Sunday, February 19, 2017

"Hidden Figures": Racism, sexism, anti-science, public health and cancer

I recently saw the wonderful film “Hidden Figures”, which tells the story of the African-American women who worked as “computers” (when the word meant “people who do computations”) on the NASA program that sent men (and later some women) into space. The focus was on three of the most significant of these women, Katherine Goble Johnson, Dorothy Vaughan, and Mary Jackson. Ms. Johnson (played by Taraji P. Henson) is a gifted mathematician who calculated the trajectories of many of the early space flights (including, as portrayed in the movie, John Glenn’s orbital flight in February, 1962) and the later Apollo 11 moon landing in July, 1969. Ms. Vaughan (played by Octavia Spencer) became an early and leading computer programmer, a supervisor at NASA. Ms. Jackson (played by Janelle MonĂ¡e) was the first African-American female engineer at NASA. All of these women, and no doubt many others, were critical to the NASA space program.
All of them, as the film documents, were “firsts”. Among many such firsts, Katherine Johnson (then Coleman) was one of the first African-Americans and first African-American woman to desegregate the graduate school of West Virginia University. Dorothy Vaughan was one of the first programmers and first African-American woman supervisor at NASA. Mary Jackson became NASA’s first African-American woman engineer, after winning a court case that allowed her to desegregate Hampton High School to attend night classes. When asked in the film by a white supervisor if she would still want to be an engineer if she were a white man, she says that if she were “I would already be an engineer!” She also gives a terrific speech to the judge in her desegregation case about the significance and importance being a “first”.

“Hidden Figures” portrays and does not downplay the blatant and overt racism and sexism that existed in that period, legally in the Jim Crow South where the film takes place at the NASA Langley facility in Hampton, VA, in 1961, after Brown vs. Board of Education but before the Civil Rights Act of 1964. There are separate drinking fountains, and a separate coffee pot for Ms. Johnson, and as graphically depicted in the film, a half-mile run for her to go to the only “colored women’s” rest room to relieve herself! The laws in the South came down, but racism – and sexism – there and in the rest of the country are hardly things of the past.

But this is not a movie-review blog; it is about medicine and public health and social justice. The social justice aspect should be obvious, but let me start the discussion of health and medicine with science. Clearly, science was at the forefront of NASA’s mission, and the film depicts how the need for “best and the brightest” overcame even the structural racism of the American South for these women. On a larger scale, though, the idea that science was the future, that knowledge and education and learning and discovery were critical to America and the world, are also implicit, scarcely discussed in the film (save for a few inspiration speeches, such as President John Kennedy’s). In 1957 Sputnik, the first satellite, was launched by the Soviet Union, in April 1961 cosmonaut Yuri Gagarin orbited the earth and a month later Alan Shepard was the first American to so suborbital flight. Glenn’s 1962 orbital flight was only 7 years before the Apollo 11 landed on the moon!

I was alive then, a fairly young child for Sputnik, older for Gagarin and Shepard and Glenn, and just graduated from college for Neil Armstrong’s “a small step for a man, a giant leap for mankind” speech. I was a part of (maybe at the time I thought “victim of”) President Kennedy’s physical fitness program, doing pushups and sit-ups and chin-ups so we could “beat the Russians”. I was also a student, learning and excited by science. I was impressed by the space program, but not as dedicated a devotee as many others. Perhaps this was because I was not enough of a science geek, but perhaps it was also in part because it seemed natural, the advancement of knowledge and science was natural, progress was natural. Maybe I was less awestruck than older people in the same way that more recent generations have been less impressed by the technology of computers and cell phones. But we all (I thought) believed that science, and learning, and advancement were what the future was about. We had come through “the war” (WWII), and Americans had jobs, and their children were going to school, and while there were still fights to be waged for racial and gender and economic justice, the outcome was, we knew, unquestionable progress.

But maybe not any more. While we built the Interstate Highway system in the 1950s, while we were able to go from suborbital flight to a man on the moon in 8 years in the ‘60s, now we are in an era where many Americans – including many of our leaders – deny the incontrovertible facts of man-made global warming and climate change. An era in which science and scientists and not to be trusted, where, when facts challenge our beliefs, we make up “alternate facts”, where education and knowledge, rather than things to be sought after and admired are seen as “elitist”, where the only persistent “good” is the enrichment of the already richest, whatever the cost to the rest of us and to the planet. On April 23, 2011 (“Cabaret" and "Inherit the Wind": Will we again reap what is being sowed?) I wrote of how the play “Inherit the Wind”, written in the late 1950s, was meant as an allegory for McCarthyism, since the “ignorance” that denied evolution in 1920 Tennessee was no longer an issue; evolution was fact. And yet 60 years later it was still being questioned. We see the same, today, for all aspects of science and knowledge; this is a real test given by a “Christian” school!

