Why is it bad to overeat but okay to sleep around?

It's official. America hates fat people.

Human beings are constantly searching for socially sanctioned reasons to feel superior to others and in 2009, those who are thin feel mighty superior to those who are not. How else could a college dare to make body mass index (BMI) a graduation requirement?

According to James DeBoy, the chair of Lincoln's Department of Health, Physical Education, and Recreation, the point of the new policy is to keep students healthy:

"There's an obesity epidemic," DeBoy says. "The data are clear that many young people are on this very, very dangerous collision course with heart disease, diabetes, and stroke—health problems that are particularly bothersome for the African-American community."

The move by Lincoln University in Pennsylvania is ironic to say the least. Proudly billing itself as "The Nation's First Black University," Lincoln seems to have forgotten why it exists in the first place. For two hundred years, irrelevant criteria, like race, have been deemed important requirements for entrance to and graduation from college. Not only has Lincoln University introduced an irrelevant requirement for graduation, but the administration has managed to choose an irrelevant requirement that is more likely to affect black students than those of other races.

Henceforth, all students will be required to endure a physical examination to determine BMI. If the BMI exceeds the arbitrary limit of 30, the student must enroll in "gym" class to qualify for graduation. Lincoln University justifies it discrimination against the overweight by invoking the purest of motives; they’re moved by the humanitarian impulse to preserve health and prevent illness. Oh, really? So why is it bad to overeat but okay to sleep around?

Arguably, promiscuous sexual behavior is responsible for more illness, emergencies, and anguish during the college years than promiscuous consumption of food. Promiscuous sexual behavior is associated with dramatic increases in sexually transmitted diseases, leading to serious infections, hospitalizations, and long term health problems like infertility and potentially fatal diseases like AIDS. Unintended pregnancy causes health problems and psychological distress. If Lincoln University is really concerned about student health, wouldn’t it make more sense to include a pelvic or penile examination as a graduation requirement? Those with sexually transmitted diseases could be forced to attend "health" class to learn about responsible sexual behavior.

And as long as we are talking about regulating student behavior, why is it bad to overeat but okay to drink yourself to death? Alcohol abuse is arguably the most serious health problem at colleges. Perhaps Lincoln University should consider locating sobriety check points throughout the college campus. Random breathalyzer testing could identify students who drink to excess, and then they can be required to take a class on responsible drinking before qualifying for graduation.

Indeed, there are colleges that have instituted specific lifestyle guidelines on drinking and premarital sexual activity, but they do so for religious reasons. They explicitly favor certain lifestyle choices over others and are not afraid to say so. They do not camouflage their views with pious claims of preserving the health of their students.

Regardless of what the administration of Lincoln University tells the world, or even each other, about their motivations for instituting a BMI requirement, the de facto discrimination against overweight students has very little if anything to do with health. If the university were truly worried about student health, they would be addressing the most important threats to student health first, instead of ignoring those altogether. Lincoln University has decided to discriminate against the overweight for the oldest reason in the book: because they can.

Prejudice against the overweight is one of the last remaining social sanctioned prejudices. Never mind that Lincoln University is in the business of education and should be granting degrees based on educational criteria. The opportunity to single out, embarrass and penalize those who overeat was just too hard to resist. Perhaps the administration might consider taking an easier and less expensive route and simply force overweight students wear apparel emblazoned with a scarlet "O."

When we are raised to believe that prejudice against those who look different is wrong, it is a relief to find a prejudice against those who look different that is right. Overt racism, sexism, ageism and even homophobia are out. Fortunately, discrimination against the overweight has never been more in.

Insured breasts matter more

Every year, for lack of timely screening and treatment, hundreds of women will die of breast cancer. No, I’m not talking about the change in mammography screening guidelines for women aged 40-49. I’m talking about women of any age who will not have access to mammography or treatment if a healthcare reform bill is not passed. Without health insurance, these women will die preventable deaths.

Republicans have exploited the release of the new mammography guidelines to argue that the Obama administration does not care if more women die of breast cancer. Ironically, their opposition to a public option for health insurance virtually condemns up to 600 women per year to die a preventable death from breast cancer. Republicans apparently believe that insured breasts matter more.

