Sad to say, but true, some folks have complained to me that I don’t give enough notice of all the good stuff. So, as usual around here, the beatings continue until morale improves…
…which is something of an apology for the fact that I’m only now mentioning that at 5 p.m. Eastern time I’ll be talking to Maryn McKenna on my monthly science-radio-web/podcast, Virtually Speaking Science (where I’m one of several hosts as we inch our way to regular weekly episodes). (You’ll be able to pick up the podcast later at that link, or on iTunes, having searched for Virtually Speaking Science.)
Maryn, for those of you who have for some odd reason not glued yourself to her blog Superbug, or immersed yourself in her book by the same name, is the leading journalist working in the US on problems of antibiotic resistance, infectious disease and similar sources of gnawing (and occasionally acute) anxiety. She and I have talked before, but, sadly, there’s always more scary bug stuff to talk about.
This time, our focus will be on an under-reported outbreak of (likely) Totally Drug Resistant Tuberculosis (TDR – TB) and on the H7N9 flu story out of China. But we’ll no doubt talk about antibiotics in agriculture and the way agribusiness and the tocsin of cheap food is posing such a thread. Should be, dare I say it, fun. Or at least interesting. Or perhaps just terrifying.
Oh — and as for that stray thought. Am I the only one wondering whether The Pet Goat will have a place of honor in Wee Bush’s presidential library?
Thought not.
ETA: Here’s a nice bit of reporting on potentially untreatable gonorrhea appearing in the US. I’ll be asking Maryn about this too.
Just a quick heads up. I’ll be talking at 5 Eastern Time today with Maryn McKenna, aka Scary Disease Girl on Virtually Speaking Science. You can listen, but if you’re a virtual kind of person you can also head over to the open air theater in Second Life see Maryn’s magnificent avatar with its gloriously purple hair. (One commenter compared the shade to Beaujolais Nouveau, but I’m not so sure.)
McKenna is a science and medicine writer who has focused the last several years of her career on the truly vexing and terrifying issue of antiobiotic resistance, focusing on the scourge of MRSA: methicillin-resistant Staphylococcus aureus, or drug-resistant staph. She blogs at Wired.com, under a title shared with the book — Superbug — that will be the leaping off point for our conversation.
So check it out, if not synchronously, then via the podcast, available either at Blog Talk Radio (from about midnight tonight, I think, though it may be tomorrow), via the RSS feed, or as found within the greater Virtually Speaking iTunes podcast.
Just to give a tease of the conversation — we’ll start by talking about the great squander: how, some 75 years into the antibiotic era, we’re on the verge of destroying what had once seemed to be a truly transformative gift, a way to salve so much human suffering…and we will start to look at the reasons why. High among them will be the area Maryn’s focused on a lot since publishing Superbug, the use of antibiotics in agriculture in a non-therapeutic situations — that is, not as a response to an infection, but either as a prophylactic, or simply to fatten up livestock before slaughter.
There’s been some news over the last week that makes this issue genuinely hot, but the most interesting aspect of it, to me, is the way agribusiness and their congressional allies (on both sides of the aisle, alas) have simply changed a few of the nouns and then copied the denialist playbook written for the tobacco wars, and updated for use in turning the threat of climate change into a world-wide conspiracy of fanatical socialist-facist greens.
Which is to say, as readers of this blog know, the transformation of science from a source of public knowledge into a post-modern body of jargon to be manipulated by those with the biggest and most sophisticated megaphones, is literally killing us — as we will discuss in a bit.
Oh — and one more thing. One of the key threads to emerge from Maryn’s work is just how badly we are served by the fragmentary system of health care delivery that we now have, that the GOP wishes to preserve, and that Obamacare goes some way to repair. The lack of uniform systems of electronic charts, the failure to disseminate key medical knowledge outside of its silos — sometimes single hospitals, or even single services within hospitals — the inability to construct a truly national system of health care knowledge and the dissemination of best practices (Death Panels!) all have contributed directly to the deaths of kids, grown ups, grandma and grandpa from preventable or much earlier-treatable MRSA infections, as Maryn has documented — and much else besides. Remember: when our friends who decry the fascism inherent in public regulation of a public good seek to repeal without replacing, they are advocating a policy choice that will kill people. This is a known, predictable consequence of any swerve to the status quo ante. In other circumstances, taking actions that a reasonable person understands will lead directly to the deaths of others has a name, and the people who do so have names to. Now we call them GOP Presidential candidates. Just sayin.
Just the cheery kind of conversation that will set you up for a truly heroic cocktail hour. May I recommend either one of these…or, maybe, doses by mouth of this concoction, repeated as necessary.
I’ve got just one quick note to add to the discussion of the Komen Foundation’s surrender to Greater Wingnuttia and the Global War on Women.
That would be that this decision is not just about the dollars. It’s genuinely a matter of life and death — of murder, really, with only the anonymity of the victims to obscure the the connection between act and consequence.*
Y’all may recall that I wrote along these lines about eight months ago in connection with Mitch Daniels’ decision to defund Planned Parenthood in Indiana. (Yup, that Daniels — the hack our friends in literate Wingnutistan see as the great hope of the GOP). Now we’re back again to run the numbers on what the removal of the services Planned Parenthood provides to women seeking preventative care for breast cancer will do.**
Here are the basic figures: over the last five years, the Komen Foundation provided Planned Parenthood with sufficient support to pay for 170,000 breast exams and 6,700 referrals for mammography. The question of how frequent and how early a mammography program should be has been, shall we say, vigorously debated, but the issue gained some clarity last year with the publication of a large scale longitudinal study by Swedish researcher in which over 133,000 women were followed for a total of 29 years.
