Trump has become the first president in US history to face criminal trial, with three other criminal cases pending.

Perhaps the largest hurdle for adoption of electric vehicles in the U.S. market right now is a lack of competent charging infrastructure. For those of us in a living situation that has dedicated garage space, charging is hardly an issue. We pull in, plug in, and barely ever have to worry about it. The average workaday…

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The ex-PM warns the "world was safer" under Donald Trump's presidency, and the West is "on the cusp" of conflict.

On April 13, the Islamic Republic of Iran launched missiles and drones at Israel. Also on April 13, as well as on April 12, 14, and 15, the Russian Federation launched missiles and drones at Ukraine—including some designed in Iran.

Few of the weapons launched by Iran hit their mark. Instead, American and European airplanes, alongside Israeli and even Jordanian airplanes, knocked the drones and missiles out of the sky.

By contrast, some of the attacks launched by Russia did destroy their targets. Ukraine, acting alone, and—thanks to the Republican leadership in the U.S. House of Representatives—running short on defensive ammunition, was unable to knock all of the drones and missiles out of the sky. On April 12 Russian strikes badly damaged an energy facility in Dnipropetrovsk. On April 13, a 61-year-old woman and 68-year-old man were killed by a Russian strike in Kharkiv. On April 14, an aerial bomb hit an apartment building in Ocheretyne, killing one and injuring two. On April 15, a Russian guided missile hit a school and killed at least two more people in the Kharkiv region.  

[Eliot A. Cohen: The ‘Israel model’ won’t work for Ukraine]

Why the difference in reaction? Why did American and European jets scramble to help Israel, but not Ukraine? Why doesn’t Ukraine have enough matériel to defend itself? One difference is the balance of nuclear power. Russia has nuclear weapons, and its propagandists periodically threaten to use them. That has made the U.S. and Europe reluctant to enter the skies over Ukraine. Israel also has nuclear weapons, but that affects the calculus in a different way: It means that the U.S., Europe, and even some Arab states are eager to make sure that Israel is never provoked enough to use them, or indeed to use any serious conventional weapons, against Iran.

A second difference between the two conflicts is that the Republican Party remains staunchly resistant to propaganda coming from the Islamic Republic of Iran. Leading Republicans do not sympathize with the mullahs, do not repeat their talking points, and do not seek to appease them when they make outrageous claims about other countries. That enables the Biden administration to rush to the aid of Israel, because no serious opposition will follow.

By contrast, a part of the Republican Party, including its presidential candidate, does sympathize with the Russian dictatorship, does repeat its talking points, and does seek to appease Russia when it invades and occupies other countries. The absence of bipartisan solidarity around Ukraine means that the Republican congressional leadership has prevented the Biden administration from sending even defensive weapons and ammunition to Ukraine. The Biden administration appears to feel constrained and unable to provide Ukraine with the spontaneous assistance that it just provided to Israel.

Open sympathy for the war aims of the Russian state is rarely stated out loud. Instead, some leading Republicans have begun, in the past few months, to argue that Ukraine should “shift to a defensive war,” to give up any hope of retaining its occupied territory, or else stop fighting altogether. Senator J. D. Vance of Ohio, in a New York Times essay written in what can only be described as extraordinary bad faith, made exactly this argument just last week. So too, for example, did Republican Representative Eli Crane of Arizona, who has said that military aid for Ukraine “should be totally off the table and replaced with a push for peace talks.”

[Eliot A. Cohen: The war is not going well for Ukraine]

But Ukraine is already fighting a defensive war. The materiel that the Republicans are refusing to send includes—let me repeat it again—defensive munitions. There is no evidence whatsoever that cutting off any further aid to Ukraine would end the fighting or bring peace talks. On the contrary, all of the evidence indicates that blocking aid would allow Russia to advance faster, take more territory, and eventually murder far more Ukrainians, as Vance and Crane surely know. Without wanting to put it that boldly, they seem already to see themselves in some kind of alliance with Russia, and therefore they want Ukraine to be defeated. They do not see themselves in alliance with Iran, despite the fact that Iran and Russia would regard one another as partners.

For the rest of the world, there are some lessons here. Plenty of countries, perhaps including Ukraine and Iran, will draw the first and most obvious conclusion: Nuclear weapons make you much safer. Not only can you deter attacks with a nuclear shield, and not only can you attack other countries with comparative impunity, but you can also, under certain circumstances, expect others to join in your defense.

