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The breathtaking lifesaving impact of vaccines, in one chart

A young girl is given an oral polio vaccine on March 3, 2024, in Srinagar, India. — Photo credit should read Umer Qadir/ Eyepix Group/Future Publishing via Getty Images

It is almost hard to believe just how effective vaccines are at saving infants’ lives.

The world has become a much safer place to be a young child in the last 50 years. Since 1974, infant mortality worldwide has plummeted. That year, one in 10 newborns died before reaching their first birthday. By 2021, that rate had fallen by over two-thirds.

A lot of factors drove this change: lower poverty and better nutrition, cleaner air and water, and readily available antibiotics and other treatments. But one of the biggest contributors, a new study from the World Health Organization (WHO) concludes, was vaccines.

Vaccines alone, the researchers find, accounted for 40 percent of the decline in infant mortality. The paper — authored by a team of researchers led by WHO epidemiologist and vaccine expert Naor Bar-Zeev — estimates that in the 50 years since 1974, vaccines prevented 154 million deaths.

Of that 154 million, 146 million lives saved were among children under 5, including 101 million infants. Because the averted deaths were so concentrated among young people, who on average would go on to live for 66 years, vaccines gave their beneficiaries an astounding 9 billion additional years of life.

The paper was commissioned on the 50th anniversary of the WHO’s Expanded Programme on Immunization, which launched in 1974 to build on the success of the agency’s work eradicating smallpox. It covers a critical period of time. The previous decades had seen a spree of important, newly developed vaccines: a joint diphtheria, pertussis, and tetanus vaccine in 1948, a polio vaccine in 1955, a measles vaccine in 1963. While rolled out quickly in wealthy countries, these immunizations were, as of 1974, not broadly available in the Global South, even as the diseases they prevented wreaked massive damage.

Over the ensuing half-century, through vaccination campaigns led by the WHO and later Gavi (a multilateral group formerly called the Global Alliance for Vaccines and Immunization), that changed radically. In sub-Saharan Africa in 2021, 68 percent of 1-year-olds received a first dose of the measles vaccine, 78 percent received the tuberculosis vaccine, and 70–71 percent received the vaccines against hepatitis B, polio, and diphtheria/tetanus/pertussis.

This progress yielded massive gains. The measles vaccine, in particular, deserves pride of place in this story. The researchers conclude that it averted 93.7 million deaths from 1974 onward, accounting for the most deaths averted by vaccines in general. In terms of lives saved, the runners-up — tetanus (28 million saved), pertussis (13.2 million), and tuberculosis (10.9 million) — pale in comparison. Stamping out measles through vaccination enabled it to go from an omnipresent, fast-spreading lethal threat to a relic of the past — though anti-vaccine activists threaten to undo some of that progress.

The data is a reminder that vaccines have historically been one of our best tools for saving lives and that redoubling efforts to discover and distribute new ones for diseases like malaria and tuberculosis could have a similarly transformative effect.

How the researchers tracked the benefit of vaccines

Studying the effect of vaccines across all continents, and across a 50-year time frame, is a daunting project. It’s not for nothing that this paper has 21 authors. (And let’s give them the credit they’re due. They are: Andrew Shattock, Helen Johnson, So Yoon Sim, Austin Carter, Philipp Lambach, Raymond Hutubessy, Kimberly Thompson, Kamran Badizadegan, Brian Lambert, Matthew Ferrari, Mark Jit, Han Fu, Sheetal Silal, Rachel Hounsell, Richard White, Jonathan Mosser, Katy Gaythorpe, Caroline Trotter, Ann Lindstrand, Katherine O’Brien, and Naor Bar-Zeev.)

The paper is essentially combining three separate kinds of data and research results:

Actual infant, child, and overall mortality across countries from 1974 to 2024, based on the UN World Population Projections dataset through 2021 as well as its projections for mortality in 2022–2024.
Vaccine coverage by country and year, using both WHO databases and those from the Vaccine Impact Modelling Consortium.
Empirically verified models of how measles, polio, hepatitis B, and several other diseases spread in the absence of vaccines, as well as estimates from the Global Burden of Disease study of the effect of vaccination on diphtheria, tetanus, pertussis, and tuberculosis.

Put simply: They used what we know about how many people got vaccinated in the last five decades and how well vaccines work to construct a version of history where all that vaccination didn’t occur, and adjusted actual death rates and health statistics accordingly.

This necessarily involves filling in some gaps in the data. They note that in many countries, our data on vaccine coverage starts in 1980, not 1974; in these places, they argue that vaccine coverage was so meager that assuming no coverage in 1974 and a steady increase thereafter is appropriate. They also conduct sensitivity analyses showing that other ways of handling this problem produce similar headline results.

