Thursday, June 30, 2005

Doctors Complicit in Torture

No military can torture without doctors. JAMA published an editorial to this effect last year. Dr Lifton writes:


To be a military physician is to be subject to potential moral conflict between commitment to the healing of individual people, on the one hand, and responsibility to the military hierarchy and the command structure, on the other. I experienced that conflict myself as an Air Force psychiatrist assigned to Japan and Korea some decades ago: I was required to decide whether to send psychologically disturbed men back to the United States, where they could best receive treatment, or to return them to their units, where they could best serve combat needs. There were, of course, other factors, such as a soldier's pride in not letting his buddies down, but for physicians this basic conflict remained.

American doctors at Abu Ghraib and elsewhere have undoubtedly been aware of their medical responsibility to document injuries and raise questions about their possible source in abuse. But those doctors and other medical personnel were part of a command structure that permitted, encouraged, and sometimes orchestrated torture to a degree that it became the norm — with which they were expected to comply — in the immediate prison environment.

The doctors thus brought a medical component to what I call an "atrocity-producing situation" — one so structured, psychologically and militarily, that ordinary people can readily engage in atrocities. Even without directly participating in the abuse, doctors may have become socialized to an environment of torture and by virtue of their medical authority helped sustain it. In studying various forms of medical abuse, I have found that the participation of doctors can confer an aura of legitimacy and can even create an illusion of therapy and healing.


It has been reported that the New England Journal will release a report this month that the US military physicians in Guantanamo Bay and Iraqi detention facilities have been breaking confidentiality to aid interrogators.

Physicians have sworn that "even under threat, I will not use my medical knowledge contrary to the laws of humanity" [Hippocratic oath formulated at Geneva]. The skills physicians learn and the trust they are given are easily perverted to the service of the state. I hope that the lessons of the past weigh on the consciences of any doctors involved in unsavory treatment of foreign combatants in US custody, and that they eventually come forward with what they know.

Wednesday, June 29, 2005

New Interns and Residents!

This is the season when new medical students, interns, and residents are starting in hospitals across the country. As the saying goes, it's the week "when those who know are replaced by those who care." I've had the pleasure of helping several of them adjust to life in medicine over the past week, and wanted to spread good vibes to any and all fresh faces in brand new white coats.

On my very first day working as a doctor, I was the psychiatry intern in a Veterans' Hospital unit. Most of the day was spent learning the computer systems, meeting new patients and nurses, and familiarizing myself with the types of computerized 'paperwork' I would have to do. At the end of the day, I thought I had been doing pretty well when the chief resident called me out of the workroom. Somberly, he walked me down to the exam room where nobody else could hear, and gave me a frank assessment of my first day on the job: "Fetter, we need to talk about how you spell 'schizophrenia'."

The classic book about the nuttiness of residency is House of God, but any doctor has stories about the ludicrous and tragic sides of medicine. Today though, before the fatigue and cynicism sink in, the hospital is full of well-rested, eager, scared-as-hell doctors-in-training, who can use all the good vibes they can get.

(And don't worry, their supervisors are eagle-eyed this time of year for beginners' mistakes, but I wouldn't schedule an elective surgery if I could help it).

Saturday, June 25, 2005

Greater New England Needs an Ally: Folkways Part 4

In this final post on the Four Folkways, we'll look at the implications of Fischer's work on the political history of the US. I'll rely as well on Michael Lind's article in the American Prospect. He notes that Greater New England, that swath of the US roughly equivalent to today's Blue States (excluding the 'battleground states') has always been associated with a particular political party (varying over time), and has a distinctive political culture with three main facets:

1. Reformism. From Puritan post-millenialism, to Prohibition, to today's anti-tobacco and fast food campaigns, New Englanders have been the standard bearers of most of America's reform movements.

2. Intellectual elitism. Stemming from the Puritan concept of ordered freedom, Lind describes a "preference for meritocratic elitism over the messiness of democracy."

3. Anti-militarism. From the war of 1812, to the Mexican War, to Vietnam and Iraq, none of these wars were popular among New Englanders.

