Sunday, October 20, 2013

Time to cut NPR?

The media landscape in the United States is not what it could be.

Often there is a lack of perspectives shared. People often share a desire for "balanced" reporting.

Then there is an issue of basic facts, often lost in the search for something approximating equal time for minds already made up on an issue.

Sometimes an organization known as NPR provides a good example of how reporting should be done. It is seen by many as being without bias, or at least less biased than major television networks.

However it seems that at least on some issues, NPR is just as prone to skewed, anxiety-filled reporting without facts.

The issue here: circumcision.

Round #1: Shoddy reporting

Here's how NPR has covered this story, through the past several years of original reporting.

In 2010, NPR's All Things Considered reports "Study: Circumcision Rates Falling Fast In U.S.".

Instead of "balance" the audio of the story audibly giggles mentioning the word "intactivists" and the single doctor interviewed is presents a completely one sided report:

"About 10 years ago, the American Academy of Pediatrics came out with a policy statement that was fairly neutral on whether circumcisions should be recommended for newborns or not," says Diekema. "And that probably changed the way physicians were talking to their families."
"It's also worth pointing out that our population is becoming increasingly Hispanic," says Diekema, "And that's a population that has not traditionally circumcised their babies." 
"Their arguments are largely emotional," says Diekema. "Just the fact that they insist on referring to this as 'genital mutilation' tells you that they're refusing to recognize whether there may be any medical benefit to the procedure."
"There is a fairly substantial, important reduction in the risk of contracting many sexually transmitted infections," says Diekema. "In newborns, there is a decreased likelihood of getting a urinary tract infection, which for a newborn baby can be a very significant illness."

Missing facts: what is the expected incidence of UTI in newborn babies?

And, he says, "at least three well-done, randomized control trials in Africa show a substantial decrease in the transmission of HIV [due to circumcision]."

Missing challenge: can we then expect increased HIV infections among the Hispanic population in the United States?
Ultimately, in spite of arguments on both sides of the issue, Diekema says that male circumcision is a decision that families should make on their own. He says a doctor's role is to make sure the family is aware of the risks and benefits of the procedure.
But, he says, "the risks of circumcision are considerably lower in the newborn population than they are if that child is older."

More missing items:

  1. What are the risks in the first place?
  2. What risks increase with age?
  3. What is the other side (that was not interviewed)?
  4. Why was the 2005 AAP report "neutral" on the issue?

Fast forward NPR's coverage to August 27, 2012. Morning Edition reports "Pediatricians Decide Boys Are Better Off Circumcised Than Not":

The article is mostly a victory lap for AAP adopting a more pro-circumcision stance. The organization still does not strongly recommend the practice, but it has changed its message considerably.

The usual health benefits line is parroted out:

"The health benefits of male circumcision include a drop in the risk of urinary tract infection in the first year of life by up to 90 percent," [Susan Blank] says.
But there's a much bigger reason to do it, Blank said. Circumcised males are far less likely to get infected with a long list of sexually transmitted diseases.
"It drops the risk of heterosexual HIV acquisition by about 60 percent. It drops the risk of human papillomavirus [HPV], herpes virus and other infectious genital ulcers," she says.
It also reduces the chances that men will spread HPV to their wives and girlfriends, protecting them from getting cervical cancer.
"We've reviewed the data and, you know, we have gone through them with a fine-tooth comb, and the data are pretty convincing," she says.

Missing facts: Gardasil. The HPV vaccine was approved by the FDA in 2006, six years before NPR and the AAP feed us these lines that attempt to convince us that circumcision lowers HPV transmission rates and would then lower cervical cancer rates.

The vaccine applies to both sexes - boys and girls can receive the vaccine and then prevent spreading HPV.

It is interesting that NPR and AAP neglect to mention that HPV as we know it now might not exist by the time a baby born today reaches sexual maturity.

Perhaps the pro-circumcision crowd can better inform the public by doing more studies.

Circumcision could prevent transmission of:

  • Measles
  • Mumps
  • Rubella
  • Polio
  • Smallpox

The appropriate studies should be undertaken immediately so media outlets have something to publish tomorrow!

The article to some extent makes up for NPR's fumbling of the issue in 2010, by quoting anti-circumcision groups:

Chapin and other critics argue that the scientific evidence is questionable. For one thing, the studies about HIV have only been done in Africa, where AIDS is much more common among heterosexuals.
"They're cherry-picking their evidence," she says. "They act as though there's this huge body of literature. It's all the same couple of studies that have been regurgitated and reprogrammed. Over the past 150 years, all kinds of medical benefits have been proposed as resulting from cutting off the foreskin, and they have all been disproven."
Critics also question the safety of the procedure, saying too many boys are damaged for life by botched circumcisions.

