There are a lot of things that we can expect to be different
in a Trump administration, not only than in the Obama administration but even
compared to that of G.W. Bush (my previous gold standard for irrational and
right-wing policies). Many of these are important, and dangerous, but are
arguably political, such as the change in our relationships with other
countries (Russia, China, Europe, Israel). However disastrous these policies
will be for people in the world (say, Syria) and even possibly destroy the
world (nuclear weapons), they proceed from a different political perspective.
Also arguably political will be the domestic changes, in the rights of LGBT
citizens (such as marriage, use of restrooms), and access to reproductive
health services for women, not only abortion but even contraception. The impact
on people will be horrific, but it derives from a different perspective
(admittedly one that completely devalues huge numbers of people; majorities in
the case of women and non-wealthy people).
There will be other changes, however, that proceed from a
rejection of science, or of what Al Gore calls “inconvenient truth”. Clearly
the biggest one is the one that Mr. Gore was speaking of, global warming,
because this will eventually destroy the planet. Maybe later, as we have
already been so slow in implementing limits on warming. Maybe sooner, if his
climate change deniers have their way. The title of Mr. Gore’s film has several
meanings; it is “inconvenient” for all of us to try to find ways to use fossil
fuels less rapaciously, but it is a financial issue for others. I am not
talking about the coal miners who will lose their jobs; that is going to happen
anyway. I am talking about the Captains of Industry, who, unlike the miners,
will never be anywhere close to poor but have the possibility of making fewer
billions if we seriously address global warming. Oh, the horror!
While of course the destruction of the environment is a
health issue, there are also more prosaic health results from those who will
try to make policies, or pass legislation, that benefits themselves or their
friends and contributors at the expense of truth. Certainly we have seen this
regarding reproductive health for years, especially at the state level, where
laws restricting women’s access to abortion (targeted regulation of abortion providers,
or TRAP, laws) have been based on what might be generously called phony
science, or, more correctly, lies. These have included fetal pain syndrome,
need for facilities appropriate for major surgery, need for admitting
privileges for doctors doing abortions, excessive waiting periods, and other made-up justifications for doing
what legislators really wanted to do – restrict access to abortion. In Florida,
a law was passed forbidding doctors from asking their patients if they had a
gun in the home, meaning they couldn’t even have a discussion about how to keep
them safe from their children accessing them.
So now we have the
probability that Congress will be restructuring
the membership of the US Preventive Services Task Force (USPSTF) to include
more specialists on a body largely made up of primary care doctors and
epidemiologists. The goal of the USPSTF is to dispassionately and objectively
evaluate the evidence for the effectiveness of tests and procedures aimed at
preventing disease. It
gives ratings in easy to understand letters (A,B,C,D,I ) that are not based
upon the opinions of the task force members but on the actual data.
Unfortunately, this doesn’t always make providers happy; if you provide a
service (say, mammography for breast cancer screening) on which you make money,
then a recommendation that says it doesn’t need to be done quite so often hits
you where it hurts – in the pocketbook. So you might come out against it. And
while advocacy groups may not have
the same direct financial interest (although if you are such an advocacy group,
contributions are usually closely related to how serious how many people think
a problem is), it may challenge your long-held beliefs. And then, if you find
some doctors who agree with you (for example, those whose income may be
decreased) you are more confident you were right.
But the goals of USPSTF recommendations is to synthesize the
existing data and base their recommendations on that, not to reach “compromise”
between those who want something done more (because they are “true believers”
and/or have a financial stake in it) and those who believe it is unnecessary
cost with little or no benefit and potential risk. This is why it is not
necessary to include specialists on these panels because of their “expertise”.
Other scientists can interpret the data accurately; a panel reviewing the data
on, say, the frequency with which mammography should be performed in a
particular population does not need mammography radiologists and breast
surgeons to understand the research. This is not to say that such specialists
are inherently biased and shouldn’t be
on USPSTF; they could be as objectively good scientists as others. But it is to
say that the reason being put forward
for them being added to the panel – that they are ‘experts’ in the topic – is
wrong. They should not bring their
experiences and expertise to ‘balance’ the data. They should be guided by it.
It is not necessarily true that expert specialists are
purposely obtuse, that they will advocate for recommendations that will make
them more money. It is also true that their perspective is skewed by the
populations that they see. Specialists see people with a disease, which is a
selected population. Screening is, by definition, testing people who are
asymptomatic and are statistically unlikely to have the disease. Therefore
different standards are applied for screening asymptomatic people (say, all
adult women between 50-75 by mammography) and for following up people
previously diagnosed with breasts cancer, or those who are at higher risk
(defined as a first-degree relative, mother or sister, with breast cancer, not
a great-aunt). And, of course, doctors are not necessarily above advocating for
laws to keep their incomes up. When, about 20 years ago, the federal Agency for
Health Research and Quality (AHRQ) recommended against a specific type of spine
surgery because it didn’t help, was risky, and cost a lot, groups
of spine surgeons tried to get that agency defunded! Oh, yes, and AHRQ
continues to be threatened with funding cuts because special interest
groups don’t like their findings! With
the ACA requiring insurers pay for any USPSTF recommendation with an “A” or “B”
rating, the political pressure is on to get such recommendations, whether the
data supports them or not. On the positive side, the
American Academy of Family Physicians (AAFP) has come out against such stacking
of the USPSTF.
Once, when I lived in a good-sized condominium, I was one of
the few families with children, and it seemed like they and their friends were
often harassed for violation of (sometimes) condo rules and (more often) an
individual’s belief of what should be a
rule. Even the rules, however, were often, in my opinion, unreasonable; I
thought the condo association rules should protect our investment and our
safety, but should not be just anything 51% of the owners wanted. On the
positive side, while they may have inconvenienced me and my family, they did
not try to overrule natural law or science. The same cannot be said for current
federal, state, and local efforts to make a law about anything they want to be
true. They cannot make global warming disappear by a law, but they can make it
illegal! And they can violate the rights and human dignity of our people. And
stack federal agencies with anti-science people or at least turn what should be
scientifically-driven decisions into a political negotiation.
This is going to be a long battle. Those with money and
power are entitled and feel that it is their right to stack the deck. Happy New Year!
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