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“The stakes are life and death”: Addiction treatment’s Covid-19 challenge

A door is painted with a message to stop selling heroin on a street in a neighborhood with a high rate of poverty and illegal drug use on October 14, 2016, in New York City. | Spencer Platt/Getty Images

The government eased access to drug addiction treatment during the pandemic. Now that could go away.

When the Covid-19 pandemic forced much of the US to lock down in the spring of 2020, officials and experts worried the necessary social distancing measures would make another public health crisis — the opioid epidemic — worse. Addiction treatment is traditionally done in person, and restrictions on gatherings and closed businesses would make it much less accessible.

So the federal government responded by easing rules for getting into treatment virtually — making it easier for treatment providers to retain patients and attract new ones. Even before the pandemic, experts had been calling for making treatment easier to get in the US, and the new rules were a big step forward.

But with vaccines for the coronavirus moving through clinical trials and the end of the pandemic in sight, advocates are worried that the old rules will snap back into place — making it harder, once again, to get people into addiction treatment.

Officials relaxed federal rules in several ways. They allowed doctors to prescribe buprenorphine, an evidence-based medication for opioid addiction, over video or audio calls without requiring an in-person evaluation. They also made it easier to prescribe the medication across state lines, which previously required prescribers to be licensed in both states. And they eased rules for take-home doses of methadone, another proven opioid addiction medication, which traditionally is administered daily to patients at an in-person clinic.

State and federal officials also made it possible for public health insurance programs, like Medicare and Medicaid, to pay for telemedicine addiction treatment services. And some places received permission to go further — for example, delivering methadone to patients rather than requiring they pick it up in person.

Providers say the changes really helped. Many of them had to go virtual almost overnight, as the threat of the coronavirus became clear to much of the country. But they had feared they wouldn’t be able to prescribe necessary medications at all, given the arduous rules on such drugs, possibly putting their patients at risk of relapse, overdose, and death.

Things haven’t gone perfectly, but the relaxed rules, providers and experts say, have helped avoid the worst of it.

“It was incredibly challenging [for us], as it was for all providers,” Alexis Geier-Horan, vice president of government relations at the addiction treatment provider CleanSlate, told me. “Thankfully, we really didn’t lose many patients. … That was only possible because of what the federal government did in response to public health emergencies.”

Addiction treatment has long been difficult to access in the US. According to federal data, only 1 in 10 people with a drug use disorder get specialty treatment. Multiple problems play into that treatment gap, including a lack of local providers, high costs, and poor insurance coverage. Much of the treatment provided lacks evidence, or even rejects evidence-based modalities, and can even be downright fraudulent — leaving potential patients resistant to getting care in a broken system.

That’s why, even before the Covid-19 pandemic, activists and providers were calling for making it easier to prescribe addiction medications. Pandemic or not, some patients have always struggled with transportation, or lived in underserved areas that would require a lengthy trip to get treatment. For these patients, getting prescriptions by telemedicine or phone, or simply having to go to a clinic less often for medication, would help.

On the flip side, the patients who now rely on these services to get treatment, regardless of the pandemic, could stand to lose if the relaxed regulations expire. That’s what those in the field are now worried about: If those patients lose their means to treatment, they might give up on it altogether.

That would come at a particularly calamitous time for the opioid epidemic. Even before the pandemic, drug overdose deaths were trending up. But with the pandemic and continuing spread of the potent opioid fentanyl, overdose deaths have skyrocketed this year: On April 2020 (the latest month of data), there were nearly 78,000 drug overdose deaths, based on preliminary federal data — a 13 percent increase from the same time last year, setting up 2020 to be the worst year for overdose deaths ever.

That’s not, advocates and experts say, a sign that the measures easing access to addiction treatment failed, but rather that the measures didn’t and couldn’t go far enough to address a rapidly worsening overdose crisis. While the measures likely helped ease some of the pain brought on by Covid-19, they couldn’t resolve all the hurdles to treatment in America. That’s a case for building on the relaxed rules, not taking them away when the pandemic subsides.

“The stakes are life and death,” Kelly Clark, president of the advocacy group Addiction Crisis Solutions, told me. “We know, absolutely, that people who are taking their maintenance medications like buprenorphine for opioid addiction have a decreased chance of dying prematurely because of their addiction compared to those who aren’t on medications. This is very clear.”