In order to win the presidency however, Greater New England has always required an alliance with at least one other folkway group. The historical moments when it stood alone spelled success for the political party representing the rest of the country, and brought us the presidencies of Andrew Jackson and Richard Nixon. But when Greater New England allied with the southern Tidewater Democrats we saw FDR's coalition, and when it allied with mid-Atlantic and midwestern Quaker descendents we saw the original Lincolnian Republican coalition which lasted until the Depression.

Today the Democrats are the New England Party, and as long as they remain so they will lose. Lind suggests the Democrats need to broaden their appeal to midwesterners through economic policies, in order to recreate a Quaker-Yankee coalition. That's certainly an option, but the other way to look at how marginalized folkgroups have reentered the fray, as Fischer himself points out, is by advancing an 'omnibus' candidate, like Eisenhower, who can talk the language of many folkways. Often military heroes, such candidates consciously draw imagery from two or more folkways ("log cabin and hard cider" evoked both the backcountry and the NE temperance movement). In contrast, the Dems have been looking for another JFK since the 60s, charismatic but deeply rooted in the Yankee folkway. In the search of that perfect leader they have neglected many party-building activities that the Right has attended to fastidiously.

If you look at the elected members of the moderate Republican Mainstreet Partnership, you see a few New Englanders, but many more folks in the Quaker settlement belt. Also of note, most of the 'battleground states' fall in this region. With its emphasis on responsible pro-capitalist economic development, environmental stewardship, egalitarian approach to civil rights and progressive nationalism, I would argue that what many refer to as the Moderate Republican philosophy is associated with the Quaker regional folkway. The lesson here is that identifying centrists as 'moderates' along the national political spectrum is not enough; to win their votes, a candidate has to be able to speak directly to the particular target voters' freedom ways.

Hence the dilemma for all centrists: to join the majority party and moderate its voice, or to join the minority party and strengthen its voice. Each of us must make the choice that seems right, but nobody should be surprised when that choice, for most people, seems less about comfort with a party's policies and platforms than its language of liberty.

Thursday, June 23, 2005

Was the Iraq War worth it?

Before the final installment of the Folkways series, here's a take on the Iraq war from the standpoint of US global strategy.

The argument was made before the war that the critical difference between Iraq and al Qaeda is that since Iraq has material assets, it is deterrable while al Qaeda is not. Thus, the argument goes, we ought to focus on destroying al Qaeda and containing Iraq.

Robert Kagan, author of Of Paradise and Power recently wrote in the Washington Post that judging if the war was worth it requires seeing through the PR for and against it leading up to the invasion:


The most sensible argument for the invasion was not that Hussein was about to strike the United States or anyone else with a nuclear bomb. It was that containment could not be preserved indefinitely, that Hussein was repeatedly defying the international community and that his defiance appeared to both the Clinton and Bush administrations to be gradually succeeding. He was driving a wedge between the United States and Britain, on one side, which wanted to maintain sanctions and containment, and France, Russia, and China, on the other, which wanted to drop sanctions and normalize relations with him.


If it's true that containment was untenable because of the inevitable breakdown of the coalition against Iraq, then there's essentially a choice between invading now or later, since there was no question Hussein was a threat to regional stability if left unchecked. What's more, it could be argued that invading Iraq makes the debate between the US/UK and France/Russia/China blocks moot, allowing them to eventually smooth over relations to work in other issues. Yet that certainly was not the explicit strategy.

But what was needed was not indefinite containment, but simply adequate containment. Could Iraq have been deterred long enough for either Hussein to die (or, less likely, be overthrown) or to be defanged by a method other than invasion? One's judgment of the effectiveness of the UN and the resolve of the US over time probably drives one's views on this. But it's clear that the US underestimated the cost of the war in blood and treasure, and may well have overestimated the cost of peace.

Hat tip to Centerfield/Centrist Coalition.

Monday, June 20, 2005

Gay Marriage: Folkways Part 3

Now we'll branch out from Fischer's own work, to examine how understanding the four folkways explains the country's different perspectives on gay marriage.