The results of this study provide low-end estimates for the lives saved by screening: for every 414 or 519 women screened*** for seven years running, one breast cancer death would be prevented. What’s more, the researchers emphasized that this is a conservative conclusion:
Evaluation of the full impact of screening, in particular estimates of absolute benefit and number needed to screen, requires follow-up times exceeding 20 years because the observed number of breast cancer deaths prevented increases with increasing time of follow-up.
I’m being deliberately dry in this telling, and I’m sure you can guess why: I do not wish the conclusion to lose any of its force to misplaced snark. The bald facts are grim enough.
How grim? Take the most modest number from this study —519 women screened for each life saved. That’son the order of 13 women from the 6,700 screened with Komen Foundation money who get to live.****
Or: that’s 13 women who will die for lack of those funds.
As I wrote about cervical cancer screening in Indiana: we won’t know who those women are. We will never know their names; who loved them; how many kids they will leave behind. But if the total funds for screening in the system drop with the withdrawal of Komen Foundation support, they’ll be dead all the same.
Caveats, before I drop this “just the facts, Ma’am” tone: this is a blunt, back of the envelope bit of arithmetic. There are all kinds of factors that a real epidemiologist would consider before making any such bold claim. Some of the obvious ones push the conclusion to a higher likely total of preventable deaths: these women are being referred for screening, which suggests that someone had an inkling that they might be at risk. Planned Parenthood sees a clientele that is likely to lack more health care services than the general population. And there are the general points the original researchers made to suggest that the total of lives saved through screening would be greater than their baseline number. There are probably factors that weigh in the other direction as well — one could imagine, for example, that the preliminary examinations turned up more aggressive cancers, which may have outcomes that mammographic detection does not much alter. You get the point. The reality of public health, medicine, and the basic biology of cancer is such that precise predictions are always wrong.
That said, the broader claim still stands: there is a significant and growing body of evidence that regular mammographic breast cancer screening saves lives. The converse follows: withholding that screening means real people will suffer.
And here I’ll drop the pretense of dispassion. The Komen Foundation’s decision links directly to illness, to death and loss and dreadful sorrow left behind.
Those losses can’t be called manslaughter either, not as I see it. Preventable deaths that flow from lack of access to the standard of care are wholly predictable, even if the individual victims are not identifiable. Those blocking access through want of funds know — or should — what will happen. There’s nothing accidental about these outcomes.w
Which means that this isn’t just another salvo in the culture war. This is nothing to be clever about in 850 word columns on the back pages of the Grey Lady. This is not a bit of clever gamesmanship to rev up a base for whom just the name Planned Parenthood conjures up all their horrors of female agency.
This is real life, and real lives lost…and, once again, this is why this election matters so much.
*Yup. Still working the refs for that Moore Award.
**Just to be clear: for what follows, I’m assuming that these services are withdrawn, that the withholding of resources from the Komen Foundation doesn’t get made up somewhere else.
*** The spread is down to the details of data collection and analysis in the Swedish study.
****The weasel is about the difference in the five year span of screening Komen funds are said to cover, and the seven year screening sequence identified in the Swedish study. I lack both the data and the skill to do more than waffle a bit here.
It’s not that I don’t like the book – it’s wonderful, and I highly recommend you all go read it.
It’s not that I don’t have some thoughts about the work. It offers plenty of grist for engagement, from its compelling story to some formal considerations in the writing, to the practical lesson Rebecca is giving us all on what it takes to promote a book in this late-stage of the traditional approaches to publishing.
It’s not that there isn’t a wealth of material to talk about. Rebecca has written a compelling story, a genuine page turner, populated with characters – people – whom you come to care about deeply, that is at the same time an important inquiry into issues of race, class, personal autonomy and the claims of authority in America.
It’s just that all of this has been said already. I agree with the assessments of the host of reviewers and bloggers who have already weighed in on the book: it’s a great achievement, it’s a compelling read, and it is at once emotionally moving and intellectually demanding, which is my idea of a fine, fine book.
So what to add?
Well, I’ve got one thing to say more from my perspective as a writer who also teaches writing than as a straight reviewer/critic. At least one of Rebecca’s choices of technique in this book was hard won, complicated, and very important to the ultimate power of the work.
That is: a number of people have noted what they see as the use of some of the story telling tools from fiction in the tale – and that’s certainly fair. Her telling of scenes from the story of Henrietta Lacks herself with a novel’s third person, seemingly omniscient narrator is a case in point.
But to me the dominant source-genre for the book is not fiction but that very tricky approach to non-fiction that falls under the umbrella of memoir.
I heard Rebecca tell Terri Gross on NPR’s Fresh Air that she resisted inserting herself into the story until it became inevitable, until her odyssey with the Lacks family became so intimately intertwined with what she thought her formal narrative to be that she had to emerge as a character in her own book.
That decision shapes the entire work, much for the better I think. We enter the tale with her 16 year old self, a not-entirely successful high school student, catching a stray remark in a biology class about an important line of cells, and their source, Henrietta Lacks, of whom the instructor said, as an aside, “she was a black woman.”
With that we’re off, and we are able to understand the entire work that follows as a journey undertaken by a maturing Rebecca to come to grips with that sudden, strange, and almost comically opaque revelation.
