"Shocking" is a word I prefer not to use much--to me, it smacks simultaneously of Leave-It-To-Beaver-era naivete and reality-TV-let's-outdo-ourselves-era behavior--but I'm hard pressed to come up with a better word to describe this week's report from the CDC about the prevalence and awareness of HIV infection among Men who have Sex with Men. Most laypeople would describe these people as "homosexual" or "gay," but the clinical term has trended toward using the acronym "MSM." This is because some men, whether for reasons owing to homophobia in their communities or to a bisexual lifestyle or both, may not define themselves as "gay" but still fit into that epidemiologic group. It's not a trivial distinction, as the act of having unprotected sex with a man who has sex with other men is, no matter what he calls himself, statistically, a much more risky proposition than having sex with one who doesn't.
Thirty years into the HIV epidemic, that shouldn't be. There should be no group more painfully aware of the ravages of this virus than gay men. An entire generation was, if not destroyed, at least pummeled by HIV. And as Randy Shilts's excellent book And The Band Played On laments, it wasn't just the kind of dark paranoia of Ronald Reagan's administration that fanned the flames of the epidemic in New York and San Fransisco in the early 1980's: the patrons and owners of gay bars and sex clubs were equally interested in ignoring early compelling evidence that something wicked was coming. Tens of thousands of people--again, mostly gay men--died as a consequence.
So if any group should be hypersensitive to the need for basic Sex Ed and the usefulness of protective sex, or at least the value in frequent HIV testing in the absence of safe sex, it should be gay men. Alas, the CDC reports this week that such is not the case. The numbers can be a bit overwhelming when you examine all of them in detail, but the bottom line is actually quite simple: nearly half of all men actively having sex with other men that are HIV-positive are totally unaware that they are infected. (Of the roughly 8,000 men who were tested, 19% were infected, which means that approximately 10 percent of men who have sex with men are both HIV-positive and unaware of this. Russian roulette, anyone?)
These stats probably represent a slight overestimate of the true number of gay men who are infected and unaware, since the men were recruited to the study were found at "appropriate venues," such as bars, organizations, and street locations where gay men were known to congregate. Thus, this group is probably more sexually active and potentially more promiscuous than the larger community. That said, it's still cold comfort: the seroprevalence in this community, despite all that has happened to them and all the suffering they have gone through over the past three decades, is basically that of sub-Saharan Africa.
If you sift through the numbers, you will see that it's even worse for MSMs in minority communities, especially blacks, where the HIV prevalence was just under one in three (the prevalence for Latinos, at 18 percent, was only slightly higher than that for whites, at 16 percent).
I would like to think that I'm not shocked by much, but this leaves my jaw in a state of drop.
You might wonder why, in an age of effective medical therapy for HIV, I'm making such a big deal out of this study. After all, once they find out they're infected, can't they just take medications and everything will be okay?
Well, no. There's two major problems with this analysis. First is that there is abundant evidence that people whose HIV infection is treated earlier tend to live longer and suffer fewer complications from the disease (such as cancer, among many other things). Second, and even more importantly from a public health standpoint, is that people who are HIV-positive but on treatment are far less likely to spread the virus. When half of one of the largest groups of people infected with the virus are unaware of their infection, controlling it is a pipe dream. And because this group still does have sex with others outside its "own group," everyone remains at risk.
--br
PS--Apropos of nothing much, I continue to be annoyed, like many, at the infantile way in which the modern media seems to have constructed political debate, where apparently only two positions seem tenable: that of laissez-faire capitalism or Stalinist/Maoist/Marxist (choose your favorite!) communism. Today, Paul Krugman of The New York Times has one of the more eloquent rejoinders to this kind of diatribing,
The market economy is a system for organizing activity — a pretty good system most of the time, though not always — with no special moral significance. The rich don’t necessarily deserve their wealth, and the poor certainly don’t deserve their poverty; nonetheless, we accept a system with considerable inequality because systems without any inequality don’t work. And before the trolls jump in to say aha, Krugman concedes the truth of supply-side economics, that’s not an argument against progressive taxation and the welfare state; it’s just an argument that says that there are limits. Cuba doesn’t work; Sweden works pretty well.
His point was actually tangential to his main post, where he was commenting on the fact that a conservative blogger had accused him of advocating full-out war as a way of stimulating the economy during economic depressions. More than anything else, my sense of despair for the politics of this country is less of a concern for left/right division than the fact that so many people make so little effort to actually understand anything at all. It is true of medicine, it is true of science, and it is no less true of economics and politics.
Tuesday, September 28, 2010
Monday, July 26, 2010
Ethics After an HIV Trial
Today the New York Times has an article about what appears to be the first successful "microbicide" that protects against HIV infection in women. Many hosannahs have been said in the medical & scientific research circles following the release of this data. No less an authority than Anthony Fauci, the head of the National Institute of Allergic and Infectious Diseases (and someone Billy thinks of as a patron saint of the profession), noted, "there’s a certain feeling of ease and pleasure for me as a scientist that any way you slice the data, it’s statistically significant." That may not sound like much, but in doctor-speak that's a pretty excited endorsement.
The "microbicide" is a vaginal gel that the woman applies both before and after having sex, and it provided protection between about 40 and 50 percent of the time (the amount varies because the researchers broke down the cohort into sub-groups based on how faithfully they applied the gel; the more faithful users, not altogether surprisingly, were better protected). That's it--the gel hardly constitutes complete protection, but previous studies have shown dismal results.
You might be tempted to ask about condoms: why not just use them? Aren't they much more effective? This depends on how you mean "effective." If you actually use a condom, then yes, it's in fact a very effective means of protection for both partners. The problem is most men, whether they're having sex with other men or with women, don't like condoms and try to avoid using them at all costs. (I'm certainly no fan of them.) So out in the real world, where the vast majority of people aren't enrolled in a clinical trial, a condom isn't actually especially effective, because it often remains on the shelf, or in the purse, or in someone's back pocket, sometimes with the owner having the best of intentions, or as the case may be, because one partner persuaded the other not to use it (regardless if the sex is "gay" or "straight"). So the gel can provide extra protection for a woman who has a partner or partners unwilling to wear The Sock. (There's some very preliminary data suggesting the gel may be protective for men in anal intercourse, but this study looked exclusively at women.)
The trial enrolled nearly 900 African women. Now, however, the trial is over. The study was funded largely by the US Government. The question is, what is the obligation that the researchers, backed by the US, have to the patients? Is it ethical to simply walk away from these patients and allow them to be at "baseline" risk of acquiring the virus--which is still largely a death sentence in Africa? Or are the researchers only obliged to enter into an agreement which ceases to be at the end of the trial? These women, after all, would mostly have become infected had they not enrolled in the trial. On the other hand, what if a microbicide is developed as a result of this trial and becomes available outside of Africa first? Does that seem fair? Shouldn't the women who "put their bodies on the line for this study" (in the words of AIDS activist Mark Harrington, quoted in the article) have first dibs on the gel?
These are not idle questions and such situations have occurred many times throughout the past 60-70 years in US medical research. Most readers will be familiar with the infamous Tuskeegee Experiment, but many other similar experiments have taken place precisely because nobody designing the trial took the kind of questions above into account. I don't mean to imply that these researchers didn't; I can only say I am concerned by the Times report. In my own field, the "intervention" we study is almost always a vaccine, and if that works you don't need to come back for more; this situation is different.
Typically, the Billy Rubin Blog tries to leave you with an opinion. Tonight I only have questions--those questions two paragraphs above, in addition to more in that vein running through my head right now--and can leave you only with a troubled shrug of my shoulders.
--br
The "microbicide" is a vaginal gel that the woman applies both before and after having sex, and it provided protection between about 40 and 50 percent of the time (the amount varies because the researchers broke down the cohort into sub-groups based on how faithfully they applied the gel; the more faithful users, not altogether surprisingly, were better protected). That's it--the gel hardly constitutes complete protection, but previous studies have shown dismal results.
You might be tempted to ask about condoms: why not just use them? Aren't they much more effective? This depends on how you mean "effective." If you actually use a condom, then yes, it's in fact a very effective means of protection for both partners. The problem is most men, whether they're having sex with other men or with women, don't like condoms and try to avoid using them at all costs. (I'm certainly no fan of them.) So out in the real world, where the vast majority of people aren't enrolled in a clinical trial, a condom isn't actually especially effective, because it often remains on the shelf, or in the purse, or in someone's back pocket, sometimes with the owner having the best of intentions, or as the case may be, because one partner persuaded the other not to use it (regardless if the sex is "gay" or "straight"). So the gel can provide extra protection for a woman who has a partner or partners unwilling to wear The Sock. (There's some very preliminary data suggesting the gel may be protective for men in anal intercourse, but this study looked exclusively at women.)
The trial enrolled nearly 900 African women. Now, however, the trial is over. The study was funded largely by the US Government. The question is, what is the obligation that the researchers, backed by the US, have to the patients? Is it ethical to simply walk away from these patients and allow them to be at "baseline" risk of acquiring the virus--which is still largely a death sentence in Africa? Or are the researchers only obliged to enter into an agreement which ceases to be at the end of the trial? These women, after all, would mostly have become infected had they not enrolled in the trial. On the other hand, what if a microbicide is developed as a result of this trial and becomes available outside of Africa first? Does that seem fair? Shouldn't the women who "put their bodies on the line for this study" (in the words of AIDS activist Mark Harrington, quoted in the article) have first dibs on the gel?
These are not idle questions and such situations have occurred many times throughout the past 60-70 years in US medical research. Most readers will be familiar with the infamous Tuskeegee Experiment, but many other similar experiments have taken place precisely because nobody designing the trial took the kind of questions above into account. I don't mean to imply that these researchers didn't; I can only say I am concerned by the Times report. In my own field, the "intervention" we study is almost always a vaccine, and if that works you don't need to come back for more; this situation is different.
Typically, the Billy Rubin Blog tries to leave you with an opinion. Tonight I only have questions--those questions two paragraphs above, in addition to more in that vein running through my head right now--and can leave you only with a troubled shrug of my shoulders.
--br
Wednesday, July 21, 2010
Rambling Reintroduction
My most recent post, alas, dates back to the election of Scott Brown to the US Senate, with a fairly prolonged harangue at President Obama and my various frustrations with him (frustrations which, I am sad to say, have if anything only increased).
Not long after that entry my father collapsed on a winter's afternoon in Columbus, Ohio while walking out to his mailbox. Though the cause is unclear, he was in cardiac arrest by the time the EMTs arrived about five to ten minutes later on the scene after a neighbor witnessed the collapse and called 911. My father would not have wanted this, though of course the neighbor could not have known that. The EMTs were able to revive him and brought him back up the street to the local hospital to "stabilize" him. My mother, needless to say, was in total shock; I was seven hundred miles away, while my older sister was twice that distance in the opposite direction--in short, not the best situation to be in for a reasonably loving & mutually supportive family to make difficult medical decisions.
There are some details which at this very moment seem tedious to recount--tedious only in that retelling them in a blog (whose readers I cannot see and may not know) ain't really why I'm writing this. Suffice it to say that my father passed away ten days after he collapsed, although as far as I am concerned, in what some readers may regard as complete heartlessness, he finished his just-too-brief stint on earth that early February day he went ambling out to peruse his bills & other ephemera.
He had just turned 76. I would have loved ten more years with him, I would have settled for five, but I have no gnawing regrets losing him when I did. And while I didn't much enjoy the ten days we spent watching the corporeal shell of what used to be my father stop functioning, overall I don't have many complaints. Pops went from being a fully functioning guy, totally independent and in control of every aspect of his life, to dead, and made that transition quickly and without prolonged suffering. As a son, I think "ah, couldn't I have just a little more time?" As a doc, all I can think is "Bravo!"
