Sicko

.
Over at a Comment is Free Christopher Hayes has an interesting comment on Michael Moore, propaganda, and Moore's new movie Sicko. By the sounds of it, the movie is a compelling critique of the US health care system. Moore's good at compelling, which is part of the reason why the right hate him. Moore's also good at logical inconsistency, various versions of 'the kite fallacy', and, of course, factual 'smoothing', which is why I feel conflicted about him*.

According to Hayes, Sicko - otherwise brilliant - ends with Michael Moore taking 9/11 rescue workers, whose health problems have been shamefully untreated in the US, to Cuba for medical attention. The first half of this premise sounds wonderful to me: given all the elixir d' propaganda that has been milked from the 9/11 heroes, the fact that some have been simply left to suffer the health consequences of the event, is not only an appalling indictment of the US health care system but also of the US itself.

And I can see the temptation of Cuba too: what better way to stick it to US elites then getting treatment from the old socialist boogieman. But the exercise is flawed in two ways. First, there's the uncomfortable fact that foreigners are charged for health care in Cuba (a point which, if Ben Whitford is to be believed, it is omitted from the film). Second, there's Cuba's human rights record - which shouldn't be, but too often is, ignored by some on the left.

Why give air to a regime like Castro's?

[Update: according to the Wikipedia "In an interview with Time Magazine, Moore states "I’m not trumpeting Castro or his regime. I just want to say to fellow Americans, "C’mon, we’re the United States! If they can [provide care for all] we can do it."^[11] Fidel Castro is also referred to as a "dictator" in the film." Which sounds a bit better - maybe I should just shut up until I've seen the film myself.]

[Update 2: Ah heck, blogs aren't about just shutting up, anyhow. So one more thing: I've been reading over the film list for this year's Telecom New Zealand film festival. In 2004, Fahrenheit 911 was afforded prime place, not so this year: we won't be seeing Sicko at all. Instead, we've got Manufacturing Dissent, a critique of Moore. What a difference a few years and a personal debunking industry can make.

Although if the Wikipedia entry is to be believed, there's some tasty irony floating round - it seems as though Manufacturing Dissent may have, erm, manufactured, claims about Michael Moore meeting Roger Smith.]
_______________________________________

* It's worth noting that polemicists from all points of the politic compass engage in these activities. The fact that Moore's indulgences are more well known is not, in my opinion, evidence that he is any worse at them than anyone else but rather the fact that he has been successful enough to foster a Moore debunking industry.

Até dia Qui bô voltà

.
As part of their series on migration the New York Times has an interesting article on a small island state and its diaspora. The country in question isn't in the Pacific though, and its emigrants aren't in here in New Zealand. Instead, the story is about a small collection of sand covered islets that float in the Harmattan-swept North Atlantic: Cabo Verde, or the Cape Verde Islands. The Islands are a small independent African nation, formerly a colony of the Portuguese.

The thrust of the story, and what makes it interesting, is its focus on the social consequences of migration. There's little denying that remittances have made the lives of both the emigrants and their families back home better off economically, but the social costs for the separated families are often high.

It's not only the families at home who suffer either: around the world migrant workers are highly vulnerable to exploitation and worse. And Cape Verdians are no different in this respect.

This is something I know from personal experience. I spent several months in the Cape Verde Islands in 1999; for the first six weeks I stayed in a rented room in the village of Palmeira on the Island of Sal. In the room adjacent to me, only partially separated by a wall that never quite made it to the ceiling, was a family; a mother and her son. Christian, the son, must have been close to my age and we slowly became friends. His mother, until I finally got invited into their room, I never met. She stayed inside all day and the only reason I knew of her presence was the almost endless muttering that drifted over the wall. When I finally was invited in by Christian I met a pale woman with the wild, wide-open eyes of some form of mental illness. Christian tried to introduce me to her, but she recoiled away - frightened I guess.

Later, as we sipped Coke in the local bar, Christian explained, keeping his Portuguese simple so I could understand. Her problem was "not one of god, but one of man; of bad things". When he was young she had left home to work as a maid in Italy. Only to return one day in a state similar to the one I met her in. She had some photos, which Christian showed me - a pretty young women on the beach and happy, it seemed, in the streets of some Italian town. But clearly something had gone very wrong. Rape? Something similar? I don't know if Christian had ever tried to find out; I certainly never felt comfortable asking him.

Eventually, I moved on, chasing waves on another island. I wrote to Christian from London - sending him the present he had asked for - a Bob Marley hat - but never heard back. So I've always wondered what became of him and his mother. And thinking about their plight has always made me sad - it's doing so again now.

