Today the Senate Special Committee on Aging (chaired by Herb Kohl, D-WI) held hearings on conflict of interest in medical education and research. Several speakers provided testimony, and if I have spare time in the coming days I will review their statements and maybe find some time for a separate entry on them. But one witness caught my eye, and his statement I read, and that is the subject of today's entry.
Thomas Stossel is a senior physician (Hematology) at the Brigham and Women's Hospital and a professor at Harvard Medical School. As I wrote last week, Stossel was the prime mover & shaker in arranging a conference for a group dedicated to the proposition that industry collaboration with physicians has been much more beneficial than harmful to patients over the past several decades. The goal of the group (Association of Clinical Researchers and Educators, or ACRE) is to organize a pushback against what they see as a movement comprised of anti-industry "zealots" who are out to "infect...medical school ethics instruction with guilt." (NB: this is more a paraphrase than an exact quote, although every word in quotations comes directly from his testimony.)
I noted after perusing their website that they were long on hot rhetoric but short on facts, and after reading Dr. Stossel's statement to the Senate Special Committee I remain not terribly impressed. His thinking seems to rely on a characterization of industry-funded CME critics as Luddites, who have a reflexive hatred of the profit motive: the "oft-repeated mantra that 'companies have a fiduciary responsibility to shareholders whereas physicians' fiduciary responsibility is to patients'...[is an] opaque platitude imply[ing] that business has no social responsibility and that physicians only behave in a venal manner when contaminated by business." In other words, Stossel believes his opponents think that industry (or profit, or both) is always equivalent to evil, and that physicians must remain pure from the evil profit motive.
Of course, that notion itself is so facile it can only induce a sigh. The issue, at least from my perspective, has always been one of bias. Physicians are a bit like little siblings of scientists in that scientists try to discover "truth" and in doing so are constantly vigilant against anything that could bias their view, while physicians have more practical concerns (their ultimate goal is generally to heal patients) but still are, and should be, deeply preoccupied with bias. Well, if lucrative financial deals don't constitute a profound source of bias, then pray tell what does?! It's not about the good or evil that comes of the profit motive, and indeed, the absolutely abominable behavior of some of the drug companies has given a bad name to the many good corporate citizens who do churn out useful products and deserve to profit from them. But to pretend that such bad behavior doesn't exist is to stick one's head in the sand. Moreover, regardless of the extent of bad behavior that has gone on in the past several years (of which there are an ample number of examples), ignoring the potential bias that can result in a physician's mind from financial perks doesn't merely ignore common sense, it ignores a great deal of psychology research that would suggest otherwise.
One can get a yuk or two in (should one be inclined to get yuks out of reading congressional testimony) by glancing at the beginning of Dr. Stossel's statement, in which he alleges that even the use of the phrase "conflict of interest" is a ploy (his exact word! see shortly) designed by that coterie of critics who wish to create an uneven playing field in the public relations war designed to win the hearts and minds of the public, and that nobody has any business even bringing the phrase to the discussion. I'm not kidding. Here is the paragraph (which, as a former English teacher, induces a cringe in me for being the polar opposite of lucid, with all of its subordinate clauses piled on top of one another, but you be the judge):
"'Conflict of interest' is only a meaningful term in terms of regulatory implications in the context of self-dealing by persons in positions of political or judicial power--and physicians and researchers do not even come close to having such influence. Therefore, the intent of the phrase in the context of medicine is a ploy, used since the beginning of recorded history, of adversaries to invoke allegedly evil motives of an opponent--such as greed--as a weapon in an argument they cannot win on substance."
Got that? Only someone in a position of political or judicial power can have a conflict of interest. Alas, this very, very narrow reading of the term is not what most people think when they utter the phrase "conflict of interest." Take this very simple, workman-like definition from Webster's New World College Dictionary: "a conflict between one's obligation to the public good and one's self-interest." That's how lots of people would define it, although even "public good" seems a touch narrow, since teachers or lawyers or the clergy have obligations to students, clients, and parishioners respectively rather than the public good. You can see how this contention that "conflict of interest" is a manufactured phrase doesn't hold up under even cursory scrutiny.
More damning to Stossel's contention, however, is the definition provided by the National Institutes of Health. That is, this is the principal body in the US that defines the ethical behavior of medical research: "a conflict of interest occurs when individuals involved with the conduct, reporting, oversight, or review of research also have financial or other interests, from which they can benefit, depending on the results of the research." Their definition doesn't even trouble itself with the characters that Stossel wants to reserve for exclusive use--judges and politicians.
Ignoring such obvious interpretations of the term might be viewed as, you know, maybe, um, a weapon in an argument one cannot win on substance.
(If the former English teacher can also get in a teaching point here, it is this: please read out loud your statement to a Senate committee before you go to Washington! The phrase the intent of the phrase in the context of medicine is a ploy really should have been written the phrase is a ploy--an "intent" can't be a ploy. Eliminate useless words, class! If there is evidence in this blog entry to the contrary, keep in mind that this blog is pretty much a first-version essay each time out with no time for revisions, and I'm not testifying before Congress.)
It's quite tedious to have to respond to the more fanciful accusations riddling Dr. Stossel's remarks: that nobody wants industry to fail, that physicians can have collegial relations (or even productive collaborations) with medical industry corporate employees, that...oh, you get the picture. The point that has to be made, again and again apparently, is that physicians can be biased by pharmaceutical companies, and that pharmaceutical companies have a responsibility to make money while physicians have a responsibility to treat patients. It's good that there's a profit incentive for corporations. It's bad when physicians are given financial incentives to try to influence the prescription patterns of their colleagues--precisely because those financial incentives allow bias not merely to creep in, but rather knock down the door, barge in, put up its feet on the coffee table, pop open a beer (or, since were talking about physicians, uncork a nice bottle of cabernet) and watch TV. That's bad for patients.
Dr. Stossel also implies that critics of my ilk are clamoring for governmental oversight into every nook and cranny of the industry-physician relationship. For my part I would prefer that government not have to legislate on such matters. Honestly. But here's the rub: I would likewise prefer that my professional brethren and sistren regard the baubles offered by the pharmaceutical industry with contempt, for after all, if the drugs the company makes are good, they will surely flourish under a peer-reviewed system in which no conflict of interest exists, right? I would hope that this would be the prevailing attitude among medical students, for instance. But--good God!--it's not even the majority position among the faculty! And if we can't get the house in order, and further and further evidence of abuses mounts, leading any sane person to conclude that there's a systemic problem out there, well...that's when you get Congress to take note. And as we have found in so many recent episodes in our country, it's not necessarily a good thing when Congress gets involved. But if it does, the fault will lie at the doorstep of the physicians who have abused the goodwill of their patients, as well as their apologists like Dr. Thomas Stossel.
Dr. Stossel's statement can be found here. It takes some time to get through but for those interested in the CME issue it's worth the time investment. In the coming days I hope to have more to offer on some of the other witnesses (or even some of the Senators!).
Hat-tip to the Carlat Blog for the link as well as his attendance. I wanted to make it to the conference as it's down the road from my house, but pressing research issues (including a meeting with the boss) took precedence.
--br
Wednesday, July 29, 2009
Tuesday, July 28, 2009
Fresh Air on Health Care Reform
Although I try to make my blog entries more than just a link to a "read/watch/hear this," today I just heard a discussion so lucid and crisp that I feel like extensive commentary would not add greatly to it. On NPR's Fresh Air, host Terri Gross invited two economists involved in health care reform to discuss the basics of the economics of health insurance, and for those who have found the news about the legislation working its way through Congress a bit confusing, this is the show for you. It only costs about forty minutes of your time, and is well worth the listen.
The economists are rather philosophical adversaries: Stuart Butler serves as the vice president for domestic and economic policy studies for the conservative think tank The Heritage Foundation, and Paul Krugman (a favorite of Billy's) recently won the Nobel Prize in Economics, writes a column for the NY Times and is a champion of political liberalism. As always, such terms as "conservative" and "liberal" get a little slippery and often aren't helpful, although in this case I use the labels since they indicate their general attitude toward their faith in "free markets" and whether they believe government involvement can improve or worsen a more laissez-faire system. Both men are highly articulate and offer a much more in-depth discussion than that found on cable network news. Moreover, given their divergent perspectives, it is astonishing listening to how much they agree about in terms of how ridiculous, wasteful, expensive and ultimately ruinous the current system is.
--br
The economists are rather philosophical adversaries: Stuart Butler serves as the vice president for domestic and economic policy studies for the conservative think tank The Heritage Foundation, and Paul Krugman (a favorite of Billy's) recently won the Nobel Prize in Economics, writes a column for the NY Times and is a champion of political liberalism. As always, such terms as "conservative" and "liberal" get a little slippery and often aren't helpful, although in this case I use the labels since they indicate their general attitude toward their faith in "free markets" and whether they believe government involvement can improve or worsen a more laissez-faire system. Both men are highly articulate and offer a much more in-depth discussion than that found on cable network news. Moreover, given their divergent perspectives, it is astonishing listening to how much they agree about in terms of how ridiculous, wasteful, expensive and ultimately ruinous the current system is.
--br
Tuesday, July 21, 2009
ACRE: Physicians Who Wish To Maintain Status Quo Fight Back
This Thursday, at Harvard Medical School, there will be a one-day conference that amounts to a new front in an ongoing war within the medical community. Probably no more than one or two hundred people will attend. I doubt it will get much play in large media outlets, but its agenda, and whether or not it wins the hearts and minds of the next generation of physicians, could have a major impact on determining the quality of care for patients for the next several decades, possibly just as important as the health-insurance reform bill working its way through Congress.
So what's the conference and why such a big deal?
First, some background and a little explanation of the "war." Over the past decade or so, an increasingly vocal but small minority of physicians have begun to publicly question the relationship that physicians have with for-profit companies involved in medicine, primarily pharmaceutical companies. They have noted that many physicians have become wealthy, for instance, by serving as "professional experts" earning honoraria speaking to audiences of physicians who are fed free dinners (compliments of the company sponsoring the event) and who receive credit for "continuing medical education." They have questioned the structure of postgraduate medical education, which can be heavily influenced by the pharmaceutical industry in the form of Medical Education and Communication Companies, or "MECCs," allowing pharm companies to sidestep sticky conflict-of-interest issues by paying physicians directly for teaching, instead using the MECC as a third-party payer. Indeed, they have highlighted the problems of medical school education as well, since many of these doctors who serve as paid speakers for drug companies also teach medical students without ever revealing that they do so.