The years of health life data allows another vantage point on gains from vaccination. Some diseases, like polio, are less lethal than the likes of measles but can cause lifelong negative health impacts, up to and including muscle paralysis. (For instance, while many doctors no longer think Franklin Delano Roosevelt’s paralysis was due to polio, it easily could have been.)

Any way you slice the data, vaccines saved a ton of lives and prevented a ton of suffering.

The past few years have been wonderful for vaccination, mostly due to the tremendously positive impact of the rapidly developed Covid-19 vaccines, but also somewhat perilous. In the US, the share of adults saying all children should be vaccinated against measles, mumps, and rubella has fallen, specifically among Republicans, a likely aftershock of how polarized the Covid vaccine issue has gotten. In that context, it’s important to remember just how much immunization has given us. In a half-century, it’s given people 9 billion additional years to live their lives. That’s nothing short of miraculous.

Read full article on: vox.com

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vox.com

Read full article on: vox.com

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Free Trade Is Dead

41 m

theatlantic.com

Democrats and Republicans don’t agree on much, but for a long time, they agreed on this: the more free trade, the better. Now they agree on the opposite: Free trade has gone too far.On Tuesday, President Joe Biden announced plans to impose steep new tariffs on certain products made in China, including a 100 percent tariff on electric cars. With that, he escalated a policy begun during the Trump administration, and marked the decisive rejection of an economic orthodoxy that had dominated American policy making for nearly half a century. The leaders of both major parties have now turned away from unfettered free trade, a fact that would have been unimaginable less than a decade ago.Since the 1980s, American economic policy has largely been guided by the belief that allowing money and goods to flow with as little friction as possible would make everyone better off. So overwhelming was the agreement on this point that it became known, along with a few other free-market dogmas, as the “Washington Consensus.” (You may know the Washington Consensus by its other names, including neoliberalism and Reaganomics.) According to this way of thinking, free trade wouldn’t just make countries rich; it would also make the world more peaceful, as nations linked by a shared economic fate wouldn’t dare wage war against one another. The world would become more democratic, too, as economic liberalization would lead to political freedom. That thinking guided the trade deals struck during the 1990s and 2000s, including the North American Free Trade Agreement in 1994 and the decision to allow China into the World Trade Organization in 2001.A few voices on both the left and the right had long criticized these theories, but they were outside the mainstream. The first major rupture took place in 2016, when Donald Trump ascended to the presidency in part by railing against NAFTA and attacking America’s leaders for shipping jobs overseas. The same year, a landmark paper was published showing that free trade with China had cost more than 1 million American manufacturing workers their jobs and plunged factory towns across the country into ruin—a phenomenon known as the “China shock.” The coronavirus pandemic further undermined the Washington Consensus as the United States, after decades of letting manufacturing capacity move overseas, found itself almost entirely dependent on other countries for supplies as basic as face masks and as crucial as semiconductors.[Michael Schuman: China has gotten the trade war it deserves]These shifts strengthened the position of critics of globalization and laissez-faire capitalism. The Biden administration, stocked with Elizabeth Warren disciples, entered office eager to challenge the free-market consensus in certain areas, notably antitrust. But on trade, the administration’s soul remained divided. In the early years of the Biden presidency, trade skeptics such as U.S. Trade Representative Katherine Tai frequently clashed with trade enthusiasts like Treasury Secretary Janet Yellen. Biden quietly kept in place the tariffs Trump had imposed on China (which Biden himself had denounced on the campaign trail), but he focused his economic agenda primarily on boosting the domestic clean-energy industry.Then China’s aggressive push into clean energy forced Biden’s hand. As recently as 2019, China barely built electric vehicles, let alone exported them. Today it is the world’s top producer of EVs, churning out millions of high-quality, super-cheap cars every year. An influx of Chinese EVs into the U.S. might seem like welcome news for an administration fighting to lower both inflation and emissions. But it could also devastate the American auto industry, destroying a vital source of well-paying jobs concentrated in key swing states. A glut of discounted solar panels and lithium-ion batteries, meanwhile—China currently produces the majority of the world’s supply of each—would undermine emerging American industries before they could even be built.To the administration, this presented a nightmare scenario. Already struggling parts of the country would experience a second China shock. The U.S. would become dependent on its biggest rival for some of the most important technologies in the world. Republicans would seize on the issue to win elections and