A Blog With A View

James Williams' "Medicine: Business Or A Basic Human Right?"

2011-08-18T19:35:00.000-07:00

Ho Chi Minh City Hall

James Williams, a junior majoring in Chemistry at Princeton University, has been working through the Oxford University Clinical Research Unit in Ho Chi Minh City, Vietnam on a summer research project aimed at analyzing the role of pigs in transmitting Japanese Encephalitis Virus. He'll be returning to the states in two weeks, but before returning home James chose to guest-write this piece for TableTalk's A Blog With A View in an effort to depict the role of private research interests in the public health sector in Ho Chi Minh City.

Tucked away in a back corner of Ho Chi Minh City’s Centre for Tropical Disease, the Union Jack waves from the second floor of a nondescript building. The building looks no different from its neighbors, where HIV and malaria patients flood into the hallways on their makeshift hospital beds. But in fact, this building is different, housing labs and offices of the Wellcome Trust, a United Kingdom-based group of international biomedical researchers with associated branches in Bangkok, Kathmandu, Dar es Salaam, and Nairobi, among other places.

Wellcome’s location in the Centre for Tropical Disease suggests something strange about the relationship between biomedical research and clinical practice, something that perhaps appears even more ominous in a developing country like Vietnam. One telling, albeit unofficial stat that was given to me: the average custodian at Oxford University earns more than the typical Vietnamese doctor. HCMC’s Hospital for Tropical Disease is a place of unders. Staff is underpaid, the hospital is undersupplied, disease goes underreported. Indeed, the only thing not in short supply seems to be the overwhelming number of patients in need of HTD’s services.

So when we realize that Wellcome’s doctors are paid far more than their Vietnamese counterparts, we’re left with a sour taste in our mouths.

At first glance, this means that money is being channeled from patient care to people whose principal job is not to heal, but rather to crank out paper after paper in European and American academic journals. And there’s some truth to this. Most work done at Wellcome won’t immediately improve patient outcomes, just as most research done in the States won’t result in the cure for cancer. In resource poor settings like Vietnam, then, it seems that money would be better spent investing in improving patient care or training more doctors. Right?

But to think so idealistically is to ignore basic economic principles. Frivolous though investment in research may seem in 90% of cases, few would deny that the remaining 10% does justify that spending. Given how interdisciplinary it is, biomedicine is a field that requires the best and brightest individuals. And in order to attract the best and brightest, there needs to be some incentive. After all, the altruistic lure of helping your fellow man may not be enough, even when one throws promises of steaming bowls of Vietnamese pho into the mix.

To understand how important this incentive is, it may be best to look at how medicine works when it isn’t there. Many people have criticized pharmaceutical companies for turning a blind eye to the millions of patients in developing countries who can’t afford their life-saving products. Between 1975 and 1999, fewer than 1% of newly designed therapeutic drugs were intended to treat tropical diseases. (Interestingly enough, a number of new medications were created to treat canine arthritis during this same time.) Research is time-intensive and expensive, and eventually there needs to be a reward for that investment, whether it comes from the wallets of sick patients or pet-owners.

This is how the market will inevitably behave, unless we tweak the incentives. The simple truth is that the individuals capable of developing the cure for cancer could make loads of money as lawyers or investment bankers instead. But it isn’t easy curing cancer; research can take years to pay off, and there needs to be an immediate incentive to attract these individuals now.

So then back to Vietnam, where tropical disease is a bigger deal than canine arthritis and this disconnect between research and clinical practice becomes much more tragic. Are we justified in funding a research team of expat doctors while Vietnamese patients suffer next door? Is medicine a business or a basic human right? Is a bird in the hand worth two in the bush?

You could argue these questions all day and not come up with a clear answer. Whatever your view, few would contest that the attention being given to tropical diseases is a good thing in any form. Ultimately, the fruitfulness of Wellcome’s research will depend on whether or not it can continue to attract the brightest researchers, and for now, there’s only one way to do that.