Many docs have become involved in this critique of the current relationship between physicians and industry--and I count myself among these people--but probably none is more important than Marcia Angell, whose book The Truth About Drug Companies: How They Deceive Us and What to Do About It lays out in just over 300 pages, and in fairly lurid detail, the tactics used by the pharmaceutical industry to deceive physicians and patients alike in order to boost sales and profits. It is an excellent and highly readable book, and remains the best overview of the critical problems in this often overlooked area of medicine.
There is a lot of pushback by the industry and those physicians already co-opted by them. One small, precious example can be found here, where one Jonathan Leo, professor of Neuroanatomy at Lincoln Memorial University in Tennessee, tried to point out to the Journal of the American Medical Association, one of the premier medical journals in the US, that one of the lead authors of a paper had not properly disclosed a serious conflict-of-interest to the journal. The study involved giving antidepressants to stroke victims prior to developing depression in an attempt to prevent it (depression being a common condition following stroke); the lead author had been a paid consultant by the very company whose drug was being studied. When Dr. Leo questioned the conflict, he never received a reply from the JAMA editors, so nearly six months later he had his letter published in the British Medical Journal, which was met with howling outrage by the JAMA editors who not only verbally threatened Dr. Leo, but also told reporters at the Wall Street Journal that Leo was a "nobody and a nothing," and that "he is trying to make a name for himself." (Question: isn't that what you're supposed to do in academics? And he sure did! And for the right reasons!) Best part: while the study showed that treatment with the study drug (Lexapro, generic name escitalopram) was significantly better than placebo, it failed to show that it was significantly better than psychotherapy. The mainstream media who picked up the piece, however, quoted the study authors as saying that they believed all stroke patients should be given antidepressants--no quotes could be found about the fact that the drug was no better than therapy.
Anyway, Thursday's get-together at Harvard is the inaugural meeting of a group called the Association of Clinical Researchers and Educators. They state that "ACRE seeks to define and promote balanced policies at academic medical centers and within government that will enhance rather than interfere with our highly valued collaboration." Seems entirely innocuous, no? After all, who isn't for "balanced policies," whatever that is?
More specifics can be found elsewhere in the website, where they state that "ACRE is to be a forum for what we believe is a hitherto silent majority of individuals engaged in clinical service, medical education and medical innovation ready to oppose (but not debate) a small but well organized and well-funded coterie responsible for an anti-industry movement. This movement has inverted reality by extrapolating from an astonishingly small number of adverse events related to industry compared to the incontrovertible evidence of social good that has eventuated from thousands of industry actions over my lifetime in medicine. The movement particularly demonizes industry marketing, despite the lack of any evidence that, on balance, such marketing impacts anything but positively on patient care."
What the writer--who appears to be Dr. Thomas Stossel of Harvard, but not fully clear--means by "oppose but not debate" is unclear to me although it sounds vaguely undemocratic, but the idea that there is a "well organized and well-funded coterie responsible for an anti-industry movement" is so remarkably laughable that it must rank as one of the great overestimations in recent American history. (I particularly like the use of the word "coterie," as if somehow I've been sitting around in a parlor sipping tea with Doc Angell snarling about the bad guys of big pharma.) If critics like Dr. Angell, or the bloggers Dr. Dan Carlat, Dr. Doug Bremner or Allison Bass are so well-funded yet so anti-industry, who has the money to fund them? The local chapter of the American Communist Party?
More disturbing is a complete lack of data on the website; as far as I can tell ACRE does not marshal one fact to support their hypothesis. There are no references on the website, although there is a "link" page which includes several articles complaining about the critics, nearly half of those articles written by Dr. Stossel. Given that this is a website whose leadership consists of academic medical researchers, one would figure there would be at least a modicum of references and facts marshaled in order to make a convincing argument. But from what I can see, there's a lot of hemming and hawwing but no argument based in evidence. Ironically, the statement above notes that "the movement demonizes industry marketing despite the lack of any evidence that...such marketing impacts anything but positively on patient care" [my emphasis], which makes one wonder whether or not the authors have taken the time to even glance at the first page of The Truth About Drug Companies. Or Jerome Kassirer's book On The Take: How Medicine's Complicity With Big Business Can Endanger Your Health. Or Jerry Avorn's book Powerful Medicines: The Benefits, Risks and Costs of Prescription Drugs. Might ACRE disagree with their conclusions? Perhaps. But to me it seems fairly ludicrous to suggest that this whole critique has been generated of whole cloth. Meanwhile, ACRE has not generated one shred of evidence to support their claim on the website.
My suspicion is that they can't rely on evidence because it's not on their side, and they require strawmen to knock down so that they can look reasonable. I myself cannot speak for the other critics, but my main objection is that some doctors are allowed to generate large sums of money in the service of pharmaceutical companies in a variety of ways, and do not consider this inappropriate. Well, I consider this inappropriate, and I believe the overwhelming majority of patients consider it equally so. And I consider it inappropriate because drug companies exist primarily to make money while doctors exist primarily to serve their patients. Anyone who refuses to see that a physician cannot serve both ends hasn't been reading about what's been happening in medicine for the past two decades.
One last link: don't say docs don't have a sense of humor! Here is a link to a satirical twin of the ACRE website: "Academics Craving Reimbursement for Everything." One juicy quote: "ACRE is to be a forum for a hitherto silent majority of doctors which believes that a small but well organized coterie of do-gooders are conspiring to prevent them from buying that third home on the lake." They even get that coterie word in. Love that.
As a quick post-script, I note that one of the featured speakers at the event will be Dr. Jeffrey Flier, who is the current Dean of Harvard Medical School. A few months ago I had written about the Harvard medical students who launched a protest about the conflict-of-interest issues in the pharmacology course, and noted that Dr. Flier had made noises that he wanted to change the policies at HMS. While those changes have partially taken place (following the lead of Johns Hopkins, although this new policy is through the hospitals affiliated with HMS, not the medical school itself), I can't say I am especially encouraged by Dr. Flier's acceptance to speak at this gathering, though we will have to see what he will say.
--br
So what's the conference and why such a big deal?
First, some background and a little explanation of the "war." Over the past decade or so, an increasingly vocal but small minority of physicians have begun to publicly question the relationship that physicians have with for-profit companies involved in medicine, primarily pharmaceutical companies. They have noted that many physicians have become wealthy, for instance, by serving as "professional experts" earning honoraria speaking to audiences of physicians who are fed free dinners (compliments of the company sponsoring the event) and who receive credit for "continuing medical education." They have questioned the structure of postgraduate medical education, which can be heavily influenced by the pharmaceutical industry in the form of Medical Education and Communication Companies, or "MECCs," allowing pharm companies to sidestep sticky conflict-of-interest issues by paying physicians directly for teaching, instead using the MECC as a third-party payer. Indeed, they have highlighted the problems of medical school education as well, since many of these doctors who serve as paid speakers for drug companies also teach medical students without ever revealing that they do so.
Many docs have become involved in this critique of the current relationship between physicians and industry--and I count myself among these people--but probably none is more important than Marcia Angell, whose book The Truth About Drug Companies: How They Deceive Us and What to Do About It lays out in just over 300 pages, and in fairly lurid detail, the tactics used by the pharmaceutical industry to deceive physicians and patients alike in order to boost sales and profits. It is an excellent and highly readable book, and remains the best overview of the critical problems in this often overlooked area of medicine.
There is a lot of pushback by the industry and those physicians already co-opted by them. One small, precious example can be found here, where one Jonathan Leo, professor of Neuroanatomy at Lincoln Memorial University in Tennessee, tried to point out to the Journal of the American Medical Association, one of the premier medical journals in the US, that one of the lead authors of a paper had not properly disclosed a serious conflict-of-interest to the journal. The study involved giving antidepressants to stroke victims prior to developing depression in an attempt to prevent it (depression being a common condition following stroke); the lead author had been a paid consultant by the very company whose drug was being studied. When Dr. Leo questioned the conflict, he never received a reply from the JAMA editors, so nearly six months later he had his letter published in the British Medical Journal, which was met with howling outrage by the JAMA editors who not only verbally threatened Dr. Leo, but also told reporters at the Wall Street Journal that Leo was a "nobody and a nothing," and that "he is trying to make a name for himself." (Question: isn't that what you're supposed to do in academics? And he sure did! And for the right reasons!) Best part: while the study showed that treatment with the study drug (Lexapro, generic name escitalopram) was significantly better than placebo, it failed to show that it was significantly better than psychotherapy. The mainstream media who picked up the piece, however, quoted the study authors as saying that they believed all stroke patients should be given antidepressants--no quotes could be found about the fact that the drug was no better than therapy.
Anyway, Thursday's get-together at Harvard is the inaugural meeting of a group called the Association of Clinical Researchers and Educators. They state that "ACRE seeks to define and promote balanced policies at academic medical centers and within government that will enhance rather than interfere with our highly valued collaboration." Seems entirely innocuous, no? After all, who isn't for "balanced policies," whatever that is?
More specifics can be found elsewhere in the website, where they state that "ACRE is to be a forum for what we believe is a hitherto silent majority of individuals engaged in clinical service, medical education and medical innovation ready to oppose (but not debate) a small but well organized and well-funded coterie responsible for an anti-industry movement. This movement has inverted reality by extrapolating from an astonishingly small number of adverse events related to industry compared to the incontrovertible evidence of social good that has eventuated from thousands of industry actions over my lifetime in medicine. The movement particularly demonizes industry marketing, despite the lack of any evidence that, on balance, such marketing impacts anything but positively on patient care."
What the writer--who appears to be Dr. Thomas Stossel of Harvard, but not fully clear--means by "oppose but not debate" is unclear to me although it sounds vaguely undemocratic, but the idea that there is a "well organized and well-funded coterie responsible for an anti-industry movement" is so remarkably laughable that it must rank as one of the great overestimations in recent American history. (I particularly like the use of the word "coterie," as if somehow I've been sitting around in a parlor sipping tea with Doc Angell snarling about the bad guys of big pharma.) If critics like Dr. Angell, or the bloggers Dr. Dan Carlat, Dr. Doug Bremner or Allison Bass are so well-funded yet so anti-industry, who has the money to fund them? The local chapter of the American Communist Party?
