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Medicare announced last week it would take the unusual step of undergoing a “national coverage determination,” a nine-month process to decide whether to cover Aduhelm and for which patients. Some experts I’ve spoken to think Medicare, which faces billions of dollars in costs because of the drug’s $56,000 price tag, shouldn’t cover it at all. Even advocates for Alzheimer’s patients who supported the drug’s approval worry some patients will need to spend as much as $10,000 of their own money to access it.

This morass has left patients and families struggling to make sense of the news. For her part, Gilbert said after reading more about the drug, she decided it wasn’t the right move for her mom. A conversation with their neurologist confirmed her decision. But it was still a bit of emotional whiplash.

“It was like having the rug pulled out from under you because you want some hope,” she told me. “But then you get down to the nitty-gritty and you’re back to square one.”

Lynn described to me a recent caregiver support group she led where family members appeared bitterly divided over what to do about Aduhelm. About half of them, she said, were enthusiastic, even after reading the negative news coverage and seeing the concerns about the drug’s unproven effectiveness.

“Their hope and the adrenaline of that hope outweighs all of their reason and they are clamoring for the drug,” Lynn said. “But there was an equal number of people who are angry as hell about this.”

Those people felt Biogen was preying on people’s desperation. Some of them were also caring for patients who would never benefit from Biogen’s drug, even if it did prove to be effective, because the disease has already progressed too far. But they still have the same problems in caring for their loved one and covering the cost of care that they did before.

This is how Lynn characterized their attitude: “Why is this $50,000 being thrown at this thing that’s not evidence-based when we have all these other needs?”

Karlawish told me he believed the FDA should not have approved the drug. When his patients ask him about it, he walks through the circuitous path to approval and he is frank about the uncertain benefits and the risks. He said that, ideally, no one would take the drug without an informed consent form, as part of a clinical trial.

But he also said that if, having heard all the information he has to provide, the patient decides they want to try it, he will be a reluctant prescriber. The disease is already robbing the person of their agency. He won’t do the same.

“I’m gonna have to respect that,” Karlawish said, “out of respect of their autonomy.”

So the struggle is far from over for Alzheimer’s patients, their families, and their doctors. Gilbert is trying to hold onto the small moments of clarity her mom still enjoys, knowing they are fleeting. The other weekend, their family gathered together to process the news of her mother’s diagnosis and to enjoy each other’s company, to have what they hoped would be one more good day.

She had teased her mom earlier in the day about a funky pair of sunglasses she was wearing and was heartened when, later that night, her mom texted her a picture with 10 pairs of “ridiculous” sunglasses she had pulled out of the closet. “Are any of these gonna work for you?” her mom quipped.

“That connection is still there,” Gilbert said. “It might be fleeting, but she’s still here.”

Yet the fear and pain are ever present — “a chronic dull ache,” as she put it.

For people who spend a lot of time around Alzheimer’s patients, every encounter is a reminder that, unless our understanding and treatment of the disease improve dramatically over the coming years, what they are seeing may be a window into their own future.

“It would be hard to not feel that way,” Lynn said. “Whenever we get a former social worker, I have this feeling of, ‘That could be you in 30 or 40 years.’”

Maddie Bialek began crafting most of her clothes as a teenager, a hobby that has helped her assess firsthand clothing prices more critically.

She added that she “isn’t always perfect,” and could make improvements in other aspects of her life, such as reducing plastic waste. But as a high- schooler, it requires a conscious effort on Bialek’s part to resist buying what everyone else is wearing. Social media might be a democratizing force for fashion, but it’s also an accelerator. Teenagers are a prime consumer market for brands, who are able to target age demographics in social media ads. Plus, the integration of “social commerce” onto platforms like Instagram and TikTok further blurs the lines between scrolling and shopping: Users don’t have to head to a retail site to intentionally browse. Their social media feeds are frequently encouraging them to buy through direct advertisements, influencers, or even their peers.

That’s how Shein, the Chinese ultra-fast fashion retailer, became one of the most recognizable retailers for young female shoppers. The US is the brand’s largest consumer market, due to a successful blend of Instagram and TikTok marketing, low prices, and a trend-forward approach. “Most of my friends buy from Shein,” said Chelsea, a 17-year-old from California, who asked to withhold her last name for privacy reasons. “It’s not my favorite place to shop, but their selection is very trendy and affordable, so if I ever need an outfit for a special event, I tend to look for it there.”

