Alas, Poor Newsweek

Next year Newsweek magazine will celebrate the 80th anniversary of its founding.  Earlier this month it was announced that the print edition will not reach that anniversary.  The magazine is going digital-only and will be called Newsweek Global.

Over the years I have subscribed, at various times, to the three traditional print news weeklies: Time, Newsweek, and US News & World Report.  As I reflect upon how long it has been since I received a print copy of any of the three of them, I realize it shouldn't surprise me in the least that Newsweek is succumbing to a changing market.  In the magazine business it is referred to as a "challenging" situation for print advertising.  Challenging, indeed.

It is difficult to make money on print advertising when print circulation is declining. Furthermore, it is easy for advertisers to tell whether online readers actually pay attention to the ads, because they click on them. No click means the ad was ignored.  You just can't tell, with a print ad, whether the reader even noticed.

[It is interesting, then, that in some lines of publishing - medical journals being an example - advertisers still want print ads in print journals, even though they know more and more readers are reading the journals electronically.  I'm still trying to figure that out, and I suspect they are, too.]

I cannot help wondering what the long-term future of news publications holds. There are so many sources of news and opinion online that are free (once you have Internet access and a device that allows you to connect and read).  People will surely expect it to be free, and if you want to charge for it, you will have to offer something of value readers cannot get elsewhere.  Otherwise they'll be thinking, hey, if your competitors can make it on ad revenues alone, why can't you?

When the New York Times started charging for online content, I started looking elsewhere for high-quality news reporting.  I thought, gee, if The Washington Post is still free, why should I pay for the Times?  It's not like their journalism is clearly superior.  They may be called the "newspaper of record," but they are also the newspaper of Jason Blair.  Woodward and Bernstein wrote for the Post.

By nature I am conservative, a creature of habit who prefers the traditional and opposes change that seems to have no impetus beyond a desire for change. However, as much as I am a creature of habit, even my habits change.  And sometimes they have help from unexpected sources.

I used to read a local newspaper.  Then we got a new carrier.  He refused to put the paper in the delivery box.  It was too much trouble.  Emails to the home delivery department of the paper resulted in his putting the paper in the box for a week or so, and then he'd go back to tossing it in the driveway.  The problem was inclement weather, in which a plastic wrapper was inadequate to the task of keeping the paper from becoming an unreadable, sodden mass by the time I got home.  A long series of emails, each followed by an all too transient change in delivery and then a return to bad behavior, led to the end of my print subscription.

I now read local news - when I want to subject myself to bad reporting and worse writing - online, without paying for a subscription.

Two years ago Newsweek merged with The Daily Beast, a news and opinion Web site.  Selected content from the new Newsweek Global will be made available via The Daily Beast.
Full subscription to Newsweek Global will be paid.  It will be interesting to see whether people will be willing to pay the extra money for that.  Maybe I'll start reading The Daily Beast to see what is being done under the editorial leadership of Tina Brown.

So far I haven't done that, largely because it never occurred to me that something with that name could be taken seriously.

I know one shouldn't judge a book by its cover, but how can one not judge a publication when its creators give it a name like that?

The target readership for Newsweek Global will be "a highly mobile, opinion-leading audience who want to learn about world events in a sophisticated context."  I'm not sure how highly mobile I am, because I've been living in the same township for 27 years.  I like being an opinion leader, however.  (Except when the drug companies want my help with marketing.  Then I just tell them they won't like my opinons.)  I desperately want to learn all I can about world events, and I long for sophistication.  So I may just have to check this out.  Except for that one nagging drawback: they'll expect me to pay for it.  Hmmm.  Maybe they'll have an introductory offer that will be too good to pass up.

I will still have to find something else to read in the barbershop.  Popular Mechanics, anyone?

Check the Earthquake Forecast

Last week I wrote about the decision by the Italian supreme court validating the claim of a plaintiff who said his cell phone caused him to develop a brain tumor. The science was, shall we say, sketchy.

