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  • ‘Plant-Based’ Peanut Butter … And Shampoo … And Booze

    ‘Plant-Based’ Peanut Butter … And Shampoo … And Booze

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    Several years ago, I made a New Year’s resolution to eat more plants. Doing so, I assumed, would be better for my health, for animals, and for the planet. Besides, it would be easy: The rise of plant-based meat alternatives, offered by companies such as Impossible Meat and Beyond Meat, made it a breeze to eat less meat but still satisfy the occasional carnivorous urge. I could have my burger and eat it too.

    Or so I thought. Meat alternatives, I found, cost more than their conventional counterparts and are made with complicated ingredients that raise doubts about their healthiness—and even then, taste just okay. Other people have had similar concerns, part of the reason the popularity of those products has declined in recent years to such a degree that Beyond Meat is reportedly now in “survival mode.” But beyond the meat aisle, the “plant-based” label lives on in virtually every food product imaginable: instant ramen, boxed mac and cheese, Kraft singles, KitKat bars, even queso. You can now buy plant-based peanut butter. You can also wash your hair with plant-based shampoo and puff on a plant-based vape.

    Queso made from cauliflower instead of milk is correctly described as plant-based. But if peanut butter is vegan to begin with, then what is the point of the label? And who asked for plant-based liquor? On packaging and ad copy, plant-based has been applied to so many items—including foods that are highly processed, or those that have never contained animal ingredients—that it has gotten “diluted to nothing,” Mark Lang, a marketing professor at the University of Tampa who studies food, told me.

    Technically, plant-based does have a clear definition. The Cornell University biochemist Thomas Colin Campbell is often credited for coining the term in the 1980s as a neutral, less fraught descriptor for diets considered “vegan” or “vegetarian.” That is what made plant-based a popular term for companies eager to sell their meat replacements to a wide range of eaters. The Plant Based Foods Association uses essentially the same criteria—foods made from plants that do not contain animal products—to determine which products can bear its “Certified Plant Based Seal.”

    Some companies describe products as “plant-based,” however, even if they don’t meet these criteria. Items sold as such include foods that have always been vegan, such as prepackaged jackfruit, and those mixed in with some animal products, such as Wahlburgers’ “Flex Blend” patties. But even a product that is properly described as “plant-based” might mean different things to different people, because there is no one reason to try and avoid the consequences of animal rearing and consumption. Health is the leading one, followed by environmental and ethical concerns, Emma Ignaszewski, the associate director of industry intelligence and initiatives at the Good Food Institute, told me.

    The label’s vagueness has been a marketer’s dream, creating an enormous opportunity to capitalize on the perceived virtuousness and healthiness of eating plant-based. Brands use the “plant-based” label to “draw people’s attention to the aggregate goodness of a particular product” and simultaneously “deflect attention” from any less appealing attributes, Joe Árvai, a professor of psychology and biological sciences at the University of Southern California, told me. Some, like coconut water, are relatively good for you; others, like booze, are probably not. And their environmental benefits remain murky: Using fewer animal ingredients generally decreases emissions, but the climate impacts are not always straightforward.

    In this way, the evolution of plant-based mirrors that of organic or gluten-free. These terms have specific meanings that are legitimately useful for helping people make choices about their food, but they have been overused into oblivion. You can now buy organic marijuana and gluten-free water along with your plant-based energy drinks. With multiple labels, including gluten-free, plant-based, GMO-free, Earth-friendly, and Fair Trade, “some products look like a NASCAR” vehicle, Lang said. “You’re just putting buttons all over the place, trying to get my attention.”

    We may have already hit peak “plant-based.” According to a recent survey from the Food Industry Association, there is substantial confusion about what the label means—and that could be discouraging people from buying plant-based products. Some are now outright skeptical of the label. A 2023 study co-authored by Árvai suggested that people are less likely to go for foods described as “plant-based” (or “vegan”) compared with those called “healthy” or “sustainable.” One reason may be negative associations with plant-based meat alternatives, which are seen as “artificial” because of their ultra-processed nature, co-author Patrycja Sleboda, an assistant professor of psychology at Baruch College, City University of New York, told me.

    Another may be that consumers are not sure whether “plant-based” foods are healthy. Americans may respond better when the actual benefits of the food are highlighted, she said. Similarly, market research conducted by Meati, a company that sells meat alternatives made of mushrooms, found that the “plant-based” label, applied to food, signaled “bad eating experience, bad flavor, bad texture, poor nutrition, too many ingredients, and overprocessing,” Christina Ra, Meati’s vice president of marketing and communications, told me.

    Some good may still come out of the messiness of “plant-based” everything. Meati deliberately avoids the label altogether, opting instead to highlight the contents of its products (“95 percent mushroom root”). A recent Whole Foods report predicted that in 2024, consumers will want to “put the ‘plant’ back in ‘plant-based’” by replacing “complex meat alternatives” with recognizable ingredients such as walnuts and legumes. In a particular literal interpretation of this prediction, the company Actual Veggies sells a greens-and-grains patty called “The Actual Green Burger.” And some milk alternatives are also now skipping “plant-based” and simplifying their ingredient lists to just two items (nuts and water).

    Shoppers just want to know what’s in their food without having to think too hard about it. Plant-based hasn’t helped with that. Even Campbell, after he coined the term, acknowledged that it was a limiting, potentially misleading phrase that left too much room for unhealthy ingredients, such as sugar and flour. Perhaps shoppers’ exasperation with the vagueness of “plant-based” eating may eventually lead brands to promote more plant-based eating: that is, just eating plants.

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    Yasmin Tayag

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  • Why Biden Should Shift the Debate to This Topic

    Why Biden Should Shift the Debate to This Topic

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    President Joe Biden and Democrats cannot win the debate over the economy without fundamentally reframing the terms of the choice they are offering voters, an extensive new research study by one of the party’s prominent electoral-strategy groups has concluded.

    The study, scheduled to be released today, seeks to mitigate one of the party’s most glaring vulnerabilities heading into the 2024 election: the consistent finding in surveys that when it comes to managing the national economy or addressing inflation, significantly more voters express confidence in Republicans than in Democrats.

    To close that gap, the study argues, Biden and Democrats must shift the debate from which party is best equipped to grow the overall economy to which side can help families achieve what the report calls a “better life.” The study argues that Democrats can win that argument with a three-pronged message centered on: delivering tangible kitchen-table economic benefits (such as increased federal subsidies for buying health insurance), confronting powerful special interests (such as major corporations), and pledging to protect key personal liberties and freedoms, led by the right to legal abortion.