In an ideal world she would have never had to leave her country to find work to support her family. But, I guess, we don't live in such a world. And so, even thinking about this sad story again, I'm still in favour of migration and guest worker programmes. What I'm also in favour of though, is domestic legislation to protect those, most vulnerable, workers when they are in New Zealand or any other host country.

The New York Times article also tells the story of a young Cape Verdian man who was sent back to the Islands from the US as a result of his delinquency. This is another untold story of migrant workers. Subject to the social stresses of life in the urban 'under class' younger migrants and, in particular, the children of migrants, sometimes fall foul of the law, which can lead to them being deported. Or, to look at it another way, something that can lead to the host nations exporting their social problems. The Maras of Central America are a classic example of this - gang members deported from the US took their ultra-violent gang culture back to San Salvador and other cities. Closer to home, it appears that the worst of recent rioting in Tonga was perpetrated not by pro-democracy activists but by gang members sent home either from Salt Lake City or, to a lesser extent, New Zealand.

In the Cape Verde Islands I got to meet a couple of their equivalents. When a French friend and I hopped off the ferry in Sao Nicolao we were met by two tattooed, bandannaed youths Juan (surely Juao?) and Jose who asked us in American accents "whatup?" and invited us to smoke some pot and "shoot some hoops". The term for such youths in Sao Nicolao was retornadas (or somthing similar) and, judging by the way the otherwise friendly, elderly hotelier who offered us his two cents worth on them later that evening spat out the words, retornadas were hardly held in high esteem. I don't know how much trouble Juan and Jose actually caused - in the small fishing port they now called home simply having tattoos was probably crime enough to warrant ostracism. Even so, there was no way to escape the fact that their home, the only country on earth where they could now live, was anything but the home they had been brought up in. They seemed utterly trapped between cultures, between geographies. Such, I guess, is the plight of the migrant.

Slavery China Style

.
I've written before about China's great leap forward into the world of capitalism and global markets. What will happen over the next 20 years and what it will mean for the people of China, and the rest of us, is surely one of the big development questions of our generation.

Or, more accurately, it is several of the biggest development questions of this day and age bundled together. One of the most important being what the current wave of economic development will mean for China's poor.

At present, China's economic growth appears to be a rising tide that is lifting most ships. But it is certainly also a tide that is lifting those at the top much higher than those at the bottom. Similarly, while it's true that sweatshops are probably a better alternative than grinding rural poverty, in the absence of independent trade unions and a free media, it's also true that the manufacturing boom isn't doing as much as it could for the country's workers. And the conditions that it is taking place under are most definitely unjust.

At its very worst this injustice is, quite literally, slavery. Here's Li Datong in OpenDemocracy:

Another shocking news story broke in China in June 2007. It was discovered that in Hongtong county, Shanxi province, people kidnapped from rural areas were being forced to work as slaves in a brick kiln. Horrifying television footage showed them after their chance rescue - they were filthy and emaciated, with their clothes in tatters and blank expressions on their faces. It was impossible not to think of the images of holocaust survivors rescued from concentration camps at the end of the Second World War.

Similar scenes occurred over the following days. After an instruction from "senior leaders in the central government" an inspection team was sent to the area. It was only at this point that local officials seemed to wake up and stir into action, beginning with a large scale investigation and rescue operation. By 22 June, several hundred "slave workers" had been rescued. Of the 3,347 Shanxi brick kilns investigated, 2,036 were operating without the proper licenses or tax registration. A total of 53,036 people were being illegally employed. The investigation uncovered cases of people being kidnapped, of restriction of personal freedom, of forced labour, use of child labour, and abuse and even murder of workers.

While we are on the subject of labour rights in China, the recent skirmish over the draft 'labour contract law' is an interesting example of the political economy of globalisation. When the Chinese government finally appeared to be taking action to provide workers with some basic protection who should spring up to oppose them? Why, western business interests, of course.

Perhaps more surprising, and definitely more inspiring, was the countervailing force that sprung up. Once again, Li Datong:

On the morning of 24 April 2006, the managers of over twenty American companies were invited by AmCham Shanghai to attend a seminar to attack the labour-contract law, with the threat of withdrawing investment. The opposition to this law by multinational firms caught the attention of the US media, and on 13 October the New York Times ran a front-page story with the headline: "China Drafts Law to Empower Unions and End Labour Abuse".

...

The reaction to the article in the New York Times surpassed any Chinese expectations: American union organisations publicly began to support the Chinese law and leftwing members of Congress wrote a letter to President Bush on 31 October stating: "We would like to declare our opposition towards the actions of American companies, which are attempting to thwart the drafting of the new Chinese labour contract law that will give workers more rights".

Oh Dear...

...it appears that dear, sweet Karl Du Fresne has Coddingtoned his stats. As I noted yesterday, he made the following claim in his Dompost Column.

