When patients start on the latest obesity drugs, they find that their food cravings drop away, and then the pounds do too. But when patients go off the drugs, the gears shift into reverse: The food cravings creep back, and then the pounds do too. Within a year of stopping semaglutide—better known by its brand names Wegovy or Ozempic—people regain, on average, two-thirds of the weight they lost. Tirzepatide, also known as Zepbound or Mounjaro, follows a similar pattern. And so the conventional medical wisdom now holds that these obesity drugs are meant to be taken indefinitely, possibly for a lifetime.

To pharmaceutical companies selling the blockbuster drugs—known collectively as GLP-1 drugs, after the natural hormone they mimic—that might be a pretty good proposition. To patients paying more than $1,000 a month out of pocket, not so much. Most Americans simply cannot afford the cost month after month after month.

This has forced some doctors to get creative, devising regimens to sub in cheaper, if less well-known, alternatives. GLP-1 drugs do work remarkably well, inducing more weight loss more quickly than any other obesity medication on the market, but some doctors now wonder whether patients need to be on GLP-1 drugs, specifically, forever. “​​What if we do a short-term investment, use it for six months to a year to get 50 pounds off?” asks Sarah Ro, an obesity-medicine doctor and the director of the University of North Carolina Physicians Network Weight Management Program. Then, as she and other doctors are now exploring, patients might transition to older, less expensive alternatives for long-term weight maintenance.

In fact, Ro has already helped patients—she estimates hundreds—make the switch out of financial necessity. Few of her patients in rural North Carolina have insurance that covers the new obesity drugs, and few can afford to continually pay out of pocket. In April, many also lost coverage when North Carolina’s health insurance for state employees abruptly cut off GLP-1 drugs for obesity. Ro switched her patients to older drugs such as topiramate, phentermine, metformin, and bupropion/naltrexone, plus lifestyle counseling. It’s not exactly an ideal solution, as these medications are generally considered less effective—they lead to about half as much weight loss as GLP-1 drugs do—but it is a far less expensive one. When prescribed as generics, Ro told me, a month’s supply of one of these drugs might cost as little as $10.

Jamy Ard, an obesity-medicine doctor at Wake Forest University, has also switched regimens for patients who lost coverage of GLP-1 drugs after retiring and getting on Medicare, which currently does not pay for any drugs to treat obesity. (Like many researchers in the field, Ard has received grants and consulting fees from companies behind obesity drugs.) Doctors I spoke with didn’t know of any studies about switching from GLP-1 drugs to older ones, but Ard says this research is a practical necessity in the United States. With GLP-1 medications exploding in popularity, more and more patients taking them will suddenly lose coverage when they hit retirement age and go on Medicare. “Now I’ve got to figure out, well, how do I treat them?” he told me.

Long-term data on the older drugs themselves are, in fact, pretty sparse, despite the drugs having been available for years and years. Until Ozempic came along, obesity drugs were not a lucrative market, so companies weren’t interested in funding the long and very expensive trials that follow patients for several years. “Studies like that cost a fortune,” Louis Aronne, an obesity-medicine doctor at Weill Cornell Medicine, told me. Some of the longest-term follow-up data about these drugs come from patients at his practice in Manhattan—not a representative population, he admits—which he published in a five-year study funded by the National Institutes of Health. (Aronne has also received grants and consulting fees from the makers of obesity drugs.)

How patients do after switching from GLP-1 to older drugs is entirely anecdotal, but so far outcomes do seem to vary quite a bit. A small minority of patients who stop GLP-1 injections are actually able to maintain their weight on diet and exercise, without any additional medications. Others may find that the older pills are simply not effective for them. In Ro’s experience, about 50 to 60 percent of her patients have so far successfully kept the weight off using one or more older drugs, on top of lifestyle changes such as cutting out fast food and sugary sodas.

The best drug to switch to may also depend on the patient. Each of the older medications works differently, hitting different biological pathways. The combination of naltrexone and bupropion, for example, makes food less pleasurable and seems to work especially well in people with a tendency toward emotional eating, Ard said. Topiramate, meanwhile, makes carbonated drinks unpleasant, which could help patients who drink a lot of soda. The older drugs also have different side effects. Aronne rattled off for me a list of health risks that might rule out a particular drug for a particular patient: seizures for bupropion, or glaucoma for topiramate. Finding the most effective and best-tolerated drug for a patient may take some trial and error.