That seems a rather bizarre distinction to make. I could understand, though not agree, if they claimed that Republican breasts matter more. They have an interest in making sure that women who will vote for them will live to return to the polls each year. But the distinction between women who are insured and those who are uninsured crosses political lines.

I could understand, though not agree, if Republicans insisted that profits matter more and supported the new guidelines to benefit their friends in Big Insurance who depend upon them to vote against healthcare reform. The US Preventive Services Task Force recommended ending routine yearly mammograms for women aged 40-49 because the data show that the risks of false positives, unnecessary biopsies and unnecessary breast cancer treatment outweigh the benefits. That can only be helpful to insurance companies who can increase profits by reducing marginally effective and ineffective procedures.

But, instead, the Republicans claim to base their opposition to the new screening guidelines on their reverence for life. They insist that President Obama, in a crass effort to save money, is rationing mammography. To hear them tell it, it is worth virtually any amount of money to save even one additional woman from becoming a breast cancer fatality. Yet the reality is that they are only concerned about the breasts already covered by health insurance.

Republicans are apparently unmoved by the fact that up to 600 women die each year because their lack of health insurance prevents timely access to mammograms, diagnostic procedures and breast cancer treatment. Insuring the breasts of the uninsured would have a far larger effect than merely saving those 600 lives (each one of which is supposedly valuable enough to justify the spending of any amount of money). That’s because the benefit would not be limited to preventing deaths from breast cancer. Current estimates suggest that as many as 45,000 people die preventable deaths every year because of lack of health insurance.

Republicans claim to oppose healthcare reform because it is too expensive. But according to them it’s worth almost any amount of money to prevent a single death. They also oppose healthcare reform because they claim it will lead to rationing. But there is no more brutal form of rationing than to ration health insurance itself, giving it arbitrarily to those who happen to work for an employer who chooses to provide access to insurance and denying it to everyone else.

Do insured breasts really matter more? Or are the Republicans hypocritically exploiting women’s fear and misunderstanding over the new guidelines in order to score political points? If Republicans truly care about making sure that not a single woman dies a preventable death from breast cancer, they’d be clamoring for a quick vote on healthcare reform, and they’d vote for a public option as the best way to end preventable deaths from breast cancer.

Otherwise, we’d be forced to conclude that Republicans don’t really care at all about saving lives and are just a bunch of hypocrites using fear mongering to divert attention from their self serving support of the insurance industry. And they wouldn’t want us to reach that conclusion, would they?

OMG, they changed the rules to save money! No, not mammograms, speed limits.

There has been much righteous indignation expressed in response to the new US Preventive Services Task Force changes that no longer recommend routine mammograms for women aged 40-49. The indignation takes two basic forms. The first is the assertion that it is worth any amount of money to save even one life. The second is that the recommendations are cynically motivated by a desire to save money by "rationing" healthcare.

Yet people fail to consider that we make policy decisions all the time because we don't believe that it is worth any amount of money to save even one life, and because we want to save time and money. Consider the case of highway speed limits.

It is well known that lower speed limits decrease fatalities. Since over 37,000 people die each year on our nation's highways, this is not merely an academic point. If we reduced the highway speed limit to 25 mph we could undoubtedly save tens of thousands of lives. If, in addition, we mandated that all cars were armored like Sherman tank, we might be able to save every one of those more than 37,000 people each year. Yet we don't do that. Why? Because it would cost time and money and we don't think that it’s worth it.

We won't even take less drastic measures to reduce highway fatalities. Knowing full well that increasing the highway speed limit from 55 mph to 65 mph would cost lives even as it saved time. That’s exactly what happened. According to researchers Ashenfelter and Greenstone:

In 1987 the federal government permitted states to raise the speed limit on their rural interstate roads, but not on their urban interstate roads, from 55 mph to 65 mph for the first time in over a decade. Since the states that adopted the higher speed limit must have valued the travel hours they saved more than the fatalities incurred ... We find that the 65 mph limit increased speeds by approximately 3.5% (i.e., 2 mph), and increased fatality rates by roughly 35%. In the 21 states that raised the speed limit and for whom we have complete data, the estimates suggest that about 125,000 hours were saved per lost life. Valuing the time saved at the average hourly wage implies that adopting states were willing to accept risks that resulted in a savings of $1.54 million (1997$) per fatality ...

