Archive for the ‘General’ Category

Gender Asbestos at The Economist

This post originally appeared on APEsphere on January 7, 2010 at this URL.

In a recent article, “Womenomics: Feminist management theorists are flirting with some dangerous arguments,” The Economist takes a position on an age-old feminist debate: are women the same as men (and therefore equal) or are women different from men (implying that men and women are unequal)?  Since at least the early 1980s, feminist scholars have recognized that this debate is a trap because it makes men the measure of all things.  If women have to be the same to be equal, then they must live up to a male standard that doesn’t fit their experience (especially if that standard includes a stay-at-home spouse and no childcare responsibilities).  If women claim to be different, then difference can be used to justify inequality.  But The Economist comes out firmly on the side of preferring the sameness argument: women should be tough and manly in order to compete with men on their own turf.

To be fair, The Economist makes some very valid points, especially in light of the simplest version of the difference argument.  Claims about women being wired differently than men, even from self-described feminists, emphasize stereotypical gender differences and undermine the goal of creating equality.  The hard-wired claim ignores the fact that gender differences in brain structures are minimal at birth and then respond to external input, so that stereotypical gender behaviours are learned and vary cross-culturally.  The Economist makes a valid point in stating that “arguments about the innate differences between men and women are sloppy and counterproductive.”  They also rightly point out that variation within subgroups, in this case men and women, is usually bigger than the difference between them.  This means that, while it may be true that risk-taking and bare-knuckle competition can lead to disasters like the recent financial crisis, one should expect women in the financial industry to share these traits with men who have similar experiences, situations, and incentives.

But on other points The Economist is confusing the issues.  The article seems to want to maintain a male standard by arguing that women should get tough and compete with men by being more stereotypically manly.  It claims that first generations of successful women, like Margaret Thatcher or Hilary Clinton, “insisted on being judged by the same standards as men” and “on getting ahead by dint of working harder and thinking smarter.”  But why should women have to be manlier than men to fulfil their potential?  When I interviewed women and men who worked on Wall Street in the 1990s for my book, I found that some women were able to be successful on men’s terms, especially if they had powerful mentors, but that women who moved up were also held to double standards: expected to be tough, competitive, aggressive workaholics on one hand, and yet to be nice, nurturing, kind, and family-oriented because they were women.  It is, of course, impossible for anyone to fulfil these expectations simultaneously. The Economist prefers to ignore the huge body of research that finds that women are subject to higher standards than men, which means that men receive more opportunities to perform and higher evaluations for the same performance as otherwise similar women.  As a result, average men have an advantage over above-average women.  In fact, those pioneering women who succeeded by men’s rules had to be beyond extraordinary in order to compete successfully with mediocre men.  That is hardly a level playing-field for establishing a meritocracy.  (I have made similar observations in previous blogs.)

The Economist’s efforts to assert the benefits of a sameness approach for creating “old-fashioned meritocracy” in business is particularly critical of Avivah Wittenberg-Cox and Alison Maitland’s arguments in Why Women Mean Business: Understanding the Emergence of Our Next Economic Revolution.  Admittedly, the book does engage in some “difference” arguments that claim that women and men have different but complementary strengths and that organizations need to recognize men and women as both equal and different – arguments that could come straight from the 19th Century First Wave of feminism.  But The Economist’s homage to Second Wave principles of treating women the same as men (with the exception of recognizing women’s greater role in raising children) wants to ignore or negate the wealth of literature on gender and organisations that has developed since at least 1990.  Scholars like Joan Acker began arguing at that time that organisations assume heterosexual male career patterns, which involve no reproductive events, no childcare responsibilities, and ideally a spouse who can take care of all non-work aspects of life.  (Obviously this ideal does not even fit most men in the 21st Century.)  This ideal worker norm and other assumptions about which traits are necessary for success in business are based on custom rather than efficiency, and establish particular subgroups of men as the standard against which all others are judged – simply because these men created the rules and standards.  The feminist argument is not that organisations should promote women in general, but that women may have something valuable to offer that has previously been overlooked because the criteria for success have heretofore been based on traditions that privileged groups of men created in their own image.  As Wittenberg-Cox and Maitland argue, if organisations do not appreciate or nurture women’s skills and experiences because of obsolete standards and traditions then the loser is the organisation.  Wittenberg-Cox and Maitland are simply making a business case for diversifying the standards for success: women represent the majority of consumers and of available talent, so organisational success depends on marketing to women and tapping women’s potential as employees.  For that reason, feminist scholars who aim to transform the workplace to become more gender-balanced and accommodating of women’s experiences and skills are correct about the need to audit the entire building for “gender asbestos.”  Sexism is built into corporate structures and processes in ways that prevent meritocracy from being achieved through any efforts toward “gender-blind” treatment.  This leads to a need to broaden the criteria for success so that individuals who demonstrate skills and insights that are useful to their organisations’ bottom lines, whether they are women or men, can earn success in business.

