Mandatory Flu Vaccine for Health Care Workers

“Are there any side effects I should know about?” asked the young lady.

“No, there aren’t,” answered the doctor.

It wasn’t the vaccine for influenza they were discussing.  It was the vaccine being marketed by Merck under the trade name Gardasil.  It is supposed to protect against the human papilloma virus, thought to be a common cause of cancer of the cervix.

I was hearing about this conversation after the fact.  The patient was in her mid-teens, bright, well-educated, and well-read.  The doctor was a family practitioner.  Trying to be charitable, I told the young lady that the doctor was being paternalistic, although that is a behavior that should be passé among physicians.  She was saying there were no side effects that should dissuade the patient from accepting the vaccine, failing to understand that was the patient’s call to make, not the doctor’s.  And she might have answered differently if the patient had been ten years older.

From my perspective, having spent many years studying biomedical and professional ethics, I considered the doctor’s behavior to violate the ordering principle of medical ethics in Western societies: patient autonomy.  The patient thought the doctor was just a liar.  Perhaps now that the patient is a college student, pre-med, who has learned a good bit about medical ethics already, she would be more charitable.  But her reaction - which was to decide against accepting the vaccine and simultaneously to decide she would not be seeing that doctor again - illustrates the importance of honesty in the doctor-patient relationship.

That young patient was my daughter, and she knew that her very conservative lifestyle meant her risk of acquiring HPV was zero, that the risk of an adverse reaction to the vaccine was small but non-zero, and that therefore the risk-benefit analysis did not come down on the side of benefit.

For many years I have worked at hospitals that strongly encouraged employees, especially nurses, to get a flu shot every year.  The “pitch” was that it would protect the recipient from getting sick.  Every time I read or heard the pitch, I bristled.  They should be honest, I said.  It is not at all clear that, for a young healthy person not in any high-risk group, the risk-benefit analysis favors benefit.  What is such a person’s chance of becoming seriously ill with seasonal flu?  Very small.  What about the risk of a serious adverse reaction to the vaccine?  (Guillain-Barre syndrome, which causes paralysis, starting in the legs and moving up, sometimes temporary, sometimes not, is the most common serious reaction.)  Also very small, but non-zero.  The risk-benefit analysis should be carefully considered by the person contemplating accepting the vaccine.

I thought the hospital management, employee health department, or infection control practitioner - whoever was making the pitch - should say the reason for being vaccinated was to protect our patients, to avoid acting as vectors of transmission of influenza from sick patients to those who were not sick with the flu but were susceptible.

As it turns out, the effectiveness of vaccinating health care workers as a way of protecting their patients is a matter of some controversy.  It is intuitively appealing.  It makes sense.  From what we know about contagion and public health and healthcare associated infections, it just has to be true.  But it’s not so easy to study, and the available evidence is not compelling.

And that brings us to the subject of this essay: mandatory vaccination.

The Centers for Disease Control and Prevention (CDC-P, or just CDC for short) currently recommends that everyone (past the age of six months) get the flu vaccine.  I have to assume the rationale is that it will reduce the total societal burden of influenza illness during flu season.  But people don’t find that persuasive.  They want to hear that it will keep them from getting sick.  So that is the message.  If the messengers are being responsible, they will include the caveat that the vaccine isn’t 100%, and it’s still important to pay attention to hygienic measures that reduce contagion.

But they aren’t as reserved in their recommendation as the facts suggest they should be.  There are important limitations with this vaccine.  The influenza virus is constantly changing.  For those who have not studied virology, don’t worry, I’m not going to torture you with the details.  But the proteins that make up the viruses mutate and rearrange, producing minor and major shifts, and occasionally new (“novel”) strains cross from other animal species to humans.  The vaccine produced each year covers just a few strains, chosen based on a best guess of what strains will be in circulation.  Those guesses aren’t always right.

With any vaccine, some people will be non-responders: the immune system just doesn’t make antibodies in response to the vaccine, at least not enough to be protective against illness.  And unfortunately the elderly, who are at greater risk of becoming seriously ill with the flu, are also at greater risk of being non-responders.

Finally, a substantial proportion of illness with flu-type symptoms - collectively called “influenza-like illness” - is caused by viruses other than the influenza virus.  The vaccine affords no protection whatsoever against those.  At the peak of flu season, about half of all influenza-like illness is caused by those other viruses.

So it’s easy to see why it’s not a certainty that vaccinating health care workers protects their patients and why it might be challenging to study it and try to prove it one way or the other.  At my hospital, employees are encouraged to get the vaccine.  If they decline, they are asked why.  If their reason doesn’t square with what is known about the vaccine - for example, some people are convinced you can get the flu from the vaccine, which simply isn’t true for the injectable version, because the virus has been inactivated - they are given information and asked to reconsider.  But vaccination isn’t compulsory.

Recently ABC News reported on the firing of a nurse in Indiana who refused influenza vaccination.  She thought she had a legitimate reason for refusing: she said her belief that she had a right to protect her body from this foreign substance could be likened to a religious belief, and religious exceptions were permitted.  Some infection control specialists don’t believe in religious exceptions.  They think people whose religious beliefs preclude vaccination shouldn’t be taking care of patients in a hospital.