But then quickly goes back to insane rhetoric:

"I think that all healthy newborn babies should be circumcised," says Edgar Schoen, a professor emeritus at the University of California, San Francisco. "I feel about newborn circumcision the way I do about immunization: It's a potent preventive health procedure that gives you a health advantage."

It's a mix of hilarious, sad and ironic that circumcision is being compared to the usefulness of vaccines in an article that so willfully ignored their existence a few paragraphs earlier.

The article presents another angle of absurdity when one realizes that it's authored by a one "Rob Stein" and quotes a one "Edgar Schoen" that happens to think everybody ought to be circumcised.

It seems that every day we can expect objective reporting on NPR.

  • Today, two people with Ashkenazi Jewish names tell us that circumcision is a cure-all
  • Tomorrow, two people with Māori names tell us that tattooing is great
  • The day after, our intrepid reporters Horace Smith & Dan Wesson explain the importance of the Second Amendment

The Stein article links to another NPR article, which is possibly even more ridiculous.

Round #2: HIV and HPV distortions

From the "Shots" health blog on August 21, 2012 comes a report - "Decline In Circumcisions Could Prove Costly".

The article says that many insurance providers, Medicaid included, are dumping coverage of routine infant cirumcision. Good for them.

But yet again, the same narrative about sexually transmitted infections comes up:

Yet three separate studies have found that circumcision reduces the risks of infection with HIV, leading the World Health Organization to recommend it in places where HIV risk runs high. Kenya, for one, is turning to circumcision of adult men to curb the spread of the virus there.

Circumcision also reduces the risk of infection with genital herpes virus and human papillomavirus. The practice can also reduce urinary tract infections in young boys. Later on, men's female sex partners are less likely to develop some infections if the guys are circumcised.

Missing facts: Gardasil (the HPV vaccine) is again not mentioned by NPR's coverage of this topic.

Onto the rest of the absurdities:

Johns Hopkins researchers analyzed how declines in circumcision would affect future health care costs, including what would happen if the rate fell to 10 percent, which is the average in Europe. The change — up or down — in HIV infections is the biggest factor.
So what's the tab? If the circumcision rate fell to 10 percent, the annual net increase in health care costs would be about a half-billion dollars a year. The findings appear in the latest issue of Archives of Pediatrics and Adolescent Medicine.

Of course, everyone knows that if the United States became more like Europe in a number of ways, overall health costs would fall through the floor.

However ridiculous the premise is, let's continue with what the study says.

The Hopkins researchers make some several big bets:

Among males in a birth cohort of 4 million, cases of infant male UTIs increased by 26 876 (211.8%), HIV infections increased by 4843 (12.2%), HPV infections increased by 57 124 (29.1%), and HSV-2 infections increased by 124 767 (19.8%) under a 10% MC rate (Table 3). Among females, cases of BV increased by 538 865 (51.2%), trichomonas infections increased by 64 585 (51.2%), HR-HPV infections increased by 33 148 (18.3%), and LR-HPV infections increased by 25 837 (12.9%).

And they make the following comparisons:

Univariate sensitivity analysis indicated that cost savings associated with increased MC coverage would persist while the cost of HIV treatment is greater than $120 000 to $125 000 and while the cost of the MC procedure is less than $640 to $660.

An interesting take on Aaron Tobian's research shows up in the comments:

George Hill
Circumcising 54 percent of American newborn boys costs $1.25 billion annually. Circumcising 100 percent of newborn boys would cost $2.3 billion annually. How would that save up money?

Tobian is spewing out pro-circumcision nonsense, which is what he is paid to do.

Using this data:
A total of 3,953,590 births were registered in the United States in 2011, down 1 percent from 2010.
Let's say exactly half are born with a penis.

1,976,795 penis havers. Taking $650 from Tobian as ballpark, it would cost $1.3 billion a year to circumcise each and every one of these penises.

Maybe Hill's estimated cost is wrong, or perhaps Tobian's estimated cost is wrong. Let's use the $1.3 billion figure just to use some of the pro-circumcision base assumptions.

Pop quiz: What are the issues with this study saying decreasing circumcision rates will increase medical costs in the United States?

It is nearly entirely based on expenses related to three infections and ignores vaccines

The three infections that show up most in their cost model:
  • HIV
  • HPV
  • Trichomoniasis
Laughably, the study links to a study of the HPV vaccine seemingly only to establish costs for cervical cancer caused by HPV. No discussion is granted to the very likely reality that HPV vaccine will greatly reduce any effects routine male circumcision will have on cervical cancer rates.

Why these three infections? Because they're the ones they could find some study showing some relationship between infection rates and circumcision.

Interestingly enough, the linked study that investigated costs of Trichomoniasis put the cost at $101 dollars per episode. Of course, there might be related costs (complications regarding births, etc) however this is how we've also itemized the cost of circumcision - about $650 per cut.