 

ACOG Up to Dirty Tricks

This post also appeared on the Huffington Post on September 1, 2009 at this URL. You can comment on it there.

A recent press release details some of the lengths that the American College of Obstetricians and Gynecologists (ACOG) is willing to go to preserve its near-monopoly over maternity care in the United States.  In an effort to deter growing numbers of women from seeking out-of-hospital maternity care, ACOG urged its members to submit anecdotal, anonymous “data” (i.e. horror stories) about women who planned out-of-hospital births. This represents an effort to develop an unscientific case against out-of-hospital birth.

ACOG is not a protector of maternal or fetal life – it is primarily concerned with avoiding competition from midwives that could negatively affect the incomes of its members.  A campaign to expose ACOG’s efforts to collect unscientific evidence used social networking tools like Facebook, Twitter, and email to encourage thousands of women to submit their own stories about healthy births in private homes and freestanding birth centers on ACOG’s website.  How did ACOG respond?  It “quickly moved to scrub its website and placed its request for unsourced data from members behind a password-protected firewall” (http://www.thebigpushformidwives.org/_ccLib/downloads/8-31-2009_PushNews_RELEASE_Viral_Internet_Campaign_Exposes_Bogus_Research.pdf).  The survey is still there, in the members-only section, where it is “protected” from the public.  What is likely to happen is that ACOG will then use the unscientific anecdotal data that it can collect from members to support lobbying campaigns directed at denying access to out-of-hospital birth and the midwives who are trained to provide it.

Will this work?  Unfortunately it might, because ACOG has professional legitimacy and receives a lot of respect from members of the media and the general public.  That’s why advocates of reproductive rights – which includes the choice of where and with whom to give birth – must increase awareness of what ACOG is doing.  Otherwise ACOG will bring out their “data” to support opposition to out-of-hospital birth whenever the press offers them some attention.  More people need to recognize that ACOG is a trade association (i.e. a cartel) that tries to protect its members from competition.  Its primary goals do not include promoting science or evidence-based maternity care – obstetrics is one of the least evidence-based specialties in all of medicine.  In fact, the cherry-picked horror stories are designed to discourage women from examining the evidence and making rational decisions about where, and with whom, to give birth.  Meanwhile, two recent well-designed, scientific studies of homebirth in the Netherlands and Canada, both published this year, provide solid evidence that planned out-of-hospital births have comparable perinatal mortality rates, lower rates of serious maternal and neonatal morbidity, and fewer interventions than hospital births among women who meet eligibility requirements for homebirth.  These studies were well-designed scientifically because they compared women with the same level of “risk.” (See Amy Romano’s excellent summary of the results here, or a press release on the Canadian results here.)  Given an opportunity to examine real evidence, like that in these recent studies, many women may rationally choose to give birth outside a hospital setting, and that’s exactly what ACOG is going to desperate measures to prevent.

Obviously birth activists who want pregnant women to have the option of midwifery are interested in this, but really everyone should care about ACOG’s self-serving behavior, which violates principles of anti-trust and is also relevant for the health reform debate.  Maternity care in the U.S. is much more expensive than any other developed nation and has far worse results – higher infant and maternal mortality, more premature and low birth-weight babies, and more infants in the NICU.  Having a baby is the most common cause of hospitalization, and cesarean sections are the most common surgery in the United States.  Out-of-control cesarean rates (around 1 in 3 births) and high-intervention obstetric care for low-risk women represent huge cost burdens on the system as a whole.  The health reform debate has said little about maternity care, and that is a major omission.  One of the best ways to reduce health care costs while improving results is to better integrate midwifery care and out-of-hospital birth into the health care system.  But ACOG clearly doesn’t want that to happen, since it would reduce its members’ bottom lines.  It’s time for this cartel to be broken up.

 

Woman-Hating and the LA Fitness Massacre: Hate Crimes against Women

This post also appeared on the Huffington Post on August 7, 2009 at this URL. You can comment on it there.