Of course not every hour saved is money earned, so the real cost per fatality is probably far lower. Regardless, as a matter of policy, the American people don’t think it is worth the amount of time and money it takes to save one additional person from a fatal car crash.

The relationship between fatalities and the highway speed limit is just one example of the myriad policy decisions that are made every year that must balance lives saved against cost. Although opponents of the new mammography guidelines are trying to characterize such decisions as tawdry at best and immoral at worst, there is no other choice. We are always forced to draw arbitrary guidelines. Why, for example, should the highway speed limit be 65 mph? Why not 75 mph? Or for that matter, why not 69.3 mph since there is nothing particularly special about whole numbers ending in 5? Each decision represents an arbitrary balancing of costs against human lives.

Similarly, though people claim to be outraged at dropping the recommendation for yearly mammograms in women aged 40-49, why aren’t they clamoring that the recommendations should be extended to yearly mammograms for women aged 30-39? If they truly believed, as they claim that they do, that it is worth any amount of money to save one life, they should be insisting on screening for women aged 30-39 since breast cancer can occur in that group, too.

Moreover, there's nothing special about whole numbers that end in 0. Why not recommend yearly screening women aged 28-39? For that matter, there’s nothing special about yearly intervals. Why aren't they recommending screening for all women every 6 months instead of every 12 months? Surely we could save a few more lives that way, too.

The fact is that we are forced to make relatively arbitrary policy decisions when it comes to safety issues of any kind. We are always forced to balance benefits and costs. We don't really believe that it is worth any amount of money to save even one life. We don't even believe that it is worth getting to our destination a little later to save 37,000 lives lost on the highway each year.

That's why the outrage over rationing is entirely misplaced. If by rationing people mean considering cost when making safety decisions, we ration every day in many ways. We live in the real world, and in the real world there is not unlimited money. A dollar spent on mammograms is a dollar not spent on another form of healthcare that may have a much better benefit to cost ratio. It is not rationing to suggest that some money spent on mammograms might be better spent elsewhere. It is merely common sense.

Medicine, mammography and the imperfect view

Americans, particularly American women, are shocked, bewildered and angered over the change in mammography guidelines. Many emphasize that it is changes like these that foster distrust in the medical system and lead people to seek alternative practitioners. That's unfortunate because the change in guidelines highlights one of the most important strengths of modern medicine: medicine is constantly changing in response to new scientific evidence; "alternative" health doesn't change because its not based on scientific evidence; its based on belief.

In other words, what lay people perceive to be the biggest weakness of modern medicine is actually its biggest strength.

Medicine is like a frost covered windshield. We cannot yet see the full view because we lack a complete understanding of how the body works, and we lack a complete understanding of many diseases, particularly cancer. Unlike the real world, where we can totally wipe away the frost obscuring our view through the windshield, in medicine we have to content ourselves with ever increasing clearing of various spots. And unlike the real world, where we can wait to totally wipe away the frost before we start to drive, in medicine we must keep moving forward despite our incomplete view.

We get into trouble when we try to shortcut the process by making assumptions instead of waiting for definitive evidence. Medical screening is just one area in which we've been forced to backtrack on our assumptions when new evidence becomes available. We have assumed that because some screening is good, more screening is better. That assumption was never supported by scientific evidence.

There is a large body of scientific evidence showing that biennial mammographic screening of low risk women aged 50-75 leads to lower death rates from breast cancer. There is no evidence that the same approach has a similar impact on death rates in women aged 40-49. Yet we implemented routine screening because we assumed that more screening is always better. The thinking was "better safe than sorry."

With more experience and with more scientific evidence we've cleared away more of the mist obscuring our view. Routine yearly mammographic screening in low risk women has minimal if any impact on death rates. That's because it picks up small tumors that aren’t likely to develop into aggressive cancer and does not increase the diagnosis rate of the aggressive tumors that are likely to kill women.