Perhaps others will draw the other obvious conclusion: A part of the Republican Party—one large enough to matter—can be co-opted, lobbied, or purchased outright. Not only can you get it to repeat your propaganda; you can get it to act directly in your interests. This probably doesn’t cost even a fraction of the price of tanks and artillery, and it can be far more effective.

No doubt many will make use of both of these lessons in the future.

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In December 1921, Leonard Thompson was admitted to Toronto General Hospital so weak and emaciated that his father had to carry him inside. Thompson was barely a teenager, weighing all of 65 pounds, dying of diabetes. With so little to lose, he was an ideal candidate to be patient No. 1 for a trial of the pancreatic extract that would come to be called insulin.

The insulin did what today we know it can. “The boy became brighter, more active, looked better and said he felt stronger,” the team of Toronto researchers and physicians reported in March 1922 in The Canadian Medical Association Journal. The article documented their use of insulin on six more patients; it had seemingly reversed the disease in every case. As John Williams, a diabetes specialist in Rochester, New York, wrote of the first patient on whom he tried insulin later that year, “The restoration of this patient to his present state of health is an achievement difficult to record in temperate language. Certainly few recoveries from impending death more dramatic than this have ever been witnessed by a physician.”

Of all the wonder drugs in the history of medicine, insulin may be the closest parallel, in both function and purpose, to this century’s miracle of a metabolic drug: the GLP-1 agonist. Sold under now-familiar brand names including Ozempic, Wegovy, and Mounjaro, these new medications for diabetes and obesity have been hailed as a generational breakthrough that may one day stand with insulin therapy among “the greatest advances in the annals of chronic disease,” as The New Yorker put it in December.

But if that analogy is apt—and the correspondences are many—then a more complicated legacy for GLP-1 drugs could be in the works. Insulin, for its part, may have changed the world of medicine, but it also brought along a raft of profound, unintended consequences. By 1950, the new therapy had tripled the number of years that patients at a major diabetes center could expect to live after diagnosis. It also kept those patients alive long enough for them to experience a wave of long-term complications. Leonard Thompson would die at 27 of pneumonia. Other young men and women who shared his illness also died far too young, their veins and arteries ravaged by the disease, and perhaps—there was no way to tell—by the insulin therapy and associated dietary protocols that had kept them alive in the first place.

In the decades that followed, diabetes, once a rare disorder, would become so common that entire drug-store aisles are now dedicated to its treatment-related paraphernalia. Roughly one in 10 Americans is afflicted. And despite a remarkable, ever-expanding armamentarium of drug therapies and medical devices, the disease—whether in its type 1 or type 2 form—is still considered chronic and progressive. Patients live far longer than ever before, yet their condition is still anticipated to get worse with time, requiring ever more aggressive therapies to keep its harms in check. One in every seven health dollars is now spent on diabetes treatment, amounting to $800 million every day.

The advent of insulin therapy also changed—I would even say distorted—the related medical science. In my latest book, Rethinking Diabetes, I document how clinical investigators in the 1920s abruptly shifted their focus from trying to understand the relationship between diet and disease to that between drug and disease. Physicians who had been treating diabetes with either fat-rich diets absent carbohydrates (which had been the accepted standard of care in both the U.S. and Europe) or very low-calorie “starvation” diets came to rely on insulin instead. Physicians would still insist that diet is the cornerstone of therapy, but only as an adjunct to the insulin therapy and in the expectation that any dietary advice they gave to patients would be ignored.

With the sudden rise of GLP-1 drugs in this decade, I worry that a similar set of transformations could occur. Dietary therapy for obesity and diabetes may be sidelined in favor of powerful pharmaceuticals—with little understanding of how the new drugs work and what they really tell us about the mechanisms of disease. And all of that may continue despite the fact that the long-term risks of taking the drugs remain uncertain.

“The ebullience surrounding GLP-1 agonists is tinged with uncertainty and even some foreboding,” Science reported in December, in its article declaring these obesity treatments the journal’s Breakthrough of the Year. “Like virtually all drugs, these blockbusters come with side effects and unknowns.” Yet given the GLP-1 agonists’ astounding popularity, such cautionary notes tend to sound like lip service. After all, the FDA has deemed these drugs safe for use, and doctors have been prescribing products in this class to diabetes patients for 20 years with little evidence of long-term harm.