I was a university student living in Montreal during the Montreal Massacre on December 6, 1989.  In a classroom at the Ecole Polytechnique of the Universite de Montreal, Marc Lepine separated the men from the women and, claiming that he was “fighting feminism,” shot all 9 women in the class and killed 6 of them.  Specifically targeting women, he managed to shoot 28 people and kill 14 women before committing suicide.  At first people said he was “crazy,” “psychotic.”  Then they started to blame his mother: she must not have loving enough, and she shouldn’t have worked outside the home.  After all, blaming mothers is one of the easiest ways to blame women for men’s crimes against women.  (Thank you, Dr. Freud.)  But despite some efforts to suppress the contents of Lepine’s suicide note, Canadians soon started to realize that the Montreal Massacre was an anti-feminist attack, an extreme form of violence against women.  After all, Lepine singled out the women and blamed them for taking the education and jobs that he felt entitled to have as a man.  His suicide letter said that the feminists had always ruined his life and that he planned to send them “to their Maker” (“Ad Patres”).  In the note, he claimed to be a rational man who just wanted to kill the feminists who enraged him.  Why did feminists enrage him so much?  Because he thought that women were taking away men’s traditional advantages in education and in the workforce, without relinquishing women’s traditional advantages (he mentioned cheaper insurance and extended maternity leave – so you know he wasn’t living the U.S.).  It also contained a list of 19 Quebec women that Lepine considered to be feminists and wished to kill.  This note, in conjunction with Lepine’s oral statements and the clear targeting of women as victims, quickly led Canadians to see the event as an antifeminist attack and an example of wider issues of violence against women.

I remember these events and the discussion afterwards well – I was a university student just like those that Lepine shot, in a classroom at another university in Montreal.  Now, nearly 20 years later there has been a strikingly similar anti-feminist attack: the shootings by George Sodini at an LA Fitness center near Pittsburgh, Pennsylvania.  Sodini walked into the aerobics room where about 30 to 40 women were exercising and started shooting, killing three women and wounding nine before fatally shooting himself.  The instructor of the class, who is pregnant, was shot twice and critically injured.  Once again it is all too close to home: I teach group fitness classes at LA Fitness (a skill I picked up back when I lived in Montreal).  Given the response to the Montreal Massacre, I wonder if this event is getting the media attention it deserves (although I’m sure LA Fitness would prefer that the attention die down – understandably, since the organization had nothing to do with the shooting or the shooters’ motives).  But this was a hate crime against women.  Don’t fall into the trap of thinking that Sodini was just a lone psychopath.  But like Lepine, Sodini targeted women in general rather than anyone personally.  He was a WOMAN-HATER.  That needs to be said because it’s too easy in this crazy political climate to accuse women who want equal treatment of being “man-haters” or to accuse people of color who recognize the effects of historic mistreatment of being “racists.”  (The ridiculous rhetoric around Judge Sotomayor’s nomination is a case in point.)

Like Lepine, Sodini’s hatred of women was based on his sense of masculine entitlement.  Sodini may have had less to say about what he believed that women took away from him economically, although he did comment in his on-line blog that the lack of a wife/sexual partner was a career disadvantage.  But Sodini’s gripes were more about what he believed women owed him sexually and did not deliver.  The suicide note (yet to be released) that was in his gym bag apparently complained about how he had never spent a weekend with a woman, vacationed with a woman, or lived with a woman, and his sexual experiences were limited.  His on-line blog documented his growing rage with women for rejecting him.  In it he said, “I actually look good. I dress good, am clean-shaven, bathe, touch of cologne – yet 30 million women rejected me – over an 18 or 25-year period. That is how I see it. Thirty million is my rough guesstimate of how many desirable single women there are.”  How does this lead to a hate crime against women?  One thing that allowed him to do such a thing to individual women who never did anything to him personally was through his objectification of women.  On the blog, he described the women he saw at the gym: “Many of the young girls here look so beautiful as to not be human, very edible.”  He also clearly believed that women were giving sexual access to men that he viewed as less entitled than himself, such as black men. “Black dudes have thier [sic] choice of best white —-. You do the math, there are enough young white so all the brothers can each have one for 3 or 6 months or so.”  While it is likely true that Sodini, like Lepine, was a disturbed man, it is clear that the channeling of his rage against women as a group makes it a hate crime against women.

Maybe few people are drawing the line between this hate-crime against women and the Montreal Massacre nearly 20 years ago.  Or perhaps few Americans remember that this happened before.  In Canada, December 6 is a commemorated as the National Day of Remembrance and Action on Violence Against Women in recognition of the political nature of Lepine’s hate crime.  How will the U.S. acknowledge the woman-hating crime that occurred in 2009?

 

The Health Care Bubble: The Status Quo is Unsustainable

This post also appeared on the Huffington Post on August 5, 2009 at this URL. You can comment on it there.

