the Dobbs leak, would prevent states from banning abortion “after fetal viability” for reasons of the mother’s life or health. Republicans claim that this means that Democrats support termination at all stages of pregnancy. Voters may not like outright bans on abortion, but they also generally don’t support abortion without limits. Conway advises Republican candidates to explain to voters whether they support exceptions for rape, incest, and the life of the mother, and get that out of the way—and then demand that their Democratic opponents define the time limits they favor. “I’d ask each and every one of them, ‘What are your exceptions? I’ve shown you mine,’” Conway told me.

    Read: The abortion absolutist

    Conway’s bullishness is belied by what some of her political allies are up to. While Democrats are pushing for ballot measures that will enshrine abortion rights into law, Republicans are trying to make it harder to pass state constitutional amendments. For example, after it became clear that a ballot measure could result in new abortion protections being added to the Ohio Constitution, state Republicans proposed their own ballot measure asking voters in a special election later this summer to raise the threshold for passing constitutional amendments.

    This scheme does not demonstrate faith that a majority of voters are with them. But it does set up Ohio as the first practical test of abortion’s salience as a political issue in 2024. If Democrats can get their voters to show up this August in the name of abortion rights, maybe they can do it next year too.

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    Elaine Godfrey

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  • The Pregnancy Risk That Doctors Won’t Mention

    The Pregnancy Risk That Doctors Won’t Mention

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    The nonexhaustive list of things women are told to avoid while pregnant includes cat litter, alfalfa sprouts, deli meat, runny egg yolks, pet hamsters, sushi, herbal teas, gardening, brie cheeses, aspirin, meat with even a hint of pink, hot tubs. The chance that any of these will harm the baby is small, but why risk it?

    Yet few doctors in the U.S. tell pregnant women about the risk of catching a ubiquitous virus called cytomegalovirus, or CMV. The name might be obscure, but CMV is the leading infectious cause of birth defects in America—far ahead of toxoplasmosis from cat litter or microbes from hamsters. Bafflingly, the majority of babies infected in the womb are unaffected, but an estimated 400 born with CMV die every year. Thousands more end up with hearing and vision loss, epilepsy, developmental delays, or microcephaly, in which the head and brain are unusually small. Exactly why the virus so dramatically affects some babies but not others is unknown. There is no cure and no vaccine.

    Amanda Devereaux’s younger child, Pippa, was born with CMV, which caused damage to her brain. Pippa is prone to seizures. She could not walk until she was 2 and a half, and she is nonverbal at age 7. “I was just flabbergasted that no one told me about CMV,” says Devereaux, who is now the program director for the National CMV Foundation, which raises awareness of the virus. The nonprofit was founded by parents of children with congenital CMV. “Every single one of them says, ‘Why didn’t I hear about this?’” Devereaux told me.

    One reason that doctors have hesitated to spread the word is that the most obvious way to avoid this virus is to avoid infected toddlers. Symptoms from CMV are usually mild to nonexistent in healthy adults and children. Toddlers, who frequently pick up CMV at day care, can continue shedding the virus in their bodily fluids for months and even years while totally healthy. “I’ve encountered a classroom of 2-year-olds where every single child was shedding CMV,” Robert Pass, a retired pediatrician and longtime CMV researcher at the University of Alabama, told me when we spoke in 2021. (He recently died, at age 81.)

    This creates a common scenario for congenital CMV: A toddler in day care brings CMV home and infects Mom, who is pregnant with a younger sibling. One recent study found that congenital CMV is nearly twice as common in second-born children than in firstborns. Devereaux’s toddler son was in day care when she was pregnant. “I was sharing food with him because he would not finish his breakfast,” she told me. She had no idea that his half-eaten muffin could end up harming her unborn daughter. In hindsight, she says, “I wish I had spent less time worrying about not eating deli meat and more time focused on, Hey I’ve got this toddler at day care. I’m at risk for CMV.”

