Wednesday, December 29, 2010

Dumb Science + Politics = Media Fascination!

The recipe is pretty simple: take some current topic of theoretical interest to many people (e.g. coffee drinking, organic food consumption, political views, amount of daydreaming, or some such), then pick some biological outcome to measure (e.g. death, prostate cancer, brain size, happiness, or some such) and try to see whether they correlate. Then, after you have made the fascinating finding (study finds that coffee drinkers less likely to develop constipation as octogenarians!), you get interviewed by "science journalists" and end up on TV and radio shows, even though most of these "journalists" appear to understand very little about science and have dismally low standards as journalists.

Case in point today comes from Salon as it references an article from the British paper The Telegraph about how different political views correlate with differences in the size of certain parts of the brain. The gist: "conservatives" appear to have larger sized amygdalas; the amygdala plays a central role in the processing of emotional reactions, which The Telegraph article describes as "often associated with anxiety and emotions." Moreover, conservatives have smaller anterior cingulates--a part of the brain the articles describe as "responsible for courage and optimism."

The reality? It's likely nonsense. The study hasn't been published yet (indeed, one very big red flag is the fact that the study findings are being released to the media before going through the theoretically rigorous process of peer review) so I can't comment with great precision on its validity. But it sure doesn't smell right: they took the "brain scans" (unclear from either story whether they were MRIs or CT scans) of two, yes, two Members of Parliament, one from Labour, the other a Conservative, and then reviewed the brain scans of 90 "students" (again, unclear if college-aged or not) and matched the sizes of the brain structures against a questionnaire designed to elicit political views. Again, the questions weren't made available, so it's really hard to know how they measured political values. Even so, the study design doesn't seem especially impressive. Students? Isn't the point of being a student to create one's worldview, meaning that some students will surely drift further toward the right in life, some further left, and some change not much at all? So how can this population be used to measure political attitudes? Is the distribution equal between men and women? Between whites and blacks? Immigrants and natives? Students and non-students? Well, we already know the answer to that question--and couldn't that bias the results all by itself?

Even more concerning is the whopper unloaded by the researcher himself when he said that he and his team were "very surprised to find that there was an area of the brain that...could predict political attitude." But his study predicted nothing at all! They took scans, administered a questionnaire, and then after the fact compared the two. Prediction would entail administering the scan and guessing what the responses would be before they were given. That's a freshman-level mistake and sure doesn't boost my overall confidence in the sophistication of this guy.

But the most odious part of this sorry little news flare is found in the first line of The Telegraph article, which begins, "Scientists have found that people with conservative views have brains with larger amygdalas." What's so singularly frustrating about this opener is that it quite possibly leaves less eagle-eyed readers with the impression that this is both a) unquestionably true because it was "found" like a little fact in the forest, and b) "scientists" are all agreed as to its truth--both of which seem dubious at best. At least in Salon, they change the passive verb formulation "scientists have found" to a more-cautious note of "a study to be published next year suggests."

It's still quite likely prattling nonsense, careful phrasing or no. And as the links supplied in the Salon piece make clear, political bloggers (apparently from both sides of the aisle) have seized on the findings and spun their own theories, each sounding as silly as the study probably is. People want scientific literacy? Find some journalists who have a sense of what constitutes good science and have them leave the junk to languish in throwaway journals, that's one place to start.

Tuesday, December 28, 2010

A Tale of Two Values

On Christmas Day, the NY Times ran a story whose title really does give readers most of the necessary information in the article: "In Budget Crunch, Science Fairs Struggle to Survive." The article goes on to quote various educators worried about the impact of these cutbacks, but there aren't any real surprises.

But while the story is accurate in collecting and relaying the details, I'd argue that it is narrowly telling the story (granted, as good journalism often should). Even without a strained economy, science education--or indeed, education of any sort--has long played second fiddle to that Great American Obsession, sports. For much of the 20th century the two were able to coexist in something approaching harmony since there was plenty of money to go around. But even before the Great Recession of recent years, public schools have been faced with cutback after cutback, while both amateur and professional sports have gotten fatter and fatter, budgetarily speaking. I recall as a kid growing up in northern Ohio and listening to the radio on election nights as my family listened to the majority of school levies, most of which were asking for a pittance, go down to defeat.

Not so the public financing of stadiums, which the public seems to adopt with a certain slobberingly stupid zeal, as witnessed in these articles on the financing of the Florida Marlins baseball stadium, an attempt to finance a professional soccer team stadium in Portland, Oregon, a brief take on the return-on-investment for Paul Brown Stadium in Cincinnati, and details and an opinion about the huge tax subsidies the city of New York granted in the construction of the new Yankees stadium. Comparing the amounts of public money that  these businesses receive to the amount that school boards meekly request is akin to comparing the size of an NFL lineman to that of a Pop Warner player: you're not in the same, um, ballpark.

And we're surprised at the decline in educational standards in this country? Right.

Thursday, December 16, 2010

No, There Is Not a Cure For HIV

One of the guiding principles of the Billy Rubin Blog is quite simple: namely, that mass media in the US provides grossly distorted and exaggerated "news" to a largely uncritical public that appears to be not only more interested in ESPN, but only interested in said network. This blog's major concern is the distortion of scientific and medical news, and this week provided an example of just how irresponsible "journalists" can become in pursuit of a sexy headline.

"German doctors declare 'cure' in HIV patient," the Reuters headline proclaimed Wednesday. The story got legs immediately, and was picked up by nearly all of the outlets one would consider mainstream: the Fox coverage can be found here, CNN's article can be found here (more on CNN shortly), Yahoo's article is here, the US News & World Report brief is here. Once the stories showed up on the respective websites, it rapidly rocketed onto the "most viewed" and "most e-mailed" lists: at the time of this writing, the CNN site lists just over 10,000 Facebook "shares" and 413 comments--easily among the top 5 health stories for that website over the past week; over at Fair & Balanced, the numbers were almost identical.

One small problem: it's not really true. Oh, sure, the facts of the story, as reported, are correct: there was a patient infected with HIV, and this same patient now does not appear to have HIV due to a bizarre quirk of cell biology and transplant medicine (more on this shortly). But the truth of the matter is that one patient with HIV became improbably, almost impossibly, lucky, and aside from the scientific curiosity that the case has for the physicians and scientists who study and treat HIV, there's nothing so hugely important in this story that merits a splashy shout-out in the health sections of major news outlets.

The headline does most of the damage: doctors declare cure. The online dictionary Your Dictionary has three separate relevant definitions for the word "cure," which are: a) restoration to health or a sound condition; b) a medicine or treatment for restoring health, remedy; c) a system, method, or course of treating a disease, ailment, etc. In declaring "cure," the German doctors were using the first definition. Technically, it is a perfectly adequate definition. But the reason why the news media ran with the story, and the reason why it's gotten flashed all over the internet in very little time, is because they understood the word "cure" in the latter two senses--that there was some new magical treatment on the horizon for the tens of millions of people infected with the virus. And that is, quite simply, a dream: there's no cure at all. One guy just got very lucky.

This reality did not stop major networks from jumping on the "cure" bandwagon, when its science and health "correspondents" should have known better. Here is CNN's Elizabeth Cohen barely containing her enthusiasm for the story:

It's important to note that the anchor, in framing the story, asks his audience to "listen up" and says that "doctors in Germany claim they may have found a cure for HIV"--which isn't what they claimed at all, and again wildly exaggerates the importance of the story based on that misreading of the word "cure." This is followed by Cohen performing the two-step of noting the facts, but ignoring the meaning those facts have, which is that this is a whole lotta ado about nothing. "This is so fascinating that, even if this isn't the cure for HIV, which it's not, it's still amazing what these doctors in Germany did," she gushes [my emphasis]. What ensues is a lot of back-and-forth graphics reminiscent of Ross Perot's presidential bid. There are, indeed, caveats that lace their way through the discussion, but the overall tone of excitement and optimism is unmistakable.

What makes such enthusiasm unfortunate is that it's a lie. Whether Cohen has deceived herself is unclear, but nevertheless the amount of fake hope generated by such a story is corrosive in at least two ways: it oversells what medicine is capable of, and in doing so helps to promote a backlash against the genuinely amazing things that modern medicine can accomplish.

CNN, to their credit, does make an attempt to contextualize the finding with an opinion piece stressing extreme caution when reading the story. But even here they screw the pooch a bit by throwing up the title "Why HIV advance is not a universal cure." Again, this is remarkably misleading--it's a cure only for one lucky person! A better title might have been, "Why HIV advance is not a cure at all."

What happened with this patient? You can read the articles for details but the quick version is that HIV lives in special immune cells, and this HIV-infected man had a cancer of the immune system. One of the principal ways we treat immune cell cancers is by completely destroying the patient's immune system and transplanting a different person's immune system into the patient (we also sometimes harvest the patient's own immune cells, get rid of the cancerous ones, and transplant them back in after "nuking" the patient's body, which is called an autologous transplant). The person who donated the immune cells to the patient had a special mutation in his immune cells that prevent HIV from entering the cell and setting up house; this donor is literally immune from HIV--part of a very, very small number of people on earth who cannot be infected by the virus.