Yet the GLP-1 agonists’ side effects have been studied carefully only out to seven years of use, and that was in a group of patients on exenatide—an early, far less potent product in this class. The study offered no follow-up on the many participants in that trial who had discontinued use. Other long-term studies have followed patients on the drugs for at least as many years, but they’ve sought (and failed to find) only very specific harms, such as pancreatic cancer and breast cancer. In the meantime, a 2023 survey found that more than two-thirds of patients prescribed the newer GLP-1 agonists for weight loss had stopped using them within a year. Why did they quit? What happened to them when they did?

The stories of Leonard Thompson and the many diabetes patients on insulin therapy who came after may be taken as a warning. The GLP-1 drugs have many traits in common with insulin. Both treatments became very popular very quickly. Within years of its discovery, insulin was being prescribed for essentially every diabetic patient whose physician could obtain the drug. Both insulin and GLP-1 agonists were originally developed as injectable treatments to control blood sugar. Both affect appetite and satiety, and both can have remarkable effects on body weight and composition. The GLP-1s, like insulin, treat only the symptoms of the disorders for which they are prescribed. Hence, the benefits of GLP-1s, like those of insulin, are sustained only with continued use.

The two treatments are also similar in that they work, directly or indirectly, by manipulating an unimaginably complex physiological system. When present in their natural state—as insulin secreted from the pancreas, or GLP-1 secreted from the gut (and perhaps the brain)—they’re both involved in the regulation of fuel metabolism and storage, what is technically known as fuel partitioning. This system tells our bodies what to do with the macronutrients (protein, fat, and carbohydrates) in the foods we eat.

Chris Feudtner, a pediatrician, medical historian, and medical ethicist at the University of Pennsylvania, has described this hormonal regulation of fuel partitioning as that of a “Council of Food Utilization.” Organs communicate with one another “via the language of hormones,” he wrote in Bittersweet, his history of the early years of insulin therapy and the transformation of type 1 diabetes from an acute to a chronic disease. “The rest of the body’s tissues listen to this ongoing discussion and react to the overall pattern of hormonal messages. The food is then used—for burning, growing, converting, storing, or retrieving.” Perturb that harmonious discourse, and the whole physiological ensemble of the human body reverberates with corrections and counter-corrections.

This is why the long-term consequences of using these drugs can be so difficult to fathom. Insulin therapy, for instance, did not just lower patients’ blood sugar; it restored their weight and then made them fatter still (even as it inhibited the voracious hunger that was a symptom of uncontrolled diabetes). Insulin therapy may also be responsible, at least in part, for diabetic complications—atherosclerosis and high blood pressure, for instance. That possibility has been acknowledged in textbooks and journal articles but never settled as a scientific matter.

With the discovery of insulin and its remarkable efficacy for treating type 1 diabetes, diabetologists came to embrace a therapeutic philosophy that is still ascendant today: Treat the immediate symptoms of the disease with drug therapy and assume that whatever the future complications, they can be treated by other drug or surgical therapies. Patients with diabetes who develop atherosclerosis may extend their lives with stents; those with hypertension may go on blood-pressure-lowering medications.

A similar pattern could emerge for people taking GLP-1s. (We see it already in the prospect of drug therapies for GLP-1-related muscle loss.) But the many clinical trials of the new obesity treatments do not and cannot look at what might happen over a decade or more of steady use, or what might happen if the injections must be discontinued after that long. We take for granted that if serious problems do emerge, far down that distant road, or if the drugs have to be discontinued because of side effects, newer treatments will be available to solve the problems or take over the job of weight maintenance.

In the meantime, young patients who stick with treatment can expect to be on their GLP-1s for half a century. What might happen during those decades—and what might happen if and when they have to discontinue use—is currently unknowable, although, at the risk of sounding ominous, we will find out.

Pregnancy is another scenario that should generate serious questions. A recently published study found no elevated risk of birth defects among women taking GLP-1 agonists for diabetes right before or during early pregnancy, as compared with those taking insulin, but birth defects are just one obvious and easily observable effect of a drug taken during pregnancy. Children of a mother with diabetes or obesity tend to be born larger and have a higher risk of developing obesity or diabetes themselves later in life. The use of GLP-1 agonists during pregnancy may reduce—or exacerbate—that risk. Should the drugs be discontinued before or during pregnancy, any sudden weight gain (or regain) by the mother could similarly affect the health of her child. The consequences cannot be foreseen and might not manifest themselves until these children reach their adult years.