Yankee Contracts
The East Anglians who settled New England had close contact with the Netherlands, and much of their cultural emphasis on contracts and covenants stemed from this influence. In religion, one of their main considerations was the Covenant between God and his People. In government, much of their political discourse was framed in terms of contracts (as opposed to the Scots-Irish emphasis on rights for example). So it's not surprising that they conceived of marriage primarily as a contract between two people, for the purpose of establishing a family.
Therefore from this perspective, any two people can enter into a contract as they see fit. If they choose to structure it like a marriage and call it a marriage, it cannot affect other peoples' marriages. This view is atomistic, as it does not recognize marriage as an institution, but as a type of contract.

Tidewater Formality
The younger sons of Royalist Wessex nobility who peopled the Chesapeake Tidewater were committed to preserving the hierarchical order that maintained their social position. As such, marriage was an institution that allowed families to survive over generations, using the authority and tradition vested in the Anglican Church.
When marriage is seen as a means to the end of family survival, gay marriage is absurd as it does not advance that goal. Marriage has a very specific meaning, and interpreting it differently, from this viewpoint, is to interpret it out of existence. Given this folkway's value of family heritage, any threat to the institution of marriage can evoke a strong reaction borne of the drive to protect what's dear.

Quaker Reciprocalism
We've discussed how Quakers systematically structured their polity to protect the rights of minority groups. This folkway is likely to see gays as a minority, and thus interpret gay marriage as a part of the gay minority's conscience freedom which ought to be protected under law.

Backcountry Self-Determination
There's little I can detect in the British borderlands or early American backcountry folkway that bears directly on gay marriage. But since there is little impetus for establishing gay marriage as a right or a tradition arising from the backcountry folkway itself, those raised and living in it would be more likely than others to perceive legal or legislative action establishing gay marriage as an imposition of foreign values from the outside.
Thus, even though from a libertarian viewpoint one might not strongly object, if the source of the gay marriage movement is not perceived as legitimate--eg. unelected judges or activists from other folkways--it will accrue substantial resistance. The gay marriage movement may be seen as just one part of an attempt to make inroads against a way of life.

The Debates
This analysis shows how people from each tradition can talk past each other. How often have you seen this type of dynamic: a New Englander asks how gay marriage harms anyone else's marriage, while a Southerner counters that gay marriage simply is not marriage, and the conversation devolves to gibberish. Or someone raised in the Backcountry folkway fights gay marriage politically in order to 'take back' his state while a baffled listener from the Yankee or Quaker folkway never felt the state was taken away.

Finally, I'd point out that this type of analysis is deeply conservative, in the Burkean sense. That is, without totally ignoring materialist explanations of social processes, it is more interested in understanding Americans as Americans: what our unique culture means about who we are and what we stand for.

Friday, June 17, 2005

American Politics and Regional Folkways Part 2: The Freedom Ways

There was a discussion at Red State a few months ago, where a Southern Republican woman and a Massachusetts Democrat man were discussing whether GW Bush's 'Mission Accomplished' photo-op was rightly seen as an appropriate gesture for a President. How can it be that two intelligent, articulate people, given the same information and images, can disagree so profoundly as to whether the President is a strong leader supporting the troops or a puerile buffoon?

The heritage of the four Migrations brings different options for the language and symbolism of freedom, order, and government. The dialogue amongst these traditions has enriched our national political life. Let's look at each tradition, realizing that at this point in history many people lay claim to more than just one--either through diverse geneology (most Americans have a majority non-British heritage), having lived in multiple regions, or by exposure to concepts outside one's original folkways. Again I rely on Fischer's work, both Albion's Seed and Liberty and Freedom.

Yankee Ordered Freedom
Early New Englanders had a concept of 'ordered liberty' which had a few different facets. In general, liberty referred to the community's right to act, not an individual's. When referring to an individual though, they maintained the medieval English idea that a liberty is a relief from a prior condition of restraint (in contrast to the modern idea of restraint as something imposed on a natural condition of liberty). Similarly, they felt people ought to be free to act in a Godly fashion, but there is no right to err; this view justified their persecution of other faiths. Finally, New Englanders believed in a liberty from becoming a victim of circumstance; that the community ought to help the unlucky--when FDR, a Puritan descendant, spoke of 'freedom from fear' he was echoing a phrase used by 1st generation Massachusetts settlers.
The symbol of freedom New Englanders used was a 'freedom tree,' usually an old growth elm or oak in a town center. The symbol alluded to the ancient use of green and leaves as symbols of rebellion in East Anglia (eg Robin Hood wearing green in the forest), and by placing it in town commons they emphasized the idea of freedom as a condition of the community, rather than that of individuals.