    CMV is such a tricky virus because few things about it are absolute. A mother cannot avoid her toddler categorically. Most pregnant women infected with CMV do not pass it to their babies. Most infected babies end up just fine. Doctors warn patients against many risks in pregnancy—see the list above—but in this case thousands of parents every year are blindsided by a very common virus. No one has a perfect answer for how to stop it.

    Day cares have been known as hot spots for CMV since at least the 1980s, when Pass, in Alabama, and other researchers in Virginia first began tracking congenital cases back to child-care centers. The virus is rampant in day cares for the same reason that other viruses are rampant in day cares: Young children are born with no immunity, and they aren’t very diligent about avoiding one another’s saliva, urine, snot, and tears, all of which harbor CMV. Of mothers with infected toddlers in day care, a third who have never had the virus catch it within a year. And getting CMV for the first time while pregnant is the riskiest scenario; these so-called primary infections are most likely to result in serious complications for the fetus. But recent research has found that reinfections and reactivations of the virus can lead to congenital CMV too. (CMV remains inside the body forever after the first infection, much like chickenpox, which is caused by a related virus.)

    So eliminating the risk of congenital CMV entirely is impossible. But some CMV experts advocate giving women a short list of actions to reduce their risk during the nine months of pregnancy: Avoid sharing food or utensils with toddlers in day care; kiss them on the top of the head instead of on the mouth; wash your hands frequently, especially after diaper changes; and clean surfaces that come in contact with saliva or urine. A study in Italy found that pregnant women who were taught these measures cut their risk of catching CMV by sixfold. A study in France found that it lowered risk too.

    In the U.S., patients are unlikely to hear this advice from their obstetricians, though. The American College of Obstetricians and Gynecologists doesn’t recommend telling patients about ways to reduce CMV risk. According to ACOG, the evidence that behavioral changes can make a difference—from just a handful of studies—is not strong enough, and the organization sees downsides to the approach. Advice such as not kissing babies and toddlers could harm “a mother’s ability to bond with her children,” and these hygiene recommendations could “falsely reassure patients” about their risk of CMV, Christopher Zahn, ACOG’s interim CEO, said in a statement to The Atlantic.

    The CMV community disagrees. “I think they’re being a bit paternalistic,” says Gail Demmler-Harrison, a pediatric-infectious-diseases doctor at Texas Children’s Hospital. A group of international CMV experts, including Demmler-Harrison, endorsed patient education in a set of consensus recommendations in 2017. Devereaux, with the CMV Foundation, frames it as a matter of choice. It shouldn’t be “somebody else is saying, ‘You can’t handle this information; I’m not going to share that with you,” she told me. Without knowing about CMV, women can’t decide what kind of risk they’re comfortable with or what kind of hygiene changes are too burdensome. “It’s your choice whether you make them or not,” she says. “Having that choice is important.”

    More data on how well these behavioral changes work might be coming soon: Karen Fowler, an epidemiologist at the University of Alabama at Birmingham, is enrolling hundreds of pregnant women in a clinical trial. Only 8 percent of participants had heard of CMV before joining the study, she says. Patients get a short information session about CMV and then 12 weeks of text-message reminders. Importantly, she says, “we’re keeping our message very simple”: Reduce saliva sharing: no eating leftover food, no sharing utensils, and no cleaning a pacifier in your mouth. This simple rule cuts off the most probable routes of transmission. Sure, CMV is also shed in urine, tears, and other bodily fluids—but mothers aren’t routinely putting any of those in their mouth.

    Prevention of CMV ends up the focus of so much attention because once a fetus is infected, the treatment options are not particularly good. The best antiviral against CMV is not considered safe to use during pregnancy, and another antiviral, although safer, is not that potent. After infected babies are born, antiviral therapy can help preserve hearing in those with other moderate to severe symptoms from CMV, but it can’t reverse damage in the brain. And it’s unclear how much antivirals help those with only mild symptoms. When does benefit outweigh risk? “There’s a big gray area,” says Laura Gibson, a pediatric-infectious-diseases doctor at the University of Massachusetts Chan Medical School. For these reasons, policies of whether to screen all newborns vary state to state, even hospital to hospital. Knowledge can be power—but with a virus as confusing as CMV, knowledge of an infection doesn’t always point to an obvious best choice.