That journey is not undertaken by an omniscient narrator, for all that the device shows up here and there; we don’t have a Virgil on this sometimes infernal journey.
Rather, we have Rebecca herself, a changing person and voice, someone with accumulating, always incomplete knowledge. Most important for the power of the book, Rebecca is implicated in the tale: each discovery she makes has both an explanatory signficance and an emotional one, for her. And hence for us, once we’ve invested our concern in the teller of the tale.
By the way, in this I don’t mean that Rebecca comes to dominate the story. Henrietta herself, and even more, Henrietta’s daughter, Deborah, are the emotional centers of the story. But that’s how memoirs work. They are not simply, or even mostly (in the best ones) about the author; rather, they provide a bridge through the author to sympathy with the people and experiences encountered on a life’s journey. A keen memoirist uses what she or he knows to be a subjective view to create a connection between the reader and both what and the way she or he sees the world.
That’s what makes the most controversial scene in Rebecca’s book so valuable, narratively. At one point, in the midst of Henrietta’s family, Rebecca experiences a kind of exorcism. She’s a rationalist, a science writer, for heaven’s sake. And yet this experience is real, felt and…as written, present for the reader.
All of which is to say, that memoir isn’t just a “what I did today” account of a life: it is a conscious and complicated narrative stance, which, when wielded by a writer of skill and sensitivity constructs a world fo feeling out of an account of fact – or what seemed like fact as lived. Doing it well is really hard – and having done so is one reason that Rebecca produced a book that works so well.
In today’s NYT, Leonhardt — one of the few really good economics reporters out there right now — writes about the “innovation gap” induced by the catastrophic failure that is the American health care “system” as it stands. In doing so, he documents, once again, how the modern Republican party is, in essence, a traitor to the American dream.
In essence, Leonhardt is reporting about the largely unmentioned elephant in the room: absent comprehensive reform of health care, the terror of losing or of failing to secure adequate insurance makes the US labor market increasingly rigid. As Leonhardt reports:
It is impossible to know how much economic damage these distortions are causing, but they clearly aren’t good. Economic research suggests that more than 1.5 million workers who would otherwise have switched jobs fail to do so every year because of fears about health insurance. Some of them would have moved to companies where they could have contributed more, and others would have started their own businesses.
…Eric Schmidt, Google’s chief executive, told me, “There clearly are people who choose to stay in their jobs due to the fact that they don’t have insurance portability.” Just consider the economic research showing that people married to someone with health insurance are more likely to work at small companies than people who aren’t so lucky.
Leonhardt does a good job of mapping in cartoon fashion what we could aim for at this point in the health care debate, quoting my MIT colleague John Gruber saying “Take the Senate on cost control and the House on affordability …and you’ve the best possible bill.”
Certainly, the central moral and social rationale for health care reform is the fact that too many Americans sicken, go bankrupt, and die for lack of access to care.
But what makes this article at once so obvious and so necessary is the light it shed on this fact: the reason we need to get going on the health care bill now, and then defy the “once every twenty years” meme for improving what we get, is that the wealth and hence power of the America our children will inhabit depends on real, ultimately transformative changes in how Americans get covered and cared for.
So the next time you read statements like this, ask yourself why the Republicans in Congress (and too many outside it) hate America so.
A few days ago I wrote this screed of disdain about David Brooks data-less, thoughtless complaint about the vapid sex lives of Kids These Days™.* I have more than once commented on the evil consequences of marrying sexual queasiness to bad science, social or otherwise — and it struck me that it is important to remember that Brooks’s queasiness about sex has a broader context and worse consequences.
The thought came to me as I was reading my pre-pub copy (what used to be called a galley) of Rebecca Skloot’s marvelous new book The Immortal Life of HEnrietta LAcks. Rebecca has written a work that is proximately the story of HeLa — the most ubiquitous (some would say ferocious) human cell line used in modern biology — and the woman from whom those cells were derived, without her knowledge or permission. It’s more than that, of course — an inquiry into race and its twisted history in America, family, medical practice and medical ethics, the autonomy — or lack therof — with which we all inhabit our own bodies, and much more besides. I’ll blog about it properly closer to pub date, but put this one on your list.
Within all that, the factoid that got me thinking was Rebecca’s discussion of the particular type of cancer that killed Henrietta Lacks so swiftly and cruelly: cervical cancer, the sequel to her multiple infections with HPV-18, one of the most malign of the 100+ strains of Human Papilloma Virus.
HPV infection was and is an epidemic. In 2008, the Centers for Disease Control reported that
HPV is the most common sexually transmitted infection in the U.S., with about 20 million people currently infected. Women have an 80 percent chance of getting HPV by the time they are 50. HPV is most common in young people who are in their late teens and early 20s.
That is: about 7 percent, give or take, of the American population — closer to ten percent of the adult population**–are infected with a virus whose consequences range from nothing to death in predictable proportions. The same CDC report tells us that each year 11,000 women are diagnosed with cervical cancer, and that 3,600 will die of it.
For those of you keeping score, the number of women who will die this year of the disease that killed Henrietta Lacks is about 80% of the total US military deaths in Iraq since 2003 — 4363, according to the latest AP count. It is greater than the number of combat deaths in that period: 3,476.
There is this difference of course: death is a necessary component of battle. War is the imposition of national will by violence, in one short hand definition, and within that context, people will die.