Shein’s advertising strategy is notoriously persistent and ubiquitous across all social platforms. There was a brief period when Chelsea would encounter Shein content wherever she went online. It became impossible to avoid the company. On TikTok, the hashtags #Shein and #SheinHaul boast billions of views, with buyers regularly showing off hundreds of dollars worth of clothes in try-on hauls, essentially serving as free marketing for the brand.

@milenalife.style

Which look is your fav Use my code S3milena15 for extra 15% off until 3.31 @shein_official #sheinhaul #springhaul #grwm #commentyourfav #fyp #you

♬ Pop Smoke candy shop - EZD

Chelsea occasionally shops secondhand, but she turns to fast fashion sites when she needs a specific item of clothing, like a graduation dress or a halter top. “When you go to a thrift store, you don’t always know what you’re going to find, which can be fun,” she said. “It’s a lot harder to find a specific style you want in a thrift store, especially during the pandemic.”

Resale apps like Depop and Poshmark have popularized secondhand or vintage buying and selling. Yet, their existence isn’t enough to curtail Gen Z’s enthusiasm towards well- known brands — even those with sustainable shortcomings. According to a survey of 7,000 teenagers by the investment firm Piper Sandler, Amazon is one of the most popular online shopping sites teens turn to for clothes and other miscellaneous items. A few ultra-fast fashion retailers like Shein and Princess Polly were also labeled as Gen Z favorites on the survey, competing with established brands like Nike, American Eagle, and Lululemon.

Like many ideas on the internet, the phrase, “There is no ethical consumption under capitalism,” has been boiled into a pithy punchline, stripped of its original anti- capitalist meaning. “People are justifying why they spent hundreds of dollars on new clothes with this phrase they really don’t understand,” explained Shreya Karnik, the 16-year-old cofounder of the publication Voices of Gen Z. “Well, yes, ethical consumption is hard, but that doesn’t mean you should just drop $500 on fast fashion.” For Karnik and her cofounder Saanvi Shetty, the goal is to shop more intentionally, although they’re aware their personal styles might evolve as they grow older.

While the statement’s meaning has been defanged by TikTok teens, it’s rooted in a general truth, especially when it comes to fashion. Fast fashion is, to put it bluntly, the product of a system that prizes profit over workers’ rights and environmental effects. To be clear, most luxury and mall brand companies are no better than fast fashion when it comes to this. (During the onset of the pandemic last spring, retailers like American Eagle and Urban Outfitters cancelled garment orders last-minute and refused to pay workers for their completed labor.)

To be a consumer requires some level of mental separation from the clothing production process. Executives know that sustainability doesn’t scale, at least not quickly enough or to achieve a billion-dollar business model. As a result, clothing supply chains have become so opaque to allow retailers to maximize profit, and it has been decades since a majority of American-designed clothes were actually made in America. Ethical consumption simply isn’t a facet of the modern fashion ecosystem.

‘no ethical consumption under capitalism’ isn’t an excuse for £100+ worth of shein hauls bestie <3

— kim (@kimchrstina) March 27, 2021

Last May, two researchers from Denmark, Nikolas Ronholt and Malthe Overgaard, published a study titled “The Fast Fashion Paradox.” The pair surveyed consumers between the ages of 22 and 25, and completed one-on-one interviews with respondents to understand why the participants kept purchasing fast fashion, despite their own desires to be more sustainable.

“What intrigued us was how the consumers said they cared about sustainability, but that care did not translate into their actual purchasing behavior,” Overgaard told me. “There was a major gap there. It’s become trendy to label yourself as a sustainable consumer, but it’s another thing to see it reflected in your behavior.”

This paradox is particularly evident in the comments section of clothing hauls on TikTok, where a few commentators would urge haulers to shop more sustainably, only for others to defend the purchase. In one Shein haul video with 500,000 likes, a user commented that they were bothered by how Shein packages each item in individual plastic bags. The creator of the video responded in agreement saying, “It is such a waste, I wish they wouldn’t :(“ The response set off a series of comments asking why she bought from Shein if she cared about packaging waste.