The last dragon in the room is HIV. It's ridiculously expensive to treat. The central claim of this study is essentially that HIV infection rates in the United States go up as circumcision rates go down. In the next paragraphs we'll see why that is questionable.

It does not estimate the savings (or expense) of the first drop.

The study realizes that circumcision rates have dropped from 79% to around 50% in the United States. It reads:
During the past 20 years, MC rates have declined from 79% to 55%, alongside reduced insurance coverage.
It does not get into what this may have already cost the United States. Of course, the time span does not allow one to watch the trend line for correlations.

Yet it is conceivable that these researchers could follow infection rates in the US and correlate them with circumcision rates through the past decades.

The researchers could specifically zero in on HIV, and tell us how large the infected population in the United States would have been had circumcision rates been even higher.

But that sounds like work.

It does not estimate the savings (or expense) of a 100% circumcision rate.

The Tobian paper on the web only itemizes expenditures at particular increments from 79% to 0%.

There is no reason why Tobian could not present us a chart that would show parents what would happen if we put the $1.3 billion a year down (as we estimated earlier) to circumcise all newborns.

Could it be these datapoints are hidden because an honest cost model would show diminishing returns?

While we have data to suggest that it is wrong, if we can assume Tobian's model of infectious disease plays out just as how he expects, the paper would then be telling Europe to raise their circumcision rate. Nothing in the paper suggests that the United States has anything much to gain from moving the sky-high circumcision rates in the US even higher.

It mangles up health data across three continents.

The heart of the paper takes a circumcision rate from Europe, an HIV study in Africa, and then attempts to inform North American health policy.

No effort is made to establish the relationship of circumcision and infection rates broadly within similar populations.

The reality is United States has high infection rates and high circumcision rates. Europe has lower circumcision rates and lower infection rates. How is this possible?

A handful of studies were done in Uganda that made a connection between HIV transmission and circumcision. In this context, the studies were done with a small sample and early results transformed into fiery crisis management.

Somehow, the numbers acquired in Africa can be projected upon populations in Europe and America by filling in a few cells in a spreadsheet and calling it close enough.

It is authored with preconceived notions about the seriousness of the procedure.

From the NPR article:

Critics of circumcision dispute the benefits and say it can lead to sexual problems. "There's no hard evidence circumcision is causing problems with sexual function or satisfaction," Tobian says.

If this were true, one could circumcise an adult male this very moment and have him report no ill effects on his sex life whatsoever.

Obviously Tobian speaks to routine infant circumcision in a dismissive manner, as the mentality that underlines his philosophy is "what they don't know won't hurt them".

The mind is able to compensate for a great many things - it might be possible to take a scalpel to many parts of the body and still find the capacity to report a satisfying sex life. 

However this does not mean that circumcision has no negative effects, and the "hard evidence" for this is the millions of males that do not elect to have the procedure in adulthood. 

Why is that? Can we survey these uncircumcised people and publish a study, so the smart people at John Hopkins can cite it?

Round #3: More health care cost hysterics

NPR continues its weird circumcision reporting in its coverage of the "health care cost" melodrama. Reporting first in All Things Considered "Doctors Stop Circumcisions After Finding Out What They Cost" and then copied again on hits Shots blog, "An Alaska-Sized Price Difference For Circumcisions".

The reporting is similar to any progressive-left media brouhaha about health care costs that one has read elsewhere.

The difference here is that the core sob story comes from the expense of a cosmetic procedure - circumcision.

NPR's Shots blog explains:

Two groups of pediatricians are taking a stand in Anchorage, Alaska, after learning that Alaska Regional Hospital is charging $2,110 for a circumcision — almost 10 times more than the $235 that Providence Hospital, the city's other major health facility, charges. Those prices are on top of a doctor's bill.
Ryan now performs the procedure in his office for $700, the same as he charged in the hospital.
"Health care dollars are limited, and we like to see them spent in ways that really provide good health care for people and necessary health care for people," Ryan says. "And when the health care dollar is being milked off by charges ... those are dollars that can't be used for more essential things."
Yet, even doctors can have difficulty finding out what hospital care costs, says Dr. Jack Percelay, a New Jersey pediatrician who also chairs the American Academy of Pediatrics committee on hospital care. Doctors are speaking up when they think a hospital is charging too much, he says, although most talk to hospital administrators behind closed doors.
"Oh, I'm sure there are many private discussions in terms of setting what seems to be reasonable fees," Percelay adds. "I have not heard of people boycotting services at one hospital based on charges previously."
Ryan says the incident has convinced him he needs to at least try to be better informed on hospital prices for all kinds of procedures. "Neither hospital is out there trying to put that information right in front of us," he says. "And sometimes it's hard information to get if you ask."