Providers now worry the lax rules could go away soon

Two of the three federally approved medications for opioid addiction, methadone and buprenorphine, are among the most regulated drugs in the country. Methadone is only administered at specialized clinics — requiring patients to go to a clinic as often as daily to get it, and only letting them earn the ability to take some doses home over time. Buprenorphine can be prescribed by a doctor and picked up at a pharmacy, like other medications, but it still requires the prescriber to go through a special certification, and starting a patient required an in-person medical evaluation.

Then the Covid-19 pandemic came, almost immediately making these requirements unfeasible for patients and providers who now had to get and do treatment virtually.

So federal agencies took advantage of the federal public health emergency declared to combat Covid-19 to ease the rules — making telemedicine, including video and audio calls, more feasible for buprenorphine, and easing rules for methadone take-home doses. Local and state agencies followed suit.

But the changes are only in effect until the public health emergency expires. That’s left advocates and providers worried, and they’re increasingly sounding the alarm — as early as possible — to get Congress or other officials to act. They’ve called on federal lawmakers to pass the TREATS Act, which would make many of the rule changes permanent, as soon as possible.

Speaking for [the American Society of Addiction Medicine], ASAM would love to see the TREATS Act passed with any kind of legislation that goes through during this lame-duck [period], so that we don’t have to face this other unknown coming into the year,” Clark, former president of ASAM and vice chair of the group’s Covid-19 task force, told me.

The typical argument for keeping the old rules comes down to fears of diversion: that the medications will be diverted to a black market for recreational uses. Buprenorphine and methadone are opioids, and, though they’re very effective for treating addiction, they can be misused. So loosening access to either too much, the argument goes, could lead to the drugs ending up in the wrong hands.

As the Drug Enforcement Administration put it, “Under normal circumstances, DEA would not consider the initiation of treatment with a controlled substance based on a mere phone call to be consistent with the framework of the [Controlled Substance Act] given that doing so creates a high risk of diversion.”

Providers take these concerns very seriously, and have adopted a range of practices, such as regular urine screenings, to make sure people are actually taking their medications and not relapsing. Many providers are concerned that loosening the rules too much, and simply doing treatment virtually, could make it harder to prevent diversion.

At the same time, some experts argue that concerns about diversion are overblown. For one, some research suggests that diversion is a result of people not being able to legally obtain buprenorphine or other treatment, forcing them to resort to illegal means of getting the medication. So the stricter regulations could be causing more diversion, not preventing it.

That indicates a balancing act is needed. If it turns out, in the pandemic, that expanding telemedicine for buprenorphine increases access without much more, if any, diversion, then maybe the right balance is more toward a laxer regime than the longstanding laws and rules suggest.

“These agencies are trying to balance the public safety side of making these changes with the public health side,” Geier-Horan, who previously worked on addiction treatment under the Obama administration, said. “From a CleanSlate perspective, the benefit of these things far outweighs those [diversion] concerns.”

Some researchers are working to find out if that’s the case, studying how virtual treatment has worked throughout the pandemic. A JAMA Psychiatry article noted there’s a dearth of research on the role of telemedicine in addiction treatment, including whether it improves access and can be done without significantly increasing diversion.

“That could be really helpful in getting people on board,” Allison Lin, lead author of the JAMA Psychiatry article and an addiction psychiatrist and researcher at the University of Michigan and the VA Center for Clinical Management Research, told me. “We do need more research to provide that data. We don’t have those kinds of answers just yet.”

Short of that, providers are sharing their own experiences, arguing that they’ve been able to maintain a level of care, and even gain some patients, throughout the pandemic despite the obvious disruptions Covid-19 has brought on. But they also worry that losing the new tools they have now could lead to the opposite result once the pandemic is over, fueling a drug overdose crisis that’s already getting worse.

Effective addiction treatment is inaccessible to many Americans

Although the Covid-19 pandemic has in some ways overshadowed it, America’s opioid epidemic is still in full force. It’s in fact gotten worse this year, based on the data we have. The widespread sense of isolation and despair that many people have felt this year, coupled with greater difficulty finding help for such problems as many places close down, has contributed to more drug overdose deaths. Paired with that, the powerful synthetic opioid fentanyl has continued to supplant heroin in more of the illicit market — and in part because it’s so potent, it’s more likely to cause overdoses and deaths.

“While our attention has gone to Covid, and rightly so, our overdose deaths have skyrocketed,” Clark said. “We have to keep overdose deaths on the map.”