London Calling

2011-08-10T11:40:00.000-07:00

The fatal shooting of Mark Duggan, a 29-year-old black resident of Tottenham in North London and father of four, ignited violence and riots which have persisted for the past week. However, reactionary riots over a shooting have spawned outbreaks of violence and disturbance across the entire country, mainly conducted by gangs of youth. While many wonder how the rioting has spun so far out of control, the correlation between these youths and teen unemployment might offer a possible explanation for the violence.

David Lammy, Tottenham Member of Parliament, explained on NPR's Morning Edition that Tottenham is a traditionally poor, inner city area, like Queens in New York, that makes up one of the most ethnically diverse districts in all of Europe. He explained that Duggan's death at the hands of the police sparked outrage and disturbance within the Tottenham community that has escalated into the widespread and senseless violence that the world has been witness to over the past several days. In the 1980s, profound racism within the police force directed towards black residents of Tottenham served as a catalyst for rioting and community violence, but, while acknowledging the parallel, Lammy explains that these riots aren't part of a greater war between a community and the police force, but instead senseless acts of violence between neighbors.

Since Saturday, mobs of young Londoners have carried the violence from Tottenham to Liverpool, Hackney, Manchester and Birmingham. Earlier on Morning Edition, Mike Hardy, director of the Institute of Community Cohesion at the University of Coventry, explained that a perception of growing disparities between those with and without wealth and opportunity has fueled the rioting throughout London. Jobless and alienated young people feel their communities are being targeted for cuts, and these youths on the margins of society feel like they're carrying the bulk of the burden imposed on society by the city's economic instability.

When I listened to this broadcast, another piece I'd recently heard on All Things Considered concerning high teen unemployment in the U.S. came to mind. Although the nation's unemployment rate declined to 9.1 percent in July, teen unemployment continues to rise, and currently we're in our third consecutive summer with teen unemployment rates above 20 percent - right now it's 25 percent. By allowing teen unemployment rates to soar, researchers worry that the country's creating a "lost generation"discouraged by bleak prospects and set back skill-wise in an already cutthroat job market.

Analysts have partially attributed the rioting to the government's austerity budget which will bring about billions in spending cuts. NPR reported that

the full impact of spending cuts has yet to be felt and the unemployment rate is stable although it highest among youth, especially in areas like Tottenham, Hackney and Croydon.

This last observation is reason for pause. Youths, the party most responsible for perpetuating the riots in London, are the ones hit the hardest by unemployment, especially in the areas that have been the hotspots of chaos over the past few weeks. Some argue that it's not that youths are unemployed, just unoccupied, and that we're just witnessing opportunistic criminality at the hands of young, unoccupied derelicts. Many believe that the creation of new jobs demands investment by the government, not the type of cutback in the budget we're seeing now. Former London mayor Ken Livingstone told the BBC that young Britons are facing "the bleakest future," and so we're seeing senselessness and violence permeating a climate of doubt and fear.

I fall into that lost generation of 16-19-year-old youths across the U.S. facing a future just as bleak as the one Livingstone depicted for young Britons. Before I came home for the summer after my first year of college, I had to make dozens of calls months in advance in order to eventually find just one restaurant in my local area in need of a server for the summer months. After several phone calls, one interview and several training periods where I raked in less than minimum wage, I finally got my summer job; however, it took a toll on my plucky, can-do attitude when I had originally set out with high hopes of joining the workforce, only to realize that virtually no one's hiring right now. I had to put in an inordinate amount of effort to pickup a part-time job in Bedford, a rural small town in southwest Virginia - I can only imagine how much more daunting my search would have been in a city like London, where you have a much more competitive labor market, or even in a city like Washington D.C. where the teen unemployment rate stood at 49 percent just this past June.

Before sociologists dismiss the London riots as a rampage of "opportunistic criminality," let's look at what the U.S. can take away from the turbulence across the pond: The unhappy, unemployed youths at the margins of society bearing the brunt of economic instability are the same youths rioting and pitching missiles at police officers.

It's not just about drawing parallels and connecting the dots, though. Here at home policy makers need to start taking precautions to remedy the sky-high teen unemployment rate, even if no one's anticipating outbreaks of violence or rioting on the scale we've seen in London. On a base level, NPR reported that

studies show the discouraged teenage job seeker can grow up to become a discouraged adult worker who is more likely to be underpaid and even unemployed.