    The study was conducted by Way to Win, a group that provides funding for candidates and organizations focused on mobilizing voters of color, in conjunction with Anat Shenker-Osorio, a message consultant for progressive candidates and causes. Last year, Way to Win was among the top advocates pushing the party to stress a message of protecting personal freedoms and democracy—an approach that helped Democrats overperform expectations despite widespread discontent about the economy.

    Reversing the advantage Donald Trump and the GOP have on the economy will require Democrats to highlight “the tangible improvements their policies have made in people’s lives, in lieu of speaking of abstract economic gains, as well as touting their future agenda of expanding on these gains, taking on corporate greed and the MAGA Republicans who aim to rule only for the wealthy few,” concludes a memo summarizing the research that was provided exclusively to The Atlantic.

    Read: The two Republican theories for beating Trump

    Based on months of polls, focus groups, and other public-opinion research, the study comes amid simmering Democratic anxieties over national and swing-state surveys showing Trump leading Biden. Especially frustrating for the White House and other Democrats has been the persistence and pervasiveness of negative public attitudes about the economy, despite robust economic growth, low unemployment, and a huge reduction in the inflation rate over the past year. Democrats were particularly unnerved by a recent survey from Democracy Corps, a group founded by the longtime party strategists James Carville and Stanley B. Greenberg, that found that voters in the key swing states gave Trump a retrospective job-approval rating for his performance as president nearly 10 percentage points higher than what they give Biden for his current performance.

    Biden has spent months trying to highlight positive trends in the economy by describing them under the rubric of “Bidenomics.” But the Way to Win study, like the Democracy Corps research, argues that it is counterproductive for the administration to try to convince voters that inflation is abating or that the economy is improving while so many are struggling to make ends meet. Telling voters that “inflation is going down [produced a] backlash” in the research, Jenifer Fernandez Ancona, Way to Win’s senior vice president, told me: “Their experience is that it’s up. If you make an overarching statement that things are getting better, it rubs people the wrong way.”

    Probably the key insight in the report is the contention that it’s a mistake for Democrats to focus the 2024 debate on any of the broad national trends in the economy, including those that have been positive under Biden, such as job growth.

    For many years, the report argues, voters have been inclined to believe that Republicans are better than Democrats at managing the overall economy—an advantage that may be especially pronounced for Trump, a former business mogul, if he’s the GOP nominee. But, the study found, swing voters, as well as the irregular voters the party needs to turn out in 2024, give Democrats an edge on which party can best deliver for “you and your family’s economic well-being.”

    “If the argument is who [handles] the economy best, even though it’s not true in any sense, that’s their brand advantage,” Shenker-Osorio told me. “If the question is who is going to create the best future for your family, that is a Democratic-brand advantage. That is a story we can tell. It’s a credible story, and it’s a story that people care more about.”

    Read: A war on blue America

    To shift the debate into this more favorable terrain, the report argues, Biden and other Democrats must simultaneously reorient their economic arguments in opposite directions. The group argues that Democrats must narrow their focus by talking less about macroeconomic trends and more about specific policies they have enacted to help families make ends meet. That includes policies that Biden has passed to lower prescription-drug and utility costs, and policies he could promote in a second term, such as restoring the expanded child tax credit that Democratic Senator Joe Manchin of West Virginia stripped from the Inflation Reduction Act last year.

    “Among both swing voters and surge voters, folks are moved more by talking about tangible gains than by talking about growing the economy,” Shenker-Osario said.

    Simultaneously, the report argues that Democrats must link their economic agenda to a broader promise to defend voters against an array of forces threatening their ability to succeed. In its research, the group found that the strongest case for Democrats blended pledges to deliver concrete economic benefits with promises to defend fundamental rights and stand up to big, wealthy corporations.

    Across all of these fronts, Fernandez Ancona argues, the key for Democrats is not just to warn about what a second Trump term could mean but to give voters a positive vision that emphasizes their success at stopping him and the prospect that reelecting Biden could deliver measurable benefits. “We really believe we can’t just rely on telling people the bad things,” Fernandez Ancona said.

    Key results in the 2022 election offer Democrats some reason for optimism that the approach urged by Way to Win can succeed. In the five swing states most likely to decide the 2024 presidential race, Democrats won seven of the nine Senate and gubernatorial races in 2022, primarily around variations on the themes that Way to Win wants the party to stress next year.

    The range of problems confronting Biden, such as doubts about his age and capacity, can’t all be resolved by recalibrating his message. Fernandez Ancona doesn’t pretend otherwise. But she argues that a more precisely targeted message will provide Biden the best chance of maximizing his support whatever the background environment looks like next year. “We can’t control what conditions are,” she told me. “Messaging can’t solve all problems. But it does do something to paint the path forward and make sure that voters go into the booth knowing what the stakes are.”

    With Trump looming as the likely GOP nominee, Democratic strategists at this point may have greater consensus about the stakes in 2024 than the path forward for the party. The sheer proliferation of studies proposing a new approach for Biden may be the most telling measure of how much more difficult this election looks than Democrats once anticipated.

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    Ronald Brownstein

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  • The Cancer-Drug Shortage Is Different

    The Cancer-Drug Shortage Is Different

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    Last November, FDA inspectors found almost farcical conditions when they inspected an Indian manufacturing plant that supplies medical drugs to the United States. The plant, owned by Intas Pharmaceuticals, had hardly any working systems for ensuring the purity or sterility of its products. And its employees were trying to conceal evidence of these problems by shredding and hiding documents or, as one quality-control officer admitted, dousing them in acid.

    Intas provided America with a lot of frontline chemotherapy drugs—half of the country’s supply in some cases—that are used to treat more than a dozen types of cancer. When the disastrous inspection led the company to halt production, other manufacturers couldn’t make up the difference. Hospitals are now reeling: In a recent survey, 93 percent of U.S. cancer centers said they were experiencing a shortage of the drug carboplatin, while 70 percent were low on another, cisplatin.