Anyway, this is the Cliff's Notes explanation. What it misses (and what the news stories largely ignored as well) is that the bone marrow transplant that led to this patient's "cure" is basically a game of Russian roulette, with a high one-year mortality rate, a not-especially-impressive remission rate (it varies depending on the type of immune cell cancer, but they have nearly universally horrible prognoses), and causes unimaginable pain and suffering for the few months before and after the transplant. Even if there were an abundance of similar donors, we'd kill tens of thousands for the iffy chance of having "cured" an equal number. In the age of perfectly adequate HIV drugs--which keep the virus at bay but do not produce "cure" and thus need to be taken for life--this seems like a mad scientist's dream.

Where was the breakdown? Part of it lies at the feet of the German physicians, who might have thought more carefully about the implications of touting cures that simply aren't practical and thus don't really, truly exist. But I'd direct my venom at the health and science editors of the news outlets I've mentioned; there just doesn't seem to be any care taken in investigating this story, and in the case of Elizabeth Cohen's CNN piece, it's worse than that, as she runs away from the more sober implications of the story, even though she is fully aware of such implications, swept up as she is in the wonder of the Modern Medical Miracle. It's tremendously irresponsible journalism. This is a story that nobody should have touched.

Curiously, after seeing the article in a Reuters link at The New York Times, I have been unable to find any other mention of it at the Times website. Here is their page devoted to news on HIV. As of this evening (December 16), they appear not to think of it as worthy of their attention or their readers' attention. I not only concur with them, I applaud their restraint!

Wednesday, December 15, 2010

Evolution Ain't a Ladder, and We Ain't at the Top

The idea that we humans are the most privileged, most developed, most special creatures on earth has been around, of course, a very long time, further back than when the Bible creation stories came into being, further back than Gilgamesh, probably further back than when some guys took to painting on a wall at Lascaux. Since Darwin, though, we've known better: humans are just another species trying to make its way in the world, quite intelligent to be sure, but no more or less special than, say, a bacterium happily living in the soil.

But thinking of ourselves as the Most Special Species--where evolution is a ladder and the top rung is occupied by humans, who preside over all life much like Adam on the Seventh Day--has been hard to root out. Even intelligent and thoughtful people can fall into the metaphor in the midst of an otherwise lucid discussion about science. Such a thing happened today when Gina Kolata, the science writer for the New York Times, was writing about some new research on the killer bug Staph aureus.

Ironically, when I saw the article I thought that it would make a great blog entry from the perspective of how warped laypersons' perceptions are about the relative dangers of various microbes. Even those only with a nodding acquaintance with science often have heard of Ebola, no matter that Ebola is a very rare disease and no human case has ever occurred in the US (not from the lethal strains, anyway). Staph, meanwhile, which is an outright killer, was barely known outside of medical circles until the past decade, when the drug-resistant staph strain MRSA was the culprit in various outbreaks, including a famous outbreak among the St. Louis Rams football team. I often feel like I could have summarized the major clinical take-home point of my fellowship in Infectious Diseases in two words: "Staph kills."

Alas--a more in-depth discussion about the warped perception the public has about various diseases will have to wait, because Kolata fell into the we're-on-top ditch midway through the article. While discussing the predilection that Staph has for human blood over other animal species, Kolata wrote, "Staph definitely preferred human blood...but there also was a definite trend, the higher up the evolutionary scale an animal was, the more the bacteria liked its blood" [my emphasis]. But Gina, it just ain't so! Those creatures whose blood was more liked by Staph were more closely related to humans on the evolutionary tree, but not higher on a scale, not more "advanced", not more worthy of the description "living thing." Evolution allows for adaption to particular living conditions, and the creatures that occupy each niche are all equal. The best way to visually think of the web of life is as a two-dimensional non-vertical tree (the vertical version, with "man" at the top, can be found in an exemplary drawing from the early 20th century below). We're just hanging out at the end of a branch like every other living thing.

Tomorrow, a brief commentary about this Reuters piece announcing a "cure" in an HIV patient. While the facts are true, the message is deeply misleading.

Wednesday, December 8, 2010

The Dearth of Republican Scientists

There's an essay in Slate today that wins points for turning arguments completely upside-down. In "Lab Politics," author Daniel Sarewitz encapsulates pretty much his entire point in the subtitle: "most scientists in this country are Democrats, and that's a problem."

So far, so good--although my own politics aren't likely to turn Red anytime soon, I don't disagree with his observation. Problem is that he seems to think that the fault of this imbalance lies largely with the scientists themselves, rather than a Republican Party whose unequivocal anti-scientific, anti-intellectual rhetoric has driven the vast majority of scientists away.

Sarewitz spends most of his time discussing the climate change debate, and making the very slippery contention that "disagreements over climate change are essentially political--and that science is just carried along for the ride." To be fair, he doesn't quite assert this: rather, he asks it rhetorically, implying that there's more than a grain of truth to it. He explains:

For 20 years, evidence about global warming has been directly and explicitly linked to a set of policy responses demanding international governance regimes, large-scale social engineering, and the redistribution of wealth. These are the sort of things that most Democrats welcome, and most Republicans hate. No wonder the Republicans are suspicious of the science.

There are at least two misconceptions here. First is that "evidence" about global warming is directly linked to a political program by the scientists themselves--implying that scientists are working in lock-step with the Democratic political establishment to bring about policy change. This is largely nonsense, and ironically describes fairly accurately how the other party operates. Second, nobody "welcomed" climate change as an excuse to legislate "large-scale social engineering,"--whatever that means--so his whole analysis sounds like a daydream to me.

Climate change is a fact. It's extent can be debated, but not its existence. To pretend that "Republicans are suspicious of the science" is to give the Republicans far too much credit: they simply deny that there's any scientific validity to anything with which they disagree a priori. No wonder the Republicans are suspicious of the science--good grief! The Republicans don't believe in evolution! How could you expect them to believe in anything that requires scientific literacy? No Republican politician in this country can reasonably expect to gain the presidential nomination if they support the teaching of evolution in public schools. How could you expect scientists to willingly join such ranks?

There are thinkers on the public scene who are vocal enthusiasts for science and who simultaneously hold beliefs that don't dovetail with the Democratic party: author and football columnist Gregg Easterbrook is one such voice of whom Billy is fond. A generation ago, his politics would have put him squarely in the center of the Republican party. But the Republicans sold their soul to the devil around that time, and decided that the best way to deal with the fallout of unpleasant scientific facts was to attack science itself. Those intellectuals are in search of a home, neither comfortable with the Democratic party (Billy sympathizes, though he no longer finds his home there because he's fallen off the other edge) for political reasons, nor with the Republicans because of their hate-mongering anti-intellecutalism.

So please, Mr. Sarewitz, spare me the false equivalencies.

Tuesday, November 16, 2010

It's Not Nice To Fool Mother Nature

The AP reported this week about an unusual method of battling dengue fever. Dengue, a virus that's transmitted by the bite of the Aedes aegypti mosquito, causes hundreds of millions of infections worldwide and accounts for about 20,000 deaths each year, the vast majority in children. Since early in the 20th century there have been only occasional cases of home-grown dengue in the states along the Texas-Mexico border, though in the past year there appears to have been a full-scale outbreak in Key West, Florida, and a case of dengue in a man who never traveled out of Miami was just reported by that city's newspaper.

While dengue has been a known disease for centuries, serious researcher on the disease dates to about World War II, when Albert Sabin (famed father of the polio vaccine) did experiments with US Army recruits, actively infecting them with the virus and studying their immune response. (It's not an exceptionally lethal virus, killing only a tiny fraction of those who are infected, but still. Times have changed.) Despite the 60+ years of work, a successful vaccine remains elusive, although there are many different groups hard at work on vaccines in various stages of clinical testing. So far, the leader is the company sanofi aventis (no caps is correct, don't ask), whose Sanofi Pasteur division has its candidate vaccine in what is called Phase 3 clinical trials, the final stage before receiving governmental approvals. Their vaccine is based on a very cool concept. They've taken the Yellow Fever vaccine, called 17D, which has been around seemingly forever--it's the first true modern vaccine--and is quite safe and very well tolerated, and spliced a piece of dengue's genetic code into the YF 17D genetic code. Since Yellow Fever and dengue are closely related viruses, this is, in concept, simple to do, and the genes that are swapped are those that encode for the surface proteins, so the human immune system "sees" a virus that looks like dengue, but the vaccine still uses the 17D proteins to replicate itself. We still need to see the results of the Phase III trial but it looks very promising at this point in time.