That's not the type of future I want to see forecasted for my generation, especially when we've seen the worst-case scenario for that type of discouragement and hopelessness over the course of the past week in London.

Not In My Backyard, Nuclear Waste Crisis

2011-07-28T19:39:00.000-07:00

Riddle me this: Why is the U.S. importing 1,000 tons of German nuclear waste for processing, and yet Americans have thousands of tons of our own nuclear waste piling up in the backyards of our 103 nuclear reactor plants?

President Obama established the White House Blue Ribbon Commission to come up with a permanent geological disposal method, but today California's Sen. Dianne Feinstein explained that

"It is clear that we lack a comprehensive national policy to address the nuclear fuel cycle, including management of nuclear waste."

What happens is that fuel rods power nuclear reactors to generate steam which in turn powers millions of households across the country, but once the fuel rods are spent there's nowhere to put them, except temporary underwater storage pools - not a sustainable or desirable solution (see, Fukushima disaster).

Now granted we're importing "low-level" nuclear waste from Germany, so we're not exactly disposing of their spent fuel rods; however, it's troubling that U.S. companies have incentives to process waste for foreign countries, yet lack incentives to develop solutions for handling our high-level waste here at home. The reason folks in Oak Ridge, Tennessee don't mind importing and processing waste is because the plant supplies jobs and generates revenue for the local population, and has for sixty-some years.

I question opening up the floodgates for foreign waste, let alone nuclear waste, when the powers that be should be focusing on devising a solution for domestic permanent disposal. Currently utility companies are sitting on tons of our nuclear waste, but why isn't the White House Blue Ribbon Commission creating incentives for those companies to come up with permanent solutions for our waste, instead of just sitting on it. In addition to all this, we're throwing caution to the wind and opening doors for potential nuclear disasters by importing nuclear waste.

Cost-Effectiveness and Bioethics

2011-07-21T10:23:00.000-07:00

I just finished reading Mountains Beyond Mountains, a story of one man's – Paul Farmer – indefatigable fight against the injustice of inequality, specifically in regards to spreading modern medicine in an effort to curb infectious disease in countries such as Haiti, Peru, Cuba and Russia in the 1990s and early 2000s. Farmer’s brain-baby, Partners In Health (PIH), continuously ran up against astronomical drug prices and cynicism from their peers directed towards the substantial costs of their public health projects aiming to provide the right treatments for their patients. Over my bowl of cereal today, I heard a story on NPR’s All Things Considered about the rising prices for meningococcal vaccines in America, a story with themes that harkened back to Farmer’s own struggle with drug prices and ethical treatments.

In the mid 1990s, the drugs to treat just one patient with multiple-drug resistant tuberculosis (MDR-TB) at Farmer’s PIH branch in Peru cost between fifteen and twenty thousand dollars. However MDR-TB patients might have only represented something like ten percent of TB patients within one Peruvian slum. In April of 1998, Farmer and his colleagues attended a special meeting of TB experts at the American Academy of Arts and Sciences in Boston, and at this meeting Alex Goldfarb, a renowned microbiologist played devil’s advocate to the PIH's exorbitant spending on only a handful of MDR-TB patients. He began,

I want to share with you a simple reality. I have six million dollars. With three million dollars I can implement DOTS (directly observed therapy for five thousand Russian inmates. And assuming that ten percent have MDR-TB, forty-five hundred will be cured and five hundred will go down with MDR-TB and die. And there’s nothing much you can do. So. I have a choice. And my choice is to use another three million dollars to treat the five hundred with MDR-TB, or go to another region and treat another five thousand. I’m working with limited resources. So my choice is not involved in the human rights of five hundred people, but five hundred people versus five thousand people. And this is a very practical question for me, because I have six million dollars. And the second question is that if I disclose to the Russian people that I spent six thousand dollars per case in MDR-TB in the prisons with tens of thousands of people dying all around, they will tell me that I am building a golden palace for a selected few. So for those of us who have to make those decisions with limited resources, it’s a very serious question. – 162

This morning I thought back to this passage from Mountains Beyond Mountains as I read about the ongoing debate within the Advisory Committee on Immunization Practices (ACIP) concerning the cost-effectiveness of distributing meningitis vaccines among infants and toddlers in the U.S. For the record, ACIP recommendations are used by both the government and private insurers to decide which vaccines they'll pay for,

and back in 2005 the ACIP recommended that every adolescent in the U.S. get the vaccine. It costs nearly $100 a dose, which means hundreds of millions of dollars a year paid by the government and private insurers. But the bacteria cause illness in only a couple of thousand people in the U.S. each year, and that number was going down even before the vaccine arrived.