    Even short delays in cancer treatment can increase a patient’s odds of death, and substitute medications may be less effective or more toxic, if they exist at all. Chemo drugs often run dry—“I can’t think of a year in the past 10 or 12 where we didn’t face some kind of shortage,” Yoram Unguru, a pediatric oncologist at the Herman & Walter Samuelson Children’s Hospital at Sinai, told me—but the current crisis is unprecedented in scale, for reasons that go beyond Intas’s woes. Fourteen cancer drugs are currently scarce, jeopardizing the care of hundreds of thousands of Americans. “I’ve been doing this forever, and this is absolute lunacy,” Patrick Timmins III, a gynecologic oncologist at Women’s Cancer Care Associates, told me.

    By delivering drugs at lower doses or over longer intervals, most oncologists are still managing to treat most of their patients—but barely. “Patients often say to us, I just need a plan,” Eleonora Teplinsky, an oncologist at Valley Health System, told me, and the shortages riddle every plan with question marks. Some institutes have already been forced to ration care. Timmins no longer has enough cisplatin and carboplatin to treat patients with recurrent tumors, even though those drugs can improve one’s quality of life or offer decent odds of another remission. “A lot of people are going to be hurt,” he told me. “Lives will be shortened.” Such tragedies are especially galling because the drugs in shortage aren’t expensive, state-of-the-art treatments that patients might struggle to access anyway, but cheap ones that have existed for decades. “It’s just unfathomable that a patient wouldn’t be able to receive them,” Amanda Fader, a gynecologic oncologist at Johns Hopkins, told me.

    Intas screwed up, but how could one manufacturer’s downfall trigger such widespread problems? The coronavirus pandemic made plain how reliant the U.S. is on brittle international supply chains, but this much-discussed fragility doesn’t explain the current shortages: Cancer drugs are not scarce for the same reasons that yeast, toilet paper, or couches were. They’re scarce because the market for some of our most important medicines—the ones that should be most accessible—is utterly dysfunctional, in a way that is both very hard to fix but also entirely fixable.

    Many recent supply-chain problems were caused by an external force—a pandemic, a hurricane, a stuck ship—that throttled a product’s availability, leading to surging demand and dwindling stocks. But most cancer-drug shortages are caused by internally generated problems, created within the market because of its structure. In other words, “they’re self-inflicted wounds,” Marta Wosińska, a health-care economist at the Brookings Institution, told me.

    Generic drugs such as cisplatin are sold at extremely low prices, which overall have fallen by more than 50 percent since 2016. These ever-tightening margins have forced many manufacturers to tap out of the market; for example, the U.S. gets all its vincristine, an anti-leukemia drug, from just one company.

    Such drugs are also hard to make. Because they’re injected into the bloodstream, often of severely ill people, they must be manufactured to the highest possible standards, free of microbes and other contaminants. But quality costs money, and generic drugs are so unprofitable that manufacturers can rarely afford to upgrade machinery or train employees. If anything, they’re compelled to cut corners, which makes them vulnerable to spontaneous manufacturing problems or disastrous inspections. And because they usually run at full capacity, any disruption to production has severe consequences. The affected manufacturer might fail to financially recover and leave the market too. Its competitors might struggle to ramp up production without triggering their own cascading shortages. And the drugs, which were never profitable enough to manufacture in surplus, quickly run out.

    These principles apply not only to cancer drugs but to generics as a whole, dozens or hundreds of which have been in shortage at any given time for the past decade. The markets that produce them are frail and shrinking. And even when a drug is manufactured by many companies, they might all rely on the same few suppliers for their active pharmaceutical ingredients (APIs)—the chemicals at the core of their medicines. Mariana Socal, a pharmaceutical-market expert at Johns Hopkins, has shown that a third of the APIs in America’s generic-drug supply are made in just two or three (mostly overseas) facilities, and another third are made in just one.

    The supply chains that link these chemicals to finished drugs are also frustratingly opaque. Consider fludarabine, one of the cancer drugs that’s currently in shortage. The FDA has approved 12 companies to make it, but only five actually market it; only because of a Senate-committee inquiry is it publically known that of those five, only one makes the drug itself; two others get theirs from Europe, and one of those used to supply the final two. Meanwhile, six facilities are registered to make fludarabine’s API, but it’s again unclear which ones really do, or which manufacturers they supply, or even, for one of them, which country it is in. The fludarabine market is clearly weaker than it first appears, but how weak is hard to gauge. The same goes for cisplatin and carboplatin, Socal told me: She and other experts thought their markets looked resilient, until the Intas shutdown dispelled the illusion.

    This opacity masks not only the market’s weaknesses but also its strengths. Erin Fox, a drug-shortage expert at the University of Utah Health, oversees a drug budget of more than $500 million, and would love to spend it on manufacturers that make the most reliable medicines, even if their products cost a little more. But “we just don’t know which products are higher-quality than others,” she told me. The FDA has an internal scoring system that it uses to decide which facilities to inspect, Fox said, but because those data aren’t publicly available, manufacturers can distinguish themselves only through price. “We get a race to the bottom where companies undercut each other to get the lowest price, and then quit either because their manufacturing is so poor, or they can’t afford to make medicines anymore,” Fox said. As Wosińska and Janet Woodcock of the FDA identified in 2013, “The fundamental problem … is the inability of the market to observe and reward quality.”

    The average generic-drug shortage lasts for about a year and a half. Many people I spoke with hoped that the current wave could abate more quickly if other manufacturers slowly ramp up. The FDA is also looking to import scarce drugs from international suppliers, and has temporarily allowed a Chinese company to sell its cisplatin in the U.S. But ultimately, “it’s very hard to solve a shortage after it started,” Allen Coukell, of the nonprofit Civica Rx, told me. They need to be prevented from happening at all.

    Some commonly suggested preventive measures might not work very well, because they misdiagnose the problem. Politicians often focus on bolstering domestic manufacturing, but Wosińska, Fox, and others told me that many drug shortages have been caused by manufacturing problems in American facilities. Because American drugmakers are subject to the same flawed markets as foreign ones, moving the problem inshore doesn’t actually solve it. Nor does stockpiling generic drugs, though a worthwhile idea. These strategies work well against an external shock like a pandemic, Wosińska said: When faced with unpredictable external forces, it pays to build a large buffer. But because the shocks that cause drug shortages arise from predictable forces inherent to the market, the best bet is to reimagine the market itself—a “very difficult problem but a solvable one,” Stephen Colvill, the executive director and a co-founder of the nonprofit RISCS, told me.