potentially roll back the Biden administration’s progress on climate change. (Trump has made the threat of Chinese EVs central to his 2024 campaign, talking about the “bloodbath” that would ensue if they were allowed into the country.)Economics, political science, geopolitics, electoral math: Many of the administration’s incentives seemed to point in the same direction. Which brings us to the tariffs imposed this week. In addition to the 100 percent EV duty, the U.S. will apply 25 to 50 percent tariffs to a handful of “strategic sectors,” in the words of a White House fact sheet: solar cells, batteries, semiconductors, medical supplies, cranes, and certain steel and aluminum products.A president announcing a new policy does not mean that the political consensus has shifted. The proof that we are living in a new era comes instead from the reaction in Washington. Congressional Democrats, many of whom vocally opposed Trump’s tariffs, have been almost universally supportive of the increases, while Republicans have been largely silent about them. Rather than attacking the tariffs, Trump claimed credit for them, telling a crowd in New Jersey that “Biden finally listened to me,” and declaring that he, Trump, would raise tariffs to 200 percent. Most of the criticism from either side of the aisle has come from those arguing that Biden either took too long to raise tariffs or didn’t go far enough. What was recently considered beyond the pale is suddenly conventional wisdom.The old Washington Consensus was built on the premise that if leaders got the economics right, then politics would follow. Cheap consumer goods would keep voters happy at home, trade ties between nations would destroy the incentive to wage war, and the desire to compete in global markets would encourage authoritarian regimes to liberalize. Reality has not been kind to those predictions. Free trade upended American politics, helping to elect a spiteful kleptocrat initially opposed by his own party. The immense wealth Russia amassed by selling oil and gas to Europe may have actually emboldened it to invade Ukraine. Access to global markets didn’t stop China from doubling down on its authoritarian political model.The new consensus on trade taps into a much older understanding of economics, sometimes referred to as “political economy.” The basic idea is that economic policy can’t just be a matter of numbers on a spreadsheet; it must take political realities into account. Free trade does bring broadly shared benefits, but it also inflicts extremely concentrated costs in the form of closed factories, lost livelihoods, and destroyed communities. A political-economic approach to free trade recognizes that those two forces aren’t symmetrical: Concentrated economic loss can create the kind of simmering resentment that can be exploited by demagogues, as Trump long ago intuited. “Back in 2000, when cheap steel from China began to flood the market, U.S. steel towns across Pennsylvania and Ohio were hit hard,” Biden said in his speech announcing the new policy, pointing out that nearly 20,000 steelworkers lost their jobs in those two states alone. “I’m not going to let that happen again.”[Franklin Foer: Biden declares war on the cult of efficiency]A more cynical way to put this is that Biden’s tariffs are a form of pandering to a bloc of swing-state voters. There’s truth to that, but it isn’t the whole story. The political-economic approach also acknowledges that foreign adversaries behave in ways that bear little resemblance to the rational economic self-interest presupposed by mathematical models. They pursue their own geopolitical agendas, market forces be damned—and so America must do the same. China’s dominance in clean-energy technologies is not a product of free markets at work; it was carefully engineered by Beijing, which for decades has poured trillions of dollars of state money into building up industries that it sees as vital to its national strength. To simply accept cheap Chinese exports under the banner of free trade would solidify that dominance, giving Beijing effective control over the energy system of the future.The shift on trade is part of a broader realignment that Biden’s national security adviser, Jake Sullivan, has aspirationally called the “new Washington consensus.” What unites Biden’s tariffs with the other core elements of his agenda, including massive investments in manufacturing and increased antitrust enforcement, is the notion that the American government should no longer passively defer to market forces; instead, it should shape markets to achieve politically and socially beneficial goals. This view has taken hold most thoroughly among Democrats, but it is making inroads among Republicans too—especially when it comes to trade.The details of this new consensus, however, are still being worked out. Trump favors a blunt approach; he has proposed a 60 percent tariff on all Chinese goods and a 10 percent tariff on foreign goods from any country, including allies. Biden argues that Trump’s plan would sharply raise prices for American consumers without much benefit. His administration instead favors what officials call a “small yard and high fence”: major restrictions on a handful of essential technologies from particular countries.These are the terms on which the debate is now being waged: not whether to restrict free trade, but where, how, and how much. That is a very big change from the world we were living in not long ago. The precise consequences of that change will take years to reveal themselves. But they’re sure to be just as big.