Furthermore, last year researchers determined that adolescents would need a booster just five years after the vaccination, now a $189 vaccination. With the additional booster the cost of the vaccination practice rose up to about $387 million for the federal government annually to implement – a measure that would prevent just 23 deaths, according to ACIP committee members.

On All Things Considered, the piece transitioned from a debate on cost-analysis towards a debate about whether you can put a price on a human life. How much is too much to spend on measures that save the lives of children? Who can really make that call?

William Schaffner, chair of preventive medicine at Vanderbilt University and an ACIP liaison representative from the National Foundation for Infectious Disease, told NPR, "We are drifting slowly to a conservative position which is, maybe it doesn't have to be recommended universally," which is the committee's current recommendation.

As I had read Goldfarb's appeal to see the necessity for cost-effective strategies in countries with "limited resources," I knew in the back of my mind that many countries lacked the infrastructure, resources and capabilities to create sustainable public health projects without primarily leaning on cost-effectiveness. However, I had never figured the U.S. would ever be lumped into that particular crab cake, like Schaffner and other ACIP members seem to be predicting as prices continue to rise.

In Farmer’s case back in 1998, PIH worked with the World Health Organization (WHO) to create the Green Light Committee to accelerate universal access to prevention, early diagnosis and effective patient-centered treatment for MDR-TB to poor countries which demonstrated the capability to use the drugs correctly. The idea behind the original committee was to create a body in charge of distributing second-line drugs at reduced prices, with reductions coming in stages. By 2000, projects buying second-line TB drugs through the GLC paid about 95 percent less for four of the second-line drugs than they would have in 1996, and 84 percent less for two others.

My point: This type of streamlined access has been made possible for the poorest of the poor, and yet the U.S. finds itself dangling from a precarious ledge at the mercy of drug companies. We're talking about going against a universal recommendation for lack of a creative solution to rising prices, which seems unacceptable when faced with the very real possibility of risking the lives of infants and small children. Why is a Green Light initiative possible in the bleakest corners of the world - Peruvian slums or Siberian prisons – but public health administrators, legislators, and researchers don’t have a similar way to streamline access to the most basic vaccines, such as meningitis vaccines, in the U.S?

Making A's Obsolete

2011-07-16T08:00:00.000-07:00

In a college level course, it should be difficult to earn an A. Period.

However, data collected throughout a study performed by the Teachers College Record indicated that, on average across a wide range of schools, A’s represent 43% of all letter grades, an increase of 28 percentage points since 1960 and 12 percentage points since 1988.

The researchers collected their data from over 200 four-year colleges and universities. However, the New York Times pointed out that private colleges and universities are more culpable than their public counterparts in driving this trend of grade inflation. The study published this week by TCRecord were consistent with this assertion: Private colleges and universities give, on average, significantly more A’s and B’s combined than public institutions with equal student selectivity.(If you really want to see how rampant grade inflation has become in American colleges and universities, this link provides actual graphical data and evidence collected between 1991 and 2007, along with comparisons of public and private schools.)

It begs to question why parents would spend the big bucks to send your kids to private institutions when all evidence points to private institutions setting the lowest standards? Let's play devil's advocate: What's wrong with grade inflation? So what if professors make an A very achievable? After all, my kid deserves it.

Here's what's wrong with it:

These prestigious schools have, in turn, continued to ramp up their grades. It is likely that at many selective and highly selective schools, undergraduate GPAs are now so saturated at the high end that they have little use as a motivator of students and as an evaluation tool for graduate and professional schools and employers.

As a result of instructors gradually lowering their standards, A has become the most common grade on American college campuses. Without regulation, or at least strong grading guidelines, grades at American institutions of higher learning likely will continue to have less and less meaning.