One of the key contributors to this crisis all along has been lack of access to evidence-based treatment. Good treatment remains very difficult to get in the US — it can cost tens of thousands of dollars out of pocket, and despite those high costs, it’s still frequently of bad to mediocre quality. One family I spoke to last year told me that they spent $200,000 on treatment before they found something that worked. That’s an extreme example, but it’s not rare, based on the thousands of responses to Vox’s survey about the issue, for people to spend an exorbitant amount on treatment and end up with little to nothing to show for it.

That’s not because evidence-based treatment doesn’t exist. For opioid addiction, the medications are truly proven to work well. Studies show buprenorphine and methadone reduce all-cause mortality among opioid addiction patients by half or more, and they do a far better job of keeping people in treatment than non-medication approaches. There are all sorts of other good treatment modalities for other kinds of addiction, including medications and paying people to stay in treatment (known as contingency management).

But these evidence-based approaches are dramatically underutilized. According to federal data, only 42 percent of the nearly 15,000 facilities tracked by the Substance Abuse and Mental Health Services Administration (SAMHSA) provide any type of medication for opioid addiction. This is largely driven by stigma — the faulty notion that medications replace one drug for another, even though the medications are proven to improve outcomes compared to continuing to use illicit drugs.

So there’s a dearth of providers for evidence-based treatment. When those providers are available, they might not be covered by insurance, and cost thousands out of pocket. If someone has gone to a treatment facility before and ended up with a bad experience due to shoddy, evidence-less care, they also might be skeptical that there’s good help out there at all. That all makes treatment less accessible, and people less receptive to it.

That’s why much of the work to combat the opioid epidemic, from legislation passed by Congress to state efforts to more localized approaches to lawsuits, has gone to expanding access to treatment: If truly effective treatment exists, then it’s just a matter of making sure it’s available to the public.

Along those lines, activists had pushed for more access to telemedicine for years. Of particular concern were underserved areas with few providers — like rural West Virginia, which has a massive overdose crisis and not enough addiction treatment providers to handle demand from patients. Telemedicine can make it easier for existing providers to serve other areas in the state, or even people in other states entirely.

It’s also about expanding the spectrum of care. Every person dealing with addiction is different. Some people are fine with being on medications; some people aren’t. Some will like treatment through Zoom or phone; some won’t. Some have a car; some have no reliable transportation. By offering a variety of options for what care is delivered and how, the hope is fewer people won’t get into treatment because there’s not an option for them.

“It’s not to say everybody should get telehealth, or everybody should get in-person [treatment],” Lin said. “It was just that, before, everybody was in person because that was the only option available.”

Covid-19 has made a lot of things worse, including the opioid crisis. A silver lining to all of this is it’s also given us a big, ongoing experiment to see if a telemedicine model can work for addiction care.

Some providers are now hoping that the eventual end of the pandemic isn’t the end of that experiment — given that it may be helping stave off what’s already the worst drug overdose crisis in American history.

Why Trump taking credit for the Covid-19 vaccines could be a good thing

President Trump wearing a face mask.
President Donald Trump tours a lab in North Carolina in July where components for a potential vaccine are made. | Jim Watson/AFP via Getty Images

After he leaves office, he can help convince his supporters to get vaccinated for Covid-19.

Donald Trump clearly wants credit for the recent successes of the Covid-19 vaccines US companies are developing. “I came up with vaccines that people didn’t think we’d have for five years,” he said on Fox News Sunday. He’s now apparently not only taking credit for his administration’s Operation Warp Speed, which has pumped billions in to the vaccine development process, but for the vaccine formulations themselves.

With each new, exciting development, Trump has taken credit. When the pharmaceutical company Pfizer announced promising results from its Covid-19 vaccine clinical trial with BioNTech, he claimed in a news conference the success was “as a result of Operation Warp Speed.”

Trump’s comments about the Pfizer vaccine weren’t quite true. Pfizer has not received money from Warp Speed, the administration’s plan to catalyze vaccine development — at least when it comes to research and development: The US government has agreed to purchase 100 million doses of Pfizer’s vaccine if it gains approval. The government has given Warp Speed money to Moderna, whose vaccine also appears to be extremely effective. Even in the case of Moderna, it definitely wasn’t Trump who catalyzed the research and development of the technology.

But you know what? Let Trump take credit for these vaccines.