A Raunchy Comedy About … Pregnancy?

41 m

theatlantic.com

Preparing a birth plan requires considering the many things that could go wrong during childbirth—or, in the best-case scenario of everything proceeding as normal, how you might attempt to mitigate earth-shattering pain. In Babes, a new comedy about two best friends navigating pregnancy and the delirium of postpartum life, one woman is determined to approach her birth plan differently. Early in her pregnancy, Eden (played by Ilana Glazer) announces that she’d like to bring a little joy into a process that’s otherwise unsettling and clinical. Wanting the day of delivery to feel more like a costume party, she decides to call it “Eden’s Prom Birth Extravaganza.”This scene, one of many that take place in her obstetrician’s office, captures the most compelling part of Babes: its attention to, and irreverence toward, the unglamorous specifics of pregnancy. The film throws the horrors, confusion, and wonders of pregnancy into a raunchy comedy that revels in gross-out bodily humor. There are no graphic Dead Ringers–like visuals, but discussions leave little to the imagination: At the start of the film, Eden’s best friend, Dawn (Michelle Buteau), is close to the end of her second pregnancy. Dawn asks Eden to check if she’s started dilating. Crouching to take a look under her friend’s dress, a wide-eyed Eden informs her, “Your vagina looks like it’s yawning.”Babes, which was directed by Pamela Adlon, is the product of an all-star team: Adlon co-created and starred in Better Things, a remarkable, offbeat FX series about a single mother trying to make it in Hollywood. The film’s screenplay comes from television heavyweights too—it was co-written by Glazer, who co-created Broad City, and Josh Rabinowitz, a consulting producer on that series who also worked on The Carmichael Show and Ramy. And Buteau, a comedian, recently starred in Survival of the Thickest, an endearing coming-of-age series she co-created. In theory, a pregnancy raunch-com coming from this crew should’ve been a riotous but poignant romp. Babes doesn’t quite get there. The film tries to balance its lighter fare with weightier themes—aging out of friendships once children come into play, the guilt that can accompany postpartum depression, the insularity of the nuclear family. That’s a tall order, and Babes never really reconciles the gravity of Dawn and Eden’s growing distance from each other with the comedic territory where its two stars are clearly more comfortable.The film’s surplus of toilet humor is admittedly not for me. (Neither was the much-discussed food-poisoning debacle in Bridesmaids.) Still, there’s something charming about how Babes exaggerates the indignity of losing control over one’s body: When Dawn is upset about being unable to produce milk after her daughter is born, she calls in a lactation consultant who ends up hawking “Her Majesty,” a terrifying contraption that looks disturbingly similar to an HVAC machine. There are mushroom trips, a gag involving Eden trying out multiple pregnancy tests, and a dreamlike sequence featuring projectile breast milk—and in these wacky scenes, Glazer and Buteau are a truly dynamic duo, leaning into the film’s over-the-top physical comedy without hesitation. [Read: American motherhood]Where Babes falters is the comedown. Eden’s pregnancy is the result of a one-night stand, and the father, for reasons I won’t spoil, isn’t in the picture. Faced with the prospect of raising a child alone in her fourth-floor walk-up, Eden chooses to go through with her pregnancy. This is a screwball comedy set in a version of New York City where she can afford a massive, light-filled apartment without family support, so maybe not everything needs to make sense. But Eden is notably flighty, and visibly horrified by the messiness of Dawn’s childbirth; still, she pitches headfirst into having a child without much thought. The unexplained decision ends up somehow feeling even less earned than the unplanned pregnancies of the Judd Apatow cinematic universe.Dawn, for her part, seems baffled by—and later resentful of—Eden’s decision, an early indication that the pregnancy will challenge the women’s already-changing relationship. Sustaining close friendships in adulthood, especially as a parent, can be incredibly challenging—and because the strain of motherhood doesn’t end with labor, Babes brings the reality of raising children in the United States into sharp focus. Through a series of calamitous events that unfold in Dawn’s household, the film portrays the effects of policy decisions that have made the U.S. a needlessly difficult place to have kids. Child-care woes keep Dawn away from work, and from the doctor’s appointments where Eden desperately wants her support. Nothing she does—for herself or for her family—ever feels like enough. “Exhausted actually doesn’t even cover it,” Dawn says in a fight with Eden, before comparing raising two youg children to “an endless loop of other people’s needs.” Through these bittersweet observations, Glazer and Buteau still bring plenty of charm. The actors are a playful pairing, building on each other’s comedic inclinations in a way that sometimes makes Babes feel like a more grown-up Broad City. Watching the moment when Dawn seems perplexed by Eden’s decision to go through with the pregnancy, I was immediately reminded of the classic Broad City scene in which Glazer’s 27-year-old character reacts to the idea of getting married by saying, “What am I, a child bride?” Dawn isn’t there to witness some of the shocking things that Eden later learns about pregnancy—like the size of the needle used in an amniocentesis, or the fact that some pregnancies stretch past the 40-week mark. But when the time finally comes for Eden’s Prom Birth Extravaganza, it’s Dawn who commiserates with her about the injustice of having to push her placenta out too: “They don’t tell you about this part.” It’s true—that detail tends to get left out of the storybook ending in which no one needs stitches. Babes isn’t perfect, but its refreshing candor still feels like an R-rated public service.