    A few new initiatives show how this could be done. Civica Rx, which was launched in 2018, sources generic drugs from manufacturers that it vets for quality; it then builds up rolling six-month inventories of those drugs, which it supplies to hospitals through long-term contracts. (Civica is also building its own generics-manufacturing facility in Virginia.) RISCS, founded in 2019, uses confidential data from manufacturers to rate generic-drug products according to the robustness of their supply chains. The FDA has also been developing its own rating system—the “quality management maturity” (QMM) program—that assesses a manufacturer’s quality-control practices; the program successfully completed two pilots but is still being developed and has no firm launch date, an FDA spokesperson said.

    In theory, these initiatives should allow hospitals to make better purchasing decisions, and shift the market toward drug companies that are least likely to be responsible for shortages. In practice, Wosińska thinks that hospitals need to be pulled into such a culture shift. For example, she and her colleague Richard G. Frank argue that Medicare could reward hospitals for proactively choosing reliable vendors or participating in programs like Civica. The FDA could support such a scheme by finally launching its QMM program. Congress could require manufacturers to disclose more details about their products and suppliers, so that supply chains can be fully mapped. HHS could offer loans to generic-drug manufacturers for upgrading or expanding their facilities. The point, Wosińska told me, is to do all of this at once, and shift the market into a new stable state. The solution, she said, needs to be comprehensive.

    It also needs to be coordinated. The drug-shortage problem lingers partly because “it’s not obvious who’s responsible for solving it,” Joshua Sharfstein, a health-policy expert at Johns Hopkins, told me. The FDA is a candidate, but economic matters sit outside its wheelhouse. Instead, Sharfstein and others suggest that the drug-shortage problem could be owned by the Administration for Strategic Preparedness and Response. It already works to shore up medical supplies in the event of emergencies such as pandemics or natural disasters, and ongoing shortages of generic drugs are effectively a perpetual state of emergency that we’re trapped in.

    Meanwhile, the exact consequences of the shortages are hard to measure. Some of today’s cancer patients will suffer, or even die, because they couldn’t get treated in time, or were given lower doses, or were given more toxic drugs as substitutes. But it’s almost impossible to know if any individual person would have fared better in a world where shortages never happened: If they died, was it because of a few weeks’ delay or because their tumor was always going to be hard to treat? The impact of the shortages can only really be assessed at a population level, and that evidence takes a long time to collect. “I don’t think we’ll see the full downside for many years,” Yoram Unguru told me.

    The measures needed to prevent such shortages will also take years to implement—if they ever are. The coronavirus pandemic revealed just how frail our supply chains and health-care system are, but it also showed how quickly attention and resources can disappear once a problem is thought to abate. But the drug problem isn’t abating, and is actually compounding the problems the pandemic created. When health-care workers can’t help their patients, whether because their hospitals are inundated by COVID or because their drugs have run out, the resulting moral distress can be unbearable. Such conditions during the pandemic drove so many health-care workers to quit that “you can feel the system shaking,” Patrick Timmins III said. He worries that this exodus followed by the current drug shortages are “a one-two punch” that will be visible to outsiders only when they have neither the drugs to cure them nor the health-care workers to treat them.

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    Ed Yong

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  • Long-Haulers Are Trying to Define Themselves

    Long-Haulers Are Trying to Define Themselves

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    Imagine you need to send a letter. The mailbox is only two blocks away, but the task feels insurmountable. Air hunger seizes you whenever you walk, you’re plagued by dizziness and headaches, and anyway, you keep blanking on your zip code for the return address. So you sit in the kitchen, disheartened by the letter you can’t send, the deadlines you’ve missed, the commitments you’ve canceled. Months have passed since you got COVID. Weren’t you supposed to feel better by now?

    Long COVID is a diverse and confusing condition, a new disease with an unclear prognosis, often-fluctuating symptoms, and a definition people still can’t agree on. And in many cases, it is disabling. In a recent survey, 1.6 percent of American adults said post-COVID symptoms limit their daily activities “a lot.” That degree of upheaval aligns with the Americans With Disabilities Act’s definition of disability: “a physical or mental impairment that substantially limits one or more major life activities.”

    But for many people experiencing long COVID who were able-bodied before, describing themselves as “disabled” is proving to be a complicated decision. This country is not kind to disabled people: American culture and institutions tend to operate on the belief that a person’s worth derives from their productivity and physical or cognitive abilities. That ableism was particularly stark in the early months of the pandemic, when some states explicitly de-prioritized certain groups of disabled people for ventilators. Despite the passage of the ADA in 1990, disabled people still confront barriers accessing things such as jobs and health care, and even a meal with friends at a restaurant. Most of our cultural narratives cast disability as either a tribulation to overcome or a tragedy.

    Consequently, incorporating disability into your identity can require a lot of reflection. Lizzie Jones, who finished her doctoral research in disability studies last year and now works for an educational consultancy, suffered a 30-foot fall that shattered half of her body a week before her college graduation. She told me that her accident prompted “radical identity shifts” as she transitioned from trying to get the life she’d imagined back on track to envisioning a new one.

    These are the sorts of mindset changes that Ibrahim Rashid struggled with after contracting COVID in November 2020, when he was a graduate student. He dealt with debilitating symptoms for months, but even after applying for disability accommodations to finish his degree, he “was so scared of that word,” he told me. Rashid was afraid of people treating him differently and of losing his internship offer. Most terrifying, calling himself disabled felt like an admission that his long COVID wasn’t going to suddenly resolve.

    Jennifer Senior: What not to ask me about my long COVID

    Aaron Teasdale, an outdoors and travel writer and a mountaineer, has also been wrestling with identity questions since he got COVID in January 2022. For months, he spent most of his time in a remote-controlled bed, gazing out the window at the Montana forests he once skied. Although his fatigue is now slowly improving, he had to take Ritalin to speak with me. He was still figuring out what being disabled meant to him, whether it simply described his current condition or reflected some new, deeper part of himself—a reckoning made more difficult by the unknowability of his prognosis. “Maybe I just need more time before I say I’m a disabled person,“ he said. “When you have your greatest passions completely taken away from you, it does leave you questioning, Well, who am I?”

    Long COVID can wax and wane, leaving people scrambling to adapt. It doesn’t mesh with the stereotype of disability as static, visible, and binary—the wheelchair user cast in opposition to the pedestrian. Nor does the fact that long COVID is often imperceptible in casual interactions, which forces long-haulers to contend with disclosure and the possibility of passing as able-bodied. One such long-hauler is Julia Moore Vogel, a program director at Scripps Research, who initially hesitated at the idea of getting a disabled-parking permit. “My first thought was, I’m not disabled, because I can walk,” she told me. But if she did walk, she’d be drained for days. Taking her daughter to the zoo or the beach was out of the question.