Paradoxically, the failure of routine screening mammography has convinced American women of its success. All of us know women, or are women, whose small breast cancer was diagnosed by a routine mammogram, who had lumpectomy, and perhaps radiation or chemo, and are now cured. The scientific evidence tells us that almost all of those cancers would have remained stable or possibly even disappeared if they had not been found and treated.

In some ways, that's even more distressing information than the change in mammography guidelines. It means that thousands of women have undergone unnecessary biopsies, unnecessary surgeries and unnecessary chemo and radiation, not to mention unnecessary anxiety and fear. We didn’t cure these women. We treated them even though they didn’t need it and then took credit for what would have happened anyway.

A disaster like this would never happen in "alternative" health because it doesn’t change with new scientific evidence since it is not based on scientific evidence. That’s one of the reasons why "alternative" health remedies are never tested before they are implemented. What would be the point? And it’s one of the reasons why advocates of "alternative" health ignore evidence that their treatments don’t work.

"Alternative" health does not advance new theories, acquire new information and modify theories based on new information. The same "remedies" that were used hundreds of years ago are offered now as if nothing has changed in the interim. Classic books in "alternative" health tend to have only one edition. There’s no need to have more editions when nothing changes.

In "alternative" health, things are simple, remedies are static, and certainty is prized. That is very comforting to human beings who value certainty in an uncertain world. Medicine is messier. The human body is complicated, and disease is complicated. We are constantly acquiring new information about both. Treatments and medical recommendations change in response to this new information. No one can be sure that the therapy recommended today won't be superseded by a better therapy found tomorrow.

Only one thing is certain. The recommendations issued this week are sure to be amended at some point in the future, most probably because we find a better screening tool for breast cancer than mammography. We need, and we are looking for, a screening tool that will be able to tell the difference between aggressive breast cancers and those that will go away on their own.

It is unfortunate that we are periodically forced to reassess medical recommendations. However, it would be tragic if people viewed this reassessment as a failure and stopped listening to recommendations. Returning to the windshield analogy: it is a shame that we sometimes need to change course when our view expands, but it would be tragic if people decided on that basis to drive without ever looking through the windshield at all.

Homebirth midwives don't want you to know

What would you think if the package insert for your new medication said the following?

Our company, Drugs4All has tested this medication in 20,000 people and collected copious data about its effects. But we made a promise to Drugs4All shareholders that we will not let anyone see that data unless they can demonstrate that they will use it to promote the well being of our company.

Therefore, we've created a two-step process for access to the data. If you'd like to learn about the safety of this medication please complete the application attached and explain your commitment to the well being of Drugs4All. Please include the your name and the names of anyone you have ever associated with. A committee will review your ideological commitment to the well being of Drugs4All to be sure that you will not use the data to harm our interests.

If you meet with our approval you will be eligible to see our safety data. That’s step 1. In step 2 you must sign our non-disclosure agreement promising not to share the data with anyone else under the pain of legal penalties.

We're sorry for any inconvenience, but our first commitment is naturally to our shareholders, not to our customers.

Your first assumption might be that Drugs4All withheld the safety data from the public because it shows that the drug is not safe. Therefore, they must restrict access to the data to those who can demonstrate in advance that they are committed to the interests of Drugs4All and have instituted penalties to be sure that no one else sees it.

Crazy, right?

Evidently not. This the procedure that the Midwives Alliance of North America (MANA), the official organization of homebirth midwives, has instituted to protect the safety data they have gathered in the past decade. In periodic public announcements over the past few years, MANA has announced the existence of the data and promised that it will be the largest and most extensive database of its kind.

Unfortunately for MANA, though, it does not show what they want it to show. Since their first commitment is to homebirth midwives, not their patients, they have publicly announced that only those who pass an ideological litmus test and sign a legal non-disclosure agreement will be allow access to the data.

According to the MANA Handbook for Researchers Interested in Obtaining Access to the Manastats Database:

[MANA} is responsible for representing the midwifery community in its relationship with investigators…Therefore [MANA] expects all investigators interested in collaboration with this community to consider how they can cooperate ... and to describe how they intend to do so in their request for data access.