New Zealand has the second-highest rate of teenage pregnancy in the OECD and our abortion rate remains one of the highest in the developed world. The rate has more than trebled since 1980 and, most tellingly, it has steadily increased in the age groups where the FPA directs much of its efforts. For girls aged 11-14 it has doubled since 1991, and for older teenagers – those aged 15-19 – it has risen by 60 per cent.

With regards to the trebling since 1980, it's not exactly clear whether he's referring to the abortion rate or the teen pregnancy rate. Let's examine both in turn.

Teenage Pregnancies:

According to Statistics New Zealand

In the early 1970s, 70 out of every 1,000 teenagers had a child in any year. By the mid-1980s the figure had fallen to 30 per 1,000. Subsequently, it varied between 30 and 35 per 1,000 until 1997. There has been a general downward trend in the last five years, and in 2002 the fertility rate for teenagers was at a historical low of 25.6 per 1,000.

In other words, the teenage pregnancy rate has not 'more than trebled since 1980'.

Abortions:
According to Statistics New Zealand

...the teenage abortion rate has almost doubled since 1980...

That's 'almost doubled,' not 'more than tripled'.

But the big picture is more interesting, as Stats NZ notes:

Interestingly, although the teenage abortion rate has almost doubled since 1980, it was accompanied by a decline in teenage fertility (see Figure 4). Thus, short-term variations aside, the known pregnancy rate (live births plus abortions) in 2001 (50 per 1,000) was almost the same as that 20 years earlier in 1981, in spite of a number of social changes, such as non-eligibility to welfare support and high levels of youth unemployment, which may have been expected to act as disincentives to teenage childbearing.

And what about the good old days (you know before our country was run by "leftist lesbians")? Guess what? Teengage pregnancy rates aren't much different from what they were in 1901. And they are much lower than they were in the 1940s and 50s.


In other words. Du Fresne's stats are nonsense.

Seeing as I've been digging round the stats website I thought I show one other table too.


You'll note that, among developed countries, New Zealand's stats on teen pregnancies and the like compare poorly. Only one country stands out as being consistently worse the United States. Home of the 'religious approach to teenage sex'. Compare that to the Netherlands which has comprehensive sex education.

In short Karl Du Fresene, in his swipe at leftists, lesbians and FPA has been utterly dishonest.

Thankfully these aren't the people writing our social policy

.
Over at Kiwiblog, David Farrar channels Karl Du Fresne from the darkest reaches of the Lunisphere and, apparently, likes much of what he hears.

Karl du Fresne slams the Family Planning Association as a failure.

New Zealand has the second-highest rate of teenage pregnancy in the OECD and our abortion rate remains one of the highest in the developed world. The rate has more than trebled since 1980 and, most tellingly, it has steadily increased in the age groups where the FPA directs much of its efforts. For girls aged 11-14 it has doubled since 1991, and for older teenagers – those aged 15-19 – it has risen by 60 per cent.

The FPA's own surveys show young people are having sex younger and putting themselves more at risk. Gonorrhea cases are up by 52 per cent and chlamydia by 28 per cent. In the Auckland area, 53 per cent of people with gonorrhea are aged between 15 and 24 and antibiotic-resistant cases are increasing.

I don't agree with everything Karl DF says on the FPA but I certainly think their "Rubba No Hubba Bubba" campaign was awful*.

I'm with DPF here this is, quite frankly, disturbing reading.

Although (and I'm guessing that this is where myself and Mr Farrar part ways) the thing I find disturbing is not the nefarious workings of the Family Planning Association and their plans to promote [gasp] sex. Rather, I'm disturbed by the sort of nonsense that gets hocked off as opinion in New Zealand newspapers these days.

Basically, Karl Du Fresne's (KDF) argument runs as such: teenage pregnancies, abortions and STIs have increased substantially over the last 27 years in New Zealand. This is the fault of FPA.

Missing, of course, is any evidence that might prove the second statement. It's true that FPA is involved in efforts to improve sexual health, but what evidence does KDF provide to show that the rise in STIs and pregnancies is a result of FPA's work, rather than there not being enough of the sort of work that FPA (which has, nationwide, a staff of fewer than 300) does? Um - none. What evidence does KDF provide that the rise in STIs and pregnancies is not the result of other social changes as opposed to FPAs proselytising promiscuity? Um - none. What evidence does he provide that sex education leads to more unprotected sex? Um - none. Indeed, if KDF had bothered to look before venting his spleen he would have discovered that those European countries that provide the most sex education tend to have the best sexual health.

But what's evidence when Mr Du Fresne has prejudice and an axe to grind. The axe in question is revealed later in his column:

I began this item with a question: why does the government continue to give our money to the FPA when it's so obviously a disaster area?

