Author Archives: Jon Zaid

Big Pharma: Don’t Hate the Player, Hate the Game

Martin Shkreli is a man I admire in an odd sort of way.

The recent controversy involving Mr. Shkreli and his price hike of the toxoplasmosis drug, Daraprim, seems to have caused misguided furor towards the 32-year-old CEO of Turing Pharmaceuticals. He may epitomize a major problem with the pharmaceutical industry but he is simply playing by the rules his pharmaceutical executive contemporaries and predecessors have helped set in place. Much like Donald Trump and his history of bankruptcies, he’d be foolish not to take advantage of every oversight weakness or loophole set up by a corrupt system that affords advantages to those who are shrewd enough and willing to exploit them. The public’s anger is directed at the man and not the system.

If Shkreli were to step down or be forced to resign, do people think that the next CEO of Turing Pharmaceuticals won’t be as zealous or brash in exploiting the system? People dislike him for the price hike, but loathe him for the way he defiantly acted in response. If I were a board member I would demand that my CEO rigorously investigate every pathway to make the company more profitable and therefore more financially stable, but I would also want them to exhibit a measure of temperance so as not to attract unwanted public spotlight. It seems as though people would be willing to forgive and forget a less brazen pharmaceutical executive. Every public dollar not claimed by Turing Pharmaceuticals is a dollar that will be spent elsewhere, or heaven forbid end up in the coffers of the competition.

As for the relationship to medical students, pharm and biotech industry sales reps are not seen or heard from during the first two years of our schooling. We are in the classroom and there is no official school-sanctioned time allotted to these groups unless specifically invited by a student organization. There are no events or talks sponsored by companies, and all faculty must divulge any real or perceived conflicts of interest when lecturing.

This changes in the clinical years (third and fourth year) when the students are out and about amongst the physicians, nurses, and patients in the hospitals and clinics. Students are left to their own devices and are sometimes in rooms with Big Pharma reps during presentations for a new product or during demonstrations of a new surgical device. The “good” reps will gravitate towards the students after they’ve made their pitch to the higher-ups and start chumming it up with those at the bottom of the totem pole and those with the least decision-making capacity.

My first encounter with a sales rep was right before entering the operating room (OR). Gowned in scrubs, all entrants into the OR look nearly identical and no hierarchy can be discerned readily, like it can be up on the patient floors. There doctors wear long white coats, nurses wear scrubs, and students wear short white coats paired with a look that can only be described as confident confusion. There the pecking order is clear. The OR is murkier—we’re all wearing blue scrubs so the nurses and students are dressed like the doctors are dressed like the students. The man approached me and asked if I was a student and we began chatting. I assumed this guy was of some import—he was tall, he spoke confidently, and he knew everyone’s name entering the OR. As the conversation shifted from what my first few days at the hospital were like, he started extolling the sophistication and ease of use of this new surgical device that would be employed for this particular operation. Then it hit me that this guy was just a salesman.

He knew who I was, right? Him selling me on his product would do absolutely nothing for his company’s bottom line and his quarterly sales wouldn’t see the slightest uptick whether or not he had ever spoken to me. He gave me his card and told me to be on the lookout for his company’s reps in all my future endeavors. Man, I thought, he was such a nice guy. As the weeks went on I encountered other reps while in the hospital. All of who were just as nice. What an endearing industry.

Drexel had done a superb job at shielding its first and second year students from the influences of third party companies. We had almost no exposure to the sales pitches coming out of the mouths of these charismatic salespeople. We were being released to the world as naïve students. Were these reps being nice for the sake of being nice? Of course that’s a possibility. What’s much more probable, however, is that they are all planting the seeds of merchandising as soon as they are able. I wouldn’t be advising any hospitals to buy any new surgical devices, nor would I be prescribing any meds for a few years, but when the time comes, I will already have that brand recognition stored somewhere in my brain.

As students we are never given formal training in how pharmaceutical companies operate and what we can expect to deal with for the rest of our careers, regardless of our specialty. We have a Business of Healthcare course that does a great job of outlining the history of US healthcare, how it came to be the way it is, and how insurance companies fit into the puzzle that is the US healthcare system. I once believed that it was a good thing that med school limited exposure to Big Pharma, and that this limited access to its students would offset some of the pernicious effects of physicians becoming beholden to a drug company. As our system is set up now, students or recent med school grads will be inundated with free luncheons, demonstrations, and gifts that are designed to both inform and persuade physicians and future physicians to prescribe certain medications. There seems to be real value in these demonstrations, as it is a way for those in healthcare to stay current with advances in research and technology.