That said, it makes perfect sense to look for other solutions to the dengue problem, and one approach has been to control the mosquito populations. Olivia Judson of the NY Times speculated about this in her blog over two years ago. The AP report this week indicates that the company Oxitec Ltd has figured out a way to genetically engineer male mosquitoes so that they are sterile. After the science of gene manipulation, the concept is simple: release enough sterile males into the environment so that they mate with females who proceed not to reproduce, and just like that your mosquito population is lowered. The AP story notes that they've released 3 million of the critters in a small area on the Cayman Islands as a pilot project. The story also goes on to quote some worry-warts who fear that the company is jumping into an ecological experiment without having considered all of the variables. The story quotes Pete Riley, the founder of GM Freeze, a British group that opposes genetic modification. "If we remove an insect like the mosquito from the ecosystem, we don't know what the impact will be," says Riley.

Count me among the worry-warts this time. "Teaching" our immune system to recognize pathogens has been a wildly successful strategy at keeping people alive and healthy for over two centuries; messing with the environment as a means to control disease has occasionally worked, but equally as often has spectacularly failed. In the 50s and 60s, there were wholescale "malaria eradication" programs in the western hemisphere where DDT and other insecticides were used in an effort to stamp out mosquito populations, and we know how that solution worked out. One point Riley makes is that a collapse of the mosquito population will have unknown effects in the food chain, and could possibly lead to some other disease being introduced by an insect predator stepping into the breach. I'm a little skeptical about this, only because Aedes aegypti populations have taken off precisely because of human development over the past 150-200 years. These critters are as domestic and reliant on civilization as we are, as we constitute their happy hunting grounds--unlike other mosquito species, who live quite placidly in the wild. That said, I do agree that you never know what's gonna happen when you do a large-scale ecological experiment, and our these kinds of projects almost always, forgive the pun, come back to bite us.

Oxitec notes that they aren't trying to bring about permanent change since the genetically sterile males can only hang around for a generation, although to me that begs the question: what's the long-run solution? Are we going to keep introducing genetically sterile males, generation after generation, to keep mosquito populations low? And how will we define "low," anyway? Leave aside the ecological implications, which has the possibility of bringing about unintended consequences (in a way that a new vaccine almost certainly doesn't), it's an incredibly costly, top-heavy solution. And the last time I checked, a huge number of the countries that really suffer from the burden of dengue don't have the kind of cash or infrastructure that would make this kind of an approach feasible. You'd get a lot more bang for your buck if you just hired people to come visit houses and identify and eliminate all areas of still water where mosquitoes lay their eggs. Do that, and watch your skeeter population drop just as much as with the fancy genetic experiment.

Wednesday, November 10, 2010

Truth, Found in Football

Killing a bit of time earlier this evening, and I happened upon an article in Slate--don't ask me why, I'm still trying to figure that out myself--by the sportswriter Stefan Fatsis. Stefan, who parlayed his weekend warrior soccer talents into a Paper Lion-style project as a placekicker for the Denver Broncos, has been a keen commentator on NFL issues given his insider experiences. I usually hear him on NPR, but since he had an article in Slate writing about the narcissism of Brett Favre, I figured I'd take a look with a few spare minutes.

Much as I'd like to talk about Favre, what caught my eye was an assertion that Fatsis made about another NFL primadonnish narcissist, Dallas Cowboys owner Jerry Jones. For those who don't follow the sport, Jones is regarded as something of a football equivalent of Yankees former owner George Steinbrenner: megalomanical, autocratic, a man who interferes with his coaches and management because he thinks that he knows everything about everything. Fatsis describes him like this:

...the meddling owner who considers himself a businessman, promoter, player personnel expert, general manager, entrepreneur, public speaker, draft guru, and coach.

This description is couched as part of a larger point, which is the link between Jones's personality and the Cowboys' rather spectacularly bad 1-7 record so far this season. Leave aside the devastating injury to Tony Romo, the star quarterback of the team, thus utterly preventing easy wins for the past several weeks, the Cowboys were still a bad team this year, despite being picked to be a contender to play in their very own stadium for this year's Super Bowl. The question is why they're so bad. Here's Fatsis's analysis:

It is hard to pinpoint exactly how and why an NFL team falls to pieces. There are so many moving parts. But a hefty share of the blame should go to the meddling owner...That ego seeps into every nook and cranny of that organization and clogs up the machinery. The result is a 1-7 team: uninspired and looking forward to Jan. 3, the first day of the offseason.

Truth can be found in a discussion of football, and the truth is this: it's not hard, especially in an age of easily procured data, to fact-check one's arguments, yet people often seem to rely on lazy assertions as long as it fits in with the prevailing narrative. Fatsis, in writing about Jones, makes not only a specious argument, but makes one while the facts are sitting quietly like Christmas presents, eagerly waiting to be opened and used by their owners.

You see, Jerry Jones has owned the Cowboys for over twenty years...there's a very long track record to establish if his ego does indeed "clog up the machinery." And to judge by his record--or rather, his team's record--it does nothing of the sort. I googled "Cowboys record by season" and within four minutes learned that, since 1989, when Jones bought the team, the Cowboys have a record of 185-159 for a winning percentage of .538, plus three Super Bowl victories. That's not too shabby, especially from the point of view of this long-suffering Cleveland Browns fan. Take away his one true lemon season, his first (which one could argue was a perfect storm of new owner combined with the departure of a legendary coach in Tom Landry), and his record is 184-144, with an even more impressive .560 winning percentage. So if Jones's megalomania is really responsible for their failure, why have they had so many successes during his ownership?

Instead, Fatsis cherry-picks the data, musing on the awful 1-7 record of this season, completely ignoring the rest of the data set. As a result, what we get is a tale of an owner run amok, and a moral lesson about the proper role of humility: don't think you're a genius at everything--just look at what Jerry Jones did to the Cowboys! Never mind that this reasoning is totally at odds with Steinbrenner's success as an owner, nor does it explain the perennially bad showing of the LA Clippers, owned by the hands-off Donald Sterling, who appears to take little interest in his team and almost never bids high for a player's services. Indeed, one reading of Jones's stewardship could be the polar opposite of the Slate article: if you are confident in yourself and trust your judgement, provided your judgement is good, sometimes that will pay off even if you don't rely on (or even overrule!) so-called "experts." (The Cowboys' record, it should be noted, is more erratic than consistently good, as the winning percentage only gives an average of the 20+ years and is misleading. They were the best team in football in the early-mid 90s, while from 2000-2003 they were positively mediocre. So Jones isn't always right, but sometimes he appears to have been as right as one could get.)

I don't care a great deal about Jones, and I care even less for the Cowboys, but what I found singularly irritating about Fatsis's assertion is that it could easily have been checked. Why he didn't is a mystery, since he normally is an intelligent writer. What is much more disturbing is that such lazy baseless assertions are not at all confined to the trivial world of sports commentary. And the assertions that people are going to make in the next few years may--I only say "may"--have a huge impact on how we fare locally and internationally for many more years still.

Sometime soon: cat scans, mammography, and lung cancer, and the media coverage thereof.

Thursday, October 21, 2010

NPR Reveals How Big Pharma Influences Your Doc, and Fires Juan Williams, Too

This entire week, National Public Radio--that known haven of insane Marxist-Socialists--has aired a series of reports illustrating in lurid detail the extent to which physicians are manipulated by pharmaceutical companies into becoming unwitting accomplices in their efforts to generate profits. When you see how the game is played (or more accurately, how doctors are played in the game) you can't help but a) cringe, and b) wonder about the amount to which your own doctor is manipulated. I am a doctor and these stories (along with other books and articles I've been reading) are making me question just how much my own prescription practices have been influenced by these tactics, and that's in spite of the fact that I have assiduously avoided drug reps since I was a fourth-year medical student. How many times have I heard lectures from senior physicians--even those from within the academic medical centers where I was trained--where some large corporation's money had influenced the speaker, who may have been unknowingly acting as a shill? How many times have I taken these lectures at face value, assuming they were given by disinterested academics who took only the best evidence into account when preparing their slides? The more I learn about these practices, the more I realize I have no idea. Just follow the link, listen to the stories, and have some scotch at the ready. It ain't pretty.

Today's installment on All Things Considered brought a new twist to the game. I have long known that the cozy little dinners at nice restaurants sponsored by drug companies were not likely to be places where one could get unbiased information. Today's story, however, explains that sometimes the drug reps target not the audience, but the speaker in order to generate revenues. The recipe: find a practicing physician with a large patient base and prescribes a large volume of drugs. (Companies have access to the prescriptions made by doctors because of arrangements they have with pharmacies. It's perfectly legal and any doctor's prescription habits, down to the last valium tablet, can be tracked.) Approach the physician and explain that he or she is a "thought leader" and welcome them to come give these dinner talks. Provide them with slides about your wonderful drug. Watch them speak. Follow that doctor's prescription patterns--not the ones who come for the cabernet and prime rib, but Dr. Thought Leader Himself/Herself--and watch the money roll in as your company's drug sales shoot through the roof for the month or two after the gig.