I haven't written over the past six months for a variety of reasons, but I would be a fool if I said that his death wasn't the major factor. My father hasn't been a major part of my day-to-day life for many years now, and I have not been depressed about his loss, though I have been sad to be sure. The act of writing, and writing about medicine in particular, has always served to connect me with my father. I think he was proud of me as a son for a variety of things in the general way that parents are (hopefully, anyway) proud of their children, but my father looked at my writing as something different entirely. He was my greatest reader. He loved it when I put pen to paper, so to speak, and I think he was a bit disappointed in me when I chose to pursue medicine as a career in my mid-twenties, hoping that I would become a professional writer.
Instead, I went my own way, although the writing bug has always remained with me. Since medical school nearly everything I have written has dealt with medicine, and I believe reading this work was more complicated and ambiguous for him: he really did love to read my stuff, but just never quite believed that I thought of myself as a doc, thinking I was pulling the wool over everyone's eyes. For a very long while I agreed with that assessment, but for many years I have considered myself to be at one with the stethoscope, part of the brotherhood and sisterhood as it were, and have made my peace with those decisions I made nearly half a lifetime ago. But to pick back up and blog on the issues that mean so much to me as a doc was just not something I could find the motivation to do until this evening.
Nothing special or magical has taken place tonight; this has been gestating for awhile (an odd metaphor for a son writing about his father, but still) and I've been considering getting back in the saddle for the past few weeks. I do not know how many readers I had when I was trying to get thoughts out weekly, and I assume that if I will continue again I will be starting back from nothing. But the time seems right for a stab at it.
I have spent the past month as a "teaching attending"--a somewhat odd practice at my medical school where the attending responsible for the education of the residents and students is frequently not the same doctor as the one responsible for the welfare of the patients. Regardless, I've thoroughly enjoyed the month and gotten a real kick out of observing younger physicians at a time of their professional lives that I haven't witnessed up close for many years. As the month got close I had a blank wall on my office (that I had just recently inherited) so I was eager to put up pictures, so that my students and residents could see what was important to me as a doc. Some docs like to display their diplomas and accolades, which is definitely not my speed. Others coat their walls in family pictures, also something I'm not eager to do. (A few visual reminders of one's kids? Sure. I'm just not looking to completely morph my personal and professional life to that degree.)
No, I wanted something like a "hall of fame," a sampling of the people whose stories in medicine have been important to me as I've grown up, my way of saying, "these are the models I hold up as exemplary, I hope you find your own too." There's Edward Jenner, of course--a pompous addition, perhaps, but after all the father of vaccinology (my field of work); he resides next to a pic of Henrietta Lacks, the African-American woman whose cervical cancer was "harvested" to become one of the first, and to this day most important, cell lines in modern medicine, the "HeLa" cells (and the subject of Rebecca Skloot's great book The Immortal Life of Henrietta Lacks); sharing the triptych with them is the granddad of modern dengue research, Albert Sabin (most people know Sabin for his work on polio, but that's not why he's on the Rubin wall). Over there on his own is Hamilton Naki, as triumphant a story in medicine as can be told, in my opinion, and he hangs out in the vicinity of Gerhardt Domagk (one of the "discoverers" of sulfa, who refused to join the Nazi Party during World War II even though all of his scientific colleagues jumped on that bandwagon) and Oswald Avery (one of the pioneers of influenza research).
I'm planning on adding some faces as time goes on but I think that's a good start for my hall of fame. However--and I pray that this doesn't come across as too smarmy--these impersonal heroes and heroines of mine all share wall space with my father, who never quite knew what to make of my later-in-life interest in medicine but never failed in being supportive (very much along with my mother, lest anyone misunderstand). It's a picture of him that was taken when he was a young man and I had never seen it before; it popped up when mom sent me some tributes about him. I don't regard myself as one easily given over to sentimentality, but frankly I think he belongs there up on that wall, not simply because he was my father but because he shaped me as a doctor--willingly, eagerly talking to me about what mattered to me in medicine, probing my ideas, challenging my perspectives, all the while not quite believing that his son chose such a path, but satisfied with the choice nevertheless.
I can't say for certain at this point if the Billy Rubin Blog is "back," but I can say the itch has returned. See you back sometime, perhaps.
--br
Not long after that entry my father collapsed on a winter's afternoon in Columbus, Ohio while walking out to his mailbox. Though the cause is unclear, he was in cardiac arrest by the time the EMTs arrived about five to ten minutes later on the scene after a neighbor witnessed the collapse and called 911. My father would not have wanted this, though of course the neighbor could not have known that. The EMTs were able to revive him and brought him back up the street to the local hospital to "stabilize" him. My mother, needless to say, was in total shock; I was seven hundred miles away, while my older sister was twice that distance in the opposite direction--in short, not the best situation to be in for a reasonably loving & mutually supportive family to make difficult medical decisions.
There are some details which at this very moment seem tedious to recount--tedious only in that retelling them in a blog (whose readers I cannot see and may not know) ain't really why I'm writing this. Suffice it to say that my father passed away ten days after he collapsed, although as far as I am concerned, in what some readers may regard as complete heartlessness, he finished his just-too-brief stint on earth that early February day he went ambling out to peruse his bills & other ephemera.
He had just turned 76. I would have loved ten more years with him, I would have settled for five, but I have no gnawing regrets losing him when I did. And while I didn't much enjoy the ten days we spent watching the corporeal shell of what used to be my father stop functioning, overall I don't have many complaints. Pops went from being a fully functioning guy, totally independent and in control of every aspect of his life, to dead, and made that transition quickly and without prolonged suffering. As a son, I think "ah, couldn't I have just a little more time?" As a doc, all I can think is "Bravo!"
I haven't written over the past six months for a variety of reasons, but I would be a fool if I said that his death wasn't the major factor. My father hasn't been a major part of my day-to-day life for many years now, and I have not been depressed about his loss, though I have been sad to be sure. The act of writing, and writing about medicine in particular, has always served to connect me with my father. I think he was proud of me as a son for a variety of things in the general way that parents are (hopefully, anyway) proud of their children, but my father looked at my writing as something different entirely. He was my greatest reader. He loved it when I put pen to paper, so to speak, and I think he was a bit disappointed in me when I chose to pursue medicine as a career in my mid-twenties, hoping that I would become a professional writer.
Instead, I went my own way, although the writing bug has always remained with me. Since medical school nearly everything I have written has dealt with medicine, and I believe reading this work was more complicated and ambiguous for him: he really did love to read my stuff, but just never quite believed that I thought of myself as a doc, thinking I was pulling the wool over everyone's eyes. For a very long while I agreed with that assessment, but for many years I have considered myself to be at one with the stethoscope, part of the brotherhood and sisterhood as it were, and have made my peace with those decisions I made nearly half a lifetime ago. But to pick back up and blog on the issues that mean so much to me as a doc was just not something I could find the motivation to do until this evening.
Nothing special or magical has taken place tonight; this has been gestating for awhile (an odd metaphor for a son writing about his father, but still) and I've been considering getting back in the saddle for the past few weeks. I do not know how many readers I had when I was trying to get thoughts out weekly, and I assume that if I will continue again I will be starting back from nothing. But the time seems right for a stab at it.
I have spent the past month as a "teaching attending"--a somewhat odd practice at my medical school where the attending responsible for the education of the residents and students is frequently not the same doctor as the one responsible for the welfare of the patients. Regardless, I've thoroughly enjoyed the month and gotten a real kick out of observing younger physicians at a time of their professional lives that I haven't witnessed up close for many years. As the month got close I had a blank wall on my office (that I had just recently inherited) so I was eager to put up pictures, so that my students and residents could see what was important to me as a doc. Some docs like to display their diplomas and accolades, which is definitely not my speed. Others coat their walls in family pictures, also something I'm not eager to do. (A few visual reminders of one's kids? Sure. I'm just not looking to completely morph my personal and professional life to that degree.)
No, I wanted something like a "hall of fame," a sampling of the people whose stories in medicine have been important to me as I've grown up, my way of saying, "these are the models I hold up as exemplary, I hope you find your own too." There's Edward Jenner, of course--a pompous addition, perhaps, but after all the father of vaccinology (my field of work); he resides next to a pic of Henrietta Lacks, the African-American woman whose cervical cancer was "harvested" to become one of the first, and to this day most important, cell lines in modern medicine, the "HeLa" cells (and the subject of Rebecca Skloot's great book The Immortal Life of Henrietta Lacks); sharing the triptych with them is the granddad of modern dengue research, Albert Sabin (most people know Sabin for his work on polio, but that's not why he's on the Rubin wall). Over there on his own is Hamilton Naki, as triumphant a story in medicine as can be told, in my opinion, and he hangs out in the vicinity of Gerhardt Domagk (one of the "discoverers" of sulfa, who refused to join the Nazi Party during World War II even though all of his scientific colleagues jumped on that bandwagon) and Oswald Avery (one of the pioneers of influenza research).
I'm planning on adding some faces as time goes on but I think that's a good start for my hall of fame. However--and I pray that this doesn't come across as too smarmy--these impersonal heroes and heroines of mine all share wall space with my father, who never quite knew what to make of my later-in-life interest in medicine but never failed in being supportive (very much along with my mother, lest anyone misunderstand). It's a picture of him that was taken when he was a young man and I had never seen it before; it popped up when mom sent me some tributes about him. I don't regard myself as one easily given over to sentimentality, but frankly I think he belongs there up on that wall, not simply because he was my father but because he shaped me as a doctor--willingly, eagerly talking to me about what mattered to me in medicine, probing my ideas, challenging my perspectives, all the while not quite believing that his son chose such a path, but satisfied with the choice nevertheless.
I can't say for certain at this point if the Billy Rubin Blog is "back," but I can say the itch has returned. See you back sometime, perhaps.
--br
Wednesday, January 20, 2010
A Progressive's View of Senator Brown's Election
That is, the other Senator Brown. This is about the new guy, not the one from my homestate (and indeed, hometown of Mansfield!) Ohio. But you already knew that. Unless you were living under a rock the past 24 hours, you were almost certainly aware that the voters of Massachusetts elected to the US Senate a little-known local politician instead of the Commonwealth's Attorney General. And as you probably heard since that fairly dramatic upset, this represents real trouble for both President Obama and the Democratic party as a whole, which is fairly astonishing given that Obama and his party swept into power with enormous popularity only one year ago. What seemed inconceivable only a few months ago now seems within the realm of possibility: that the Republican party, who gave us eight straight years of George W. Bush and some of the most odious policies in the history of the Republic, might return to power in the House (it is statistically impossible in the Senate, which has only 17 Democratic seats up for grabs; even if all were lost to Republicans the majority would drop to 52).
So who is responsible for this and what lessons can be drawn? First, one should dispense with some of the nonsense uttered by some of the Democratic party establishment in Massachusetts. "Any analysis of this that does anything but celebrate Martha Coakley--her service and the efforts of this campaign--misses the boat," says Dem state party chairman John Walsh, in what has to be one of the more spectacular expressions of denial in recent years. Walsh may be trying to protect some turf in his self-serving foolishness, but nearly everyone else recognizes that this was a debacle: Brown's victory occurred in a state where the majority philosophy leans toward the Democratic party, and strongly so. That Brown could have achieved such a large margin of victory, even with a fairly large turnout (2.2 million people voted yesterday), speaks to the complete disintegration of the Coakley campaign. Making pleasant sounds about Coakley in the aftermath, as Walsh suggests, is like putting a cherry on top of a pile of dung and declaring it a sundae.