The FDA and Big Pharma continue to battle about how much free speech the for-profit pharmaceutical companies can claim when marketing their drugs and devices. Students are not given much information regarding the politics of what is going on in Washington, D.C. It is important to learn about how our healthcare system works and to truly be advocates for our patients, doctors need to be versed in the discussions going on in the capital. Perhaps to steer clear of politics and controversy, medical schools opt to leave this discussion out altogether.

Or perhaps not; in order for physicians to best advocate for our patients and their health, we need to know the rules of the game. Med schools need to find the balance between creating competent, knowledgeable physicians who understand their field very well but that are also aware of all of the players in the game and what’s at stake. I’ve found that many of my colleagues find the political aspect of medicine tedious, boring, and too time consuming to delve into the intricacies of policy creation. It is this lack of knowledge or fundamental misunderstanding of the relationship between physicians, pharmaceuticals, and the government that makes doctors more susceptible to persuasion by the sales reps as conflicts of interest in the health practitioner field aren’t readily apparent.

The relationship between pharmaceutical and biotech companies with medical schools shouldn’t be adversarial, but when the goals of the healthcare provider and healthcare-related companies don’t coincide, the physician and the patients need to be made aware. Talks by prominent physicians that are on the payroll of drug companies need to be scrutinized. Papers applauding new breakthrough treatments need to be rigorously investigated because even peer-reviewed journals are not free from bias. There is no ideal time during the course of our education that this information would naturally fit, but it is vital and it should be taught early on so that when we are released into the hospitals we will have practice with critiquing sources and being mindful of current legislature concerning what parties are spending money and where they are spending it. If you set up a system that can be exploited you will attract those that are the best at this exploitation.

It is easy to set the ire and pent up aggravation at a wasteful system onto the figurehead with the likeness of a James Bond super-villian, but the release of the collective frustration still does not change the underlying current of how our healthcare system is run. If we’re not educating future doctors on how to effectively combat an (at best) unfair or (at worst) corrupt system, then who can we rely on to give patients a better handle on their own health?

As far as Mr. Shkreli is concerned, he’s just a example of what can happen when an arrogant, young, former hedge-fund manager gets his hands on a product that people need. He’s willing to be the face of a controversy and actually exemplify to the public how screwy the system is. Like Donald Trump proclaiming to donate heavily to both parties in order to personally benefit, Shkreli is opening our eyes to the nature of business side healthcare. Rather than being angry at why someone would do this, be angry at how someone could do this. Don’t hate the player, hate the game.

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Filed under 2016 Presidential Election, Business, Medicine, US Political System

Anti-Vaxxers: Why Medical Students Aren’t Being Trained to Weigh-in

With increasing frequency I have been asked by friends and well-wishers about how “anti-vaxxers” are being broached by my medical school professors. Simply put, we aren’t being taught anything on the matter. This is insight on how future physicians are being groomed to handle public misinformation and media outcry. Obviously we are given the molecular biology and public health angles as to how vaccinations work from the micro to macro scale, but we aren’t supplied with the tools on how to discuss these seemingly controversial topics with our patients. This could be for a few reasons.

First, the rising trend in vaccination refusals and recent measles outbreak, coupled with subsequent media hysteria, will raise awareness of the harm of not vaccinating children—and this trend will correct itself. After all, it seems affluent Millennials are seeing the greatest raise in foregoing vaccinations. They understand that chemicals are pervasive in today’s world, and while they might not buy that vaccines cause autism, they certainly don’t believe that injecting children with man-made concoctions at an early age increases their biological fitness. Therefore, when the educated anti-vaxxers see the harm they may be causing society as a whole, let alone their own kids, the trend will inevitably correct itself. One would hope.

