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Two months ago, I celebrated what seemed to be an emerging recession in cosmetic surgery. That assessment was based on anecdotes and sketchy data from Reuters and the Los Angeles Times. The good news, I argued, was that the rough economy was reminding people which medical procedures were necessary and which weren't. It was also forcing doctors to shift from cosmetic profit back to the real work of promoting health.
Last week, a follow-up Reuters story cast doubt on the trend. Britain's biggest cosmetic surgery company reported a 35 percent increase in procedures in less than a year, led by a 59 percent increase in tummy tucks and a 40 percent increase in breast augmentations. A company spokeswoman opined:
It's interesting to see what people cut back on during a credit crunch. Research among our patients has shown that despite cutting back across all other areas ... people aren't cutting back on money they spend on themselves. For many who are undertaking an abdomnoplasty this is something they've planned for years. For this reason, they're unlikely to want to now put this off and instead they consider their procedure to be an investment.
How depressing. I know it's now standard practice to peddle every product or service as an investment. But cosmetic surgery? It's not health. It's not even disposable property.
Now further data are backing up the original trend reports. Natasha Singer of the New York Times says the two-year waiting lists of a few years ago have dried up:
Earlier this month, this reporter, using a script, made identical anonymous calls to the offices of 48 prominent plastic surgeons in makeover meccas like Orange County, Calif., and the Upper East Side of Manhattan, asking staff members about the earliest possible appointment dates for consultations and cosmetic surgery. I selected plastic surgeons who have appeared regularly on television, or in glossy magazines, or who are listed in the 2007 edition of "America's Top Doctors" ... [A]bout 90 percent of the doctors' offices offered consultations in three weeks or sooner; and about 94 percent offered surgery dates in June or July.
More broadly, total cosmetic surgeries are still 3 percent below the levels of eight years ago.
Why the shrinkage? Because money is tight. "A survey in April and May of more than 600 plastic surgeons, by the American Society for Aesthetic Plastic Surgery, reported that almost 53 percent said the downturn in the economy has had an adverse impact on plastic surgery practices," Singer reports. Data show that the recession hasn't driven clients out of the cosmetic market altogether. But it has downshifted their spending from expensive surgeries to Botox and other cheaper nonsurgical procedures.
One plastic surgeon tells Singer that in previous years he had clients "refinancing their homes and using them as A.T.M.s" to pay for breast augmentations and liposuction. Ponder the insanity of that: risking the most expensive of life's three traditional needs—food, clothing, and shelter—for pure vanity. And then, when you can't pay the mortgage, we're supposed to bail you out? And your surgeon calls what you did an "investment"?
Fortunately, not every doctor has lost perspective. When asked to explain the drop in clientele, another plastic surgeon tells the Times: "We are a luxury item. People want us, but they don't actually need us."
Exactly. Skip the boob job. Keep the house.
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The movement to stamp out birth control appears to have taken an ominous turn. Until now, women with contraceptive prescriptions were just being turned down by individual pharmacists. Now they're being turned down by whole pharmacies. Refusals from individuals behind the counter have "resulted in pharmacists being fired, fined or reprimanded," reports Rob Stein in Monday's Washington Post. "In response, some pharmacists have stopped carrying the products or have opened pharmacies that do not stock any." Pharmacists for Life International names seven pharmacies that have signed a "pro-life" pledge and says others are doing the same.
It's not clear how many of these proprietors object to birth control per se and how many are abstaining because they think emergency contraception is abortion. Stein points out that in some states, the only legal way to refuse a prescription for emergency contraception is to abstain from offering contraceptives generally.
What's the reaction from pro-choicers and bioethicists? Here are excerpts from the Post story:
1) "I'm very, very troubled by this," said Marcia Greenberger of the National Women's Law Center, a Washington advocacy group. "Contraception is essential for women's health. A pharmacy like this is walling off an essential part of health care. That could endanger women's health."
2) "Why do you care about the sexual health of men but not women?" asked Anita L. Nelson, a professor of obstetrics and gynecology at the David Geffen School of Medicine at UCLA. "If he gets his Viagra, why can't she get her contraception?"