There are to my mind three major reasons for Coakley's loss: her breathtaking arrogance; the perception that Obama is in the pocket of Wall Street; and the Democratic party's handling of healthcare reform. The first item about Coakley's ineptitude and political tin ear is a relatively local affair and I won't discuss much further, except to note that her fall from grace has been tremendously precipitous. It's not merely that she was nearly 30 points up only a few weeks ago; she was a very popular and well-liked politician in this state, second only to John Kerry, even more popular than the Governor, Duval Patrick. That she could lose by such a large margin speaks to her ability to alienate people, and I suspect she has permanently damaged her brand among the Massachusetts electorate, which is quite a pity since she is a highly competent Attorney General. Simply put, Scott Brown never took one vote for granted and never condescended to the people of Massachusetts. Neither of those are compelling reasons to have voted for the man, but he deserves immense credit for his hustle.
More important for the President are the second two reasons, and Coakley can't really be blamed for either. Leave aside Obama's troublingly cozy relationship with the financial industry for a moment, the question is: with regard to healthcare reform, what should Obama have done differently? To me, the answer lies in two separate flaws in the plan, the first a tactical mistake that is only clear in hindsight, the second--which is much more concerning--lies in a major character flaw of the President.
The tactical mistake was created in the wake of the failure of the Clinton plan in 1993, which was perceived by Congress as being imposing and top-down in structure, with the Clinton White House (and, in particular, its soon-to-be-unpopular first lady) dictating terms to congressional leaders. Obama, hoping to avoid this problem, only created another by "leaving the bill writing to Congress while it tries to charm an industry that controls nearly one-fifth of the US economy," as Ceci Connolly aptly put in the pages of the Washington Post last June. Consequently Obama tended to other duties--which, one grants, are not insubstantial with two ongoing wars, problems with the banking industry, staggering unemployment and a host of other, minor problems such as global warming.
But the tactic backfired: congressional leaders squabbled, "centrists" like Max Baucus and Joe Lieberman suddenly were extracting pounds of political flesh (an apt simile in this case) to a cowed Senate majority leader, while Republicans congealed together a host of exaggerations and outright lies to drag down the popularity of a once-popular notion. By the fall, it was clear the process had run amok, and Obama's hands-off approach in retrospect had failed miserably. Had Obama merely tried to nudge the legislation along, using his formidable powers as an orator to advocate for what he wanted, filling up auditoriums around the country as an out-front advocate for healthcare reform, explaining to the American people his vision for the legislation, a good deal of pressure might have been brought to bear on several senators and representatives who probably intentionally dithered for reasons ranging from humbuggery to outright corruption. Instead, for more than six months there was mostly a vacuum of advocacy, and worse, the White House never really found its footing, saying on one day that the public option was non-negotiable, followed by the exact opposite indicator a few days later. Is it any wonder that Congress couldn't move the proverbial ball past the goal line?
The second reason underlying Obama's failure to shepherd along a meaningful or decent healthcare bill lies in who President Obama is, and that is, namely, one whose primary aim is to achieve consensus rather than to advocate for a given belief. We have seen what such consensus-seeking did for the Clinton presidency: after the 1994 congressional drubbing that landed the Republicans in control of both the House and Senate, Democratic party faithful were given a moderate Republican president in all but name, who stood before that congress proudly declaring that "the era of big government is over," who happily signed the Defense of Marriage Act, who sought to further enable the kinds of financial shenanigans that led to the economic crisis we find ourselves in right now. It only took a small sliver of disaffected Democrats to turn away from Clinton's successor and hand the Presidency to George W. Bush. Against all odds President Obama has followed Clinton's script. Contrary to the mildly insane claims of some pundits and politicians, President Obama has given his left-leaning base precisely nothing of what it has asked for. Glenn Greenwald pointed out quite accurately today:
In what universe must someone be living to believe that the Democratic Party is controlled by "the Left," let alone "the furthest left elements" of the Party? As Ezra Klein says, the Left "ha[s] gotten exactly nothing they wanted in recent months." The Left wanted a single-payer system, then settled for a public option, then an opt-out public option, then Medicare expansion -- only to get none of it, instead being handed a bill that forces every American to buy health insurance from the private insurance industry. Nor was it "the Left" -- but rather corporatist Democrats like Evan Bayh and Lanny Davis -- who cheered for the hated Wall Street bailout; blocked drug re-importation; are stopping genuine reform of the financial industry; prevented a larger stimulus package to lower unemployment; refuse to allow programs to help Americans with foreclosures; supported escalation in Afghanistan (twice); and favor the same Bush/Cheney terrorism policies of indefinite detention, military commissions, and state secrets.
This is not the approach of a robust advocate for traditional Democratic policies. This is the winning-is-more-important-than-fighting stance of a neoliberal, like Clinton before him; it is the pose, it pains me to say, of a wuss. And said wuss has fought for very little--indeed, nothing--he promised his base, the very people who catapulted him over the Hillary Clinton juggernaut one year ago. As I recall, this man, who offered such a thoughtful critique of the Iraq war (when it was far from politically expedient to do so), came to us with the promise of hope and change. Since the election we have been given hollow platitudes by a man unwilling to capitalize on his success, proceeding far too cautiously on the national stage (both links to Paul Krugman's column/blog in NYT).
Contrast Obama's lack of full-throated advocacy over the summer with George Bush's re-election in 2004. Bush, you will recall, had just managed to eke out a narrow victory, as a sitting war President, over another Massachusetts politician with a tin ear. Still, despite Bush's underwhelming performance (he garnered 50.7% of the vote and won by 2.4 points) he came before the American people the following day and confidently declared, "I have political capital, and I intend to spend it." Whether or not one finds that statement astonishing in its chutzpah, Bush immediately proceeded to campaign, election-style, for the privatization of Social Security, and did so in the face of enormous uncertainty, given Social Security's popularity. Bush of course did lose that fight, but as I see it the lesson here was that Bush was willing to fight for his party's beliefs at all.
President Obama? I have not only not seen such boldness on the whole, I have seen its opposite. You see, as I write this, the New York Times is leading with a headline that can only be described as dumbfounding. It reads, "Obama Weighs Shift In Health Plan, Seeking G.O.P. Backing." In the first graf: "President Obama on Wednesday signaled that he might be willing to set aside his goal of achieving near-universal health coverage for all Americans in favor of a stripped-down measure with bipartisan support." He has 59 votes in the Senate, and he might be willing to set aside his goal? Would the last President have asked for progressive input had he held a 59-seat majority in the upper chamber? I'm thinking not.
As a progressive, I think there is now only one option, and that is to declare war. On the Obama Presidency. He has not merely lost my support, he has lost my vote. Whether another politician will try to wrest control of the party from him in the coming few years remains to be seen, but barring a total turnaround, I am finished with him.
--br
Update #1: I have some additional thoughts which I can't write until later today, but in the meantime there was one error in the original post: in 1994 the Democrats lost control of both chambers, not just the House. The text above is corrected.
Update #2: Several thoughts.
One reader on Facebook asks: "[Obama's lack of courage] doesn't explain why MA voted for Brown. If voters thought the country so badly needs healthcare reform (and were frustrated for lack of progress), how is electing Brown going to help?" In the short run, of course, it won't--although to my mind even when Kennedy/Kirk was Senator and the Dems did have that supposedly precious filibuster-proof majority, the best the Senate could produce was a handsome subsidy for the private insurance industry. The House in all likelihood would not accept the Senate bill--after all, they still could, and rightly have given no indication that they want to pass it. In the upper chamber, politicians like Baucus, Lieberman, and Ben Nelson to name only a few have made it clear that if even a hair of their version of the legislation is tampered with, there won't be enough votes for cloture. Thus, Brown's presence on the political scene makes only a modest amount of difference. This is President Obama's fault. This is entirely President Obama's fault.
Also, it should be noted that (obviously) elections have binary outcomes even though the motivations of the voters run the gamut. (Technically there were three outcomes, not two given the Libertarian party candidate Joseph Kennedy--no laughing out there--but you get the point.) My back-of-the-napkin calculation goes something like this: of Scott Brown's majority of 52%, something like just under 15% represented the hard-core social conservative or ideological libertarian vote, who were not only in the bag but energized to vote. Another 20% represented the moderate members of the Republican base, socially progressive but friendly to business interests, and who generally determine what Republicans are viable for statewide office (Brown slipped by because everyone had left him for dead and no moderate Republican cared to lose to Coakley). About another, say, 13% represent mostly blue-collar workers in the suburbs who usually vote Democrat but were either alienated by Coakley's arrogance or charmed by Brown's little-engine-that-could shtick or both. Now all Brown's gotta do to win is pick off a fairly small percentage of disenchanted voters who are disgusted with "what's going on in Washington," regardless of whether or not they could offer a cogent critique, and wanted "to send a message." Add to that a lower voter turnout than usual due to the off-off cycle (turnout was 40 percent; turnout at Obama's election was a near-record 72 percent; typically in a non-Presidential but regular cycle it would be closer to 50 percent) and a disillusioned base, and bing! You have the making of a stunning upset. Basically, Coakley was able to count on urban voters and lefties (several Republicans in MA are also "liberals," so not the best term even though the two are almost interchangeable outside New England). That got her to 47 percent--actually an impressive number given how small lefty blocs are in other states--but it wasn't nearly enough. There is some question as to whether the other highly qualified candidate, congressional representative Mike Capuano, would have done better in the working class suburbs, but for me that's useless second-guessing. Though I'm glad I didn't wake up Wednesday morning being Capuano, wondering what could have been. Still, one might think that Capuano is actually now the odds-on favorite to win the Senate seat back in 2012, even though Brown just won!
As I said, Brown's ascension to Senator does not help Democrats' goals in the short run. But in the case of Republicans, neither did the wildcat candidacy of Douglas Hoffman in the NY 23rd district, whose tea party run (technically he was the "Conservative Party" candidate) against Republican Dede Scozzafava led to the election of Democrat Bill Owens in a reliably Red district. There, the conservative base found Scozzafava so unpalatable that they would rather have lost the election than vote for her. What did they get in return? In the short run, Owens. But less than two years from now, they are almost certainly going to get "their" candidate, whomever that is (and quite possibly Hoffman himself), on the ticket, and Owens will be playing defense. I think the political views of most of these people are totally nuts, but I deeply admire their resolve, and more importantly, I recognize that their strategy is almost certain to succeed. Incredibly, that strategy may well succeed not only in the NY-23 but in swing districts across the country, returning the Republican party to power only two years after the most disastrous defeat they have suffered in decades.
President Obama, on the whole, bears responsibility for this, and, although I am aware that I am opening myself to the charge of "left-wing nutcase" by suggesting this, he needs to be succeeded by another leader. He seemed like a highly thoughtful, extremely articulate, bold and confident leader. He continues to have the first two qualities but lacks the latter two, and we need the latter two. We have needed them for two generations. Think about this for a moment--here is the list of our national party leaders since our last truly effective leader, Lyndon Johnson (that could start a fight, but I'll stand by it): Humphrey, McGovern, Carter, Mondale, Dukakis, Clinton (blech!), Gore, Kerry, and Obama. With the exception of the current Prez, just look at that list! What a sorry collection of milquetoasts! And, alas, Obama's missteps have shown him to be of a piece with them. Yes, he has three years left and I do realize it sounds insane to write off his presidency. But I've seen not one shred of evidence to suggest that he's capable of even understanding his errors over the past several months, let alone attempt a course correction (or succeed at it). He needs to go, and if party loyalists stick by their man, they're going to go down.