It isn’t only the Millennials; some of the unvaccinated come from isolated religious communities, and the poorer counties within a state tend to have lower levels of vaccination rates. Each patient is unique and asks questions regarding vaccinations with different levels of background knowledge. Therefore different ways to convey the same message about the effectiveness of vaccines would need to be employed by the physician. This is a technique developed more during third and fourth year of med school (I’m still in my second year which is primarily classroom-based) so maybe it is more appropriate to have these discussions later in schooling. Sometimes a patient’s anecdotal evidence (e.g. “My friend’s sister had a normal child until they got vaccinated and then the child became autistic”) is too ingrained and no amount of sound evidence can dissuade them from their preset justification. My school might just be trying to allow its students to form their own ways of picking and choosing their battles when it comes to handling these issues with the patients.

Lastly, perhaps doctors feel that by and large they are above the entire “debate” about whether vaccinations are good or bad. Let the 24-hour news cycle run its course. Football just ended, it’s too early for 2016 elections, Russia and Ukraine’s ceasefire is mildly interesting, and by national news standards there’s not really much going on besides the latest ISIS comings and goings. By physicians engaging in a discussion about the merits of vaccinating your kids, it may lend credence to the extreme minority’s position as a legitimate conversation starter. Last year, noted scientist Bill Nye entered a debate with noted Amish-look-alike Young Earth Creationist (YEC) Ken Ham on whether creationism and a 6,000-year-old Earth is a viable model for our origin. Many people felt that Nye showing up to the debate was essentially giving YECs publicity and a form of legitimization, even though they are an extremely small and vocal minority without the backing of any evidence or scientific merit—much like the anti-vaxxers. The biggest difference being that someone believing Earth is 6,000 years old won’t necessarily raise the chance that my child gets a debilitating illness.

As far as med school teaching is concerned, we are urged to strongly recommend for vaccinations for inquiring patients, but maybe we should also be discussing issues on a larger scale and how it relates to public health. Although we have a bioethics course, which excels at giving students the facts regarding the law and why and how the law was passed, we are never given the tools for how to make more permanent change in the community. We are not instructed on how to engage in ethical discussions about whether or not something like vaccinations should be mandated by the government. In the last decade there have been failed or short-lived attempts at making HPV vaccinations mandatory throughout the U.S. The issue has been up for legislation in nearly half of the states and has failed in all but Virginia and D.C. (it was passed and later repealed in Texas). Perhaps not surprisingly, people would prefer to have the opportunity to make the wrong decision rather than having the right decision forced upon them.

I believe that people are very much products of their environment and will naturally gravitate towards the path of least resistance. Change on a macroscopic scale, like how society views public health mandates, can be unnecessarily slow to develop, except in rare cases like the polio vaccine—which was almost literally an overnight sensation. If many of the medical aspects of how we treat our bodies are dealt with in an “opt out” fashion I believe that we may see a significant increase in the quality of life across all strata of society. A great example of this is Spain’s organ donation rates. They have the highest rates of organ donation on the planet primarily due the country’s policy that each individual is automatically enrolled as an organ donor. If you want your organs to stay in your body to take them with you to heaven (or hell) after you die, you would have to fill out some paperwork. Well guess what? People generally find paperwork to be a nuisance and a tedious endeavor. You want me to fill out these forms just to be able to fill out more forms like we’re in some bureaucratic Soviet state? I’d rather just let you have my organs.

And that is the idea: create a society in which it is commonplace for people to generously donate their unneeded organs and they will eventually do so, not because it is the path of least resistance because it is the right thing to do to save other people’s lives. I envision after years or perhaps generations with a certain policy in place (like having to opt out of donating blood) that when the opt out policy is removed people still donate at the same rate because donating blood is something that people should feel compelled to do to help their fellow man. In the meantime, don’t incentivize performing a positive action, simply tack on some form of negative reinforcement to make a negative action (such as not donating blood or organs) more difficult. This way only those who have a true objection to the task will take these necessary steps.

In all likelihood there is no formal teaching for medical students on how to deal with anti-vaxxers in our pre-clinical years because it may not come up in doctors offices as much as the cable news-watching public may think. According to the CDC, vaccination rates have only had a very modest dip over the past decade and it should be far down the list of concerns doctors have for their patients. Some combination of it being a trendy topic, each patient’s situation being unique, and that it’s just beneath us as physicians to discuss, is what’s most likely being employed by our professors. There is already so much packed in our ever-expanding curriculum that we simply might not have time to really delve into the issues surrounding medical trends. Plus, by the time I actually become a doctor seeing my own patients, the medical landscape could be so vastly different that people questioning vaccinations would be a relic of a bygone era.