But now another Italian court has rendered a decision that cannot be called anything but stunningly irrational.

On March 31, 2009, Italy's National Commission for Prediction and Prevention of Major Risks met to consider the significance of a series of minor tremors (an earthquake "swarm") in central Italy's Abruzzo region.  Enzo Boschi, president of the National Institute of Geophysics and Volcanology, was asked if the swarm was a portent of a major quake in the immediate future.  Boschi said it was possible but unlikely.  The city of L'Aquila was struck by an earthquake six days later: magnitude 6.3, causing the collapse of tens of thousands of buildings, leaving more than 67,000 homeless and 308 dead.

The international consensus among geophysicists and seismologists is that the current state of scientific knowledge does not permit the prediction of earthquakes with any sort of precision or accuracy.  Thus we read about the likelihood that a particular region will likely suffer a major quake some time in the next century.  This is not exactly the sort of information on which you can base any short-term decisions, such as whether to evacuate a city, although you might choose not to live in a quake-prone region, just as many decide against living along parts of the Atlantic coast frequented by tropical storms and hurricanes.

I live in southwestern Pennsylvania, where we don't get much in the way of natural disasters.  Earthquakes and tornados are rare, and we get only remnants of hurricanes.  But I've been in a few car crashes on icy roads, which folks who live in hurricane and earthquake zones generally don't have to worry about.  So nothing is perfect.  We all make our choices.

But now seven members of the Commission have been convicted of manslaughter for failing to predict the major quake and issue a warning.  Their sentence - likely to be appealed - is six years in prison.

This truly defies reason.  In June 2010 an open letter was sent to the Italian president from the American Association for the Advancement of Science, which is the world's largest general scientific society and publisher of the internationally renowned and prestigious journal Science.  The letter, urging the dismissal of charges against the Italian commissioners, said:

Years of research, much of it conducted by distinguished seismologists in your own country, have demonstrated that there is no accepted scientific method for earthquake prediction that can be reliably used to warn citizens of an impending disaster. To expect more of science at this time is unreasonable. It is manifestly unfair for scientists to be criminally charged for failing to act on information that the international scientific community would consider inadequate as a basis for issuing a warning.

In a disturbing similarity to the kinds of things that happen in American civil courts, there was emotional testimony from witnesses who had lost loved ones in the quake - the sort of testimony that should have been considered irrelevant and highly prejudicial, and therefore excluded.

It is very difficult to imagine how competent jurisprudence could have failed to rely on the best scientific evidence and reach the conclusion that, tragic though the outcome surely was, no standard of criminal (or civil) negligence could possibly exist under which the Commission should be held responsible.

We have so much more to learn about earthquakes and other natural disasters. Perhaps some day scientists will be able to tell us when and where an earthquake will strike, much as we now get fairly accurate warnings about hurricanes, giving authorities days to order evacuations and spare many lives.

In Japanese mythology, the Namazu (鯰) is a giant catfish who lives in the mud under the island nation and causes earthquakes.  He is generally restrained by the god Kashima, but when Kashima becomes complacent and lets his guard down, the catfish thrashes about, and earthquakes result.

In modern science, Namazu has been replaced by plate tectonic theory.  But it seems the Italian legal authorities think their seismologists must be Kashima.

Cell Phones and Brain Tumors

Are cell phones harmful to your health?  From personal experience I can say yes.

Over 20 years ago, when a cell phone had the size, shape, and heft of a brick, holding my phone for frequent, lengthy calls, the phone against the right side of my head, my right elbow flexed to a very acute angle, gave me a nasty case of lateral epicondylitis (often called tennis elbow).