Healthcare reform is quite probably dead for another generation. As I see it, there is only one way to avoid such a mess in the future: take a page from the Republican playbook, and refuse to vote for candidates who do not meet a litmus test, even if it means losing elections for a cycle or two...or more. I am not advocating a wide-ranging litmus test: I have mildly strong opinions about abortion, I have stronger ones about gun control, and stronger ones still about gay rights, but I recognize that the party needs to allow for minority views as part of a successful coalition. But healthcare reform and bank regulation? These seem to me pretty easy issues where Democrats can say, "Look, this party stands for federal government-backed health insurance, period. If you don't agree with that principle, you do not belong here, and we will not vote for you even if it means that we will lose a House or Senate district, or the Presidency itself." Then when you finally do win big, like the Dems did only one brief year ago, you won't squander the golden opportunity that dropped into your lap.
Another friend linked to a piece analyzing the structural peculiarities of the Democratic party. It has a slightly different take from my own, but I don't have any qualms about his writing except for the fact that Republicans, too, have their own structural issues, harmonizing the desires of libertarians, social conservatives, religious fundamentalists, and corporate interests, and they seem to have done a fairly good job of things since Ronald Reagan's election. And while I interpret Obama's motivations differently than Anonymous #1, I certainly see where he or she is coming from.
Update #3: How could the President redeem himself? Here's a thought: the radically right-wing Supreme Court just ruled today in a 5-4 vote that "corporations cannot be banned from using their general funds to pay for political advertising." As Andrew Leonard of "How the World Works" points out, this is going to profoundly influence Wall Street's reaction to the President's come-to-Jesus moment on banking reform, with the likely scenario being a huge influx of money supporting candidates who will block reform at every turn. So what can be done given a demoralized base and a surly electorate? How about a Constitutional Amendment barring such contributions? I'd like to see Joe Lieberman explain his vote against that. I'd also love to see Obama breathe fire on the campaign trail in, say August of this year--setting up a Constitutional Amendment vote just in time for the elections. Make that the story of the campaign. After all, the Republicans thought flag burning and gay marriage were such critical issues that they didn't hesitate to introduce CA's banning them; surely the Dems could do the same, especially as they (theoretically) oppose the Supremes' decision. Will we see the President adopt such aggressive tactics? I'm not holding my breath.
Update #4: I know I'm rambling, but just thought I'd add that the only person on the national stage that I can think of in my lifetime who was a politically viable Dem who simultaneously appeared to show genuine resolve was Howard Dean.
So who is responsible for this and what lessons can be drawn? First, one should dispense with some of the nonsense uttered by some of the Democratic party establishment in Massachusetts. "Any analysis of this that does anything but celebrate Martha Coakley--her service and the efforts of this campaign--misses the boat," says Dem state party chairman John Walsh, in what has to be one of the more spectacular expressions of denial in recent years. Walsh may be trying to protect some turf in his self-serving foolishness, but nearly everyone else recognizes that this was a debacle: Brown's victory occurred in a state where the majority philosophy leans toward the Democratic party, and strongly so. That Brown could have achieved such a large margin of victory, even with a fairly large turnout (2.2 million people voted yesterday), speaks to the complete disintegration of the Coakley campaign. Making pleasant sounds about Coakley in the aftermath, as Walsh suggests, is like putting a cherry on top of a pile of dung and declaring it a sundae.
There are to my mind three major reasons for Coakley's loss: her breathtaking arrogance; the perception that Obama is in the pocket of Wall Street; and the Democratic party's handling of healthcare reform. The first item about Coakley's ineptitude and political tin ear is a relatively local affair and I won't discuss much further, except to note that her fall from grace has been tremendously precipitous. It's not merely that she was nearly 30 points up only a few weeks ago; she was a very popular and well-liked politician in this state, second only to John Kerry, even more popular than the Governor, Duval Patrick. That she could lose by such a large margin speaks to her ability to alienate people, and I suspect she has permanently damaged her brand among the Massachusetts electorate, which is quite a pity since she is a highly competent Attorney General. Simply put, Scott Brown never took one vote for granted and never condescended to the people of Massachusetts. Neither of those are compelling reasons to have voted for the man, but he deserves immense credit for his hustle.
More important for the President are the second two reasons, and Coakley can't really be blamed for either. Leave aside Obama's troublingly cozy relationship with the financial industry for a moment, the question is: with regard to healthcare reform, what should Obama have done differently? To me, the answer lies in two separate flaws in the plan, the first a tactical mistake that is only clear in hindsight, the second--which is much more concerning--lies in a major character flaw of the President.
The tactical mistake was created in the wake of the failure of the Clinton plan in 1993, which was perceived by Congress as being imposing and top-down in structure, with the Clinton White House (and, in particular, its soon-to-be-unpopular first lady) dictating terms to congressional leaders. Obama, hoping to avoid this problem, only created another by "leaving the bill writing to Congress while it tries to charm an industry that controls nearly one-fifth of the US economy," as Ceci Connolly aptly put in the pages of the Washington Post last June. Consequently Obama tended to other duties--which, one grants, are not insubstantial with two ongoing wars, problems with the banking industry, staggering unemployment and a host of other, minor problems such as global warming.
But the tactic backfired: congressional leaders squabbled, "centrists" like Max Baucus and Joe Lieberman suddenly were extracting pounds of political flesh (an apt simile in this case) to a cowed Senate majority leader, while Republicans congealed together a host of exaggerations and outright lies to drag down the popularity of a once-popular notion. By the fall, it was clear the process had run amok, and Obama's hands-off approach in retrospect had failed miserably. Had Obama merely tried to nudge the legislation along, using his formidable powers as an orator to advocate for what he wanted, filling up auditoriums around the country as an out-front advocate for healthcare reform, explaining to the American people his vision for the legislation, a good deal of pressure might have been brought to bear on several senators and representatives who probably intentionally dithered for reasons ranging from humbuggery to outright corruption. Instead, for more than six months there was mostly a vacuum of advocacy, and worse, the White House never really found its footing, saying on one day that the public option was non-negotiable, followed by the exact opposite indicator a few days later. Is it any wonder that Congress couldn't move the proverbial ball past the goal line?
The second reason underlying Obama's failure to shepherd along a meaningful or decent healthcare bill lies in who President Obama is, and that is, namely, one whose primary aim is to achieve consensus rather than to advocate for a given belief. We have seen what such consensus-seeking did for the Clinton presidency: after the 1994 congressional drubbing that landed the Republicans in control of both the House and Senate, Democratic party faithful were given a moderate Republican president in all but name, who stood before that congress proudly declaring that "the era of big government is over," who happily signed the Defense of Marriage Act, who sought to further enable the kinds of financial shenanigans that led to the economic crisis we find ourselves in right now. It only took a small sliver of disaffected Democrats to turn away from Clinton's successor and hand the Presidency to George W. Bush. Against all odds President Obama has followed Clinton's script. Contrary to the mildly insane claims of some pundits and politicians, President Obama has given his left-leaning base precisely nothing of what it has asked for. Glenn Greenwald pointed out quite accurately today:
In what universe must someone be living to believe that the Democratic Party is controlled by "the Left," let alone "the furthest left elements" of the Party? As Ezra Klein says, the Left "ha[s] gotten exactly nothing they wanted in recent months." The Left wanted a single-payer system, then settled for a public option, then an opt-out public option, then Medicare expansion -- only to get none of it, instead being handed a bill that forces every American to buy health insurance from the private insurance industry. Nor was it "the Left" -- but rather corporatist Democrats like Evan Bayh and Lanny Davis -- who cheered for the hated Wall Street bailout; blocked drug re-importation; are stopping genuine reform of the financial industry; prevented a larger stimulus package to lower unemployment; refuse to allow programs to help Americans with foreclosures; supported escalation in Afghanistan (twice); and favor the same Bush/Cheney terrorism policies of indefinite detention, military commissions, and state secrets.
This is not the approach of a robust advocate for traditional Democratic policies. This is the winning-is-more-important-than-fighting stance of a neoliberal, like Clinton before him; it is the pose, it pains me to say, of a wuss. And said wuss has fought for very little--indeed, nothing--he promised his base, the very people who catapulted him over the Hillary Clinton juggernaut one year ago. As I recall, this man, who offered such a thoughtful critique of the Iraq war (when it was far from politically expedient to do so), came to us with the promise of hope and change. Since the election we have been given hollow platitudes by a man unwilling to capitalize on his success, proceeding far too cautiously on the national stage (both links to Paul Krugman's column/blog in NYT).
Contrast Obama's lack of full-throated advocacy over the summer with George Bush's re-election in 2004. Bush, you will recall, had just managed to eke out a narrow victory, as a sitting war President, over another Massachusetts politician with a tin ear. Still, despite Bush's underwhelming performance (he garnered 50.7% of the vote and won by 2.4 points) he came before the American people the following day and confidently declared, "I have political capital, and I intend to spend it." Whether or not one finds that statement astonishing in its chutzpah, Bush immediately proceeded to campaign, election-style, for the privatization of Social Security, and did so in the face of enormous uncertainty, given Social Security's popularity. Bush of course did lose that fight, but as I see it the lesson here was that Bush was willing to fight for his party's beliefs at all.
President Obama? I have not only not seen such boldness on the whole, I have seen its opposite. You see, as I write this, the New York Times is leading with a headline that can only be described as dumbfounding. It reads, "Obama Weighs Shift In Health Plan, Seeking G.O.P. Backing." In the first graf: "President Obama on Wednesday signaled that he might be willing to set aside his goal of achieving near-universal health coverage for all Americans in favor of a stripped-down measure with bipartisan support." He has 59 votes in the Senate, and he might be willing to set aside his goal? Would the last President have asked for progressive input had he held a 59-seat majority in the upper chamber? I'm thinking not.
As a progressive, I think there is now only one option, and that is to declare war. On the Obama Presidency. He has not merely lost my support, he has lost my vote. Whether another politician will try to wrest control of the party from him in the coming few years remains to be seen, but barring a total turnaround, I am finished with him.
--br
Update #1: I have some additional thoughts which I can't write until later today, but in the meantime there was one error in the original post: in 1994 the Democrats lost control of both chambers, not just the House. The text above is corrected.
Update #2: Several thoughts.
One reader on Facebook asks: "[Obama's lack of courage] doesn't explain why MA voted for Brown. If voters thought the country so badly needs healthcare reform (and were frustrated for lack of progress), how is electing Brown going to help?" In the short run, of course, it won't--although to my mind even when Kennedy/Kirk was Senator and the Dems did have that supposedly precious filibuster-proof majority, the best the Senate could produce was a handsome subsidy for the private insurance industry. The House in all likelihood would not accept the Senate bill--after all, they still could, and rightly have given no indication that they want to pass it. In the upper chamber, politicians like Baucus, Lieberman, and Ben Nelson to name only a few have made it clear that if even a hair of their version of the legislation is tampered with, there won't be enough votes for cloture. Thus, Brown's presence on the political scene makes only a modest amount of difference. This is President Obama's fault. This is entirely President Obama's fault.