By contrast, no one — or rather, within a generation, very close to no one — need die of HPV infection. The HPV vaccine, approved by the FDA in 2006, protects against four of the strains of HPV, including those that cause genital warts and cancer. It is effective, according to the CDC, and safe:
As of June 30, 2008 VAERS has received a total of 9,749 reports of potential adverse events following HPV vaccination. Ninety-four percent (94%) of these reports were about non-serious adverse events.
Six percent (6%) of adverse events reported for the HPV vaccine were considered serious, which is about half of the average number of serious reports for other vaccines. In comparison, the overall average in VAERS for any serious adverse event following vaccination ranges from 10% to 15%; therefore, the percentage of serious reports for Gardasil® is less than the overall average for other vaccines.
The CDC goes on to caution that the number of adverse events actually caused by the virus vaccine is almost certainly lower than that number, due to the post hoc ergo propter hoc problem.
The virus vaccine is recommended for girls aged 11-12. Why? Because this is before the age of likely infection, given that HPV is a sexually transmitted pathogen.
We all know where this goes. The notion of protecting girls from a deadly disease transmitted in the context — oh get the fainting couch ready — of the sexual lives of their older selves is terrifying, at least to some.
So much so that those terrified of especially female sexual appetite and expression (see for an allegedly respectable example, Chunky Reese Averse Ross Douthat) would rather kill people than acquiesce in the possibility that human beings might on occasion make the beast with two backs.
Recall: Texas secessionist Governor Rick Perry wasn’t always 100% crazy. Back when the loon quotient was down to no more than 95% or so, he actually, in a moment of clarity in 2007, signed an order that all require all sixth grade girls in Texas to receive the HPV vaccine. The response? As you’d expect. Texas legislators “rushed to file bills that would override the governor’s order, which they said revokes parental rights and could encourage young girls to be promiscuous.”
To his credit Perry stood up for modern public health:
Providing the HPV vaccine doesn’t promote sexual promiscuity any more than the Hepatitis B vaccine promotes drug use,” Perry said Monday. “If the medical community developed a vaccine for lung cancer, would the same critics oppose it, claiming it would encourage smoking?”
Soon, though — damn soon — in fact, he lost. Though he complained — accurately, that the legislators who had voted in favor of the bill overturning his executive order would rather tell women that ”We could have prevented this disease for your daughters and your granddaughters, but we just didn’t have the gumption to address all the misguided and misleading political rhetoric,” he lacked the votes to prevent his veto from being overturned, and allowed the bill, unsigned, to become law.
Perry, it should be noted, still defends this decision. I have no time for just about everything Perry stands for – but on this one, he has it right.
So let’s recap: we face a disease that kills more women in this country each year than have died in battle in the last six in our war in Iraq….
…that will be allowed to persist in the lives of our daughters because to some people it is more important to pretend that human beings don’t have sex with more than one person in their lives than it is to prevent wholly avoidable suffering.
So, finally, to return to why I find David Brooks’s maundering about the sex lives of New Yorkers so pernicious is not just because of the gaping crater of intellectual shoddiness at its heart: it that he offers a well-spoken version of the attitude that declares, whatever may actually happen in real human experience, women shouldn’t have the temerity to uncross their legs. Remember the corollary of that belief as well: if they do, then, by gum, disease, distress and death are merely the appropriate consequences for such sin.
Last note: when ever I hear the term “value voters” I throw up in my mouth. The single central value of just about any ethical system, including those advanced by the sages of traditional religion, is that it is wrong to use other people as objects, rather than subjects, individuals of intrinsic value. Requiring others to die to avoid unpleasant contradiction with one’s own value system is not a virtue. It is, in the only true sense of the word, the very definition of a sin.
A pox upon them.
I mean that literally.
Oh — and one more thing. If anyone wants to draw the obvious connection to the current health care debates (Joe Stupak, are you listening? Senators?) then I think that is an entirely appropriate link. The entire anti-health care movement is in the end a decision to allow innocents to die in large numbers in order to achieve other ends; it sacrifices individuals in the service of either or both abstract “values” and the financial interests of various elites. Mere sin hardly covers the case; evil is more like it.
*I later found out that Brooks’ silliness was deeper than I thought, for I chanced across the original article in New York magazine in which the editors described the process by which they accumulated the sex diaries that so confounded the gentle Mr. Brooks. These were, which I’m sure will surprise no one, wholly selected for maximum effect. Producing social commentary on the basis of sought-and-found soft porn purveyed to prop up an at-risk publishing model is something only the credulous or the contemptuous-of-their-readers would attempt. Consider this an exercise for the readers to decide which it might be.
**and yes, I know that plenty of under-18s will have HPV infections. This is numerical shorthand here — an attempt to express scale. It is not, as I hope the language makes obvious, a precise claim.
Update: minor but crucial edits above (for “virus” read “vaccine” twice) thanks to the eagle eye of Lovable Liberal.
Tonight, Thursday, October 15, Andrea Barrett — wonderful and much acclaimed novelist and short story virtuouso — will be giving a rare talk in the Boston area.
Barrett is the perfect creator of fictions to speak to an MIT-esque audience. She creates powerful stories, lives examined in connection with each other, under the pressure of selves, loss, time. And much of what those characters care about has something to do with science. Barrett is best known, I think, for her jeweler-precise use of the history of biology as engines for her stories, though geology certainly comes in, and in the work I’m reading today, The Air We Breathe, the paleontology that forms one of her people’s passions jostles with the history of x-rays, chemistry, and the fact and feeling of ideas of health and disease as it organized itself around the TB epidemic of the early part of the last century.