Mind you, this is all above board: there's no quid pro quo as part of these speaking gigs. There doesn't have to be one. Beyond the speaking fee (which is typically around one grand: very nice money to be sure) there is no explicit arrangement as to the content of the talks. Indeed, the overwhelming majority of docs would be seriously indignant if there were any implication that they should explicitly endorse drug X at someone's instruction before a talk. No, the key to the scam (let's call it what it is) is that such docs are manipulated through a psychological trick that allows them to succumb to influence precisely because they think they're above influence. "[Doctors] come to the table with the belief that because they have gone through this rigorous academic training that they are somehow impervious," says Dr. David Switzer, a doc who blogs about the interactions between drug reps and physicians. "I don't think that we're as good at that as we think that we are."

According to one former drug rep quoted in the story, a $1500 investment in the speaker's fee plus, undoubtedly, a whole ton of flattery to a high-prescribing doctor could result in a bump of $100,000 to $200,000 for the drug in question--all from just the speaker. One can't draw too many conclusions from just one example, but the yarn is enough to make me believe that various drug companies would make it part of their marketing arsenal. Indeed, if it's legal and other companies are out there doing it, they'd be fools not to.

One of the only humorous moments of the story was when one of the drug reps had to explain what to do with some of the less stellar "thought leaders." Recall, the game is to try to target the doctor who prescribes a lot. Such a doc might not be charismatic, might be unattractive, might not even be a very good doctor, but all of that is beside the point. If they are all of the above, that's clearly a bonus and you want to have the added benefit of that speaker's influence on the audience. But if those qualities are not in play and all you are trying to do is to get the doc to push your drug, you want to limit the damage, and you book the gig at a fast-food style restaurant to ensure low attendance. (Doc Rubin, no doubt, would do no better than top billing at a parking lot outside the local coffee & donut shop!)

If you are a political junkie, you may also have seen how NPR got Big Media to pay attention to it briefly, for firing Juan Williams, their longtime news analyst. Williams, who lived the weird double-life as a commentator for both NPR and Fox News, has slowly and inexorably been moving toward this moment for some years probably. I have been unimpressed by Williams's thoughts on NPR for a very long time (not unlike its other major political commentator, the even more vapid Cokie Roberts), but his stellar performance on Fox was a piece of work, and NPR couldn't abide by it, leading to a he-said-she-said (literally) trading of accusations documented at NPR.

In case you hadn't followed all this, the brouhaha started when Bill O'Reilly opined in a guest spot on The View that "Muslims killed us on 9/11," causing the usual media flap (to say nothing of hosts Joy Behar and Whoopi Goldberg's emphatic reaction of walking off the set, bless their hearts). Part of said flap was Fox News guy Brian Kilmeade defending O'Reilly's nonsense by asserting that "not all Muslims are terrorists, but all terrorists are Muslims," causing all teachers of Symbolic Logic to have one simultaneous nationwide seizure. Williams got into the act as something resembling the Dumb House Liberal, a role he apparently plays on Fox, by noting with an aw-shucks statement conceding that Bill-O was right: "I mean, look, Bill, I'm not a bigot. You know the kind of books I've written about the civil rights movement in this country. But when I get on the plane, I got to tell you, if I see people who are in Muslim garb and I think, you know, they are identifying themselves first and foremost as Muslims, I get worried. I get nervous." NPR, saying that the remarks were "inconsistent with our editorial standards and practices," fired him.

Whether or not NPR meted out an unjust punishment is, I suppose, up for debate. But what isn't really up for debate is that Juan Williams said something completely idiotic and, yes, of course, bigoted. The defense that Williams was just speaking his mind and should be praised for his honesty holds about as much water as Carl Paladino's insistence that forwarding ha-ha e-mails of a jungle-bunnyish Barack Obama doing a tribal dance wasn't racist, which is to say not at all. Let's try this one out:

You know, when I get on the plane, I got to tell you, if I see people who are black and wearing baggy pants and bandanas, and I think, you know, they are identifying themselves first and foremost as black people, I get worried. I get nervous.

How's that sound? Umm...bigoted, maybe? So Mr. Williams lost his job at NPR. This appears to have been a boon to both Fox and Williams, though, who seems to have gotten a raise in the wake of the whole matter. Boo Hoo Hoo.

Monday, October 11, 2010

The Dark Side of Medicine, in Corporate Form

Carl Elliot, a physician by training and currently a medical ethicist at the University of Minnesota, might have been pleased, in a twisted way, to hear the recent revelations about the US government's research project in Guatemala in the 1940's where physicians deliberately attempted to infect prison inmates, patients in mental institutions as well as soldiers with syphilis. After all, when you're writing a book about how the machinery of medicine can be used for unethical behavior, how much better can you do than by getting some free publicity from a news story about truly outrageous behavior by doctors employed by the feds?

There is one major difference between Elliot's thoroughly-researched book and the Guatemala Syphilis Experiment story, however: most of what Elliot documents is corporate-driven malfeasance, while the Syphilis study was done at the behest of government and, however wildly misguided its aims, with national security in mind. The bad behavior that goes on today in the medical research world is done in the name of the almighty dollar.
Elliot's title might seem a bit misleading--at first glance, I thought it was the memoir of a Chasidic Jew in the world of secular medicine--but White Coat, Black Hat more than makes up for it by painting a picture of just how the system of medical research, in particular pharmaceutical research, can be gamed by savvy corporations whose bottom line often doesn't overlap with patient needs. And a pretty picture it ain't. Elliot acknowledges in the introduction that he is not trying to paint a balanced picture of how the entire system works, and that he assumes there are many corporate-employed researchers as well as executives who really do want to succeed in business by making better drugs for patients ("There are still plenty of honest doctors out there. But honesty is getting harder all the time."). He does, however, aim to review the known abuses to give readers a sense of how patients and doctors alike can be conned, sometimes with lethal consequences.

The book dissects the system from the standpoint of the various players within it: he looks at "guinea pigs" (research study volunteers who have turned being a serial study subject into a most unusual professional career), "ghosts" (writers who author medical manuscripts), "detail men" (drug reps), "thought leaders" (MDs who have turned into shills for the companies), "flacks" (the corporate execs) and "ethicists." Throughout every step he recounts the half-truths and highly iffy behavior of pretty much everyone involved, and what happens to the careers of those whose ethical misgivings finally override their desire for wealth and admiration, leading them to speak out. The short version is that while it's not wise to mess with these entities, but it's decidedly highly unwise to mess with them after you've sucked at their teat for a few years.

For those who follow the New York Times regularly many of these stories won't come as much of a surprise, but when collected together the portrait does have a rather compelling effect, a bit like the difference between the distate one experiences when seeing one cockroach compared to watching the scene with Harrison Ford in Indiana Jones and the Temple of Doom when he discovers that the walls are enitrely covered with creepy-crawlies. Yes, the bugs probably aren't going to kill you, but the more you shine a light on them and discover how abundant they are, you can't escape the overwhelming sense of contamination.

PS--On the subject of Chasidic Jews and good timing--bravo to Carl Paladino! The Republican candidate for the Governorship of the State of New York couldn't have timed his ranting anti-gay speech better. In an address to members of the Sha'arei Chaim congregation (that's "Gates of Life" for non-Tribe members out there) that was greeted by applause, Paladino said, "I just think my children and your children would be much better off and much more successful getting married and raising a family, and I don’t want them brainwashed into thinking that homosexuality is an equally valid and successful option — it isn’t." Nicely done, Carl! Especially within days of the ugly revelations of the targeted assaults of gay men in the Bronx. Carl, you may be aware, is a fine example of the G-rated squeaky-clean right wing candidate who likes to decry the sexual lewdness of a permissive culture, until it turns out that he's not so squeaky-clean, as the revelations of e-mails containing bestiality and racism surfaced earlier this year. In Paladino's case, the revelations came months before the anti-gay speech. I'm not following the NY Gov's race close enough, but it smacks of someone trying to change the subject. Ladies and Gentlemen, the Tea Party!

Tuesday, September 28, 2010

The HIV Epidemic Rolls On

"Shocking" is a word I prefer not to use much--to me, it smacks simultaneously of Leave-It-To-Beaver-era naivete and reality-TV-let's-outdo-ourselves-era behavior--but I'm hard pressed to come up with a better word to describe this week's report from the CDC about the prevalence and awareness of HIV infection among Men who have Sex with Men. Most laypeople would describe these people as "homosexual" or "gay," but the clinical term has trended toward using the acronym "MSM." This is because some men, whether for reasons owing to homophobia in their communities or to a bisexual lifestyle or both, may not define themselves as "gay" but still fit into that epidemiologic group. It's not a trivial distinction, as the act of having unprotected sex with a man who has sex with other men is, no matter what he calls himself, statistically, a much more risky proposition than having sex with one who doesn't.