    Once she got over her apprehension, identifying as disabled ended up feeling empowering. Getting that permit was “one of the best things I’ve done for myself,” Vogel told me. She could drive her kid to the playground, park nearby, and then sit and watch her play. After plenty of therapy and conversations with other disabled people, Rashid, too, came to embrace disability as part of his identity, so much so that he now speaks and writes about chronic illness.

    Read: The future of long COVID

    Usually, the community around a disease—including advocacy among those it disables—arises after scientists name it. Long COVID upended that order, because the term first spread through hashtags and support groups in 2020. Instead of doctors informing patients of whether their symptoms fit a certain illness, patients were telling doctors what symptoms their illness entailed. And there were a lot of symptoms: everything from life-altering neurocognitive problems and dizziness to a mild, persistent cough.

    As long-COVID networks blossomed online, members began seeking support from wider disability-rights communities, and contributing fresh energy and resources to those groups. People who’d fought similar battles for decades sometimes bristled at the greater political capital afforded to long-haulers, whose advocacy didn’t universally extend to other disabled people; for the most part, though, long-haulers were welcomed.

    Tapping into conversations among disabled people “has shown me that I’m simply not alone,” Eris Eady, a writer and an artist who works for Planned Parenthood, told me. Eady, who is queer and Black, found that long COVID interplayed with struggles they already faced on account of their identity. So they sought advice from disabled Black women about interdependence, mutual aid, and accessibility, as well as about being dismissed by doctors, an experience more prevalent among women and people of color.

    Disabled communities have years of experience supporting people through identity changes. The writer and disability-justice organizer Leah Lakshmi Piepzna-Samarasinha told me that when she was newly disabled, she was dogged with heavy questions: Am I going to be able to make a living? Am I datable? Her isolation and fear dissipated only when she met other young disabled people, who taught her how to be creative in “hacking the world.”

    For long-haulers navigating these transitions for the first time, the process can be rocky. Rachel Robles, a contributor to The Long COVID Survival Guide, told me she spent her early months with long COVID “waking up every day and thinking, Okay, is this the day it’s left my body?” Conceiving of herself as disabled didn’t take away her long COVID. She didn’t stop seeing doctors and trying treatments. But thinking about accessibility did inspire her to return to gymnastics, which she’d quit decades earlier because of a heart condition. If she couldn’t lift her hands over her head sometimes, and if a dive roll would never be in her future, then so be it: Gymnastics could be about enjoying what her body could do, not yearning for what it couldn’t. Before she identified as disabled, returning to gymnastics “was something I would have never, ever imagined,” Robles said. And she never would have done it had she remained focused only on when she might recover.

    Read: Long COVID is being erased—again

    Hoping for improvement is a natural response to illness, especially one with a trajectory as uncertain as long COVID’s. But focusing exclusively on relinquished past identities or unrealized future ones can dampen our curiosity about the present. A better way to think about it is “What are the things you can do with the body that you have, and what are the things you might not know you can do yet?” Piepzna-Samarasinha said. “Who am I right now?”

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    Lindsay Ryan

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  • American Religion Is Not Dead Yet

    American Religion Is Not Dead Yet

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    Take a drive down Main Street of just about any major city in the country, and—with the housing market ground to a halt—you might pass more churches for sale than homes. This phenomenon isn’t likely to change anytime soon; according to the author of a 2021 report on the future of religion in America, 30 percent of congregations are not likely to survive the next 20 years. Add in declining attendance and dwindling affiliation rates, and you’d be forgiven for concluding that American religion is heading toward extinction.

    But the old metrics of success—attendance and affiliation, or, more colloquially, “butts, budgets, and buildings”—may no longer capture the state of American religion. Although participation in traditional religious settings (churches, synagogues, mosques, schools, etc.) is in decline, signs of life are popping up elsewhere: in conversations with chaplains, in communities started online that end up forming in-person bonds as well, in social-justice groups rooted in shared faith.

    For centuries, houses of worship have been the center of their communities, where people met their friends and partners, where they raised their kids, where they found solace, where they broke bread, where they organized around important issues.

    Shadi Hamid: America without God

    As Robert D. Putnam and David E. Campbell demonstrated in their 2010 book, American Grace: How Religion Divides and Unites Us, most Americans no longer orient their lives around houses of worship. And that loss is about more than just missing out on prayer services. It means that when people move to a new city, they have to work much harder to find new friends than previous generations did. When someone falls ill, they might not have a cadre of their fellow faithful to offer home-cooked meals and prayers for healing. This reorientation away from houses of worship is one of the factors that has led to the decline of a sense of community, the rise of social isolation, and the corresponding negative effects on public health, especially for older adults.

    Religion has historically done four main “jobs.” First, it provides a framework for meaning-making, whether helping our ancient ancestors explain why it rained when it rained, or helping us today make sense of why bad things happen to good people. Second, religion offers rituals that enable us to mark time, process loss, and celebrate joys—from births to coming of age to family formation to death. Third, it creates and supports communities, allowing each of us to find a place of belonging. And finally, fueled by each of the first three, religion inspires us to take prophetic action—to partake in building a world that is more just, more kind, and more loving. Through the pursuit of these four jobs, religious folks might also experience a sense of wonder, discover some new truth about themselves or the world, or even have an encounter with the divine.

    So rather than asking how many people went to church last Sunday morning, we should ask, “Where are Americans finding meaning in their lives? How are they marking the passing of sacred time? Where are they building pockets of vibrant communities? And what are they doing to answer the prophetic call, however it is that they hear it?”

    There have never been more ways to answer these questions, even if fewer and fewer people are stepping into a sanctuary. People are meaning-making in one-on-one sessions with spiritual directors and chaplains. One in four Americans—across racial and religious (and nonreligious) backgrounds—has met with a chaplain in their lifetime, according to a recent survey that Gallup conducted for the Chaplaincy Innovation Lab, of which one of us, Wendy, is a founder. Most find their time with chaplains valuable.

    People are preparing for the end of life with the Shomer Collective, a group that helps people as they prepare for and navigate the end of life, offering wisdom from the Jewish tradition. Death doulas now work with people from a variety of backgrounds, giving hand massages, preparing food, and doing much more for dying people and their loved ones.