Everyone loves to be angry with Wall Street and the mortgage lenders for causing a big financial mess. That’s understandable, and I have certainly had my share to say about high bonuses on Wall Street. But I am struck by the sheer idiocy of some comments from defenders of the private health insurers in the U.S. who don’t seem to recognize that health care built on private insurance companies is headed for the same kind of train wreck. Planted by Republicans and lobbyists to disrupt town meetings, and writing comments on articles and blogs in support of health care reform, defenders of the status quo seem unable to see the big insurance bubble for what it is: an unsustainable out-of-control behemoth headed for a huge collision.

Never mind that I am chronically angry with my health insurance company, United Healthcare, which cost over $17,000 in the last fiscal year, a large chunk of which is paid by my employer. If that’s not a huge tax, I don’t know what is. No wonder we have not received adequate cost-of-living salary adjustments during the nine years that I have worked here. Meanwhile, they recently denied the claim for my son’s 2-year-old check-up. The American Academy of Pediatrics recommends well-child check-ups at 15, 18, and 24 months, and then every year after that. But the plan says that he has maxed out his benefits for well-child check-ups this year so I get the bill. Do the defenders of private insurance companies never receive this kind of absurd denial of payment after paying through the nose for the coverage that they love so much?

But all hatred aside, it is clear that the current system of private health insurance is economically unsustainable. Health care costs have been rising 12% per year, while incomes were rising 2% per year before the current recession. As increases in income are likely to be small or non-existent this year because many people have lost their jobs or had to accept pay-cuts or furloughs, health care costs just keep rising. The math simply doesn’t work. It’s like the housing bubble that few seemed to see coming as prices peaked in 2006. House prices can’t increase 30% a year forever. It doesn’t take long before people can’t afford to buy a house, and those who already own them can’t pay their mortgages. We all know how that story ended: in a huge recession. The story of a health insurance system built on private companies whose primary goal is the pursuit of profits for their shareholders will also have a bad, bad ending.

It is clear that retaining the existing health care system in the U.S. will drive the economy into the ground. It is also clear that the most economical solution to covering everyone and reducing costs is to implement a universal single-payer insurance system. Unfortunately there is no political support for that – partly because the health insurance and pharmaceutical industries own the two houses of Congress and partly because Americans fetishize the free market with its valorization of private over public (both of which, again, brought you the housing bubble and the financial meltdown). What isn’t clear is whether the lobby-funded lawmakers will reform health care in a way that benefits the public and the economy, or will keep letting big business run this country into the ground. Maybe then I will finally convince my husband that we should move back to Canada, where health care is both cheaper and has better results.

 

Is a Woman in Labor a “Person”? New Assaults on Pregnant Women’s Civil Rights in NJ Case

This post also appeared on the Huffington Post on July 21, 2009 at this URL. You can comment on it there.

Yet another ruling is providing legal support for the false belief that obstetricians are infallible, and stripping pregnant women of basic civil rights that are accorded to other individuals.  In the case, New Jersey Division of Youth and Family Services v. V.M. and B.G., the New Jersey appellate court found that V.M. and B.G. had abused and neglected their child, based on the fact that the mother, V.M. refused to consent to a cesarean section and behaved erratically while in labor.  The mother gave birth vaginally without incident, and the baby was “in good medical condition.”  Then she was never returned to her parents, and the judge in the case approved a plan to terminate their parental rights and give custody of the child to foster parents.  What, beyond the obvious, is wrong with this picture?

First, from a legal perspective, individuals have a right to informed consent and bodily integrity.  In obstetrics, informed consent is a blurry concept since many hospitals perform obstetric procedures on laboring women without informing them of the evidence concerning those procedures or their risks.  Perhaps this legal case illustrates how paternalistic hospitals can be with respect to pregnant women – assuming that the hospital staff know best and that informed consent is unnecessary.  Never mind that hospitals tend to be run with organizational efficiency, rather than patient interests, in mind.  In this specific case, one obstetrician who tried to convince the mother to consent to a c-section concluded that she was not psychotic and had the capacity for informed consent with regard to the c-section. It is clear within the law there is no informed consent without informed refusal, so this obstetrician’s conclusion should have made V.M.’s refusal to consent to the c-section her decision alone.  If this mother is not legally permitted to refuse major abdominal surgery, then she is clearly stripped of her civil rights to informed consent.