Tidewater Hegemonic Liberty
The cavalliers of the Chesapeake Tidewater had a very different idea of liberty. As nobles, they thought of liberty as the right to rule over others, but especially the responsibility to rule over oneself. Their rhetoric often contrasted liberty with its opposite, slavery, a condition which an Englishman could acquire by ceasing to rule. Freedom was not simply a condition, but a rank. By this view, the state should be kept to the minimum power and influence necessary to preserve the hierarchy. An important symbol for the Tidewater folkway is found in first flag of South Carolina: a right crescent, which in English heraldry was incorporated into the coat of arms of a younger son, a common founder of Tidewater families in America. This symbol tied together many of the Tidewater elite families both under a banner they shared, and the crescent's allusion to ancient martial valor was appealing.
This initial form of hegemonic liberty seems quite contradictory to modern ears, and it went through many transformations over time. In the 19th and 20th centuries, this tradition became more egalitarian, admitting all persons potentially to the 'ruling class' without a requirement of controlling others, befitting a democracy. However, it also expected the responsibilities that came with the rank of free persons, retaining a premium on loyalty, and on having command of oneself. The Tidewater folkway is a source of the strong individualism of American culture.

Quaker Reciprocal Liberty
William Penn wrote over 60 books on the topic of soul freedom. Quakers went beyond the traditional Protestant idea of liberty as the freedom to do what's right, and quite explicitly took the Golden Rule to apply to those they disagreed with, to give them the right to practice religion according to their consciences. Quakers were optimistic, and believed that the truth would come to light if left free to overcome error. Penn's own life taught him the lesson that coersion of conscience was not just wrong, but never really worked. His colony didn't just restrain itself from persecuting other religions, but systematically enacted provisions to protect them, including then-radical ideas of trial by a jury of peers and protection for the jury from punishment for its verdict. Penn felt property rights were an important facet of individual civil rights, and wrote in Pennsylvania's charter a protection against arbitrary seizure of property. He also required that any taxes being imposed have the consent of the governed, by establishing a legislature with the power structure taxes. But Quakers were pragmatic; Penn wrote "liberty without obedience is confusion, and obedience without liberty is slavery."
Quakers comprised the main body of the antislavery movement in the 18th century. One of the first acts of the newly independent Pennsylvania was to ban slave importation. The primary symbol of liberty in the Quaker tradition was the Liberty Bell. Initially bought to commemorate the 50th anniversary of the colony, it became a cherished symbol as a signal for freedom that all can hear equally. It was taken up as the abolitionists' symbol in the mid 19th century, and continues to be rung on great occasions in the life of the country, including the deaths of Lafayette and Washington, and D-Day.

Backcountry Natural Liberty
In the war-torn British bordercountry, there was every reason to be hostile to the ordering institutions of nascent nation-states. After centuries of political and economic oppression, English, Scottish, and Irish peasants believed that the natural state of man was to seek escape from control. Their concept of order was the right to retaliate--their descendents in America continue to own guns at a higher rate than any other major folk group. But at the moment in history when the conditions that bore the borderland freedom way were changing forever, it was brought by immigrants to the American backcountry. Perhaps the most famous revolutionary war era backcountryman was Patrick Henry, who strenuously advanced the ideals of minimal government, light taxes, and the right of armed resistance to authority. Tellingly, when Parliament passed the Intolerable Acts, as a member of the Continental Congress he stated that "government is dissolved... we are in a state of nature." This type of rhetoric was deeply disturbing to the children of other waves of migration, but to the sons of the borderlands it made perfect sense to argue that when the support of the people is lost, the government ceases to be. Border dwellers had never recognized rule by birth in local government, and resented rule by 'divine right' from afar. Indeed, Patrick Henry's mother described the American Revolution as merely another set of 'lowland troubles'.
Natural Liberty was an absolute, and so did not require reciprocity; deviation from the norm could be violently suppressed. But it did require 'elbow room,' literally space to distance oneself from infringing on others' rights and having the government infringe on one's own rights. The favored backcountry symbol of freedom was the American rattlesnake, saying 'don't tread on me'--it was said that the snake is solitary, but rallies together for defense; it never strikes first but is an implacable opponent once aroused. 'Don't tread on me' was flown from privateers during Revolution itself, and after 9/11 it now again flies on US Navy ships.