However, these studies have placed a Tonka truck-sized load of blame onto instructors for permitting inflation, but many this research fails to consider another factor - student pressure. How many grade grubbers do you think professors receive at office hours weekly begging for a couple extra points on their last lab grade? How many students do you think show up week after week after class to heckle at least half a letter grade on their last test? Professors aren't throwing extra slack without a little bit of arm pulling from students, students who feel entitled to nothing shy of an A or A-.

It's a sad day for American education when excellence becomes obsolete.

Charlie Tyson's "How to Write Simply: Why Pretentious Writing Should be Illegal"

2011-07-15T18:35:00.000-07:00

Let me tell you about my first college paper.

I remember the panic. Staring hollow-eyed at a blank Word document, I felt the hours melt into each other and I tipped into despair. I may have been able to trick my high school teachers into thinking I had a modicum of intelligence, but could I convince a professor? He has a PhD, I reminded myself. He was reading “Finnegan’s Wake” when I was laboring through the Hardy Boys.

In a flash of inspiration—or desperation—I turned to my texts for the class. These texts, by the way, were thrillingly raunchy. Like many of today’s higher-ed humanities offerings, my course was equal parts academia and soft-core porn. Presumably the graphic musings on human sexuality make the book-learning go down easier (or maybe they just make going down easier, am I right?). Blowing through three chapters on the politics of oral sex, I waded through the filth for ideas I could seize. I found nothing. My mind, I knew, was ruined by trash TV and trashier Google searches.

All I saw on the pages were words (well, duh, they’re books. But bear with me). Big, smart-sounding words. I still didn’t understand the underlying ideas, but the words I could use.

So I made word salad. Paradigm prolixity therefore repudiation utilization modality homogeneity prevarication…

And my professor loved it.

Flick through the nearest academic journal and you’ll see why. For years, passive voice, jargon, and needless complexity have sucked clarity and relevance from scholarly writing. Many publications are now more or less impenetrable.

Take, say, this infamous jawbreaker by Judith Butler:

“The move from a structuralist account in which capital is understood to structure social relations in relatively homologous ways to a view of hegemony in which power relations are subject to repetition, convergence, and rearticulation brought the question of temporality into the thinking of structure, and marked a shift from a form of Althusserian theory that takes structural totalities as theoretical objects to one in which the insights into the contingent possibility of structure inaugurate a renewed conception of hegemony as bound up with the contingent sites and strategies of the rearticulation of power.”

(From “Further Reflections on the Conversations of Our Time,” a 1997 article in the scholarly journal Diacritics).

Wait. In a structuralist model, something—here, capital—structures something else? And we reinforce power relations by repetition? Time has something to do with all of this? Keep talking, Butler. I’ll be reading my X-rated history books. (But those are pretentiously written, too—so really, I’ll be on Facebook.)

It’s unclear, by the way, whether Butler sees any irony in criticizing rearticulation when she’s committing that very fault in her prose. She repeats (in various forms) the words: structure, contingent, relations, and theory. Even the word “rearticulation” is rearticulated. All in the same 94-word sentence. While some repetition is tolerable, toss in the phrase “Althusserian theory” and you’ve lost even the most dogged reader.

Friends, this kind of writing is a crime. Somewhere in the history of letters, we moved from “brevity is the soul of wit” to a misguided belief that for a text to be important or intelligent, it must be hard to read.

Consequently, everyday writing has split into two poles. On one side academics, legislators, and bureaucrats spew turgid unreadable prose. On the other, people like you and me write Tweets that l00k lik3 dis. The problem is, the former group is supposed to be writing for the latter group. And the things they write can greatly impact our lives. But have you ever tried to read a bill? Or a tax form? Or a scientific study?

Being able to write things no one understands does not mean you’re smart. If you’re an academic, it could mean you care more about sounding intelligent than getting your ideas across. Never mind that scholarly work should enable progress and help us better understand the world we live in.

If you’re in politics, it could mean you’re full of noncommittal BS, or maybe you have something to hide. Never mind that our political process should be open, transparent, and subject to public oversight.

If you’re a scientist or engineer, it could mean you’re a scientist or engineer. You’re trying your best.

