LATIMES.COM/OPINION TUESDAY, AUGUST 6, 2019A
OP-ED
A
cademic cancer centers
are exalted for producing
cutting-edge research and
providing superior cancer
care. Doctors and the public
look to them for unbiased evidence on
which cancer treatments lead to mean-
ingful improvements in survival and
quality of life — and which do not. Can-
cer center patients expect treatment
recommendations that are driven
solely by this science.
But there’s a lot of money in cancer,
and that means other influences can
come into play. Cancer therapeutics is
now the pharmaceutical industry’s
largest market and its primary focus for
new drug development. Not surpris-
ingly, industry money has infiltrated ac-
ademic institutions. Last fall, the chief
medical officer at Memorial Sloan Ket-
tering Cancer Center resigned following
the revelation that he had failed to dis-
close nearly $3.5 million in industry
payments over four years.
On Monday, we published a research
letter in JAMA Internal Medicine sum-
marizing industry payments to the 53
physicians who direct major cancer
centers across the United States. These
are the nation’s most prominent cancer
centers, those designated by the Na-
tional Cancer Institute in recognition of
their scientific leadership.
We were surprised by what we found:
Slightly over half of the physician can-
cer center directors received noindus-
try payments in 2017. That’s good news.
Of course, that means slightly under
half didreceive industry payments. To
be fair, payments to many directors fell
under the category of chump change – a
meal, a night in a hotel, an airline ticket
— well under the $5,000 threshold the
NCI uses to define a significant finan-
cial interest. About a third of all direc-
tors, however, were above this threshold
— typically receiving payments for re-
search and consulting. A few were well
above it (one had payments exceeding
$2 million).
Industry payment data are available
because of the Sunshine Act — a part of
the Affordable Care Act that mandates
that drug and device manufacturers re-
port all payments made to any Ameri-
can physician. The data are public and
available to anyone with an internet
connection.
Go ahead and look up your oncolo-
gist — or your orthopedic surgeon. Let
the sun shine in.
There is an inherent tension be-
tween the interests of industry and
those of the public in medical care. In-
dustry has an interest in developing
new products and promoting them — in
an effort to maximize price and volume.
The public has an interest in the unbi-
ased evaluation of new products — in an
effort to determine their potential ben-
efits and their associated harms.
Drug and device manufacturers
should innovate, not evaluate their “in-
novations.” Yet most clinical trials eval-
uating new products are funded by
industry, giving them considerable in-
put in the design and conduct of re-
search. That’s a problem.
The reason is simple: Industry-
funded evaluations are more likely to
reach pro-industry conclusions. There
is a considerable body of research at-
testing to this fact. Industry funding
has been shown to distort medical
research through a variety of mecha-
nisms that all work in the same direc-
tion: overstating the value of new prod-
ucts. One study of studies showed that
the odds of a pro-industry conclusion
were more than three times higher in in-
dustry-funded evaluations. Another
concluded, “Systematic bias favors
products which are made by the com-
pany funding the research.”
Well, duh. But sometimes it’s impor-
tant to document the obvious.
If industry funding can skew aca-
demic physicians’ research, imagine
the problems with consulting fees, stock
options and corporate board
compensation. The conflicting inter-
ests of product promotion vs. unbiased
evaluation will always persist. That’s
why it is important to separate the two.
NCI-designated cancer centers have
a central role in shaping cancer care in
the United States. They receive more
than $300 million in federal funding to
support their core infrastructure —
plus millions more in public dollars for
specific research projects. Their direc-
tors should be free of industry pay-
ments in order to serve the public inter-
est in unbiased evaluation of cancer
therapies — and to be in a position to
make disinterested judgments about
the conflicts of researchers on their fac-
ulties.
The good news is that half of all NCI
physician cancer center directors ap-
pear to have already come to this con-
clusion. Let’s hope the others follow.
H. Gilbert Welchis a physician and
senior researcher in the Center for
Surgery and Public Health at the
Brigham and Women’s Hospital in
Boston. He is the author of “Less
Medicine, More Health: 7 Assumptions
That Drive Too Much Medical Care.”
David Carr is a physician and fellow in
the department of pathology at UC
San Diego.
Pharma
money at
top cancer
centers
By H. Gilbert Welch
and David Carr
A
merica is sick.Just
about everybody
recognizes it, and we
didn’t need two
more mass shoot-
ings to convince anybody of
anything. Most Americans think
the country is on the wrong
track, despite a roaring econo-
my. You can blame President
Trump, but Americans have
been unsatisfied with the coun-
try’s direction for most of the
last two decades.
Amazingly, given the level of
partisan animosity in this coun-
try, both sides see the problem
much the same way: The coun-
try is plagued by selfishness,
alienation, variously defined
bigotries, inequality and a lack
of social solidarity. Even more
bizarre, the right and the left
call for similar solutions.