    These spiritual offerings are not just for individuals. People are gathering in communities in new ways to celebrate Shabbat rituals with OneTable, and mourning the loss of their loved ones with the Dinner Party. They’re joining small groups through the New Wine Collective, a movement helping people build spiritual communities, and the Nearness, a platform for nurturing your spiritual life while discovering community online. And they’re pursuing faith-driven justice work with organizations such as the Faith Matters Network and Living Redemption.

    From the April 2017 issue: Breaking faith

    Many theological schools aren’t yet training their students to reimagine how to serve people outside traditional religious contexts. Most are still preparing clergy to serve in congregations, a job with diminishing prospects these days. However, a growing number of groups, many of them led by seminary graduates, support spiritual leaders who are fostering new kinds of spirituality in their flocks.

    The Glean Network, of which Elan is the founding director, has incubated more than 100 faith-rooted ventures over the past seven years through its partnership with Columbia Business School. Some of these programs focus on meaning-making, many on building communities, others on creative rituals, and still others on answering a prophetic call. The Chaplaincy Innovation Lab brings chaplains traditionally siloed in the settings where they work—health care, the military, higher education, prisons—into a broader learning community. More than 4,000 chaplains belong to the Lab’s private Facebook group—what we believe to be the largest virtual gathering of chaplains in the world—sharing advice, insights, and improvisational rituals from around the globe. These networks and a growing number of others equip spiritual leaders from a broad range of faith traditions to do their best work, and challenge theological schools to make their education more responsive, expansive, accessible, and practical.

    This swell of spiritual creativity comes at a time when Americans seem to need it most. We are more lonely, more divided, less hopeful, and less trusting than in previous decades. And while there is much to celebrate as these new offerings take shape, their growth comes alongside an unprecedented decline in religious affiliation, which does entail losing some things that are unlikely to be replaced by these creative efforts.

    We are witnessing a tectonic shift in the landscape of American religious life. Putnam was right when he declared a decade ago that religious disaffiliation has “the potential for completely transforming American society.” But he also predicted that it “has the potential for just eliminating religion,” and we beg to differ. Before we conclude that this transformation is solely about decline, let’s make sure we’re looking in all the right places.

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    Wendy Cadge

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  • America’s COVID Booster Rates Are a Bad Sign for Winter

    America’s COVID Booster Rates Are a Bad Sign for Winter

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    And just like that, with the passing of Labor Day, fall was upon us. Seemingly overnight, six-packs of pumpkin beer materialized on grocery shelves, hordes of city dwellers descended upon apple orchards—and America rolled out new COVID boosters. The timing wasn’t a coincidence. Since the beginning of the pandemic, cases in North America and Europe have risen during the fall and winter, and there was no reason to expect anything different this year. Spreading during colder weather is simply what respiratory diseases like COVID do. The hope for the fall booster rollout was that Americans would take it as an opportunity to supercharge their immunological defenses against the coronavirus in advance of a winter wave that we know is going to come.

    So far, reality isn’t living up to that hope. Since the new booster became available in early September, fewer than 20 million Americans have gotten the shot, according to the CDC—just 8.5 percent of those who are eligible. The White House COVID-19 response coordinator, Ashish Jha, said at a press conference earlier this month that he expects booster uptake to increase in October as the temperatures drop and people start taking winter diseases more seriously. That doesn’t seem to be happening yet. America’s booster campaign is going so badly that by late September, only half of Americans had heard even “some” information about the bivalent boosters, according to a recent survey. The low numbers are especially unfortunate because the remaining 91.5 percent of booster-eligible people have already shown that they’re open to vaccines by getting at least their first two shots—if not already at least one booster.

    Now the bungled booster rollout could soon run headfirst into the winter wave. The virus is not yet surging in the United States—at least as far as we can tell—but as the weather cools down, cases have been on the rise in Western Europe, which has previously foreshadowed what happens in the U.S. At the same time, new Omicron offshoots such as BQ.1 and BQ.1.1 are gaining traction in the U.S., and others, including XBB, are creating problems in Singapore. Boosters are our best chance at protecting ourselves from getting swept up in whatever this virus throws at us next, but too few of us are getting them. What will happen if that doesn’t change?

    The whole reason for new shots is that though the protection conferred by the original vaccines is tremendous, it has waned over time and with new variants. The latest booster, which is called “bivalent” because it targets both the original SARS-CoV-2 virus and BA.5, is meant to kick-start the production of more neutralizing antibodies, which in turn should prevent new infection in the short term, Katelyn Jetelina, a public-health expert who writes the newsletter Your Local Epidemiologist, told me. The other two goals for the vaccine are still being studied: The hope is that it will also broaden protection by teaching the immune system to recognize other aspects of the virus, and that it will make protection longer-lasting.

    In theory, this souped-up booster would make a big difference heading into another wave. In September, a forecast presented by the Advisory Committee on Immunization Practices (ACIP), which advises the CDC, showed that if people get the bivalent booster at the same rate as they do the flu vaccine—optimistic, given that about 50 percent of people have gotten the flu vaccine in recent years—roughly 25 million infections, 1 million hospitalizations, and 100,000 deaths could be averted by the end of March 2023.

    But these numbers shouldn’t be taken as gospel, because protection across the population varies widely and modeling can’t account for all of the nuance that happens in real life. Gaming out exactly what our dreadful booster rates mean going forward is not a simple endeavor “given that the immune landscape is becoming more and more complex,” Jetelina told me. People received their first shots and boosters at different times, if they got them at all. And the same is true of infections over the past year, with the added wrinkle that those who fell sick all didn’t get the same type of Omicron. All of these factors play a role in how much America’s immunological guardrails will hold up in the coming months. “But it’s very clear that a high booster rate would certainly help this winter,” Jetelina said.

    At this point in the pandemic, getting COVID is far less daunting for healthy people than it was a year or two ago (although the prospect of developing long COVID still looms). The biggest concerns are hospitalizations and deaths, which make low booster uptake among vulnerable groups such as the elderly and immunocompromised especially worrying. That said, everyone aged 5 and up who has received their primary vaccine is encouraged to get the new boosters. It bears repeating that vaccination not only protects against severe illness and death but has the secondary effect of preventing transmission, thereby reducing the chances of infecting the vulnerable.