    In an ideal world, all of this could be made obsolete with a CMV vaccine. But such a vaccine has proved elusive despite a lot of interest. In the U.S., the Institute of Medicine deemed a CMV vaccine the highest priority around the turn of the millennium, and about two dozen vaccine candidates have been or are being studied. All of the completed clinical trials, though, have failed. “The immunity may look robust in the first month or year, but then it wanes,” Demmler-Harrison says. And even vaccines that elicit some immune response are not necessarily able to elicit one strong enough to protect against CMV infection entirely.

    CMV is such a challenging virus to vaccinate against because it knows our immune system’s tricks. “It’s evolved with humans for millions of years,” Gibson says. “It knows how to get around and live with our immune system.” Our immune system is never able to eliminate the virus, which emerges occasionally from our cells to replicate and try to find another host. And so a vaccine that completely protects against CMV would need to prompt our immune system to do something it cannot naturally do. It would need to be better than our immune system. “As time goes on, I think fewer and fewer people are thinking that might work,” Gibson says. But a vaccine doesn’t have to protect against all infections to be useful. Because first infections are the riskiest for fetuses, being vaccinated could still reduce risk of congenital CMV.

    Whom to vaccinate is another complicated question to answer for CMV. We could vaccinate all toddlers, as we do against rubella, which is also most dangerous when passed from mother to fetus. This has the potential advantage of promoting widespread immunity that tamps down circulation of CMV, period. But the virus doesn’t actually harm toddlers much, and immunity could wane by the time they grow up to childbearing age. Or we could vaccinate teenagers, as we do against meningococcal disease, but teens are more likely to miss vaccines and again, immunity could wane too soon. So what about all pregnant women? By the time someone shows up at the doctor pregnant, it’s probably too late to protect during CMV’s highest risk period, in the first trimester. A better understanding of CMV immunity and spread could help scientists decide on the best strategy. Gibson is conducting a study (funded by Moderna, which is testing a CMV-vaccine candidate) on how the virus spreads and what kinds of immune responses are correlated with shedding.

    Until a vaccine is developed—should it happen at all—the only way to prevent CMV infection is the very old-tech method of avoiding bodily fluids. It’s imperfect. Its exact effectiveness is hard to quantify. Some people might not find it worthwhile, given the small absolute risk of CMV in any single pregnancy. There are, after all, already so many things to worry about when expecting a baby. Yet another one? Or, you might think of it, what’s one more?

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    Sarah Zhang

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  • The Moral Case Against Euphemism

    The Moral Case Against Euphemism

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    The Sierra Club’s Equity Language Guide discourages using the words stand, Americans, blind, and crazy. The first two fail at inclusion, because not everyone can stand and not everyone living in this country is a citizen. The third and fourth, even as figures of speech (“Legislators are blind to climate change”), are insulting to the disabled. The guide also rejects the disabled in favor of people living with disabilities, for the same reason that enslaved person has generally replaced slave : to affirm, by the tenets of what’s called “people-first language,” that “everyone is first and foremost a person, not their disability or other identity.”

    Explore the April 2023 Issue

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    The guide’s purpose is not just to make sure that the Sierra Club avoids obviously derogatory terms, such as welfare queen. It seeks to cleanse language of any trace of privilege, hierarchy, bias, or exclusion. In its zeal, the Sierra Club has clear-cut a whole national park of words. Urban, vibrant, hardworking, and brown bag all crash to earth for subtle racism. Y’all supplants the patriarchal you guys, and elevate voices replaces empower, which used to be uplifting but is now condescending. The poor is classist; battle and minefield disrespect veterans; depressing appropriates a disability; migrant—no explanation, it just has to go.

