19 May 2007

sex versus aging with atul gawande

embarrassing admission: i am a medical-tales junkie. i am even more of a medical-tales junkie when medical tales have to do with health care policy. (like many of my political-cultural-intellectual preoccupations, this one can be traced to a ken sharpe class, in this case practical wisdom.)

so i've been enjoying the month of guest columns by the current new yorker medical writer, atul gawande, in the times. he's not meant to do short form, i don't think -- many of these columns seem too pat, or merely commonsensical, or insufficiently dense. but most have been well worth the reading, and today's is no exception. after going through some terrifying statistics on birth control failure rates, he arrives at a policy prescription: we (that's the state-and-society we) should be more explicit about sex and birth control. he continues more ominously:
An effective national campaign would provide the details — on television, on billboards — and actively use what evidence shows works best to cut our massive rate of unwanted pregnancies. But politics precludes this. There’s not going to be such a campaign anytime soon.

but then, rather breezily:
Nonetheless, there’s no reason you have to join the one in three — or as a male, contribute to it. You just have to understand: the effort is strictly Do-It-Yourself.
i guess that, strictly and literally speaking, that's true. but the oddly individualistic DIY exhortation takes the edge off the epidemiological fact of the matter, namely: information is not free. for fuck's sake, we need those billboards.

gawande's most recent long piece runs in a similar sort of way but doesn't sidestep the difficulties with individualistic, DIY solutions -- here, investigating the decline of geriatrics, gawande gets to the state-and-society piece of the puzzle (not enough geriatric specialists for the aging population), shows how some well-heeled individuals cope (fancy-ass retirement communities, extremely good preventative care), and assesses the costs (hella high). DIY, or analogs thereto, begin to seem like less and less of an option.

this despite the fact that the much-missed geriatricians perform essentially the same role as the longed-for sex billboards: they provide preventative information. to be sure, it's personally-tailored, but it's really the same sort of (statistical) information. birth control fails 8% of the time; there are three important risk factors for falls in older adults. so why would we read the information-to-effort ratio as so much lower when we're talking about sex?

(or is this a path dependency problem -- gawande knows that there have been and could be geriatricians; he's never seen an american sex ed campaign; somebody call paul pierson -- ?)