A Rat Purge Saved This Island

41 m

theatlantic.com

This article was originally published by Hakai Magazine.The last rat on Tromelin Island—a small teardrop of scrubby sand in the western Indian Ocean near Madagascar—was killed in 2005.Rats had lived on the island for hundreds of rat generations. The rodents likely arrived in the late 1700s, when a French ship—carrying Malagasy people kidnapped for the slave trade—wrecked there, says Matthieu Le Corre, an ecologist at the University of Reunion Island, a French overseas region off the coast of Madagascar. Tromelin Island was probably home to at least eight different seabird species, including hundreds of thousands of frigate birds, terns, and boobies, before the rodents arrived. But, like on countless other islands around the world, the rats ate their way through those birds’ eggs, eventually decimating the populations. By 2005, when researchers and French authorities finally began eradicating the rodents, only two bird species were left: a few hundred pairs of masked and red-footed boobies.Today, nearly two decades after authorities banished the rats, Tromelin Island is once again a thriving seabird paradise, home to thousands of breeding pairs belonging to seven different species. Even more encouraging, the island is one of a growing number of cases where seabirds have returned on their own once invasive predators were successfully eliminated.[Read: The mystery of the disappearing seabird]“In terms of conservation, it’s a wonderful success,” says Le Corre, one of the authors of a recent study documenting the recovery.Ridding a landscape of invaders is one of the main challenges to reestablishing seabird colonies worldwide. On big islands with complex terrain—or even those with numerous buildings and abundant food, like New York’s Manhattan island—it can be virtually impossible. Some rat-removal campaigns have involved spending many years and millions of dollars to eliminate every last rodent. But as a whole, exterminators have gotten pretty efficient. “We have the technology, and we’ve been doing this since 1950,” says Holly Jones, an ecologist at Northern Illinois University who was not involved with the new paper. According to a 2022 review, 88 percent of efforts to eliminate invasive vertebrates from islands succeeded from 1900 to 2020.On Tromelin Island, which is just one square kilometer and uninhabited save for a small scientific-research station, French authorities eradicated Norway rats in a month using poisoned bait.After the predators are gone, researchers may need to help seabird communities on some islands recover, including by restoring vegetation, placing life-size models of birds on the island, or playing recorded calls to lure birds in. But Le Corre says no such efforts have been made on Tromelin Island.As it turns out, the seabirds there didn’t need the help. By 2013, populations of both red-footed and masked boobies had more than doubled. Soon after, white terns, brown noddies, sooty terns, wedge-tailed shearwaters, and lesser noddies showed up in rapid succession. The terns and noddies hadn’t been documented breeding on Tromelin Island since 1856, and there were no records of wedge-tailed shearwaters reproducing there.Impressive as it was, the recovery didn’t surprise Jones. “We know that seabirds, in general, are going to do better once invasive mammals aren’t around,” she says.[Read: Give invasive species a job]Seabirds in other locations have bounced back independently in similar ways. On Burgess Island, New Zealand, for example, common diving petrels and little shearwaters returned within two decades after rats were removed.But not all colonies will recover in 20 or even 30 years, Jones notes. On remote islands, far from other thriving seabird populations, recovery can take much longer, because few birds are likely to fly past and decide to stay. Seabirds tend to return faster to islands close to existing colonies, yet even in the case of remote Tromelin Island, birds can eventually find their way back.Tromelin Island’s recovery was relatively quick, in part because the seabird community is mostly dominated by species, such as terns, that regularly disperse to new homes. But some species are particularly slow to bounce back. Albatrosses, petrels, and other seabirds that remain loyal to one breeding spot rarely try new locations, even if birds from the same species have lived there before. Communities of those seabirds might need coaxing to return.Despite the promising start, Tromelin Island’s seabirds still face the same threats that imperil seabirds worldwide: They can be caught accidentally in commercial fisheries, and overfishing and changing ocean conditions rob them of food. But small as it is, Tromelin Island shows that seabirds are resilient. If people can get rid of invasive predators, island restoration can work—sometimes stunningly.