    Equity-language guides are proliferating among some of the country’s leading institutions, particularly nonprofits. The American Cancer Society has one. So do the American Heart Association, the American Psychological Association, the American Medical Association, the National Recreation and Park Association, the Columbia University School of Professional Studies, and the University of Washington. The words these guides recommend or reject are sometimes exactly the same, justified in nearly identical language. This is because most of the guides draw on the same sources from activist organizations: A Progressive’s Style Guide, the Racial Equity Tools glossary, and a couple of others. The guides also cite one another. The total number of people behind this project of linguistic purification is relatively small, but their power is potentially immense. The new language might not stick in broad swaths of American society, but it already influences highly educated precincts, spreading from the authorities that establish it and the organizations that adopt it to mainstream publications, such as this one.

    Although the guides refer to language “evolving,” these changes are a revolution from above. They haven’t emerged organically from the shifting linguistic habits of large numbers of people. They are handed down in communiqués written by obscure “experts” who purport to speak for vaguely defined “communities,” remaining unanswerable to a public that’s being morally coerced. A new term wins an argument without having to debate. When the San Francisco Board of Supervisors replaces felon with justice-involved person, it is making an ideological claim—that there is something illegitimate about laws, courts, and prisons. If you accept the change—as, in certain contexts, you’ll surely feel you must—then you also acquiesce in the argument.

    In a few cases, the gap between equity language and ordinary speech has produced a populist backlash. When Latinx began to be used in advanced milieus, a poll found that a large majority of Latinos and Hispanics continued to go by the familiar terms and hadn’t heard of the newly coined, nearly unpronounceable one. Latinx wobbled and took a step back. The American Cancer Society advises that Latinx, along with the equally gender-neutral Latine, Latin@, and Latinu, “may or may not be fully embraced by older generations and may need additional explanation.” Public criticism led Stanford to abolish outright its Elimination of Harmful Language Initiative—not for being ridiculous, but, the university announced, for being “broadly viewed as counter to inclusivity.”

    In general, though, equity language invites no response, and condemned words are almost never redeemed. Once a new rule takes hold—once a day in history can no longer be dark, or a waitress has to be a server, or underserved and vulnerable suddenly acquire red warning labels—there’s no going back. Continuing to use a word that’s been declared harmful is evidence of ignorance at best or, at worst, a determination to offend.

    Conor Friedersdorf: The AMA embraces leftist language—and leaves patients behind

    Like any prescribed usage, equity language has a willed, unnatural quality. The guides use scientific-sounding concepts to lend an impression of objectivity to subjective judgments: structural racialization, diversity value proposition, arbitrary status hierarchies. The concepts themselves create status hierarchies—they assert intellectual and moral authority by piling abstract nouns into unfamiliar shapes that immediately let you know you have work to do. Though the guides recommend the use of words that are available to everyone (one suggests a sixth-to-eighth-grade reading level), their glossaries read like technical manuals, put together by highly specialized teams of insiders, whose purpose is to warn off the uninitiated. This language confers the power to establish orthodoxy.

    Mastering equity language is a discipline that requires effort and reflection, like learning a sacred foreign tongue—ancient Hebrew or Sanskrit. The Sierra Club urges its staff “to take the space and time you need to implement these recommendations in your own work thoughtfully.” “Sometimes, you will get it wrong or forget and that’s OK,” the National Recreation and Park Association guide tells readers. “Take a moment, acknowledge it, and commit to doing better next time.”