Best of all, her treatment of all this is meticulous, accurate, engrossing — and yet always in service of the story. Great stuff, both for those whose first love is fiction, and those, like me, who wonder how best to speak of science to our fellow citizens.
Also — if you like the public seals of approval: Barrett won the National Book Award for Ship Fever, a story collection, received wide acclaim and best seller status for several other works, of which The Voyage of the Narwhal might be the best known, and has more recently published Servants of the Map* and The Air We Breathe. She can add a MacArthur “Genius” Fellowship and finalist recognition for the Pulitzer to her trophy case — but the point for me is that the work is consistently gripping.
Come if you can.
*This collection of stories can serve as a deft introduction to the history of evolutionary biology from early nineteenth century efforts to reconcile the fossil record with scripture, through the impact of the Darwinian moment, to the present day. It’s a full-service read, IOW.
Update: Hello and thanks to everyone coming over from Balloon Juice (and elsewhere.) It took me a while to acknowledge y’all as I’ve been enjoying the strangely liberating experience of being on Amtrak and without intertubes for the last several hours.
Also, picking up on the comment below by Joel, let me emphasize that I don’t want to suggest that Acemoglu et al.’s later work contradicts the earlier paper discussed below; rather, as good research/ers does/do pursuing a question in detail leads to a more complex understanding of the problem. The point is that if you are trying to argue from someone else’s work, you can’t just pick and choose the bits you like.
______
OK, by now it’s clear that this is overkill. One post by Megan McArdle does not need this kind of rant; it’s like using a howitzer to plink a tin can off a fence. [For grotesque demonstration of my logorrhea problem, check out parts one, two, and three of this series]
But in some sense, all I’m doing is channelling my inner John Foster Dulles: McArdle, and her ilk are not going away. Sadly, no amount of day-by-day debunking seems able to evoke the kind of respect for their claimed craft that would produce even a smidgeon more care and honor in their ongoing attempt to write into reality their unexamined assumptions. So, after Dulles, consider this a kind of blogospheric massive retaliation, an attempt to shock and awe the recalcitrant into the virtues of intellectual honesty.
Which brings us to one more thing that McArdle did not do in her attempt to recruit what she claims as the gold-standard of authority, the academic literature, to bolster her assertion that any attempt to control drug expenditures in the US medical system is tantamount to a pact to kill nice old people.
I’ve used two posts so far to ridicule McArdle’s attempt to demonstrate her intellectual chops by basing this argument on a paper by the Rand Corporation, paid for by Pfizer (the world’s largest drug company) that relies on a secret-sauce “model” to produce the conclusion that free market negotiation by large customers (the US government, e.g.) and/or price controls would reduce the pace of innovation in the drug business, resulting in a loss of months of life expectancy.
In other words: I don’t think much of a study paid for by the man that comes to the shocking conclusion that we must pay that man or he’ll shoot grandma.
But having disposed of the follies inherent in taking advocacy research too seriously, I want to point out one last and deeper flaw in McArdle’s dishonest brandishing of the sword and buckler of academic authority.
Recall that her core argument is that she is a truth teller, while her critics are ideologically driven bullies. She writes
Or we could go to the academic literature. Not the literature from advocacy groups which too often fills the pages of political magazines on the left and right, but something from someplace like Rand….
She says, in other words, that we should believe her because she performs research through the academic literature, and not mere advocacy. (She actually contradicts herself below, by saying that we should believe her because she talks to Big Pharma, and thus is willing to dirty her hands in pursuit of truth that those who insist on relying on (presumptively) disinterested research by those “who have never run or even studied businesses”…but never mind.)
But in fact, leaving aside that Rand is in fact a producer of advocacy literature, the Rand paper and McArdle cite a genuine academic source for a crucial part of the argument, a study that they claim demonstrates that changes in pharma revenue produce outsize shifts in the rate of pharmaceutical innovation.
And yet: McArdle did not in fact “go to the academic literature,” for all of her properly provided hyperlink to the paper in question.
How do I know?
Because I checked.
Here’s the deal: in science journalism — in any attempt to write about technical material for the public — it’s not enough simply to read an abstract or even the whole piece and call it done.
You can’t just read the paper and assume –unless you are genuinely expert in that subdiscipline of the field you wish to cover, and often not even then — that you know what its authors’ actually have done and what it means.
That’s why scientists go to conferences, for one thing — because there is more to grasping the meaning of important work than just reading the stylized and usually telegraphically compressed report of a piece of research in the professional press.
And if you are a reporter, then, by gum, you have to report on the piece, which is a much more involved and difficult task than many give it credit for being, at least if you do it right.
I’m not claiming that I did enough of that complicated work to write an independent piece on the very interesting research McArdle pointed to. But I did do enough to confirm a suspicion formed on reading both McArdle and Rand: Acemoglu and Linn’s paper, does not say what they thought or perhaps simply asserted it did.
This is the ultimate point I’ve been laboring towards all this long while. Science writing is hard because of two related issues. The first is that science — and aspiring sciences like economics — is/are hard. Such work involves complicated ideas, intricate, often mathematically complex methods, jargons that can take quite a while to penetrate and so on.