Also, it should be noted that (obviously) elections have binary outcomes even though the motivations of the voters run the gamut. (Technically there were three outcomes, not two given the Libertarian party candidate Joseph Kennedy--no laughing out there--but you get the point.) My back-of-the-napkin calculation goes something like this: of Scott Brown's majority of 52%, something like just under 15% represented the hard-core social conservative or ideological libertarian vote, who were not only in the bag but energized to vote. Another 20% represented the moderate members of the Republican base, socially progressive but friendly to business interests, and who generally determine what Republicans are viable for statewide office (Brown slipped by because everyone had left him for dead and no moderate Republican cared to lose to Coakley). About another, say, 13% represent mostly blue-collar workers in the suburbs who usually vote Democrat but were either alienated by Coakley's arrogance or charmed by Brown's little-engine-that-could shtick or both. Now all Brown's gotta do to win is pick off a fairly small percentage of disenchanted voters who are disgusted with "what's going on in Washington," regardless of whether or not they could offer a cogent critique, and wanted "to send a message." Add to that a lower voter turnout than usual due to the off-off cycle (turnout was 40 percent; turnout at Obama's election was a near-record 72 percent; typically in a non-Presidential but regular cycle it would be closer to 50 percent) and a disillusioned base, and bing! You have the making of a stunning upset. Basically, Coakley was able to count on urban voters and lefties (several Republicans in MA are also "liberals," so not the best term even though the two are almost interchangeable outside New England). That got her to 47 percent--actually an impressive number given how small lefty blocs are in other states--but it wasn't nearly enough. There is some question as to whether the other highly qualified candidate, congressional representative Mike Capuano, would have done better in the working class suburbs, but for me that's useless second-guessing. Though I'm glad I didn't wake up Wednesday morning being Capuano, wondering what could have been. Still, one might think that Capuano is actually now the odds-on favorite to win the Senate seat back in 2012, even though Brown just won!
As I said, Brown's ascension to Senator does not help Democrats' goals in the short run. But in the case of Republicans, neither did the wildcat candidacy of Douglas Hoffman in the NY 23rd district, whose tea party run (technically he was the "Conservative Party" candidate) against Republican Dede Scozzafava led to the election of Democrat Bill Owens in a reliably Red district. There, the conservative base found Scozzafava so unpalatable that they would rather have lost the election than vote for her. What did they get in return? In the short run, Owens. But less than two years from now, they are almost certainly going to get "their" candidate, whomever that is (and quite possibly Hoffman himself), on the ticket, and Owens will be playing defense. I think the political views of most of these people are totally nuts, but I deeply admire their resolve, and more importantly, I recognize that their strategy is almost certain to succeed. Incredibly, that strategy may well succeed not only in the NY-23 but in swing districts across the country, returning the Republican party to power only two years after the most disastrous defeat they have suffered in decades.
President Obama, on the whole, bears responsibility for this, and, although I am aware that I am opening myself to the charge of "left-wing nutcase" by suggesting this, he needs to be succeeded by another leader. He seemed like a highly thoughtful, extremely articulate, bold and confident leader. He continues to have the first two qualities but lacks the latter two, and we need the latter two. We have needed them for two generations. Think about this for a moment--here is the list of our national party leaders since our last truly effective leader, Lyndon Johnson (that could start a fight, but I'll stand by it): Humphrey, McGovern, Carter, Mondale, Dukakis, Clinton (blech!), Gore, Kerry, and Obama. With the exception of the current Prez, just look at that list! What a sorry collection of milquetoasts! And, alas, Obama's missteps have shown him to be of a piece with them. Yes, he has three years left and I do realize it sounds insane to write off his presidency. But I've seen not one shred of evidence to suggest that he's capable of even understanding his errors over the past several months, let alone attempt a course correction (or succeed at it). He needs to go, and if party loyalists stick by their man, they're going to go down.
Healthcare reform is quite probably dead for another generation. As I see it, there is only one way to avoid such a mess in the future: take a page from the Republican playbook, and refuse to vote for candidates who do not meet a litmus test, even if it means losing elections for a cycle or two...or more. I am not advocating a wide-ranging litmus test: I have mildly strong opinions about abortion, I have stronger ones about gun control, and stronger ones still about gay rights, but I recognize that the party needs to allow for minority views as part of a successful coalition. But healthcare reform and bank regulation? These seem to me pretty easy issues where Democrats can say, "Look, this party stands for federal government-backed health insurance, period. If you don't agree with that principle, you do not belong here, and we will not vote for you even if it means that we will lose a House or Senate district, or the Presidency itself." Then when you finally do win big, like the Dems did only one brief year ago, you won't squander the golden opportunity that dropped into your lap.
Another friend linked to a piece analyzing the structural peculiarities of the Democratic party. It has a slightly different take from my own, but I don't have any qualms about his writing except for the fact that Republicans, too, have their own structural issues, harmonizing the desires of libertarians, social conservatives, religious fundamentalists, and corporate interests, and they seem to have done a fairly good job of things since Ronald Reagan's election. And while I interpret Obama's motivations differently than Anonymous #1, I certainly see where he or she is coming from.
Update #3: How could the President redeem himself? Here's a thought: the radically right-wing Supreme Court just ruled today in a 5-4 vote that "corporations cannot be banned from using their general funds to pay for political advertising." As Andrew Leonard of "How the World Works" points out, this is going to profoundly influence Wall Street's reaction to the President's come-to-Jesus moment on banking reform, with the likely scenario being a huge influx of money supporting candidates who will block reform at every turn. So what can be done given a demoralized base and a surly electorate? How about a Constitutional Amendment barring such contributions? I'd like to see Joe Lieberman explain his vote against that. I'd also love to see Obama breathe fire on the campaign trail in, say August of this year--setting up a Constitutional Amendment vote just in time for the elections. Make that the story of the campaign. After all, the Republicans thought flag burning and gay marriage were such critical issues that they didn't hesitate to introduce CA's banning them; surely the Dems could do the same, especially as they (theoretically) oppose the Supremes' decision. Will we see the President adopt such aggressive tactics? I'm not holding my breath.
Update #4: I know I'm rambling, but just thought I'd add that the only person on the national stage that I can think of in my lifetime who was a politically viable Dem who simultaneously appeared to show genuine resolve was Howard Dean.
Thursday, January 14, 2010
Various Thoughts on Haiti
a. Before starting, if anyone has decided that they would like to make a donation but do not know which group to donate to, please consider making a donation to Hopital Albert Schweitzer in Deschapelles (about 3 hours northeast of Port-au-Prince). I worked there for a brief stretch during my residency. Their website notes that areas outside Port were affected, and the hospital has been swamped with patients and the doctors, nurses and support staff are stretched very thin. I don't want to divert money from the Red Cross but this is a more "tangible" donation, so if you have not yet contributed please do take a look at their website.
b.
Pat Robertson's insane monologue yesterday is perhaps remarkable only for its particularly twisted form of logic. After all, religious fanatics have been in the business of interpreting natural disasters as divine retribution for millenia; what makes Robertson's thoughts on the matter so singularly flabbergasting is that he believes that Haitians, who had received a century of the most brutal treatment endured by humans at the hands of Christians, somehow made a "pact with the devil" ("true story!" the Reverend adds helpfully, as if he had found it in Wikipedia just before going on air) by not turning to Christianity. Assuming that he was trying to make any sense at all, I would guess that he's referring to the Haitian practice of voodoo. Even if one ignores his thoroughly peculiar logic, the vast majority of Haitians regard themselves as Christians. If Robertson thinks their particular brand of Christianity, with its African animistic influences, isn't up to Godly snuff, then why hasn't such a calamity befallen Rome? And why did God wait more than 200 years to get around to a punishment like this? No, what is most amazing about a raving lunatic like Pat Robertson--who, it must be remembered, made these comments on a show trying to raise money for the relief effort--is that his network, CBN, reaches millions of viewers in the US and millions more worldwide. "He's not like David Koresh," a colleague of mine quipped today, referring to the religious cult leader at the center of the Waco, Texas tragedy. "I mean, Robertson's got followers."
The irony is that because of their Christianity, a good many Haitians don't disagree with Robertson's assessment, although again I'm not sure they would concur with Robertson's underlying thought process. The quote of note from the writer in the above link: "If God exists, he's really got it in for Haiti."
c. Haiti was not an easy place to spend a month, and I continue to have conflicted feelings about the country. (And it goes without saying that spending one month in Haiti hardly makes me an expert. What observations I have are tentative, and what thoughts I have I myself regard with skepticism.) The story of the Haitian revolution and throwing off the yoke of bondage by the French at the outset of the 19th century has to rank as one of the greatest stories of self-determination in the history of humanity. Based off the very principles that defined the American and French revolutions, Haitian independence was a logical response to French oppression. It should be no surprise that politicians in the United States (Southern or Northern) or anywhere else had absolutely no interest in fostering this nascent state, and so, denied the ability to engage in trade like any other free nation (and Haiti was a country of vast resources at that time, and would have made a powerful trading partner for molasses and rum which were critical parts of the early American economy, to say nothing of the Spanish colonies), nor allowed to develop a navy for basic defense (attacks by the US prevented this), Haiti turned inward and began a two-centuries long process of auto-cannibalism that has been more-or-less uninterrupted. The US was heavily involved in Haiti in the early 20th century, occupying the country from 1915-34 (my jaw dropped when I saw WPA-style bridges there while riding through the countryside, as I had been totally ignorant of my country's involvement in Haiti); the Soviets also added to the infrastructure a bit during the 50s and 60s while Papa Doc Duvalier cleverly played the superpowers against one another. But besides these relatively short-term relationships, few nations have generally cared much about Haiti except for it to serve as a cautionary tale. Paul Farmer, now the famous doctor and subject of the bestseller Mountains Beyond Mountains, wrote about the history of Haiti's relationship to other independent nations over the past two centuries in his book The Uses of Haiti. It is worth the read. To have any hope of understanding the magnitude of the disaster that has just befallen Haiti, one needs to read a book such as this. This earthquake really couldn't have happened to a less prepared country.
d. You will read multiple descriptions of Haiti in the coming days as a place of "tremendous poverty." While that is undoubtedly true, describing Haiti as "impoverished" doesn't really give one the full scope of the core problems that its people face. For instance, when compared to an African nation of roughly equal population and area, Haiti (168th) outranks Rwanda (179th) in per capita GDP, and by a fairly sizeable amount ($1300 vs. $900; the US ranks 8th at $47,500, while Zimbabwe is last in 194th with a per capita GDP of $200). Rwanda's infant mortality ratio (17th highest in the world) is higher than Haiti's (37th), with similar data for life expectancy at birth (50.5 years versus 60.8). But Rwanda is a considerably more stable country than Haiti, with a government responding to the needs of its people, and there is a general sense among the people that their lives are improving. This is all the more remarkable given Rwanda's recent genocide; Rwanda's near-miraculous turnaround is the subject of New York Times reporter Stephen Kinzer's book A Thousand Hills, which has gotten some airplay in the US. In Rwanda, despite its recent horrors, the people have a sense of hope and of common purpose. In Haiti, where its leaders have been either uninterested or unable to help its citizens, there is no similar attitude--or at least, if it is, it is hidden well underneath the surface. I saw no evidence of it when I was there. Instead I often felt a sense of foreboding--especially in Port, where it was impossible for me to walk the streets without being accosted by people wanting my money. By contrast, when my wife worked in Kigali for a few weeks while building a high school there a few years ago, she was a magnet not for money, but for her camera--kids were constantly asking her simply to take their pictures. This in a place that, by the numbers, is even more impoverished than Haiti. So poverty is only a chunk of the problem. I don't want to imply that this is a fault of Haitians, and I don't want to sound callous to the needs of those people who came up to me on the streets of Port. Rather, my point is that if one only thinks about the earthquake without making some attempt to understand a little of Haiti's history, and if one also regards this as "earthquake hits impoverished place," one won't have understood anything about what's going on there. The earthquake hit a place that most of the nations of the world (including and often especially the US) have used as a punching bag for two centuries, and the people aren't merely impoverished, they are desperate, which to me is a critical difference.
e. At the risk of sounding pedantic, one final point about the scope of the disaster is that Haiti has no real "government" in the sense that we--so far, anyway--think of as "government." Despite some bad apples and assorted pockets of corruption, most Americans tend to think of their police as being there to protect them; there is no equivalent in Haiti. Here we take some of the most important functions of a government for granted, two of which are conspicuously absent in Haiti: garbage removal and a clean public water supply. I can't say how disheartened I feel here when I see families choose brand-name bottled water in their own homes while perfectly potable water taps in their kitchen sinks sit unmolested. Haitians right now would die for such a privilege. And because of the lack of potable water, many more may.