More disturbing is a complete lack of data on the website; as far as I can tell ACRE does not marshal one fact to support their hypothesis. There are no references on the website, although there is a "link" page which includes several articles complaining about the critics, nearly half of those articles written by Dr. Stossel. Given that this is a website whose leadership consists of academic medical researchers, one would figure there would be at least a modicum of references and facts marshaled in order to make a convincing argument. But from what I can see, there's a lot of hemming and hawwing but no argument based in evidence. Ironically, the statement above notes that "the movement demonizes industry marketing despite the lack of any evidence that...such marketing impacts anything but positively on patient care" [my emphasis], which makes one wonder whether or not the authors have taken the time to even glance at the first page of The Truth About Drug Companies. Or Jerome Kassirer's book On The Take: How Medicine's Complicity With Big Business Can Endanger Your Health. Or Jerry Avorn's book Powerful Medicines: The Benefits, Risks and Costs of Prescription Drugs. Might ACRE disagree with their conclusions? Perhaps. But to me it seems fairly ludicrous to suggest that this whole critique has been generated of whole cloth. Meanwhile, ACRE has not generated one shred of evidence to support their claim on the website.
My suspicion is that they can't rely on evidence because it's not on their side, and they require strawmen to knock down so that they can look reasonable. I myself cannot speak for the other critics, but my main objection is that some doctors are allowed to generate large sums of money in the service of pharmaceutical companies in a variety of ways, and do not consider this inappropriate. Well, I consider this inappropriate, and I believe the overwhelming majority of patients consider it equally so. And I consider it inappropriate because drug companies exist primarily to make money while doctors exist primarily to serve their patients. Anyone who refuses to see that a physician cannot serve both ends hasn't been reading about what's been happening in medicine for the past two decades.
One last link: don't say docs don't have a sense of humor! Here is a link to a satirical twin of the ACRE website: "Academics Craving Reimbursement for Everything." One juicy quote: "ACRE is to be a forum for a hitherto silent majority of doctors which believes that a small but well organized coterie of do-gooders are conspiring to prevent them from buying that third home on the lake." They even get that coterie word in. Love that.
As a quick post-script, I note that one of the featured speakers at the event will be Dr. Jeffrey Flier, who is the current Dean of Harvard Medical School. A few months ago I had written about the Harvard medical students who launched a protest about the conflict-of-interest issues in the pharmacology course, and noted that Dr. Flier had made noises that he wanted to change the policies at HMS. While those changes have partially taken place (following the lead of Johns Hopkins, although this new policy is through the hospitals affiliated with HMS, not the medical school itself), I can't say I am especially encouraged by Dr. Flier's acceptance to speak at this gathering, though we will have to see what he will say.
--br
Monday, July 13, 2009
Effects of the Anti-Vaccine Campaign
Anyone out there thinking about going to merry old England for a summer excursion? Well, think carefully before you go--especially if you head to the northeast of that storied country, where they are experiencing the largest measles outbreak in nearly 20 years. A local public health official noted that "the majority of these cases could have been prevented as most were in children who were not fully protected with MMR." MMR is the acronym for the measles, mumps, and rubella vaccine, which has been around for decades and is one of the safest vaccines known to man.
The vaccine rate for MMR was quite high in England until 1998, when a gastroenterologist named Andrew Wakefield held a press conference where he presented research that indicated the MMR vaccine was linked with autism. The "findings" were trumpeted by the British press, and the vaccination rate fell over the next several years from 92 percent to below 80 percent. Alas, Dr. Wakefield's research was later found to have massive financial conflicts of interest; by March 2004 a dozen of Wakefield's co-authors, including some of the preeminent names in medical research in the UK, withdrew their names from the paper. But by that time the horses were out of that particular barn, and the effects are still being felt there today. And the problem has spread to our shores as well, with any number of otherwise educated people spouting about the vaccines-autism connection as if it were fact. Newsweek magazine provides the whole story in all its sordid details here. They did a commendable job of providing crucial context and essential details; would that mainstream journalism produce this kind of work more often.
Since most Americans--or for that matter most anyone who lives in a relatively developed country--hardly give it a thought, a couple of facts about the measles might be worth sharing. It is one of the most highly contagious viruses known to humans; consequences of infection can range from mild (a few days of generalized illness and the famous facial rash) to serious (among other things, a slowly progressive brain disorder called subacute sclerosing panencephalitis, which is as ugly as it sounds), to death. In fact, in countries where the MMR vaccine is not available due to adequate funds, refrigeration, or trained personnel to administer the vaccine, it is an all-out killer: in 1999 it had killed 873,000 children (and a smaller number of adults) in just one year. As part of a massive vaccination campaign in the areas where the children are not immunized or given boosters (mostly India, Indonesia, Pakistan, Somalia, Sudan and the distant rural provinces of China), the World Health Organization has been trying to get the number under control, with the annual mortality down to under 250,000 children in recent years. To give you some sense of perspective, in any given year just a bit over 10,000 children younger than age 14 die in the US each year. So this is by no means a trivial problem.
For further reading, you can peruse the information here (a guide to the studies about vaccines and autism) and here (stuff about vaccine ingredients), among other places. Also, Dr. Paul Offit, one of vaccine's greatest and most lucid proponents has written a book about the whole controversy entitled Autism's False Prophets, which I have not read but it is on my reading list. I am, however, working my way through journalist Arthur Allen's tome Vaccine: The Controversial Story of Medicine's Greatest Lifesaver, and it's been a very good read thus far.
--br
The vaccine rate for MMR was quite high in England until 1998, when a gastroenterologist named Andrew Wakefield held a press conference where he presented research that indicated the MMR vaccine was linked with autism. The "findings" were trumpeted by the British press, and the vaccination rate fell over the next several years from 92 percent to below 80 percent. Alas, Dr. Wakefield's research was later found to have massive financial conflicts of interest; by March 2004 a dozen of Wakefield's co-authors, including some of the preeminent names in medical research in the UK, withdrew their names from the paper. But by that time the horses were out of that particular barn, and the effects are still being felt there today. And the problem has spread to our shores as well, with any number of otherwise educated people spouting about the vaccines-autism connection as if it were fact. Newsweek magazine provides the whole story in all its sordid details here. They did a commendable job of providing crucial context and essential details; would that mainstream journalism produce this kind of work more often.
Since most Americans--or for that matter most anyone who lives in a relatively developed country--hardly give it a thought, a couple of facts about the measles might be worth sharing. It is one of the most highly contagious viruses known to humans; consequences of infection can range from mild (a few days of generalized illness and the famous facial rash) to serious (among other things, a slowly progressive brain disorder called subacute sclerosing panencephalitis, which is as ugly as it sounds), to death. In fact, in countries where the MMR vaccine is not available due to adequate funds, refrigeration, or trained personnel to administer the vaccine, it is an all-out killer: in 1999 it had killed 873,000 children (and a smaller number of adults) in just one year. As part of a massive vaccination campaign in the areas where the children are not immunized or given boosters (mostly India, Indonesia, Pakistan, Somalia, Sudan and the distant rural provinces of China), the World Health Organization has been trying to get the number under control, with the annual mortality down to under 250,000 children in recent years. To give you some sense of perspective, in any given year just a bit over 10,000 children younger than age 14 die in the US each year. So this is by no means a trivial problem.
For further reading, you can peruse the information here (a guide to the studies about vaccines and autism) and here (stuff about vaccine ingredients), among other places. Also, Dr. Paul Offit, one of vaccine's greatest and most lucid proponents has written a book about the whole controversy entitled Autism's False Prophets, which I have not read but it is on my reading list. I am, however, working my way through journalist Arthur Allen's tome Vaccine: The Controversial Story of Medicine's Greatest Lifesaver, and it's been a very good read thus far.
--br
Wednesday, July 8, 2009
Scientific Dialogue on Fox News
Something pretty incredible happened on Fox News today. Really. Given that Fox has managed to take the practice of using racial euphemism to the point of high art (no real surprise that, given that the whole shebang is run by master propagandist Roger Ailes), one would not expect one of their employees to depart from polished rhetoric and just go on a baldly racist rant, but one would have been quite surprised tuning into this morning's Fox offerings, if of course one wanted to torture oneself by sitting in front of such mind-numbing nonsense (like all television news networks, it must be said in fairness). And what a surprise it would have been.
On Fox & Friends a little chat was taking place over what under any sane conditions would be a study that would receive approximately zero attention by any serious science or health journalist, though nobody would confuse any of the three hosts of this show with such a beast. The study under discussion involved Scandanavian seniors, among whom those who had remained married appeared to be less likely to have Alzheimer's dementia.
Much could be said about the generally minimal worth of such a study, but that is merely a sideshow to the main attraction, which came when co-host Brian Kilmeade explained why he thought the results of such a study did not apply in the US. His reasoning? "We are...we keep marrying other species and other ethnics and other..." was his first foray into the thickets of reason.
Immediately--and to her great credit--his fair-haired co-host Gretchen Carlson tried to cut him off with a not-so-subtle rebuke: "You're sure you're not suffering from some of the causes of dementia right now?" Say what you will about the formulaic arrangement of a pretty blonde chatting with two guys on the morning news; she understood the potential for ugly consequences within milliseconds of hearing the sounds that issued from Kilmeade's mouth.
Undaunted, Kilmeade pressed on, saying, "See, the problem is the Swedes have pure genes. Because they marry other Swedes .... Finns marry other Finns, so they have a pure society." Again, Carlson responded with a look of puzzlement worthy of an Emmy, and third co-host Dave Briggs appeared to try to find middle ground with a half-question half-exclamation of "Huh?!" in response. You really have to see this thing to believe it.
The nakedly racist bent of Kilmeade's "analysis" is really only half the point (and requires no further commentary). At least as important though is the idea that this man--who reveals himself through this short little piece to be a woefully uninformed and deeply unsophisticated anchor--has been chosen by a major television news network to hold forth on the latest in medical research. Moreover, said anchor is spouting off on this inconsequential study, chosen by some superior, instead of any number of other medical or scientific topics that might be of some actual use to its viewers. Lastly, the size & reach of Fox News relative to, say, the "Health & Medicine" section of the New York Times is of course considerably larger, so the impact of such vapidity is amplified.
Video is here:
--br
On Fox & Friends a little chat was taking place over what under any sane conditions would be a study that would receive approximately zero attention by any serious science or health journalist, though nobody would confuse any of the three hosts of this show with such a beast. The study under discussion involved Scandanavian seniors, among whom those who had remained married appeared to be less likely to have Alzheimer's dementia.
Much could be said about the generally minimal worth of such a study, but that is merely a sideshow to the main attraction, which came when co-host Brian Kilmeade explained why he thought the results of such a study did not apply in the US. His reasoning? "We are...we keep marrying other species and other ethnics and other..." was his first foray into the thickets of reason.
Immediately--and to her great credit--his fair-haired co-host Gretchen Carlson tried to cut him off with a not-so-subtle rebuke: "You're sure you're not suffering from some of the causes of dementia right now?" Say what you will about the formulaic arrangement of a pretty blonde chatting with two guys on the morning news; she understood the potential for ugly consequences within milliseconds of hearing the sounds that issued from Kilmeade's mouth.