And not because he’s been an actual champion of science, scientists, or the regulatory process. Let him take credit because it may serve a greater good: convincing his Republican followers to trust and take the vaccine when it becomes broadly available. That, ultimately, could save many lives.

Many Americans are hesitant of an eventual Covid-19 vaccine — Republicans more so than Democrats

We may eventually have vaccines, but the question remains: Will people take them?

Only 58 percent of respondents on a recent Gallup poll indicated they’d take the vaccine when it first gains approval. This figure is up from a low of 50 percent back in September. Before that, willingness to get vaccinated had been declining throughout the summer.


Gallup

What’s more, the surveys might actually be underestimating the problem of mistrust. “When we look at seasonal influenza vaccination rates, for example, surveys always overestimate the number of people who get it,” Matt Motta, a political scientist at Oklahoma State University, told me over the summer. It’s a lot easier to tell a pollster that you’re going to get a vaccine than it is to actually go get one.

According to Gallup, just 49 percent of Republicans say they’d get a vaccine when it’s approved. (Democrats are more confident, at 69 percent, with their their confidence on the upswing.) Which means there’s a chance for Trump to do some actual good in his final days in office and after he leaves by continuing to trumpet his contribution to the vaccine process, thereby inspiring some of his Republican followers to take the vaccine.


Gallup

To beat the virus, we’ll need a large proportion of vaccinated people across the country (at least 50 percent or higher), and that number needs to include people of all political beliefs.

Trump’s power to sway minds is real. Can he put it to good use?

Trump owns a lot of the blame for much of the Covid-19 vaccine hesitancy for many reasons: for instance, his constant attacks on scientists and his insinuations that the career officials at the Food and Drug Administration played politics with the vaccine approval.

But he has an incredible power to shift the opinions, nearly overnight, of his followers. My colleague Dylan Matthews has documented sudden changes in opinion on topics like Russia and Vladimir Putin, free trade, and support of the news media’s watchdog role. Or consider how Trump riled up Republicans hostility toward the NFL after calling on the league to fire players who kneeled in protest during the national anthem.

Trump’s power to sway Republican minds has also been shown experimentally, as I wrote about in a 2018 piece on the “follow the leader” effect in political science.

In January 2017, BYU political scientists Michael Barber and Jeremy Pope designed an experiment that wondered: Are Trump’s supporters ideological, or will they follow him wherever his policy whims go? Right after Trump’s inauguration, they ran an online experiment with 1,300 Republicans.

The study was pretty simple. Participants were asked to rate whether they supported or opposed policies like a higher minimum wage, the nuclear agreement with Iran, restrictions on abortion access, background checks for gun owners, and so on. These are the types of issues conservatives and liberals tend to be sharply divided on.

Barber and Pope wondered: Would Republicans be more likely to endorse a liberal policy if they were told Trump supported it?

The answer: “On average, across all of the questions that we asked, when presented with a liberal policy, Republicans became about 15 percentage points more likely to support that liberal policy” when they were told Trump supported it, Pope says. They follow their leader. “The conclusion we should draw is that the public, the average Republican sitting out there in America, is not going to stop Trump from doing whatever he wants.”

The effect even held true on questions about immigration. If Trump supported a lax immigration policy, his supporters were more likely to say they did, too. (They’ve also replicated these results with new responses, later in the Trump presidency, though these new findings have yet to be published in a peer-reviewed journal.)

I recently contacted Barber and Pope and asked them: Do they think Trump has the power to sway GOP minds to take the vaccine? “Trump’s best move from a public health perspective would be to take credit for whatever vaccine emerges — moving Republican voters to be more trusting of the vaccine,” Barber said in an email.

Not only would it help to encourage more people to get the vaccine overall, but also Trump supporters getting the vaccine could be particularly helpful in stopping the pandemic.

Trump supporters are less likely to engage in behaviors that help stop the spread of the virus, like mask-wearing, which will still be needed for some time even if there’s an approved vaccine, and have been more vocally opposed to stay-at-home orders. If they’re still feeling loyal to Trump in 2021 after he leaves office, they could be a big part of the solution when it comes to the vaccine.

There could be other consequences to a Trump vaccine endorsement, however: If Trump supports the eventual approved vaccines, might Democratic voters be less likely to get it? Yes, Trump can change the minds of his own voters, and he may also change the minds of his opposition, in the opposite direction: The recent decline in Democrats’ trust in a potential vaccine may be linked to Trump’s rhetoric.