Now let me attempt to answer it. I believe it's because the FPA is one of the cosy cluster of ideologically compatible, state-dependent organisations with which Labour has surrounded itself.

Gill Greer, the FPA's executive director till last year (when she accepted an appointment to International Planned Parenthood, presumably on the basis of her breathtaking success with the FPA), is a former Labour parliamentary candidate. She is also a lesbian, which would normally be neither here nor there but in this context is worth noting.

New Zealanders are generally unconcerned with people's sexual orientations, and rightly so, but they might well wonder whether a leftist lesbian was the ideal person to be running something called the Family Planning Association.

Astute readers will have noted, of course, that Mr Du Fresne's stats above start at 1980 and 91, and they might be wondering whether it isn't just a little unfair to blame Ms Greer and the Labour party for increases, the bulk of which happened before they came to power. But hey, as I've always said, if you can't blame leftist lesbians for their inability to time travel, how else can you imply that only rightwing heterosexuals can have positions of power in this country.

I suppose you could try, as Mr Du Fresne does, to imply that lefties and lesbians don't actually know anything about families (most of them having been grown in test-tubes and raised on communes) but in Ms Greer's case there's a problem. You see, she has a family. Kids and all. So I'd say that - even in la la land of Karl Du Fresne's prejudices - she'd be perfectly fit to run the Family Planning Association. In the real world (not a place I suspect that KDF visits often) she'd be even more so.

_____________________________________
* DPF's mistaken here, this campaign was run by the Ministry of Health.

Democracy Struggles

.
I know I've promised before and have yet to deliver but, one day, I really do plan on writing more on deliberative democracy. For now though, I thought I'd point to an example of representative democracy struggling.

Democracy, relies on informed voter choice* and so, it follows, that it is always going to struggle to be any better than the information sources available to voters. And too often these sources are far from perfect.

In the particular case of the proposed Therapeutic Products and Medicines Bill**, as Media Watch so excellently showed this morning, our own major information sources have been pitifully inadequate on the matter. Television discussions have been one-sided and the lines between news and infomercials have been blurred shamefully in several newspapers. Which has meant that campaigners against the bill (the campaign has been driven to a significant part by business interests) have been able to spread a lot of shoddy information.

Me personally - and this is a view that I have come to over the years that I have lived with chronic illness and tried a variety of alternative treatments - I am in favour of a regulation system for natural health products. One that (a) means that the sellers of such products can't lie about their effects and (b) which means that dangerous products can't be sold to the public. This is the exact same way I feel about pharmaceuticals. I am, however, not wholeheartedly in favour of the Therapeutic Products and Medicines bill. It's regulation costs may be prohibitive and biased against small businesses, and it may be in conflict with the Treaty of Waitangi.

About these two points I would like some honest information. Instead, though, I am getting utter nonsense (often from vested interests) like the claim that the bill will be the end of the All Blacks (no, seriously).

This is all too typical of our current form of democracy where most media organisations are run as businesses; something that means that money talks. Not always, not entirely, but enough to drown out the truth too often.

It also means that we get to hear far too much from people from Christine Rankine; people who are well off, well connected, and well stupid.

[Update: just to be clear, I've got friends and colleagues opposed the bill, and they are most definitely not stupid. So my comment above is not meant to imply that all the bill's opponents are stupid, just that Christine Rankine's proclamations on it almost always are.]

* as well as voting (of course) civil society, social capital and a moderately snug fit with soft institutions.
** another galling example from the last week has been National Radio's decision to rely on tax accountants for the bulk of commentary the proposed plan to remove the ability use losses on rental property as a tax write off. Am I the only one who can see a conflict of interest here?

What's the Matter with ...

.
...

Good Reading on Globalisation

.
Well worth a read: Rodrik on Wolf on Globalisation.

What is Post-Structuralism? And is it any use?

.
I still struggle to get my head around the posts (modernism, structuralism, development, Marxism) but one definition of post-structuralism that I like (mainly because it is a metaphor) is as follows. Post-structuralism turns Marx on his head, unearthing again Hegel and his dialectics. Except that now the dialectics have been torn out by the roots and are no longer anchored to an ultimate truth. Instead, they're just dangling in the air competing against each other.

In practice this means that post structuralists no longer want to understand the world (ala Hegel), nor even to change it (in the way that Marx wanted philosophers to do); rather, they want to understand the way we understand the world and, maybe, to change that instead.

The classic charge levied against post-structuralists is that of relativism or an absence of a normative prescription of a world to strive for. Against which most post-structuralists will argue that no they aren't relativists, that not all discourses are equal, and they seek those which are emancipatory.

Me I'm not so sure. To the extent I've looked, I don't find answers to the question "what is good". At least when it comes to outcomes I don't. I do hear normative positions on procedures though. And interesting ones at that.