Fischer concludes that each of these freedom ways has enriched the political debate of the country through its history, producing a more complete freedom than any one folkway could have engendered alone. I would add that every American has access to parts of each folkway's freedom way because the Constitution was able to hold them together and force them to talk. Joseph Ellis points out that the Constitution provided a mechanism to space out important debates such as that of slavery. It is in this sense that I say that America is great because Americans just don't get along.

Returning to our original question, whether Bush is a strong leader or a buffoon is still beyond the scope of this article. But the type of liberty one wants the government to protect will define the type of leader best suited to defend it.

Wednesday, June 15, 2005

American Politics and Regional Folkways Part 1: The Great Migrations

There were Red and Blue States in the Rennaisance.

We were taught in grade school that factions and regional interests have shaped our national politics since the Revolution. But the work of David Hackett Fischer traces the roots of cultural differences in American regions all the way back to England. Albion's Seed is an exhaustive study of four Great Migrations from England and how each created a distinct regional folkway in America--I will rely heavily on it. This will be the first in a four-part series of posts summarizing this fascinating work, and interpreting how it illuminates modern American politics.

While much 20th century American history focused on subsequent immigrant groups, Fischer notes that these groups tended to assimilate much of the culture, especially political ideas and definitions of American values of the Anglo-Saxon inhabitants of the regions they move to. Studying the four great English migrations is a high-yield enterprise.

The Yankee Migration
English people had made several early settlements in the New World, but the first massive influx occurred 1630-1641 with over 200 ships bringing 21,000 individuals to New England. They were motivated by their Calvinist religion, mostly concerned with the spiritual upbringing of their own children, not conversion, though that was a secondary task. Accordingly they came as nuclear family units. They very rich and very poor were systematically excluded, providing an artificial economic class equality. The place names of New England reflect their origins in East Anglia in the Southeast. The people of East Anglia had played host to many rebellions to arbitrary power, and they traditionally had been more Protestant than most other areas. Sea travel was easier than overland travel in much of this region, and so they developed close ties to the Netherlands in terms of trade, legal traditions, and political ideas. The same sea access made them vulnerable to Norse depredations, which also left their cultural mark. This region also had many more freemen than other regions of England during the Middle Ages. Their churches were Congregational--a weak confederacy of independent congregations and a weak synod. Finally, the generation of East Anglians who came to America is important. They departed during the "eleven years' tyranny," a time when the king abolished Parliament and persecuted Calvinists. New Englanders continued to ruminate about constitutional issues like the separation of church and state in a way defined by this moment in history, even after the Mother Country had resolved the debate in its own way. The descendents of these East Anglians became Yankees, and they spread to the West in a pattern roughly approximating the Blue States.

The Chesapeake Tidewater
In 1641 Sir William Berkley became the Royal Governor of Virginia and spent the ensuing 40 years molding a society which fit the cultural values of southwest England. He actively recruited Royalist nobility, mostly landless younger sons. The demand for American land from this group soared after the King was defeated at the Battle of Worcester in 1651. Most of Virginia's ruling families arrived within a decade of 1655. Their recent defeat gave them an obsession with honor and a constitutional concern for preserving hierarchical order in government which they carried on for years. However, more than 75% of the immigrants were indentured servants. Thus Virginia from its inception was home to the highest and the lowest of classes, with no real middle class. The place names betray their Royalist politics: Prince George, Princess Anne, King and Queen County. The vast majority of places named after English cities are named for spots in southeast England--in particular, Wessex. The language and laws of southeast England are Saxon, as are its units of land and weights. The countryside was divided into large manors, as opposed to East Anglia's farms. Slavery existed here during the early middle ages on a large scale, and lasted longer than in any other area of England. It had been long abolished by the migration to America, but other forms of social bondage were strong.
Though history Wessex had stood by the King and the Anglican Church traditionally; it supported the Western Rebellion against Prostestants in 1549. When they came to America, the Royalists found in the Chesapeake tidewater that the geography suited their purposes; complicated estuaries allowing sea-access to strips of arable land. They made a virtually town-less society of scattered manors. Living in nuclear family units, they had a stronger sense of extended family association than their New England counterparts. This was partly because of the high mortality rate from malaria, and partly a function of the family ways of Wessex. An important theme linking family, church and government in this regional folkway was the idea of deference to an the elder-patriarch, a leader of several households. This was distinctive from the New Englanders' concept of an elder-saint whose long life was seen as a sign of God's favor.