But what about medicine and health? Is that not still the New Frontier? We may have abandoned even the shuttle program with manned spaceflight, and the launches from Cape Canaveral may be all private satellites out to make a profit (or spy on us), but isn’t NIH our new NASA? Didn’t President Obama promise a campaign to defeat cancer in the same way President Kennedy declared our intention to get to the moon? Well, maybe. NIH’s budget is not only stagnant, but its funding overwhelmingly goes to very basic research and to find “bullets” to kill cancer, as if it were a disease rather than scores of diseases, almost all different. But there is far, far less funding to prevent cancer, not only to find the causes of these diseases, but to even eliminate the causes when we know them. Where is the funding for public health? Sure, there are some victories. Smoking, the major cause of death for decades (and, although it is a cause of many cancers, more of the deaths it causes is from increased heart disease and chronic lung disease than cancer), is down, but the fight against it has been a long and hard one and is not over. Other environmental causes of cancer such as air, water, and soil pollution are minimally addressed, because, like smoking bans, they might decrease the profits for some businesses and the wealth of the wealthiest.

“Hidden Figures” has some brave acts by its white characters. John Glenn (Glen Powell) refuses to fly unless Katherine Johnson rechecks the calculations (and thus she gets her job back). Al Harrison (Kevin Costner), the NASA chief, takes a crowbar to the “Colored Women’s Restroom” sign when he discovers that it is traveling to far-off segregated restrooms that are taking Ms. Johnson away from her job. Yes, these can be seen as self-serving (helping them to get their jobs done) but they are also, in the context, heroic. I was recently sent copies of archives of mimeographed newsletters from civil rights groups based in southern Brooklyn, where I grew up; one of them contains an article from 1965 about young African-American women being denied membership in a “cabana club” (in the NORTH! In Brooklyn, NY! In 1965!), until the singer  Julius LaRosa shows up asks the folks picketing outside why they are there, says “I don’t perform in segregated places”, and intervenes.

John Kennedy said we should go into space not because it was easy but because it was hard. Maybe we shouldn’t do things just because they are hard, but we need to not deny what we don’t completely understand just because it is easy. We need science and we need progress and we need public health. People may not know everything themselves that environmental scientists and scholars and mathematicians and physicists and doctors and public health workers know, but they should be proud of those who do, and encourage and support them. We need more girls and minorities to enter the STEM fields, as in programs such as that in NYC documented in the February 17 New York Times.  We need more Katherine Johnsons, and Dorothy Vaughans, and Mary Jacksons, and the love and respect for learning and truth that they stood for.

We even need more Julius LaRosas.

Thursday, February 9, 2017

"There's a sucker born every minute": False and inflated health claims

There is,” in a phrase rightly or wrongly attributed to P.T. Barnum, “a sucker born every minute.” To Barnum, and to countless others before and since, this was a business opportunity. They can get rich off us because we want stuff to be true even when every input from our senses should show us that it isn’t; we want magical, easy cures and money-making schemes, even when we know that they only work for the scheme’s designers, not the suckers who take the bait. Betsy DeVos, the recently approved Secretary of Education, who knows nothing about education and devalues public education (I could go on, but that’s another story…) is the beneficiary of such desires. She is in the position that she is in because of her great wealth which has bought her great influence, and that great wealth, at least the portion from her husband’s side, derives from the Ponzi scheme known as Amway. It is clear that Amway was in fact the path to wealth that it was claimed to be, for the DeVoses anyway.

The persistent and widespread greed of people despite evidence that the odds are stacked way against them is testimony to either optimism or stupidity, or some of both. It is one of the oldest memes in literature, from the alchemists who would turn lead into gold (or Rumpelstiltskin who would weave it) to Faust who would sell his soul to the devil (and maybe so did guitarist Robert Johnson) to Ralph Kramden (and his cartoon successor Fred Flintstone) and George “Kingfish” Stevens, doubly oppressed and vulnerable, being poor and black. And the outcome is always the same, the little guy gets screwed.