    The liturgy changes without public discussion, and with a suddenness and frequency that keep the novitiate off-balance, forever trying to catch up, and feeling vaguely impious. A ban that seemed ludicrous yesterday will be unquestionable by tomorrow. The guides themselves can’t always stay current. People of color becomes standard usage until the day it is demoted, by the American Heart Association and others, for being too general. The American Cancer Society prefers marginalized to the more “victimizing” underresourced or underserved—but in the National Recreation and Park Association’s guide, marginalized now acquires “negative connotations when used in a broad way. However, it may be necessary and appropriate in context. If you do use it, avoid ‘the marginalized,’ and don’t use marginalized as an adjective.” Historically marginalized is sometimes okay; marginalized people is not. The most devoted student of the National Recreation and Park Association guide can’t possibly know when and when not to say marginalized; the instructions seem designed to make users so anxious that they can barely speak. But this confused guidance is inevitable, because with repeated use, the taint of negative meaning rubs off on even the most anodyne language, until it has to be scrubbed clean. The erasures will continue indefinitely, because the thing itself—injustice—will always exist.

    Helen Lewis: In defense of saying ‘pregnant women’

    In the spirit of Strunk and White, the guides call for using specific rather than general terms, plain speech instead of euphemisms, active not passive voice. Yet they continually violate their own guidance, and the crusade to eliminate harmful language could hardly do otherwise. A division of the University of Southern California’s School of Social Work has abandoned field, as in fieldwork (which could be associated with slavery or immigrant labor) in favor of the obscure Latinism practicum. The Sierra Club offers refuse to take action instead of paralyzed by fear, replacing a concrete image with a phrase that evokes no mental picture. It suggests the mushy protect our rights over the more active stand up for our rights. Which is more euphemistic, mentally ill or person living with a mental-health condition? Which is more vague, ballsy or risk-taker? What are diversity, equity, and inclusion but abstractions with uncertain meanings whose repetition creates an artificial consensus and muddies clear thought? When a university administrator refers to an individual student as “diverse,” the word has lost contact with anything tangible—which is the point.

    The whole tendency of equity language is to blur the contours of hard, often unpleasant facts. This aversion to reality is its main appeal. Once you acquire the vocabulary, it’s actually easier to say people with limited financial resources than the poor. The first rolls off your tongue without interruption, leaves no aftertaste, arouses no emotion. The second is rudely blunt and bitter, and it might make someone angry or sad. Imprecise language is less likely to offend. Good writing—vivid imagery, strong statements—will hurt, because it’s bound to convey painful truths.

    Katherine Boo’s Behind the Beautiful Forevers is a nonfiction masterpiece that tells the story of Mumbai slum dwellers with the intimacy of a novel. The book was published in 2012, before the new language emerged:

    The One Leg’s given name was Sita. She had fair skin, usually an asset, but the runt leg had smacked down her bride price. Her Hindu parents had taken the single offer they got: poor, unattractive, hard-working, Muslim, old—“half-dead, but who else wanted her,” as her mother had once said with a frown.

    Translated into equity language, this passage might read:

    Sita was a person living with a disability. Because she lived in a system that centered whiteness while producing inequities among racial and ethnic groups, her physical appearance conferred an unearned set of privileges and benefits, but her disability lowered her status to potential partners. Her parents, who were Hindu persons, accepted a marriage proposal from a member of a community with limited financial resources, a person whose physical appearance was defined as being different from the traits of the dominant group and resulted in his being set apart for unequal treatment, a person who was considered in the dominant discourse to be “hardworking,” a Muslim person, an older person. In referring to him, Sita’s mother used language that is considered harmful by representatives of historically marginalized communities.

    Equity language fails at what it claims to do. This translation doesn’t create more empathy for Sita and her struggles. Just the opposite—it alienates Sita from the reader, placing her at a great distance. A heavy fog of jargon rolls in and hides all that Boo’s short burst of prose makes clear with true understanding, true empathy.

    The battle against euphemism and cliché is long-standing and, mostly, a losing one. What’s new and perhaps more threatening about equity language is the special kind of pressure it brings to bear. The conformity it demands isn’t just bureaucratic; it’s moral. But assembling preapproved phrases from a handbook into sentences that sound like an algorithmic catechism has no moral value. Moral language comes from the struggle of an individual mind to absorb and convey the truth as faithfully as possible. Because the effort is hard and the result unsparing, it isn’t obvious that writing like Boo’s has a future. Her book is too real for us. The very project of a white American journalist spending three years in an Indian slum to tell the story of families who live there could be considered a gross act of cultural exploitation. By the new rules, shelf upon shelf of great writing might go the way of blind and urban. Open Light in August or Invisible Man to any page and see how little would survive.