The Delaware Valley Migration
Over 23,000 English Quakers arrived in the Delaware valley between 1675-1715 to found the colonies of Pennsylvania and Delaware, and settle areas of Maryland and New Jersey. They were another religious group fleeing persecution, but that was not the main reason they came; they wanted to demonstrate Quakerism flourishing without outside interference. Quakers were a radically egalitarian sect, whose beliefs centered on the doctrine of the 'inner light,' that every person had a direct connection to Jesus' love and virtue. They lived in a very different spiritual world from the Calvinists, whose God ruled angrily and mysteriously, and from the Anglicans whose God comprised an Ultimate Patriarch.
English elites were not fond of Quakers, and wealthy Quakers often funded poorer ones' adventures to the New World, so Delaware settlers tended to be poorer than their neighbors to the North, but more middle-class than those in the Tidewater. They were primarily poor farmers or craftsmen from from the Northern Midlands of England (especially the Pennine Moors), or artisans from the vicinity of London. Place names in Pennsylvania reflected social ideals--eg Philadelphia--or northern English places like Chester, York and Lancaster. The North Midlands was historically an area of Norse settlement, sparsely populated and dangerous from bandits at the time of the migration. The inhabitants--Quaker or not--were known for egalitarianism; it was said that the farmhands had dinner with their landowners. The Norman nobility was never seen as fully legitimate by the people, and they felt alienated from the schools, churches, and political institutions controlled by London. This attitude was reflected in Quakers' affinity for basic learning, but disdain for higher learning--the first university in Pennsylvania was founded by Benjamin Franklin, a hundred years after the colony's founding. Quaker egalitarianism extended to disdain for an elite of money or birth (famously they refused to give 'hat honor', removing the hat, to their 'social betters', never used 'Mister' or 'My Lord' and used the informal 'thee' instead of the formal 'you' addressing them), but they strongly believed in leadership by an elite of virtue.
William Penn actively recruited German Pietists and other radical Protestant sects, the only of the four migrations' leaders to do so. The impetus for this recruiting can be found in the historical period that produced the migration itself--the Restoration was a period in which England was wrestling with the question of how people of different beliefs could all live together in peace, and the Quakers found an answer in radical pluralism, stemming directly from the doctrine of Inner Light. Making pluralism work was critical to demonstrating the success of Quakerism. Finally, Quakers had an original idea of order as peace, distinct from New England's concept of order as unity, or the Tidewater's ideal of order as hierarchy. While Quakerism as an organized sect declined over the ensuing years, a linguistic map of Northern Midlands dialect in the US shows their theme of egalitarianism was carried across the Appalachians to Ohio, most of the Midwest, and into the northern Mountain states.

The Backcountry Migration
The final Great Migration took place over a much longer period, from about 1717-1775, and as much of 1/3 of it may have occurred in the four years before Independence. They were called "Scots-Irish", a mix of English, Irish and Scottish borderland natives. This was a region rattled by war almost every year for seven centuries. This violence shaped the culture in many ways: clans formed as blood relations were the most stable relationship possible in turbulent times. Homes were typically temporary in nature since one never knew when one would be forced off the land--the characteristic hovel was adapted to the American envionment to become the log cabin (prior migrants built more permanent homes even early on) and this temporary home has carried to today in the form of the mobile home. In the period of the Migration, the area was being systematically 'pacified' as entire clans were outlawed and killed en masse. Hence the desperate search for space to live away from oppression, and a political concern in this generation with the question of whether the rights of English gentlemen also belonged to other people.
The Scots-Irish mostly arrived in Philadelphia, and moved into Western Pennsylvania when they found little in common with the Quakers. They belonged to many denominations, but worshipped in large groups with dramatic services led by charismatic leaders (a pattern predating Christianity in this region), instead of smaller, silent Quaker meetings. The men wore shirts with broad horizontal seams across the back to emphasize broad shoulders (which evolved into the typical country-western shirt), and the women wore more revealing clothes, than the simple modest Quaker garb. And the Scots-Irish came for political and economic reasons, to escape oppressive English landlords, not for a social experiment. They moved inland, north and south along the backcountry, and in the 19th century into the Southwest. Their decendents occupy the area roughly where country-western music is popular.