Such conditions don't make headlines, but brain tumors do.  You may have read about the recent decision from SCORI.  (I made up that acronym.  The Supreme Court of the United States is often called SCOTUS for short, so why not do the same for the Supreme Court of Repubblica Italiana?  OK, OK, for those of you who are fussy about accuracy, the Italians actually call it Corte Suprema di Cassazione.)
Anyway, the Italian court ruled that a businessman who said he held a cell phone to his left ear, with his left hand, often while taking notes with his right hand, six hours a day for twelve years, had a valid claim when he said this caused him to develop a benign tumor of one of his cranial nerves.  Testifying on behalf of the plaintiff were a neurosurgeon and an oncologist who specializes in environmental factors contributing to cancer.

Dr. Marco Coppola,
Speaker of the ACEP Council

Never having made a study of the Italian system of jurisprudence, I have no idea what the standards of evidence are.
I also have no way of knowing what the expert witnesses said.
Even if I could get transcripts of their trial testimony, I would have to get someone to translate them for me.
(Marco, would you help me with that?)

What I do know, however, is that Italian courts must work a lot like ours do, because the overwhelming weight of the evidence in the published scientific literature fails to support a causal link between cell phone use and development of brain tumors.

To be fair, it is entirely within the realm of possibility that the amount of use described by the plaintiff in this case caused his tumor.  The scientific evidence does suggest that extremely heavy use might be a problem.  But if the standard of evidence were "clear and convincing," that wouldn't make his case.  Even with a "preponderance of the evidence" standard, it should have fallen well short.  So I am forced to conclude that in handling civil torts of this nature, the Italian courts operate the way ours do: maybe it was their fault, so we'll give you lots of their (or their insurance company's) money.

My own review of the literature found more than a dozen studies of varying design and variable quality in methods and statistical analysis.  Nearly all failed to find a link (let alone causation) between cell phone use and brain tumors.  Note that I said "nearly all."  There was one well-done Swedish epidemiologic study that showed a link to the development of a certain type of benign tumor (similar to the one afflicting the plaintiff in the Italian case) for people who were very heavy users of cell phones for more than a decade.  Again, this is an association, which doesn't prove causation.  But I suspect this is the study on which the Corte Suprema di Cassazione relied.

I found it interesting that, in an interview with the British tabloid The Sun, the oncologist said, "The court decision is extremely important.  It finally officially recognizes the link.  It will open not a road but a motorway to legal actions by victims.  We're considering a class action."  What this quotation tells us is that the witness was serving not as an impartial expert on the relevant scientific evidence but as an advocate for the plaintiff.  Such behavior on the part of experts, which is all too common in U.S. courts too, does not aid the search for truth or advance the interests of justice.  Those among my readers who know enough about the American legal system to have become appropriately cynical are now smirking at the notion that truth and justice play any role at all.

The more I observe use of cell phones and smartphones nowadays, the more convinced I am that all these concerns about brain tumors are rapidly becoming passé.  First, many users do more texting than calling.  A recent study showed three times as many texts as voice calls for the average user, and the proportions favor texting even more heavily among younger users.  Second, hands-free calling is becoming more common all the time.  In some states only hands-free use is legal while driving a car.  There was a time, not that long ago, when a person using wireless, hands-free (bluetooth) technology would be perceived by others as likely schizophrenic, apparently having an animated conversation with himself. But bluetooth is now so common that no one even notices such behavior.  All this hands-free use means the phone is nowhere near the head.

But for those who like to worry about adverse effects of technology on our health, go right ahead and keep worrying. You now have "texting thumb" to obsess about.  Not as frightening as a brain tumor, perhaps.  And you could solve the problem by using an Android phone with a Swype keyboard.  But then you'll have to find something else to fret over.

I am happy to oblige.  Phones cause far more trouble when people use them while driving.  In order of risk, texting > handheld calling > hands-free calling.  And how many people have you seen texting while walking? They shouldn't be trying to cross streets when they're texting.  This is like a blind person crossing the street with neither a guide dog nor the heightened sense of hearing that the blind possess.  We like to multi-task, but we should remember that some tasks are just not meant for "multi" - unless you like to live dangerously.