Thirty years into the HIV epidemic, that shouldn't be. There should be no group more painfully aware of the ravages of this virus than gay men. An entire generation was, if not destroyed, at least pummeled by HIV. And as Randy Shilts's excellent book And The Band Played On laments, it wasn't just the kind of dark paranoia of Ronald Reagan's administration that fanned the flames of the epidemic in New York and San Fransisco in the early 1980's: the patrons and owners of gay bars and sex clubs were equally interested in ignoring early compelling evidence that something wicked was coming. Tens of thousands of people--again, mostly gay men--died as a consequence.

So if any group should be hypersensitive to the need for basic Sex Ed and the usefulness of protective sex, or at least the value in frequent HIV testing in the absence of safe sex, it should be gay men. Alas, the CDC reports this week that such is not the case. The numbers can be a bit overwhelming when you examine all of them in detail, but the bottom line is actually quite simple: nearly half of all men actively having sex with other men that are HIV-positive are totally unaware that they are infected. (Of the roughly 8,000 men who were tested, 19% were infected, which means that approximately 10 percent of men who have sex with men are both HIV-positive and unaware of this. Russian roulette, anyone?)

These stats probably represent a slight overestimate of the true number of gay men who are infected and unaware, since the men were recruited to the study were found at "appropriate venues," such as bars, organizations, and street locations where gay men were known to congregate. Thus, this group is probably more sexually active and potentially more promiscuous than the larger community. That said, it's still cold comfort: the seroprevalence in this community, despite all that has happened to them and all the suffering they have gone through over the past three decades, is basically that of sub-Saharan Africa.

If you sift through the numbers, you will see that it's even worse for MSMs in minority communities, especially blacks, where the HIV prevalence was just under one in three (the prevalence for Latinos, at 18 percent, was only slightly higher than that for whites, at 16 percent).

I would like to think that I'm not shocked by much, but this leaves my jaw in a state of drop.

You might wonder why, in an age of effective medical therapy for HIV, I'm making such a big deal out of this study. After all, once they find out they're infected, can't they just take medications and everything will be okay?

Well, no. There's two major problems with this analysis. First is that there is abundant evidence that people whose HIV infection is treated earlier tend to live longer and suffer fewer complications from the disease (such as cancer, among many other things). Second, and even more importantly from a public health standpoint, is that people who are HIV-positive but on treatment are far less likely to spread the virus. When half of one of the largest groups of people infected with the virus are unaware of their infection, controlling it is a pipe dream. And because this group still does have sex with others outside its "own group," everyone remains at risk.


PS--Apropos of nothing much, I continue to be annoyed, like many, at the infantile way in which the modern media seems to have constructed political debate, where apparently only two positions seem tenable: that of laissez-faire capitalism or Stalinist/Maoist/Marxist (choose your favorite!) communism. Today, Paul Krugman of The New York Times has one of the more eloquent rejoinders to this kind of diatribing,

The market economy is a system for organizing activity — a pretty good system most of the time, though not always — with no special moral significance. The rich don’t necessarily deserve their wealth, and the poor certainly don’t deserve their poverty; nonetheless, we accept a system with considerable inequality because systems without any inequality don’t work. And before the trolls jump in to say aha, Krugman concedes the truth of supply-side economics, that’s not an argument against progressive taxation and the welfare state; it’s just an argument that says that there are limits. Cuba doesn’t work; Sweden works pretty well.

His point was actually tangential to his main post, where he was commenting on the fact that a conservative blogger had accused him of advocating full-out war as a way of stimulating the economy during economic depressions. More than anything else, my sense of despair for the politics of this country is less of a concern for left/right division than the fact that so many people make so little effort to actually understand anything at all. It is true of medicine, it is true of science, and it is no less true of economics and politics.

Monday, July 26, 2010

Ethics After an HIV Trial

Today the New York Times has an article about what appears to be the first successful "microbicide" that protects against HIV infection in women. Many hosannahs have been said in the medical & scientific research circles following the release of this data. No less an authority than Anthony Fauci, the head of the National Institute of Allergic and Infectious Diseases (and someone Billy thinks of as a patron saint of the profession), noted, "there’s a certain feeling of ease and pleasure for me as a scientist that any way you slice the data, it’s statistically significant." That may not sound like much, but in doctor-speak that's a pretty excited endorsement.

The "microbicide" is a vaginal gel that the woman applies both before and after having sex, and it provided protection between about 40 and 50 percent of the time (the amount varies because the researchers broke down the cohort into sub-groups based on how faithfully they applied the gel; the more faithful users, not altogether surprisingly, were better protected). That's it--the gel hardly constitutes complete protection, but previous studies have shown dismal results.

You might be tempted to ask about condoms: why not just use them? Aren't they much more effective? This depends on how you mean "effective." If you actually use a condom, then yes, it's in fact a very effective means of protection for both partners. The problem is most men, whether they're having sex with other men or with women, don't like condoms and try to avoid using them at all costs. (I'm certainly no fan of them.) So out in the real world, where the vast majority of people aren't enrolled in a clinical trial, a condom isn't actually especially effective, because it often remains on the shelf, or in the purse, or in someone's back pocket, sometimes with the owner having the best of intentions, or as the case may be, because one partner persuaded the other not to use it (regardless if the sex is "gay" or "straight"). So the gel can provide extra protection for a woman who has a partner or partners unwilling to wear The Sock. (There's some very preliminary data suggesting the gel may be protective for men in anal intercourse, but this study looked exclusively at women.)

The trial enrolled nearly 900 African women. Now, however, the trial is over. The study was funded largely by the US Government. The question is, what is the obligation that the researchers, backed by the US, have to the patients? Is it ethical to simply walk away from these patients and allow them to be at "baseline" risk of acquiring the virus--which is still largely a death sentence in Africa? Or are the researchers only obliged to enter into an agreement which ceases to be at the end of the trial? These women, after all, would mostly have become infected had they not enrolled in the trial. On the other hand, what if a microbicide is developed as a result of this trial and becomes available outside of Africa first? Does that seem fair? Shouldn't the women who "put their bodies on the line for this study" (in the words of AIDS activist Mark Harrington, quoted in the article) have first dibs on the gel?

These are not idle questions and such situations have occurred many times throughout the past 60-70 years in US medical research. Most readers will be familiar with the infamous Tuskeegee Experiment, but many other similar experiments have taken place precisely because nobody designing the trial took the kind of questions above into account. I don't mean to imply that these researchers didn't; I can only say I am concerned by the Times report. In my own field, the "intervention" we study is almost always a vaccine, and if that works you don't need to come back for more; this situation is different.

Typically, the Billy Rubin Blog tries to leave you with an opinion. Tonight I only have questions--those questions two paragraphs above, in addition to more in that vein running through my head right now--and can leave you only with a troubled shrug of my shoulders.

Wednesday, July 21, 2010

Rambling Reintroduction

My most recent post, alas, dates back to the election of Scott Brown to the US Senate, with a fairly prolonged harangue at President Obama and my various frustrations with him (frustrations which, I am sad to say, have if anything only increased).

Not long after that entry my father collapsed on a winter's afternoon in Columbus, Ohio while walking out to his mailbox. Though the cause is unclear, he was in cardiac arrest by the time the EMTs arrived about five to ten minutes later on the scene after a neighbor witnessed the collapse and called 911. My father would not have wanted this, though of course the neighbor could not have known that. The EMTs were able to revive him and brought him back up the street to the local hospital to "stabilize" him. My mother, needless to say, was in total shock; I was seven hundred miles away, while my older sister was twice that distance in the opposite direction--in short, not the best situation to be in for a reasonably loving & mutually supportive family to make difficult medical decisions.

There are some details which at this very moment seem tedious to recount--tedious only in that retelling them in a blog (whose readers I cannot see and may not know) ain't really why I'm writing this. Suffice it to say that my father passed away ten days after he collapsed, although as far as I am concerned, in what some readers may regard as complete heartlessness, he finished his just-too-brief stint on earth that early February day he went ambling out to peruse his bills & other ephemera.

He had just turned 76. I would have loved ten more years with him, I would have settled for five, but I have no gnawing regrets losing him when I did. And while I didn't much enjoy the ten days we spent watching the corporeal shell of what used to be my father stop functioning, overall I don't have many complaints. Pops went from being a fully functioning guy, totally independent and in control of every aspect of his life, to dead, and made that transition quickly and without prolonged suffering. As a son, I think "ah, couldn't I have just a little more time?" As a doc, all I can think is "Bravo!"