In fact, individuals are not legally required to consent to invasive procedures even to save other individuals, including fetuses that lack full legal status.  But in this case the district and appellate courts subverted a pregnant woman’s informed medical decision-making in the name of fetal rights, arguing that her refusal was a form of abuse and neglect of the child that had not yet been born.  This is another dangerous precedent, along with other court-ordered cesarean cases, that will allow all pregnant women to lose their rights to bodily integrity and informed consent. It may be understandable, if not excusable, that the courts don’t understand medicine or recognize that medical judgment is fallible, but it is hard to understand how they could so fundamentally misinterpret the law, in which performing surgery on an individual without that person’s permission can constitute criminal “battery” under common law.

The court’s opinion also suggests that lawmakers have no concept of what it is like to be in labor. Women in labor tend to find themselves on a different mental plane, where they have to focus inward and work with their bodies to give birth.  As midwives know, some women become belligerent.  Some seek privacy and seclusion.  Most women in labor are likely to find the routine and usually unnecessary procedures of hospitals to be invasive and unwelcome. Yet the courts that decided this case didn’t seem to be aware that women are unlikely to behave the same way when they are in labor than when they aren’t. The decision cites hospital records that describe the mother, V.M., as “combative,” “uncooperative,” erratic,” noncompliant,” “irrational” and “inappropriate.” Also, her husband indicated that the way she was acting was not her “normal manner and that she is not as ‘tranquil.’” Why would anyone expect a woman in labor to be compliant, tranquil, or rational?  What kinds of expectations does our society have for women undergoing a powerful physiological process, often with an absurd amount of poking, prodding, and general interference?  This mother was uncooperative with hospital staff, but clearly her uncooperativeness had nothing to do with the well-being of her baby.  There is no reason to believe that she did not have the well-being her baby as her top priority, even though she was not a model patient.  There is also no reason to believe that everything the hospital staff wanted to do was essential or even beneficial for the well-being of either mother or baby.  In fact, typical obstetric care engages in many procedures that are unnecessary and often harmful, more out of habit and for the convenience of hospital staff than in the best interest of patients.

While the court opinion also focuses on the parents’ psychiatric diagnoses (which are fallible medical judgments) and their history of care in determining their fitness as parents and abrogating their parental rights, their psychiatric state would never have been questioned if the mother had not refused invasive abdominal surgery – which was entirely within her rights. The tragic consequence for this family was separation from their infant daughter from the moment of her otherwise uneventful vaginal birth.  That kind of injustice can’t have been good for the psyche.

 

Buyer Beware: Bankers Selling Administration on Watered-Down Financial Regulation

This post also appeared on the Huffington Post on July20, 2009 at this URL.  You can comment there.

The bankers are cozying up to the regulators, and what good could come of it?  Goldman Sachs and JPMorgan Chase rake in record profits and get off the taxpayer dole.  It seems good that taxpayers aren’t bankrolling them anymore, but now they aren’t accountable either.  The only way to make them accountable is to regulate them effectively, and you can be sure that they’re going to fight that tooth and nail, just like the health insurers will fight health care reform that eats into their profits.

The New York Times reports that Jamie Dimon, CEO of JP Morgan Chase, is in close personal contact with Rahm Emmanuel.  What is Mr. Dimon selling the administration?  Clearly he wants to limit the reach of new regulations, especially regulation of derivatives – which is one of the products that landed Wall Street and the global economy in this mess in the first place.  When the Wall Street eliminated fixed commissions in 1975 in response to SEC pressure, it reduced their revenue stream from institutional investors, who could suddenly demand volume discounts instead of paying the same price per share as small investors.  What did Wall Street do to remain profitable, and grow dramatically over time?  Increasingly they created derivative products so that they could build their fees into the products themselves.  As the NYT reports, “While JPMorgan favors new reporting requirements for the complex financial instruments, it opposes the administration proposal to force trades onto public exchanges; doing so would likely cut into the firm’s lucrative business of selling clients custom-made instruments.”  Custom-made instruments mean that more fees can be built in.  As others have noted regarding the problem of derivatives based on sub-prime mortgages, derivative products contain a murky combination of assets, some of which may not be as sound as they first appear.  But they certainly are profitable for Wall Street firms!

Taxpayers and investors are often the same people, and even more so in the era of the big banking bailout.  But this is another case where the buyer must beware.  Wall Street and the health insurance industry both deserve no trust when it comes to your interests – they are focused on their own profits.  We’ve seen what unfettered markets bring, and it’s time to abandon market fetishism.

Please also join me on Twitter.

 

The False Premises of “Welfare Reform”

This post also appeared on the Huffington Post on July15, 2009 at this URL.  You can comment there.