Doctors are now discovering that some patients can maintain the weight they lost on lower or less frequent doses of GLP-1 drugs. “For the first time in my career, we’re lowering the dose of medicines,” Aronne said. Just reducing the dose doesn’t save money, though, as lower-dose injection pens cost the same as those with higher doses. However, by instead extending the time between doses from the standard seven days to a longer 10-day interval, doctors told me, some patients have been able to stretch their supplies.

But tapering off obesity medications entirely, GLP-1 or otherwise, will probably not be possible for most patients. Weight loss tends to trigger a powerful set of compensatory mechanisms in the body, which evolved long ago to protect us from starvation. The more weight we lose, the more the body fights back. The fight never quite goes away, and most patients will likely require some kind of continued intervention just to stay at a lower weight. Long-term weight maintenance has always been the “holy grail” of obesity treatment, Susan Yanovski, a co-director of the ​​Office of Obesity Research at the National Institutes of Health told me. The best maintenance strategy—whether it involves GLP-1 drugs, and at what dose—may ultimately be pretty individual. What works best and for whom still needs to be studied. “These are really good research questions,” Yanovski said. But they are not necessarily the questions that pharmaceutical companies focused on developing new meds are most keen to answer.

In time, the current crop of GLP-1 drugs will eventually become available as generics, too, and cost may no longer drive patients to seek out cheaper alternatives. But for now, it very much does.

The protest season at universities usually crescendos just before commencement: The weather is balmy and most term papers are done, but what student or professor would wish to stay around campus during summer break if they did not absolutely have to? This year, the protests have taken an uglier turn, as encampments have sprouted up. The demonstrators—most of them students, many not, often masked—are calling for divestment by their universities from companies based in or doing business with Israel. Some of the protesters see this goal as an interim step toward the destruction of the state of Israel.

In each case, students, faculty, and administrators participating in or supporting the protests assert that universities have a special obligation to take an institutional stand, separate and apart from what any of their members believe, say, or do as individuals.

Universities have reacted in various ways. University of Florida President Ben Sasse was firm and unambiguous; the administrations at Tufts and Cornell similarly refused to fold, and the students threw in the towel when they realized that their protests were going nowhere. Union Theological Seminary, which is affiliated with Columbia, accepted the demands, while the larger university vacillated between tolerance and crackdowns, ultimately having the police storm an occupied building. But some elite institutions—Brown, Northwestern, and Harvard among them—have chosen to end the encampments by offering disciplinary amnesty for nonviolent protesters, and promising to review investments in Israel, often through expedited processes.

The reality behind this last approach is a desperate squirm.

On the one hand, university presidents do not want riots in the quad, and they know that calling in the cops can trigger more extreme demonstrations by faculty and students. On the other hand, they are feeling the fury of pro-Israel alumni and donors and, after watching congressional hearings on television, have a healthy fear of being, as one might say, Stefaniked.

Their solution, however, is no solution, resting as it does on flawed practical politics, wishful thinking about the real animus on their campuses, and, most seriously, a misunderstanding of the moral concerns and values that universities can legitimately represent.

[Michael Powell: The unreality of Columbia’s ‘liberated zone’]

The amnesty and investment reviews are attempts to buy off protesters, in the hope that by the time the university committees do their work, the war in Gaza will be over, and in any case the divestment decisions (almost assuredly negative, because the alternative would open up an equally ugly can of worms) can be made this summer or next, while the kids are backpacking in Mongolia.

The problem is that the appearance of caving is caving. If you tacitly tell students that violating university rules will bring no sanctions, they will do it again. The chances are pretty good that the students and others will see through the “we will look carefully at our investment decisions” dodge and come back, with more insistent demands and an awareness that the university lacks the gumption to suspend or expel them for setting up tent cities, blocking access to buildings, and disrupting study in libraries and dormitories.

