Lupus, doctors like to say, affects no two patients the same. The disease causes the immune system to go rogue in a way that can strike virtually any organ in the body, but when and where is maddeningly elusive. One patient might have lesions on the face, likened to wolf bites by the 13th-century physician who gave lupus its name. Another patient might have kidney failure. Another, fluid around the lungs. What doctors can say to every patient, though, is that they will have lupus for the rest of their life. The origins of autoimmune diseases like it are often mysterious, and an immune system that sees the body it inhabits as an enemy will never completely relax. Lupus cannot be cured. No autoimmune disease can be cured.

Two years ago, however, a study came out of Germany that rocked all of these assumptions. Five patients with uncontrolled lupus went into complete remission after undergoing a repurposed cancer treatment called CAR-T-cell therapy, which largely wiped out their rogue immune cells. The first treated patient has had no symptoms for almost four years now. “We never dared to think about the cure for our disease,” says Anca Askanase, a rheumatologist at Columbia University’s medical center who specializes in lupus. But these stunning results—remission in every patient—have fueled a new wave of optimism. More than 40 people with lupus worldwide have now undergone CAR-T-cell therapy, and most have gone into drug-free remission. It is too early to declare any of these patients cured for life, but that now seems within the realm of possibility.

Beyond lupus, doctors hope CAR-T portends a bigger breakthrough against autoimmune diseases, whose prevalence has been on a troubling rise. CAR-T has already been used experimentally to treat patients with other autoimmune diseases, including multiple sclerosis, myositis, and myasthenia gravis. And the success of CAR-T has inspired researchers to borrow other—cheaper and simpler—strategies from cancer therapy to kill immune cells gone awry. Not all of these ideas will pan out, but if any do, the next few years could bring an inflection point in treating some of the most frustrating and intractable diseases of our modern era.

CAR-T-cell therapy was originally developed as a way to kill malignant cells in blood cancer. It could, scientists later reasoned, also be used to kill specific white blood cells, called B cells, that go haywire with certain autoimmune diseases. One group tried a CAR-T-like therapy against an autoimmune disease called pemphigus vulgaris, and another CAR-T against lupus. It worked—but these experiments were only in mice.

This was the sum total of available scientific evidence when a 20-year-old woman came to her doctors in Erlangen, Germany, asking to try anything for her severe and uncontrolled lupus. None of the long-term medications typically used to manage lupus were working. Her kidneys, heart, and lungs were all failing, and she could walk only 30 feet by herself. CAR-T was risky, her doctor agreed, but lupus was killing her.

CAR-T-cell therapy could essentially turn her immune system against itself. First, doctors extracted from her blood a class of immune cells, called T cells, which they then engineered into chimeric antigen receptor T (CAR-T) cells that could recognize and destroy the B cells driving her lupus. CAR-T cells can cause dangerous and overwhelming inflammatory responses in cancer patients, and her doctors did worry that CAR-T could do the same for someone with autoimmune disease, whose immune system is already in overdrive. “We take the T cells out, activate them like crazy, and then shoot those massively overactivated T cells in an activated autoimmune disease. So if you think about it, that's kind of crazy to do that, right?” says Fabian Müller, a hematologist-oncologist at the University Hospital of Erlangen and one of the doctors on the German team that pioneered the treatment. But fortunately, the woman with lupus did not have any serious side effects, nor did any of the other patients the German group has since dosed. They are all living their everyday lives, free of lupus symptoms and medications. The woman who could walk a mere 30 feet now runs five times a week, Müller told me. She’s gone back to school and is considering studying for a master’s in immunology.

Müller and his colleagues believe that CAR-T-cell therapy works by wiping out enough B cells to trigger a “deep reset” of the immune system. CAR-T cells are dogged little assassins; they are able to find and destroy even the B cells hiding deep in the body’s tissues. A patient’s B-cell count eventually recovers, but the new ones no longer erroneously attack the body itself. Cancer patients are sometimes considered “cured” after five years of remission, and the first lupus patient to receive CAR-T is not so far off from that milestone. But the therapy cannot erase the genetic predisposition many patients have for the disease, says Donald Thomas, a rheumatologist in Maryland. Whether remission is actually durable enough to be a “cure” will take time to find out.