The Power of Hearing Family Stories

41 m

theatlantic.com

This is an edition of The Wonder Reader, a newsletter in which our editors recommend a set of stories to spark your curiosity and fill you with delight. Sign up here to get it every Saturday morning.As I watch my friends grow older and enter new phases of life, I’ve noticed a common thread: Year after year, many of us happen upon questions we wish we’d asked the loved ones who are no longer with us. Some of these questions are capacious: What kind of friend were they in their youth? Others focus on the everyday: What was the one song they couldn’t live without? And what, exactly, was that famous chocolate-cake recipe?It’s not realistic, of course, to ask every single question while we can. But sometimes our loved ones need a nudge to share a bit more than they might’ve otherwise: “You may be surprised by how much your parents and grandparents haven’t told you, perhaps because they thought you wouldn’t be interested, or they weren’t sure how you’d judge them,” Elizabeth Keating wrote in 2022. Opening that door can lead to insight you never knew existed.On Oral HistoryThe Questions We Don’t Ask Our Families but ShouldBy Elizabeth KeatingMany people don’t know very much about their older relatives. But if we don’t ask, we risk never knowing our own history.Read the article.The Underestimated Reliability of Oral HistoriesBy Stephen E. Nash and SapiensNot only written narratives have stood the test of time.Read the article.What Ordinary Family Photos Teach Us About OurselvesBy Syreeta McFaddenA new book honors unsung figures who have for generations captured the most delicate moments of Black life. (From 2023)Read the article.Still Curious? Learn your family’s history: Ordinary photos and stories can connect you with your roots, Kate Cray wrote in 2023. What kids learn from hearing family stories: Reading to children has education benefits, of course—but so does sharing tales from the past, Elaine Reese wrote in 2013. Other Diversions The strange ritual of commencement speeches Six books that explore what’s out there The godfather of American comedy P.S. Courtesy of Antoine A. I recently asked readers to share a photo of something that sparks their sense of awe in the world. Antoine A., 28, from Versailles, France, sent a photo of Solalex, “a small hamlet in Switzerland, at the foot of the Diablerets mountains.”I’ll continue to feature your responses in the coming weeks. If you’d like to share, reply to this email with a photo and a short description so we can share your wonder with fellow readers in a future edition of this newsletter or on our website. Please include your name (initials are okay), age, and location. By doing so, you agree that The Atlantic has permission to publish your photo and publicly attribute the response to you, including your first name and last initial, age, and/or location that you share with your submission.— Isabel