Note that the "cheap" version of the procedure in this story is still $40 more than Tobian's highest estimate. Perhaps an anomaly because it is Alaska, but interesting nonetheless.

Back to the story at hand - this is how NPR covers the story:

"Good ol' Dr Ryan. He's keeping the profiteering hospitals honest!"

However the story closer to reality:

"Parents still stupidly wasting money on costly elective procedures."

Dr Ryan is not doing charity or saving the rainforest here. He's pocketing $700 and performing an medically unnecessary procedure. Ryan himself describes the procedure as not "essential".

The bit veers into the absurd when it's the hospital that is the bogeyman for taking everywhere from $235 to $2110 for what amounts to a facilities fee.

Any way you slice it, (ouch) parents in Alaska are wasting about $935 on the total cost of an in-hospital circumcision performed by an MD. On a good day.

The idea that they might be taken to the cleaners for another thousand dollars merely changes the story from crazy to absolutely preposterous. 

The story of circumcision.

It has everything:
  • Bad superstitions
  • Shoddy reporting
  • Shaky science
  • Terrible economics
What is it about the circumcision issue that makes everyone lose their minds?

Why do people dilute medical science by trying to justify the procedure in a post-hoc manner?

Let us be honest about circumcision.

It is done primarily for cosmetic or religious reasons.

The relentless idea that we might want to keep cutting in order to support some secondary health indicators smells of a desperate need to always frame one's own choices in terms of the greater good or some bizarre objective superiority. 

Perhaps questionable conclusions regarding sexually transmitted infections run far in the pro-circumcision crowd as it gives certain groups the opportunity to very literally wave their dick in the air and claim that it is safer than a Volvo.

Here's an idea - NPR and the crew at Johns Hopkins University can place the topic in proper context, do things like mention HPV vaccines

The organizations might also feel the need to mention that Europe exists and is not currently falling into the ocean due to the weight of all that extra foreskin.

Meanwhile, parents can own their decision acting under the assumption that it is a completely unnecessary procedure. If they can't live with the possibility that the procedure is not glued to rates of infection, then they're playing with fire.

A good default is to leave some skin in the game.


  1. "The article presents another angle of absurdity when one realizes that it's authored by a one "Rob Stein" and quotes a one 'Edgar Schoen' that happens to think everybody ought to be circumcised."

    Aha! A clue as to your gender;)

  2. Edgar Schoen has made a lifetime career of promoting circumcision. No matter what facts are presented, he and others like him would have to abandon a career full of fanatical support of circumcision. At one time, NPR would have done a better job of finding a person to quote.

    Apparently, no one has read even summaries of those African studies. They were at best incompetent and at worst fraudulent. For some reason, people want to say, "The studies only apply in Africa." In the real world, they don't apply anywhere. Oh, and Johns Hopkins personnel were involved in at least one of the studies. Bias, anyone? At one time, NPR would have had one of their reporters read the studies and point out the problems with them. .

    The kind of reporting that NPR used to do was thorough. Unfortunately, the need to raise money by advertising and sucking up to foundations and the occasional oil company and billionaire have reduced the reporting to the drivel mentioned here. It is pretty typical of the reporting (and many of the news feature shows) that we now have at NPR.

    For years the right wing has campaigned against NPR. Now that it is toothless and lazy, maybe it is time for the rest of us to just let it go.

    1. We agree. In the US you already have Hillary Clinton, NIH, CDC USAID issuing million dollar grants. These already have given them a tarnish.

  3. NPR is consistently biased and sloppy. Terry Gross and Nina Totenberg are the only one's worth a damn. The rest are pathetic hacks practicing yellow journalism. NPR's disingenuous defense of circumcision indicates that their strings can easily be pulled.

    During the 2004 dem primaries, their "national political expert" -- and Brown alum -- Mara Liasson, said of candidate Joe Lieberman, "he should do well in New England, as he's from Connecticut, which is right next to New England."

    In 2008, NPR openly supported barack obama over Hillary Clinton. I stopped listening after that.

    My sister's boyfriend, a commercial fisherman and public advocate for sustainable fishing practices, was recently interviewed by NPR. He pulled up to the dock to find a twenty-something airhead tapping her foot. "I've been waiting to interview you for hours!' she complained. "Yeah? I've been out fishing for hours." She asked him three or four inane questions, then spent another half hour with her mike held down to the water, collecting those trademark ambient sounds.

    1. Hillary Clinton actually preached about HIV/AIDs prevention through circumcision of African men. She sent 80 million dollars through USAID to propagandize and circumcise 30 million boys and men by this year 2016.
      It is reported so far only ten percent of that goal was reached, but some African health ministries have asked for mandatory circumcisions!