    What will happen next is hard to predict, Michael Osterholm, an epidemiologist at the University of Minnesota, told me, but now is a bad time for booster rates to be this low. Conditions are ripe for COVID’s spread. Protection is waning among the unboosted, immunity-dodging variants are emerging, and Americans just don’t seem to care about COVID anymore, Osterholm explained. The combination of these factors, he said, is “not a pretty picture.” By skipping boosters, people are missing out on the chance to offset these risks, though non-vaccine interventions such as masking and ventilation improvements can help, too.

    That’s not to say that the immunity conferred by the vaccination and the initial boosters is moot. Earlier doses still offer “pretty substantial protection,” Saad Omer, a Yale epidemiologist, told me. Not only are eligible Americans slacking on booster uptake, but lately vaccine uptake among the unvaccinated hasn’t risen much either. Before the new bivalent shots came around, less than half of eligible Americans had gotten a booster. “That means we are, as a population, much more vulnerable going into this fall,” James Lawler, an infectious-diseases expert at the University of Nebraska Medical Center, told me.

    If booster uptake—and vaccine uptake overall—remains low, expecting more illness, particularly among the vulnerable, would be reasonable, William Schaffner, a professor of infectious diseases at Vanderbilt University Medical Center, told me. Hospitalizations will rise more than they would otherwise, and with them the stress on the health-care system, which will also be grappling with the hundreds of thousands of people likely to be hospitalized for flu. While Omicron causes relatively minor symptoms, “it’s quite capable of producing severe disease,” Schaffner said. Since August, it has killed an average of 300 to 400 people each day.

    All of this assumes that we won’t get a completely new variant, of course. So far, the BA.5 subvariant targeted by the bivalent booster is still dominating cases around the world. Newer ones, such as XBB, BQ.1.1, and BQ.1, are steadily gaining traction, but they’re still offshoots of Omicron. “We’re still very hopeful that the booster will be effective,” Jetelina said. But the odds of what she called an “Omicron-like event,” in which a completely new SARS-CoV-2 lineage—one that warrants a new Greek letter—emerges out of left field, are about 20 to 30 percent, she estimated. Even in this case, the bivalent nature of the booster would come in handy, helping protect against a wider crop of potential variants. The effectiveness of our shots against a brand-new variant depends on its mutations, and how much they overlap with those we’ve already seen, so “we’ll see,” Omer said.

    Just as it isn’t too late to get boosted, there’s still time to improve uptake in advance of a wave. If you’re three to six months out from an infection or your last shot, the best thing you can do for your immune system right now is to get another dose, and do it soon. Though there’s no perfect and easy solution that can overcome widespread vaccine fatigue, that doesn’t mean trying isn’t worthwhile. “Right now, we don’t have a lot of people that feel the pandemic is that big of a problem,” and people are more likely to get vaccinated if they feel their health is challenged, Osterholm said.

    There’s also plenty of room to crank the volume on the messaging in general: Not long ago, the initial vaccine campaign involved blasting social media with celebrity endorsers such as Dolly Parton and Olivia Rodrigo. Where is that now? Lots of pharmacies are swimming in vaccines, but making getting boosted even easier and more convenient can go a long way too. “We need to catch them where they come,” said Omer, who thinks boosters should be offered at workplaces, in churches and community centers, and at specialty clinics such as dialysis centers where patients are vulnerable by default.

    After more than two years of covering and living through the pandemic, believe me: I get that people are over it. It’s easy not to care when the risks of COVID seem to be negligible. But while shedding masks is one thing, taking a blasé attitude toward boosters is another. Shots alone can’t solve all of our pandemic problems, but their unrivaled protective effects are fading. Without a re-up, when the winter wave reaches U.S. shores and more people start getting sick, the risks may no longer be so easy to ignore.

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    Yasmin Tayag

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  • Democrats Might Avoid a Midterm Wipeout

    Democrats Might Avoid a Midterm Wipeout

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    If Democrats avoid the worst outcome in November’s midterm elections, the principal reason will likely be the GOP’s failure to reverse its decline in white-collar suburbs during the Donald Trump era.

    That’s a clear message from yesterday’s crowded primary calendar, which showed the GOP mostly continuing to nominate Trump-style culture-war candidates around the country. And yet, the resounding defeat of an anti-abortion ballot initiative in Kansas showed how many voters in larger population centers are recoiling from that Trumpist vision.

    Democrats still face enormous headwinds in November, including sweeping voter dissatisfaction over inflation, low approval ratings for President Joe Biden, and the near unbroken history since the Civil War of the party that holds the White House losing seats in the House of Representatives during a president’s first two years.

    Polls indicate that many college-educated center-right voters have soured on the performance of Biden and the Democrats controlling both congressional chambers. Yet in Tudor Dixon, the GOP gubernatorial nominee in Michigan, and Blake Masters, the party’s Senate selection in Arizona, Republicans have chosen nominees suited less to recapturing socially moderate white-collar voters than to energizing Trump’s working-class and nonurban base through culture-war appeals like support of near-total abortion bans. With Trump-backed Kari Lake moving into the lead as counting continues in the Arizona Republican gubernatorial primary, the top GOP nominees both there and in Michigan will likely be composed entirely of candidates who embrace Trump’s lie that he won their state in 2020.

    In the intermediate term, most Democratic strategists believe that the party must find ways to combat the GOP’s strong performance during the Trump era with working-class voters, particularly its improvement since 2016 among blue-collar Hispanic voters. But with inflation so badly squeezing the finances of many working- and middle-class families, recovering much ground with such voters before November may be tough for most Democratic candidates. Those working-class voters “know the shoe is pinching,” says Tom Davis, the former chair of the National Republican Congressional Committee, quoting the late political scientist V. O. Key Jr.

    The more realistic route for Democrats in key races may be to defend, as much as possible, the inroads they made into the white-collar suburbs of virtually every major metropolitan area during the past three elections. Although, compared with 2020, the party will likely lose ground with all groups, Democrats are positioned to hold much more of their previous support among college-educated than noncollege voters, according to Ethan Winter, a Democratic pollster.

    An array of recent public polls suggest he’s right. A Monmouth University poll released today showed that white voters without a college degree preferred Republicans for Congress by a 25-percentage-point margin, but white voters with at least a four-year degree backed Democrats by 18 points.