In coming posts, we'll examine how different ideas of liberty and cultural values in each of these regional folkways have driven much of the political history of the United States.

Monday, June 13, 2005

Aid to Africa: Payback time?

Tony Blair may be cashing in some political capital with President Bush soon. Blair plans to use upcoming presidency of the EU to drum up aid to Africa, and if he has to fight to get US participation, that can only help him overcome his image overseas as an American lackey. But it probably would be a good idea for the US to demonstrate that our loyal friends end up with some pull with our policy.

The debate is well known between those who feel that African countries have to be well governed enough to get aid to those who need it before developed countries offer it, and those who feel the need in Africa is urgent enough to warrant plunging right in with subsidies and loan forgiveness. There are some merits to either point of view. As the Economist rightly points out though, it's the government subsidies to developed nations' own agriculture industries--including small farmers--which really hurt Africa's opportunity for development the most, by eliminating its most promising markets. This underlying structural feature of the world economy is unlikely to be fixed any time soon; all politics is local. But if Bush and Blair really want to help Africa, cutting agricultural subsidies is where they should start.

Saturday, June 11, 2005

Vioxx: Betrayal of Trust

NPR recently broke the story that the vice president of Merck, makers of Vioxx, may have pressured the academic departments of physicians who were speaking out about the drug's potential (now known) cardiovascular side effects in 2000.

To fully understand the disappointing nature of this revelation, it helps to know the background that Merck is one of the oldest pharmaceutical firms, and perhaps the most respected among them, with a reputation for integrity. There is a sense of 'even Merck?' in the medical field. Without mentioning names, there are other companies this behavior would have been less surprising from.

So what exactly happened with Vioxx? Just to briefly review the history of this drug, in the early 90s a number of drug companies began a race for COX-2 inhibitors, a type of nonsteroidal pain medicine which, unlike the older generation (Motrin, Aleve) would not cause stomach upset and bleeding--a side effect which can be life threatening in patients taking large doses for long periods of time. When the COX-2 inhibitors Vioxx, Celebrex and Bextra were released, it was understood that they were designed as second-line drugs for those who needed nonsteroidal pain meds but had additional risk factors for gastrointestinal bleeding. Most people should be on Motrin or Aleve-like agents.

The first place the story gets fishy is when direct-to-consumer marketing campaigns (remember the Dorothy Hamill ads?) were released, implying that Vioxx was a first-line agent. The ensuing surge in requests to doctors, eager to make patients happy, resulted in Vioxx's launch as a 'blockbuster' drug with enormous sales. But remember, at this point thousands of people have been prescribed the drug off label, as first-line therapy.

In 1999, the VIGOR trial showed that patients on Vioxx had a statistically significant increase in heart attacks in comparison to naproxen (Aleve). For every 1000 patient-years, 8 stomach bleeds could be avoided, but 4 heart attacks were caused. The interesting thing here is that the investigators interpreted these results to mean that naproxen might be protective, not that Vioxx could be harmful. This is a dubious conclusion, since naproxen has been available for many years and there has never been any data supporting that conclusion.

Then, in 2004 the drug safety panel following the APPROVe study stopped the trial. This was an effort to show that Vioxx might protect against colon polyps. The panel had noted that the difference in cardiovascular events had just become statistically significant, and needed to unblind the groups to determine whether the drug was protective or harmful--and of course the rest is history. Merck volunarily decided to withdraw the drug from the market, but other COX 2 manufacturers continued to sell it.

A meta-analysis, or synthesis of multiple studies, recently found that significant information to withdraw the medication from the market in 2000 or 2001--check out the link, there's a telling graph.