3) "If you are a health-care professional, you are bound by professional obligations," said Nancy Berlinger, deputy director of the Hastings Center, a bioethics think tank in Garrison, N.Y. "You can't say you won't do part of that profession."
4) Critics also worry that women might unsuspectingly seek contraceptives at such a store and be humiliated, or that women needing the morning-after pill, which is most effective when used quickly, may waste precious time. "Rape victims could end up in a pharmacy not understanding this pharmacy will not meet their needs," Greenberger said.
5) "We may find ourselves with whole regions of the country where virtually every pharmacy follows these limiting, discriminatory policies and women are unable to access legal, physician-prescribed medications," said R. Alta Charo, a University of Wisconsin lawyer and bioethicist. "We're talking about creating a separate universe of pharmacies that puts women at a disadvantage."
Let's take these objections one at a time.
First: "Walling off" women's health care? Beware dramatic metaphors from lawyers. There is no wall. You bring your scrip to the pharmacy, and the guy at the counter says, "Sorry, we don't stock contraceptives." That's annoying and, in my view, stupid. But nobody's walling you in. Your burden consists of finding another pharmacy.
Second: Why Viagra and not contraception? Because some pro-lifers view hormonal contraception as potentially lethal. I don't share their anxiety about this theoretical risk to an early embryo, particularly when the alternative, in the event of pregnancy, is a high likelihood of fetal killing. But you can't blow off the argument by assuming that contraception should be covered because it's more important than Viagra. The whole point of the argument is that you're looking at it backward: The fact that contraception is more consequential than Viagra is a reason to be more wary, not less, of distributing it.
Third: "Professional obligations" to provide all health care? Actually, doctors and hospitals draw moral lines around their practices all the time. This doctor won't pull the plug; that one won't do abortions; this other one can't in good conscience collaborate in your faith-based treatment plan.
Fourth: Humiliation? Sorry, but part of true equality is brushing off people who don't respect you. If the guy behind the counter won't sell birth control, he's the one who should be embarrassed, not you. Walk out, and don't come back.
Fifth: Whole regions where pharmacies won't stock contraceptives? Come on. Only seven have even signed the "pro-life" pledge. It's true that abortions have been driven out of rural counties. But politically, the resistance to birth control is nothing like the resistance to abortion. A pharmacy that won't stock contraceptives looks pretty silly.
Greenberger does make a good point about wasting women's time when, as in the case of morning-after pills, speed is essential. And Stein's reporting suggests the abstaining pharmacies aren't making their policies clear enough. If they won't do this voluntarily—by posting them, for instance—the law should make them do it. If I were writing the regulations, I'd draw up a big, fat, standardized "We don't stock birth control" notice, complete with a 24-hour toll-free number that will direct you to the nearest pharmacy that has what you need.
But I wouldn't force pharmacies to sell birth control if they don't want to. In particular, I dread Charo's suggestion that providers should be compelled to offer "legal" drugs. One of this country's greatest achievements is its separation of legality from morality, so that individuals can hold themselves to a higher standard, as they see it, without forcing it on everyone else. This is the principle many pro-lifers have rejected as they press for abortion bans to "teach" the immorality of killing fetuses. Happily, some have shifted their energy from attacking abortion clinics to setting up "alternative" pregnancy centers. It's a shift from violence and harassment to exhortation and, at worst, deceit.
So, please, don't tell moralists they have to do or sell whatever's legal. If you do, you won't like what happens to the law.
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Yesterday, Sen. Ted Kennedy got out of the hospital. He'd been there since last week, when he had surgery to remove a brain tumor. How long he'll live, nobody knows. The last report from his doctors was right after the operation: "Senator Kennedy was awake during the resection, and should therefore experience no permanent neurological effects from the surgery."
Awake during brain surgery? And this helped? How?