Frankly, I don’t have an opinion on religious beliefs about vaccination.  I don’t know enough about them to have an informed opinion, and I don’t think I should have uninformed opinions.

But this much I do know: the principle that vaccinating health care workers against influenza protects their patients is based on a consensus of expert opinion, not compelling scientific evidence.  A consensus of expert opinion may be a sufficient basis for recommendations.  It is not a sufficient basis for compulsory vaccination.

It is time to start being honest about the difference between what we think is a good idea and what is supported by a solid foundation of medical science.  And it is time to start making policy decisions that may violate individual autonomy as though we understand that difference.

Depressed? Try Life Unsweetened

People who should know better insist on trying to discover links between diseases and lifestyle choices by doing studies that cannot tell us whether there is a cause-and-effect relationship.

Obviously I wish they would stop.  But they won't.  They keep doing these studies, and presenting them at medical meetings, and publishing them in medical journals.  And, not content to regale their colleagues with this nonsense, they look for a wider audience, an audience full of people who may not know enough about epidemiology or biostatistics to say, "Rubbish!"

Sometimes they don't even wait for their colleagues to say, "Rubbish!" before seeking that unsuspecting wider audience.  And so yesterday there came a press release from the American Academy of Neurology (AAN).  The message: sweetened beverages are linked to depression, and artificially sweetened beverages are even worse than the ones with sugar.

You know I'm going to tell you why this is rubbish, but instead of going right to that, let's approach this as if we were scientists interested in whether it might not be rubbish.  We would take this notion and turn it into a hypothesis to be tested using something that would actually qualify as science, in stark contrast with the subject of the AAN press release.

We would start by recruiting a large group of people.   Ten thousand would probably be enough, but there are statistical calculations you can do to figure out how many you'd need. The recruits would have to be willing to be randomized.  That means accepting assignment, generated at random by computer, to one of two groups.  The first group would be told they should drink artificially sweetened beverages as much as they want to, and they would be asked to keep a diary of their beverage-consuming behavior.  The second group would be told to keep a diary, too, but that they should really try to avoid drinking artificially sweetened beverages.

Then, periodically, the subjects would be asked to come in to have their diaries reviewed and to be asked a bunch of questions.  They wouldn't know what exactly the study was about.  The questions would be sufficiently wide-ranging that they couldn't figure it out.  The interviewers wouldn't know which group the subjects were in or what information was revealed by their diaries.  They also wouldn't know the purpose of the study.

The questionnaire would, of course, include numerous questions of the sort used to screen people for depression, and the subjects would be asked if they were being treated for any physical or mental health problems.

After we'd followed the subjects for a decade or so, we could see what differences, if any, emerged between the two groups.  The information in the diaries could tell us how well the subjects did what they were asked to do (with the caveat of "self-reporting bias"), and it could enable us to exclude from a portion of the analysis, if we were so inclined, subjects who really didn't do what they were asked to do.

This is what medical scientists call a prospective, randomized, double-blind, controlled trial.  This is toward the top of the hierarchy of what we call evidence-based medicine (EBM). (If you look at the pyramid, you'll see the only thing higher is the systematic review, in which smart people look systematically at the medical literature for all the studies that might shed light on a specific question, evaluate the studies, and tell us what the accumulation of scientific evidence reveals.)

This would not be an easy study to do.  To begin with, you can imagine the challenge of recruiting a large number of subjects willing to accept random assignment to one group or another with implications for a specific lifestyle choice that would go on for years.

So, not surprisingly, the investigators whose findings were reported in the press release from the AAN did not do that study.  Let me rephrase that, for emphasis: they did not do the only kind of study that could answer the question, rather than merely generating a hypothesis.

No, instead, they did an observational study.  They took a large number of people - more than a quarter of a million - and collected information about their beverage-consuming habits for one year, and then ten years later asked them if they'd been diagnosed with depression.

The first problem is obvious.  We don't know anything about their habits outside of that one year.  We also don't know if they were really depressed, only whether someone had made that diagnosis.  There may have been many people diagnosed with depression who didn't really meet accepted diagnostic criteria. Even more likely is that there were quite a few people who were depressed but hadn't been diagnosed.

The biggest problem, however, is that we have no way of knowing what other factors - and there could be many - might be what scientists call confounders: other influences on the likelihood of developing depression that might themselves be linked with the consumption of sweet beverages (whether naturally or artificially sweet).

The most obvious potential confounder is obesity.  It is so obvious that one would hope the researchers looked for differences in the incidence of obesity and tried to adjust for such differences.  That way, if people were more likely to be depressed because in our society it is sad to be fat, and fat people are more likely to drink sweet beverages with sugar (which help to make or keep them fat) or artificially sweetened beverages (because they are trying to lose weight), we can "correct" for the fact that more of the people who had been diagnosed with depression were also fat and, through statistical manipulation, try to eliminate the influence of that confounder.