--br
ps--Now at the risk of sounding ridiculous, one small way to continue to make a contribution to Haitian GNP in the coming years, for those of you who like to drink alcohol, is to buy Haitian rum, one of their few true exports widely available in the US. I am a fan of Rhum Barbancourt, and recommend that you check it out the next time you are at the liquor store.
The irony is that because of their Christianity, a good many Haitians don't disagree with Robertson's assessment, although again I'm not sure they would concur with Robertson's underlying thought process. The quote of note from the writer in the above link: "If God exists, he's really got it in for Haiti."
c. Haiti was not an easy place to spend a month, and I continue to have conflicted feelings about the country. (And it goes without saying that spending one month in Haiti hardly makes me an expert. What observations I have are tentative, and what thoughts I have I myself regard with skepticism.) The story of the Haitian revolution and throwing off the yoke of bondage by the French at the outset of the 19th century has to rank as one of the greatest stories of self-determination in the history of humanity. Based off the very principles that defined the American and French revolutions, Haitian independence was a logical response to French oppression. It should be no surprise that politicians in the United States (Southern or Northern) or anywhere else had absolutely no interest in fostering this nascent state, and so, denied the ability to engage in trade like any other free nation (and Haiti was a country of vast resources at that time, and would have made a powerful trading partner for molasses and rum which were critical parts of the early American economy, to say nothing of the Spanish colonies), nor allowed to develop a navy for basic defense (attacks by the US prevented this), Haiti turned inward and began a two-centuries long process of auto-cannibalism that has been more-or-less uninterrupted. The US was heavily involved in Haiti in the early 20th century, occupying the country from 1915-34 (my jaw dropped when I saw WPA-style bridges there while riding through the countryside, as I had been totally ignorant of my country's involvement in Haiti); the Soviets also added to the infrastructure a bit during the 50s and 60s while Papa Doc Duvalier cleverly played the superpowers against one another. But besides these relatively short-term relationships, few nations have generally cared much about Haiti except for it to serve as a cautionary tale. Paul Farmer, now the famous doctor and subject of the bestseller Mountains Beyond Mountains, wrote about the history of Haiti's relationship to other independent nations over the past two centuries in his book The Uses of Haiti. It is worth the read. To have any hope of understanding the magnitude of the disaster that has just befallen Haiti, one needs to read a book such as this. This earthquake really couldn't have happened to a less prepared country.
d. You will read multiple descriptions of Haiti in the coming days as a place of "tremendous poverty." While that is undoubtedly true, describing Haiti as "impoverished" doesn't really give one the full scope of the core problems that its people face. For instance, when compared to an African nation of roughly equal population and area, Haiti (168th) outranks Rwanda (179th) in per capita GDP, and by a fairly sizeable amount ($1300 vs. $900; the US ranks 8th at $47,500, while Zimbabwe is last in 194th with a per capita GDP of $200). Rwanda's infant mortality ratio (17th highest in the world) is higher than Haiti's (37th), with similar data for life expectancy at birth (50.5 years versus 60.8). But Rwanda is a considerably more stable country than Haiti, with a government responding to the needs of its people, and there is a general sense among the people that their lives are improving. This is all the more remarkable given Rwanda's recent genocide; Rwanda's near-miraculous turnaround is the subject of New York Times reporter Stephen Kinzer's book A Thousand Hills, which has gotten some airplay in the US. In Rwanda, despite its recent horrors, the people have a sense of hope and of common purpose. In Haiti, where its leaders have been either uninterested or unable to help its citizens, there is no similar attitude--or at least, if it is, it is hidden well underneath the surface. I saw no evidence of it when I was there. Instead I often felt a sense of foreboding--especially in Port, where it was impossible for me to walk the streets without being accosted by people wanting my money. By contrast, when my wife worked in Kigali for a few weeks while building a high school there a few years ago, she was a magnet not for money, but for her camera--kids were constantly asking her simply to take their pictures. This in a place that, by the numbers, is even more impoverished than Haiti. So poverty is only a chunk of the problem. I don't want to imply that this is a fault of Haitians, and I don't want to sound callous to the needs of those people who came up to me on the streets of Port. Rather, my point is that if one only thinks about the earthquake without making some attempt to understand a little of Haiti's history, and if one also regards this as "earthquake hits impoverished place," one won't have understood anything about what's going on there. The earthquake hit a place that most of the nations of the world (including and often especially the US) have used as a punching bag for two centuries, and the people aren't merely impoverished, they are desperate, which to me is a critical difference.
e. At the risk of sounding pedantic, one final point about the scope of the disaster is that Haiti has no real "government" in the sense that we--so far, anyway--think of as "government." Despite some bad apples and assorted pockets of corruption, most Americans tend to think of their police as being there to protect them; there is no equivalent in Haiti. Here we take some of the most important functions of a government for granted, two of which are conspicuously absent in Haiti: garbage removal and a clean public water supply. I can't say how disheartened I feel here when I see families choose brand-name bottled water in their own homes while perfectly potable water taps in their kitchen sinks sit unmolested. Haitians right now would die for such a privilege. And because of the lack of potable water, many more may.
--br
ps--Now at the risk of sounding ridiculous, one small way to continue to make a contribution to Haitian GNP in the coming years, for those of you who like to drink alcohol, is to buy Haitian rum, one of their few true exports widely available in the US. I am a fan of Rhum Barbancourt, and recommend that you check it out the next time you are at the liquor store.
Monday, January 11, 2010
Ross Douthat, Professional Yutz
Ah, the New York Times Editorial Page. Though I am not certain, I suspect that the Times readership is overwhelmingly socially liberal--not just by a modest amount but a huge one (say, 70/30 or 75/25, and note that I'm only talking here about views on social rather than financial policy). Nevertheless the Times seems to try mightily to avoid the accusation that it has a "liberal bias," and so retains among its staff a few house conservatives, the ideological descendants of William Safire, just to prove otherwise. Recently this included Bill Kristol contributing op-eds, although mercifully that experiment came to an end. Some centristy readers (among them my mother) find David Brooks intermittently enlightening; for my part I regard him as a harmless ninny. But Kristol's spiritual replacement--that representing the nutter wing of conservatism--was Ross Douthat, and ironically, Douthat's column yesterday centered around a situation in which Kristol The Younger found himself: Brit Hume's indefensible comments about Buddhism. And Douthat, consistent with being a nutter, tried to defend those very comments.
If you weren't glued to Fox a week ago Sunday, what Hume said, in an offhand remark at the end of a panel discussion, was this: "The extent to which [Woods] can recover seems to me depends on his faith. He is said to be a Buddhist. I don't think that kind of faith offers the kind of forgiveness and redemption that is offered by the Christian faith. So my message to Tiger is, 'Tiger, turn to the Christian faith and you can make a total recovery and be a great example to the world.'" [my emphasis]
(The comments--clip below--are followed after a cut by Kristol, a Jew, shifting in his seat just a touch uncomfortably, for a split second, as he tries to finesse Hume's remark. Makes for amusing theater.)
Hume's statement caused the usual mini-media tempest--and I even made my own brief contribution to it at the end of a recent entry. Douthat's editorial yesterday took on that tempest with the goal of lecturing "liberals" on "liberalism." Said Douthat: "In practice, the admirable theory that nobody should be persecuted for their beliefs often blurs into the more illiberal idea that nobody should ever publicly criticize another religion. Or champion one's own faith as an alternative. Or say anything whatsoever about religion, outside the privacy of the church, synagogue, or home."
(Um...are the words "mosque" and "temple" deliberately missing there?)
Ever since college I have regularly encountered this hide-behind-free-speech argument and I remain unimpressed by it. Those who advance it, like Douthat, appear to willfully confuse criticism of some person for their ideas with persecution of that same person, and then try to bask in a little feelgood (and consequence-free!) martyrdom. Did anyone suggest Brit be imprisoned for his ideas, or be punished by some legal means? No. All Jon Stewart did was laugh at him because of Hume's perfect arrogance that Douthat seems to be incapable of understanding. (It's instructive to watch the clip particularly because it reveals Fox News's hypocrisy with respect to their own obviously obnoxious pronouncements on Islam.)
Douthat notes that "the debate [about the value of religion in peoples' lives] kicked off by Brit Hume a week ago is still worth having." That may be so. But the outrage, which Douthat condescendingly describes as "knee-jerk," centers around how poorly Hume chose to frame the debate--not necessarily the debate itself, and Douthat has missed this point entirely. For instance, did Brit Hume make this conclusion based off of his expansive knowledge of Buddhism? Did he, for instance, do a survey of Buddhist teachings and conclude that there would be no chance that Woods would find redemption through that faith? I'm thinking, um, not. So if he knows little about Buddhism, what's he doing singling out Woods when he seems to have not made a peep about current Christians with issues astonishingly similar to Woods, such as Mark Sanford (R-SC), John Ensign (R-Nev), David Vitter (R-LA), and that great miscegenist in the sky, Jesse Helms (R-NC)? No, it's something much more simple than all of this, and is the reason why so many thoughtful people, Christians and non-Christians, believers and non-believers alike, were outraged: Hume was talking smack.
Honest public discussions about religion, race, sex and sexuality should not be mere free-for-alls where anything goes, and Douthat knows this. He blathers on about how America should be a marketplace of ideas where open competition between different perspectives is welcome. I agree with him--but that doesn't mean that major TV networks have a responsibility to allow airtime to racists and bigots! We give Nazis and their ilk the right to say what they want as a matter of law, but that's not the same as giving them a platform. There is such a notion as "polite" discourse where some kinds of talk (that is, racist and/or bigoted dialogue) are deemed out-of-bounds, and where there are consequences to violating that etiquette. And Hume (who has only appeared to gain status on Fox, getting a cushy interview from Bill O'Reilly, allowing him to defend himself without having to actually face a critic), clearly violated that etiquette. In discussions about race we've grown sensitive enough as a culture to punish people who step out of line, as in the case of Jimmy The Greek's racial theories on the origin of the black athlete or Rush Limbaugh's goofy thoughts on Eagles' quarterback Donovan McNabb. But because Hume took a shot at Buddhism and not, say, black people, he has only had to suffer minor ridicule at most.
What might a thoughtful Christian have said? Not being Christian I cannot fully presume, but I have some ideas about a reasonable way to inject religion into such a conversation. Hume might have said, "I have been following the Tiger Woods saga. For me, Christianity has provided the possibility for redemption and forgiveness." That way it's really a discussion about Hume's own experience and is not a judgement on the inadequacy of some other faith. Hume has had his share of tragedy, as his son commited suicide in 1998, which triggered his religious awakening (he is described in Wikipedia as being Episcopalian), and has given interviews to which I have no objection, where he describes the role his renewed faith has played in his life.