The wishful thinking about what is actually going on is much worse. The brute fact is that many American universities and colleges, including some of the best, have seen a surge in anti-Semitism, including protesters mobbing students wearing kippahs and shouting that Zionists—that is, people who believe that the Jews deserve a state of their own—deserve death. Many Jewish students, as a result, feel unsafe and unwelcome, and university leaders have only rarely denounced anti-Semitic outbursts without reference to other forms of bias, thereby skirting the core problem.

The deeper misunderstanding of universities’ roles and moral standing, however, is the most troubling aspect of the Great Academic Squirm of 2024. Universities cannot claim and do not deserve some special status as arbiters of a moral foreign policy. After all, they are not, and have never been, paragons of moral virtue. Both Harvard and Johns Hopkins, universities with which I have been proudly affiliated over many years, in the past century had rabidly anti-Semitic presidents: A. Lawrence Lowell and Isaiah Bowman, respectively. They were accomplished academic leaders and architects of much of the modern university. They had academic vision, and they did good things for their institutions. They just also happened to be bigots.

Modern university leaders have recognized the sins of their predecessors and apologized copiously for them, but that is not the point. The lesson, rather, is that as individuals, they are probably every bit as fallible, albeit in different directions. They should aim for humility, not self-flagellation.

The students and faculty are even worse from this point of view. Nineteen-year-olds make good soldiers, but not good generals, judges, corporate executives, or bishops, for the excellent reason that their emotions and passions, noble or ignoble, have yet to be tamed by wisdom and good judgment. It was the best and brightest on our campuses who signed up for the original America First movement, after all, pushing for isolationism as the Nazis seized power in Germany. (Many, of course, more than compensated for the puerility of their collegiate political views by honorable service in World War II.)

Today’s students are no better or worse than their predecessors. They are, as befits their age, morally selective to a fault: Can anyone recall a demonstration against Pernod Ricard for failing to fully halt exports of Absolut Vodka to Russia until about a year ago? Where are the mass demonstrations about the Rohingya, Sudan, the Uyghurs, the Syrian massacres, or for that matter the Chinese laogai penal-labor system or the prisons of North Korea? Or, in an earlier era, against Robert Mugabe’s murderous tyranny in Zimbabwe or the Vietnamese gulag after the fall of Saigon?

Presumably, students come to a university for an education, which implies that they need to be educated, which means that they are not, in fact, ready to make the deeper judgments on which society depends. They are high on passion, and, as interviewers have found, many of them are extraordinarily ignorant about the causes for which they are demonstrating.

As for faculty, reading the novels of David Lodge and Julie Schumacher—not to mention viewing Who’s Afraid of Virginia Woolf?—would confirm the view that I have come to after 40 years in departmental meetings, that one should not expect too much by way of prudence and profound moral and political judgment from them, either.

There are sterling characters among the professoriate—heroic, self-sacrificing, and wise. There are a great many more who are simply passionately dedicated to a subject, be it broad or arcane, and just want to teach and research it and otherwise be left in peace. But in addition, there are the garden-variety intriguers, backstabbers, prima donnas, and bullies. There are also quite a few adulterers, predators, egomaniacs, and borderline swindlers, and even a sociopath or two. Some professors are experienced in the ways of the world; most of them are not, having viewed it with all the blessed autonomy and freedom from the constraints of politics or war that universities appropriately provide. They have no special qualification for the role of society’s conscience.

The university’s real missions are noble: education, particularly of the young, and the pursuit of the truth. The people engaged in that mission may or may not be the finest characters in the world, or have the best moral or political judgment, but the missions are of the highest importance.

It is the business of academic leaders to sustain their institution’s commitment to those missions, and nothing more. They have neither the moral standing nor the credibility in wider society for exceeding that mandate, or doing anything other than creating an optimal environment for learning and research, upholding the rules, and stewarding the institution’s finances.

The leaders of universities do not exist to pass judgment on politics, or twist their endowments into moralistic knots, or attempt to shape the course of American foreign policy. As individuals, they (and students, faculty, and administrators) may have something useful to say about politics and every right to do so. In their official roles, they should have none.

When educational leaders exceed their mission or, conversely, lack the courage to defend it resolutely, they will bring more discredit, more unwelcome political attention, and more turmoil upon themselves and their institutions than they already have. And however much they squirm today, the protesters will come back to make them squirm more tomorrow.