@kenzthebenzz

i only tried 4 things on lol part 2?? #shein #tryonhaul #NewYearNewMiO #foryou

♬ Lofi - Domknowz

Ronholt and Overgaard’s research gets at the heart of this responsibility paradox. Who is to blame in this transaction: the lone shopper who purchased hundreds of dollars worth of clothes, or the billion-dollar retailer? Should social media platforms also be held liable? A majority of consumers surveyed expect the retailers to take more sustainable steps, but history has proven that, unless pushed to do so by shoppers, brands are usually slow to act.

Plus, most corporate brands tend to greenwash their efforts with buzzy branding words like “conscious” or “ethical,” while failing to be specific about their goals. In 2018, for example, H&M was criticized by the Norwegian Consumer Authority for “misleading” marketing of its Conscious Collection; the retailer wasn’t specific about what types of “sustainable” materials its clothes were sourced from or what its clear goals were.

“The current situation looks like a deadlock,” said Ronholt. “There’s this duality in response from consumers who felt they could do better, but still wanted more transparency from retailers. Some even suggested political intervention to solve this, like a tax on things that aren’t sustainably produced.”

But even with sustainability hanging in the back of people’s minds, Ronholt added that young consumers have developed a, “I like it, I buy it,” mentality that does little to offset how often they shop. This, of course, is exacerbated by social media’s effects on trend cycles and clothing seasonality: Fast fashion and major retailers no longer rely on the traditional fashion calendar, and instead operate on the premise of “faster is better” to drive sales based on novelty.

Karnik, the co-founder of Voices of Gen Z, admits she likes to browse Shein, even if she’s not planning to buy, in order to stay up-to-date on trends. As a teenager, Karnik’s clothing purchases are usually made under financial constraints. Price, as well as sizing availability, is a major fast fashion appeal for shoppers with budgets or other limitations.

“I’m guilty of looking, and I have like 98 items saved in my cart, although I haven’t bought anything in the past year,” she told me. “I’ve become aware that fast fashion is all about trends, though, so I’m trying to look for staple pieces that will stick with me for a couple of years.”

The most sustainable thing consumers can do, according to fashion critic Barber, is to buy less overall. Her proposed solution doesn’t require everyone to be perfect; it depends on individual efforts to resist novelty and trend cycles, ideally at a large scale.

“There’s a significant correlation between fast fashion, the way we consume clothing, and the rise of social media,” Barber told me. “You have teens saying they don’t want to wear the same outfit twice on social media, and to be honest, that makes me a bit sad.”

The challenge for sustainability advocates is, in Barber’s opinion, education. The number of people working in apparel manufacturing in the US has steadily declined since the 1980s, and less people know firsthand workers that craft their clothes. As a result, it’s become easy to turn a blind eye as to how clothes are constructed and to accept the unsustainable status quo. “In general, we’re losing tradespeople in our society,” Barber said. “If more people knew how much time went into sewing a pin cushion, they could recognize exploitation in a $3 shirt and become better, more informed consumers.”

The core of Barber’s work is deconstructing corporate-driven sustainability and the bevy of products that are marketed to middle- and upper-class people, items that theoretically make them feel better about buying. Most young shoppers can’t afford, for example, handmade clothes. Some proclaim that a sustainable lifestyle feels out of reach because the products are too expensive or don’t come in their sizes.

But according to Barber, sustainability isn’t a product, but a mindset that’s often established out of scarcity and championed by marginalized people, like her mother, who reused almost every plastic container she came across. Low-income people aren’t the consumers keeping fashion corporations afloat. “The most sustainable thing you can do is wear what’s in your closet,” Barber said. “And keep wearing it. When you need to replace something, do so with options that are secondhand.”

As the youngest demographic of consumers, there is an expectation foisted upon Gen Z to reform their shopping habits, sometimes by their peers. And, as Shetty of Voices of Gen Z pointed out, the sustainability movement feels very gendered. Young people’s consumerist tendencies, it seems, are still malleable, and their politics largely progressive. Yet, the task of undoing decades of marketing strategy and environmental degradation shouldn’t solely fall on a generation born within these circumstances. Significant change requires action from a cohort of policymakers, marketers, and retailers — in addition to shoppers, especially those with disposable income.