I haven't written over the past six months for a variety of reasons, but I would be a fool if I said that his death wasn't the major factor. My father hasn't been a major part of my day-to-day life for many years now, and I have not been depressed about his loss, though I have been sad to be sure. The act of writing, and writing about medicine in particular, has always served to connect me with my father. I think he was proud of me as a son for a variety of things in the general way that parents are (hopefully, anyway) proud of their children, but my father looked at my writing as something different entirely. He was my greatest reader. He loved it when I put pen to paper, so to speak, and I think he was a bit disappointed in me when I chose to pursue medicine as a career in my mid-twenties, hoping that I would become a professional writer.

Instead, I went my own way, although the writing bug has always remained with me. Since medical school nearly everything I have written has dealt with medicine, and I believe reading this work was more complicated and ambiguous for him: he really did love to read my stuff, but just never quite believed that I thought of myself as a doc, thinking I was pulling the wool over everyone's eyes. For a very long while I agreed with that assessment, but for many years I have considered myself to be at one with the stethoscope, part of the brotherhood and sisterhood as it were, and have made my peace with those decisions I made nearly half a lifetime ago. But to pick back up and blog on the issues that mean so much to me as a doc was just not something I could find the motivation to do until this evening.

Nothing special or magical has taken place tonight; this has been gestating for awhile (an odd metaphor for a son writing about his father, but still) and I've been considering getting back in the saddle for the past few weeks. I do not know how many readers I had when I was trying to get thoughts out weekly, and I assume that if I will continue again I will be starting back from nothing. But the time seems right for a stab at it.

I have spent the past month as a "teaching attending"--a somewhat odd practice at my medical school where the attending responsible for the education of the residents and students is frequently not the same doctor as the one responsible for the welfare of the patients. Regardless, I've thoroughly enjoyed the month and gotten a real kick out of observing younger physicians at a time of their professional lives that I haven't witnessed up close for many years. As the month got close I had a blank wall on my office (that I had just recently inherited) so I was eager to put up pictures, so that my students and residents could see what was important to me as a doc. Some docs like to display their diplomas and accolades, which is definitely not my speed. Others coat their walls in family pictures, also something I'm not eager to do. (A few visual reminders of one's kids? Sure. I'm just not looking to completely morph my personal and professional life to that degree.)

No, I wanted something like a "hall of fame," a sampling of the people whose stories in medicine have been important to me as I've grown up, my way of saying, "these are the models I hold up as exemplary, I hope you find your own too." There's Edward Jenner, of course--a pompous addition, perhaps, but after all the father of vaccinology (my field of work); he resides next to a pic of Henrietta Lacks, the African-American woman whose cervical cancer was "harvested" to become one of the first, and to this day most important, cell lines in modern medicine, the "HeLa" cells (and the subject of Rebecca Skloot's great book The Immortal Life of Henrietta Lacks); sharing the triptych with them is the granddad of modern dengue research, Albert Sabin (most people know Sabin for his work on polio, but that's not why he's on the Rubin wall). Over there on his own is Hamilton Naki, as triumphant a story in medicine as can be told, in my opinion, and he hangs out in the vicinity of Gerhardt Domagk (one of the "discoverers" of sulfa, who refused to join the Nazi Party during World War II even though all of his scientific colleagues jumped on that bandwagon) and Oswald Avery (one of the pioneers of influenza research).

I'm planning on adding some faces as time goes on but I think that's a good start for my hall of fame. However--and I pray that this doesn't come across as too smarmy--these impersonal heroes and heroines of mine all share wall space with my father, who never quite knew what to make of my later-in-life interest in medicine but never failed in being supportive (very much along with my mother, lest anyone misunderstand). It's a picture of him that was taken when he was a young man and I had never seen it before; it popped up when mom sent me some tributes about him. I don't regard myself as one easily given over to sentimentality, but frankly I think he belongs there up on that wall, not simply because he was my father but because he shaped me as a doctor--willingly, eagerly talking to me about what mattered to me in medicine, probing my ideas, challenging my perspectives, all the while not quite believing that his son chose such a path, but satisfied with the choice nevertheless.

I can't say for certain at this point if the Billy Rubin Blog is "back," but I can say the itch has returned. See you back sometime, perhaps.

Wednesday, January 20, 2010

A Progressive's View of Senator Brown's Election

That is, the other Senator Brown. This is about the new guy, not the one from my homestate (and indeed, hometown of Mansfield!) Ohio. But you already knew that. Unless you were living under a rock the past 24 hours, you were almost certainly aware that the voters of Massachusetts elected to the US Senate a little-known local politician instead of the Commonwealth's Attorney General. And as you probably heard since that fairly dramatic upset, this represents real trouble for both President Obama and the Democratic party as a whole, which is fairly astonishing given that Obama and his party swept into power with enormous popularity only one year ago. What seemed inconceivable only a few months ago now seems within the realm of possibility: that the Republican party, who gave us eight straight years of George W. Bush and some of the most odious policies in the history of the Republic, might return to power in the House (it is statistically impossible in the Senate, which has only 17 Democratic seats up for grabs; even if all were lost to Republicans the majority would drop to 52).

So who is responsible for this and what lessons can be drawn? First, one should dispense with some of the  nonsense uttered by some of the Democratic party establishment in Massachusetts. "Any analysis of this that does anything but celebrate Martha Coakley--her service and the efforts of this campaign--misses the boat," says Dem state party chairman John Walsh, in what has to be one of the more spectacular expressions of denial in recent years. Walsh may be trying to protect some turf in his self-serving foolishness, but nearly everyone else recognizes that this was a debacle: Brown's victory occurred in a state where the majority philosophy leans toward the Democratic party, and strongly so. That Brown could have achieved such a large margin of victory, even with a fairly large turnout (2.2 million people voted yesterday), speaks to the complete disintegration of the Coakley campaign. Making pleasant sounds about Coakley in the aftermath, as Walsh suggests, is like putting a cherry on top of a pile of dung and declaring it a sundae.

There are to my mind three major reasons for Coakley's loss: her breathtaking arrogance; the perception that Obama is in the pocket of Wall Street; and the Democratic party's handling of healthcare reform. The first item about Coakley's ineptitude and political tin ear is a relatively local affair and I won't discuss much further, except to note that her fall from grace has been tremendously precipitous. It's not merely that she was nearly 30 points up only a few weeks ago; she was a very popular and well-liked politician in this state, second only to John Kerry, even more popular than the Governor, Duval Patrick. That she could lose by such a large margin speaks to her ability to alienate people, and I suspect she has permanently damaged her brand among the Massachusetts electorate, which is quite a pity since she is a highly competent Attorney General. Simply put, Scott Brown never took one vote for granted and never condescended to the people of Massachusetts. Neither of those are compelling reasons to have voted for the man, but he deserves immense credit for his hustle.

More important for the President are the second two reasons, and Coakley can't really be blamed for either. Leave aside Obama's troublingly cozy relationship with the financial industry for a moment, the question is: with regard to healthcare reform, what should Obama have done differently? To me, the answer lies in two separate flaws in the plan, the first a tactical mistake that is only clear in hindsight, the second--which is much more concerning--lies in a major character flaw of the President.

The tactical mistake was created in the wake of the failure of the Clinton plan in 1993, which was perceived by Congress as being imposing and top-down in structure, with the Clinton White House (and, in particular, its soon-to-be-unpopular first lady) dictating terms to congressional leaders. Obama, hoping to avoid this problem, only created another by "leaving the bill writing to Congress while it tries to charm an industry that controls nearly one-fifth of the US economy," as Ceci Connolly aptly put in the pages of the Washington Post last June. Consequently Obama tended to other duties--which, one grants, are not insubstantial with two ongoing wars, problems with the banking industry, staggering unemployment and a host of other, minor problems such as global warming.

But the tactic backfired: congressional leaders squabbled, "centrists" like Max Baucus and Joe Lieberman suddenly were extracting pounds of political flesh (an apt simile in this case) to a cowed Senate majority leader, while Republicans congealed together a host of exaggerations and outright lies to drag down the popularity of a once-popular notion. By the fall, it was clear the process had run amok, and Obama's hands-off approach in retrospect had failed miserably. Had Obama merely tried to nudge the legislation along, using his formidable powers as an orator to advocate for what he wanted, filling up auditoriums around the country as an out-front advocate for healthcare reform, explaining to the American people his vision for the legislation, a good deal of pressure might have been brought to bear on several senators and representatives who probably intentionally dithered for reasons ranging from humbuggery to outright corruption. Instead, for more than six months there was mostly a vacuum of advocacy, and worse, the White House never really found its footing, saying on one day that the public option was non-negotiable, followed by the exact opposite indicator a few days later. Is it any wonder that Congress couldn't move the proverbial ball past the goal line?