Upon approval of a research application, access will be predicated on the signing of a ... a Confidentiality and Non-Disclosure Agreement...

It is difficult to imagine a more unethical procedure for gaining access to the database. MANA has made several things clear.

1. It's first priority is the benefit of its shareholders.
2. MANA does not believe that patients have any right to know the truth about homebirth safety
3. The data is potentially so damaging to homebirth midwives that it must not be allowed to get out to anyone who hasn't been vetted in advance and promised to keep it secret from the public.

It does not take a rocket scientist to surmise that MANA's own data show that homebirth with an American homebirth midwife is not safe. Withholding that information from patients is both unethical and immoral.

MANA should publicly release all their available safety data immediately. Will that hurt the employment prospects of homebirth midwives? Probably, but that's just too bad.

No one can make an informed decision about homebirth without access to information. But I guess that's the point. An informed patient might not become a customer, and as MANA has helpfully informed us, representing the interests of homebirth midwives is its most important priority.

Men fake orgasm?

Everyone has heard about women faking orgasm, but most people assume that men would never do so, and that it is impossible in any case.

A new study in the Journal of Sex Research aims to over turn the conventional wisdom. Men's and Women's Reports of Pretending Orgasm, Muehlenhard and Shippee, Journal of Sex Research, 46, 1–16, 2009 investigated the issue among college students:

Research shows that many women pretend or "fake" orgasm, but little is known about whether men pretend orgasm… Participants were 180 male and 101 female college students … Participants completed a qualitative questionnaire anonymously. Both men (25%) and women (50%) reported pretending orgasm (28% and 67%, respectively, for PVI-experienced participants). Most pretended during PVI [penile vaginal intercourse], but some pretended during oral sex, manual stimulation, and phone sex...

The authors found that 50% of women reported having faked orgasm, and, surprisingly, 25% of men also reported faking orgasm. However, the rationale and reasons varied dramatically between the two groups. Women were more likely to fake orgasm because they considered themselves incapable of achieving orgasm in similar situations, or at all. The main reason offered by women for faking orgasm was to protect a partner's feelings. In contrast, the men who faked orgasm most often did so because they were either too drunk to perform or had had one more orgasms within the previous hours. The most common reason for faking orgasm offered by men was wanting to end the encounter.

The authors helpfully provide examples:

My 1st girlfriend in high school and I lost our virginity to each other. She wanted to have sex ALL the time, even at times I wasn't—Approx. 5–7x daily—able to. I would motivate myself, we'd have sex, and she wouldn't stop till we both orgasmed. I'd fake it to get it over with. (After the 3rd orgasm, it's REALLY hard to go again.)

As the authors explain:

Men most often wanted sex to end because they were tired or wanted to sleep. For example, one man wrote, "After a while my body was getting tired and worn out so I decided to act like I came so she would get off of me."

Men were more creative than women in pretending. While 90% of women reported acting out orgasm, only 78% of men faked orgasm in that way.

Over one-fourth of the men ... reported telling their partners after the supposed orgasm (e.g., "I was getting tired and she wasn't that cute so my dick couldn't stay hard so I just told [her] I came and I got up and left,")... Interestingly, several men (18%), but no women, mentioned that they had pretended by stopping having sex. One man, who checked that he had pretended, mentioned no method of pretending other than stopping ... One wrote that he pretended by "[saying] That felt good and stopping." Another wrote, "I just stopped and told her I was done and left."

The authors were apparently exhaustive in their analysis, but, curiously, one important detail was not examined. The questionnaires asked if the person had ever faked an orgasm, not how often they had done so. So we do not know if men the men who faked orgasm did so habitually or only when drunk or otherwise impaired.

Though men and women differed in many parameters, on one they were united. Most women and most men who faked orgasm did so to please the men. Women faked orgasm to make the men happy, and men faked orgasm to make themselves happy.