As the US withdrawal deadline nears, “Operation Allies Refuge” will evacuate Afghans who helped American forces.

The Biden administration will begin evacuating thousands of Afghans who worked for the US government later this month, ahead of an August 31 deadline for the end of US military operations in Afghanistan.

Current and former Afghan translators, interpreters, and others who have worked with the US government in Afghanistan are facing deadly danger as the US drawdown continues and the Taliban reclaims territory once controlled by Afghan and coalition forces.

As Task & Purpose reported this month, “an estimated 70,000 Afghans who have worked for the United States — and their family members — are at risk of being killed as the Taliban push for a final victory.”

Because of that danger, according to a senior administration official, flights for “interested and eligible Afghan nationals and their families who have supported the United States and our partners in Afghanistan and are in the [Special Immigrant Visa] application pipeline” will begin in the last week of July as part of Operation Allies Refuge.

The Special Immigrant Visa, or SIV, program allows Afghans who work or worked “by or on behalf of the U.S. government in Afghanistan,” as well as family members, to qualify for visas and lawful permanent resident status in the US.

JUST IN: The White House is launching “Operation Allies Refuge” to evacuate Afghan nationals who assisted US and allied forces (plus families) from Afghanistan.

From a senior administration official: pic.twitter.com/4Bet68C6hb

— Andrew Feinberg (@AndrewFeinberg) July 14, 2021

“Our message to those women and men is clear,” President Joe Biden said in a speech about Afghanistan earlier this month. “There is a home for you in the United States if you so choose, and we will stand with you just as you stood with us.”

On Thursday, White House press secretary Jen Psaki told reporters that some 20,000 Afghans have applied for SIVs so far, though the number eligible is likely far larger — potentially as many as 100,000 people, according to Deutsche Welle.

Psaki says approximately 20,000 Afghans have applied for the special immigrant visas for Afghans that supported the U.S. during the Afghanistan War and details how the vetting process for the visas will work. pic.twitter.com/PDhEx6QZnk

— CBS News (@CBSNews) July 15, 2021

The news comes after sustained bipartisan scrutiny from lawmakers, including Sen. Angus King (I-ME), who said last month that he “[wanted] the White House’s hair on fire” over the issue — and a rapid Taliban offensive in Afghanistan has only heightened concerns.

“It’s not only a moral issue, it’s a national security issue,” King told reporters in a telephone briefing, according to Military.com. “This can’t just be business as usual at the State Department. … History judges you for how you go into a war, but also how you leave it.”

Currently, however, only about 2,500 of those evacuees in the SIV program will be allowed to travel directly to the US, according to NBC News. Many others — about 10,000 people whose background checks for a visa are still pending — will instead likely be flown to third countries or to overseas US military bases. Details are still unclear, but Guam, a US territory, is reportedly under consideration as an interim location.

Congress wants to do more for the US’s Afghan allies

Congress has welcomed the Biden administration’s announcement — but lawmakers are still urging the White House to do more to protect the US’s Afghan allies and ease their entry into the US, as well as pushing for legislative solutions.

One such bill, the proposed HOPE for Afghan SIVs Act, would postpone the SIV medical exam requirement until applicants arrive in the US, eliminating a major hurdle for many Afghans.

As things stand, limited access to clinics in Afghanistan that can conduct the exam has created a chokepoint in the process. According to Rep. Jason Crow (D-CO), one of the bill’s cosponsors and a former US Army Ranger who served tours in Iraq and Afghanistan, “there is currently only one facility in Kabul that conducts all immigrant visa examinations for the entire country, forcing applicants from the outer provinces to travel to Kabul in often dangerous circumstances.”

A former interpreter for the United 
States Marine Corps in Afghanistan poses for a portrait in Kabul. Andrew Quilty/The Washington Post/Getty Images
Naseri, formerly an interpreter for the US Marine Corps in Afghanistan, poses for a portrait in Kabul.