The rise of GLP-1 drugs may also distort our understanding of obesity itself, in much the way that insulin therapy distorted the thinking in diabetes research. With insulin’s discovery, physicians assumed that all diabetes was an insulin-deficiency disorder, even though this is true today for only 5 to 10 percent of diabetic patients, those with type 1. It took until the 1960s for specialists to accept that type 2 diabetes was a very different disorder—a physiological resistance to insulin, inducing the pancreas to respond by secreting too much of the hormone rather than not enough. And although the prognosis today for a newly diagnosed patient with type 2 diabetes is better than ever, physicians have yet to establish whether the progression and long-term complications of the disease are truly inevitable, or whether they might be, in fact, a consequence of the insulin and other drug therapies that are used to control blood sugar, and perhaps even of the diets that patients are encouraged to eat to accommodate these drug therapies.

Already, assumptions are being made about the mechanisms of GLP-1 agonists without the rigorous testing necessary to assess their validity. They’re broadly understood to work by inhibiting hunger and slowing the passage of food from the stomach—effects that sound benign, as if the drugs were little more than pharmacological versions of a fiber-rich diet. But changes to a patient’s appetite and rate of gastric emptying only happen to be easy to observe and study; they do not necessarily reflect the drugs’ most important or direct actions in the body.

When I spoke with Chris Feudtner about these issues, we returned repeatedly to the concept that Donald Rumsfeld captured so well with his framing of situational uncertainty: the known unknowns and the unknown unknowns. “This isn’t a you-take-it-once-and-then-you’re-done drug,” Feudtner said. “This is a new lifestyle, a new maintenance. We have to look down the road a bit with our patients to help them think through some of the future consequences.”

Patients, understandably, may have little time for a lecture on all that we don’t know about these drugs. Obesity itself comes with so many burdens—health-related, psychological, and social—that deciding, after a lifetime of struggle, to take these drugs in spite of potential harms can always seem a reasonable choice. History tells us, though, that physicians and their patients should be wary as they try to balance known benefits against a future, however distant, of unknown risk.

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My dentist is my enemy. But first, here are three new stories from The Atlantic:

The truth about organic milk Britain is leaving the U.S. gender-medicine debate behind. Trump has transformed the GOP all the way down.

Clean Teeth, Weak Spirit

When you’re a kid, the dentist’s office is a frightening place full of loud noises and sharp instruments. But at least people speak softly to you, and at the end of all the scraping and scrubbing, you get a pat on the back and a little prize from a treasure box.

When you are an adult, there are no prizes. There is only pain.

The dentist’s office is the only place in the modern health-care system where I still expect to be unrelentingly shamed. My normal doctor tolerates me well enough, and the nurse who takes my blood pressure there is always warm and kind. My dermatologist laughs at my jokes. But my dental hygienist? She would never.

Seconds after entering the exam room, the hygienist—let’s call her Deb—is annoyed. She looks at the screen to see what she is dealing with and sighs as if to say, You again. She snaps on her rubber gloves. “All the way up,” Deb says, because I am not yet reclined on the chair. I smile nervously and go horizontal, as instructed, my legs sticking to the vinyl.

It’s important to mention, before we go any further, that I have a decent set of chompers. They are relatively straight, and a color I will call “pleasantly off-white.” I have never had a cavity as an adult; I do not drink soft drinks; I do not regularly eat candy. My breath is … fine, I think. Could I be flossing more? Sure. Should I be brushing more gently? Probably. But I am, at least in my own estimation, a pretty good—if not ideal—dental patient. Deb does not agree.

If I am due for an X-ray, Deb will spend the next few minutes jamming pointy shapes into all corners of my mouth, ignoring when I wince. Surely an X-ray would be a cinch, you might think to yourself. But you would be wrong. Normal body X-rays are straightforward, painless. Dental X-rays are stabby, pinchy. How have we, as a society, not yet found a pain-free way to send electromagnetic waves through jaws? I cannot ask Deb this question, because she is elbow-deep in my mouth, wedging plastic into my gums.

Next, we begin the cleaning process, which is very complex and involves more sighing from Deb. First, she scrapes the plaque off of my teeth with a tool that is ominously called a “scaler” and sounds like nails on a chalkboard. Then she uses her mechanical brush to grind gravelly mint toothpaste across my molars. So far, so good, I tell myself, breathing through it. Then the flossing begins. Deb performs the first vigorous round with regular floss, which breaks at least once. My gums burn and bleed. “Are we flossing regularly?” Deb asks, tilting her head to give me a better view of her judgmental frown. “Yes, but not this hard,” I reply. Then Deb does a second round of flossing with some kind of ice-cold water spout, and I dissociate.