All of which makes me think that post-structuralism can compliment liberal-analytical or Habermassian (dear god how do you spell that) takes on the world, but that on its own it ultimately flounders. Post-structuralism is like driving lessons that can tell you how better to drive the car but which, at the same time, give you no idea where exactly it is you are going. For that you need a road map.
__________________________

Disclaimer 1: There is a nearly 100% chance that I don't actually no what I'm talking about here.
Disclaimer 2: There is a huge variety of thought amongst post-structuralists too. So a critique of one may not lead to a critique of the other.

Free to Choose?

.
There was, in some ways, more to Milton Freidman than met the eye. He was far from a typical conservative for a start: he opposed military conscription; he was in favour of the legalisation of drugs; he opposed the invasion of Iraq. He even had the decency to admit at least once before his death that key elements of his his hard-line monetarism (quantity of money targeting) were flawed. Yet he remained, to the end, an advocate of small government and free markets.

In Matt Parker's biography of John Kenneth Galbraith (on page 522) there is a quote which summarises nicely Freidman, the social liberal's, distain of economic liberals (I'm using the word liberal here in the American sense).

Many reformers...have as their basic objection to a free market that it frustrates them in achieving their reforms, because it enables people to have what they want, not what the reformers want. Hence every reformer has a strong tendency to to be adverse to a free market.

In short, part of us reformers' problem with free markets is that we don't like people being free to choose. Particularly, as they will probably choose things we don't like.

So is that true? As a reformer do I really hate freedom, so to speak.

Um, no.

My problem with under-regulated markets is not that they provide too much freedom of choice. Almost the opposite, in fact: my problem with unrestricted markets is that they reduce the freedom to choose of a majority of the population. There are four key reasons why I feel this way.

First up, the sum total of choices that any one person has in their life is not simply a derivative of negative liberties. It's also a function of entitlements: ceteris paribas a person with a million dollars in the bank has a whole heap more choices available to her than a person with $10. And, whatever else you may say about markets, they don't guarantee entitlements. For this we need government. This isn't to say that the state should intervene to ensure absolutely equal entitlements but that it should provide people - where it can - with enough resources that they can have at least some good choices in their lives.

Second, is the fact that people's choices are usually only as good as the information they base them on. To use the famous example of this problem, if I am to be really free to choose to by a car or not, I need to know whether it's engine will still work once I get it home. Most likely the car salesperson knows the answer to this question, but whether they tell me or not is another thing altogether. So if we want me to be able to choose wisely when buying a car we'll need a law or two intervening in the pure market process to prohibit the salesperson from lying to me.

Related to imperfect information is contaminated information. What if the information we receive about products was designed not to tell us what we need to know to choose but rather to manipulate us into purchasing? Well hey, then we'd call it advertising - the business of influencing our choices. Freidman thinks that I dislike free markets because the let people choose things I don't like; to the contrary, my problem with the sort of free markets that Freidman advocates is that they end up manipulating people into buying things that they don't like. It's hard to see what's free about this.

Finally, there's the fact that the choices I make will influence the choices that you make. If I choose to built a 10 story house on my section then your choice to live in sunlight may be rather diminished. But free markets alone - unless you somehow an implausible market for sunlight and shade had been developed - won't let you stop my choices from restricting yours. The government might though.

All of these limitations of markets can be found in any first year economics textbook. So, presumably, you'd imagine that Freidman might have heard them sometime. Which makes his accusation that reformers don't want people to be free to choose disingenuous plain and simple.

Oh this is good, this is very good...

.
Continuing my recent fascination with economics and economists:

Economist's View points to recent research that finds that, under experimental situations, people derive pleasure not only from giving money voluntarily, but also from paying taxes. The conditions of the experiment are restrictive (the money goes to an undeniably worthwhile cause: a food bank) but, even bearing the restrictions in mind, the experiment adds to the mass of evidence (not to mention plain common sense) which suggests that human beings are far from purely self-interested. This is bad news for those who wish to use simplistic takes on economic theory as a justification for right-wing view points and it also has interesting ramifications for concepts such as Pareto Optimality. But that's not what got me chuckling; this was:

The study gives economists a novel look inside the brain during taxation, said co-author William T. Harbaugh, a UO professor of economics and member of the National Bureau of Economic Research in Cambridge, Mass. “To economists, the surprising thing about this paper is that we actually see people getting rewards as they give up money,” he said.

Progressive Taxation

.
A handy discussion of the case(s) for progressive taxation from Economist's Voice.

'Let their People Come'

.
Via Dani Rodrik, the New York Times Weekend Magazine has an article on development economist Lant Prichard. In the article Prichard makes an impassioned plea for the globalisation of Labour. If full globalisation is not on the cards, Prichard is willing to settle for guest worker programmes as a compromise.