And the second hurdle for good writing about hard stuff for the public is that the goal of science writing requires that you learn not just how to understand what’s being said in the terms of a discipline itself, but also how to identify, and then convey the core ideas in any given bit of science to an audience that doesn’t have the time you’ve taken to figure it all out.
So what you do if you are a properly trained and ethical science journalist/popular writer is read first, of course, with care and attention to all the places you either or both don’t understand and/or get the sense of an important subtlety…and then you call.
You talk to someone, lots of someones if necessary.
You get people in the field to explain what they are doing; you allow yourself to appear dumb to yourself; (you won’t seem stupid to just about any good faith expert source — only the assholes expect you to have mastered every paper in every journal tangentially bearing on their crucial work before calling, and there really aren’t as many of those as legends suggest); you ask simple questions, and then more complicated ones, until you and your interlocutor agree you’ve got what you need.
You have to persist — and if someone says check out this or that, you do, looking up the papers if necessary and then calling back…and so on. You do what a good reporter does: you cover the story.
This McArdle did not do. If she read the Acemoglu and Linn paper with care, and especially if she had talked with someone who was familiar with the work, she would have realized the subtle distinction those authors made. They looked at the role of market size on innovation for each particular market segment — a disease or group of diseases addressed by a set of competing drugs. The Rand authors, with McArdle trailing happily along, conflated that to an argument about the effect of total market size on innovation across all drugs.
Again — this is subtle, and I had to talk at some length with an economist colleague to get why it mattered.* But the essence of the idea is that the shifts in pharma innovation Acemoglu and Linn identified tracked the relative value of the market for individual areas of interest. It does not follow that gross revenue changes produce the differences in innovation overall that both McArdle and Rand cite. Rather, the two MIT economists simply demonstrated that more market share by drug category produced more new drugs within that category.
Or, more simply: when the Rand/Pfizer authors claimed, and what McArdle (deliberately?) uncritically parroted — that a respected academic body of research confirmed that cuts in gross pharma revenue = cuts in innovation overall — they were, to phrase it most kindly, in error.
It actually gets worse, of course.
There is this thing called the internet. It contains things like the homepages of scholars, which often include lists of their publications…which will often reveal ongoing lines of research or areas of interest.
As it happened, Acemoglu and Linn followed up their 2003/4 paper with a subsequent study, published in 2006 with David Cutler and Amy Finkelstein joining the original pair as co-authors. This second paper looked at the impact of Medicare funding on innovation.
McArdle and the Rand folks do not mention this study, and it’s pretty clear why they might have wanted to ignore it. For what did its authors find?
Bupkis.
More formally, they wrote, “Our reading of the evidence is that there is no compelling case that Medicare induced significant pharmaceutical innovation.”
That’s not conclusive either, as one of the economists with whom I spoke explained to me. What is clear — and those I asked agreed — is that connection between drug producer prices, market size and innovation is at best a mess (my word). There is no basis on which to assert, as McArdle does, that
The upshot is that the overwhelming weight of the available evidence indicates that the effect of price controls in the US would be real, significant, and bad….The idea that any significant change in the profit margins on drugs sold here [in the US] will have enormous impact on the future of pharmaceuticals, is as close to a fact as we can get in this vale of uncertainty.
That is unproven in the sources she cites, and it is unproven in the real world. On the basis of the academic literature she so proudly proclaims as her guide, she cannot know what she thinks (or wishes) were true.
To cover up this and prior errors, she is reduced to insulting her critics who have pointed out her ignorance, sloppiness and general lack of understanding of what real work looks like in the field in which her competence is supposed to lie. (Economics Editor of America’s Oldest Serious Magazine™!)
It’s time I finished this off, and by now the message, I think, must be obvious. This is one tired horse I’m beating.
But here is a last thought, to try and generalize from one rather minor example of shoddy work on the internet. It is a sign of both ignorance and bad faith to treat the real world and attempts to understand it as cavalierly as McArdle does here, and the right-punditocracy has done so often of late.
But this is where the right is just now. You can see bad faith and sloth too in George Will’s embarrassing attempts to weigh in on climate change.** You can see an almost comical (were it not so willed) misreading of the research in almost any attempt to produce a scientific justification for failing to credit the fact of evolution. You can sure find the attempt to claim unearned authority running through McArdle’s work.
In each case, whatever the variations of motive, method and intent, all of this rests on the writer’s determination to ignore how science actually works — and hence how human beings actually find out useful knowledge about the world. In each case — the root intellectual activity is to cherry pick what ever serves to bolster conclusions reached long before the notorious liberal bias of reality has had any chance to sully their perfect thoughts.
And as for McArdle herself? Her sins are typical, but for that very reason, I guess, hardly worth the bludgeon I’ve tried to wield over the last several thousand words. Except for this: a failure to think clearly about how to repair a deeply flawed health care system kills people. There are significant studies that explore those excess deaths. Here’s one.*** And if you take that work seriously, then you have to see the Panglossian mission of McArdle and her herd of thundering ilk to present chunks of the status quo as best of all possible outcomes as implicated in those deaths.
More broadly: writing about the things that matter in real people’s lives — that may end some of those lives — is not a game.
That McArdle writes as if it were is the true measure of her work.
*I’m not naming by source, because that person dislikes the hurly burly of the blogosphere…and while I know that unnamed sources are more or less worth what you know about them, you have to decide here whether I’m a reliable enough interlocutor to believe what follows.