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What Did I Just Pay For?

One year down and the greater part of a decade to go. As a first year medical student, having finished class for a couple months has allowed for ample time to digest much of what happened to me over the last twelve months, I can’t help but ask the question: what did I just sign up to pay for?

Students aren’t afforded the time to process the new information, surroundings, and lifestyle that comes with being a med student—it just sort of happens to you whether you like it or not. Medical school confronts students with a unique problem from the very first day of class: too many teaching resources to learn from and not enough time to use them all. It is up to the student to determine the most efficient way to retain information and stick with it for the year. The problem is that different subjects require different types of learning—some rote memorization, others require more critical thinking and problem solving—so there isn’t a magic bullet for getting by. Most students would agree that the material offered in medical school is not particularly difficult, there is just a lot of it. A policy at my school, along with many other medical schools, is to record all lectures and to ease restraints on mandatory attendance. This decision has deep ramifications that may end up changing the face of not only medical school, but higher education in its entirety.

The motivation behind recording all lectures with the professor’s corresponding notes is presumably to make life easier on the students, and in doing so, move medical education into the 21st century. The theory is that if all students have the ability to go back and listen to old lectures surely test scores will rise, as will the scores for the all-important and ever-looming United States Medical License Exam (USMLE) Step 1, which is a national standardized test given to all medical students following completion of their second year.

I’m not complaining. Streamlining content and making it accessible from anywhere on the planet is certainly more beneficial to students than having to attend each lecture and furiously scribble notes while simultaneously attempting to comprehend what is being dictated. I have it easier than classes before me and classes after me will have it easier than me. This is a good thing.

Not all courses involve professors standing in a lecture hall speaking to students. There are several courses in which students are taught how to interact with patients, colleagues, and peers, as well as using small groups and teams to discuss and work through cases. These require the students to be present because some things—like interviewing patients and teamwork—just don’t translate to the digital world yet. While watching lectures at a time and place of my choosing I can pause, rewind, and increase the lecture speed to ensure that everything I need to spend more time on I can go over slowly, and material that I know well I can just skim through.

Every now and then a lecturer will get called into an emergency and cannot attend class, so the lecture from last year on the same topic will be posted online. This is also good. No classes are ever really canceled or postponed due to unforeseen circumstances because there is always the previous year’s lecture ready to be posted at a moment’s notice. Lectures that were canceled but would have discussed updated material to reflect new findings in the field would have an emailed addendum with the additional slides or lecture notes to reflect such changes.

During this year alone our class had over 20 lectures used from last year (out of over 450), most of which came during the unusually snowy winter. I appreciate the option to learn medicine while in my pajamas and not having to go to campus each day, but what if every class simply used the previous year’s recorded lectures and then addenda were sent out addressing the newest research or pertinent clinical findings so that students are current on the given topic? Since the vast majority of students don’t attend lectures anyway this would only affect 2 groups: the professors themselves and the students who do attend lectures in person. I am usually hesitant to call for automation at the expense of other people’s labor, salaries and livelihoods, but if it can be shown that the cost of paying the salaries for lecturers can be used on other important learning tools then I believe it is an interesting proposition. The average medical school tuition is over $40,000 per year with an average class size of 135 students, meaning about 8 full-time professors/faculty making $85,000 a year would need to be laid off in order to reduce tuition just $5,000/year per student. Keep in mind the cost of medical school is far greater than just tuition, and more accurately comes to $60,000 and upwards each year (with many students coming out owing well over $200,000) and does not even include interest. All of this to say that saving $5,000 or so on tuition each year is really only a drop in the bucket from a student’s perspective and money should be spent on technology and facilities that find innovative ways improve learning. Additionally, most of the professors do not teach full time but perform research on campus and use teaching as supplemental income (or it’s part of their contract), or hold other positions on the medical school staff such as advisors, committee members, etc. I’m sure many of the professors would prefer to spend more time in their laboratory and less time in front of students teaching, but would they really wish to do so at the expense of a decreased salary?