Toxicophobia, fear of poisoning

Believers in pseudoscience appear to suffer from a free floating fear. What unites vaccine rejectionsists, organic food devotees, and consumers of "alternative" health? They are united by a pervasive fear of being poisoned. And not poisoned accidentally, either. They are united by a fear of being poisoned surreptitiously, deliberately, and as part of a giant conspiracy perpetrated by Big Pharma and Big Farma. They suffer from toxicophobia, the irrational fear of being poisoned.

It is axiomatic among vaccine rejectionists, organic food devotees and consumers of "alternative" health that vaccines, conventionally grown food and the water supply are filled with "toxins." Sometimes these toxins are named; often they are not. In all cases, though, there is no evidence that anyone is actually being harmed by "toxins," but, of course, proof is not a requirement in the fantasy world inhabited by pseudoscience believers.

Vaccines supposedly contain "toxins" that cause autism. (N.B. Toxins always and only cause diseases and syndromes whose etiology is still unknown. No one ever claims that toxins cause strep throat, or sickle cell anemia, or gallstones.) Our food supply is purportedly contaminated by toxins too numerous to even bother mentioning by name. Our water supply is supposedly contaminated by the toxins in pesticides. And, of course, all medications produces by Big Pharma have myriad secret and toxic side effects.

That all pervasive fear would be disabling enough on its own. Apparently, pseudoscience devotees imagine themselves navigating a world pervaded by an unseen toxic miasma. What's worse, though, is that the entities responsible for creating this toxic miasma know all about it, did it deliberately to make money, and are engaged in a vast conspiracy to keep it secret from the rest of us. Oh, it is a nefarious world indeed!

Big Pharma deliberately adds toxins to its vaccines. Sounds like overkill to me, since vaccine rejectionists also claim that the vaccines themselves are toxic. And vaccine manufacturers know all about this and do it to make more money. And the government knows all about it, too, and insists that we take more and more vaccines every year. And the government pays for it. And the government has granted vaccine makers indemnity from prosecution. It is a wicked world.

Big Farma covers our fruits and vegetables with toxins, and, if that weren't enough, adds toxins in the guise of preservatives to everything else. And these toxins cause cancer! What kind? Don't ask, no one knows, and why would that matter anyway? Cancer is cancer. And if all that weren’t bad enough, Big Farma now wants to flood our food supply with … genetically modified food. Horror of horrors, genetically modified foods (they modified the GENES, for chrissakes) are sure to be filled with unnamed toxins of all sorts. And if that weren't bad enough, Big Farma wants to irradiate our food to kill harmful bacteria (they're going to expose our food to RADIATION, for chrissakes). Next thing you know we'll all be gigantic and super-powerful. Oh, wait, maybe we'll all be stunted and weak. It doesn't matter; regardless of what they do you can be sure it will "weaken" our immune systems.

We are facing a big problem. Contrary to what the food and medicine toxicophobes believe, it is not the deliberate contamination of our food and pharmaceutical systems. The problem is a sociological problem. Large segments of the populations are suffering from the delusion that industry and the government are colluding to deliberately poison them.

To be clear, I'm not suggesting that medications don't have side effects or that pesticides or preservatives are theoretically incapable of being harmful. Everything has potential side effects, but there's a big difference between "potential" and "real." Vaccines, for example, are known to cause brain damage and death in a tiny proportion of children who are vaccinated. That is real. But vaccines don't cause autism. That's fantasy.

What is the source of this toxicophobia? In part it stems for Americans' apparent inability to understand risk. Americans are so obsessed with side effects that they forget about effects. They vastly overestimate the real risk of side effects and vastly underestimate the effects of the treatment in question. That tendency to overestimate side effects is directly related to the sense of control that Americans do or do not feel. Just as Americans routinely underestimate the risks of driving, they routinely overestimate the risk of plane flight. They believe themselves to be in control while driving, yet they develop irrational fears about the risk of an unforeseen and unforeseeable plane crash.

So Americans obsess over the risk of side effects from medication and the theoretical risk of side effects from agricultural methods that have made the food supply larger and safer. They are consumed with anxiety by the belief that they are secretly being poisoned.