To write clearly is to think clearly. That’s why it’s hard. The ability to write plainly and well should be a quality we demand in those who draft our laws and design our curricula. But incentives push writers in the opposite direction—because writing clearly is scary. If your ideas are clear, it’s easier to find fault with your work. You don’t have a shield of jargon to hide behind. On the other hand, if no one knows what you’re talking about, you’re harder to criticize. People look at your big words and assume you’re right; or, if you’re not, it’s not worth the trouble of slogging through your paper to correct you.

Now, I’m not saying dumb everything down. Flashy words exist for a reason, and using them well can lend power and control to your writing. I’m saying needless verbiage must go.

Even so, sometimes it’s okay to be jargon-y. Write for your audience. If you’re a specialist writing in a scientific journal on, say, the effects of some obscure treatment on some obscure cancer, you’re probably writing for fellow scientists and specialists. If your science is good, your prose need not be crystal-clear. What a lay reader may find perplexing a scientist may find plain. But if there’s a breakthrough, the guy whose father has that type of rare cancer deserves to understand what’s going on, and he’s not going to want to read your article.

Nor should he have to. Information must not be confined to an elite thesaurus-wielding group. Thank god for the journalists who explain bloated pieces of legislation or academic studies to the public. Still, they shouldn’t have to do that legwork. In legal documents especially, bad prose is a public hazard. Those long-winded sentences are the thugs of writing, standing arms-crossed at the doorway of a document, intimidating those who seek to enter. While academia does not have the same obligation to the public as, well, our government, learning should be more accessible. Overly difficult scholarly writing restricts ideas to an erudite circle, which means those ideas have little impact and limited reach. Sure, not all work needs to be for a general audience. But if intellectuals wish to bring about change on a scale broader than the conference room of their college’s Philosophy department, they need to write in a style more people can understand and appreciate. That way, those educators will be doing their jobs—educating!

So, back to that paper. I got an A-minus. I probably deserved a C. But under puffed-up prose I was able to disguise my lack of original thought—sort of like how numerous academics and bureaucrats get by. But what did my paper accomplish in the long run? Nothing. But imagine if I had stumbled on a revolutionary idea in the course of writing my essay. And if I had communicated that idea loudly and lucidly? Great ideas can change the world.

So, friends, I challenge you to do the hard thing. Write with meaning. Write with vigor. Write with force. But above all—write simply.

Charlie Tyson is a second year at the University of Virginia and a regular TableTalk contributor.

Protecting the First Amendment, Without Remedies for Social Diseases

2011-06-28T09:39:00.000-07:00

"No doubt a state possesses legitimate power to protect children from harm," said Justice Antonin Scalia, who wrote the majority opinion. "But that does not include a free-floating power to restrict the ideas to which children may be exposed."

The Supreme Court overruled California's ban on the sale gratuitously violent video games to minors, so now teens will continue to be able to buy video games, regardless of parental approval. The 7-2 ruling in favor of free-speech protections comes under fire because many fear the decision enables to spread of aggressive and violent behaviors in minors.

Although most minors play video games without reproducing similar acts of violence, evidence suggests the possibility and risk for both the desensitization to and reproduction of extreme violence. Consider cases such as Eric Harris and Dylan Klebold, the Columbine shooters. According to CNN

Jerald Block, a researcher and psychiatrist in Portland, has concluded that Eric Harris and Dylan Klebold went on their shooting rampage at Columbine High School after their parents took away their video game privileges.

As members of the Trenchcoat Mafia, a gang of misfit gamers, Harris and Klebold had significant exposure to violent video games, such as Doom, a shooter video game developed by id Software. With cases such as Columbine in mind, Justice Alito wrote

"We should not jump to the conclusion that new technology is fundamentally the same as some older [form of speech] with which we are familiar."

The court ultimately sent a loud and clear message that protection of the First Amendment takes priority over protecting against social diseases, such as violence. By striking down the 2005 California law, the high court upheld the constitutional values and rights the justices have sworn to protect. They did right by their professional oaths. However, the decision calls into question whether or not the government should regulate against forces that spread social diseases, whether they be violence, sexism, or racism, and what stipulations will make regulation constitutional.