Undaunted, Kilmeade pressed on, saying, "See, the problem is the Swedes have pure genes. Because they marry other Swedes .... Finns marry other Finns, so they have a pure society." Again, Carlson responded with a look of puzzlement worthy of an Emmy, and third co-host Dave Briggs appeared to try to find middle ground with a half-question half-exclamation of "Huh?!" in response. You really have to see this thing to believe it.
The nakedly racist bent of Kilmeade's "analysis" is really only half the point (and requires no further commentary). At least as important though is the idea that this man--who reveals himself through this short little piece to be a woefully uninformed and deeply unsophisticated anchor--has been chosen by a major television news network to hold forth on the latest in medical research. Moreover, said anchor is spouting off on this inconsequential study, chosen by some superior, instead of any number of other medical or scientific topics that might be of some actual use to its viewers. Lastly, the size & reach of Fox News relative to, say, the "Health & Medicine" section of the New York Times is of course considerably larger, so the impact of such vapidity is amplified.
Video is here:
--br
Monday, July 6, 2009
Sarah Palin's Personality Disorder Problem
Evidence of the overall cheapness of American political dialogue can be found in the news surrounding Sarah Palin--not in her announcement that she would be resigning her office, but rather in Todd Purdum's Vanity Fair article that may have contributed to the timing of her announcement. Purdum's article is for the most part a rehash of insider gossip about the tensions between McCain's advisors and Governor Palin during the campaign, and is remarkable only for the candor with which some of the political staffers spoke.
Among the unremarkable features of the article includes a little medical soliloquy, and it's unremarkable because we've seen this happen before in national political discussions. Purdum wrote:
More than once in my travels in Alaska, people brought up, without prompting, the question of Palin’s extravagant self-regard. Several told me, independently of one another, that they had consulted the definition of “narcissistic personality disorder” in the Diagnostic and Statistical Manual of Mental Disorders—“a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy”—and thought it fit her perfectly. When Trig was born, Palin wrote an e-mail letter to friends and relatives, describing the belated news of her pregnancy and detailing Trig’s condition; she wrote the e-mail not in her own name but in God’s, and signed it “Trig’s Creator, Your Heavenly Father.”
There it is--Purdum, who is in theory a journalist, includes accusations that Sarah Palin has Narcissistic Personality Disorder because "several people told" him, and apparently they read the Diagnostic and Statistical Manual for Mental Disorders (in the biz called simply the "DSM") and it looked to them like it fit. Within days of the article's release, TV and radio personalities as well as various websites began trumpeting the Governor's "diagnosis" basically assuming it was factually true; for instance, a Yahoo! news bit can be found here, while Salon's War Room (Billy is normally a fan) discussed it here.
This is prattling nonsense of the worst sort, with armchair diagnosis passing for professional opinion, and then repeated again and again as if it were fact. As if to substantiate his own claim, Purdum includes a lil' note from Palin on the birth of her child Trig, noting that it was signed "Your Heavenly Father." Is it a touch odd for Palin to sign the note thus? From my perspective, yes, but I'm an agnostic east-coast Jew so I'm not so sure whether or not this is just a cultural thing and perhaps passes for normal and heartwarming among Christians in Alaska. Does it indicate that Palin thinks--as the placement of this story in this particular paragraph suggests--that she is the Heavenly Father, or speaks directly for him? That seems like such a stretch to me that Purdum appears guilty of the worst kind of guilt-by-innuendo journalism that marks so much of political reportage these days.
For what it's worth, here is the current DSM definition of Narcississtic Personality Disorder:
The symptoms of narcissistic personality disorder revolve around a pattern of grandiosity, need for admiration, and sense of entitlement. Often individuals feel overly important and will exaggerate achievements and will accept, and often demand, praise and admiration despite worthy achievements. They may be overwhelmed with fantasies involving unlimited success, power, love, or beauty and feel that they can only be understood by others who are, like them, superior in some aspect of life.
There is a sense of entitlement, of being more deserving than others based solely on their superiority. These symptoms, however, are a result of an underlying sense of inferiority and are often seen as overcompensation. Because of this, they are often envious and even angry of others who have more, receive more respect or attention, or otherwise steal away the spotlight.
This, though, doesn't describe the features which distinguish personality disorders as a whole from the unflattering qualities that they represent. DSM elaborates on this, noting that to be diagnosed with a personality disorder, the following criteria must be met:
-Symptoms have been present for an extended period of time, are inflexible and pervasive, and are not a result of alcohol or drugs or another psychiatric disorder.
Could Governor Palin be vain, vindictive, grandiose, have a sense of entitlement, and demand praise and admiration? Certainly--and I think there's plenty of evidence to indicate that at least some of these adjectives apply to her. But that doesn't give her the diagnosis of Narcissistic Personality Disorder. And Vanity Fair's Purdum (to say nothing of his editors), in blithely repeating these assertions from unnamed sources who almost definitely are not mental health professionals, attaches a clinical tag to her troubles. (Indeed, when considering this list of personal attributes and applying them to other politicians, President Obama's Chief of Staff Rahm Emmanuel has a reputation for being profoundly vindictive; one can find more than a whiff of vindictiveness in this story about how the White House is offended by one lefty Democratic congressman's willingness to call out the administration on what he believed was a lousy energy bill. Do they all have personality disorders as well?)
Liberal readers may recall that the shoe was on the other foot not too long ago, when then Senate Majority Leader and potential Presidential candidate (and, lest we not forget, actual physician) Bill Frist took to the Senate floor to pronounce his diagnosis that Terri Schiavo was not in a persistent vegetative state. At the time, the howls of indignation came from many corners, and rightly so: Frist was so far out of bounds as to deserve censure from his state medical ethics board in my opinion.
In Palin's case this is no less true. Nobody but appropriately qualified professionals should be bandying about diagnoses. Sarah Palin does not have a personality disorder; she does, however, have a personality disorder problem--the problem of snarky and shallow journalists shoving this kind of bilge on what appears to be an uncritical public.
I find Sarah Palin the politician contemptible in any number of ways. My principal objections to her is that she appears to be not merely uninformed but incurious, and she also appears to revel in anti-intellectualism. But I don't claim to know anything about Sarah Palin the person. From a distance I see a woman who made it to the position of Governor by her early forties--no mean feat, that--and has a family who appear to love her, whatever issues they may have (as all families do). I am perfectly willing to condemn any number of stands that she has taken since she has risen to political prominence. I am fearful of the prospect of a President Palin, although this happily seems to be increasingly unlikely. But I am not willing to go along with the idea that its okay for journalists to lazily repeat assertions of her supposed personality disorder.
--br
Among the unremarkable features of the article includes a little medical soliloquy, and it's unremarkable because we've seen this happen before in national political discussions. Purdum wrote:
More than once in my travels in Alaska, people brought up, without prompting, the question of Palin’s extravagant self-regard. Several told me, independently of one another, that they had consulted the definition of “narcissistic personality disorder” in the Diagnostic and Statistical Manual of Mental Disorders—“a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy”—and thought it fit her perfectly. When Trig was born, Palin wrote an e-mail letter to friends and relatives, describing the belated news of her pregnancy and detailing Trig’s condition; she wrote the e-mail not in her own name but in God’s, and signed it “Trig’s Creator, Your Heavenly Father.”
There it is--Purdum, who is in theory a journalist, includes accusations that Sarah Palin has Narcissistic Personality Disorder because "several people told" him, and apparently they read the Diagnostic and Statistical Manual for Mental Disorders (in the biz called simply the "DSM") and it looked to them like it fit. Within days of the article's release, TV and radio personalities as well as various websites began trumpeting the Governor's "diagnosis" basically assuming it was factually true; for instance, a Yahoo! news bit can be found here, while Salon's War Room (Billy is normally a fan) discussed it here.
This is prattling nonsense of the worst sort, with armchair diagnosis passing for professional opinion, and then repeated again and again as if it were fact. As if to substantiate his own claim, Purdum includes a lil' note from Palin on the birth of her child Trig, noting that it was signed "Your Heavenly Father." Is it a touch odd for Palin to sign the note thus? From my perspective, yes, but I'm an agnostic east-coast Jew so I'm not so sure whether or not this is just a cultural thing and perhaps passes for normal and heartwarming among Christians in Alaska. Does it indicate that Palin thinks--as the placement of this story in this particular paragraph suggests--that she is the Heavenly Father, or speaks directly for him? That seems like such a stretch to me that Purdum appears guilty of the worst kind of guilt-by-innuendo journalism that marks so much of political reportage these days.
For what it's worth, here is the current DSM definition of Narcississtic Personality Disorder:
The symptoms of narcissistic personality disorder revolve around a pattern of grandiosity, need for admiration, and sense of entitlement. Often individuals feel overly important and will exaggerate achievements and will accept, and often demand, praise and admiration despite worthy achievements. They may be overwhelmed with fantasies involving unlimited success, power, love, or beauty and feel that they can only be understood by others who are, like them, superior in some aspect of life.
There is a sense of entitlement, of being more deserving than others based solely on their superiority. These symptoms, however, are a result of an underlying sense of inferiority and are often seen as overcompensation. Because of this, they are often envious and even angry of others who have more, receive more respect or attention, or otherwise steal away the spotlight.
This, though, doesn't describe the features which distinguish personality disorders as a whole from the unflattering qualities that they represent. DSM elaborates on this, noting that to be diagnosed with a personality disorder, the following criteria must be met:
-Symptoms have been present for an extended period of time, are inflexible and pervasive, and are not a result of alcohol or drugs or another psychiatric disorder.
-The history of symptoms can be traced back to adolescence or at least early adulthood.
-The symptoms have caused and continue to cause significant distress or negative consequences in different aspects of the person's life.
-Symptoms are seen in at least two of the following areas:
Thoughts (ways of looking at the world, thinking about self or others, and interacting)
Emotions (appropriateness, intensity, and range of emotional functioning)
Interpersonal Functioning (relationships and interpersonal skills)
Impulse Control
Could Governor Palin be vain, vindictive, grandiose, have a sense of entitlement, and demand praise and admiration? Certainly--and I think there's plenty of evidence to indicate that at least some of these adjectives apply to her. But that doesn't give her the diagnosis of Narcissistic Personality Disorder. And Vanity Fair's Purdum (to say nothing of his editors), in blithely repeating these assertions from unnamed sources who almost definitely are not mental health professionals, attaches a clinical tag to her troubles. (Indeed, when considering this list of personal attributes and applying them to other politicians, President Obama's Chief of Staff Rahm Emmanuel has a reputation for being profoundly vindictive; one can find more than a whiff of vindictiveness in this story about how the White House is offended by one lefty Democratic congressman's willingness to call out the administration on what he believed was a lousy energy bill. Do they all have personality disorders as well?)