The trouble with confounders is twofold.  First, statistical manipulation to correct for them is imperfect.  Second, and most important, is that you can try to correct for confounders only if you identify them.  And there may always be confounders that you have not identified.

The purpose of doing a randomized controlled trial is that, with a large enough sample size, the randomization is very effective in eliminating differences between the two groups (other than the one difference you wish to study) that might occur by chance.

So the sweet-beverage drinkers were a bit more likely, ten years later, to say they'd been diagnosed with depression.  And the ones who drank artificially sweetened beverages were a tad more likely than the sugary-drink consumers to say so.

There are questions that might not occur to you but that do occur to me because I practice in an academic medical center and review manuscripts submitted for possible publication in medical journals.  First, why would anyone do a study that cannot answer any important question?  Trying to put a positive spin on this, I'd say sometimes finding correlations or associations is interesting even if we know nothing about causality, and sometimes such findings can generate hypotheses worthy of being tested in a study which can get at the question of causality.

Second, why would a medical journal publish such a study?  I don't have a good answer for that one, because the results are not, I think, important enough to justify publication.  Third, although it is common for research findings to be presented at medical meetings when they haven't been (and may never be) accepted for publication, why would a medical association issue a press release drawing attention to such findings?

My favorite beverage.
I am an entirely
 uncompensated spokesperson.

Sadly, the answer is all too simple.  Results like this will capture the attention of the popular press and the legions of journalists who have no idea how to put them through the filter of intelligent skepticism.  They will then post and print articles about the findings, generating PR for the medical group.  And the unsuspecting public will think maybe they should stop drinking Pepsi One or Coke Zero.

This blog has never won any awards.
I expect that to remain true.

But not you.  Because you read this blog.  And you will say, "Rubbish!"

After the AR-15, How About a Tank?

I like to read Yahoo News.  If I didn't, I would be unaware of the existence of Honey Boo Boo.  I wouldn't know that Kim Kardashian and Kanye West are providing the latest bit of evidence in support of the arguments, made by some curmudgeons, that one should have to apply for a license to reproduce.


And I wouldn't know that Arnold Schwarzenegger owns a tank.  From Yahoo:

The tank in question is an M47 Patton. Produced between 1951 and 1953, the 50-ton behemoths are still in service across the globe 60 years later. And Schwarzenegger told me and an assembled group of around 15 journalists on Friday that this was “exactly the very tank that I drove in the Austrian Army when I was 18 years old.”

There is no mention in the article of whether Arnold's tank has the original 90mm cannon or the .30 and .50 caliber machine guns.  Neither does it say whether the former California governor, action film star, and competitive body builder has a supply of ammunition for those guns.

I'm guessing it didn't even occur to the reporters to ask about any of that, because we're talking about a famous person here, not just an average citizen. The thought of an average private citizen in possession of any of that would be horrifying beyond description, but Arnold is OK.  The rich and famous are different from you and me.

This reminded me of a recent discussion thread on a social media network about the right to keep and bear arms.  One participant said some of his friends who are gun rights advocates took the position, which he clearly viewed as extreme, that they should be allowed to own tanks and Apache helicopters.


A constant feature of these discussions is the idea that no one needs a (fill in the blank, usually something like an AR-15) to go hunting.  Every time I read that, I'm reminded of the bumper sticker slogan, "The Second Amendment Ain't About Duck Hunting."

So what is it about?  Well, it's true that it's not about hunting.  If you go back and read the writings of the Framers, you will find very little about hunting.  They put the Second Amendment in the Bill of Rights for two reasons.  First, they considered an armed citizenry to be a bulwark against tyranny.  (I almost never see the word bulwark used in any other context nowadays.)  Second, they considered armed self-defense to be a fundamental, natural human right that was sufficiently important to be guaranteed by the Bill of Rights.  Notice that this right exists independent of the Bill of Rights. A fundamental, natural human right is not created by the Bill of Rights - merely secured by it, against government infringement.

In the "bulwark against tyranny" framework, the right to keep and bear arms must encompass "arms ...  of the kind in common use [in military service] at the time."  (U.S. Supreme Court, United States vs. Miller, 1939.)  In this case Miller was in possession of a "sawed-off shotgun," and the Court said that in order to prevail in the case against him, Miller would have to show evidence that this was the sort of weapon one might have to use if he were to be called upon to serve in a citizens' militia. As it turns out, short-barreled shotguns were in use by the military in those days, but Miller did not present evidence, and the Court ruled against him.

Some opponents of gun rights say that if we are going to subscribe to the "bulwark against tyranny" argument, private citizens must be able to own machine guns, rocket-propelled grenade launchers, and shoulder-fired missiles. Such a position has not, to my knowledge, been taken publicly by any gun-rights advocates, although its logic is compelling, and I suspect the Framers would likely agree with it, as it is consistent with their original intent.

It is easy to dismiss that original intent by declaring that, more than two centuries later, we need not fear government tyranny.