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God’s Doctors

1 h

theatlantic.com

Nearly 20 million people gained health-insurance coverage between 2010 and 2016 under the Affordable Care Act. But about half of insured adults worry about affording their monthly premiums, while roughly the same number worry about affording their deductibles. At least six states don’t include dental coverage in Medicaid, and 10 still refuse to expand Medicaid to low-income adults under the ACA. Many people with addiction never get treatment.Religious groups have stepped in to offer help—food, community support, medical and dental care—to the desperate.Over nine months last year, the photographer Matt Eich documented the efforts of five such organizations in his home state of Virginia. These groups operate out of trailers and formerly abandoned buildings; they are led by pastors, nuns, reverends and imams. In many cases, they are the most trusted members of their communities, and they fill care gaps others can’t or won’t. —Bryce CovertThe Health WagonWise, Virginia A doctor visits with a patient at the Health Wagon in Wise, Virginia. March 14, 2023. The Health Wagon is the oldest mobile free clinic in the country. It was founded in 1980 by Sister Bernie Kenny, a Catholic nun and nurse practitioner, who first offered care out of a Volkswagen Beetle. Today it has four mobile units that operate out of RVs, plus two buildings that offer medical and dental care. It plans to soon open the first nonprofit pharmacy in the region.This is Appalachia—the western tip of the state, near the Kentucky border. The place has been hit hard by the opioid crisis, and residents suffer from high rates of cardiovascular disease, mental-health problems, diabetes, asthma, and cancer. “We’re the Lung Belt, we’re the Heart Belt, we’re the Kidney-Stone Belt,” Teresa Owens Tyson, who has been with the clinic since its early days and is now its CEO, told me. Most of the people the Health Wagon serves either don’t have insurance or have such high copays and deductibles that they can’t afford to use their policies. Tyson said she’s seen lines of people 1,600 deep waiting at the clinic at 6 a.m. Dental services are in particularly high demand: A 12-year-old recently came in whose teeth were so decayed, the child already needed dentures. Dr. Robert Kilgore takes a dental impression for dentures. March 14, 2023. A conference room at the Health Wagon. March 14, 2023. The RecLuray, Virginia Audre King, Director of The REC in Luray, Virginia on Friday, June 16, 2023. Reverend Audre King grew up in Luray. He went away to college, got married, and was living hours away in Northern Virginia when he says God told him in a dream to go back home and begin a ministry there. He tried to buy a long-abandoned building on his childhood block, but no bank would give him a loan. Finally, the owner agreed to sell it to him for cheap if he used it to serve the community. Digging out all of the dirt and dead animals and hooking the place up to electricity and water took months, but in 2017, the Rec was up and running.It now serves hundreds of hot meals in area where many people live in motels without kitchens. It also provides mental-health programming, kids’ activities, a computer lab, and fitness classes. “Our goal is that anything, for whatever reason, the town or county can’t or won’t be able to fund—a resource they won’t provide—we want to be that help,” King told me.All of its services are provided almost entirely by volunteers; the only person who gets paid is a bus driver who transports kids from their schools and homes to the Rec and back. King doesn’t take a salary for either the Rec or at the Eternal Restoration Church of God in Christ, where he serves as minister; he works for a gas company.When he preaches at the church, he’s teaching the Gospel, he told me; but at the Rec, he’s “living the Gospel.” He pointed to Matthew 25:35–40: “For I was hungry and you gave me food … I was naked and you clothed me, I was sick and you visited me.” Audre King guides kids across Main Street before a group outing to a playground on Friday, June 16, 2023. Audre King and Damon Mendez play basketball with participants from the REC. June 16, 2023 Left: Lunch time at the REC. Right: Damon Mendez carries a speaker into the REC. June 16, 2023 CrossOver Healthcare MinistryRichmond, Virginia Marilyn Metzler, a registered nurse who has volunteered for 27 years, speaks with Father Markorieos Ava Mina at CrossOver Healthcare Ministry in Richmond, Virginia. June 1, 2023. Last fiscal year, CrossOver treated more than 6,700 patients, over half of whom came from other countries as immigrants and refugees. Most undocumented immigrants can’t access Medicaid; those who can may still struggle to navigate the complex health-care system, especially if English isn’t their first language. The interdenominational group runs two free clinics offering primary care as well as cardiology and pulmonology, OB-GYN care, dental and vision care, behavioral-health services, pediatric care for children over 3, and a low-cost pharmacy. CrossOver relies on more than 400 volunteers to see patients, and still can’t open up enough appointments for everyone who comes seeking care: “We turn away about 30 to 35 people a week,” Julie Bilodeau, the group’s CEO, told me. Scenes from CrossOver Healthcare Ministry. June 1, 2023. Maria Santiago Morente receives an ultrasound from Laurel Wallace, D.O., a volunteer at CrossOver Healthcare Ministry on Thursday, June 1, 2023. Adams Compassionate Healthcare NetworkChantilly, VirginiaAbout 10 years ago, Yahya Alvi applied for a job at the Adams Compassionate Healthcare Network, half an hour from Washington, D.C. The organization’s president told him that his dream was to open a free clinic. “That is my passion,” Alvi responded. He started by securing empty space at a nearby mosque and taking free equipment from a clinic that was giving it away. At the beginning, he employed only one doctor and himself, and the clinic was open just one day a week.Today, it operates six days a week and has two paid nurse practitioners in addition to the two doctors. The clinic was founded by Muslims, but it accepts anyone without insurance or the money to pay for medical care, from anywhere in the country and practicing any religion. “Our religion says that all human beings are created by God almighty,” Alvi told me. “And all deserve equal treatment.” ADAMS Compassionate Healthcare Network in Chantilly, Virginia. November 13, 2023. A patient receives an eye examination from a volunteer doctor at Adams. August 12, 2023. Left: Tori Finney, a volunteer, measures a patient at Adams. August 12, 2023. Right: Dr. Fathiya Warsame helps a patient at Adams. November 13, 2023. Dr. Sadia Ali Aden, the executive director of Adams Compassionate Healthcare Network. November 13, 2023. Adams Compassionate Healthcare Network. November 13, 2023. Madam Russell United MethodistSaltville, Virginia Pastor Lisa Bryant at Madam Russell Memorial United Methodist Church in Saltville, Virginia. March 13, 2023. One day in 2021, Steve Hunt was on the side of the road, trying to hitchhike to a grocery store about seven miles from his home in Saltville, Virginia. Hunt had lost his sight a few years earlier, after an infection in his leg went septic and he fell and knocked his retinas loose. Lisa Bryant saw him when she pulled up at a stop sign. She’s a pastor, and she had just finished a service at one church and had to be at another in an hour. She was in a hurry. But just the week before, she had preached about Jesus calling his followers to bring the blind and suffering to him. She gave Hunt a ride. The interaction came at a crucial time for Hunt. “I was at bottom at that point,” he told me. His house was strewn with glass shards because he kept breaking things. He was struggling with addiction. “Everything was falling down around me, mentally and emotionally,” he said. “I was asking God to kill me that day she picked me up.”Instead, Hunt started going to the new 12-step program Bryant had started at her main church, Madam Russell United Methodist. “They just kind of pulled around me, supported me,” he said of the congregation. He’s helped Bryant expand that program, the only one in a town where opioid use is rife but all the addiction-recovery programs are oversubscribed. Bryant has also set up community-service opportunities at her church for people convicted of drug offenses, and is working to secure transitional housing for people dealing with addiction. Bryant doesn’t think the point of being a Christian is just to get to heaven after death, but to see the kingdom of heaven on Earth, too. She’s realized that “giving these people a new community, a healthy community, is one of the best things we can do for them,” she said. “We all need each other. That’s just how we’re created.” People gather before a meeting of the Saltville 12 Step Recovery Group in the basement of Madam Russell Memorial United Methodist Church. March 13, 2023. Saltville, Virginia. March 13, 2023. Support for this story was provided by the Magnum Foundation, in partnership with the Commonwealth Fund.