Awake craniotomy has been around for decades and is gradually becoming more common. Kennedy's surgery will certainly get more patients and doctors talking about it. Here's the initial problem: Your doctors need to cut out your tumor, but it's hard to tell where regular brain tissue stops and the tumor begins. Which parts can they cut out? Which parts can they cut through? Overall brain structure is similar from person to person, but details vary enormously.
If the operation were on your leg, the surgeons could check and map their route while you slept. That's where most of us would like to be during surgery: out cold. I don't know about you, but my feelings about going under the knife are pretty close to Woody Allen's feelings about death: It's not that I'm afraid of it; I just don't want to be there when it happens.
But when the surgery is on your brain, you need to be there, because the feedback that will tell your doctors where to cut or not to cut isn't strictly physical. It's mental. According to the Boston Globe, "Kennedy's tumor was located in a region of the brain involved with language and movement." How can doctors find out whether snipping the next bit of tissue in their path would mess with his verbal ability? By asking him questions. "Tiny electrodes are placed on the brain to introduce an electrical current," the Globe explains. If the electrified zone is verbally important, says a neurosurgeon, the charge "will stop their speech. You know then that's a region you usually try to stay away from or preserve while you're doing surgery."
Depending on the tumor and surgeon, the test may be as simple as counting to 10 or as complex as conversation. Here's one account from the San Francisco Chronicle a couple of years ago:
[Dr.] Perry starts flashing the pictures on the computer screen, and Hill hits them as if he's been studying. "Window, owl, elephant, football, scissors, hammer." Before Perry asks each question, [Dr.] Berger receives a cue to stimulate a tiny piece of brain with an electrical current ... Suddenly that line is crossed. Hill starts getting confused, his brain waves spiking on an EEG monitor. He calls a door a car. Then he starts calling every picture chicken.
And here's a British case reported by BBC News:
[Dr.] Marsh used an electrical pulse to find out where Adrian's tumor ended and where the region of the brain that controls speech began. The pulse temporarily slurred Adrian's speech, giving [Dr.] Marsh a clear idea of what tissue he needed to remove. Throughout the surgery, Adrian was asked to identify a series of pictures, such as a tripod, a compass and an accordion. ... Marsh decided to stop the surgery after Adrian started to become muddled.
This is the hardest thing to accept about brain surgery: What's being operated on isn't some body part you can think about or not think about it. What's being operated on is you. If the surgeon goofs, you don't wake up like Ronald Reagan in Kings Row, shouting at your missing legs, "Where's the rest of me?" The word me simply doesn't mean the same thing anymore. You may never know that there ever was a "rest of me."
This is why the surgeon in the British case warned his patient up front that
there was a risk in cutting so deep into the brain to remove as much of the growth as possible: the parts of the brain which govern speech, language or personality might be affected. "The difficulty is that you are operating very close to the regions of the brain that affect people's thoughts, feelings and speech. It could change their personalities forever," he said.
So take my advice: If you ever get a tumor next to the parts of your brain that think or speak, ask for the awake surgery. It'll be pretty weird trying to answer questions or hold a conversation while you're being zapped. But it's better to wake up and live the nightmare for a few minutes than to sleep and live it forever.
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Friday morning, I thought I was all done investigating the ins and outs of the Chinese one-child policy. And then this happened. On Friday evening, Xinhua, the state news service, reported:
China's family planning authority are to send a medical team to conduct surgery to reverse sterilization operations on parents wanting another child in China's earthquake zone. Zhang Shikun, director of the science and technology bureau of the National Population and Family Planning Commission, said, "The team, comprised of experts on childbearing, will conduct surgery in the quake-hit areas to provide technological support for those wanting to give birth to another." The team was part of the commission's plan to provide free reproduction services, including counseling, guidance, surgery, and the implementation of artificial reproduction technology, for those who wish to have another child, she said.
You have to hand it to the Chinese government. First, they tell you not to give birth to more than one child (unless you run a farm, or you're an ethnic minority, or you and your spouse have no siblings, or a bunch of other exceptions). On the other hand, they're going all-out to make sure that if you obeyed that policy and lost your only child in the quake, you can get another.