Still, these extraordinary results have set off a gold rush among biotech companies eager to solve autoimmune diseases. CAR-T start-ups founded to treat cancer are pivoting to target autoimmune diseases. And large pharmaceutical companies such as Bristol Myers Squibb, AstraZeneca, and Novartis are developing their own therapies. Columbia’s Askanase is now an investigator on five separate trials, all using CAR-T or a similar cellular therapy, and she hears from more companies all the time. There’s so much interest, she told me, “I don’t even know there are enough patients” to test new treatments. About 1.5 million Americans have lupus, but only a minority of them—those sick enough to justify experimental treatment but not so sick that they’ve suffered too much irreversible organ damage—are eligible for trials.

For now, CAR-T for lupus and other autoimmune diseases is pretty much only accessible in the U.S. through clinical trials—which, in effect, means it’s inaccessible to almost all lupus patients. Jonathan Greer, a rheumatologist in Florida, works in a seven-doctor practice that treats hundreds of people with lupus; not a single one has received CAR-T. He doesn’t know of a single center in Florida that is up and running to do these studies, so interested patients would have to travel out of state.

Even if it becomes FDA approved for autoimmune diseases, CAR-T is a long and expensive process. Because each patient’s own cells are reengineered, it cannot be easily scaled up. The cost of CAR-T for cancer runs about $500,000. Patients also need chemotherapy to kill existing T cells to make room for CAR-T, which adds risk, and in lupus, they usually need to taper off any medications keeping their disease in check, which can cause flare-ups. All these complications make the current iteration of CAR-T suitable only for lupus patients with severe disease, who have run out of other options.

The practical limitations of CAR-T have dogged the cancer field for a long time now, and researchers have already come up with ideas to get around it. A number of simpler strategies for killing B cells are now making their way from blood cancer to autoimmune disease. They include using donor T cells, a different type of immune cell called natural killer cells, or a molecule that binds a T cell to the B cell it’s meant to destroy. Those molecules, called bispecific T-cell engagers, or BiTEs, are “cheap, fast, uncomplicated,” Müller said, but they may not penetrate as deeply into the tissues where B cells reside. Nevertheless, in September, The New England Journal of Medicine published two successful case reports describing successful treatment in a handful of autoimmune diseases, including lupus, with a BiTE called teclistamab. Similar BiTES on the market could be repurposed for autoimmune disease too.

These simpler therapies may ultimately be “good enough,” Askanase said. And their ease of use could ultimately beat out custom CAR-T therapy, which is unlikely to reach all of the millions of people with lupus worldwide. It’s simply too expensive and too cumbersome, a problem that has held back other cutting-edge therapies that were approved to much initial fanfare. Even if CAR-T itself is never widely adopted for autoimmune diseases, it has opened the door to new ideas that could one day revolutionize their treatment.

In the fall of 2022, pro-democracy protesters in cities across mainland China developed a clever tactic for speaking out against government forces that wished to silence them. They began holding up blank sheets of paper, as well as tacking up blank paper in public spaces, to register their disapproval of restrictive lockdown rules as well as their disapprobation of the government’s repressive censorship laws.

Observers from all over the world noted with admiration the courage and creativity of the protesters, who’d found a bold way to speak out while saying nothing at all. Chinese authorities cracked down on the dissenters, censoring online reporting about them and arresting or otherwise threatening those who have tried to remind people of the movement since then.

In America, a country consecrated to freedom, the dystopian scenes out of China seemed distant. Americans understand on a bone-deep level that, to paraphrase James Madison, absolute sovereignty belongs to the people, not the government. Americans are free to say what we believe, and free to share our ideas with our fellow citizens. We are free to criticize the government, which is accountable to the people, not the other way around. The First Amendment does not grant us these freedoms—they are an inviolable right. The First Amendment does, however, dictate that the government dare not interfere with these freedoms, that officials have no right to cut down the American people’s speech, including the people’s right to free press.

To be comfortable in these freedoms, to assume that we would never need to resort to holding up blank sheets of paper to criticize the powerful, is a luxury that Americans cannot presently afford.