The second reason underlying Obama's failure to shepherd along a meaningful or decent healthcare bill lies in who President Obama is, and that is, namely, one whose primary aim is to achieve consensus rather than to advocate for a given belief. We have seen what such consensus-seeking did for the Clinton presidency: after the 1994 congressional drubbing that landed the Republicans in control of both the House and Senate, Democratic party faithful were given a moderate Republican president in all but name, who stood before that congress proudly declaring that "the era of big government is over," who happily signed the Defense of Marriage Act, who sought to further enable the kinds of financial shenanigans that led to the economic crisis we find ourselves in right now. It only took a small sliver of disaffected Democrats to turn away from Clinton's successor and hand the Presidency to George W. Bush. Against all odds President Obama has followed Clinton's script. Contrary to the mildly insane claims of some pundits and politicians, President Obama has given his left-leaning base precisely nothing of what it has asked for. Glenn Greenwald pointed out quite accurately today:

In what universe must someone be living to believe that the Democratic Party is controlled by "the Left," let alone "the furthest left elements" of the Party?  As Ezra Klein says, the Left "ha[s] gotten exactly nothing they wanted in recent months."  The Left wanted a single-payer system, then settled for a public option, then an opt-out public option, then Medicare expansion -- only to get none of it, instead being handed a bill that forces every American to buy health insurance from the private insurance industry.  Nor was it "the Left" -- but rather corporatist Democrats like Evan Bayh and Lanny Davis -- who cheered for the hated Wall Street bailout; blocked drug re-importation; are stopping genuine reform of the financial industry; prevented a larger stimulus package to lower unemployment; refuse to allow programs to help Americans with foreclosures; supported escalation in Afghanistan (twice); and favor the same Bush/Cheney terrorism policies of indefinite detention, military commissions, and state secrets. 

This is not the approach of a robust advocate for traditional Democratic policies. This is the winning-is-more-important-than-fighting stance of a neoliberal, like Clinton before him; it is the pose, it pains me to say, of a wuss. And said wuss has fought for very little--indeed, nothing--he promised his base, the very people who catapulted him over the Hillary Clinton juggernaut one year ago. As I recall, this man, who offered such a thoughtful critique of the Iraq war (when it was far from politically expedient to do so), came to us with the promise of hope and change. Since the election we have been given hollow platitudes by a man unwilling to capitalize on his success, proceeding far too cautiously on the national stage (both links to Paul Krugman's column/blog in NYT).

Contrast Obama's lack of full-throated advocacy over the summer with George Bush's re-election in 2004. Bush, you will recall, had just managed to eke out a narrow victory, as a sitting war President, over another Massachusetts politician with a tin ear. Still, despite Bush's underwhelming performance (he garnered 50.7% of the vote and won by 2.4 points) he came before the American people the following day and confidently declared, "I have political capital, and I intend to spend it." Whether or not one finds that statement astonishing in its chutzpah, Bush immediately proceeded to campaign, election-style, for the privatization of Social Security, and did so in the face of enormous uncertainty, given Social Security's popularity. Bush of course did lose that fight, but as I see it the lesson here was that Bush was willing to fight for his party's beliefs at all.

President Obama? I have not only not seen such boldness on the whole, I have seen its opposite. You see, as I write this, the New York Times is leading with a headline that can only be described as dumbfounding. It reads, "Obama Weighs Shift In Health Plan, Seeking G.O.P. Backing." In the first graf: "President Obama on Wednesday signaled that he might be willing to set aside his goal of achieving near-universal health coverage for all Americans in favor of a stripped-down measure with bipartisan support." He has 59 votes in the Senate, and he might be willing to set aside his goal? Would the last President have asked for progressive input had he held a 59-seat majority in the upper chamber? I'm thinking not.

As a progressive, I think there is now only one option, and that is to declare war. On the Obama Presidency. He has not merely lost my support, he has lost my vote. Whether another politician will try to wrest control of the party from him in the coming few years remains to be seen, but barring a total turnaround, I am finished with him.

Update #1: I have some additional thoughts which I can't write until later today, but in the meantime there was one error in the original post: in 1994 the Democrats lost control of both chambers, not just the House. The text above is corrected.

Update #2: Several thoughts.
One reader on Facebook asks: "[Obama's lack of courage] doesn't explain why MA voted for Brown. If voters thought the country so badly needs healthcare reform (and were frustrated for lack of progress), how is electing Brown going to help?" In the short run, of course, it won't--although to my mind even when Kennedy/Kirk was Senator and the Dems did have that supposedly precious filibuster-proof majority, the best the Senate could produce was a handsome subsidy for the private insurance industry. The House in all likelihood would not accept the Senate bill--after all, they still could, and rightly have given no indication that they want to pass it. In the upper chamber, politicians like Baucus, Lieberman, and Ben Nelson to name only a few have made it clear that if even a hair of their version of the legislation is tampered with, there won't be enough votes for cloture. Thus, Brown's presence on the political scene makes only a modest amount of difference. This is President Obama's fault. This is entirely President Obama's fault.

Also, it should be noted that (obviously) elections have binary outcomes even though the motivations of the voters run the gamut. (Technically there were three outcomes, not two given the Libertarian party candidate Joseph Kennedy--no laughing out there--but you get the point.) My back-of-the-napkin calculation goes something like this: of Scott Brown's majority of 52%, something like just under 15% represented the hard-core social conservative or ideological libertarian vote, who were not only in the bag but energized to vote. Another 20% represented the moderate members of the Republican base, socially progressive but friendly to business interests, and who generally determine what Republicans are viable for statewide office (Brown slipped by because everyone had left him for dead and no moderate Republican cared to lose to Coakley). About another, say, 13% represent mostly blue-collar workers in the suburbs who usually vote Democrat but were either alienated by Coakley's arrogance or charmed by Brown's little-engine-that-could shtick or both. Now all Brown's gotta do to win is pick off a fairly small percentage of disenchanted voters who are disgusted with "what's going on in Washington," regardless of whether or not they could offer a cogent critique, and wanted "to send a message." Add to that a lower voter turnout than usual due to the off-off cycle (turnout was 40 percent; turnout at Obama's election was a near-record 72 percent; typically in a non-Presidential but regular cycle it would be closer to 50 percent) and a disillusioned base, and bing! You have the making of a stunning upset. Basically, Coakley was able to count on urban voters and lefties (several Republicans in MA are also "liberals," so not the best term even though the two are almost interchangeable outside New England). That got her to 47 percent--actually an impressive number given how small lefty blocs are in other states--but it wasn't nearly enough. There is some question as to whether the other highly qualified candidate, congressional representative Mike Capuano, would have done better in the working class suburbs, but for me that's useless second-guessing. Though I'm glad I didn't wake up Wednesday morning being Capuano, wondering what could have been. Still, one might think that Capuano is actually now the odds-on favorite to win the Senate seat back in 2012, even though Brown just won!

As I said, Brown's ascension to Senator does not help Democrats' goals in the short run. But in the case of Republicans, neither did the wildcat candidacy of Douglas Hoffman in the NY 23rd district, whose tea party run (technically he was the "Conservative Party" candidate) against Republican Dede Scozzafava led to the election of Democrat Bill Owens in a reliably Red district. There, the conservative base found Scozzafava so unpalatable that they would rather have lost the election than vote for her. What did they get in return? In the short run, Owens. But less than two years from now, they are almost certainly going to get "their" candidate, whomever that is (and quite possibly Hoffman himself), on the ticket, and Owens will be playing defense. I think the political views of most of these people are totally nuts, but I deeply admire their resolve, and more importantly, I recognize that their strategy is almost certain to succeed. Incredibly, that strategy may well succeed not only in the NY-23 but in swing districts across the country, returning the Republican party to power only two years after the most disastrous defeat they have suffered in decades.

President Obama, on the whole, bears responsibility for this, and, although I am aware that I am opening myself to the charge of "left-wing nutcase" by suggesting this, he needs to be succeeded by another leader. He seemed like a highly thoughtful, extremely articulate, bold and confident leader. He continues to have the first two qualities but lacks the latter two, and we need the latter two. We have needed them for two generations. Think about this for a moment--here is the list of our national party leaders since our last truly effective leader, Lyndon Johnson (that could start a fight, but I'll stand by it): Humphrey, McGovern, Carter, Mondale, Dukakis, Clinton (blech!), Gore, Kerry, and Obama. With the exception of the current Prez, just look at that list! What a sorry collection of milquetoasts! And, alas, Obama's missteps have shown him to be of a piece with them. Yes, he has three years left and I do realize it sounds insane to write off his presidency. But I've seen not one shred of evidence to suggest that he's capable of even understanding his errors over the past several months, let alone attempt a course correction (or succeed at it). He needs to go, and if party loyalists stick by their man, they're going to go down.

Healthcare reform is quite probably dead for another generation. As I see it, there is only one way to avoid such a mess in the future: take a page from the Republican playbook, and refuse to vote for candidates who do not meet a litmus test, even if it means losing elections for a cycle or two...or more. I am not advocating a wide-ranging litmus test: I have mildly strong opinions about abortion, I have stronger ones about gun control, and stronger ones still about gay rights, but I recognize that the party needs to allow for minority views as part of a successful coalition. But healthcare reform and bank regulation? These seem to me pretty easy issues where Democrats can say, "Look, this party stands for federal government-backed health insurance, period. If you don't agree with that principle, you do not belong here, and we will not vote for you even if it means that we will lose a House or Senate district, or the Presidency itself." Then when you finally do win big, like the Dems did only one brief year ago, you won't squander the golden opportunity that dropped into your lap.