There are, I think, problems with guest worker programmes. I agree with Jeffrey Sachs, who is interviewed in the article that, ultimately, such programmes aren't substitutes in-country development. (Although the capital sent home in the form of remittances may help spur such development). Also, I think Paul Krugman has a point, that there are issues of political economy which need to be considered. Temporary guest workers have no political rights and so there is a considerable risk that their needs will not be considered by politicians. Hopefully, these risks can be mitigated by social justice movements of the politically enfranchised campaigning for guest workers rights. But this is a far from perfect solution. There is also the risk that guest workers will be exploited by unscrupulous employers - confident that workers without rights will not stand up to them. In the US though, this risk while real is, presumably, less than for illegal immigrants (who we can assume that the guest workers would be substituting for?). Here in New Zealand I am more confident that a well designed programme with union buy-in ought to be able to minimise these problems. Finally, there are the social costs associated with separated families etc.

All of these debates are relevant to us New Zealanders too as we've just enacted legislation around a Pacific guest worker programme.

Personally, I support this particular initiative, not because it is problem free - there are no solutions in development which are - but because, if nothing else, it should provide some Pacific Islanders with greater incomes and opportunities then they would have had otherwise.

==

As an aside, they New York Times article follows Prichard on a tour of Nepal and, alongside everything else, gives some stark examples of just how tough life is in extreme poverty.

As Easy as Stealing Life Expectancy From a Baby

.
To often discussions around the problems of the developing world - mine included - revolve around the good things we could be doing for developing nations and fail to mention the bad things that we already are.

Fortunately, George Monbiot doesn't suffer from this problem.

The leaders of the G8 nations present themselves as a force for unmitigated good. Sometimes they fail, but they seek only to make the world a kinder place. Bob Geldof and Bono give oxygen to this deception, speaking of the good works the leaders might perform, or of the good works they have failed to perform - but not mentioning the active harm. They refuse to acknowledge that what the rich nations give with one finger they take with both hands.

Look at what is happening, right now, in the Philippines. This country has many problems, but one stands out: just 16% of children between four and five months old are exclusively breastfed. This is one of the lowest documented rates on earth, and it has fallen by a third since 1998. As 70% of Filipinos have inadequate access to clean water, the result is a public health disaster. Every year, according to the World Health Organisation, some 16,000 Filipino children die as a result of "inappropriate feeding practices".
...

Both the government of the Philippines and the UN blame the manufacturers of baby formula for much of the decline in breastfeeding. These companies spend over $100m a year on advertising breastmilk substitutes in the Philippines, which equates to more than half the department of health's annual budget. Those who appear most susceptible to this advertising are the poor, who are also the most likely to be using contaminated water to make up the feed. Some spend as much as one third of their household income on formula. Powdered milk now accounts for more sales than any other consumer product in the Philippines. Almost all of it is produced by companies based in the rich nations.

Since Ferdinand Marcos was deposed in 1986, the government of the Philippines has been trying to stand between these corporations and vulnerable mothers. It has failed. It plugs one loophole; the formula companies find another. Baby Milk Action, one of the world's most impressive public health campaigns, has compiled a dossier of breaches of the marketing code drawn up by the World Health Organisation. Formula companies have been dispensing gifts to both health workers and mothers, running promotional classes and meetings and advertising their wares on television and in magazines and papers. These practices, though mostly legal in the Philippines, are all discouraged by the code.

In February this year, the Pharmaceutical and Healthcare Association of the Philippines (Phap), which represents multinational companies, ran a series of advertisements expressing concern for women unable to breastfeed their children. The campaign was described by Jean Ziegler, the UN's special rapporteur on the right to food, as "misleading, deceptive, and malicious in intent". He claimed the adverts "manipulate data emanating from UN specialised agencies such as WHO and Unicef ... with the sole purpose to protect the milk companies' huge profits, regardless of the best interest of Filipino mothers and children".

Last year, in the hope of arresting this public health disaster, the Philippines' department of health drew up a new set of rules. It prohibited all advertising and promotion of infant formula for children up to two years old. It forbade the formula companies from giving away gifts or samples, and from providing assistance to health workers or classes to mothers. The new rules seem stiff, but they all come straight from the WHO's code. Phap, whose members include most of the world's largest pharmaceutical companies, went to the supreme court to try to obtain a restraining order. When it failed the big guns arrived.

The US embassy and the US regional trade representative started lobbying the Philippines government. Then the chief executive of the US Chamber of Commerce in Washington - which represents 3m businesses - wrote a letter to the president of the Philippines, Gloria Arroyo. The new rules, he claimed, would have "unintended negative consequences for investors' confidence". The country's reputation "as a stable and viable destination for investment is at risk". Four days later, the supreme court reversed its decision and imposed the restraining order Phap had requested. It remains in force today. The government is currently unable to prevent companies from breaking the international code.

