In October 2020, Francis Collins, then the director of the National Institutes of Health, sent an email that maligned a colleague. A few days before, Jay Bhattacharya, a professor of health policy at Stanford University, had, with two others, put out a statement—the Great Barrington Declaration—calling for looser public-health restrictions in the face of the pandemic. In place of lockdowns, the statement contended, the nation could simply let infections spread among most of the population while the old and infirm remained in relative isolation. Collins, like many other scientists, thought this was a dangerous idea. Bhattacharya and his co-authors were “fringe epidemiologists” whose proposal needed a “quick and devastating” rebuttal, Collins wrote in an email that later came to light through a public-records request. Collins doubled down on this dismissal in a media interview a week later: “This is a fringe component of epidemiology,” he told The Washington Post. “This is not mainstream sncience.”

So where are these two now? Collins abruptly ended his 32-year career at NIH last week, while Bhattacharya is Donald Trump’s pick to take over the agency. The turnabout has created a pleasing narrative for those aggrieved at scientific governance. “It’s remarkable to see that you’re nominated to be the head of the very institution whose leaders persecuted you because of what you believed,” Jim Banks, a Republican senator from Indiana, said at Bhattacharya’s confirmation hearing yesterday. For Bhattacharya, a man who has described himself as the victim of “a propaganda attack” perpetrated by the nation’s $48 billion biomedical-research establishment, Collins’s insult has become a badge of pride, even a leading qualification for employment in the U.S. Department of Health and Human Services. The “fringe” is now in charge.

Last year, when Collins was asked by a House committee about his comments on the Great Barrington Declaration, he said he was alarmed that the proposal had so quickly made its way to his boss, Alex Azar, who was then the secretary of Health and Human Services. Now that role is filled by another figure from the fringe, Robert F. Kennedy Jr., and presumably, outsider scholars such as Bhattacharya—a health economist and a nonpracticing physician with a predilection for contrary views—will have greater sway than ever. (Bhattacharya declined to be interviewed for this story. Collins did not respond to a request for comment.)

“Science, to succeed, needs free speech,” Bhattacharya told the committee during the hearing. “It needs an environment where there’s tolerance to dissent.” This has long been his message—and warning—to the scientific community. In Bhattacharya’s view, Collins helped coordinate an effort to discredit his and others’ calls for an alternative approach to the pandemic; Collins’s role at an institution that disperses billions of dollars in research funding gave him a frightening power to “cast out heretics,” as Bhattacharya put it in 2023, “just like the medieval Catholic Church did.”

Now he means to use the same authority to rectify that wrong. In his opening remarks yesterday, Bhattacharya vowed to “create an environment where scientists, including early-career scientists and scientists that disagree with me, can express disagreement respectfully.” What this means in practice isn’t yet clear, but The Wall Street Journal has reported that he might try to prioritize funding for universities that score high on to-be-determined measures of campus-wide “academic freedom.” In other words, Bhattacharya may attempt to use the agency’s billion-dollar leverage in reverse, to bully academics into being tolerant.

These aspirations match up with those of his allies who are riding into Washington as champions of the underheard in science. Last month, Kennedy promised in his first speech to his staff that he would foster debate and “convene representatives of all viewpoints” to study chronic disease. “Nothing is going to be off-limits,” he said. Marty Makary, the nominee for FDA commissioner, has talked about his experience of the “censorship complex” and bemoaned an atmosphere of “total intolerance” in public health. Consensus thinking is oppressive, these men suggest. Alternative ideas, whatever those might be, have intrinsic value.

[Read: Revenge of the COVID contrarians]

Surely we can all agree that groupthink is a drag. But a curious pattern is emerging among the fringe-ocrats who are coming into power. Their dissenting views, strewn across the outskirts of conventional belief, appear to be curling toward a new and fringe consensus of its own. On the subject of vaccines, for instance, there used to be some space between the positions of Kennedy, the nation’s leading figure casting doubt on the safety and benefits of inoculations, and Bhattacharya. Kennedy has made false claims about the dangers of the mRNA-based COVID shots. Bhattacharya, meanwhile, once called the same vaccines “a medical miracle—extremely valuable for protecting the vulnerable against severe COVID-19 disease.” (He even criticized Anthony Fauci for downplaying the benefits of COVID shots by continuing to wear a mask after being immunized.)

Bhattacharya has in the past been tolerant of others’ more outrageous claims about vaccines. But that neutrality has lately drifted into a gentle posture of acceptance, like a one-armed hug. Under questioning from senators, he said that he is convinced that there is no link between autism and the MMR vaccine (and that he fully supports vaccinating children against measles). But he also floated the idea that Kennedy’s goal of doing further research on the topic would be worthwhile just the same. Last July, despite his past enthusiasm for mRNA-based COVID-19 shots, Bhattacharya said that he was planning to sign on to a statement calling for their deauthorization, because they are “contributing to an alarming rise in disability and excess deaths.” Kennedy has petitioned for the same, on the same grounds. (There is, in fact, no meaningful evidence that the vaccines have caused a spate of excess deaths.) In a post on X, Bhattacharya explained that he’d been hesitant to take this step at first, because some groups might still benefit from the vaccines, but then he came to realize that pulling the vaccine will create the conditions necessary for testing whether it still has any value.