The 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) – more commonly referred to as “welfare reform” – radically changed federal policies for assisting needy individuals and families throughout the United States.  Most media coverage in the years immediately following its implementation hailed welfare reform as a success based on the reduction of government costs and because the policy appeared to reform the highly unpopular earlier program, Aid to Families with Dependent Children (AFDC).  But there is growing evidence that the neediest families are falling through the cracks under the new regime, especially in this weak economy.  A recent New York Times article, “Safety Net is Fraying for the Very Poor,” described a new study by the Center on Budget and Policy Priorities that has found that public assistance programs have provided less help to the most desperately poor since the mid-1990s, even before the current recession.  The most desperately poor are mainly non-working families with children, most of which are headed by single mothers with limited education and few marketable skills.

Part of the problem with welfare reform was that it was based on false premises: lawmakers at the time were focused on what they saw as the moral failures of the poor, rather than on assisting them out of poverty.  The PRWORA was premised on the idea that if poor single mothers worked outside the home, and if poor women would get married before having children and stay married after, then there would be no poverty.  Never mind that someone working a full-time job 50 weeks a year earning the soon-to-be minimum wage ($7.25/hour, as of July 24, 2009) earns less than the poverty threshold for one adult and one dependent child, or the fact that the women who become poor single mothers tend to couple with men who lack marketable skills and stable full-time employment.  Welfare reform envisioned two primary options for women to leave welfare: leaving welfare through employment (which Sharon Hays called the “Work Plan” in her 2003 book, Flat Broke with Children: Women in the Age of Welfare Reform), and leaving welfare through marriage (which Hays called the “Family Plan”).

In promoting these strategies for exiting welfare, policy-makers seemed to assume that marriage and paid employment would offer similar economic benefits to poor single mothers who rely on public assistance as they do to women who are not in poverty.  Researchers who study poor families and welfare have contested this assumption, arguing that the employment and marriage prospects that are available to low-income women offer much smaller economic benefits than those available to women who are not poor.  With a graduate student, Katrina Running, I have used the Survey of Program Dynamics, Third Longitudinal File, to test the differential effects of paid employment and marriage on the economic well-being of women who have received public assistance versus those who have not.  The data were designed for longitudinal analyses of the effects of welfare reform on individuals, families, and households.  We examined the impact of marriage and employment (hours worked in the last week and weeks worked in the last year) on women’s household income as a percent of the federal poverty line, adjusted for family size.  Marriage and paid work both increased the household economic well-being of women who received welfare at some point in time far less than they increased the relative incomes of women who did not collect welfare during the survey period.  The relative increase associated with marriage was about half as large for women who were needy.  The relative increase in economic well-being associated with full-time work was also half as large for women who needed public assistance.  It is clear that law-makers based their theories about how to improve the economic well-being of single mothers with dependent children on the experiences of middle-class families.  Rather than increasing the range of choices for women on welfare, welfare reform has pushed many poor women into the workforce without improving their opportunities to rise out of poverty.

Time limits in the PRWORA also mean that some of the poorest families are not eligible for any cash assistance at all, even as their already narrow job opportunities have shrunk even further.  The data in the Survey of Program Dynamics encompass the strong economy of the 1990s and end in 2001, so imagine how much less effective the Work Plan and the Family Plan are now.  As a result of the 1996 welfare reform policy, when this recession began in late 2007, the social safety net was already weakened for the poorest families in America.  It was weakened for ideological reasons, and under assumptions about work and family structure that are demonstrably false.

 

Dick Morris Doesn’t Understand Birth or Health Care

This post also appeared on the Huffington Post on June 29 at this URL.  You can comment there.

On the June 24 edition of The O’Reilly Factor, Dick Morris said that “right now the government is telling people, cut back on cesarean sections, go through natural childbirth. It’s a lower cost.”  Aside from the simple fact that this is false, there’s a lot wrong with this picture, especially given that he chose the example of cesarean sections.

It would be understandable that Americans are worried about the rationing of health care, except that private insurance companies do a lot more rationing of care than single-payer systems in other developed countries.  But it’s especially interesting that Morris made his false claims about childbirth, since American maternity care is unnecessarily expensive and has very poor results. The U.S. pays twice as much per birth as other developed nations.  The American infant mortality rate is the second-worst in the developed world and ranks 37th in the world, behind South Korea and Cuba. Maternal mortality rates have been rising since 1982 in the U.S., which currently ranks 41st among 171 countries. In August 2007, the CDC reported that the number of women dying in childbirth in the United States increased in 2004 for the first time in decades. National data on infant mortality rates in the U.S. also reveal an increase in 2005 and no improvement since 2000.  In fact, countries with universal health care systems have much better maternal and infant outcomes, as well as lower cesarean rates.