At the Jewish High Holy Days in the autumn of 1992, the 500th anniversary of the voyage of Columbus to the New World - and also an important year (1492) in the Spanish inquisition - our rabbi spoke of the many Jews of Spain who converted to the official religion of Catholicism.  He asked the congregation to imagine facing a choice of conversion or leaving the country with nothing but the clothes on our backs.  What would we do if we knew government agents would be knocking on our doors to present that choice?

I turned to my wife and said I’d head down to the basement and start loading magazines.

In the 21st century we do not believe our government will be tyrannical or oppressive.  The Jews of Catholic Spain and Nazi Germany hadn’t believed it could happen, either.

If you are convinced that we need have no fear of our government, perhaps you recall episodes of civil unrest in which law-abiding citizens relied on privately owned weapons for defense.

In March, 1991, a young man named Rodney King was beaten by Los Angeles police officers.  The beating was caught on videotape and appeared to show that the officers used excessive force.  Four officers were charged.  In April 1992, they were acquitted on nearly all charges.  South Central Los Angeles erupted in riots.  Over fifty people were killed, and more than two thousand were injured. There was extensive looting.  Among businesses apparently targeted in the looting were Korean retail establishments.  At the time it was said that the black underclass in that part of the city resented the economically successful Korean immigrants.  Whatever the motivations for looting - and mob violence often has no motivation other than random mayhem - TV networks showed video footage, forever etched in my memory, of Korean shopkeepers on the roofs of their stores, holding AR-15s (or similar arms), which seemed effective in redirecting looters elsewhere.

I own semiautomatic rifles because I am a recreational shooter and enjoy a day at the range trying to make holes in a paper target at 100 yards in the smallest possible group.  Being able to fire a shot with each squeeze of the trigger and have the rifle’s mechanism cycle the next round into the chamber without having to work a bolt, which would interfere with my steady hold aligning the sights with the target, makes the semiautomatic rifle ideal for this pastime.

Do I expect to need my AR-15 to defend my home against a criminal mob, like the Korean shop owners during the rioting that followed the Rodney King verdict?  Not really.  I live in an area where the risk of attack by a small pack of coyotes is much greater than that of facing a group of malevolent humans.  Am I expecting agents of the government to knock on my door commanding religious conversion?  Certainly not, although I believe a government that trusts the people with arms may be more deserving of the people’s trust (paraphrasing James Madison).

Unlike Arnold, I do not wish to own a tank.  For one thing, I have no place to park it.  And I cannot afford to operate a vehicle whose fuel consumption is measured in gallons per mile (the M47's fuel capacity is 233 gallons, and its average range is 100 miles).

But I am convinced of this: telling folks such as I that we may not purchase semiautomatic rifles or high-capacity magazines is extremely unlikely to save the life of a single innocent who might be imperiled by a deranged killer.  Pistols with ten-round magazines can be reloaded quickly and are more than adequate as implements of such mayhem.

We can pass all the gun control legislation we want, but allowing that endeavor to distract us from the task of getting at the root causes of these horrific crimes, in the psyche of the perpetrator, will satisfy those who fear and loathe guns while leaving the fundamental problem unsolved.

Rodney King died last June.  During the riots, which King recognized as fundamentally destructive of civil society, he asked, "Can we all get along?"  This could be asked of the advocates of gun control and of gun rights.  And the answer is yes, if we remain focused on the problem of human behavior that is fundamentally destructive of civil society, rather than the implements of that destruction.

  

What Does NHL Stand For?

I am not a hockey fan.

This is not to say that I do not like to watch a hockey game now and then.  But it's different with baseball, or football, or basketball. Especially baseball.

I grew up in a city whose baseball team was terrible in those years. The Phillies were perennial cellar dwellers.  And I now live in a city with a team that has strung together 20 losing seasons.  But I have always been a fan of the game.

Not so with hockey.  I am loyal to my town's teams, so I root for the Penguins.  But in nearly 35 years, I've been to one Penguins game.  And until I got a big-screen TV, I rarely watched hockey on TV, because I could never see the puck.

So I'm a Penguins fan, but not a hockey fan: a fan of the team, but not really of the game.  Abbreviations tell the tale.  (Remember, I'm a doctor.)  Say "NHL," and I'm more likely to think Non-Hodgkins Lymphoma than National Hockey League.

Thus, the NHL lockout hasn't been a big deal for me.  I've hopefully followed the NFL season until the Steelers, still in control of their own destiny, could not beat the Bengals in Pittsburgh in Game 15 and failed to secure a wild card berth.  And I've enjoyed the college football rivalries and bowl games.

Watching Heisman Trophy winner Johnny Manziel perform magnificently as he led Texas A&M to victory over Oklahoma in the Cotton Bowl was a delight.  Even though I have no direct ties to Alabama or Notre Dame, I am much more interested in who wins their national championship game tomorrow night than I am in whether there is an NHL season this year.

In the two decades since the Pirates' last winning season there have been four (!) NHL labor disputes, with one season entirely scrubbed and three others dramatically shortened.  I barely noticed.

But I have to wonder what the owners think they're accomplishing. How many hockey fans have been turned into folks like me, just not that into it any more?  Professional athletic competition is entertainment. It's show business.  If there's no show, there's no business.  And when there's no business, some customers who are turned away will never return.  No matter how much the owners succeed in striking a better deal with the players, this cannot be a good thing.