About the problem, both are
largely correct. About the reme-
dy, both are very wrong.
On the right, a growing num-
ber of intellectuals see national-
ism as the cure for what ails us.
Definitions vary, but all nation-
alists emphasize a renewed
passion for America as a dis-
tinct culture or people and not
just an “idea.” The Hudson
Institute’s Christopher DeMuth
argues that nationalism is an
idea whose time has come
(again) because it reminds us
“of our dependence on one
another.” He likens it to the
religious “Great Awakenings” ofthe past. Catholic writer Sohrab
Ahmari wants an awakening
that delivers “order,” “social
cohesion” and policies aimed at
the “Highest Good” — in the
classical philosophic sense
(summum bonum).
On the left, listen closely to
the proselytizers of the new
socialist awakening. You’ll no-
tice that it has less to do with
economics than a yearning for a
more cooperative and egalitari-
an alternative to selfish capi-
talism driven not by nationalism
but government — which is “the
only thing we all belong to,” as a
video at the 2012 Democratic
Convention asserted.
The vocabulary they use is
different, but the underlying
indictment of the status quo is
remarkably similar. Nationalism
is an obscenity to the left and
socialism to the right, but a
nationalizing or centralizing
spirit suffuses both sides.
Team Trump’s “economic
nationalism” has echoes of the
“economic patriotism” of Eliza-
beth Warren, who speaks with
an almost Trumpian passion
about how the “system is
rigged.” A slew of wannabe GOP
successors to Trump, with Sen.
Josh Hawley (R-Mo.) in the lead,
seem desperate to craft a new
“daddy state” industrial policy
for right-wingers.
As a conservative of a classi-
cally liberal bent, I find this new
convergence of left and right
dismaying and disheartening.
But that doesn’t mean theydon’t have a point that some-
thing is very wrong. You only
have to look at the rising suicide
rates, opioid deaths, declining
life expectancy and, of course,
the onslaught of mass shootings
to see the country’s despair. A
recent survey found that more
than a fifth of millennials say
they have no friends, a poignant
illustration of the loneliness
crisis that probably has at least
as much to do with mass shoot-
ings as white supremacy or
video games.
Where everyone loses me is
the idea that the solution to
these maladies can be found in
Washington or in nationalizing
movements of the right or left.
One of the reasons social
media is so toxic is that it is a
nationalizing force; it makes us
feel like strangers thousands of
miles away are neighbors — and
we get mad when neighbors are
living the “wrong” way. Cable
news does the same thing, just
with better production values,
plucking anecdotal stories and
making them part of a “national
conversation.” The problem isthat there’s no such thing as an
actual national conversation.
What we need are communi-
ties, and the idea of national
community is a myth. Conversa-
tion is done face-to-face and
person-to-person, and so is
community.
The nationalization of cul-
ture drives centralized govern-
ment, and centralized govern-
ment saps communities of
mutual dependence. It renders
the rich ecosystem between the
individual and the state obso-
lete, yet it is that habitat where
humans actually live and find
meaning.
The nationalizing move-
ments aim to fill the void left by
the decline or disappearance of
not just industrial jobs, but of
the healthy communities that
grew up around the factories.
Government has a role in
dealing with the challenges of
globalization and automation,
but these movements cannot fill
the holes in our souls. And the
prospect that either side is
eager to try only raises the
stakes for the other. This is how
nationalization fuels winner-
take-all polarization. When each
tribe seeks to impose a one-size-
fits-all “Highest Good” on all
Americans, the paranoid belief
that “all we hold dear” is at stake
at the ballot box metastasizes
for many.
And, for a few, ballots give
way to bullets.[email protected]Curing America’s serious malaise
JONAH GOLDBERG Conservatives are
embracing nationalism
and liberals are calling
for socialist policies,
but neither will fix
what ails the country.
I
n the last week, more than 30 people
have died in three separate mass shoot-
ings in Gilroy, El Paso and Dayton,
Ohio. We believe that analyzing and
understanding data about who com-
mits such massacres can help prevent more
lives being lost.
For two years we’ve been studying the life
histories of mass shooters in the United
States for a project funded by the National
Institute of Justice, the research arm of the
U.S. Department of Justice. We’ve built a
database dating back to 1966 of every mass
shooter who shot and killed four or more peo-
ple in a public place, and every shooting inci-
dent at schools, workplaces and places of
worship since 1999. We’ve interviewed incar-
cerated perpetrators and their families,
shooting survivors and first responders.
We’ve read media and social media, mani-
festos, suicide notes, trial transcripts and
medical records.
Our goal has been to find new, data-driv-
en pathways for preventing such shootings.
Although we haven’t found that mass shoot-
ers are all alike, our data do reveal four com-
monalities among the perpetrators of nearly
all the mass shootings we studied.