Liberal readers may recall that the shoe was on the other foot not too long ago, when then Senate Majority Leader and potential Presidential candidate (and, lest we not forget, actual physician) Bill Frist took to the Senate floor to pronounce his diagnosis that Terri Schiavo was not in a persistent vegetative state. At the time, the howls of indignation came from many corners, and rightly so: Frist was so far out of bounds as to deserve censure from his state medical ethics board in my opinion.
In Palin's case this is no less true. Nobody but appropriately qualified professionals should be bandying about diagnoses. Sarah Palin does not have a personality disorder; she does, however, have a personality disorder problem--the problem of snarky and shallow journalists shoving this kind of bilge on what appears to be an uncritical public.
I find Sarah Palin the politician contemptible in any number of ways. My principal objections to her is that she appears to be not merely uninformed but incurious, and she also appears to revel in anti-intellectualism. But I don't claim to know anything about Sarah Palin the person. From a distance I see a woman who made it to the position of Governor by her early forties--no mean feat, that--and has a family who appear to love her, whatever issues they may have (as all families do). I am perfectly willing to condemn any number of stands that she has taken since she has risen to political prominence. I am fearful of the prospect of a President Palin, although this happily seems to be increasingly unlikely. But I am not willing to go along with the idea that its okay for journalists to lazily repeat assertions of her supposed personality disorder.
--br
Tuesday, June 30, 2009
The Myth of Our Great Healthcare System
In response to my latest entry (and an additional remark in which I noted that we have been attempting without success to achieve some kind of health care reform for almost 100 years), a Facebook friend writes:
Of course--we have had the best health care system in the world for the last 100 years--so I can't believe we have not changed it. (Please don't tell me you believe Michael Moore and go to Cuba for your healthcare needs). And I'm sure we can agree that a public option is not the only one way to radically ... Read Morechange the system [sic]. Examples are: delink insurance from your job--it should be similar to car insurance--I have had the same car insurance for 15 years because they pay my claims, I trust them, they provide a plan I like, etc---ahhhh--liberty is great!!! Or we could go with health savings plans, or just up the level at which people can go on Medicaid--and don't tell me Medicaid is horrible---where ever I have worked Medicaid patients received the exact same treatment as everyone else.
A couple of points are worth making:
"We have had the best health care system in the world." This used to be a claim about which people could actually have spirited disagreement; now it's demonstrably false by any objective metric one chooses. Before we even discuss the cost of our "best healthcare system in the world" let's just focus on what we get for it: our actual health. Here the US is pretty shabby. Here is a quick summary of the average life expectancy, by country, according to the CIA World Factbook (well known for its commie leanings), where we learn that, leaving aside teeny non UN-member states, the United States ranks 30th at 78.06 years. That is well behind other industrialized nations of its caliber: Japan (2nd, 82.07); France (5th, 80.87); Australia (8th, 80.62); Canada (10th, 80.34); Germany (24th, 78.95); and even the only country with actual, bona-fide socialized medicine, the UK (26th, 78.70). If we want to make the rallying cry "we're better than Cyprus!" (31st on the list), then we're in good shape, I suppose, but I can't believe most politicians or policy wonks will find this fact comforting...which is why you (almost) never hear anybody, even people who ostensibly want a better system, like Obama, say this out loud. We don't have the best system in the world; we stink. (A nice pic showing life expectancy by country in a world map format can be found here.)
Now for the best part: we pay a lot for that 30th slot. Our per-capita expenditure for health care for 2007 is $6096. That is, we spend six thousand dollars per person on health care each year in the US--not just people who have health insurance, all people (UN statistics, the link here). Congrats, we are number one. More telling is how far off a cliff you fall in the next few spots: funny little Luxembourg comes in 2nd at $5,178 (too many MRIs out there? too much plastic surgery? hard to say), then Norway and Switzerland come in at just over $4000, and every country's per capita expenses are under four after that. France, which has been the butt of Republican party jokes for at least the last 20 years on any number of political issues amounting to a shorthand meaning "if it's dumb then France does it," has a per-capita expenditure of $3040, precisely half the amount of the US.
These are two simple and indisputable facts, the very two facts that should be driving the debate on healthcare reform in the US and barely ever mentioned: we spend more that twice as much as most countries on healthcare, and for that cash outlay, the health of our nation is toward the back of the pack of industrialized countries.
Which brings us to Cuba. Michael Moore's documentary Sicko floats out some stats about the state of healthcare in the US, and although he does this is his own inimitable agit-propstery way, he nails the basic gist of the above paragraphs. Recall, the gist is we stink in terms of what we get out of how much we spend; everything else is details. He noted that Cuba--little, backwards, poor and commie Cuba--gets a lot more bang for its buck in terms of life expectancy. According to UN stats, Cuba spends $229 per person per year on healthcare. That's a whole lot less than the gaudy six thousand figure for the US, and what does that get them? If you take the UN figures that average expenditures over a five-year period, it's exactly one rank higher than the US on the life expectancy list (on the list I cite above, it ranks lower at 53rd, 75.08 years).
Let's leave the commies of Cuba behind and look at this through a different lens: the bankruptcy of General Motors. Here in Warm & Wunnerful Capitalism USA there has been much that has been said and written about the downfall of GM, and one of the critiques from the laissez-faire crowd is that this is how the system should work: it rewards the ingenious and punishes the inept. Oddly, GM is the maker of the critically acclaimed Chevy Malibu and also won the 2007 Motortrend Car of the Year Award for its Cadillac GTS. These ain't K-cars, so why is the second-biggest (just surpassed by Toyota last year) car maker in the world in such dire straits? Well, if the health insurance drag on its bottom line ain't the single critical factor, it's certainly one of them. Nate Silver of fivethirtyeight.com has a brief piece about this here, and references a WaPo article here. Money quote (literally!): "most of the excess costs it requires to produce a Buick versus a Toyota come in the form of legacy costs, not what those employees are receiving in salary and benefits today." I don't think it's too much to suggest that that the piece that brought down one of American capitalism's greatest icons, General Motors, was the lack of government involvement in healthcare insurance. (And, incidentally, we were on the verge of having a form of nationalized health insurance just when GM was entering its juggernaut phase in the late 1940s. The reason why it couldn't pass then? Not because of any nonsense used in today's debates, but because southern Democratic party politicians refused to allow for racial integration of hospitals, which a nationalized insurance structure would create since hospitals wouldn't be reimbursed if they didn't integrate.)
This is what we have of our medical insurance system, the only one of industrialized nations whose policies are created by a philosophy that government involvement in the healthcare of its citizens is somehow an encroachment on personal liberties. So I ask: ain't "liberty" great?
A couple of final points: after a Google search I don't know what "Morechange the system" is but assume it was an error of quick typing. I do highly recommend Jonathan Cohn's book "Sick," which is not to be confused with the more popularly-known movie by Michael Moore, as it is a considerably more sober, though less funny, discussion. In it he includes a lengthy discussion of the possible rational solutions, a subject that I've not even ventured to touch upon here.
And my friend refers to Medicaid's popularity, which only makes my point for me as this is a government-run insurance program, although I suspect that she means Medicare rather than Medicaid, but I could be wrong. Medicare is the highly popular government-run health insurance program for seniors, while Medicaid is also a government-run health insurance for the very poor. Why the politicians in favor of reform haven't figured out that the simple phrase "Medicare For All" is a much more winning slogan than all of the jargony claptrap that they use is totally beyond me.
My guess is this: if the debate continues to revolve around what seems to me the overly facile distinction of "liberty" versus "the cold dark hand of government" then we ain't getting nowhere. If we could burst the myth that the system we've got is so good, even if viewed from the perspective of American capitalist interests (as I tried to explain with reference to GM, and the same could be said of even the smallest of companies these days that struggle with offering insurance as a benefit to employees), we might start on the road to fixing it.
--br
Of course--we have had the best health care system in the world for the last 100 years--so I can't believe we have not changed it. (Please don't tell me you believe Michael Moore and go to Cuba for your healthcare needs). And I'm sure we can agree that a public option is not the only one way to radically ... Read Morechange the system [sic]. Examples are: delink insurance from your job--it should be similar to car insurance--I have had the same car insurance for 15 years because they pay my claims, I trust them, they provide a plan I like, etc---ahhhh--liberty is great!!! Or we could go with health savings plans, or just up the level at which people can go on Medicaid--and don't tell me Medicaid is horrible---where ever I have worked Medicaid patients received the exact same treatment as everyone else.
A couple of points are worth making:
"We have had the best health care system in the world." This used to be a claim about which people could actually have spirited disagreement; now it's demonstrably false by any objective metric one chooses. Before we even discuss the cost of our "best healthcare system in the world" let's just focus on what we get for it: our actual health. Here the US is pretty shabby. Here is a quick summary of the average life expectancy, by country, according to the CIA World Factbook (well known for its commie leanings), where we learn that, leaving aside teeny non UN-member states, the United States ranks 30th at 78.06 years. That is well behind other industrialized nations of its caliber: Japan (2nd, 82.07); France (5th, 80.87); Australia (8th, 80.62); Canada (10th, 80.34); Germany (24th, 78.95); and even the only country with actual, bona-fide socialized medicine, the UK (26th, 78.70). If we want to make the rallying cry "we're better than Cyprus!" (31st on the list), then we're in good shape, I suppose, but I can't believe most politicians or policy wonks will find this fact comforting...which is why you (almost) never hear anybody, even people who ostensibly want a better system, like Obama, say this out loud. We don't have the best system in the world; we stink. (A nice pic showing life expectancy by country in a world map format can be found here.)
Now for the best part: we pay a lot for that 30th slot. Our per-capita expenditure for health care for 2007 is $6096. That is, we spend six thousand dollars per person on health care each year in the US--not just people who have health insurance, all people (UN statistics, the link here). Congrats, we are number one. More telling is how far off a cliff you fall in the next few spots: funny little Luxembourg comes in 2nd at $5,178 (too many MRIs out there? too much plastic surgery? hard to say), then Norway and Switzerland come in at just over $4000, and every country's per capita expenses are under four after that. France, which has been the butt of Republican party jokes for at least the last 20 years on any number of political issues amounting to a shorthand meaning "if it's dumb then France does it," has a per-capita expenditure of $3040, precisely half the amount of the US.
These are two simple and indisputable facts, the very two facts that should be driving the debate on healthcare reform in the US and barely ever mentioned: we spend more that twice as much as most countries on healthcare, and for that cash outlay, the health of our nation is toward the back of the pack of industrialized countries.