The regular season in the NHL could be 48 games instead of 82, and by the end of it, fans will likely still be satisfied, because then the second season (also known as the playoffs) begins.  I suspect there are a lot of lukewarm fans who, like me, don't really watch many regular-season games anyway, and really don't pay a whole lot of attention until the playoffs.  (No doubt the same is true for the NBA, whose playoffs are also long enough to constitute a second season.)

But how many serious hockey fans are just thoroughly disgusted by the whole thing?  This is, after all, about the game, the competition, the beauty and the guts and the glory of matching athletic skill and finesse - and, yes, brute strength and street-fighting ability, too - against another team on the ice.  That's what it's about for the fans.  And the fans are pretty sure that's what it's mostly about for the players, too.  Sure, they want to make a good living, and they like being famous. But they enjoy the adulation of their fans, and they know what it takes to earn that.  It's what they do on the ice, the fast skating, the great passes, the breakaway goals, the brilliant saves, and the slamming of an opponent into the boards to separate him from the puck.  It's all about the game.

Yes, the fans know that for the owners it's all about the money.  They're businessmen. Sure, they like the game, and they want to put a winning team on the ice.  But for the vast majority of them, that's only because they may be able to make more money that way.  Do they care about the players?  Do they care about the communities in which their teams play, and the economic impact of a professional sport - or a missing season?  Do they care about the fans?

We know they care about the money.  They haven't shown us they care about anything else.

The Zero Curse

Last month, in the final weeks, and then days, preceding the presidential election, the pundits were talking about how close the race seemed to be.  They were intently focused on the "battleground states."  They worried (or were they really rubbing their hands together in eager anticipation?) that some of the state vote tallies might be so close as to trigger automatic recounts.  And that could lead to legal challenges.  There were echoes of Florida in 2000.  It didn't turn out that way, probably to the disappointment of some journalists (and maybe lawyers) and the relief of everyone else.

But it brought to mind conversations I'd had during the six weeks or so of the contested election of 2000, that period between Election Day and the U.S. Supreme Court's ruling.  Perhaps, I said to the medical students and residents I was supervising in the emergency department, neither Bush nor Gore should want to be the winner, because of the tragic history of presidents elected in years ending in zero.

I noted that the last president elected in a year ending in zero, Ronald Reagan (1980), had been shot soon after taking office and come perilously close to death. Who, I asked them, was the last president before Reagan to be elected in a year ending in zero and not die in office?

I didn't expect anyone to know the answer straight away.  I wanted to see how they would approach the question, what they knew of presidential history, which I would be able to tell if they tried to work their way back through the years that were multiples of 20 - the presidential election years ending in zero.

Nearly all (I was aghast that it was not all) knew that John F. Kennedy was elected in 1960 and assassinated.  But things went downhill quickly from there. Most did not know that Franklin Roosevelt was elected in 1940 (and, of course, also 1932, 1936, and 1944) and died in office (in the spring of 1945, from a cerebral hemorrhage), to be succeeded by Harry Truman.

As I recall, exactly no one knew that Warren Harding was elected in 1920, died in office, and was succeeded by Vice President Calvin Coolidge.  I believe one person knew William McKinley was elected in 1900, assassinated by an anarchist, and succeeded by Teddy Roosevelt.

1880.  James Garfield was shot in 1881 by a psychotic man who believed Garfield should have recognized the work he'd done on behalf of the presidential campaign (which was trivial) and appointed him to an important job. The bullet wound was actually not that bad - nowhere near as serious as the one that almost took the life of Ronald Reagan.  Garfield was more a victim of the terrible medical care he received.  No one knew that.  I can't say I was surprised, but I was disappointed just the same, if only because the medical part of the story was so important.

Truly appalling, however, was that not everyone knew 1860 was the year of Lincoln's first election, although of course everyone knew he'd been assassinated.

1840 offers yet another especially interesting piece of presidential history. William Henry Harrison was elected.  In those days inauguration was on March 4th.  (It didn't move into January until FDR was president.  The nation decided that the wait until nearly spring for Roosevelt's inauguration had been too long, given the urgency of addressing the economic woes of the Great Depression.  So 1933 was the last year it was March 4th, and it was then moved to January 20th). Harrison gave his inaugural address outdoors.  The weather in early March in Washington, D.C. is usually mild, but in 1841 it was not.  Harrison did not wear an overcoat.  A month later he died of pneumonia.  Causality, of course, is open to question, but the result was that Harrison became the first U.S. president to die in office.

No.  That's the answer to your question.  Not a single one of the young medical trainees knew anything about Harrison or his vice president, John Tyler.  What a shame.  Because it's a fascinating story.