But even with this possible more gentle comment that could have been hypothetically posed by Hume, I still have to hold my nose a bit because it's really not a piece of advice to an actual person but rather a bland pronouncement. Tiger Woods isn't some guy that Brit Hume is on intimate terms with, I am nearly certain. Instead Woods is just really just a concept in Hume's diatribe rather than an actual person to whom he is giving genuine advice. Is that what Hume has learned from his faith--to use people as props in an attempt to evangelize? And is that what Douthat considers worth defending?
--br
If you weren't glued to Fox a week ago Sunday, what Hume said, in an offhand remark at the end of a panel discussion, was this: "The extent to which [Woods] can recover seems to me depends on his faith. He is said to be a Buddhist. I don't think that kind of faith offers the kind of forgiveness and redemption that is offered by the Christian faith. So my message to Tiger is, 'Tiger, turn to the Christian faith and you can make a total recovery and be a great example to the world.'" [my emphasis]
(The comments--clip below--are followed after a cut by Kristol, a Jew, shifting in his seat just a touch uncomfortably, for a split second, as he tries to finesse Hume's remark. Makes for amusing theater.)
Hume's statement caused the usual mini-media tempest--and I even made my own brief contribution to it at the end of a recent entry. Douthat's editorial yesterday took on that tempest with the goal of lecturing "liberals" on "liberalism." Said Douthat: "In practice, the admirable theory that nobody should be persecuted for their beliefs often blurs into the more illiberal idea that nobody should ever publicly criticize another religion. Or champion one's own faith as an alternative. Or say anything whatsoever about religion, outside the privacy of the church, synagogue, or home."
(Um...are the words "mosque" and "temple" deliberately missing there?)
Ever since college I have regularly encountered this hide-behind-free-speech argument and I remain unimpressed by it. Those who advance it, like Douthat, appear to willfully confuse criticism of some person for their ideas with persecution of that same person, and then try to bask in a little feelgood (and consequence-free!) martyrdom. Did anyone suggest Brit be imprisoned for his ideas, or be punished by some legal means? No. All Jon Stewart did was laugh at him because of Hume's perfect arrogance that Douthat seems to be incapable of understanding. (It's instructive to watch the clip particularly because it reveals Fox News's hypocrisy with respect to their own obviously obnoxious pronouncements on Islam.)
Douthat notes that "the debate [about the value of religion in peoples' lives] kicked off by Brit Hume a week ago is still worth having." That may be so. But the outrage, which Douthat condescendingly describes as "knee-jerk," centers around how poorly Hume chose to frame the debate--not necessarily the debate itself, and Douthat has missed this point entirely. For instance, did Brit Hume make this conclusion based off of his expansive knowledge of Buddhism? Did he, for instance, do a survey of Buddhist teachings and conclude that there would be no chance that Woods would find redemption through that faith? I'm thinking, um, not. So if he knows little about Buddhism, what's he doing singling out Woods when he seems to have not made a peep about current Christians with issues astonishingly similar to Woods, such as Mark Sanford (R-SC), John Ensign (R-Nev), David Vitter (R-LA), and that great miscegenist in the sky, Jesse Helms (R-NC)? No, it's something much more simple than all of this, and is the reason why so many thoughtful people, Christians and non-Christians, believers and non-believers alike, were outraged: Hume was talking smack.
Honest public discussions about religion, race, sex and sexuality should not be mere free-for-alls where anything goes, and Douthat knows this. He blathers on about how America should be a marketplace of ideas where open competition between different perspectives is welcome. I agree with him--but that doesn't mean that major TV networks have a responsibility to allow airtime to racists and bigots! We give Nazis and their ilk the right to say what they want as a matter of law, but that's not the same as giving them a platform. There is such a notion as "polite" discourse where some kinds of talk (that is, racist and/or bigoted dialogue) are deemed out-of-bounds, and where there are consequences to violating that etiquette. And Hume (who has only appeared to gain status on Fox, getting a cushy interview from Bill O'Reilly, allowing him to defend himself without having to actually face a critic), clearly violated that etiquette. In discussions about race we've grown sensitive enough as a culture to punish people who step out of line, as in the case of Jimmy The Greek's racial theories on the origin of the black athlete or Rush Limbaugh's goofy thoughts on Eagles' quarterback Donovan McNabb. But because Hume took a shot at Buddhism and not, say, black people, he has only had to suffer minor ridicule at most.
What might a thoughtful Christian have said? Not being Christian I cannot fully presume, but I have some ideas about a reasonable way to inject religion into such a conversation. Hume might have said, "I have been following the Tiger Woods saga. For me, Christianity has provided the possibility for redemption and forgiveness." That way it's really a discussion about Hume's own experience and is not a judgement on the inadequacy of some other faith. Hume has had his share of tragedy, as his son commited suicide in 1998, which triggered his religious awakening (he is described in Wikipedia as being Episcopalian), and has given interviews to which I have no objection, where he describes the role his renewed faith has played in his life.
But even with this possible more gentle comment that could have been hypothetically posed by Hume, I still have to hold my nose a bit because it's really not a piece of advice to an actual person but rather a bland pronouncement. Tiger Woods isn't some guy that Brit Hume is on intimate terms with, I am nearly certain. Instead Woods is just really just a concept in Hume's diatribe rather than an actual person to whom he is giving genuine advice. Is that what Hume has learned from his faith--to use people as props in an attempt to evangelize? And is that what Douthat considers worth defending?
--br
Wednesday, January 6, 2010
Mike Leach Debacle Wrap-Up
I grew up as a boy in the 1970s and '80s in a small industrial town in northern Ohio, which is another way of saying that I grew up a rabid fan of football in general, and of the Cleveland Browns in particular. After owner Art Modell moved the Browns to Baltimore because the taxpayers of Cuyahoga county declined to build him a new stadium (so that he could go from being merely wildly rich to uber-rich), I gave up following professional football. At that point I turned my attentions exclusively to my "other" team in the collegiate ranks, the Ohio State Buckeyes. But over the past ten years even following college football has left rather a sour taste in my mouth. College football is deeply corrupt--huge amounts of cash slosh around the system, coaches get millions while their players get, at best, a free education typically valued at something like $15,000 per year, and a huge number of these boys are duped because they aren't equipped for college and can't make the NFL--and is only surpassed in ickiness by (men's) college basketball.
And then comes Mike Leach.
Leach, for the non-football fans reading this who aren't aware, was the coach of the Texas Tech Red Raiders. He had just finished a successful season and was one year into a five-year, $12-million stint as the boss. Alas, reports began to surface before their bowl game that he had locked a player in a confined area because he had complained about suffering the effects of a concussion. In the sports media, there was an amazing attention to what to me seemed fairly unimportant details: the player (Adam James) was the son of an ESPN analyst so there was a question of the boy using his father's leverage to exact revenge against the coach; James was described by Leach as "lazy" and not having a solid work ethic; James was placed in an unlit space with no room to move...or maybe not, and maybe was well-lit, or remarkably dark. Yet despite multiple stories combing over these details, the essential fact never was in dispute: Coach Leach took one of his players and locked him away as punishment for some infraction. Does anything else really matter, like whether he was in a dark or lit room? I say no. I call this a sadistic act of a megalomaniac--and any waffling about the particulars ignores this reality.
Suppose, for one moment, that Adam James was lazy and had no work ethic. So what? The coach has the option of benching the player in the hopes of motivating him (cf Nate Robinson's 41-point return to the Knicks after being benched for a month). He can exclude him from practice. He can, as an extreme, drop the player from the team. But locking a kid in any kind of closet is assault. I am glad his ass got canned, and pray that his work as a head coach in the college ranks is over. (I noted that a quick blurb on espn.com says he might be up for the head coach job at the Oakland Raiders for next year. Let's see you try those motivational tactics out with professionals, Mike!)
But Leach's story is really only the most disgusting in a year where some exceptionally ugly facts about all levels of football have come into sharp relief. The columnist Gregg Easterbrook has a really good discussion about the significance of Leach's firing. His main point:
You don't need to be a bully to be an effective football coach -- you can treat players in a respectful manner, while holding your own ego in check. But bullies are drawn to football coaching, and the fact that so many coaches get away with little-god behavior is an indictment both of the sport's culture and of the lack of supervision by the schools coaches work for.
At the Rubin blog, we agree. And the Leach incident is trivial by comparison to death by heatstroke, with one of the most recent episodes happening to a 16 year-old kid in Maryland this past July. Of the 39 heat-related football deaths since 1995, 29 have occurred at the high school level. Normally this is exactly the kind of statistic that drives me bananas--40 kids dying over a 15-year period is a remarkably small number compared to the overall number of total deaths of kids under 18 for that time span (roughly the number would be something like just under 200,000). But these are, in theory, totally unnecessary deaths, and appear to occur because some small-time coach with a big-time Napoleon complex thought that a kid asking for water on a 90-degree day while running drills was only something a sissy would ask for. Think I'm kidding? Follow this link to learn of Coach David Jason Stinson of Louisville, KY, who was charged with reckless homicide and wanton endangerment after a player died of heatstroke in 2008. Coach Stinson "ordered [wind sprints] as punishment for lack of effort on a day where the temperature...[was] 94 degrees." Despite such compelling facts, it took the jury 90 minutes to acquit Stinson. Stories like these make Billy wish he did have conventional religious beliefs about the afterlife, because then he would rest more comfortably in the knowledge that Coach Stinson would roast in hell for eternity. Alas.
To cap things off, the NFL has been dealing with the problem of concussions, and doing it rather poorly. Despite mounting, compelling data suggesting that frequent hits to the head in football dramatically increase the risk of later neurologic problems including dementia, NFL Commissioner Roger Goodell dragged his feet until the season was nearly over before issuing an allegedly "stringent" new concussion policy in December. Again, the small number of NFL players affected does not make this a public health problem. But as the above article notes, "the culture of playing through brain injuries in the NFL has also influenced younger players...because the governing bodies at the college and high school levels do not have rules regarding concussion management, amateur players routinely return after concussions, even after they are evaluated by a doctor or athletic trainer." [my emphasis]
Now that's a public health problem.
--br
Monday, January 4, 2010
Harvard on "Consultant" Pay--a Step in the Right Direction
It took some time, and, while "Harvard" (see further as to why the quotes) isn't the first institution to institute new and considerably more sane policies about conflict-of-interest in medical academia, it is the most renowned.
The story appeared in the Saturday NYT and I noticed a similar one in the Boston Sunday Globe. They note that Partners HealthCare, the parent corporation of two of the largest of the hospitals affiliated with Harvard Medical School, Massachusetts General Hospital and the Brigham and Women's Hospital (thus technically not the medical school itself), have established a set of rules intended to minimize conflict-of-interest and draw a sharper line at the boundary between industry and academia.
I say, "Bravo!" This is a huge step in the right direction. And because of the cachet that the name "Harvard" carries, other academic medical institutions are sure to follow suit. There are two main restrictions on academic physicians. First (and, to my mind, most important) is that docs affiliated with Harvard can no longer accept "speaking fees" from drug companies. For those unaware, these "talks" frequently come in the form of an after-dinner lecture where the drug company in question pays for dinner for the audience. These dinners aren't held at Burger King, it should be said. Officially, the editorial policy of drug companies is completely hands-off with respect to the content of the talk except for the general topic (like, say, emphysema). That said, only a fool would believe that there isn't an implicit plug-our-product directive, and that the audience isn't in on the arrangement. These speaking fees can net a doc who's willing to hustle a very nice little side income: say, $40 or 50 grand annually for two or three talks a month. That little gravy train is over at the Partners hospitals now.