This obsession is magnified by the belief that Big Pharma and Big Farma know about all these side effects and are hiding them. Do large corporations hide damaging information from the public? Yes, unfortunately, they do. But Big Pharma and Big Farma are no different from other large corporations. Yet no one has stopped driving because they fear the auto industry has designed cars that will blow up at the slightest provocation (even though that actually happened with the Ford Pinto) and no one has stopped crossing bridges for fear that shoddy construction will lead them to collapse (even though that has actually happened, too).

Simply put, there is no basis in reality for this pervasive toxicophobia, suggesting that it may be serving a psychological function. I'm going to go way out on a limb here, and raise the possibility that American toxicophobia is psychosomatic. Americans are not being poisoned, but they imagine they are because it is a way to channel their fear of being left behind in an increasingly technological world, and their anger at being so easily manipulated by large corporate entities like banks and other special interests, and their frustration at their perceived powerlessness. Toxicophobia projects this fear, anger and frustration onto medications and food. Unfortunately, rather than being protective, toxicophobia diverts attention from the real problems onto imaginary ones. And, paradoxically, toxicophobia doesn't improve health, it puts health at risk.

I've joined Science-Based Medicine

I am very happy to announce that I've joined Science-Based Medicine (http://www.sciencebasedmedicine.org/). My first post appears today and it's about ... homebirth.

Detailed report on infant mortality neglects the most important detail

The new CDC report on infant mortality, Behind International Rankings of Infant Mortality: How the United States Compares with Europe, is an object example of how to deceive with statistics. It purports to be a detailed investigation of infant mortality, but it inexplicably fails to investigate the most important detail.

According to today's article in the NYTimes:

High rates of premature birth are the main reason the United States has higher infant mortality than do many other rich countries, government researchers reported Tuesday in their first detailed analysis of a longstanding problem.

In Sweden, for instance, 6.3 percent of births were premature, compared with 12.4 percent in the United States in 2005, the latest year for which international rankings are available. Infant mortality also differed markedly: for every 1,000 births in the United States, 6.9 infants died before they turned 1, compared with 2.4 in Sweden. Twenty-nine other countries also had lower rates.

If the United States could match Sweden's prematurity rate, the new report said, "nearly 8,000 infant deaths would be averted each year, and the U.S. infant mortality rate would be one-third lower."

The use of this example highlights to disingenuousness of the authors. In their supposedly "detailed" report on infant mortality, they fail to analyze the most important detail: race. Unfortunately, African descent is a major risk factor for prematurity, and prematurity is a major cause of infant mortality. Therefore, it is hardly surprising that the US has a higher infant mortality rate than Sweden. The US has the highest proportion of women of African descent of any first world country. Sweden, of course, has virtually none.

The authors, however, seem more interested in jeering the US for its supposedly low standing in international comparisons than they seem in actually getting to the source of the problem. The report is filled with grim looking graphs that show how "poorly" the US fares when compared to other first world countries.

The first graph highlights the fact that the US is ranked 30th in the world for infant mortality. But the authors acknowledge that the US has a more comprehensive definition of infant mortality than other first world countries, many of which exclude the deaths of very premature infants even when they are born alive. The authors present a second graph adjusting for this discrepancy. In that more accurate graph, the US ranks 18th.

The authors mention the impact of race on prematurity, but they never adjust for it. The CDC Wonder website gives us access to the same database that MacDorman used in the study. Therefore, we can adjust for race. Doing so, would put the US 14th in the rankings.

The authors also mention assisted reproductive technology, but they don't adjust for that either. The rates of twins, triplets and higher is greater in the US than in many European countries because of differing rates of assisted reproductive technologies and the difference in techniques.

The authors acknowledge that on an age specific basis, the US actually does better than almost all European countries. In other words, we are better at saving premature babies. Our relatively low ranking is the result of a higher rate of prematurity.

So our higher rate of infant mortality does not reflect poor medical care. It reflects factors beyond the control of doctors. Race is an uncontrollable factor; obstetricians and pediatricians have no control over assisted reproductive techniques. In fact, the data actually show obstetricians and pediatricians do a remarkable job of ensuring infant health.