The United States is on the eve of an election that could see the return to power of Donald Trump, an autocrat who vociferously and repeatedly threatens the basic freedoms of the American people—with a particular preoccupation with curbing freedom of speech and freedom of the press. Worse still, he has persuaded his followers to cheer on the demise of their own freedoms. When Trump tells people that journalists are “the enemy of the American people,” or “evil,” when he says that Americans who describe the criminal charges he faces should be investigated for treason, he is not merely denigrating a professional class; he is directly attacking the rights of all Americans. He is attacking those who happen to work as journalists, but he is likewise attacking their neighbors—every American who has the right to free speech and free press themselves.

“I think the bigger problem is the enemy from within,” Trump said in an interview with Fox Business’s Maria Bartiromo in October. “We have some very bad people; we have some sick people, radical-left lunatics,” he said, using the term he often directs at American citizens who work in journalism, as well as his political foes generally. He went on: “And it should be very easily handled by, if necessary, by the National Guard, or if really necessary by the military.”

Donald Trump does not seem to believe in free speech or the freedom of the press at all. He believes that when his fellow citizens say things he doesn’t like, he should have the power to shut them up. And he has repeatedly suggested investigating and imprisoning Americans, as well as turning the U.S. military on the American people in order to do so. No wonder Trump is so starry-eyed over China’s dictator, Xi Jinping, whom Trump often praises in effusive terms. No wonder Trump has similarly embraced the dictator and former president of the Philippines, Rodrigo Duterte, who bragged about leading his country to the extrajudicial killing of thousands of Filipino citizens, including those working as journalists. (“Just because you’re a journalist, you are not exempted from assassination if you’re a son of a bitch,” Duterte once said.) And no wonder Trump openly admires the autocrats Vladimir Putin (“genius”) and Viktor Orbán (“a great man”), both of whom he describes as being “at the top of their game, whether you like it or not.”

In Trump’s recent interview with the podcaster Joe Rogan, Trump complained about the Americans who have noticed his pattern of adulation for the brutal leaders of antidemocratic regimes, whose citizens do not have the right to free speech. “They hate when I say—you know, when the press—when I call President Xi, they said, ‘He called President Xi brilliant.’ Well, he’s a brilliant guy. He controls 1.4 billion people with an iron fist.” He went on: “Actually, we have evil people in our country.”

Trump is making it abundantly clear that dictators aren’t the problem—rather, Americans exercising their right to free speech and free press are the problem, and they are a problem that should be solved by dictatorial rule.

One person who seems to share Trump’s confusion over basic American freedoms is Elon Musk, who strangely claims to be a free-speech absolutist, all while remaking Twitter into a propaganda arm of the Trump campaign. Musk, like Trump, is fixated on tearing down American citizens and their right to free press. Musk likes to post spirited calls to action on his social platform such as “We are the mainstream media now,” seeming to believe that he is the one who grants Americans their right to expression. (Never mind that a social platform that is truly absolutist in letting anyone say whatever they want would probably look more like 4Chan than anything else—that is, it would neither delete its users’ comments nor deploy algorithms to amplify its owners’ political views.)

Musk has long aspired to be taken seriously by the news industry, and his aggrievement seems to stem, in part, from the fact that he is not. Before his $44 billion purchase of Twitter, he floated the idea of starting various news sites—including one in which users would upvote or downvote stories as part of a “credibility-ranking site for people to rate journalists and news organizations,” not realizing or perhaps not caring that truth, and therefore credibility, is not something that can be established or eliminated through the clicking of buttons on the internet at scale. (Such a system would, however, be very useful for efforts at political warfare.)

Today, Musk claims that Twitter is “the top source of news on Earth!” when in reality it is among the closest analogues that America has ever seen to a state-run media outlet. And although several operators of huge social platforms have floated the idea of accreditation or licensing for journalists the way lawyers take the bar and doctors take board exams, there is no special class of licensed journalists, and that is by design. Every American citizen has the right to free press. You do not need to work full-time as a journalist, or pass a test, or join a professional association to exercise this right.

One of the knock-on effects of living in a country whose citizens have the right to say and publish whatever they want is that people sometimes say abhorrent things. (And also: People can consume the information they wish. But for that to happen, your fellow citizens have to be free to offer it to you in the first place, whether what you’re seeking is Newsmax, Joe Rogan, or The New York Times.) In practice, the rights of free speech and free press are interwoven this way. And any American who consumes media, or publishes their own research, reporting, or opinions on any platform—whether on a flyer stuck to a telephone poll, in an Instagram post, or in a local newspaper—is benefiting from the protection of these rights, and would suffer greatly if they were curtailed.