The correlation between poor outcomes of the American maternity care system and high cesarean rates, which have risen from 4.5% of U.S. births in 1965 to 31.8% in 2007, is not spurious.  Morris implies that cutting back on cesareans and encouraging natural childbirth would do a disservice to the health of mothers and babies – an implication that is patently false.  Cesarean can be a lifesaving procedure, but it also increases the risk of neonatal respiratory problems and carries a much higher risk of maternal complications and a four times higher risk of maternal death than vaginal birth. Based on scientific evidence, the World Health Organization (WHO) recommends a cesarean rate of 10-15%: below 10% the benefits of the surgery outweigh the risks to the health and life of mothers and infants, while over 15% the risks of surgery outweigh the benefits. According to the WHO, the rate of cesarean section should not exceed 15% in any country because maternal deaths increase at higher rates. However, the cesarean rate in the contemporary United States is more than double this recommended upper-limit.

As Media Matters reported with respect to Morris’ absurd claims, the AMA and five other health care organizations issued proposals to address the overuse of certain procedures on June 1. “In its attachment to the letter, the AMA stated that the ‘AMA-convened’ Physician Consortium for Performance Improvement (PCPI) recommended addressing ‘the overuse of certain services or procedures,’ including ‘Induction of labor/Caesarean Sections.’”  The proposals addressed overuse, and it is clear from the medical research literature are that labor induction and cesarean sections are over-used in the United States, and that this overuse is detrimental to the health of women and babies.  If healthcare reform in this country leads to fewer c-sections, it will save money and lives.  Aside from a few obstetricians who prefer the surgical route, whatever its ultimate health consequences, who can really complain about that?

 

Address Medical Liability with Science, Not Caps: The “Standard of Care” is not the same as evidence-based medicine

This post originally appeared on the Huffington Post on June 17, 2009 at this URL.

On June 15, the New York Times described how Obama is open to reining in medical suits by trying to reduce malpractice suits.  There are some fundamental issues that need to be on the table when thinking about this issue, the most important being that the “standard of care” is not necessarily evidence-based.  There are also far more medical errors than there are malpractice suits, and the few frivolous suits that exist rarely make it to settlement, let alone court.  I am currently exploring the effects of malpractice on maternity care, and will address these issues below.

The AMA and doctors are in favor of protecting doctors from malpractice lawsuits, and they have good reason: medical liability insurance premiums are absurdly expensive, especially in some states (e.g. Florida).  Practitioners must then pass along the costs to consumers, leading to inflation of healthcare costs.  However, premiums are not based entirely on the risk of being sued: liability insurers invest the premiums and then must increase their rates when their return on investments decline (as would be happening now in the recession).  They also raise their rates when they don’t face competition, and some states have only one or two liability insurers.  So liability insurance isn’t in sync with actual malpractice activity.  Using the National Practitioners Data Bank, I have found that obstetric malpractice suits have fluctuated over the years 1991-2004 rather than increasing over time.  This is not what one would expect based on the increased fear of litigation that doctors express.

In fact, many doctors practice in fear of litigation, and some have argued that this leads to “defensive medicine”: medical practices designed to avert the future possibility of malpractice suits, rather than to benefit the patient.  This drives up the cost of healthcare, because payers end up paying for unnecessary procedures.  But again, their fear is out of proportion to the actual risk: the risks of lawsuits have not increased, and the average awards in medical malpractice suits have increased only slightly (adjusted for inflation).

On the other hand, negligent medical errors are far more common than people in favor of capping damages want to acknowledge.  In the Harvard Malpractice Study, Dr. David Studdert led a team of eight researchers from Harvard School of Public Health, Brigham and Women’s Hospital, and the Harvard Risk Management Foundation.  The study used a conservative methodology to determine whether or not negligence occurred in 31,000 medical records, dating from the mid-1980s.  Practicing doctors and nurses evaluated the cases, and the study made a finding of negligence only if two doctors, working independently, separately reached that conclusion.  The study found that doctors were injuring 1 out of every 25 patients, and only 4% of these injured patients sued.  So the actual rate of negligent medical error is much higher than the litigation system suggests.  Also, fewer than 10% of cases were “frivolous,” meaning that no negligent medical error occurred, and the courts efficiently threw them out.  Only 6 cases where researchers couldn’t detect injury received even token compensation.