The measure passed the House late last month by a bipartisan vote of 366 to 46 and has bipartisan backing in the Senate.

“Approximately 20,000 Afghans are currently stuck in the backlog,” Sen. Alex Padilla (D-CA) said in a statement with Sen. John Cornyn (R-TX). “This bill is a commonsense solution that will help pave a more expeditious path to safety for these Afghans and their families.”

In many cases, the Taliban marks interpreters for death specifically for their cooperation with the US. Some have already been killed, or their family members have been targeted — according to the advocacy group No One Left Behind, more than 300 interpreters and their family members have been killed since 2014.

“I gave everything I had to the Americans, but once they are gone, I will be killed,” one former Afghan interpreter for US forces, Abdul Rashid Shirzad, told the Washington Post. “They keep track of us, and they don’t shoot us like they do Afghan soldiers. If they catch me, they will behead me.”

Currently, Shirzad’s SIV application is pending, according to the Post. In 2016, he was denied a visa for reasons that remain unclear.

’Why didn’t we do this before we withdrew our forces?" Matt Zeller, co-founder of No One Left Behind, shares a harrowing story to illustrate the frantic desperation of Afghan interpreters who worked with the U.S. trying to escape the Taliban’s advance. @mattczeller @n1leftbehind pic.twitter.com/0fSWouSEGA

— Maddow Blog (@MaddowBlog) July 15, 2021

Separate from the the HOPE for Afghan SIVs Act, Sen. Pat Leahy (D-VT) is also pushing for Congress to raise the cap on SIVs to 46,500 visas — a potential increase of 20,000 from current levels.

There are currently several permutations of the SIV program, according to the State Department. Special immigrant visas are also available to Iraqis who worked with the US, and specifically for Iraqi and Afghan translators and interpreters who worked with the US military.

Leahy’s proposed cap increase is part of a potential $3.7 billion security supplemental, which Leahy introduced last week to increase funding for Capitol security in the wake of the January 6 attack.

The package would also make a number of other changes to the SIV program. According to Roll Call’s Caroline Simon, the Leahy plan would “reduce the employment requirement for eligibility from two years to one year, postpone the required medical exam until the applicant reaches the United States, overhaul the appeal process for denials and provide SIV status for family members of murdered applicants, among other changes.”

And it would include $100 million in “emergency aid” for an expected surge in Afghan refugees as the Taliban continue to claw back territory in Afghanistan.

Many of those same provisions are also included in the standalone Afghan Allies Protection Act, a bipartisan bill cosponsored by King, Leahy, and 15 other senators. A version of the bill also has bipartisan support in the House.

However, the Leahy plan for the Afghan SIV program doesn’t have universal support: Sen. Richard Shelby (R-AL), the ranking member opposite Leahy on the Senate Appropriations Committee, has instead proposed a much narrower supplemental package that would only fund Capitol security and does not include money for the Afghan SIV program.

“We made a promise to the Afghans who risked their own lives to support and protect our troops and our country,” Leahy said in a statement on the security supplemental. “As a country, our word is our bond, and we all agree, Republicans and Democrats, that bond will not be broken on our watch. If we do not address this now, then when?”

The US deadline to get out of Afghanistan is approaching quickly

As Leahy’s statement suggests, time is running out for Afghans who have worked with the US — and for the US to find a solution for its allies that meets the moment. In the same July speech where Biden announced the US evacuation effort for Afghan visa recipients, he also set a new withdrawal date for US forces: August 31.

That’s about a week and a half earlier than the previously announced date, September 11, and already, most US troops — more than 90 percent of all forces, according to US Central Command — have withdrawn from the country.

Earlier this month, the US pulled out of Bagram Air Base, the largest US airfield in the country. According to the AP, US soldiers made a quiet overnight departure, shutting off power to the base and leaving without alerting the incoming Afghan base commander.

Bagram has long been the hub for US operations in Afghanistan, and it carries additional symbolic importance as “a gateway to and from a war that cut across constant changes on the battlefield and in presidential administrations,” writes New York Times reporter Thomas Gibbons-Neff.