Harrison, you see, was not a politician, but a war hero, best remembered for the Battle of Tippecanoe.  (Remember the campaign slogan, "Tippecanoe and Tyler, too?")  He was recruited by the Whig Party, which was desperate to win the White House.  The Whig party was opposed to just about everything Andrew Jackson (Democratic president elected in 1828 and 1832) stood for, but they had learned from dealing with the hero of the Battle of New Orleans (1815) just how popular war heroes can be.  Harrison was perfectly willing to run on the Whig party platform, which was very short on detail, as he had no fixed political principles of his own.  The Whigs then needed a candidate for the #2 spot on the ticket.  Harrison was from Ohio, so they looked south of the Mason-Dixon line for geographic balance and asked John Tyler of Virginia.  Tyler was a Democrat, but apparently not a loyal Democrat, as he agreed to run for VP as a Whig.

Then Harrison died, and Tyler assumed the office.  This had never happened before, and the Constitution was not entirely clear on how it should work.  The Constitution said that in the event of the death of the president, the "powers and duties" of the office "shall devolve on the Vice President."  What wasn't clear, however, was whether the VP actually became president, with all of the accoutrements of the office, or whether he was just the acting president.

It probably wouldn't have been a big deal if Tyler had been a loyal Whig.  But not only was he really, after all, a Virginia Democrat who differed with the Whig party's principles in important ways, but he started doing something earlier presidents had generally not done: vetoing bills passed by Congress because he didn't like them.

[Before Tyler, presidents typically vetoed a bill only if they could plausibly contend it was unconstitutional.  Nowadays we think of it as the Supreme Court's job to address such questions (which it does only if a challenge is brought before it), established very early in the 1800s by Chief Justice John Marshall as the doctrine of judicial review, and presidents routinely veto bills with which they disagree.  But the president is sworn to uphold the constitution and certainly shouldn't sign into law a bill he thinks is unconstitutional.]

Congressional Whigs were livid, and came very close to mustering the votes to impeach Tyler.  They refused to call him the president, referring to him as the acting president - or "His Accidency."

No one I asked knew any of this.  Nor did they know that our fifth president, James Monroe, had been elected in 1816 and 1820 and served his two terms in full, the last president before Reagan to be elected in a year ending in zero and survive to the end of his elected tenure.

So I did not expect anyone to respond to my initial question by saying, "James Monroe!"  I just wanted to see what they knew of presidential history.  Damned little, as it turned out.

Far too few of us show much interest in history in grade school or college, and I'm sure it's at least partly because there are too few history teachers who make the subject interesting, as some of mine did.  This is a terrible shame.  American history is fascinating, and studying presidential history is a wonderful way to approach it.  Thomas Carlyle said, "The history of the world is but the biography of great men."  We've had forty-three presidents (Grover Cleveland, who served two non-continuous terms, is counted twice to get to #44 for Barack Obama). The history of our nation is most certainly the history of these men, especially if you read the sort of expansive biography - the man and his times - that is the kind really worth reading.

I tell residents who train at our institution that there is more to learn in the emergency department than medicine.  A sense of history is something I hope to give each of them, at least a little bit, by the time they've completed the three years I have to influence their lives.

Soak the Rich

On Christmas Day, we are filled with thoughts of charity toward our fellow man. We also think more about all things spiritual, such as the immortality of the soul and the afterlife.  Those who believe in Heaven have all heard that it is easier for a camel to fit through the eye of a needle than for the rich to gain entrance to Heaven.



Pastor Rick Warren was shown, in a video clip I saw several times on CNN yesterday, saying that it is not a sin to be rich, but it is a sin to die rich. That is a fine argument for philanthropy.



And so, when CNBC's Website yesterday ran an article (titled "Majority of Rich Want Themselves Taxed More") about how the well-to-do say they are willing to pay higher taxes, it seemed entirely in keeping with the Christmas spirit.




Sadly, but not surprisingly, however, reading beyond the headline revealed that this was just another example in an unending stream of shoddy journalism.

The article cited a poll done by American Express Publishing and The Harrison Group showing that "67% of the top one percent support higher income taxes."  More specifically, "more than half" support higher taxes on those making more than $500,000 per year.  (In case you're wondering, estimates of what household income places you in the top one percent range from about $400,000 to over $500,000.)

"More than half" of the top one percent?  That's a very interesting breakpoint.  If you do a bit of research, there is a very substantial difference in both income and wealth

between the bottom and top halves of that top one percent.
The bottom half includes professionals like doctors and lawyers who are comfortably upper middle class but not truly wealthy.

The top half of that one percent - and especially the top 0.1% of all taxpayers - is where the real concentration of wealth is found.

An understanding of the big difference between the lower and upper halves of that top one percent makes it easy to understand how half of this group could be supportive of higher taxes on themselves (because they can easily afford it), while the other half are not so keen.  And that explains why more than 60% of the top 1% say they "carry an unfair burden" in the amount of their income they pay in taxes, which doesn't sound as though they would be at all supportive of taxing themselves more.

The CNBC article goes on to tell us that "Other recent surveys show that the wealthy support higher taxes as part of a balanced solution to the government debt problem that includes spending cuts."

A "balanced solution" must include spending cuts?  That's what we've been told. How about some arithmetic?  I know, it's Christmas Day, and you'd like to give your brain a rest, but don't worry, I've done the arithmetic, so all you have to do is read it.