What have we learned from this? Commentators have come up with many points, but here are a few I think are salient.

1. The FDA needs both teeth and eyes.
Currently, the FDA is not allowed to require additional safety studies once a medication has been approved, and it needs that authority. But what's less known is that they get much of their budget from drug companies--that's right, the companies they regulate--for the express purpose of expediting drug approvals. Their post-marketing monitoring budget is all from the Congress, and it's just not enough to keep track of all the drugs approved out there.

2. Drug marketing to consumers should be better regulated.
There's plenty of good reasons to use drugs off label, but patients shouldn't be basing that decision on an ad.

3. Doctors need an easy-to-use database of drug adverse effects.
Anyone who's looked at a Physicians' Desk Reference knows how difficult it is to know whether the side effects listed there are common, or spurious findings in one obscure study. The FDA's website just isn't as easy to use as, say, the CDC. A better FDA database online would be a big help.

4. When reading a medical study sponsored by a drug company, read the data, not the conclusions.

As this ongoing saga evolves, we will doubtless learn more about what really happened at the managerial level at Merck, and it's not going to be reassuring.

Thursday, June 02, 2005

Minimum Wage

The Republican leadership has lately been giving moderates a lot of reason to be disgruntled, but there are good reasons we're not Democrats, and the minimum wage is a good case in point. Unfortunately, as you can see by my sources, the research in the field is heavily politicized.

The Liberal argument asserts that corporations divert much of the fruits of workers' labor into CEO salaries and stock dividends, so government regulation to establish a minimum wage is a means to moderate incomes. An influential book published in the mid 90s Myth and Measurement often quoted on liberal blogs to this day purports to show empirical evidence that there was no economic downside to 4 specific minimum wage hikes.

However fiscal conservatives strenuously argue that increasing the minimum wage is a barrier to hiring low-wage workers. They further note that raising the wages of low-wage earners requires many employers to raise the wages of more skilled workers, further reducing their ability to hire (and train) more people. The Cato Institute specifically refutes the data in Myth and Measurement.

While it's tempting to segue with some platitude like 'the truth lies in the middle' I think the truth is actually askew both these arguments. If the government set no minimum wage, there would be a small number of people at the tail of the wage bell-curve who would be worse off, but it would be a small number and there would indeed be government programs to prevent utter destitution. If the minimum wage were suddenly exorbitantly high, say $20 per hour, one could imagine a period of high inflation and wage increases as the market adjusted, then there would still be a bell curve of wages with the minimum wage at about the same point on it once the market reached equilibrium. There is thus probably a certain range of minimum wages which do not significantly affect employment, while still benefiting low wage earners. (Mr Laffer is rolling over in his grave, assuming he's dead). However, there's no way to know if we're in that range, since we can only study the effect of changes in the minimum wage--we can't add the minimum wage to an economy that never had one and observe the effects. This uncertainty allows folks at either end of the political spectrum to make whatever unprovable yet indisputable claims they like.

Furthermore, there's not a single labor market, there are multiple markets--for doctors, engineers, salemen, designers, etc. who are not interchangable. Any minimum wage is really applied only to the unskilled labor market. Some evidence supports the notion that increasing the minimum wage will affect teens more than adults. Also, it's pretty clear that the effect the minimum wage rate has on a given worker's salary is determined by the worker's substitutability; the more easily substituted (usually this means the lower his skill level) the more his salary is affected by a minimum wage hike. As far as total employment, the effect of the minimum wage is to make those workers whose labor is valued below the minimum wage unemployable, while employers invest in some capital to make those whose labor is valued just above the minimum wage more efficient and hire more of them. The net effect cancels out: some loss of low skilled workers' job prospects, and increase in more skilled worker employment. If this provides a structural incentive for low-skilled workers to get an education, it may be a good arrangement. More detailed discussion along these lines can be found here.

The bottom line: a minimum wage is not a disaster, and is not a panacea. Its most effective use is as a policy to support for a politician to seem populist, without directly costing the government any money necessitating tax increases. Since a minimum wage may help a small minority of people a great deal, I would not abolish it altogether. I would favor its being kept low however, since it can do more harm than good as an obstacle to low-skilled workers participating in the labor force.