    The rationale for equity-language guides is hard to fault. They seek a world without oppression and injustice. Because achieving this goal is beyond anyone’s power, they turn to what can be controlled and try to purge language until it leaves no one out and can’t harm those who already suffer. Avoiding slurs, calling attention to inadvertent insults, and speaking to people with dignity are essential things in any decent society. It’s polite to address people as they request, and context always matters: A therapist is unlikely to use terms with a patient that she would with a colleague. But it isn’t the job of writers to present people as they want to be presented; writers owe allegiance to their readers, and the truth.

    The universal mission of equity language is a quest for salvation, not political reform or personal courtesy—a Protestant quest and, despite the guides’ aversion to any reference to U.S. citizenship, an American one, for we do nothing by half measures. The guides follow the grammar of Puritan preaching to the last clause. Once you have embarked on this expedition, you can’t stop at Oriental or thug, because that would leave far too much evil at large. So you take off in hot pursuit of gentrification and legal resident, food stamps and gun control, until the last sin is hunted down and made right—which can never happen in a fallen world.

    This huge expense of energy to purify language reveals a weakened belief in more material forms of progress. If we don’t know how to end racism, we can at least call it structural. The guides want to make the ugliness of our society disappear by linguistic fiat. Even by their own lights, they do more ill than good—not because of their absurd bans on ordinary words like congresswoman and expat, or the self-torture they require of conscientious users, but because they make it impossible to face squarely the wrongs they want to right, which is the starting point for any change. Prison does not become a less brutal place by calling someone locked up in one a person experiencing the criminal-justice system. Obesity isn’t any healthier for people with high weight. It’s hard to know who is likely to be harmed by a phrase like native New Yorker or under fire; I doubt that even the writers of the guides are truly offended. But the people in Behind the Beautiful Forevers know they’re poor; they can’t afford to wrap themselves in soft sheets of euphemism. Equity language doesn’t fool anyone who lives with real afflictions. It’s meant to spare only the feelings of those who use it.

    The project of the guides is utopian, but they’re a symptom of deep pessimism. They belong to a fractured culture in which symbolic gestures are preferable to concrete actions, argument is no longer desirable, each viewpoint has its own impenetrable dialect, and only the most fluent insiders possess the power to say what is real. What I’ve described is not just a problem of the progressive left. The far right has a different vocabulary, but it, too, relies on authoritarian shibboleths to enforce orthodoxy. It will be a sign of political renewal if Americans can say maddening things to one another in a common language that doesn’t require any guide.

    This article appears in the April 2023 print edition with the headline “The Moral Case Against Euphemism.” When you buy a book using a link on this page, we receive a commission. Thank you for supporting The Atlantic.

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    George Packer

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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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  • Expiration Dates Are Meaningless

    Expiration Dates Are Meaningless

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    For refrigerators across America, the passing of Thanksgiving promises a major purge. The good stuff is the first to go: the mashed potatoes, the buttery remains of stuffing, breakfast-worthy cold pie. But what’s that in the distance, huddled gloomily behind the leftovers? There lie the marginalized relics of pre-Thanksgiving grocery runs. Heavy cream, a few days past its sell-by date. A desolate bag of spinach whose label says it went bad on Sunday. Bread so hard you wonder if it’s from last Thanksgiving.

    The alimentarily unthinking, myself included, tend to move right past expiration dates. Last week, I considered the contents of a petite container in the bowels of my fridge that had transcended its best-by date by six weeks. Did I dare eat a peach yogurt? I sure did, and it was great. In most households, old items don’t stand a chance. It makes sense for people to be wary of expired food, which can occasionally be vile and incite a frenzied dash to the toilet, but food scientists have been telling us for years—if not decades—that expiration dates are mostly useless when it comes to food safety. Indeed, an enormous portion of what we deem trash is perfectly fine to eat: The food-waste nonprofit ReFED estimated that 305 million pounds of food would be needlessly discarded this Thanksgiving.

