Friday, May 14, 2010

Placebo Effects and Policy Limits or what Olivia Judson can teach David Brooks



The May 4th New York Times Op-Ed section presented us with a great contrast between scientific thinking and pseudo-scientific ideology in the columns by Olivia Judson and David Brooks. I am sure you can already guess which one is which, but lets go through it anyway because when the Times inadvertently gives us such a useful contrast, it is well worth paying attention.

So, Brooks' piece first and he begins, of course, with the Northern European as a standard. Swedes in Sweden and Swedes in the United States have the same rate of poverty, 6.7% "Two groups with similar historical backgrounds living in entirely different political systems, and the poverty outcomes were the same." Brooks further notes that the average life expectancy of Swedes has not changed much since 1950 despite their commitment to build "a large welfare state with a national health service, while the U.S. did not." In 1950 Swedes lived an average of 2.6 years longer than Americans, and now live 2.7 years later.

Of course, the second thing to note is that Brooks is using averages rather than differences between the mean life expectancy. But this is not so much my problem with his piece, although it would be useful to compare the results of we used mean rather than average. Instead, the thing that can be pointed out in this little post is the stark contrast between the essays by Brooks and Judson.

Brooks tells us that:
"Ethnicity correlates to huge differences in how people live.....All we can say for sure is that different psychological, cultural, and social factors combine in myriad ways to produce different viewpoints. As a result of these different viewpoints, the average behavior is different between different ethnic and geographical groups, leading to different life outcomes.... So when we're arguing about politics, we should be aware of how policy fits into the larger scheme of cultural and social influences. Bad policy can decimate the social fabric, but good policy can only modestly improve it." [Notice that average has appeared again, as in the "average behavior" of the bodies that make up a population.]

So let's take three concepts that Brooks uses: ethnicity, culture, and politics. What exactly does he mean by these terms in this little article.

POLITICS: is for Brooks simply the means to institute social policy for the control of a population. The problem is that social policies can do very little to affect social change. Social change comes from elsewhere, if it comes at all, and it comes from the internal forces within populations, or "tribes of people," to use Brooks' phrase. Thus, politics and social policy can have only modest effects on the lives of the humans in a given population. Politics, on the other hand, is not about social change, it is about articulating the "viewpoints" of various "ethnic and geographical groups". Politics is about which group can enforce its "viewpoint" and the first rule of the policies that flow from these viewpoints is "don't promulgate a policy that will destroy social bonds" because these bonds are the foundation of politics. At bottom, all politics is rooted in ethnicity and emotion, as in "emotional bonds".

If each "tribe" is given a "basic level of economic and physical security" they will each "create a culture of achievement --- if you are lucky." And if the policy can strengthen the "emotional bonds" of a people, all the better. Brooks cites two examples of successful policies that have strengthen emotional ties: "preschool and military service" but in the end, "we should all probably calm down about politics. Most of the proposals we argue about so ferociously will have only marginal effects on how we live, especially compared with the ethnic, regional and social differences that we so studiously ignore."

So politics is in the end arguing from our ethnic, regional, and social "viewpoints" about policies that will not really help very many people, but might at least strengthen the "emotional bonds" that unite different tribes, or keep them in their place. It is a good argument for the status quo, and that is exactly the kind of argument one can expect from the "progressive conservatism" that Brooks claims to support.

CULTURE: is for Brooks, at least in this piece, about the habits of different ethnic, cultural, or emotional tribes or populations. But it exists in a tautology for him. Namely, Culture rests on ethnicity, but ethnicity is culture. Culture consists of the habits and material production of tribes, and you can define a tribe, an ethnicity, by its habits and material production. Emotional bonds are between families and tribes, and families and tribes are defined by the extent of their emotional bonds. None of this tell sus very much except again that acceptance or restoration of the status quo is always the point of Brooks'commentary.

ETHNICITY: Really, the talk of tribes and emotional bonds, of the importance of the status quo would not be so disturbing if it were not in the context of Brook's use of the concept of ethnicity as a stand in for race. Whenever Brooks discusses differences, he relates those differences to ethnicity and geographical differences, but ethnicity clearly is for him the most important factor. In fact, the Times accompanied the commentary with the blurb "How ethnicity swamps politics." When Brooks wants to talk about ethnic differences, he uses for his evidence data based upon racial differences, in particular the differences between what Cuvier called the three primary races of man, European, African, and Asian. Native Americans and Hispanics make appear only to to compared to the other three "ethnic... tribes".

One can not be sure of what Brooks means by ethnicity, but certainly it does at points stand in directly for race, just as "viewpoint" stands in for "ideology". "The influence of politics and policy is usually swamped by the influence of culture, ethnicity, psychology, and a dozen other factors." The other factors are not worth naming, as apparently culture, ethnicity, and psychology predominate.

And this takes us back to the Swedes that Brooks began with. There is something that makes a Swede a Swede whether they are in South Dakota or Stockholm. Policies, he says, will not change the basic "ethnic" disposition of a Swede.

But let us look just across the page to Olivia Judson's commentary on the placebo effect.

If policy and politics can not trump ethnicity, one might expect that the placebo effect would suffer a similar failure. Swedes in Sweden should respond to a placebo just as Swedes in the US, to follow Brooks' reasoning about ethnicity.
In fact, Judson does not mention Swedes, but she does mention Germans. However, the results are not what one would expect if we followed Brooks on ethnicity/race/tribe/nation. Let us allow her to speak for herself regarding the ethnic/tribal differences and the placebo effect.

Different studies of the placebo effect report wildly different results. One survey of 117 trials of two ulcer drugs found that, depending on the trial, patients in the placebo group had anywhere from zero to a 100 percent recovery rate.

The drugs also varied in their effectiveness from one trial to the next; sometimes patients on the placebo did better than those on the drug. Intriguingly, the results varied from country to country, with Brazilians showing no placebo effect and Germans having a strong one. Why? No one knows, but it doesn’t appear to be because of anything inherently German: trials of drugs for hypertension found a weaker placebo effect in Germany than in other countries.

The problem is that humans are not machines, and emotions are not abstractions. Hope and expectation, anxiety and fear, trust and suspicion — these cause physiological changes in the brain that can interact with drugs, changing their effects.

Given that Brooks wants to hide the workings of power behind the mask of culture and ethnicity, it is remarkable how Judson almost relpies to his avoidence of power. It is power, and not ethnicity, that has the strongest influence on the placebo effect.

...the most reliable source of a strong placebo effect appears to be: the doctor.
Placebo treatments are more powerful if your doctor believes in them. They are also more powerful if the doctor tells you so. In one study, for example, patients who had just come out of surgery were given a saline infusion, and — whenever they asked for it — the pain killer buprenorphine. However, some patients were told the saline infusion was a powerful painkiller, others that it might be one, while a third group wasn’t told anything. Over the course of three days, those in the “know-nothing” group asked for more buprenorphine than those in the “maybe” group, who in turn asked for more than those told they were getting a real drug.

Finally, Judson, whose blog is one of the best from the New York Times, comments on these differences

Differences in hopes and fears, and the resulting physiological changes, may explain why the placebo effect varies so much: individual experiences matter. Some people are more anxious than others, or may find the thought of a particular disease especially alarming. Moreover, in different cultures, similar diseases may be treated with different degrees of gravity.

So different cultures matter, but not in the way that Brooks would have it. And what matters most is the power relationship of those confronting a problem, whether medical or political, and not the ethnic differences between them, even if we could detach Brooks' use of ethnicity from his silent deployment of racialist thinking.

Only those in power would have the "viewpoint" that politics is not about power, or believe that social change is not possible.