The top one percent represents about 1.4 million taxpayers, with an average taxed income of about $1.3 million.  If we were to add a 4% surcharge (which is what the president has proposed) to the top marginal tax rate on the amount of income taxed at the top rate (which means the income above about $180,000/year), that would generate about $62.72 billion in additional revenue.  The federal budget deficit for the current fiscal year is about $1.372 trillion.  So this surcharge on the top one percent of taxpayers would reduce the budget deficit by about 4.6%.

The House Republicans don't want higher taxes on anyone, but they have suggested they could go for a cut-off of $1 million, while the president is seeking higher taxes on incomes above $250K.

The NCPA needs a reality check itself!

You have to be careful about believing the numbers you read.  The National Center for Policy Analysis, which espouses free-market ideals and doesn't like taxes or government regulation, says the proposed higher taxes on those with incomes over $250K would bring in an additional $42 billion.  That cannot be correct, because that proposal would mean higher taxes on a lot more people, so it would have to raise revenues by more than the $62.72 billion I estimated for the top 1%, and the NCPA does not claim to have taken reduced economic growth (which economists say would result from higher taxes) into account.

Do I claim my numbers are accurate?  Of course not.  First of all, I took only a year of economics in college, and I've been only a casual student of economics in the 35 years since I graduated.  Second, calculations made by even the most erudite economic theorists rest on a set of assumptions, any of which could turn out to be wrong.


The point, however, remains: we cannot tax our way out of these enormous deficits.  We must dramatically reduce government spending.  The "soak the rich" approach may make those of us in the other 99% feel better, and at least some of the wealthy seem to be eager to pay higher taxes.

(If you haven't heard Warren Buffett's preaching about this, you've been hiding under a really big rock.)

We all have different ideas about how to cut spending, from getting out of wars and ceasing to be the world's policeman to cutting off entitlement programs for those who are too lazy to be productive citizens and contribute to society instead of sponging.






The point is that if we don't soon have the kind of political leadership it will take to build national consensus about how to reduce government spending, the drag on our economy created by spectacular annual deficits and mind-boggling national debt will cause the most powerful economic engine in the history of the world to grind to a halt.

A Culture of Violence

Eight days ago a disturbed 20-year-old man visited unimaginable horror upon an idyllic town in New England.  Twenty children and six adults at an elementary school in Newtown, Connecticut fell victim to this violent attack.

Much attention has been focused on the implements used in such mass murders, especially a semiautomatic rifle chambered in a caliber called .223 Remington, also known as 5.56mm NATO.  The latter designation has drawn particular note, and such a rifle is often described in news reports as a "military style assault weapon."  Those who are careful in their use of terminology point out that the rifles used by the military are designed to be fired in fully automatic mode (squeeze and hold the trigger, and bullets are launched from the muzzle in rapid succession until the magazine is empty), and that only such a "machine gun" is accurately described as an "assault rifle."

When the problem brought into relief by such a terrible incident is captured by the phrase "gun violence," it is easy to understand the focus on the gun.  But when we consider that the number of guns in the United States is nearly as large as the number of people, and the overwhelming majority of these guns are never used in acts of violence, it seems logical to suggest that our focus should be on the behavior rather than the implement.

So, while it has been said many times by people on both sides of the debate about the role of firearms in our society that America has a "gun culture" (see, for example, William R. Tonso's 1990 book The Gun Culture and Its Enemies), I believe it may be more helpful to focus on the fact that America has a culture of violence.

Many social scientists have studied and written about the way violence is portrayed in entertainment media.  The word "glorified" is often used, and much attention is directed to violence in movies, television shows, and - especially - video games.

When I was growing up I wondered about Saturday morning cartoons. Characters in those programs routinely did terrible things to each other.  In the Road Runner cartoons, Wile E. Coyote was endlessly getting blown up or having large, heavy objects fall upon him from great heights.  In Tom & Jerry, literally a running cat-and-mouse game, awful things happened to the cat several times per episode.  Vivid in my memory is a scene in which Tom (the cat) is struck a fearsome blow to the head with a frying pan by Jerry (the mouse) while he is sleeping.  I was especially intrigued by the fact that these cartoon characters nearly always appeared in the very next scene as though nothing had happened to them, and I thought this might mislead young children about the consequences of violent acts.  I have since decided that young children are probably a little better than we give them credit for at distinguishing fantasy from reality, and perhaps when the fantasy is a cartoon it is that much easier.

In television shows and cinema, however, it is all about realism.  Directors and cinematographers are very much intent on the goal of making everything that happens look quite real.  Psychologists have worried about how this may desensitize viewers to violence.  I am quite certain it does exactly that.  The only question is how much, and with what consequences.

Video games bring an entirely new dimension to this discussion.  Their realism is ever greater as the technology advances.  Unlike the violence we see on television shows and in the movies, when we play these video games we are not passive spectators.  We are the actors.