So the department of health asked a senior government lawyer, Nestor Ballocillo, to contest the order. In December Ballocillo and his son were shot dead while walking from their home. The case remains unsolved; Ballocillo was working on several contentious cases at the time.

One of best ways we could reduce corruption in the developing world is to stop our own business interests participating in it. One of the best ways we could aid development in these same countries is to stop our business interests from actively subverting it.

[Update: repaired a typo and added the word expectancy to the heading]

Herceptin and the Right to Health Care

Quite a while ago, under a post of mine on health care, Sage NZ, made the following comment.

"But when it comes to health, in my opinion, every New Zealander does have the right to health care" so the question for you is whether or not that includes herceptin?

There's more to his comment but the above bit is the interesting sentence.

Sage is making reference to the part of my own post where I say that:

Markets, when they function properly, optimise efficiency. They promise nothing when it comes to distribution. Or in other words, a purely market system, doesn’t guarantee provision of services or products to all. That’s fine when it comes to Hamburgers – I don’t think every New Zealander has the intrinsic right to eat McDonalds. But when it comes to health, in my opinion, every New Zealander does have the right to health care.

Herceptin has, of course, attracted much media attention in New Zealand recently as the miracle cancer drug that Pharmac (the New Zealand drug funding agency) refused to fund for women with early-stage breast cancer (Herceptin is, IIRC, already funded for women with advanced breast cancer) despite evidence that the drug halved the recurrence rate of the disease. Pharmac found itself caught in a pincer movement between the publicity campaign of the
drug company that produced the drug, the lobbying of breast cancer suffers who - quite understandably - are keen for access to a drug that may save their lives, and some of the worst media reporting imaginable.

Buried among all this clamour were a few important facts. The first of these being that survival rates among women with early-stage breast cancer are already high so, while a 50% reduction sounds impressive, it needs to be borne in mind that, in an absolute sense, the numbers of livessavecd are small. At the same time Herceptin brings with it an increased risk of heart disease. The New Scientist explains [open link]:

Now, appreciating the drug's true benefit means understanding relative and absolute risk. That 52 percent is a reduction in relative risk. Since the chance of breast cancer recurring when treated early is already small, a 52 per cent reduction in that risk is commensurately small. Even women with early breast cancer who receive no treatment after lumpectomy, see recurrence peak at 10 per cent per year after two years, then drop, levelling off at around 3 per cent at 10 years. After other standard therapies, recurrence is lower still. Importantly, as in many trials, prolonging life isn't the main yardstick: researchers focus on how long a drug can keep patients disease-free. However, the disease may return, often with renewed vigour. So disease-free survival does not by any means translate into prolongation of life.

Looking at overall survival rate at the end of one of the studies, there were 37 deaths in the control group (2.2 percent) as opposed to 29 deaths (1.7 per cent) in the Herceptin group. The slight difference in the deaths was most likely chance alone, so adding Herceptin to chemotherapy conferred no meaningful survival advantage.

Now, Herceptin does have a small but significant positive effect on the absolute rate of recurrence in a minority of women with early stage breast cancer. But look closely at the causes of death. In one of the studies, there were 23 breast-cancer related deaths (1.4 per cent) in the Herceptin group compared with 34 (2.0 per cent) in the observation group. In terms of absolute risk, the Herceptin group achieved a very modest 0.6 per cent reduction in breast-cancer related deaths. This small gain has, however, to be weighed against the fact that Herceptin turns out to produce heart damage in 4.1 per cent of the early-stage breast cancer patients.

Oh, and there's one other thing: Herceptin treatment carries with it a price tag of over $60,000 per person.

Once you become aware of this (which you wouldn't do if you relied on our TV 'current affairs' programmes) Pharmac doesn't seem quite so heartless for refusing funding (and, in the end they even compromised on this agreeing to pay for a 9 week treatment course of the drug - something that appears to be as effective as the full 52 week treatment).

And yet, I have to confess that - so long as the decrease in cancer mortality is isn't outweighed by the increase in heart disease mortality - I'd still support the funding of the Herceptin. Even if the absolute number of women's lives saved is small they are still lives saved; people's mothers, sisters, and daughters who will get the chance to live longer and happy lives.

The trouble is though, the drug needs to be paid for. The easy answer would simply be to raise taxes accordingly, but that's hardly going to happen in today's political climate. The other option is taking the money from something else, most likely from Pharmac's budget, which means that other potentially more effective treatments for other diseases may have to be sacrificed.

And this, I think, gets to the heart of Sage's question: if you view health care as a right, regardless of one's level of wealth, as I do, where do you draw the line?