[Read: The inflated risk of vaccine-induced cardiac arrest]

On this and other issues, the dissenting voices have started to combine into a chorus. The lab-leak theory of COVID’s origin provides another case in point. In yesterday’s hearing, Bhattacharya described scientific experts’ early dismissal of the possibility that the coronavirus spread from a lab in Wuhan, China, as “a low point in the history of science.” That’s an overstatement, but the criticism is fair: Dissenting views were stifled and ignored. But here again, what started as mere endorsement of debate has evolved into a countervailing sense of certainty. Although there’s still plenty of reason to believe that the pandemic did, in fact, begin with the natural passage of the virus from an animal host, the most important details about the pandemic’s origin remain unknown. Yet the fringe is nearly settled on the alternative interpretation. Bhattacharya has said that the pandemic “likely” started in a lab (a position that has been endorsed, albeit with low or moderate confidence, by almost half of the government agencies that have looked into it). Makary called the theory “a no-brainer.” And RFK Jr. published a 600-page book, The Wuhan Cover-Up, in support of it.

Based on the Senate’s Republican majority and the precedent of Kennedy’s confirmation, Bhattacharya is almost certain to sail through his Senate vote, and in short order. His prospects of delivering on his mission, though, are hazier. Some of his positions are already being undermined by the Trump administration’s prior actions. According to a new report in Nature, the agency is terminating hundreds of active research grants that may be construed to have a focus on gender or diversity, among other topics. Some work may be permitted to continue as long as any “DEI language” has been stripped from associated documents. This is hardly the “culture of respect for free speech” that Bhattacharya promised yesterday. Other, basic workings of the NIH have been dismantled under the second Trump administration: Approximately 1,200 employees have been fired, grant reviews have been frozen, and policies have been declared that would squeeze research funding for the nation’s universities. Bhattacharya is about to take the levers of power, but those levers have been ripped from their housing, and the springs removed and sold as scrap.

[Read: Inside the collapse at the NIH]

When pressed on these developments yesterday, Bhattacharya kept returning to a single line: “I fully commit to making sure that all the scientists at the NIH, and the scientists that the NIH supports, have the resources they need.” Whether he’d have the authority or know-how to do so remains in doubt. “Dr. Bhattacharya doesn’t really understand how NIH works, and he doesn’t understand how decisions are made,” Harold Varmus, who ran the agency in the 1990s, told me shortly after the hearing ended. As for Bhattacharya’s goals of promoting free speech among scientists and nurturing cutting-edge ideas for research, Varmus said that the problem has been misdiagnosed: Whatever conservatism exists doesn’t really come from the top, he said, but from the grant-review committees and the scientists themselves. “It’s exasperating for me to see what is about to happen,” he told me, “because this guy should not be in my old office.”

For what it’s worth, Bhattacharya has also shared other ambitious plans. He aims, for instance, to make science more reliable by incorporating into NIH-funded research the dreary work of replicating findings. “Replication is the heart and soul of what truth is in science,” he said during the hearing. That might help solve a pressing problem in the sciences, but it would also be a very costly project, started at a time when research costs are being cut. Under current conditions, even just the basic job of running the NIH seems pretty stressful on its own. Bhattacharya has, by his account, experienced lots of stress in recent years due to the many efforts to discredit him. His confirmation may not bring him full relief.

Leading the FDA has long been one of the greatest professional achievements in American health. At the start of every administration, doctors jockey for the role, hoping to steer an agency that regulates 20 cents of every dollar spent in the United States. To be the FDA commissioner who presides over the approval of a cure for a previously intractable disease, or who launches an investigation into a product that is sickening Americans, is to etch your name into the annals of modern medicine. Perhaps you’ve never heard of David Kessler, the FDA commissioner for much of the 1990s, but he is largely the reason the federal government regulates cigarettes at all.   

Marty Makary, Donald Trump’s pick for FDA commissioner, is undoubtedly qualified for the job. A longtime Johns Hopkins surgeon and best-selling author, he has advised the World Health Organization and been elected to the National Academy of Medicine. (Makary, whose confirmation hearings kicked off in the Senate this morning, told Senator Rand Paul that he spent part of yesterday removing a patient’s gallbladder.) Makary is not universally embraced: As a Fox News contributor, he has repeatedly critiqued the medical establishment on air. But he’s still widely regarded as well-credentialed. “He has the ability to become one of the greatest commissioners we’ve seen,” Kavita Patel, a physician and former Obama administration official who considers Makary a personal friend, told me.