This issue of medical error is already part of the argument against reform: many who are against caps on damages point to the high rate of error and its impact on patients and their families.  But the missing piece that no one on either side of this debate seems to talk about is that the “standard of care” is part of the problem.  The New York Times article suggests that President Obama is “open to offering some liability protection to doctors who follow standard guidelines for medical practice.”  But standard guidelines are often not based on the best scientific evidence, and this is especially true in the case of obstetrics.  Evidence-based medicine suggests that optimal management of birth involves minimal interventions, and yet the standard of care involves high rates of induction of labor, often using drugs like Cytotec that are contra-indicated for this purpose (see here and here on the dangers of this drug), artificial stimulation of labor, amniotomy, confinement to bed, restriction of food and drink, non-physiologic positions for pushing, and very high rates of cesarean section (currently about 1/3 of births nationwide).  This is the “standard of care” but is not evidence-based – there is a large body of scientific research that finds that all of these practices are harmful and lead to unnecessary and preventable instances of fetal distress, cesarean section, and maternal mortality and morbidity.  Moreover, there is some evidence that doctors do more interventions and more cesareans as a defensive practice, because it fits the standard of care and despite the fact that it goes against the scientific evidence.  So offering protection to doctors who follow standard guidelines for medical practice will not reduce medical errors and preventable injuries, at least not in obstetrics.  In order to do that, President Obama’s healthcare reform should think about offering liability protection to doctors who practice evidence-based medicine.  To let the “standard of care” continue to rule is akin to letting the fox guard the henhouse.

 

Still Selling Women Short

This post originally appeared on the Huffington Post on December 2, 2007 at this URL.

A Dec. 1 NYT article, “Top Ranks of Women on Wall Street are Shrinking” tells tales of political infighting and the subprime mortgage crisis as catalysts for the ouster of Zoe Cruz from a high executive position at Morgan Stanley. Since she was Wall Street’s best bet for a woman chief executive, it now seems there are no women with “a viable chance of becoming chief executive anytime soon.” Are women back to square one, circa 1970, on Wall Street?

Landon Thomas Jr. says that industry insiders wonder if this high-powered executive’s “status as a demanding woman in a male-dominated industry” may have tipped the scales against her. Of course her gender was part of it.

When I interviewed women and men who worked on Wall Street in the 1990s, I found that stereotyping profoundly influenced the way that women were treated. Like Zoe Cruz, some women were able to be successful, especially if they had powerful mentors. But women who moved up were increasingly held to double standards: expected to be tough, competitive, aggressive workaholics on one hand, and yet to be nice, nurturing, kind, and family-oriented because they were women. It is, of course, impossible for anyone to fulfill these expectations simultaneously. I found that women who had proven themselves and attained positions of power on Wall Street were often especially negatively regarded.  These women faced expectations that they would behave in appropriately feminine ways, even though cultural ideas of femininity clashed with definitions of managerial competence in Wall Street’s male-dominated culture.  People have a difficult time accepting aggressive and dominant behavior from women, like speaking with a stern facial expression, making a lot of eye contact while speaking, or making verbal or non-verbal threats.  At the same time, women on Wall Street had to exhibit these types of “masculine” personality traits and contradict expectations of femininity to prove their competence within Wall Street’s culture.

This created a double standard for their actions, made it difficult for them to wield authority in the workplace. One of the women I interviewed observed, “I’ll talk firmly to an analyst and say, ‘I need these numbers by this time.  And you better proof it.  And I want it right and formatted.’ That will come back to me that I was being a ‘bitch.’  I’ll get a call from the staffer that says, ‘You can’t talk like that.’ Whereas a guy, my officemate, would say to some guy – same guy – ‘You know, you’re such an asshole. How can you be so stupid? Don’t you know this is how you do this?  And don’t come back into my office until it’s right.’ And that doesn’t warrant a phone call.” Women in high positions receive more negative evaluations than men who exhibited similar behavior. When expectations for their behavior are so contradictory, how can women compete?

It’s unfortunate, perhaps tragic, that industry insiders like Elaine La Roche are saying “I think in recent years the advances made by women in the 1990s have reversed.” Things weren’t so great for women in the 1990s, as my research shows, but there were some women making headway in this lucrative industry. Is retrenchment a sign of a general backlash against principles of gender equity in the Bush era (as denial of systematic gender inequity has escalated while statistics about it have been removed from government webpages)? Or is a sign of backlash against the lawsuits and settlements of the past decade?

Louise Marie Roth is an Associate Professor of Sociology at the University of Arizona, and author of Selling Women Short: Gender and Money on Wall Street published by Princeton University Press.