“You’re right to worry about decreased trust among Democrats, but I think that might be mitigated if the scientists also backed the vaccine — people like [Dr. Anthony] Fauci and others in the FDA/CDC,” Barber says.

Trump can’t solve vaccine hesitancy alone

Of course, Trump inspiring his followers to take the vaccine doesn’t solve the overall hesitancy problem. Surveys have also found higher rates of hesitancy among women and Black Americans, groups that are generally less likely to listen to Trump.

It’s not just that people are afraid the science is being rushed or that the administration is playing politics with the approval process; as I reported in August, people are also worried about costs and access.

The lesson here isn’t that Trump can fix this giant mess he’s created. It’s that everyone in power who has influence over public opinion should encourage their followers to get the vaccine if it’s deemed to be safe and effective by the scientific community. The messaging needs to be extra clear and consistent because both of the most promising vaccines — the Moderna vaccine and the one from Pfizer — require two doses. People will need to be motivated to sign up for not just one shot, but two.

There’s so much about the US response to the pandemic that has been botched. We failed on testing early and then failed to scale it up. We failed on contact tracing and on reopening many of our communities safely. But we haven’t screwed up a vaccine campaign yet.

There’s still time to get it right. Trump endorsing a vaccine that’s shown to be safe and effective is a decent start — even if it comes with a heap of undue boasting.

What happened to department stores?


The fates of the American middle class and American department stores have always been intertwined.

Department stores, once a symbol of the American middle class, have been declining for years, along with the shopping malls they anchor in communities across the US. Just last year, both the high-end Barneys and the country’s oldest department store, Lord & Taylor, went bankrupt and announced plans to close all their locations.

Then came the coronavirus pandemic, which shocked the economy, hitting lower- and middle-income Americans the hardest by forcing them out of work and deeper into debt, with little or no relief in sight. The crisis also temporarily shuttered most nonessential physical retail stores and kept people at home for months, giving them more reasons than ever before to shop online at e-commerce giants like Amazon or from the smaller direct-to-consumer brands whose ads follow us all around the internet.

As we near the end of 2020, the prognosis for the American department store is grimmer than it’s ever been. The reasons extend far beyond Covid-19 or even the continued rise of online shopping, and have more to do with trends in the American economy that have been shrinking the middle class while enriching the already wealthy. That’s why the decline of these retail giants is something to pay attention to. They employ hundreds of thousands of people and occupy an outsize space in our communities; their gradual disappearance, as well as what is replacing them, tells us something about where we’re headed.

—Samantha Oltman, editor of Recode


The death of the department store and the American middle class

The collapse of America’s middle class crushed department stores. Amazon and the pandemic are the final blows.

by Jason Del Rey



Pop culture’s department stores taught us what to want

by Constance Grady



The death and rebirth of America’s department stores, in charts | coming Wednesday

by Rani Molla



What one of Amazon’s biggest critics thinks about the future of the industry | coming Thursday

by Shirin Ghaffary



How retailers track your every move in exchange for coupons and convenience | coming Friday

by Sara Morrison


Pop culture’s department stores taught us what to want

Animated drawing of a television set showing a scene from the remake of the movie Miracle on 34th Street, a young girl sitting on Santa’s lap with a twinkling Christmas tree behind them.
Shaneé Benjamin for Vox

In movies like Splash, Miracle on 34th Street, and The Women, the department store is where we go to learn middle-class values.

There’s a French movie from 1930, black-and-white and silent, that begins with a young country girl named Denise walking into Paris. Upon her arrival, Denise is greeted by ads: sign after sign, billboards, banners, parades, flyers that blow right into her outstretched hands. And all of them are advertising just one thing: the city’s grand new department store, Au Bonheur des Dames, the Ladies’ Paradise.

At this magical new department store, from which the film takes its title, Denise can find whatever she wants. That’s what the ads promise her: The department store holds all that you desire.

The department store is one of the great movie and TV backdrops of the 20th century. Expansive, luxurious, and filled with props that lend themselves to everything from comedy to romance to horror, department stores are by their nature cinematic. The camera sweeps lovingly over their racks upon racks of goods in movies and TV alike: Splash, Mad Men, Miracle on 34th Street, The Queen’s Gambit, Dawn of the Dead. Department stores are where we go to find all that we desire. And they teach us what it is that we’re supposed to desire, too.