We could go on and on with this theme. The temptation to tie it to the election and reign of Donald Trump is enormous; people want something to be true (that they’ll get good jobs back, that their streets will be safe, that they can have all the health care they want and need without paying for it when they don’t need it, whatever) and Trump promised it all, and of course he is not and will not deliver, but many still love him. If you want a good article about this, try Matt Taibbi in Rolling Stone, The end of facts in the Trump era”. But, after all, this blog is about public health and medicine, and there is no shortage of examples in those fields. After all, con men and grifters, whether low level hucksters, Amway merchants, or Wall Street bankers are all regularly called “snake oil salesmen”, and what was snake oil but a promise of better health? And the liniment sold by these folks might have worked a bit since it had red pepper, a bit like current capsaicin. When they were convicted it was because their oil did not come from snakes, not because it was a fraudulent cure.

You’d think that people would wonder why, if there is a miracle easy (and sometimes even relatively cheap) cure for all their ills that everyone else hasn’t benefited from it. Ah, but that is part of the attraction – being in the know about something everyone else isn’t. Is that not the way that inside traders work? Isn’t that how they fix sporting events, how your brother-in-law knows that this 100-1 shot will come in at Santa Anita? Is that not how Arnold Rothstein got rich? So, sure, it’s done in health. Watch daytime television sometime. It is mostly about medicine, from Dr. Oz (a font of misinformation), to an electric scooter you can get FREE (or at no cost to you, other than as a taxpayer paying into Medicare), or a miracle drug that will allow you to have even better relief from your arthritis or asthma or will keep your blood from clotting even better than warfarin, at only 1000 times the price, and at great potential risk to your immune system.

The hucksters present not only misinformation about individual medical care, but also public health. The most obvious, and likely most serious, current issue is that of vaccines. Despite there being no evidence linking vaccines to autism, and strong evidence showing there is no link, the myth persists. The price will likely be serious outbreaks of vaccine-preventable diseases, especially measles, as discussed by Peter J. Hoetz in his NY Times Op-Ed “How the anti-vaxxers are winning”, February 7, 2017. Water fluoridation suffers from similar myths. Public health may be even more susceptible to such hype than medical care, since so many of its benefits are things (like measles, or tooth decay) that don’t happen, rather than those that do. We rarely wake up saying “Gee, I’m glad I don’t have cholera today because we have clean water”; indeed, we mostly worry about water quality when something specifically bad is happening, like lead poisoning in Flint. People are susceptible to liars and charlatans who tell them things that they want to believe, as well as things that seem to make sense, but as I tell students, something that seems to make sense is called a research question; only when the study is done will we know if it is true.

But it is not only the more obvious (to the discerning, anyway) scams. Mainstream medicine does it often. Every new discovery, every potential ameliorant (if not cure) is trumpeted by both the companies that manufacture it and, at an earlier stage, the university for which they work. Of course, most of these discoveries are scarcely the magic breakthroughs that they are initially claimed to be. That is the nature of science; things are learned and knowledge grows incrementally. But a new discovery by a scientist at your university is worth a lot of publicity! Maybe it is a cure for Alzheimers! Or at least a step in that direction! Certainly worth millions of dollars more in NIH funding! There is nothing wrong in incremental discoveries; the problem is when they are hyped as the Holy Grail. Indeed, on July 16, 2010, I wrote about Rosiglitazone and the "Holy Grail", and how disappointed diabetes advocates were that Avandia® was being taken off the market just because it caused heart disease, because it did lower blood sugar! (A diabetes advocate noted that lowering blood sugar was the “Holy Grail”.) This story is a terrific example of the peskiness caused by the human body being an integral organism; something that is very good for one condition may still cause big problems. And so, maybe we should wait before we hype it too much. On the other hand, what an opportunity we have to get big publicity before that happens…

A recent example involves using low-dose CT screening for lung cancer. The US Preventive Services Task Force recommends it (as a “B” recommendation) for men 55-80 years old with a history of smoking. This “B” recommendation is worth a lot to the CT manufacturers and radiologists who read them, since the ACA requires insurers to cover USPSTF “A” and “B” recommendations. But a big Veterans Administration study just published in JAMA shows that it is not quite as good as previously thought. “Of the 2106 patients screened, 1257 (59.7%) had nodules; 1184 of these patients (56.2%) required tracking, 42 (2.0%) required further evaluation but the findings were not cancer, and 31 (1.5%) had lung cancer.” Does this mean that it is a bad idea to get screened? Not necessarily; if I had a patient with a significant smoking history, I would discuss the risks inherent in getting this procedure but prepare them for the probability that even a positive test would likely not mean they had cancer, and that they might have to undergo more procedures with some risk to find out. The point is not that this is a bad idea, but it is not some amazing breakthrough, as touted.

Just because you want to get rich quick, or avoid needle sticks, or find the magic cure for your arthritis or cancer that has been denied you, and someone is selling something that claims to do it, doesn’t make it true. If you think so, I’ve got a couple of bridges to sell you.

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