Those tubes you tied, thinking you were done procreating? We'll untie them for you, gratis. Vasectomy? Schmectomy. In fact, if you're too old now to make babies the old-fashioned way, we'll provide "artificial reproduction technology" to help you along.
Now, that's what I call full-service public health insurance.
What's really going on here, of course, is public fury over all the kids who died in poorly built schools. The government limited those families to one child and then failed to protect their kids. The whole premise of Saving Private Ryan was that the U.S. government dare not cost a family its last child. But that's exactly what has happened in China, thousands of times over. According to Xinhua, family-planning authorities in Sichuan, the quake-hit province, estimate that 7,000 families lost their sole children in the disaster, and 16,000 sole children in other families suffered injuries or disabilities.
Through this combination of totalitarianism and incompetence, the Chinese government took away one of nature's greatest fulfillments: procreation. Now it's trying to make up for that theft by delivering surgeries and technologies to replace your lost child with a new one. You have to wonder what other options the government would be offering bereft parents in their 40s if reproductive cloning were sufficiently refined.
Would that be wrong, once the technology is safe? If the one-child limit is morally defensible, and if that child dies through government neglect, and if it's OK to use artificial technology to help the couple make a new child ... what's wrong with cloning the old one?
Go ahead, speak up. It's a free country.
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Last week I wrote about the warranty on children killed by the recent earthquake in China. I referred to an exemption to the country's one-child policy, allowing parents who lost their kids to replace them. At one point, I asked, "Why should the warranty apply only to this earthquake? What about the floods of 1991 and 1998? What about the drought of 1988? How many couples lost their only kids in those calamities? Where's their compensation?"
Many of you wrote in to correct me, noting that the replacement allowance is a general rule under the one-child policy. I wasn't satisfied with these assertions, so I went to the Chinese government's Web site for clarification. After some digging around, the only direct nationwide statement I could find was in the "Population and Family Planning Law of the People's Republic of China," adopted in 2001. Here's the basic language (Article 18):
The State maintains its current policy for reproduction, encouraging late marriage and childbearing and advocating one child per couple. Where the requirements specified by laws and regulations are met, plans for a second child, if requested, may be made. Specific measures in this regard shall be formulated by the people's congress or its standing committee of a province, autonomous region, or municipality directly under the Central Government.
And here's the sole reference to damaged children (Article 27):
Where the only child of a couple is disabled or killed in accidents, and the couple decides not to have or adopt another child, the local people's government shall provide the couple with necessary assistance.
So, the general policy is vague. Implicitly, at least, you can decide to have another child if yours is killed or even disabled, as long as the tragedy was an accident.
Slate's Lucy Morrow Caldwell contacted several China experts who helped us with the original "Explainer" on this topic. We couldn't find records of the policy being waived in previous disasters, but Vanessa Fong of Harvard and Wang Feng of the University of California confirmed that the policy has traditionally permitted a second child if the first is killed or disabled. Cindy Sun of Fudan University directed us to a May 28 statement from the National Population and Family Planning Commission of China. The statement includes a clause that an acquaintance of mine translates as follows:
To the families whose children were injured or killed in the earthquake, the benefit of additional birth should be given, according to the number, sex, and injury of the children who survived the disaster.
In other words, precise numerical replacement, with different values for boys and girls, since many rural parents are allowed to have a second child if the first is a girl.
We also found a link to the earthquake policy issued by the Family Planning Commission in Chengdu, the capital of Sichuan Province, which bore the brunt of the disaster. A second acquaintance paraphrases its main points this way:
1) A "green light" for parents whose only child was injured, disabled, or killed.
2) The government will proactively work with these parents if they wish to have another child. This includes registering them and providing reproductive services.
Here's his translation of the policy's fine print on injury or disability:
Medical identification shall be conducted on injured/disabled children of single-child families. If the child is certified to have second-degree or above injury or disability, the parents shall be assisted to apply for bearing a second child.