    Expiration dates, it seems, are hard to quit. But if there were ever a moment to wean ourselves off the habit of throwing out “expired” but perfectly fine items because of excessive caution, it is now. Food waste has long been a huge climate issue—rotting food’s annual emissions in the U.S. approximate that of 42 coal-fired power plants—and with inflation’s brutal toll on grocery bills, it’s also a problem for your wallet. People throw away roughly $1,300 a year in wasted food, Zach Conrad, an assistant professor of food systems at William and Mary, told me. In this economy? The only things we should be tossing are expiration dates themselves.

    Expiration dates, part of a sprawling family of labels that includes the easily confused siblings “best before,” “sell by,” and “best if used by,” have long muddled our conception of what is edible. They do so by insinuating that food has a definitive point of no return, past which it is dead, kaput, expired—and you might be, too, if you dare eat it. If only food were as simple as that.

    The problem is that most expiration dates convey only information about an item’s quality. With the exception of infant formula, where they really do refer to expiration, dates generally represent a manufacturer’s best estimate of how long food is optimally fresh and tasty, though what this actually means varies widely, not least because there is no federal oversight over labeling. Milk in Idaho, for example, can be “sold by” grocery stores more than 10 days later than in neighboring Montana, though the interim makes no difference in terms of quality. Some states, such as New York and Tennessee, don’t require labels at all.

    Date labels have been this haphazard since they arose in the 1970s. At the time, most Americans had begun to rely on grocery stores to get their food—and on manufacturers to know about its freshness. Now “the large majority of consumers think that these [labels] are related to safety,” Emily Broad Leib, a Harvard Law Professor and the founding director of its Food Law and Policy Clinic, told me. A study she co-authored in 2019 found that 84 percent of Americans at least occasionally throw out food close to the date listed on the package. But quality and safety are two very different things. Plenty of products can be edible, if not tasty, long past their expiration date. Safety, to food experts, refers to an item’s ability to cause the kind of food poisoning that sends people to the hospital. It’s “no joke,” Roni Neff, a food-waste expert at Johns Hopkins University, told me.

    Consider milk, which is among the most-wasted foods in the world. Milk that has already soured or curdled can—get this—still be perfectly safe to consume. (In fact, it makes for fluffy pancakes and biscuits and … skin-softening face masks.) “If you take a sip of that milk, you’re not going to end up with a foodborne illness,” Broad Leib said, adding that milk is one of the safest foods on the market because pasteurization kills all of the germs. Her rule of thumb for other refrigerated items is that anything destined for the stove or oven is safe past its expiration date, so long as it doesn’t smell or look odd. In industry speak, cooking is a “kill step”—one that destroys harmful interlopers—if done correctly. And then there is the pantry, an Eden of forever-stable food. Generally, dry goods never become unsafe, even if their flavor dulls. “You’re not taking your life into your hands if you’re eating a stale cracker or cereal,” said Broad Leib.

    Of course it would just be easier if labels were geared toward safety, but for the majority of food, the factors are too complex to sum up in a single date. Food is considered unsafe if it carries pathogens such as listeria, E. coli, or salmonella that can cause foodborne illness. These sneak into food through contamination, like when E. coli–tainted water is used to grow romaine lettuce. Proper storage, which means temperatures colder than 40 degrees Fahrenheit or hotter than 140 degrees Fahrenheit, inhibits their growth (except for listeria, which is particularly scary because it can thrive during refrigeration). It would be extremely difficult for a label to reflect all of this information, especially given that unsafe storage and contamination tend to occur after purchase, in hot car trunks and on unsanitized countertops. But as long as food doesn’t carry these germs to begin with, pathogens won’t suddenly appear the moment the clock strikes midnight on the expiration date. “They’re not spontaneous. Your crackers aren’t, like, contracting salmonella from the shelf,” said Broad Leib.