** Click that link to see why Chris Mooney gets around in public more than I do: he gets done in 800 words what I’ve just spent in excess of 4,000 spouting about. Still, someone at MIT has to take on the Henry Jenkins mantle of ridiculously overextended blogorrhea.
*** For a quick guide to skepticism in the face of research, here are a couple of guide points on this study: It’s funded under a NRSA (NIH) grant — not by an advocacy group. It draws on a history of similar studies engaged with the same question: whether or not uninsured status correlates with excess deaths. The paper contains some detail on their methodology, and crucially, includes a section on limitations and potential sources of error in the work. To gain confidence in its quite commanding conclusion — that lack of insurance is associated with more than 44,000 deaths per year — you (I) would need to do quite a bit more reporting than a simple read of the paper. But my point here is that this piece of work passes several of the smell tests that the Rand study, and McArdle’s writing, did not. You have something to go on here. And with this, the sermon endeth.
This is the third part of a ridiculously oversized tome on one example of what I see as a systematic failure on the right to engage science in any meaningful way. [Part one is here; part two, here]
In part two, I noted that serial offender Megan McArdle was trying to defend a claim about how health care reform will kill grandpa by asserting that the scientific literature supported that view.
The literature she cited began and mostly ended with a long paragraph quoted from a study by the Rand corporation…and in the previous post I noted that one of the problems in making the claim that McArdle’s argument was based on a rigorous review of the literature was that this paper was essentially research for hire, where the client was the world’s largest drug company.
While it is not true that just because Pfizer paid for a study that showed cutting Big Pharma revenues would result in a decline in pharma innovation that would lead to a loss in life expectancy*…it does mean that you can’t just do what McArdle did here: say “look — some folks with initials after their names confirm my unexamined conclusions. Therefore I win! Yippee.”
Rather, what you have to do with any piece of research, and especially one that is both making a major claim and is doing so from a clear position of interest in the outcome of the research, is to check. You gotta interrogate the paper, its methods, its claims, its interpretations, its conclusions, the lot.
You know — basic reporting, the basic lesson we make sure each science journalism student we encounter at my shop (and every other good science writing/journalism program too) learns in the first weeks of study.
This McArdle clearly did not do. How do I know? I’m not (I promise) going to fisk the Rand paper top to bottom, but there are several issues with it that don’t pass the smell test right off.
The first is that the authors present their results as the output of a complicated model, itself derived from several other models for the behavior of the large variety of inputs needed to understand whether or not a cut in drug company revenue will have an impact on innovation.
A first plausible question is how the model actually works, and to what extent it has been tested. Not to get too wonky — and not to claim expertise I certainly don’t have — but if this were a serious paper for the professional literature, you’d expect at least some discussion about the underlying logical and mathematical structure and strategy of the model. It’s not there, at least in the publicly released form of the paper.
Next: check out the authors’ rhetoric . It doesn’t read like scientific writing…and there’s a good reason for that.
To see what I mean, look to the paper both the Rand folks and McArdle cite as supportive of their arguments, Acemoglu and Linn, written by two MIT economists. There you can scroll down to the final section and you see a set of graphics supplied to support the discussion above.
Some are labelled “tables” and they contain accounts of the data collected to support the model, complete with explanatory captions to allow a reader to follow the reasoning that led the authors to gather that particular slice of reality and not some other.
Some are called “figures,” and they come in the form of graphs which show what happens to that data when run through a model calculation.
Now go look at the Rand document. It presents six graphics. Each presents some feature of the argument they seek to make — how a given approach to pharmaceutical cost control affects innovation and or longevity. They are easy to read, striking, even, with graphs or bar charts to show the devastating consequence of reducing producer payments to big drug companies. They should scare anyone who wants to live their fully alloted span — as they appear to have terrified the young and impressionable McArdle.
But if you want to figure out if the graphs represent much of anything beyond conclusions expressing the assumptions with which their creators began, you can’t. Each has the identical caption:
Source: Authors’ calculations based on the Global Pharmaceutical Policy Model [the authors' rather modest signfiier for their black box of an analytical engine].
Just in case you were wondering — that’s the language of advocacy, not research.
The authors are saying “Trust me,” and anyone with even a passing knowledge of the movie business knows that this is the punch line to the old joke:
How does a Hollywood executive say “F*ck you?
And if you needed a yet more obvious clue, check out the label put on each graphic. It’s not “Figure,” or “Table,” or even “Results.” Oh no. This is no mere milque-toast publication of data and the logic that lies behind the authors’ inferences. That kind of thing is for the intellectually conservative, or those committed to an attempt at disinterested investigation.
The Rand team, hired by Pfizer, knows what it is doing. It is making a case for a particular policy outcome, and hence its graphics are labeled — and I’m not kidding — “Exhibits.”
Not to belabor this — I’m after McArdle and the approach to argument she embodies, not the well-known habits of the bespoke policy research game — but one of the first and most basic lessons we try to teach our students in the Graduate Program in Science Writing in MIT is that just because some document looks like a real scientific paper, or that some result gets published somewhere that looks impressive, you cannot then safely conclude that what it says is true.
Rather, we tell our students, you have to read it not just for the results, but for the degree to which the paper itself does what a serious piece of research should. Does it at a minimum provide you with enough information to ask intelligent questions about what it purports to show. If, as here, you see such a broad tell as the word “exhibit,” then you have to know that this demands a lot more digging before you can accept its claims. The say-so of the paper and its authors isn’t enough; they’ve told you so themselves.