Under capitalism, you are what you buy. If you’re a respectable member of the bourgeoisie, for most of the 20th century, you buy at a department store.

So the department store offers pop culture a place for teasing out issues of class, and specifically the middle class. For nearly a century, the department store has been where pop culture has gone to think about the middle class.

And now, as the American middle class compresses, the department store is leaving, too.

At the department store, you can learn to become a real girl

Arguably the greatest cinematic innovation of the department store film is the makeover montage. The chance to watch characters try on identity after identity, and every last one of those identities is for sale. And at the center of the makeover montage is the character learning how to perform class and gender, how to become respectably middle class, and how to live out a hegemonic gender identity.

This idea goes back to Au Bonheur Des Dames, which features Denise, newly hired as an in-store model at that fancy department store, learning how to walk and dress the way a bourgeois woman walks and dresses. She paces back and forth through the models’ dressing room in her slip while the other models laugh and jeer at her, but by the time the store hosts a fashion show, she’s learned how to sway her hips correctly.

And it stretches to this year, when 2020’s The Queen’s Gambit sees chess prodigy Beth go straight to a department store with her chess winnings so she can buy proper suburban ’60s teen black-and-white saddle shoes, all the better to lord it over the mean girls at school who mocked her for her orphanage-standard brown ones.

In 1984’s Splash, when Madison the mermaid wants to learn how to be a human woman, she heads right to Bloomingdale’s, where a kindly saleslady informs her that her men’s suiting just won’t do. The saleslady puts her in a miniskirt and heels, and Madison wanders over to the electronics department to watch a jazzercise class on a TV bank. Within hours, she’s speaking fluent English.

Perhaps the most elaborate department store makeover montage of all comes in 1987’s Mannequin, when Emmy — a time-traveling Egyptian ghost who is also a department store mannequin; truly, this movie is exquisite — leads her window-dresser boyfriend through a variety of quick-change costumes and dances. As synth-heavy ’80s hits play in the background, rapidly they become rock stars, gangsters, vampires, and beach bums.

The character justification for this montage is that Emmy longed to see the world and try out new things back when she was alive, but she never had the chance. Now that she’s a mannequin within the rich, wide world of a department store, she can do it all — kind of. She can be anyone she wants to be because the multitude of clothes offered by a department store will make her that person. Emmy doesn’t need real life as long as she has the department store.

And the department store offers employment to those deserving members of the middle class who have fallen on hard times. When Mad Men secretary Joan leaves her office job upon her marriage, only to find that her husband can’t support them after all, she gets a job at a department store. When The Marvelous Mrs. Maisel’s Midge divorces her husband, before her career in standup comedy works out, she too supports herself with a department store job.

But the class movement the department store offers isn’t always presented as a good thing. The adultery that powers 1930’s The Women begins when a wealthy husband goes to a department store to buy perfume for his wife, and then he ends up falling for the perfume salesgirl. And when the wife’s rich and catty friends go to the store to confront the salesgirl, such are her savvy street smarts that they end up falling into an elegant store-branded trash bin, shrieking in humiliation. When the salesgirl enters another department store as a customer and dares to meet the wife on equal footing, the wife knows at last that she has lost.

Even horror movies know that department stores are where we go to reestablish our identities as safe, respectable members of the bourgeoisie. In George Romero’s 1978 film Dawn of the Dead, it’s the mall and especially JC Penney where the survivors of a zombie plague try to shelter. But the zombies are irresistibly drawn there too, by “some kind of instinct. Memory.” After all, “this was an important place in their lives.”

The story of the department store in pop culture is the story of the rise and fall of the middle class

In pop culture, the department store builds and reaffirms the middle class, and in this way the store itself comes to stand in for the class. Films and TV have tracked the creation and supremacy of department stores, and their decline. And the message is clear: When the store that sells all your desires with a smile is in danger, the middle class is, too. The department store must be protected.

Not that the department store is always in danger. When Au Bonheur des Dames hit screens in 1930 and codified the tropes of the department store movie, the department store is the big new bully on the street, and it’s destroying Denise’s family boutique drapery. It drives her uncle to madness, and after he runs at the department store with a gun, he’s fatally run over by one of their trucks. The shop’s owner, stricken with remorse, offers to give the store up — but Denise, seeing the writing on the wall, tells him no: He must keep the store and marry her. Together, they will make Au Bonheur des Dames into the biggest store in the world, never mind what lives are destroyed in the process. That is their dream; that is capitalism.