However, the real question is: if the vast majority of lectures are posted online, how far away is medical school from becoming an online degree? Facilities such as the simulation laboratory (a robot patient that interacts with student doctors and responds to treatments given), and micro and gross anatomy laboratories have difficulty translating into the virtual world, but with new technology we are not far from having a fully interactive human body that looks and responds to our scalpels in the same way that our actual cadavers do. As technology streamlines education, how will this affect students’ abilities to learn the required material? Most schools have the same core curriculum that covers standard topics that are required for the USMLE. Doesn’t it make sense to have a centralized database in which there are only a handful of professors lecturing on topics to every med student in the U.S.? This somewhat exists already for students studying for the USMLE exams. The vast majority of students use only a handful of resources to prepare for the test. Couldn’t this be adopted for actual school material throughout the year rather than only for USMLE prep?

Curriculum for U.S. med schools is not completely uniform, however, as a school in a rural area will be more likely to have classes that are geared towards illnesses afflicting the surrounding population than a school in an urban environment. This variation can also be accounted for in recorded lectures and shouldn’t deter the schools from adopting more online-only content.

The reasons for having a physical campus for medical school is to be able to put in face time with peers to create a sense of community and attend the occasional classes in which groups of students are required debate and discuss case studies. Extracurricular activities and student groups also need places to meet. Students should meet with their advisors and professors for office hours, although I will admit that the increasing ease and frequency of video conferencing programs such Skype makes this less pressing. Students need to be face to face with their “mock patients” when conducting interviews and physical exams, but even the traditional doctor-patient relationship is becoming a thing of the past. As of this point, learning the hands-on aspects of becoming a physician cannot be substituted for an internet connection. In the same vein, gross anatomy needs to be attended by students because getting close to the cadavers is an important experience that means more than just learning to cut flesh and identify organs. It is important to strip away much of the excessive or redundant amount of information coming at the student, yet keep the humanistic and emotional aspect of learning to become a more complete physician intact.

The physical med school will require adequate study space, but a library with books is certainly not as necessary as it once was. As a matter of fact, I recently received an email from my school notifying all students that librarian hours will be cut to 20 hours per week due to the lack of student demand. Of course the library will remain open 24/7 but faculty and staff will no longer be available for as many hours. With almost all textbooks having digital formats, less and less space will be needed on bookshelves but students should have the opportunity to order physical books through their library, or a central library in a city or region. I began college in 2004 and all textbooks in biology were over 500 pages, weighed 10 lbs. and cost hundreds of dollars with a new addition of the book arriving every other year, making the books resale value almost nil. My younger brother recently graduated from college studying biology and all of his textbooks were digital, much cheaper, contained animations of biological pathways and reactions, and have the added benefit of being able to download updates so that the book always has the newest material. This is how the new generation of doctors will be studying. I still like the feel of paper between my fingers but there’s no reason to prefer it beyond familiarity and nostalgia. Digital formats are superior in every aspect except maybe they’re a little harsher on the eyes (but that could also be because I didn’t grow up staring at monitors).

The med school of the future still needs to contain conference rooms and an auditorium for notable lecturers or guest speakers so that more ears can be reached rather than speaking to a mostly empty room but with a digital camera pointed at the speaker. Something needs to be said about being in the presence of a great speaker who can advocate passionately about their novel ideas, and the sound of clapping that gives energy to a room can really make their notions hit home.

Ultimately if students are doing 80% of their learning in front of their computer screen is there a point where administrators have to be careful so that students don’t start to ask, “am I getting my money’s worth?”

If more schools develop online-only learning tools, how will teachers and professors be viewed by society? Will they be marginalized in their own classroom and become relegated to only answering the sparse questions from the student that can’t find his answer on Google? Will this shift free up more time for professors at higher institutions to pursue their own research or projects regardless of the field? These are the questions that medical schools will begin to face as more universities begin to shift their content into online databases that can be accessed by enrolled students as well as the public.

As tuition skyrockets and students are saddled with hundreds of thousands of dollars of debt, many feel as though they need to make up for lost time not spent earning a paycheck in the workforce and become highly specialized physicians. Highly specialized physicians are great when there is a pressing need for them, but the Association of American Medical Colleges (AAMC) reports that there will be a shortfall of 45,000 primary care physicians by 2020 so more needs to be done to incentivize students to pursue more broad (and often lower paying) types of doctors. There is also projected to be a shortfall of specialty physicians, but if primary care is emphasized in America, the use of specialty physician will wane as diseases and other illnesses will be caught and treated earlier rather than being able to progress to more difficult-to-treat stages which ends up increasing health insurance premiums across the board.