The second restriction is on senior faculty who sit on the boards of various pharm companies. These policies apply to a much smaller group of physicians, and because of Harvard's privileged status, there's a disproportionate number of Harvard faculty on such corporate boards. The limits are still quite generous: they are allowed compensation for corporate board work, but now set the limit at "a level befitting an academic role," which the article states should be no more than $5,000 per day (!). The article further helpfully notes, just in case you're startled by this seemingly large amount, that "some [faculty] had been receiving more than $200,000 per year." There is also a great line by one Dr. Dennis Ausiello, who was compensated by Pfizer to the tune of $220K per year, about how he'll continue in his role on the Pfizer board with less cash in hand. "I think I should be compensated fairly...but if my institution rules otherwise, I will continue to work on the board." Apparently he thinks that five large a day isn't "fair compensation." Poor Dennis!
There are some quotes in the article from some academics expressing outrage at the leniency of the new policy, but for my part I am heartened. The problem of the relationship governing the most highly placed senior faculty making beaucoup bucks on the boards of Big Pharma seems to me to be minor compared to speaker's fees. The lecture circuit is widespread, obviously corrupt to anyone willing to think for more than two or three seconds, and virtually everyone's in on the joke. When medical faculty play along, they are sending an explicit message of "not to worry--you deserve these freebies that the drug companies toss out to us. You get the free fancy dinners, I get a thousand or two dollars. After all, aren't we entitled to this because we work so hard?" Needless to say, as much as I like nice dinners and making money, I don't think this is a good message to be sending in the medical community. And Harvard just took a definitive step toward shutting that message down. The battle ain't over, but I think that we just witnessed the turning of the tide.
--br
Other stuff:
a. I had, of course, meant to write about some great books that I read in 2009 (a short list includes the fantastic book by Steven Johnson The Ghost Map about the cholera outbreak in London and the genius who solved the question of cholera's cause, John Snow; John Barry's classic book of a few years back but no more relevant than in 2009 The Great Influenza; The Wine Trials--don't ask as to why I think that belongs in a blog about medicine; Adam Gopnik's quirky little book about Darwin and Abraham Lincoln--a great book for the sesquicentennial of the publication of Origin of Species--called Angels and Ages). That got swept under the rug due to time and family constraints. But for those who are fans of Malcolm Gladwell, he has a new book that is a collection of his writings during his past 10+ years at The New Yorker, called What the Dog Saw. In it there is a gem of an essay about the development of the pill, women's menstrual cycles and its relationship to "female" cancers, and living in the industrial age. You will get your money's worth if you read nothing other than this essay. That said, the rest of his writing is equally riveting. For those who have the time for audiobooks, Gladwell reads his own work, and he's an exceptionally powerful reader. Leave aside his talent as a writer, I would say his reading ability is second only to that of the immortal Scott Brick. But this may be getting too far afield except for the die-hard audiobookers.
b. Did Brit Hume really say that? You gotta love the guy. Oh, wait. No, you don't. The skinny is that Brit took a potshot at Buddhism while discussing the recent troubles of a fairly well-known golfer who, according to Hume, "is said to be a Buddhist." Hume then explained that turning to the Christian faith would far outstrip whatever Buddhism had to offer. One of the comments at the website above notes, "I've said it before: there was a very good reason why Rome threw them to the lions." Billy couldn't help but chuckle.
c. Also in the "I wanted to write about this but no time to give it its proper due" category was this excellent discussion of the difficulty surrounding the use of sedation in end-of-life care. It's a Sunday NYT piece so it takes some time, but I recommend it highly.
Friday, December 25, 2009
A Dose of Christmas Humbug
Today's Boston Globe reads, "Health Win in Hand." You can almost feel the exclamation point coming off the page. It follows with the caution, "Hurdles Ahead." Noting that the healthcare bill still faces the challenge of reconciling the two substantively different bills passed by both houses of Congress, not to mention Constitutional challenges and whatever other dirty tricks the Senate Republicans can muster between now and the passage of the reconciled bill, the Globe has a side article usefully informing its readers that this bill may still not become law because the coalition supporting the bill is so fragile it may come apart during the usually perfunctory reconciliation phase. That said, assuming that no 11th hour roadblocks are raised, universal health care is going to become law in the US. Our President has put a happy face on things, saying he got "95 percent of what I want."
On this Christmas Day, allow me to honor a ghost of Christmas past (and doing so as a virtually-atheist Jew, no less) by saying...HUMBUG!
Paul Krugman--not normally a man predisposed to cheery pronouncements just for the sake of feeling good--writes in the NYT that the bill, despite a number of flaws, really is a major accomplishment and will lead to improvement in the lives of Americans in the coming years. But he does provide an analysis of why so many people are so unhappy:
So why are so many people complaining? First, there’s the crazy right, the tea party and death panel people — a lunatic fringe that is no longer a fringe but has moved into the heart of the Republican Party. In the past, there was a general understanding, a sort of implicit clause in the rules of American politics, that major parties would at least pretend to distance themselves from irrational extremists. But those rules are no longer operative. No, Virginia, at this point there is no sanity clause...Finally, there has been opposition from some progressives who are unhappy with the bill’s limitations. Some would settle for nothing less than a full, Medicare-type, single-payer system. Others had their hearts set on the creation of a public option to compete with private insurers. And there are complaints that the subsidies are inadequate, that many families will still have trouble paying for medical care...Unlike the tea partiers and the humbuggers, disappointed progressives have valid complaints. But those complaints don’t add up to a reason to reject the bill. Yes, it’s a hackneyed phrase, but politics is the art of the possible. [my emphasis]
So what's a disappointed progressive to do?
Let me go out on a limb here--very, very far out on a limb--and suggest that maybe the nutso wing of the Republican party (which is now the de-facto leadership of the Republican party) has the right strategy, and maybe it is time for progressives to take a page from their playbook. The phrase that's been bandied about over the past year in relation to the tea-partiers is that they demand of their representatives that they "pass a political litmus test" demonstrating a level of ideological purity. We saw this most clearly in evidence in the New York 23rd Congressional race this November, where so-called "liberal" Republican Dede Scozzafava was abandoned by the Republican base in favor of 3rd-party candidate Douglas Hoffman, allowing Democrat Bill Owens to win in an overwhelmingly Republican district. The conventional wisdom of that election was that the far right had become so crazy that they would rather be out of power than have an electable candidate who wasn't absolutely ideologically pure. My own sense is that the Tea-Party choice, Hoffman, very nearly won the election (he lost by just over 3,000 votes out of 140,000 cast), and almost certainly would have won had he had an additional few months to gain momentum.
So while the strategy of demanding ideological purity failed the far right on the political equivalent of a broken play, I suspect it will pay long-term dividends. Even in marginal districts, potential Republican party candidates are going to be very careful not to run afoul of this very determined, apparently reasonably well-organized group. Yes, in the short run they may have some setbacks as they had in the NY 23rd. But next year I am willing to bet that Owens will be out and he will be replaced by someone approved of by "the base," maybe Hoffman himself.
Might it not be time to demand this from Democrats? Particularly Democrats running for Senate seats? Or even President of the United States? I am not suggesting that an ideological litmus test need to be applied to every single issue that faces us. But demanding support for the Public Option (which, after all, was the compromise position that progressives had decided to live with instead of a Medicare-For-All, single-payer system that would represent real change) would have been a starting point.
Anyway, perhaps Krugman is right and the reasons to be unhappy with the bill are not reasons enough to walk away from it. But I do note that Krugman's view is not universal among progressives, and I'm quite sympathetic to their viewpoint. Here is a great summary in an editorial for CNN online by the mightily courageous Congressional representative from the NY 28th district, Louise Slaughter. She has one line, nicely summarizing the critical difference between the House and Senate versions of the health care bill, that captures it all for me: "I do not want to subsidize the private insurance market; the whole point of creating a government option is to bring prices down." I have yet to hear anything from the leadership of the Democratic party that lucid. Perhaps it is time to think about withholding our support from leaders who do not speak or act as clearly as Congresswoman Slaughter.
--br
Thursday, December 17, 2009
Do NOT Go Spelunking in Sub-Saharan Africa! (Plus Mammogram Stuff.)
Whoa.
--br
PS--As a follow-up to the news on CT scans and people misoverestimating its dangers (as Bush 43 might say), a good comparison can be found in the recent brouhaha about the US Preventive Services Task Force revised recommendations about when women should obtain mammograms. In mid-November, the USPTS rolled back the recommendations for annual mammograms for women under 50, and for women over 50, they recommended mammograms every other year.
There was a firestorm, with outraged women calling up congressfolk and other government people howling about how women's lives are worth less than men's. Even prominent academics took to the airwaves and cyberspace to pile on, as this piece by the University of Pennsylvania's Center for Bioethics Arthur Caplan demonstrates. "Screening is what responsible and health-conscious women do to take control of their bodies and prevent disease," Caplan wrote. Those are commendable and powerful virtues, and...more compelling than a pile of bland data...there is no reason to doubt the accuracy of the scientists' findings...but there is every reason to doubt that the numbers they compiled will be sufficient to overturn a medical practice that carries so much ethical weight for women." [my emphasis]
Ladies and gentlemen, a nominee for Most Cowardly Writing By An Academic For 2009! That little pile of bland data suggested that, whatever "ethical weight" pre-50 mammograms may have for women, it would lead to unnecessary amounts of radiation, agonizing trials for women awaiting biopsies of tissue that didn't need to be biopsied, and, in some cases, completely useless mastectomies. Could a guy like Caplan maybe have considered it his responsibility to use his status as Big Time Academic to try to help explain this data, and give it the proper context it deserved because the data indicate a better way to treat women? He will have to answer for that. In the meantime, a nice counter-example can be found in this NYT op-ed by the very awesome mathematician John Allen Paulos, who tried his best to explain to women the potential benefits of the USPTS recs, at least in terms of the mathematics of the probability of a "positive" mammogram being a "false-positive" due to the relatively low prevalence of breast cancer in the 40-50 group.
The US Senate, which has shown remarkable ineptitude thus far in getting even the most modest health care bill passed, rushed to include an amendment to cover the mammograms its own USPTS no longer recommends...pleasing wild-eyed constituents and providing just the kind of unnecessary radiation discussed in the cat scan studies that so freaked people out! (Though yes, a mammogram has far less radiation than a standard cat scan.)
So I say of this: you can't have it both ways!
Perhaps the USPTS might have been more media-savvy about announcing their new recs, and perhaps they might have more shrewdly thought out how to get this information out. But the notion--which seems to have been uncritically bandied about by people in positions of authority in both government and academia--that this is part of science's ongoing war against women is not merely short-sighted, it may well harm women! This may be the final irony of what medical historians in the coming years might call the "Radiation Flap of 2009." Too much radiation from CTs, not enough radiation for mammograms...and not enough people with a bully pulpit brave enough to try to help show people the way.
I do want to note that the issue gets stickier when one considers African-American women under 50. Please--for the few people who read this blog, pass this information on to African-American women! They are at higher risk of having breast cancer before age 50 compared to white women. The problem is that it's not fully clear that earlier mammography will put a dent in the excess mortality rate, because the most lethal types of breast cancer, and the kind that AA women are more likely to have, grow more rapidly than the kind of cancers that mammograms are good at detecting and thus "pop up" in between screens due to their rapid growth and can be found simply by feeling them. A good discussion of the problem can be found here at the Science-Based Medicine blog. In short, African-American women aged 40-50 need to take special care and not simply take the USPTS recs at face value. Not that anyone is, but still.
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