By 1947, Miracle on 34th Street sees the department store transcending any questions of bullying other stores or being in any danger itself. The Macy’s where Kris Kringle sets up shop simply is, as eternal and unchanging as the vision of Christmas that Hollywood was at the same time busily enshrining into American popular consciousness. And when Kris Kringle institutes a new policy of sending shoppers to competitors if Macy’s doesn’t stock exactly what they’re looking for, it comes across as an act of condescending noblesse oblige. Of course Macy’s can afford to be generous. Everyone knows that its competitors don’t pose it any real threat.

But by the time Mannequin came around in 1987, the classic grand and gracious department store of the beginning of the century — stores like the Herald Square Macy’s of Miracle on 34th Street — was already in danger. The tawdry new-money department store had arrived to threaten it.

In Mannequin, Emmy’s store of choice, Prince & Co., is represented onscreen by Philadelphia’s iconic Wanamaker building. Wanamakers was the first American department store, and it’s built like a cathedral, with a giant organ that spans multiple stories of the vast marble mezzanine and an ethos of fine craftsmanship and personalized customer service.

Prince & Co. is facing stiff competition from trashy nearby Illustra, which features plastic hangers, windowless underground shopping levels, faceless modern mannequins, and budget-friendly low prices. But Emmy and her boyfriend are able to bring a new level of prestige and excitement to Prince & Co. with their groundbreaking window displays — which means that as they save Prince & Co. from Illustra, they’re saving a specific idea of what it means to be middle class.

The trajectory these films outline is one in which stores get progressively more and more impersonal and soulless. And every time they do so, our pop culture warns us, we take a step away from beauty and humanity and a step toward alienation and self-loathing.

But the journey doesn’t end with the transition from elegant Prince & Co. to cheap and convenient Illustra.

Since the 1980s, department stores have slowly faded out of popular culture’s present day. Sure, Rachel on Friends worked at Bloomingdale’s, and Mr. and Mrs. Smith had a shootout in a department store in 2005. But generally, department stores have stopped feeling all that relevant to pop culture that’s meant to be contemporary and urgent. Instead, over the past few decades, when department stores have shown up in the movies or on TV, they’ve tended to be in period pieces, where part of the point is to get lost in the glamour of a bygone world: Cate Blanchett swanning through a department store toy floor in her fur coat in 2015’s Carol; Rachel Brosnahan pitching the perfect red lipstick on The Marvelous Mrs. Maisel.

And in 2015, a new show emerged about a store that continued that promise to sell you all that you desire.

“One-stop shopping for everything you could ever need” is how this new store is described in the opening of the first episode. “Do you want to be thinner, fatter, happier, sadder? Are you looking for friendship? Solitude? Or even love?” This new store was there to sell them all to you.

But it’s not a department store. The show is Superstore, and the store it’s describing is Cloud Nine, a big-box store in the mold of Walmart or Target. That’s the new place our pop culture sends us to find everything we desire: a store just as destructive to mom-and-pop businesses as Au Bonheur des Dames was, but without the seductive trappings of luxury and glamour to compensate. The new signifier of the middle class is a lot more precarious and a lot less beautiful than the old one was.

And the superstore isn’t the last step, either. After all, if there’s a single place in the world that’s going to sell you all that you desire, that will take us to the final word on convenience, affordability, and alienation, it’s not the department store. And it’s not the superstore, either.

It’s the Everything Store. It’s Amazon.

This week in TikTok: The only election that mattered


The TikTok Room awards might be the future of celebrity fandom.

Hello from The Goods’ twice-weekly newsletter! On Tuesdays, internet culture reporter Rebecca Jennings uses this space to update you all on what’s been going on in the world of TikTok. Is there something you want to see more of? Less of? Different of? Email rebecca.jennings@vox.com, and subscribe to The Goods’ newsletter here.

The only awards show that mattered this year went down over the weekend, but you couldn’t watch it on TV. It happened on Instagram, on the most important account for Gen Z social media stars and their followers: TikTok Room.

It’s hard to overstate the influence of TikTok Room to the growing world of the micro-famous (and now, some actually famous) TikTokers who comprise the most followed users on the app. Like the Shade Room, which it is directly modeled after, the account posts gossip and other hard-to-find morsels of drama, like deleted tweets, recordings of livestreams, or screenshots of comments, replies, and likes between popular creators.