It is tempting simply to ignore any paper like this one — anytime someone tells you that they’ve come up with some complicated model that gives a magic answer, a long life in science writing tells you that they are blowing smoke. Remember: big claims require big justification.
Over time, with experience in the business (either that of science or science writing) you learn when to get revved up about something, and when to sit back and let shoddy work slide by without close examination. Life is too short to spend one’s time doing what xkcd so famously documented.
But let’s give the Rand paper, and McArdle yet more benefit of the doubt. All that I’ve said above suggests that the Rand paper itself is telling you that you need to dig deeper before you rely on it. Who knows? Maybe its conclusions are true, even if it is impossible to determine that from the evidence presented.
Well, I haven’t done anything like a proper job of reporting to that depth. But what I got in a morning’s reading and calling is strong hint that the Rand paper is, as expected, propaganda, nicely garbed in Rand blue.
So: on to the bill of particulars on McArdle’s recent attempt to claim the intellectual high ground in her ongoing attempt to convince us that we live in the best of all possible drug markets. [Part one is here]
I’m not going to fisk the entire piece in question. Instead, I’m going to focus on one passage in which she invokes the research community to defend her assertion that artificially high US drug prices for big pharma are essential to the future of drug innovation. You can read in the way she treats this literature that she either doesn’t or willfully won’t engage her subject up to the level that would allow her to make believable arguments.
She introduces her bravura display of rigor this way:
…we could go to the academic literature. Not the literature from advocacy groups which too often fills the pages of political magazines on the left and right, but something from someplace like Rand. And fortuitously, Rand happens to have published a paper on this very topic!
McArdle goes on to quote at length a passage about what would happen to longevity if the US imposed price controls on pharmaceuticals to bring US costs down to those paid by Europeans (about 20% less than current prices, according to the paper).
McArdle then seeks to emphasize the urgency, even the moral quality of her concern for maintaining the status quo in pricing by citing this conclusion from the Rand group:
…. the introduction of price controls would reduce life expectancy by two-tenths of a year for Americans ages 55-59 alive in 2010 and by one-tenth for Europeans ages 55-59 alive in the same year. In percentage terms, these correspond to 0.8 percent and 0.7 percent declines from the status quo.
And, just to finish laying the groundwork, she adds one more cite from the professional literature to affirm the authority of the quite striking claim above:
If you’re wondering how much levels of spending matter, you could go to Acemoglu and Linn, who estimate that a 1% increase in market size (aka revenue) for pharmaceuticals results in a 3-4% increase in the number of drugs being approved.
Sounds pretty devastating, right?
Well, yes…and that ought to be the clue. In science, and in common experience too, of course, the rule of thumb is that the more striking the claim the greater the appropriate level of skepticism. So before you endorse or adopt such positions, you need to test the inference.
There are a number of ways to do so, of course. Step one is to consider the source.
Did McArdle? Not really. A first reality check comes from an inquiry into the background of the Rand study.
Go to what the Rand paper actually says: It analyzes two cases: either reduce payments to drug companies, or increase subsidies to consumers to get an effect on consumer pocketbooks (absent the tax consquences of the latter policy) that would be the same. Reducing drug expenditures though it saves consumers money but, according to this analysis, costs them life expectancy. Subsidies leave consumer finances unchanged, but do not impose the cost in months of life lost. As the value of life in the model exceeds that of the saving on drug costs, the conclusion is obvious: No attempt to reduce drug company receipts should be made, with policy makers concerned about the effects of the cost of health care instead told to focus on further subsidizing the purchase of drugs.
That is: pay the man, or we will kill grandpa before his time.*
But then, if you go on to read to the end of the study, you find something interesting. The study was not a piece of social science research undertaken by a body of disinterested researchers. Rather, you are reminded that Rand is a private, nonprofit research shop, available to perform academic-level, but not academic-housed studies for those willing to pay. The lead funder for this study?
McArdle does not point this out. I’m not sure if she noticed it in her first reading of the piece. She does respond in the comment thread to a reader who pointed this out, writing”If you can find articles on the subject that are not funded by an institution with a clear dog in this fight, please send them. Rand is a widely respected institution.”
This is…how to put it…seriously weak sauce.
Juxtapose it with her snark about “the literature from advocacy groups which too often fills the pages of political magazines on the left and right.”
In other words, she’s relying on the argument from authority, again: Rand is respectable…a member of the village. The fact that it is an intellectual gun-for-hire does not seem to matter to her, and of course her defense — that everybody does it — is wrong, a false statement.
You don’t have to go far to find the confounding counter-example. The other paper she cites, (on which more later), was written by two economists both then at MIT. The work, published in the Quarterly Journal of Economics, lists its outside funders: first the National Science Foundation, and then the Russell Sage Foundation, a one hundred year old philanthropic institution with a focus on “the improvement of social and living conditions in the United States.”
Oh well…
Now of course, the fact that Rand was hired by the world’s largest drug company, and then produced a paper which argued that the pharmaceutical industry’s revenue should under no circumstances be cut unless you are willing to accept death and lamentations, is not in itself prima facie evidence that this paper is a put-up job, astroturf research with Rand serving as the cut-out for big Pharma.
But it does, or it should, compel you to interrogate the paper with great care.
And for that: look to part three of this series.
*Or perhaps, if you follow the learned doctor M. Python, pay the man and we’ll kill grandpa before his time…;)
What’s more, the researchers emphasized that this is a conservative conclusion:
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