Which brings us to Cuba. Michael Moore's documentary Sicko floats out some stats about the state of healthcare in the US, and although he does this is his own inimitable agit-propstery way, he nails the basic gist of the above paragraphs. Recall, the gist is we stink in terms of what we get out of how much we spend; everything else is details. He noted that Cuba--little, backwards, poor and commie Cuba--gets a lot more bang for its buck in terms of life expectancy. According to UN stats, Cuba spends $229 per person per year on healthcare. That's a whole lot less than the gaudy six thousand figure for the US, and what does that get them? If you take the UN figures that average expenditures over a five-year period, it's exactly one rank higher than the US on the life expectancy list (on the list I cite above, it ranks lower at 53rd, 75.08 years).
Let's leave the commies of Cuba behind and look at this through a different lens: the bankruptcy of General Motors. Here in Warm & Wunnerful Capitalism USA there has been much that has been said and written about the downfall of GM, and one of the critiques from the laissez-faire crowd is that this is how the system should work: it rewards the ingenious and punishes the inept. Oddly, GM is the maker of the critically acclaimed Chevy Malibu and also won the 2007 Motortrend Car of the Year Award for its Cadillac GTS. These ain't K-cars, so why is the second-biggest (just surpassed by Toyota last year) car maker in the world in such dire straits? Well, if the health insurance drag on its bottom line ain't the single critical factor, it's certainly one of them. Nate Silver of fivethirtyeight.com has a brief piece about this here, and references a WaPo article here. Money quote (literally!): "most of the excess costs it requires to produce a Buick versus a Toyota come in the form of legacy costs, not what those employees are receiving in salary and benefits today." I don't think it's too much to suggest that that the piece that brought down one of American capitalism's greatest icons, General Motors, was the lack of government involvement in healthcare insurance. (And, incidentally, we were on the verge of having a form of nationalized health insurance just when GM was entering its juggernaut phase in the late 1940s. The reason why it couldn't pass then? Not because of any nonsense used in today's debates, but because southern Democratic party politicians refused to allow for racial integration of hospitals, which a nationalized insurance structure would create since hospitals wouldn't be reimbursed if they didn't integrate.)
This is what we have of our medical insurance system, the only one of industrialized nations whose policies are created by a philosophy that government involvement in the healthcare of its citizens is somehow an encroachment on personal liberties. So I ask: ain't "liberty" great?
A couple of final points: after a Google search I don't know what "Morechange the system" is but assume it was an error of quick typing. I do highly recommend Jonathan Cohn's book "Sick," which is not to be confused with the more popularly-known movie by Michael Moore, as it is a considerably more sober, though less funny, discussion. In it he includes a lengthy discussion of the possible rational solutions, a subject that I've not even ventured to touch upon here.
And my friend refers to Medicaid's popularity, which only makes my point for me as this is a government-run insurance program, although I suspect that she means Medicare rather than Medicaid, but I could be wrong. Medicare is the highly popular government-run health insurance program for seniors, while Medicaid is also a government-run health insurance for the very poor. Why the politicians in favor of reform haven't figured out that the simple phrase "Medicare For All" is a much more winning slogan than all of the jargony claptrap that they use is totally beyond me.
My guess is this: if the debate continues to revolve around what seems to me the overly facile distinction of "liberty" versus "the cold dark hand of government" then we ain't getting nowhere. If we could burst the myth that the system we've got is so good, even if viewed from the perspective of American capitalist interests (as I tried to explain with reference to GM, and the same could be said of even the smallest of companies these days that struggle with offering insurance as a benefit to employees), we might start on the road to fixing it.
--br
Thursday, June 25, 2009
The AMA and Health Care Reform
Nick Kristof has a great op-ed today in the NY Times about the AMA and its very, very puzzling reluctance to support the "public insurance option" as part of the health insurance legislation currently working its way through congress. For those not aware, the AMA has, for the past several years, unambiguously supported the notion that all Americans deserve basic medical care. (This is a seeming departure from decades of AMA philosophy, which has been remarkably conservative on a number of issues.) However, as the rubber meets the road and legislators discuss the brass tax required to meet such a lofty goal, the AMA has settled back into its more comfortable position of opposing progressive policies and has decided to oppose any bill that includes a public plan. Their logic is priceless: "the introduction of a new public plan threatens to restrict patient choice by driving out private insurers," they note in a letter to the Senate Finance committee. That is, if we have a public option, and that option is so good that people might want to opt for it over private insurance, we should not do so because it hurts the...sit tight for this...insurers! One might have thought that the AMA was an organization representing the interests of patients, but apparently they are much more concerned for the welfare of insurers. And "welfare" is a particularly apt word.
Money quote, from President Obama's former private-practice internist Dr. David Scheiner, in criticizing the AMA: "they’ve always been on the wrong side of things. They may be protecting their interests, but they’re not protecting the interests of the American public. In the past, physicians have risked their lives to take care of patients. The patient’s health was the bottom line, not the checkbook. Today, it’s just immoral what’s going on. It’s abominable, all these people without health care."
One key point not emphasized by Kristof is that while physician membership in the AMA is dwindling (he estimates that only one in five docs are current members), and there are other physician groups such as the American College of Physicians who are supportive of a more robust public health care policy, the AMA still is regarded by most laypeople as the definitive body that speaks for America's physicians. As a consequence of the AMA's Good Houskeeping Seal of Approval, their opposition to the public finance option makes it seem like physicians as a whole are opposed to it, and while I have not seen polling data, I suspect that this is not the case. Such short-sightedness thus makes us all look bad.
--br
Money quote, from President Obama's former private-practice internist Dr. David Scheiner, in criticizing the AMA: "they’ve always been on the wrong side of things. They may be protecting their interests, but they’re not protecting the interests of the American public. In the past, physicians have risked their lives to take care of patients. The patient’s health was the bottom line, not the checkbook. Today, it’s just immoral what’s going on. It’s abominable, all these people without health care."
One key point not emphasized by Kristof is that while physician membership in the AMA is dwindling (he estimates that only one in five docs are current members), and there are other physician groups such as the American College of Physicians who are supportive of a more robust public health care policy, the AMA still is regarded by most laypeople as the definitive body that speaks for America's physicians. As a consequence of the AMA's Good Houskeeping Seal of Approval, their opposition to the public finance option makes it seem like physicians as a whole are opposed to it, and while I have not seen polling data, I suspect that this is not the case. Such short-sightedness thus makes us all look bad.
--br
Tuesday, June 23, 2009
N of One, part II
A.
Self magazine--which advertises itself as "the first-ever magazine of total well-being, merging beauty and health, fitness and nutrition, and happiness and personal style together in one package...for the woman who wants to stay informed, get inspired, grow and achieve her personal goals"--recently ran an in-depth story about generic medicines entitled "Bad Bargain." The subtitle captures the essence of the piece: All of us want cheaper medicine—but not if it costs us our health. Troubling reactions and a series of recalls are making some doctors wonder, Are generic drugs as safe as the FDA says they are? SELF investigates.
I am not a journalist but I'll give the piece a generally good grade for doing in-depth research, taking great pains to explain in detail how the generic medicine industry is regulated, and even devoting a few paragraphs to those who are skeptical about the claims that generics aren't safe. As articles on medicine and industry go I've seen and read a lot worse. But despite some impressive homework by the Self staff they still make at least one and possibly two major errors of contextualization that, from my standpoint, casts doubt on their claim that generics are scary. Boo.
The first problem, the more minor of the two, shows up at the beginning of the article, when Self describes the medical odyssey of Beth Hubbard, a woman whose life came undone when she was switched from the brand-name anti-depressant Wellbutrin to the generic Budeprion. The article devotes many paragraphs to Hubbard's story (nearly 20 percent of the article), and her discovery that the switch to generic was the likely cause of her decline. During her trials she ended up being prescribed a large number of other medications (more on this anon), but eventually sorted out that the problem lay somehow in the generic formulation, and Self moves on from there to discuss the problem of generics.
Health journalists love using this particular conceit, which is a classic "N of One" scenario. If a journalist looks hard enough, he or she will find all number of strange tales of odd reactions and failures to respond to medications. How much can one conclude from such isolated stories? Not much. The important question is whether or not such a story is representative of something larger. In this case Self at least tries to use the story as an entree to discuss larger trends, and while it makes a few key points to support its claim I remain skeptical that they've demonstrated that this is a massive systemic problem. You be the judge; I'd love to hear feedback.
The second and much more troubling problem is that they pluck the issue of generic medicine regulation out of context and discuss it as if there are no problems with brand-name drugs. The article clearly implies that buying generics is more dangerous than buying brand-name drugs, yet does no comparison of the relative safety of brand-name versus generic drugs (that could be done easily enough). They note that the part of the FDA charged with oversight of generics is overwhelmed and understaffed--a claim that seems all too plausible to me--but don't bother to point out that the same situation applies to the FDA as a whole, especially including regulation of patented and new drugs. In fact, in one of the richest bits in the article, the writer notes that as part of Ms. Hubbard's trials, she took the drug Zelnorm to help cure her symptoms. Zelnorm, made by Novartis Pharmaceuticals, was approved in 2002 to treat Irritable Bowel Syndrome (about which much more could be written, but not today), and not long after approval advertisements on television started popping up showing women revealing their happy midriffs to the world, gleeful with satisfaction from being relieved of their IBS. Alas, the drug was removed from the market in March 2007 at the FDA's request because "data from 29 clinical studies with more than 18,000 patients showed that patients taking Zelnorm were eight times as likely to have heart attacks and strokes compared with those taking placebos." That's your brand-name industry working for you! At its height, Zelnorm prescriptions numbered two million annually. Not so great if you're a 30-something lady suffering from intermittent constipation and suddenly find yourself suffering from a heart attack.
Might there be real problems with the regulation of generics? Indeed, and Self does a reasonably good job for making that case. Might there be real problems with the regulation of all medications, thus making the attack on generics seem weird? I think so. Might the fact that brand-name drug makers advertise heavily in television and print media, while generic manufacturers advertise much less, have some influence on this asymmetric attack on generics? Hmmm.
B.
For my part, I think that if you had to boil down all useful political punditry, you couldn't do much better than being a regular reader of just two writers: Paul Krugman and Bob Somersby of The Daily Howler. Paul, the more famous of the two due to his perch at the NY Times and that prize he got in Stockholm recently, uses his pulpit not only to discuss economics in a manner intelligible to the educated layperson, but also delves into various political topics. A few weeks back he did the latter, and to my mind made a fairly egregious N of One type mistake.