Another effort to lower costs of medical school is being explored by New York University, and having a 3 year medical degree. Although this is a new frontier for U.S. schools, where is the incentive for a private university to completely forego millions of dollars from its students by axing a year of payable tuition? This is another example where the profit-motive and efficient and effective healthcare do not coincide. The medical school industry, much like healthcare in the U.S., needs to reduce costs but maintain its efficiency in pumping out quality physicians. There is a difference between taking shortcuts and cutting corners and right now medical schools in the U.S. aren’t doing either, which is hurting both medical students as well as the future delivery of healthcare in America. The shortsightedness of the medical education system is forcing students to rack up enormous amounts of debt which ultimately will end up harming the population decades down the line either because the debt will discourage enrollment, or students will feel compelled to pursue higher-paying specialties rather than serving in a more utilitarian role. Medical schools would be wise to implement cost-saving measures that may prove to enhance student training while by embracing the latest technological advances. In many circumstances bloated industries and less-effective methods would be phased out by new and cheaper start-ups. In the highly regulated medical school field this type of progress is impeded by old ways of thinking and layers upon layers of bureaucracy. The last thing anybody wants to think walking out of the supermarket, a car dealership, or a campus is, “What did I just pay for?”

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The Tactful Hypocrite

The World Cup, and more specifically its international organizing body, FIFA, has come under immense scrutiny leading up to its 2014 iteration in Brazil. Most criticisms of the situation are aimed at the host country’s inability to provide adequate hospitals, schools, and shelter to its citizens while FIFA, a tax exempt non-profit organization that is expected to rake in $4 billion plunders what it can from its host nations. The tournament’s conclusion will see FIFA leave the host country with a projected $15 billion tab but with beautiful new stadiums that history has shown have little utility once the games have been completed. All this while the vast majority of Brazilians live in an underdeveloped nation where, according to Pew Research they cite their most pressing concerns are crime, government corruption, and healthcare.

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I’ve seen City of God. I know how this ends, and it isn’t good.

Late night comedian John Oliver had an especially poignant if not sardonic (let’s just say I did reputably on the SATs) take on FIFA. I won’t rehash any more of it, but in the end he remarks that he will still watch the games because ultimately he is passionate about the product/sport. Like a drug dealer that knows he’s got the best product around, FIFA essentially has free reign to charge whatever it wants to obtain the largest profit (see: Qatar). It can make ridiculous demands as countries bid for the prestige and exclusivity that comes with being a World Cup host. That irony isn’t lost on me, in which citizens protesting this “coveted” honor have their elected government sending out its own soldiers to protect, well not the nation’s but someone’s interest.

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I am not a huge soccer fan but I will watch some of the World Cup. I image that there are a lot of people that aren’t happy with how FIFA conducts its business but will keep their eyes glued to the TV regardless. After all, it is the most widely viewed sporting event in the world by a large margin so this is the biggest game out there in terms of advertising revenue. I fear that if the Philadelphia Phillies were found to be using sweat shop labor to make their frog lawn accessories I still don’t think I could let myself root for another team—some sacrifices are non-negotiable. But why is this and what is the conscientious sports fan to do? Should I swear not to purchase any products I see advertised during the World Cup for a year? Or should it be two? Maybe I should just agree to only buy the competitor’s products (hello RC Cola, Powerade and Hydrox!) for a time. If I truly wanted to stay away from companies that promote suffering in the world be it directly or indirectly, I’d be a) spending a lot of time doing research and b) lead a much more bland lifestyle. If I don’t wish to separate myself from all companies that promote harm, at what point do I say, “I’m okay with the level of public harm that is caused by Target, but I won’t dare touch any Nike products”?

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What John Oliver doesn’t quite approach but hints at during his monologue is a real problem for those who wish to promote the greater good. For many people to watch the World Cup and turn a blind eye is as easy as can be. For some, like the Danish reporter who got paid to be in Brazil to cover the tournament, he could no longer cover the sport while stomaching the idea of the destruction that FIFA and the government are causing to line the pockets of the few. FIFA is a prime example of a dilemma presented to the public in which an entity that controls a popular and addictive product could be performing a net disservice to the world. Sepp Blatter, President of FIFA, has become the corrupt, sycophantic face of much of the ire. There have been calls on him to not seek re-election as FIFA President, but Sepp, being the consummate professional, has no plans to step down or cease his attempt at being elected for a 5th term. And why should he? FIFA has been widely criticized for its vast—and quite honestly, impressive—displays of alleged corruption for years but people keep coming back in record numbers to watch the sport they love. Changing heads of this often-called mob-run organization will do little to change its destructive ways. If anything, FIFA will find less overt ways to extract money and resources from nations, and perhaps they will skim a little less of the top, but no doubt they will still leave poor nations worse off than before they arrived. This will subdue calls for the abolition of FIFA for a long enough time until people forget about the destruction in their wake.