Social media is miraculous in its flattening ability—people can self-publish their ideas with very little friction and no financial cost; they have the potential to reach a massive audience in an instant. These qualities are positive on their face, and sometimes mean that people mistake Twitter for an engine of free speech, when in fact it is a private company run by an illiberal man who is throwing everything he has behind an anti-free-speech politician who wants to attack his fellow Americans with their own military.

Trump’s and Musk’s most ardent supporters are fond of posting a meme that goes like this: “You don’t hate journalists enough. You think you do, but you don’t.” Musk, of course, has every right to run his social platform how he chooses. If he wants to make it a forum for railing against the American right to free speech and free press, while believing he can convince people that doing so demonstrates his commitment to free speech, that’s his prerogative. If he wants to stoke hatred and partisanship, and advocate for interruptions to the peaceful transfer of power in the United States, he can.

But Musk cannot grant the American people their right to free speech any more than Trump can. The American right to free speech and free press is God-given. And the Constitution is intended to protect Americans from government tyrants who would attempt to quash our freedom in just the way that Trump is threatening to do, with Musk’s full-throated endorsement.

Trump’s threats are already effectively silencing Americans. Consider, for example, Jeff Bezos’s profound cowardice in banning The Washington Post from publishing its endorsement of Trump’s rival. (Ditto Patrick Soon-Shiong over at the Los Angeles Times.) Bezos, like Musk, is free to run his business how he chooses. But that shouldn’t shield him from criticism over his actions. In explaining his decision, Bezos blamed the American citizens who work as journalists for being hated, denigrated, and threatened by Trump. “Our profession is now the least trusted of all,” he wrote in an essay explaining himself, with no apparent trace of irony given the breach of trust that his actions represented. “Something we are doing is clearly not working.”

Something that is apparently working: Trump’s Musk-assisted campaign to tell Americans they should rail against their own right to free press and free speech. The illiberal techno-authoritarian crowd cheered Bezos on for his kowtowing, and for his chastising of the journalism industry, and Trump began using the newspaper’s non-endorsement as a campaign talking point. (It may seem odd that Trump would boast about a newspaper’s decision not to endorse his rival, given his hatred of the press, but he dismisses newspapers as “fake news” only when they criticize him.)

This is how tyranny works: Amplify praise for the dear leader, silence dissent, crack down on individual freedoms, repeat. A free society’s fall into authoritarianism does not start with citizens being forced to protest using blank sheets of paper. But it can get to that point with dizzying speed. This is the warning that people in once-free nations always repeat: You’re free until you are not. And destroying a people’s right to speak and publish freely is always one of the first moves in the autocrat’s playbook.

Centuries ago, the American colonists forging a new way of life on this continent found themselves subject to laws and restrictions on free speech that dated back to medieval England. You could not criticize the government without facing violent punishment. Public whippings were routine. One Maryland man, who called his local legislature a “turdy shitten assembly” in 1666, was sentenced to be tied to an apple tree and lashed 30 times, according to Stephen D. Solomon’s account in Revolutionary Dissent: How the Founding Generation Created the Freedom of Speech. A Virginia man who criticized the government had his arms broken and was beaten by a group of men who flogged him with their rifles. Courts sentenced others to have their ears cut off, as in the case of a Massachusetts man who denounced the Church and the government in 1631. Americans were lashed and beaten and bloodied for their right to speak freely. Eventually many of them fought and died to protect themselves, and they did so to create a free society that would protect future American citizens from such barbarism and tyrannical government overreach.

Trump would like to convince the American people that his hatred is laser-focused. He would like Americans to believe that his threats of retribution are reserved only for his political foes, for the former advisers he now deems disloyal, for the tens of thousands of American citizens who work as journalists. What Americans need to understand is that anyone who would threaten to quash the most fundamental rights of some of their fellow citizens is threatening to impinge the rights of all Americans. The United States is still a nation consecrated to freedom. And the American people should not hand it over to anyone who would dare try to convince you otherwise.