Another friend linked to a piece analyzing the structural peculiarities of the Democratic party. It has a slightly different take from my own, but I don't have any qualms about his writing except for the fact that Republicans, too, have their own structural issues, harmonizing the desires of libertarians, social conservatives, religious fundamentalists, and corporate interests, and they seem to have done a fairly good job of things since Ronald Reagan's election. And while I interpret Obama's motivations differently than Anonymous #1, I certainly see where he or she is coming from.

Update #3: How could the President redeem himself? Here's a thought: the radically right-wing Supreme Court just ruled today in a 5-4 vote that "corporations cannot be banned from using their general funds to pay for political advertising." As Andrew Leonard of "How the World Works" points out, this is going to profoundly influence Wall Street's reaction to the President's come-to-Jesus moment on banking reform, with the likely scenario being a huge influx of money supporting candidates who will block reform at every turn. So what can be done given a demoralized base and a surly electorate? How about a Constitutional Amendment barring such contributions? I'd like to see Joe Lieberman explain his vote against that. I'd also love to see Obama breathe fire on the campaign trail in, say August of this year--setting up a Constitutional Amendment vote just in time for the elections. Make that the story of the campaign. After all, the Republicans thought flag burning and gay marriage were such critical issues that they didn't hesitate to introduce CA's banning them; surely the Dems could do the same, especially as they (theoretically) oppose the Supremes' decision. Will we see the President adopt such aggressive tactics? I'm not holding my breath.

Update #4: I know I'm rambling, but just thought I'd add that the only person on the national stage that I can think of in my lifetime who was a politically viable Dem who simultaneously appeared to show genuine resolve was Howard Dean.

Thursday, January 14, 2010

Various Thoughts on Haiti

a. Before starting, if anyone has decided that they would like to make a donation but do not know which group to donate to, please consider making a donation to Hopital Albert Schweitzer in Deschapelles (about 3 hours northeast of Port-au-Prince). I worked there for a brief stretch during my residency. Their website notes that areas outside Port were affected, and the hospital has been swamped with patients and the doctors, nurses and support staff are stretched very thin. I don't want to divert money from the Red Cross but this is a more "tangible" donation, so if you have not yet contributed please do take a look at their website.


Pat Robertson's insane monologue yesterday is perhaps remarkable only for its particularly twisted form of logic. After all, religious fanatics have been in the business of interpreting natural disasters as divine retribution  for millenia; what makes Robertson's thoughts on the matter so singularly flabbergasting is that he believes that Haitians, who had received a century of the most brutal treatment endured by humans at the hands of Christians, somehow made a "pact with the devil" ("true story!" the Reverend adds helpfully, as if he had found it in Wikipedia just before going on air) by not turning to Christianity. Assuming that he was trying to make any sense at all, I would guess that he's referring to the Haitian practice of voodoo. Even if one ignores his thoroughly peculiar logic, the vast majority of Haitians regard themselves as Christians. If Robertson thinks their particular brand of Christianity, with its African animistic influences, isn't up to Godly snuff, then why hasn't such a calamity befallen Rome? And why did God wait more than 200 years to get around to a punishment like this? No, what is most amazing about a raving lunatic like Pat Robertson--who, it must be remembered, made these comments on a show trying to raise money for the relief effort--is that his network, CBN, reaches millions of viewers in the US and millions more worldwide. "He's not like David Koresh," a colleague of mine quipped today, referring to the religious cult leader at the center of the Waco, Texas tragedy. "I mean, Robertson's got followers."

The irony is that because of their Christianity, a good many Haitians don't disagree with Robertson's assessment, although again I'm not sure they would concur with Robertson's underlying thought process. The quote of note from the writer in the above link: "If God exists, he's really got it in for Haiti."

c. Haiti was not an easy place to spend a month, and I continue to have conflicted feelings about the country. (And it goes without saying that spending one month in Haiti hardly makes me an expert. What observations I have are tentative, and what thoughts I have I myself regard with skepticism.) The story of the Haitian revolution and throwing off the yoke of bondage by the French at the outset of the 19th century has to rank as one of the greatest stories of self-determination in the history of humanity. Based off the very principles that defined the American and French revolutions, Haitian independence was a logical response to French oppression. It should be no surprise that politicians in the United States (Southern or Northern) or anywhere else had absolutely no interest in fostering this nascent state, and so, denied the ability to engage in trade like any other free nation (and Haiti was a country of vast resources at that time, and would have made a powerful trading partner for molasses and rum which were critical parts of the early American economy, to say nothing of the Spanish colonies), nor allowed to develop a navy for basic defense (attacks by the US prevented this), Haiti turned inward and began a two-centuries long process of auto-cannibalism that has been more-or-less uninterrupted. The US was heavily involved in Haiti in the early 20th century, occupying the country from 1915-34 (my jaw dropped when I saw WPA-style bridges there while riding through the countryside, as I had been totally ignorant of my country's involvement in Haiti); the Soviets also added to the infrastructure a bit during the 50s and 60s while Papa Doc Duvalier cleverly played the superpowers against one another. But besides these relatively short-term relationships, few nations have generally cared much about Haiti except for it to serve as a cautionary tale. Paul Farmer, now the famous doctor and subject of the bestseller Mountains Beyond Mountains, wrote about the history of Haiti's relationship to other independent nations over the past two centuries in his book The Uses of Haiti. It is worth the read. To have any hope of understanding the magnitude of the disaster that has just befallen Haiti, one needs to read a book such as this. This earthquake really couldn't have happened to a less prepared country.

d. You will read multiple descriptions of Haiti in the coming days as a place of "tremendous poverty." While that is undoubtedly true, describing Haiti as "impoverished" doesn't really give one the full scope of the core problems that its people face. For instance, when compared to an African nation of roughly equal population and area, Haiti (168th) outranks Rwanda (179th) in per capita GDP, and by a fairly sizeable amount ($1300 vs. $900; the US ranks 8th at $47,500, while Zimbabwe is last in 194th with a per capita GDP of $200). Rwanda's infant mortality ratio (17th highest in the world) is higher than Haiti's (37th), with similar data for life expectancy at birth (50.5 years versus 60.8). But Rwanda is a considerably more stable country than Haiti, with a government responding to the needs of its people, and there is a general sense among the people that their lives are improving. This is all the more remarkable given Rwanda's recent genocide; Rwanda's near-miraculous turnaround is the subject of New York Times reporter Stephen Kinzer's book A Thousand Hills, which has gotten some airplay in the US. In Rwanda, despite its recent horrors, the people have a sense of hope and of common purpose. In Haiti, where its leaders have been either uninterested or unable to help its citizens, there is no similar attitude--or at least, if it is, it is hidden well underneath the surface. I saw no evidence of it when I was there. Instead I often felt a sense of foreboding--especially in Port, where it was impossible for me to walk the streets without being accosted by people wanting my money. By contrast, when my wife worked in Kigali for a few weeks while building a high school there a few years ago, she was a magnet not for money, but for her camera--kids were constantly asking her simply to take their pictures. This in a place that, by the numbers, is even more impoverished than Haiti. So poverty is only a chunk of the problem. I don't want to imply that this is a fault of  Haitians, and I don't want to sound callous to the needs of those people who came up to me on the streets of Port. Rather, my point is that if one only thinks about the earthquake without making some attempt to understand a little of Haiti's history, and if one also regards this as "earthquake hits impoverished place," one won't have understood anything about what's going on there. The earthquake hit a place that most of the nations of the world (including and often especially the US) have used as a punching bag for two centuries, and the people aren't merely impoverished, they are desperate, which to me is a critical difference.

e. At the risk of sounding pedantic, one final point about the scope of the disaster is that Haiti has no real "government" in the sense that we--so far, anyway--think of as "government." Despite some bad apples and assorted pockets of corruption, most Americans tend to think of their police as being there to protect them; there is no equivalent in Haiti. Here we take some of the most important functions of a government for granted, two of which are conspicuously absent in Haiti: garbage removal and a clean public water supply. I can't say how disheartened I feel here when I see families choose brand-name bottled water in their own homes while perfectly potable water taps in their kitchen sinks sit unmolested. Haitians right now would die for such a privilege. And because of the lack of potable water, many more may.

ps--Now at the risk of sounding ridiculous, one small way to continue to make a contribution to Haitian GNP in the coming years, for those of you who like to drink alcohol, is to buy Haitian rum, one of their few true exports widely available in the US. I am a fan of Rhum Barbancourt, and recommend that you check it out the next time you are at the liquor store.