During the pandemic, when kids and teens are living their lives online and spending less time with classmates and friends, digital dirt is more essential than ever. When I wrote about TikTok Room in February, the account had nearly 300,000 followers; now it has almost 2 million.

Most importantly, TikTok Room is run by two regular fans who are anonymous outside of their first names: Elasia, a 19-year-old college student in New Jersey, and Nat, a 17-year-old high schooler in Texas. Its graphic design and branding may seem slightly amateurish, but that’s also what makes it feel so authentic: Nat and Elasia are just genuinely so obsessed with creator culture that the account posts dozens of times a day, often within minutes of major drama occurring. (I asked Elasia if she considers herself a journalist; she said, “We don’t post fake tea.”)

All this is to say that when TikTok Room announced that it would be holding its first awards show in November, it was a pretty big deal. Nominees such as Charli D’Amelio, Bryce Hall, and Loren Gray encouraged their fans to vote for them in categories like “Best Dance Creator,” “Best Clapback,” “Least Problematic Female,” and “Best Ship” (for creators who haven’t confirmed their relationship status but whom fans love to see together). Voting took place last week via Google Form, and the results, which were rolled out in a series of timed Instagram posts on Saturday night, included pie chart breakdowns of the voting results for transparency.

The winners were not particularly surprising. Beauty YouTuber James Charles won “Best Makeup.” “Best Role Model” went to body-positive creator Sienna Gomez (as did “Least Problematic”). Charli won “Most Achieved Female,” and “Best Dance Creator” went to “Say So” choreographer (and Vox profile subject) Haley Sharpe. These are the users TikTok is synonymous with, and that says volumes about the future of social media stardom: These users are, for the most part, white, cis, thin, and primed to make hundreds of thousands, if not millions, of dollars from their followings.

Maybe more pressingly, the TikTok Room awards prove how little “real” awards shows matter anymore, and how much mainstream celebrity culture has to catch up on. According to the awards’ results, nearly 500,000 votes were cast, which would illustrate an enormous rate of user engagement for the account’s 1.9 million followers. There are rapidly expanding and increasingly niche fandoms for more and more TikTok creators, and the power rankings are constantly in flux. We already know how overnight fame can affect young people’s lives and mental healthespecially when it goes away. These mechanisms are already in hyperdrive, and they’re getting faster.

Whatever this sort of attention does to the influencers themselves, TikTok Room and its marquee awards are a wildly impressive feat for two regular teenagers who might be the future of entertainment media. Though kids under 18 may not have been able to vote in that other election last month, to some of them, the TikTok Room awards might have been the one that mattered more.

TikTok in the news

  • ByteDance has been given yet another deadline extension to sell TikTok to US ownership. (It’s now December 4.) An amazing holiday present would be to give up the whole charade and let us TikTok in peace.
  • “How did I end up on Cartel TikTok?” is a question you’ll see asked a lot on social media, as videos of dozens of bags containing what are assumed to be illegal drugs or exotic pets and luxury cars have popped up on hundreds of thousands of TikTok users’ feeds. Yet according to experts on organized crime, it’s all just “narco-marketing” — that is, “the latest propaganda campaign designed to mask the bloodbath and use the promise of infinite wealth to attract expendable young recruits.”
  • Relatedly, many TikTok users, including me, have been served videos that appear to be filmed in North Korea. Some appear to be staged; for instance, one video shows people waiting at the top of a staircase seeming to wait for a cue. The account describes itself as “North Korean residents sharing their current daily life” and says it is produced in the Chinese city of Dandong, next to the North Korean border. But like all media that purports to come from North Korea, where citizens are subject to some of the world’s most extreme censorship measures, its origins and intentions are suspect.
  • Former Target employees are claiming on TikTok that Target will “let” you steal from stores, all the while tracking everything you take over time until the total is more than enough to prosecute people for grand larceny. Current Target employees, DM me!
  • Here’s a cool mini-doc on how LGBTQ Muslims are building a community on TikTok.
  • Megan Thee Stallion remains Thee queen of TikTok trends.

One Last Thing

Sick of seeing everyone’s perfectly color-coordinated Christmas trees on Instagram Stories? Here is a TikTok for those who appreciate a tree with, uh, “character.”