Last week, Army Gen. Austin “Scott” Miller officially stepped down from his post as the top US commander in the country, marking the effective conclusion of the US presence in Afghanistan. Only about 600 US troops are still in the country, according to the Washington Post — primarily to protect the US Embassy and international airport in Kabul, Afghanistan.

“Our job now is just not to forget,” Miller said ahead of his departure from Kabul Monday. “With the families that have lost people across this conflict, it will be important to know that someone remembers, that someone cares, and that we’re able to talk about it in the future.”

The two men shake hands on a military runway, Austin, a tall Black man in 
a navy suit; Miller, a white man with gray hair in light-patterned Army fatigues and boots. Alex Brandon/AFP/Getty Images

Secretary of Defense Lloyd Austin (left) greets Army Gen. Scott Miller, the former top US commander in Afghanistan, upon Miller’s return to the US at Andrews Air Force Base, Maryland, on July 14, 2021.

Previously, the Trump administration had set May 1 of this year as the deadline to end the US troop presence in Afghanistan; under Biden, May 1 became the start date for a final US withdrawal.

The withdrawal has generated substantial pushback: Former President George W. Bush criticized it as a “mistake” last week in an interview with Deutsche Welle, and former top US Afghanistan commander Gen. David Petraeus told CNN Sunday that “I fear we will look back and regret the decision to withdraw.”

“I’m afraid Afghan women and girls are going to suffer unspeakable harm,” Bush, who launched the US war in Afghanistan in 2001, said. “They’re just going to be left behind to be slaughtered by these very brutal people, and it breaks my heart.”

Biden has said the US will continue to support the Afghanistan government and provide humanitarian assistance, but he stood by his decision to withdraw US troops in remarks this month.

“Nearly 20 years of experience has shown us that the current security situation only confirms that ‘just one more year’ of fighting in Afghanistan is not a solution but a recipe for being there indefinitely,” he said.

The Taliban offensive doesn’t bode well for Afghanistan’s government

As the US drawdown continues, a major Taliban offensive against the Afghan army has succeeded in reclaiming large swaths of territory, raising fears that Kabul, Afghanistan’s capital, could fall in short order after the US mission there concludes.

Since the US withdrawal began in May, the Taliban have steadily expanded their reach in Afghanistan, and are now believed to control “more than a third of Afghanistan’s 421 districts and district centers,” according to the AP.

The Taliban’s increasing hold over Afghanistan.#AFPgraphics map showing parts of Afghanistan under government control and territories under the influence of the Taliban, from April to July 13 pic.twitter.com/f1Mbeuqvla

— AFP News Agency (@AFP) July 16, 2021

Casualties are also mounting: The Taliban murdered at least 22 Afghan commandos last month as they tried to surrender, and Reuters photojournalist Danish Siddiqui was shot and killed in Kandahar on Friday.

Some Afghan troops have also fled the country in the face of the Taliban offensive, crossing the border into neighboring Tajikistan in the north.

Those stories reflect what the Washington Post reported last month is “the new consensus” of US intelligence officials: That the Kabul-based Afghan government, led by President Ashraf Ghani, could fall to the Taliban over the next six months to a year.

The rapid Taliban advance reportedly led the US to consider delaying its withdrawal from Bagram, but officials ultimately opted against it.

Even if the Afghan government remains intact, however, the Taliban offensive is a bad sign. In June, Miller, the former US commander in Afghanistan, warned that Afghanistan could slide into a civil war as the US presence there dwindles.

Whatever happens afterward, however, the US timetable is clear: After two decades of war, US military operations will wind down on August 31.

And with most troops already out of the country, there’s more urgency than ever in the fight to save America’s Afghan allies.

“This is a massive step in the right direction,” Rep. Seth Moulton (D-MA), a Marine Corps veteran, said of the newly announced Operation Allies Refuge. “Now, we just need to keep pressure on the White House to ensure they see this through until all our Afghan allies are evacuated to safety.”

“This is a massive step in the right direction.” says Rep. Seth Moulton on the Biden administration’s plan to evacuate Afghan allies.

“Now, we just need to keep pressure on the White House to ensure they see this through until all our Afghan allies are evacuated to safety.” pic.twitter.com/uyxt6WAIqD

— The Lead CNN (@TheLeadCNN) July 14, 2021

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