    There is, however, one category of food that should be labeled. Sometimes referred to as “foods pregnant women should avoid,” it includes certain ready-to-eat products such as deli meats, raw fish, sprouted vegetables, and unpasteurized milk and cheese, Brian Roe, a professor at Ohio State University’s Food Innovation Center, told me. These require extra caution because they can carry listeria, which is invisible to the senses, and are usually served cold—that is, they don’t go through a kill step before serving. Experts I spoke with agreed that high-risk foods should be identified as such, because there’s no way to tell if they’ve become unsafe. As things stand, the date label is the only information available, and it is “not helping people protect themselves from that handful of foods,” said Broad Leib. To overcome this setback, efforts are under way in the Senate and the House to replace all date labels with two phrases: best if used by to denote quality and use by for safety.

    But it’s one thing to know expiration dates are bogus and another to live accordingly. In America, dates have become a tradition we can’t escape, Neff said, adding that the stickler of each household usually gets to set the rules. And even for more adventurous eaters, date labels serve a purpose: They’re a tool for calibrating judgment, or merely for providing the comfort of a reference point. “There’s something about seeing a number there that we think tells us something that gives us a sense of security,” Neff said. Manufacturers, meanwhile, maintain date labels because they don’t want to risk consumers buying products past their prime, even if they are safe and still (mostly) tasty.

    Although there’s no perfect way to know whether food is safe or not, there are better ways than expiration dates to tell. The adage “When in doubt, throw it out” doesn’t cut it anymore, said Neff; if you’re not sure, just look it up. Good tools are available online: She recommends FoodKeeper, an app developed by the U.S. Department of Agriculture, which lets users look up roughly how long food lasts. The Waste-Free Kitchen Handbook, by the food-waste pioneer Dana Gunders, gives detailed practical advice, such as scraping a half-inch below blue-green mold on hard cheese to safely recover the rest. Leftovers require slightly more caution, noted Broad Leib, because reheating, transferring between containers, and frequent touching with utensils (which, admit it, have been in your mouth) introduces more risk for contamination; her recommendation is to eat them within three to five days, and reheat them well—to a pathogen-killing internal temperature of 165 degrees Fahrenheit. And if doing so proves tedious, consider Roe’s take on the old saying: “When in doubt, cover it with panko, fry it up, and give it to your kids.”

    Yet for most foods, one tactic reigns supreme: the smell test. Your senses can give you most of the information you need. “If something smells off, you know,” said Broad Leib. Humans evolved disgust because it taught us to avoid the stench of pathogen-tainted food. But because most people are out of practice, they struggle to tell good from bad or don’t trust their senses. To be fair, it can be hard to discern whether weird smells are coming from the milk or the carton. To restore the food knowledge that has been lost since Americans shifted away from agriculture, all of the experts I spoke with supported the revival of home-economics classes—albeit with different branding and less sexism. Teaching students how to handle perishable food means teaching them what perished looks and smells like. Adults can learn this at home, of course, by opening that milk carton and daring to sniff deeply. It may be the first sniff of the rest of your life.

    It’s unlikely that we’ll ever return en masse to the pre-1970s idyll of purchasing food directly from farmers or growing it ourselves. Americans are “several generations removed now from agriculture and food production, so we don’t know our food as well as they once did,” Jackie Suggitt, the director of capital, innovation, and engagement at ReFED, told me. A smell rebellion, if you will, can’t restore our severed relationship with food, but hey, it’s a start. The lonely items lingering in one’s post-Thanksgiving fridge may be one inhale away from renewed relevance. If I deigned to sniff that “expired” heavy cream, I might be delighted to encounter a future garnish for pumpkin pie. And what is wilted spinach anyway but a can of artichokes away from dip?

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    Yasmin Tayag

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