After the shooting of Dr. George Tiller in Witchita, Kansas, Krugman wrote an article entitled "The Big Hate," in which he provocatively asserted "right-wing extremism is being systematically fed by the conservative media and political establishment." Krugman noted that the shooting at the Holocaust Memorial Museum by white supremacist/anti-Semite James W. von Brunn, in addition to the Tiller killing, represented a definite trend that had been predicted by an internal report for the Office of Homeland Security--a report that was met with howling indignation by conservatives.
Do these two examples show that the Homeland Security report was right? Maybe. One counter example that pops a bit of a hole in the right-wing violence theory is the "left-wing" killing of Private Quinton Ezeagwula in Little Rock AK by "Muslim convert" Abdul Hakim Mujahid Muhammad earlier this month. (Unclear if "left-wing" is a useful designation here, but Muhammad's actions are certainly motivated by political beliefs very different from those of the other shooters, and as such doesn't really fit into the scenarios discussed by the Homeland Security report.)
Is Krugman accurate in his assertion that the conservative media feed the kind of hatred that results in such killings? I think yes--although I think he mixes his examples and ends up with a sticky argument. Sometimes an N of One makes a certain amount of sense, if and only if you can demonstrate it to be the end result of a causal chain. Can one trace the killing of Dr. Tiller to the wide exposure he received on Bill O'Reilly's show, where he was frequently called out by name as a "baby-killer" and one who ran a "death mill"? Definitely maybe--at least it's more than reasonable to see if one can trace a line from O'Reilly to the shooter. (Politifact highlights the number of times that O'Reilly singled out Tiller for abuse here.) But can von Brunn's actions be lumped in with this, and are they attributable to the increasingly violent rhetoric of the right-wing media? I think not; von Brunn was a nut, and his hatred of any form of "establishment" media, whether right or left, was uniform. He threatened conservative publications as much as liberal ones. This was no O'Reilly fan, and while O'Reilly and his ilk certainly should be taken to task for the light and heat of their rhetoric, they can't be blamed for von Brunn's actions.
--br
Self magazine--which advertises itself as "the first-ever magazine of total well-being, merging beauty and health, fitness and nutrition, and happiness and personal style together in one package...for the woman who wants to stay informed, get inspired, grow and achieve her personal goals"--recently ran an in-depth story about generic medicines entitled "Bad Bargain." The subtitle captures the essence of the piece: All of us want cheaper medicine—but not if it costs us our health. Troubling reactions and a series of recalls are making some doctors wonder, Are generic drugs as safe as the FDA says they are? SELF investigates.
I am not a journalist but I'll give the piece a generally good grade for doing in-depth research, taking great pains to explain in detail how the generic medicine industry is regulated, and even devoting a few paragraphs to those who are skeptical about the claims that generics aren't safe. As articles on medicine and industry go I've seen and read a lot worse. But despite some impressive homework by the Self staff they still make at least one and possibly two major errors of contextualization that, from my standpoint, casts doubt on their claim that generics are scary. Boo.
The first problem, the more minor of the two, shows up at the beginning of the article, when Self describes the medical odyssey of Beth Hubbard, a woman whose life came undone when she was switched from the brand-name anti-depressant Wellbutrin to the generic Budeprion. The article devotes many paragraphs to Hubbard's story (nearly 20 percent of the article), and her discovery that the switch to generic was the likely cause of her decline. During her trials she ended up being prescribed a large number of other medications (more on this anon), but eventually sorted out that the problem lay somehow in the generic formulation, and Self moves on from there to discuss the problem of generics.
Health journalists love using this particular conceit, which is a classic "N of One" scenario. If a journalist looks hard enough, he or she will find all number of strange tales of odd reactions and failures to respond to medications. How much can one conclude from such isolated stories? Not much. The important question is whether or not such a story is representative of something larger. In this case Self at least tries to use the story as an entree to discuss larger trends, and while it makes a few key points to support its claim I remain skeptical that they've demonstrated that this is a massive systemic problem. You be the judge; I'd love to hear feedback.
The second and much more troubling problem is that they pluck the issue of generic medicine regulation out of context and discuss it as if there are no problems with brand-name drugs. The article clearly implies that buying generics is more dangerous than buying brand-name drugs, yet does no comparison of the relative safety of brand-name versus generic drugs (that could be done easily enough). They note that the part of the FDA charged with oversight of generics is overwhelmed and understaffed--a claim that seems all too plausible to me--but don't bother to point out that the same situation applies to the FDA as a whole, especially including regulation of patented and new drugs. In fact, in one of the richest bits in the article, the writer notes that as part of Ms. Hubbard's trials, she took the drug Zelnorm to help cure her symptoms. Zelnorm, made by Novartis Pharmaceuticals, was approved in 2002 to treat Irritable Bowel Syndrome (about which much more could be written, but not today), and not long after approval advertisements on television started popping up showing women revealing their happy midriffs to the world, gleeful with satisfaction from being relieved of their IBS. Alas, the drug was removed from the market in March 2007 at the FDA's request because "data from 29 clinical studies with more than 18,000 patients showed that patients taking Zelnorm were eight times as likely to have heart attacks and strokes compared with those taking placebos." That's your brand-name industry working for you! At its height, Zelnorm prescriptions numbered two million annually. Not so great if you're a 30-something lady suffering from intermittent constipation and suddenly find yourself suffering from a heart attack.
Might there be real problems with the regulation of generics? Indeed, and Self does a reasonably good job for making that case. Might there be real problems with the regulation of all medications, thus making the attack on generics seem weird? I think so. Might the fact that brand-name drug makers advertise heavily in television and print media, while generic manufacturers advertise much less, have some influence on this asymmetric attack on generics? Hmmm.
B.
For my part, I think that if you had to boil down all useful political punditry, you couldn't do much better than being a regular reader of just two writers: Paul Krugman and Bob Somersby of The Daily Howler. Paul, the more famous of the two due to his perch at the NY Times and that prize he got in Stockholm recently, uses his pulpit not only to discuss economics in a manner intelligible to the educated layperson, but also delves into various political topics. A few weeks back he did the latter, and to my mind made a fairly egregious N of One type mistake.
After the shooting of Dr. George Tiller in Witchita, Kansas, Krugman wrote an article entitled "The Big Hate," in which he provocatively asserted "right-wing extremism is being systematically fed by the conservative media and political establishment." Krugman noted that the shooting at the Holocaust Memorial Museum by white supremacist/anti-Semite James W. von Brunn, in addition to the Tiller killing, represented a definite trend that had been predicted by an internal report for the Office of Homeland Security--a report that was met with howling indignation by conservatives.
Do these two examples show that the Homeland Security report was right? Maybe. One counter example that pops a bit of a hole in the right-wing violence theory is the "left-wing" killing of Private Quinton Ezeagwula in Little Rock AK by "Muslim convert" Abdul Hakim Mujahid Muhammad earlier this month. (Unclear if "left-wing" is a useful designation here, but Muhammad's actions are certainly motivated by political beliefs very different from those of the other shooters, and as such doesn't really fit into the scenarios discussed by the Homeland Security report.)
Is Krugman accurate in his assertion that the conservative media feed the kind of hatred that results in such killings? I think yes--although I think he mixes his examples and ends up with a sticky argument. Sometimes an N of One makes a certain amount of sense, if and only if you can demonstrate it to be the end result of a causal chain. Can one trace the killing of Dr. Tiller to the wide exposure he received on Bill O'Reilly's show, where he was frequently called out by name as a "baby-killer" and one who ran a "death mill"? Definitely maybe--at least it's more than reasonable to see if one can trace a line from O'Reilly to the shooter. (Politifact highlights the number of times that O'Reilly singled out Tiller for abuse here.) But can von Brunn's actions be lumped in with this, and are they attributable to the increasingly violent rhetoric of the right-wing media? I think not; von Brunn was a nut, and his hatred of any form of "establishment" media, whether right or left, was uniform. He threatened conservative publications as much as liberal ones. This was no O'Reilly fan, and while O'Reilly and his ilk certainly should be taken to task for the light and heat of their rhetoric, they can't be blamed for von Brunn's actions.
--br
Sunday, June 7, 2009
N of One
My sense of American political discourse is that it is often shabby, and that one of the key contributing factors to the shabbiness is the absolute lack of scientific and mathematic literacy among the vast majority of its citizens. Mind you, I don’t mean “scientific and mathematic literacy” in its traditional, narrow sense; I don’t really care if your person on the street can tell me whether Pluto has been reclassified as dwarf planet, or if he or she knows how to demonstrate a side-angle-side proof given pencil and paper. I am talking about the kind of math/science literacy that engenders a sophisticated understanding of public policy (not just science policy). This kind of literacy is well within the grasp of persons who are not unusually stupid, and would make political dialogue in the US an order of magnitude better. And the first place where that dumb-dumberry starts, that willful ignorance of even the most basic concepts that centuries of very bright people have toiled to make accessible to the masses, is with the mainstream media. Let me explain.
Let’s take just two examples from the mass media—one extremely well-publicized but not directly related to medicine, and one less well known but that bears directly on the state of medicine. Both stories hinge on a willful misrepresentation of the facts, and at least in the former case an entire brouhaha has resulted because very few pundits have understood the simple mathematical misconception that has formed the basis of the misunderstanding. In the latter case, which I will discuss in a separate entry in the days to come, the same mathematical twit-headedness is used in a different way, but one much loved by the mainstream media.
By now, anyone with a pulse who has been following “real” news (read: not Jon and Kate Plus 8) will be aware that President Obama has nominated Judge Sonia Sotomayor to the Supreme Court of the United States. Sotomayor, a New Yorker of Puerto Rican heritage, has had one of those heartwarming, kid-from-the-neighborhood-makes-good stories that undoubtedly must have played a major consideration in Obama’s choice to nominate her. I am not a lawyer but from all the reports I have read, it appears that she is not an especially highly-charged ideologue as a nominee, less like Judge Robert Bork (one of Reagan’s failed SCOTUS nominees) or Anthony Scalia (one of Reagan’s successful SCOTUS nominees) and more like, say, John Roberts—which is not to say that Sotomayor and Roberts have the same judicial philosophy or temperament, only that they aren’t or weren’t obvious ideological firebrands as nominees. If anything, and despite the loud farts that I have smelled from the right-wing about her being a virtual communist in disguise, I have concluded that the word that best describes her is “establishment.” (And, for what that’s worth, I don’t mean that as a glowing compliment.)