A third acquaintance translates the fine print somewhat differently:
For those whose only child was disabled in the earthquake, local Birth-Control Agencies shall record the cases and compare them to the "Medical Disability Standards for Children from One-Child Family." For those qualified, the local agencies shall help them file the applications for the birth of a second child. The Birth-Control Council of Chengdu city will perform medical assessment and approval process promptly.
One final note: Article 11 of Sichuan's family-planning regulations stipulates that couples may have a second child if "the first child has non-genetic defects and is unable to grow up to be a normal laborer."
So, here's the full policy, as far as I can piece it together from the available documents: You can replace your child (in the numerical sense) in the event of death or disability, as long as the cause was an accident. Extent of replacement depends on the number and sex of the children you lost. Replacement for disability requires medical certification that the damage is second-degree, as measured by official standards. Replacement is also available for disabling defects, but not if they're genetic, presumably because in that case the replacement might be similarly defective.
Got that? To me, it sounds a lot like the piece of paper that came with my PC monitor. So, there's your warranty. Let's hope you never have to use it.
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Here's something good you can do for your body and your planet: Eat more bugs.
Janet Raloff has the goods in this week's Science News. We're facing worldwide environmental, obesity, and food crises. Bugs are the answer.
Consider the nutritional value of the humble cricket: Each 100 grams of dehydrated tissue has 1,550 milligrams of iron, 340 milligrams of calcium, and 25 milligrams of zinc -- three minerals often lacking in the diets of third-world countries. If you're ever lost in the woods, three crickets a day will meet your iron needs. Compared to beef or pork, bugs deliver more minerals and healthier fats.
Bugs are also more energy-efficient. Crickets deliver twice as much edible tissue as pigs and almost six times as much as steers based on the same food input. And that's not counting their superior rate of reproduction. One scholar calculates that overall, they're 20 times more efficient than steers.
That global food crisis you've been reading about? No problem. An Asian expert reports that in Thailand, each family can raise crickets independently on a tiny parcel of land. In a pair of villages, 400 families are cranking out 10 metric tons of crickets during the peak season.
Bug-eating also reduces the need for pesticides. The more bugs you eat, the less you have to spray. That's what happened in Thailand, where locusts have been brought under control through culinary culling.
You've never eaten bugs? You're missing out. People in most countries eat insects. Central Americans eat butterfly larvae. South Americans eat beetles. Africans eat ants, caterpillars, and grubs. Asians eat fried crickets. Aborigines eat honey ants.
You say bugs are gross? Why? Is it the exoskeleton? The appendages? The weird eyes? Guess what: You already eat animals with these characteristics. They're called crustaceans. Shrimp, crabs, lobsters -- they're arthropods, just like crickets. They're also scavengers, which means their diets are as filthy as any bug's.
Many of these arguments have been around for more than a century. Vincent Holt made the original case in his 1885 manifesto, Why Not Eat Insects? Lately, a Web site called food-insects.com has taken up the cause. Three years ago, an Italian professor published Ecological Implications of Minilivestock: Potential Of Insects, Rodents, Frogs And Snails. A company called Sunrise Land Shrimp is bringing the movement to the United States. "Mmm," says the company's cricket logo. "That's good Land Shrimp!"
See what a few good euphemisms can accomplish? "Minilivestock" and "land shrimp" can do for bugs what "mountain oysters" have done for bull testicles. And for those of you who still can't stand the idea of beetle-munching, there's even better news. Remember that project I've been touting to grow meat without growing animals? Dutch researchers are extending it to insects. Raloff reports:
They're using biotechnology to produce vats of insect cells -- just isolated cells. The researchers described their efforts last year in Biotechnology Advances. The goal, explains Marjoleine C. Verkerk of Wageningen University, is to produce a sanitized source of bug proteins that can be dried and added to breads or perhaps molded into pseudo-burgers. Her team is mass producing isolated ovary cells of silkworms, fall armyworms, cabbage loopers and gypsy moths.
All that good insect protein, without the eyes and legs. What could be better?
Mmm. That's good land shrimp.