After my soul has returned to my body, Deb offers to do a fluoride treatment for an additional $30 out of pocket. “No, thank you,” I reply politely, spitting blood into the sink. Deb frowns and says, “Next time.”

Now the dentist appears. In real life, I might find this smiling, bespectacled man sweet. But here, in this place, he is my enemy. He studies my X-rays and tells me the good news: no cavities, all clear. I start to feel hopeful; he starts to sell me Invisalign. He tells me how small and dangerously close together my teeth are. “You don’t have any issues now, but without Invisalign, you could have some serious problems down the road,” he says, a grave expression on his face. But I have already fallen for this once, when I purchased an ill-fitting Invisalign night guard for $300. “No, thank you,” I say again. I just want to go home.

“Get a new dentist!” you might advise. I have thought of this, my friend. Shopping for a new health-care provider requires time and motivation that I simply don’t have. But much more important, a new dentist doesn’t seem likely to solve the problem. Because the problem is with dentistry itself. It goes beyond the judgy bedside manner: The whole industry seems too focused on selling products and too eager to overtreat patients with expensive procedures. Plus, many standard dental treatments are “not well substantiated by research,” as Ferris Jabr once wrote in this magazine.

The dentist digs around in my mouth for a while, his cold metal tools clinging and clanging together. After a moment, he clears his throat and asks the very last question I am expecting to hear: “So, do you think Donald Trump could really win?” It is kind of my dentist to remember that I work as a political reporter; I’m sure he’s trying to brighten up this experience for me. But the only thing more unpleasant than trying to talk with your mouth full of sharp metal instruments is trying to talk about the 2024 presidential election with your mouth full of sharp metal instruments. I force a smile, as my mouth hangs open like a snake’s unhinged lower jaw. “Who knows!” I muster.

Finally, it’s over. My teeth are glimmering, but my spirit is weak. When I leave the room, Deb and the dentist watch me, their eyes downcast, as though they’re reluctant to let my teeth go home with me.

My ego will be sore for a week. So will my mouth. I have a cap on one of my front teeth because of an unfortunate apple incident a few years back. Two weeks ago at the dentist’s, that cap came loose after some overeager flossing and digging. I can feel it right now, wiggling slightly in the front of my mouth, taunting me. I’m trying to ignore it, because the truth is hard to face: The only fix is a return to the dentist.

Related:

The truth about dentistry Why dentistry is separate from medicine

Today’s News

The House passed a modified surveillance bill that reauthorizes a section of the Foreign Intelligence Surveillance Act for two years, two days after some House Republicans voted against an earlier version of the bill. President Joe Biden canceled $7.4 billion in student-loan debt, affecting roughly 277,000 people. The move is separate from his announcement earlier this week about a large-scale plan to forgive some or all student loans for some 30 million people. A driver ran an 18-wheeler truck into a Department of Public Safety office in Brenham, Texas, seriously injuring multiple people. The suspect is in custody, according to police.

Dispatches

The Books Briefing: The Children’s Bach, by Helen Garner, is an oblique and beautiful book, Gal Beckerman writes. Atlantic Intelligence: AI has drastically improved voice recognition—a technology that researchers have long struggled with, Caroline Mimbs Nyce wrote this week.

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Evening Read

Alamy

Tupperware Is in Trouble

By Amanda Mull

For the first several decades of my life, most of the meals I ate involved at least one piece of Tupperware. My mom’s pieces were mostly the greens and yellows of a 1970s kitchen, purchased from co-workers or neighbors who circulated catalogs around the office or slipped them into mailboxes in our suburban subdivision. Many of her containers were acquired before my brother and I were born and remained in regular use well after I flew the nest for college in the mid-2000s …

The market for storage containers, on the whole, is thriving … But Tupperware has fallen on hard times. At the end of last month, for a second year in a row, the company warned financial regulators that it would be unable to file its annual report on time and raised doubts about its ability to continue as a business, citing a “challenging financial condition.” Sales are in decline. These should be boom times for Tupperware. What happened?

Read the full article.

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Stephanie Bai contributed to this newsletter.

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