Conservatives have had a hard time deciding their line of attack against Sotomayor. It is theoretically clear that on a variety of constitutional issues she is more likely to side with the court’s so-called “liberal” wing than its “conservative” one (though one should take the example of the very justice she is replacing, Justice David Souter, appointed by the senior Bush, as a warning about making confident predictions of future decisions on the court), and as a consequence the conservatives have drawn battle lines against the President on this. The problem is: how to attack a woman whose hard-work-reaps-benefits feelgood story resonates with so many Americans—and in particular the much sought after Hispanic population, who have been leaving Republicans in droves despite a fairly progressive policy adopted by the Bush administration?
The answer is that conservatives—many of whom all but in name “run” the Republican party—have decided that Sotomayor—a Latina woman from decidedly humble beginnings—is...a racist. No, I am not making this stuff up. Assuming that the readership of this blog is already familiar with this, let us zero in on the smoking gun: the words that the right-wing talking heads have used to make their case. Sotomayor, in a speech in 2001, said the following:
I would hope that a wise Latina woman with the richness of her experiences would more often than not reach a better conclusion than a white male who hasn't lived that life.
It is this quote, this single quote—along with her single decision in a case involving the City of New Haven in which she sided with a district court judge in ruling against a group of white plaintiffs alleging reverse-discrimination (see here)—that has formed the basis of charges of racism. After discovering this ammunition, the blowhards on Fox News, Newt Gingrich on his blog, and of course the right-wing’s leading pundit, Rush Limbaugh, began to beat the drum of Sotomayor’s racism (covered nicely by Dana Milbank here).
But this is absurd—and it’s absurd not because Sotomayor represents Light and Truth or because Limbaugh represents the forces of Darkness. No matter the relative truth of at least the latter half of that equation, the political positions of Sotomayor’s proponents and opponents are totally irrelevant. The key point here is that, as a judge, Sotomayor has generated thousands and thousands of words in hundreds of decisions. Going bananas over one brief quip, or even one decision (one unsigned decision!), reveals the naked contempt that these commentators have for their audience. You cannot make particularly good judgments about anything when you have a sample size of one.
But wait!—you say. Isn’t what Sotomayor said above racist? Doesn’t the logic of this sentence imply that, simply by virtue of being a Latina woman, that one has an inherently richer life experience than a white male, and that as a consequence she reaches better conclusions? And how can’t that be racist?
I don’t know. It is true that this small clip of Sotomayor’s speech leaves an unfortunate taste in the mouth—assuming that she said precisely what she meant. It may have been that you nudge a few words in a different direction, and you have something perfectly reasonable that a kum-ba-ya doc such as me would welcome with open arms: “I would hope that a wise Latina woman…would at least as often reach as good a conclusion than a white male…” Or she might have been trying to say something else entirely, or she might have just not realized the implications of what she was saying. I don’t mean to imply that she gets a free pass on the statement—it will require explanation, and it is entirely fair game to come up in the hearings. But this statement has to be viewed in the context of all of her decisions and speeches, or for that matter even the rest of her speech, which can be found here.
After careful consideration of that large volume of material, should one wish to make the case that Sotomayor is some crazed Hispanic nationalist legislating hatred of the white man from the bench, then by all means one should do so. But my guess is that no such ideology is to be found in her public or judicial statements, and that absence explains the level of volume in the criticism of her. When they ain’t got nothing good, they just shout louder.
Lest anyone mistake this entry for a cheer-on-the-liberals, boo-the-bad-conservatives piece, thus missing that the key point here is that you can’t have thoughtful political dialogue of any kind when you trot out sample sizes of one to make a point, Bob Somersby at The Daily Howler (one of Billy’s very favorite blogs) discusses the Sotomayor kerfuffle here and here in a way that may make some liberals unsettled. Money quote:
As the Cult of the Offhand Comment advances, are journalists and liberals even capable of shaping intelligent discourse? […When taking quotes out of context to attack opponents,] we ourselves have shown an occasional tendency to sign up with this dim-witted cult. John McCain said he wants a hundred-year war! We had some fun with that gong-show claim until we learned an unfortunate fact: When we talk sh*t about Saint McCain, the mainstream press corps won’t go along! But we’ve already seen some liberals on TV explaining what Sotomayor meant; their explanations aren’t necessarily all that convincing, however dogmatic they’re willing to be.
Remember: whenever you hear a political discussion about anything, and the entirety of said discussion rotates around sample sizes of one (which in the biz is referred to as “n=1,” whence the title of this entry), you can elevate the level of dialogue just by inquiring how much you can conclude from one single fact without context.
Later this week, I’m going to demonstrate a different way in which an “n of 1” is used and abused, this time about something closer to Billy’s heart…the scariness of the generic medicine industry. Boo.
--br
Let’s take just two examples from the mass media—one extremely well-publicized but not directly related to medicine, and one less well known but that bears directly on the state of medicine. Both stories hinge on a willful misrepresentation of the facts, and at least in the former case an entire brouhaha has resulted because very few pundits have understood the simple mathematical misconception that has formed the basis of the misunderstanding. In the latter case, which I will discuss in a separate entry in the days to come, the same mathematical twit-headedness is used in a different way, but one much loved by the mainstream media.
By now, anyone with a pulse who has been following “real” news (read: not Jon and Kate Plus 8) will be aware that President Obama has nominated Judge Sonia Sotomayor to the Supreme Court of the United States. Sotomayor, a New Yorker of Puerto Rican heritage, has had one of those heartwarming, kid-from-the-neighborhood-makes-good stories that undoubtedly must have played a major consideration in Obama’s choice to nominate her. I am not a lawyer but from all the reports I have read, it appears that she is not an especially highly-charged ideologue as a nominee, less like Judge Robert Bork (one of Reagan’s failed SCOTUS nominees) or Anthony Scalia (one of Reagan’s successful SCOTUS nominees) and more like, say, John Roberts—which is not to say that Sotomayor and Roberts have the same judicial philosophy or temperament, only that they aren’t or weren’t obvious ideological firebrands as nominees. If anything, and despite the loud farts that I have smelled from the right-wing about her being a virtual communist in disguise, I have concluded that the word that best describes her is “establishment.” (And, for what that’s worth, I don’t mean that as a glowing compliment.)
Conservatives have had a hard time deciding their line of attack against Sotomayor. It is theoretically clear that on a variety of constitutional issues she is more likely to side with the court’s so-called “liberal” wing than its “conservative” one (though one should take the example of the very justice she is replacing, Justice David Souter, appointed by the senior Bush, as a warning about making confident predictions of future decisions on the court), and as a consequence the conservatives have drawn battle lines against the President on this. The problem is: how to attack a woman whose hard-work-reaps-benefits feelgood story resonates with so many Americans—and in particular the much sought after Hispanic population, who have been leaving Republicans in droves despite a fairly progressive policy adopted by the Bush administration?
The answer is that conservatives—many of whom all but in name “run” the Republican party—have decided that Sotomayor—a Latina woman from decidedly humble beginnings—is...a racist. No, I am not making this stuff up. Assuming that the readership of this blog is already familiar with this, let us zero in on the smoking gun: the words that the right-wing talking heads have used to make their case. Sotomayor, in a speech in 2001, said the following:
I would hope that a wise Latina woman with the richness of her experiences would more often than not reach a better conclusion than a white male who hasn't lived that life.
It is this quote, this single quote—along with her single decision in a case involving the City of New Haven in which she sided with a district court judge in ruling against a group of white plaintiffs alleging reverse-discrimination (see here)—that has formed the basis of charges of racism. After discovering this ammunition, the blowhards on Fox News, Newt Gingrich on his blog, and of course the right-wing’s leading pundit, Rush Limbaugh, began to beat the drum of Sotomayor’s racism (covered nicely by Dana Milbank here).
But this is absurd—and it’s absurd not because Sotomayor represents Light and Truth or because Limbaugh represents the forces of Darkness. No matter the relative truth of at least the latter half of that equation, the political positions of Sotomayor’s proponents and opponents are totally irrelevant. The key point here is that, as a judge, Sotomayor has generated thousands and thousands of words in hundreds of decisions. Going bananas over one brief quip, or even one decision (one unsigned decision!), reveals the naked contempt that these commentators have for their audience. You cannot make particularly good judgments about anything when you have a sample size of one.
But wait!—you say. Isn’t what Sotomayor said above racist? Doesn’t the logic of this sentence imply that, simply by virtue of being a Latina woman, that one has an inherently richer life experience than a white male, and that as a consequence she reaches better conclusions? And how can’t that be racist?
I don’t know. It is true that this small clip of Sotomayor’s speech leaves an unfortunate taste in the mouth—assuming that she said precisely what she meant. It may have been that you nudge a few words in a different direction, and you have something perfectly reasonable that a kum-ba-ya doc such as me would welcome with open arms: “I would hope that a wise Latina woman…would at least as often reach as good a conclusion than a white male…” Or she might have been trying to say something else entirely, or she might have just not realized the implications of what she was saying. I don’t mean to imply that she gets a free pass on the statement—it will require explanation, and it is entirely fair game to come up in the hearings. But this statement has to be viewed in the context of all of her decisions and speeches, or for that matter even the rest of her speech, which can be found here.
After careful consideration of that large volume of material, should one wish to make the case that Sotomayor is some crazed Hispanic nationalist legislating hatred of the white man from the bench, then by all means one should do so. But my guess is that no such ideology is to be found in her public or judicial statements, and that absence explains the level of volume in the criticism of her. When they ain’t got nothing good, they just shout louder.
Lest anyone mistake this entry for a cheer-on-the-liberals, boo-the-bad-conservatives piece, thus missing that the key point here is that you can’t have thoughtful political dialogue of any kind when you trot out sample sizes of one to make a point, Bob Somersby at The Daily Howler (one of Billy’s very favorite blogs) discusses the Sotomayor kerfuffle here and here in a way that may make some liberals unsettled. Money quote:
As the Cult of the Offhand Comment advances, are journalists and liberals even capable of shaping intelligent discourse? […When taking quotes out of context to attack opponents,] we ourselves have shown an occasional tendency to sign up with this dim-witted cult. John McCain said he wants a hundred-year war! We had some fun with that gong-show claim until we learned an unfortunate fact: When we talk sh*t about Saint McCain, the mainstream press corps won’t go along! But we’ve already seen some liberals on TV explaining what Sotomayor meant; their explanations aren’t necessarily all that convincing, however dogmatic they’re willing to be.
Remember: whenever you hear a political discussion about anything, and the entirety of said discussion rotates around sample sizes of one (which in the biz is referred to as “n=1,” whence the title of this entry), you can elevate the level of dialogue just by inquiring how much you can conclude from one single fact without context.
Later this week, I’m going to demonstrate a different way in which an “n of 1” is used and abused, this time about something closer to Billy’s heart…the scariness of the generic medicine industry. Boo.
--br
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