A quick overview of some of the titles may lead one to suspect the violent nature of the content.  With names like Assassin's Creed, Mortal Kombat, Call of Duty: Modern Warfare, and Sniper Elite, it is easy to imagine what participants in these games may be doing.  Even the television commercials advertising these games can be more than a bit disturbing, and when the voice-over notes that a game is rated "mature," it is easy to understand why.

Have you ever used Google's specialized search functions?  Mostly I use ordinary "search" or "maps."  (Regular readers know that for some of my essays I use Google Images to find appropriate graphics.  I haven't done that for this one, because the subject is so "graphic" when we just read or talk about it that I didn't think it needed any help.)  I am quite fond of Google Scholar, which has become an excellent way to find out what research has been published on a particular subject.

I could tell you that entering the combined search terms "video games" and "violent behavior" yielded 43,000 "hits."  But it drives me bonkers when speakers at a scientific meeting show a slide that depicts such results, because that doesn't tell you how many of the results might just be researchers endlessly citing their own and others' work.  Most important, it doesn't tell you how much good or important or illuminating research has been published.

So it is necessary to do some careful reading of the stuff we get to by clicking on the links.  And thus I'd like you to know about Craig A. Anderson, Ph.D., Distinguished Professor and Director of the Center for the Study of Violence at Iowa State University.

A 2004 paper by Anderson in the Journal of Adolescence introduces the subject:

For many in the general public, the problem of video game violence first emerged with school shootings by avid players of such games at West Paducah, Kentucky (December, 1997); Jonesboro, Arkansas (March, 1998); Springfield, Oregon (May, 1998), and Littleton, Colorado (April, 1999).  More recent violent crimes that have been linked to violent video games include a school shooting spree in Santee, California (March, 2001); a violent crime spree in Oakland, California (January, 2003); five homicides in Long Prairie and Minneapolis, Minnesota (May, 2003); beating deaths in Medina, Ohio (November, 2002) and Wyoming, Michigan (November, 2002); school shootings in Wellsboro, Pennsylvania (June, 2003) and Red Lion, Pennsylvania (April, 2003); and the Washington, DC.‘‘Beltway’’ sniper shootings (Fall, 2002).Video game related violent crimes have also been reported in several other industrialized countries, including Germany (April, 2002), and Japan (Sakamoto, 2000).

Anderson has devoted many years to this work.  He has published extensively. For those of you who are interested, I strongly recommend that you Google him and visit his home page.  The more you read, the more you will understand one of his salient conclusions:

...as documented in several articles in this special issue as well as in other recent reports, a lot of youths are playing violent video games for many hours per week.  When large numbers of youths (including young adults) are exposed to many hours of media violence (including violent video games), even a small effect can have extremely large societal consequences.

The American Academy of Pediatrics has a longstanding and well-developed interest in the effects of exposure to violence in entertainment on the development of children and their behavioral health.  Noting that medical professionals have been concerned about portrayals of violence in the media since the 1950s and that the U.S. Surgeon General issued a report on the subject in 1972, the AAP issued a policy statement in 2009 that said, "The evidence is now clear and convincing: media violence is one of the causal factors of real-life violence and aggression."

Some of you are probably thinking that many medical professional organizations are also on record as supporting all manner of gun control legislation.  The AAP, for example, has said a home with children is no place for firearms.  But there are important differences.  There is no evidence that access to guns, or learning how to shoot them for sport, makes people prone to use them to commit violent acts. There are abundant data to the contrary.  For example, people who obtain permits to carry concealed handguns for personal protection almost never use their guns in the commission of crimes.  In this instance of the intersection of public policy with health policy, by contrast, there are many studies all supporting the same conclusion that violence in entertainment has a real and causal link to violent acts in real life.

There is another important difference to keep in mind.  We had a ban on the importation and sale of a vast array of semiautomatic rifles, as well as a ban on high-capacity magazines, on the books for ten years.  The statistics kept by the Department of Justice tell us the result in all its simplicity: there was no effect on violent crime committed with firearms.

In case you have forgotten since you started reading, our nation is awash in guns.  Limiting the sales of certain new ones will be like looking at a backyard swimming pool, recognizing the danger it poses to the toddler who cannot swim, and deciding we must not add more water to the pool.  Unless we intend not only to ban the sale of all new guns but also to confiscate all the old ones, we cannot expect to prevent the commission of violent acts with guns by controlling their availability.  For those who may think confiscation is a fine idea, I will note that self defense is a fundamental, natural, human right.  In human societies, armed self defense must be available, else the slow, the weak, and the infirm will ever be at the mercy of the young, the fast, and the strong who just happen to be amoral.

Yesterday the NRA held a press conference in which the organization suggested that placing well-trained, armed security guards in schools might be a valuable and effective short-term solution.  The NRA was promptly scorned by those who thought - contrary to what anyone who knows anything about the Association's history over the last 50 years would have expected - that the NRA was holding a press conference to announce it would embrace new gun control legislation in a spirit of compromise.

We can enact all sorts of new gun control legislation.  We may do exactly that. We will certainly spend a great deal of time talking about the merits of doing so. But the time and effort we devote to this must not detract from the attention directed toward our culture of violence and how we can go about changing that.