But Makary might end up with one of the worst jobs in the entire Trump administration. His scientific bona fides are at odds with the impulses of his boss, Robert F. Kennedy Jr. The newly confirmed secretary of Health and Human Services, who has a penchant for spreading conspiracy theories, has promised lawmakers that he will empower scientists and won’t “impose my preordained opinions on anybody.” But he has also promised to change the agency so radically that delivering on that vision would require Makary to throw much of his medical training out the window. What Makary decides to do will go a long way in determining the extent to which Kennedy is able to remake American health in his image.

That’s not to say that Makary, who did not respond to a request for comment, will be waging a war of resistance against everything RFK Jr. wants and believes. During his testimony this morning, Makary spoke about his desire to improve America’s diet and address chronic disease—both of which Kennedy has made his central focus as America’s health secretary. “We now have a generational opportunity in American health care,” Makary said. “President Trump and Secretary Kennedy’s focus on healthy foods has galvanized a grassroots movement in America.” Last fall, he took part in a roundtable with Kennedy where he lamented that “highly addictive chemicals” lace the U.S. food supply. Tackling that issue will be Makary’s surest bet for delivering on what Kennedy wants.

Contrary to Kennedy’s long-standing anti-vaccine advocacy, Makary reiterated in his Senate testimony that he believes that “vaccines save lives.” But like Kennedy and several other prominent Trump health advisers, Makary has been a vocal critic of how the Biden administration handled COVID. In 2021, he called out the FDA’s decision to approve COVID boosters for young, healthy Americans, citing a lack of clear evidence for their benefits relative to the potential side effects. The government’s “policies are no longer driven by science,” he wrote at the time, and “data is being cherry-picked to support predetermined agendas.” (The FDA pushed forward with boosters for young adults without convening its own independent advisory committee, though the agency said its decision was supported by data.) Other statements Makary has made are more questionable. In an appearance on Fox News in July 2023, he said that “100 percent” of Kennedy’s book on Anthony Fauci was true. He didn’t acknowledge that the book falsely claims that “COVID vaccines were causing far more deaths than they were averting.” (“The Marty you might see on Fox News clips is obviously not the person I know,” Patel told me.)

Much of what Makary actually wants to do at the FDA remains unclear. He spent little time during his testimony on Thursday outlining his moves once confirmed. Still, most of the changes Kennedy wants to see at the agency are untenable for any FDA commissioner concerned about adhering to basic science. Kennedy has said that the FDA’s “war” on treatments such as stem cells and psychedelic drugs “is about to end.” Decisions on how to regulate these products typically don’t rest with the health secretary or the FDA commissioner, but with the agency’s scientists and doctors. In both cases, there is no scientific reason for the FDA to change course. The agency doesn’t allow stem-cell treatments for most conditions because they aren’t proven to work and can cause people serious harm; last year, the FDA rejected what would have been the first MDMA-based medical treatment, likely due to shoddy clinical-trial data.

On his own, Makary can do only so much. The FDA’s powers are actually given by law to the HHS secretary, who then has historically delegated powers to the FDA commissioner, according to Lewis Grossman, a law professor at American University. What is given can be taken away; if Kennedy wants to meddle in Makary’s work, he’s well within his rights to do so.

Still, should Makary stand up to Kennedy, he will not be the first FDA secretary to clash with more powerful officials in the administration. Kessler’s efforts to investigate the tobacco industry were so controversial in Washington that, as he wrote in his memoir, the White House worried he would resign if they didn’t allow him to continue his work. If Makary can conjure up a similar power—using whatever leverage and cache he would have as FDA commissioner to negotiate with Kennedy and the Trump White House—he may hold his own. Makary “has both a mandate and an authority to not feel like he needs to step in line with any secretary, much less RFK Jr.,” Patel said.

The first major test for how willing Makary is to stand up to his boss will likely center on mifepristone, an abortion pill. Kennedy told senators in January that he would order the FDA and NIH to review the safety of the drug to determine whether access to it should be restricted. (Access to mifepristone varies by state, though prescriptions via telehealth have complicated the picture.) But that review has already been done. The FDA recently rereviewed the drug’s safety information, and determined that previous restrictions around the drug, namely that patients needed to physically go to a clinic to get it, were unnecessary. The agency is unlikely to find any new evidence that the drug is especially dangerous. If Makary comes up with a reason to question its safety, and thus meddles with the agency’s previous findings, it will show that his loyalty rests more with Kennedy than FDA’s scientists. During his confirmation hearing, Makary was unwilling to preview how exactly he would come down on the issue, much to the frustration of some Democratic senators.

In any administration, overseeing the FDA’s sprawling, vital work is a colossal undertaking. Should he be confirmed, Makary will be tasked with safeguarding the infant formula Americans feed their newborns, the cosmetics we use on our skin, the painkillers we take when we have a headache, the chemotherapy we receive to fight cancer, the pacemakers that keep hearts ticking, the flu shots we get every fall, and even the hand sanitizer we reach for when our hands are dirty. Makary’s biggest challenge, however, could turn out to be his ability to manage up. His ideal version of the FDA presumably is different from Kennedy’s. They both can’t get their way.