The Emergency Department as Health Insurance

It was bad enough when George W. Bush told us the poor have access to health care because they can just go to the ER.  We had come to expect W to say dumb things.  But Mitt Romney?  I expected better.  Yes, I know, I piled on when the Brits called him a "wazzock" for ill-considered remarks he made last summer in connection with the Olympics.  And, in fairness, he didn't say the ED is a substitute for health insurance.  He merely pointed out that the poor are not dropping dead of heart attacks in the streets for want of health insurance, because our EMS colleagues pick them up and take them to hospitals, where they receive care.  But, for those with little depth of understanding of the consequences of being uninsured, Romney's remark reinforces a very foolish notion.

Earlier this month I addressed the Council of the American College of Emergency Physicians.  My subject was the problem of the uninsured.  Here is an excerpt of that address.

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Today I want to talk to you about a woman I met in August.  I’ll call her Nancy.  Nancy came to see me in the emergency department.  She was coughing up blood.  I took a quick look at her records.  Fifty-seven years old.  Diagnosed in July with lung cancer.  

Wait a minute.  That was July of 2011.  Not a month ago, but thirteen months ago.  She must be going somewhere else for her cancer care.

“Where?” I asked her.

“Nowhere.  I lost my job and my health insurance.”

I asked about COBRA, or the possibility that she might have become eligible for Medicaid or Medicare.  She looked at me blankly.  Everyone else she knew who had lost health insurance simply went without health care.  She assumed that was her lot.  She focused on finding a new job.  She was still working on that.

I ordered a CAT scan of the chest and compared it with the old one.  I explained the difference to her.  She told me she had a grandson who was about to start twelfth grade.  She looked into my eyes, through her tears, and said, “I’m not going to get to see him graduate, am I?”

ACEP has long had a policy position advocating universal coverage.  So have several other medical professional organizations: the AMA, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Surgeons among them.

Harry Truman sought universal coverage.  We made some progress in the 1960s with Medicare and Medicaid.  But we have fifty million uninsured.  And even with the passage of the Affordable Care Act, we stand to make only modest inroads.  Those newly covered under Medicaid are supposed to have equal access, but that is true only if you accept an Orwellian vision in which some are more equal than others.

Why can’t we get there?  Because most Americans have health insurance.  In the abstract they support universal coverage, just as we do.  But when you get down to particulars, they don’t want any changes that will affect what they have. And they balk at the prospect of higher taxes, even when they are told that access to longitudinal primary care for those with chronic diseases can save money.

The public must understand that the uninsured are everyone’s problem.  This is partly a matter of social justice.  It is also a matter of providing health care to all in the most cost-efficient way possible.

It is not enough to adopt this as an advocacy position if doing so does not influence the national debate. There are 850,000 licensed physicians in the United States.  If we all tell the public in a loud, clear, united voice that the status quo is unacceptable, we can transform public opinion.

Why should ACEP take the lead on this?

Emergency physicians provide more uncompensated care than doctors across all specialties by a factor of ten.  We can stand up and say this.  We can say we do this because we have always believed it is our ethical duty.  We wear this as a badge of honor.

But when the wealthiest nation in the history of the world has fifty million uninsured, that is a badge of shame.

We must take the lead in carrying this message to the public, and we must get all of our colleagues across all specialties to join us.

How do I know this is what we must do?

I know what Nancy’s grandson would say.  Shout it from the rooftops - and the studios of CNN.  Go tell it on the mountain - and the pages of the Wall Street Journal.  With strong physician leadership,  America can solve this problem. 

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So, Romney is right.  If you're having a heart attack, you don't have to sit at home and wait to die because you have no health insurance.  You can call 9-1-1, and you will be taken to a hospital ED and receive excellent health care.

But you might never have gotten to that point if you'd had health insurance and primary care to manage your high blood pressure, high cholesterol, or diabetes. Sometimes an ounce of prevention is worth ... well, you know what it's worth. And so does Mitt Romney.  We all do.  So why are we being penny wise and pound foolish?