Dr. MacDorman's bias is most evident is her gratuitous swipe at obstetricians. According to the Times article:

Another factor in the United States, she said, is the increasing use of Caesarean sections and labor-inducing drugs to deliver babies early. The American College of Obstetricians and Gynecologists has guidelines stating that babies should not be delivered before 39 weeks without a medical reason, but doctors may be declaring a medical need more quickly than they did in the past.

"I don't think there are doctors doing preterm Caesarean sections or inductions without some indications," Dr. MacDorman said, "but there sort of has been this shift in the culture. Fifteen or 20 years ago, if a woman had high blood pressure or diabetes, she would be put in the hospital, and they would try to wait it out. It was called expectant management.

"Now I think there's more of a tendency to take the baby out early if there's any question at all."

Dr. MacDorman neglects to mention that there is no evidence that such births are contributing in any way to the infant mortality rate. Indeed, the existing evidence suggests that these births actually save lives. During the time period when early deliveries increased, the rate of stillbirth dropped by 29%.

Infant mortality and prematurity are real and serious problems, and they won't be solved by pretending they are simply medical problems. Infant mortality in general, and prematurity in particular, is the result of racial, social and economic disparities that must be investigated and addressed. MacDorman’s report risks obscuring this critical point in favor of castigating medical practitioners. Doctors are not responsible for the US ranking in infant mortality statistics, and therefore, they cannot fix it. If our goal is to prevent infant deaths, we must be honest about the real causes.

Skin cream made from aborted fetus?

It sounds like a horror story made up by an anti-abortion group, but it is not. Neocutis, a Swiss "cosmeceutical," is being marketed as a "Bio-restorative Skin Cream with PSP™" for "sensitive, stressed and irritated skin." PSP are processed skin-cell proteins and the manufacturer, Neocutis SA, is honest about where they came from:

Inspired by fetal skin's unique properties, Neocutis' proprietary technology uses cultured fetal skin cells to obtain an optimal, naturally balanced mixture of skin nutrients including cytokines, growth factors and antioxidants.

Neocutis SA, cognizant of the ethical objections, declares:

Since the 1930s, the international medical community has used donated fetal tissue to better understand cell biology and as an essential tool in the development of vaccines, which are credited with saving millions of lives worldwide. The 1954 Nobel Prize for medicine was awarded to researchers who utilized fetal kidney cells to develop the polio vaccine… Our view—which is shared by most medical professionals and patients—is that the limited, prudent and responsible use of donated fetal skin tissue can continue to ease suffering, speed healing, save lives, and improve the well-being of many patients around the globe.

In other words, Neocutis SA believes that this is yet another benefit of stem cell research. But is this what proponents have in mind when urging the funding of stem cell research? Does support for stem cell research to cure fatal diseases extend to support for stem cells in cosmetics?

Dr. Summer Johnson of Bioethics.net asks:

... [W]hat moral complicity exists for those who choose to put fetal skin protein creams on their faces?

She acknowledges that consumers are likely to have one of two responses:

Yet for some, this will have no moral implication at all. For them, fetal proteins in a face cream aren't any different from animal or plant protein because for them the moral status of the aborted fetus doesn't have the moral status to give one concern if consent to both abortion and research took place.

But for many, it would be unthinkable to fetal ANYTHING into their deepening wrinkles to make them become less so. In fact, many would rather have crow's feet deeper than the Grand Canyon than have a fetal tissue cell touch their face as a result of their moral conviction...

I must admit that this issue has never occurred to me. When I think of stem cell research, I think of life saving technologies, not cosmetics. Does it matter, though, what the stem cells will be used for once you’ve decided they can be used? Is there any moral difference between using the tissue of aborted fetuses to cure cancer and using it to cure wrinkles? And if it does matter, what does this tell us about the status of fetal tissue? Are fetal cells no different from the animal and plant cells often used in the manufacture of cosmetics?

At a minimum, people deserve to know when products are manufactured using the tissue of aborted fetuses so they can decide for themselves whether to buy and use them. The real question is whether we should go further. Instead of leaving the moral decision to individuals, should we restrict the use of fetal tissue to life saving products, or even to no products at all?