This is a very good question as - in upcoming years - thanks to the ever expanding basket of treatments available (and patented) and thanks to our aging population (the elderly being more medicine intensive) the price of running an all-inclusive public health care system is going to increase substantially.

Sage's own preferred solution - privatisation - is a non starter for the simple reason that the evidence suggests that private health care systems like the United States's are even less efficient than our own. What's more, despite Medicaid, the United States still has a significant proportion of its population without access to health care. It might work if you're wealthy but it sure ain't health care as a right.

My preferred solution, raised taxes, would require more sophistication from our democracy than currently seems possible (having a media that effectively functions as a tax cuts lobby doesn't help).

Which leads to the probable outcome of rationing where, some basic health care will still be provided to the public, but where access to the rest will depend on wealth. This, obviously, is an option that I'd be keen to avoid.

Perhaps we may be able to squeeze more efficiency out of our current system, but I'm not sure. Efficiency seems largely to be a byword for overworked doctors and nurses.

More promising, perhaps, is a shift to preventative care wherever possible. There are considerable benefits associated with moving the ambulance to the top of the cliff. Getting it there though, still isn't an easy task. How, exactly, does the state (dear ol' nanny-state) get people to exercise more and eat more fruit and vegetables?

All thoughts welcome...

Dueling Doxies

.
Cool. The Christopher Hayes article from the Nation that I linked to a few days ago has spawned some fascinating debate. Most of it is at TPM cafe where there are posts by Thomas Palley, Brad Delong, Julie Nelson, David Ruccio, Mark Thorma, James Galbraith, Max Sawicky, Paul Krugman and others. Elsewhere, Dani Rodrik comments twice, Sandwich Man & Barkley Rosser offer comments at Max Speak, while Ingrid Robeyns, Henry Farrell, and John Quiggin weigh in at Crooked timber.

A few random thoughts:

I think Henry Farrell, Paul Krugman and Brad Delong are right when they say that neo-classical economics doesn't have to lead to right-wing thought. I think Henry is interesting when he says that:

There seem to me to be two different fights going on here, which often get confused (and are systematically confused together by some of the post-autistic economics crew). One is whether economists’ reliance on the rational actor model, assumptions of self-interest, supply and demand and so on is intellectually good or bad). The second is whether ‘mainstream’ economics is necessarily right wing. (or, a little less polemically, whether it confines ‘legitimate’ debate to a political spectrum ranging from moderate Democrats to extreme Republicans). All too often, these get jumbled together into the implicit or explicit claim that economists’ reliance on the rational actor model means that they come up with results that are necessarily right wing. This is wrong. There’s lots of very interesting work out there, including some that is self-avowedly Marxist (the ‘no bullshit’ variety of Marxism that Harry Brighouse and I have both been influenced by), which relies extensively on economistic arguments about self-interested rational utility maximizing actors, and is no less left wing for it.

That being said, I don't back down from my own earlier comment that:

What's more, by ignoring the less cut-throat elements of human behavior certain economists have neatly used something akin to a tautology to smuggle in their political beliefs. If you believe that humans only act in their own self interest then it follows that you'll have system that venerates this.

It's definitely true that assumptions about rational self-interested actors don't necessarily lead to right-wing world views, but I do think such a position eliminates from the start more some of the more interesting leftish ideas out there. I don't see this as such a problem when it comes to pure economics but it bugs me more when economics starts venturing into the worlds of sociology and political science (public choice stuff in particular*). I also think that the aforementioned assumptions do leave the right with a larger hamper to smuggle in their politics.

Another interesting aspect of the debates, and Chris Hayes article, was the way that ideas cross the border from Heterodoxia to Orthodoxia. To the defenders of the orthodoxy this shows that everthing is ok actually, to the heterdox by the time the ideas have limped over the borders they have been tamed and robbed of much of their power. It also seemed from the discussion that even when ideas cross over, often the economists are left behind. Probably some of this is personal choice, but it also reminds me a bit of the current state of economic globalisation: we can trade (ideas) across borders, but labour stays trapped - mostly - within the nation state. What ever else you might say a bout this situation, greater immigration would certainly bring about more rapid cultural change. Presumably this would be true too when it comes to the slow tacking away of the good ship orthodoxy from rational expectations and hard line monetarism.

Slow as it is, change, however, has taken place in orthodox economics though and I think that this is something I should have emphasised more in my original post.

And, finally, I thought I should explain just why I'm interested in these sorts of debates. After all, I'm not an economist (my primary interest is in political science). Really, the reason why I blog much more about economics is that it is at the heart of many of the immediate debates in New Zealand politics and international development. And as an informed voter and NGO staff members it seems important to me to be at least broadly familiar with what is going on out there.

_____________________________________________
*To the extent that I understand it.