    A recent Fox News Poll in Pennsylvania showed the Democratic Senate nominee John Fetterman crushing Republican Mehmet Oz among college-educated white voters, while the two closely split those without degrees. Another recent Fox News poll in Georgia found Senator Raphael Warnock trailing his opponent Herschel Walker among noncollege white voters by more than 40 percentage points but running essentially even among those with degrees (which would likely be enough to win, given his preponderant support in the Black community). The most recent public surveys in New Hampshire and Wisconsin likewise found Republicans leading comfortably among voters without advanced education, but Democrats holding solid advantages among those with four-year or graduate degrees. A poll this week by Siena College, in New York, found Democratic Governor Kathy Hochul splitting noncollege voters evenly with Republican Lee Zeldin, but beating him by more than two-to-one among those with a degree.

    This strength among college-educated voters may be worth slightly more for Democrats in the midterms than in a general election. Voters without a degree cast a majority of ballots in both types of contests. But calculations by Catalist, a Democratic-voter-targeting firm, and Michael McDonald, a University of Florida political scientist who specializes in voter turnout, have found that voters with a college degree consistently make up about three to four percentage points more of the electorate in a midterm than in a presidential election. “When we see lower turnout elections,” like a midterm, “the gap between high-education and low-education voters increases,” McDonald told me. In close races, that gap could place a thumb on the scale for Democrats, partially offsetting the tendency of decreased turnout from younger and nonwhite voters in midterm elections.

    Republicans have mostly counted on voters’ dissatisfaction with inflation and Biden’s overall performance to recover lost ground in white-collar communities. But as the polls noted above suggest, many voters in those places are, at least for now, decoupling their disenchantment with Biden from their choices in House, Senate, and governor’s races. “Voters have concerns about the direction of the country,” the Democratic strategist Jesse Ferguson told me, “but they’re terrified of the direction it would take if these MAGA Republicans took power.”

    Geraldo L. Cadava: The battle for Latino voters in the rust belt

    One reason for this decoupling may be that, although all families are feeling the effects of inflation, for white-collar professionals, it generally represents something more like an inconvenience than the agonizing vise it constitutes for working-class families.

    That doesn’t mean white-collar voters are unconcerned about the economy, but with less worry about week-to-week financial survival, they are more likely to be influenced by the trifecta of issues that have exploded in visibility over the past several months: abortion rights,  gun control, and the threats to American democracy revealed by the House committee investigating the January 6 insurrection.

    As last night’s Kansas result showed, abortion rights may be an especially powerful weapon for Democrats in white-collar areas. Polls, such as a recent survey by the nonpartisan Pew Research Center, have generally found that about two-thirds or more of voters with at least a four-year college degree believe abortion should remain legal in all or most circumstances. That support is evident even in states that generally lean toward the GOP: Recent public surveys found that strong majorities of voters with college degrees supported legal abortion in Georgia and Texas, and another survey showed majority backing among more affluent voters in Arizona.

    In deep-red Kansas, two-thirds or more of voters have just supported abortion rights in four of the state’s five largest counties. Particularly noteworthy was the huge turnout and massive margin (68 percent to 32 percent at latest count) for the pro-choice position in Johnson County, a well-educated suburb of Kansas City that demographically resembles many of the suburban areas that have moved toward Democrats around such cities as Philadelphia, Detroit, Atlanta, Austin, and Phoenix.

    Republican candidates this year have ceded virtually no ground to the pro-abortion-rights or pro-gun-control sentiments in those suburban areas. With the national protection for abortion revoked by the Supreme Court, almost all Republican-controlled states are on track to ban or restrict the practice. In swing states that have not yet done so, GOP gubernatorial candidates are promising to pursue tight limits. Dixon, the GOP’s Michigan nominee, said recently that she would push for an abortion ban with no exceptions for rape, incest, or the health of the mother (while she would allow them only in cases that threaten the mother’s life). Asked during a recent interview about a hypothetical case of a 14-year-old who had been impregnated by an uncle, Dixon explicitly said the teenager should carry the baby to term because “a life is a life for me.”

    Matt Mackowiak, a Texas-based Republican consultant, told me that the magnitude of the pro-abortion-rights vote in Kansas was “unexpected,” but it does not guarantee Democratic candidates’ suburban domination in November. “This was a rare up or down vote on this issue,” he told me in an email. “November will be different, as voters will have lots of reasons to vote and lots of issues to consider … Polls consistently show the economy trumping this issue in the minds of the voters.”

    But Democrats believe that the contrast on abortion will be highly consequential, especially in governor’s races, where Democrats such as the incumbent Gretchen Whitmer in Michigan and the nominee Josh Shapiro in Pennsylvania are presenting themselves as a last line of defense against Republicans intent on banning the procedure. Suburban “voters might have been thinking about voting Republican because they are unhappy with the direction of country and inflation, and they might decide to back Whitmer because of abortion,” Winter, the Democratic pollster, told me.

    The choice may not carry such immediate implications in House and Senate races, but leading Democrats are running on promises to pass legislation restoring the national right to abortion, while Republicans are either opposing such a bill or signaling openness to imposing a national ban. The two top Democratic challengers for Republican-held Senate seats (John Fetterman in Pennsylvania and Mandela Barnes in Wisconsin) have both called for ending the filibuster to pass legislation codifying national abortion rights.

    Davis, the former NRCC chair who represented a suburban Northern Virginia district, believes that even in white-collar communities supportive of abortion rights and gun control, Democrats won’t escape discontent over inflation. If Republicans could frame the election simply as a referendum on Biden’s performance, Davis told me, “that’s their path to victory and a path to an electoral landslide.” But, he added, the choice by GOP voters in so many states to nominate “exotic candidates” mostly linked to Trump has provided Democrats with an opportunity, particularly in higher-profile Senate and governor contests, to make this “a choice election.” And that, he said, gives Democrats a shot at winning enough “white ticket-splitters” to at least hold down their losses.

    Given the headwinds, Democrats would take a November outcome in which they narrowly lose the House but hold their Senate majority and preserve control of the governorships in the key swing states of Michigan, Pennsylvania, and Wisconsin, while perhaps adding some others, such as Arizona. With Biden’s approval rating still scuffling, that outcome is hardly guaranteed. But it remains a possibility largely because, as yesterday’s primaries showed, Republicans have responded to their suburban erosion by betting even more heavily on the policies and rhetoric that triggered their decline in the first place. In November, white-collar suburbs may be the deciding factor between a Republican rout and a split decision that leaves Democrats still standing to fight another day.

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    Ronald Brownstein

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