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Consumers were expected to retreat as inflation skyrocketed, hitting a 9.1 percent peak in June 2022 and remaining stubbornly above the Federal Reserve’s target rate of 2 percent. Instead, Americans just kept buying more, even accounting for price increases and beyond growth in their disposable income. Their spending helped drive US economic growth in 2023 and remained high in the first months of this year. In March, consumer spending increased by 0.8 percent, exceeding expectations from financial analysts. There is a sign that Americans’ shopping spree might be finally coming to an end: Retail spending stayed the same in April as compared to the previous month, falling short of analyst projections for growth. However, those numbers don’t capture spending on services — for example, health care, transportation, and insurance — which has increased markedly this year. And both Preston Caldwell, a senior US economist at Morningstar, and Scott Hoyt, a Moody’s Analytics economist, said those numbers could easily bounce back next month, even if they’re expecting spending to cool by the end of the year. “I am anticipating that we do see eventually a consumer slowdown over the course of this year,” Caldwell said. “It’s premature to say that that’s already playing out right now.” Indeed, spending is bound to come down at some point under the pressure of high interest rates, which the Fed isn’t expected to cut until later this year — or potentially at all in 2024. So why, despite all the doom and gloom among consumers, has spending been so resilient? Who is driving high spending? Two things are simultaneously true: People feel really negatively about the economy, and that’s not stopping them from spending. In May, the University of Michigan recorded its lowest consumer sentiment reading in six months — an index of 67.4 out of 100 — as part of its long-running survey. That’s up from this time last year, but still well below pre-pandemic consumer sentiment readings, which hovered in the upper 80s and 90s. The trend in sentiment was widespread across demographic lines: Consumers “expressed worries that inflation, unemployment and interest rates may all be moving in an unfavorable direction in the year ahead,” the University of Michigan report reads. It’s hard to reconcile that with high spending figures. But in short, the rich currently feel rich and account for a large share of overall spending. The middle class feels a little better off too, and likely still has some savings built up they can burn through. They might not yet have felt the pressure of high interest rates and inflation to the same degree as people who rent and have fewer investments. (But that’s due to change.) High-income consumers — households in the top 20 percent of income earning at least $244,025 before taxes as of 2022 — have been largely cushioned from economic headwinds and are flush with cash to spend. The pandemic saw Americans’ average percentage of income saved increase to an all-time high of 32 percent in April 2020 after many households received stimulus checks. That has helped fuel spending, but unlike in other high-income countries where consumers have proved more thrifty, Americans are close to depleting those savings. “The excess savings [are] still kind of sloshing their way through the system. Depending on how you estimate excess savings, they will be depleted sometime in the middle of 2024 or maybe by as late as mid-2025,” Caldwell said. Many high-income consumers also locked in low interest rates on their mortgages before the Federal Reserve started raising rates in March 2022, and they’re seeing their home values continue to go up nonetheless. The average US home price increased from $287,000 in 2019 to $450,000 in 2024. This is in part due to persistent low inventory: High interest rates have kept would-be sellers on the sidelines because their mortgage payments would be higher if they bought a new place. High-income consumers have also seen their investment portfolios balloon in the last year. The stock market repeatedly tested new highs in recent months, with the latest record set on Thursday in the wake of new data showing that inflation is slowing. And wealthy older Americans who allocate more of their portfolios to government bonds are benefiting from higher interest rates. “That sort of gives consumers an incentive to spend out of their newfound wealth,” Hoyt said. “And since this set of consumers still has excess savings left over from the pandemic, that gives them the easy, relatively liquid monies to do so.” The question is how long the stock market can sustain this run. Some analysts think stocks are currently overpriced and due for a correction — which might cause some people to finally close their wallets. “Equity prices are starting to move more into arguably overvalued territory,” Caldwell said. “So that’s probably not going to be a tailwind [for spending] over the next year.” At the same time, the factors currently fueling spending at the highest income levels aren’t universal. Not all consumers can afford to spend more. Even though inflation has come down significantly from its 2022 peak, low-income Americans are struggling with higher prices. Consumers in general say they are budgeting more on everyday essentials like fresh produce and baby supplies. Among people living paycheck to paycheck, pandemic savings (if they ever really had any) might be long gone. Low and moderate-income consumers are also increasingly weighed down by credit card debt and struggling to pay it down due to high interest rates, which research suggests could be a major contributor to overall economic pessimism. Though credit card debt levels dipped during the pandemic, they are now returning to pre-pandemic levels, with the average balance per consumer increasing by 8.5 percent in the last year to $6,218. More than half of people earning less than $25,000 carry a balance on their credit cards. Their only consolation is that the job market remains strong, meaning they might be able to count on another paycheck — but even that might not last. Analysts including Caldwell expect the unemployment rate to rise from 3.8 percent to 3.9 percent and wage growth to slow in 2024. Ultimately, however, low-income consumers “just don’t account for that big of a share of total spending,” Hoyt said. “It’s the high end of the income distribution that accounts for a disproportionate share of the spending.”

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