First, the vast majority of mass shooters
in our study experienced trauma and expo-
sure to violence at a young age. The nature of
their exposure included parental suicide,
physical or sexual abuse, neglect, domestic
violence and/or severe bullying. The trauma
was often a precursor to mental health con-
cerns, including depression, anxiety,
thought disorders or suicidality.
Second, practically every mass shooter
we studied had reached an identifiable crisis
point in the weeks or months leading up to
the shooting. They often had become angry
and despondent because of a specific griev-
ance. For workplace shooters, a change in job
status was frequently the trigger. For shoot-ers in other contexts, relationship rejection
or loss often played a role. Such crises were,
in many cases, communicated to others
through a marked change in behavior, an ex-
pression of suicidal thoughts or plans, or spe-
cific threats of violence.
Third, most of the shooters had studied
the actions of other shooters and sought val-
idation for their motives. People in crisis
have always existed. But in the age of 24-hour
rolling news and social media, there are
scripts to follow that promise notoriety in
death. Societal fear and fascination with
mass shootings partly drives the motivation
to commit them. Hence, as we have seen in
the last week, mass shootings tend to come
in clusters. They are socially contagious. Per-
petrators study other perpetrators and
model their acts after previous shootings.
Many are radicalized online in their search
for validation from others that their will to
murder is justified.
Fourth, the shooters all had the means to
carry out their plans. Once someone decides
life is no longer worth living and that murder-
ing others would be a proper revenge, only
means and opportunity stand in the way of
another mass shooting. Is an appropriate
shooting site accessible? Can the would-be
shooter obtain firearms? In 80% of school
shootings, perpetrators got their weapons
from family members, according to our data.
Workplace shooters tended to use handguns
they legally owned. Other public shooters
were more likely to acquire them illegally.
So what do these commonalities tell us
about how to prevent future shootings?
One step needs to be depriving potential
shooters of the means to carry out their
plans. Potential shooting sites can be made
less accessible with visible security measures
such as metal detectors and police officers.
And weapons need to be better controlled,
through age restrictions, permit-to-pur-
chase licensing, background checks, safe
storage campaigns and red-flag laws — mea-
sures that help control firearm access for vul-
nerable individuals or people in crisis.
Another step is to try to make it more dif-
ficult for potential perpetrators to find val-
idation for their planned actions. Media
campaigns like #nonotoriety are helping
starve perpetrators of the oxygen of publi-
city, and technology companies are increas-
ingly being held accountable for facilitating
mass violence. But we all can slow the spreadof mass shootings by changing how we con-
sume, produce and distribute violent con-
tent on media and social media. Don’t like or
share violent content. Don’t read or share
killers’ manifestos and other hate screeds
posted on the internet. We also need to study
our current approaches. For example, do
lockdown and active-shooter drills help chil-
dren prepare for the worst or hand potential
shooters the script for mass violence by nor-
malizing or rehearsing it?
We also need to, as a society, be more pro-
active. Most mass public shooters are suicid-
al, and their crises are often well known to
others before the shooting occurs. The vast
majority of shooters leak their plans ahead of
time. People who see or sense something is
wrong, however, may not always say some-
thing to someone owing to the absence of
clear reporting protocols or fear of overreac-
tion and unduly labeling a person as a poten-
tial threat. Proactive violence prevention
starts with schools, colleges, churches and
employers initiating conversations about
mental health and establishing systems for
identifying individuals in crisis, reporting
concerns and reaching out — not with puni-
tive measures but with resources and long-
term intervention. Everyone should be
trained to recognize the signs of a crisis.
Proactivity needs to extend also to the
traumas in early life that are common to so
many mass shooters. Those early exposures
to violence need addressing when they hap-
pen with ready access to social services and
high-quality, affordable mental health treat-
ment in the community. School counselors
and social workers, employee wellness pro-
grams, projects that teach resilience and so-
cial emotional learning, and policies and
practices that decrease the stigma around
mental illness will not just help prevent mass
shootings, but will also help promote the so-
cial and emotional success of all Americans.
Our data show that mass shooters have
much in common. Instead of simply rehears-
ing for the inevitable, we need to use that
data to drive effective prevention strategies.Jillian Petersonis a psychologist and
professor of criminology and criminal
justice at Hamline University. James
Densleyis a sociologist and professor
of criminal justice at Metropolitan State
University. Together, they run the Violence
Project.MASS SHOOTINGSlike the one in El Paso illustrate the importance of understanding what motivates the perpetrators.
A database of every such attack since 1966 offers insights into the shooters and suggests how to prevent the violence.Larry W. SmithEPA/ShutterstockWho are the mass shooters?
Perpetrators of the attacks share
certain traits. Understanding what
they have in common could help
prevent future violence.
By Jillian Peterson
and James Densley