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Of course FIFA is not the only party at fault, as politicians from the host country use the initial World Cup excitement as a platform on which to seek re-election or push through less than popular agendas. For countries like South Africa and Brazil (and perhaps Qatar in 2022), being awarded the World Cup is a signal to the rest of the world that your country is an official player in geopolitics. Never mind the crumbling infrastructure, protests, and mass strikes, Brazil as a part of the BRIC economies was on its way to playing with the big boys as far as world leaders believe, but now, almost as importantly, it is cemented in the minds of the international public too.

How can I criticize these entities’ clear apathy towards the treatment of the poorer citizens of their host country, even find ways to profit off of it, yet participate in the excitement and pageantry that this spectacle has become? Justifying watching the games at a bar is just one way. Telling myself that I’m not tuning in on my own TV and ratings companies have no way of tracking that I am indeed contributing as one out of those hundreds of millions of viewers. That doesn’t sound so bad actually. I could also justify that not wearing a few pieces of Nike clothing won’t shut the sweatshop down so it couldn’t be all that bad. If everyone thought this way then of course activism wouldn’t accomplish much and corporate interests would consistently triumph.

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Being aware of a cause, although perhaps not actively engaging in protests, writing letters to politicians, or boycotting their sources of funds holds value as well. As Malcolm Gladwell outlined in The Tipping Point, prior to blood doping becoming popular among bicyclists at the turn of the century, there was a time when many honest riders held off on cheating until they believed that they were no longer in the majority of being a clean athlete, or that they felt their chances of winning were too compromised not to cheat. This point from inaction to action (aptly termed the tipping point) can send a shockwave through a movement and can facilitate its growth exponentially. In his example, when the tipping point for doping was reached, a large number of bicyclists suddenly began to dope even though they were initially morally against or ambiguous towards it. There are personal decisions that I can make to try to speed up this point of no return for causes, but being preachy or a wet blanket at jovial events isn’t really as fun as it sounds. Oh I see you’re drinking a cold, refreshing Coke. Did you know Coke is alleged to be involved in murder and torture of union-affiliated employees over the past several decades in Guatemalan and Colombian bottling plants? See, moralizing kinda sucks for everyone involved. On the flip side, going to bed without a roof over your head and with an empty stomach in a dangerous favela also seems pretty sucky.

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Perhaps the salt in the wound for the poor and those that take advantage of the public works is that soccer is their game. One of the biggest reasons that soccer is so prevalent throughout the world is because a ball can be easily stitched together with all kinds of materials, it can be played nearly on any type of ground surface, and it is a fundamentally simple sport to pick up and play with virtually no learning curve. This is not ice hockey that FIFA is “forcing” countries to take on massive amounts of debt and build stadiums for. They aren’t erecting coliseums for polo. Soccer is their game that is getting marketed, re-branded, and sold back to the people for an exorbitant cost. It would somehow be more appropriate if FIFA was displaying games that didn’t interest the very people it screws.

Even in a country like the U.S. that has many adequate facilities already in place to be able to support a large, multi-city “mega-event” such as the World Cup, it doesn’t necessarily make economic sense to become a host. According to economics professor Dr. Dennis Coates in World Cup Economics, on whether the U.S. should seek the World Cup in 2022:

“A study of the 1994 World Cup hosted by the United States found substantial lost output, with the final result showing that the pre-World Cup predictions were up to $13 billion off-target. The existing evidence of negative economic impact from other World Cups, combined with the self-interested motivation of the Bid Committee members and the lack of disclosure of the economic impact study all point to the conclusion that the US taxpayers are better off saying no to an expensive and secretive World Cup bid.”

This dilemma has no easy solution. The name of the game is deciding how much time/effort/money to put towards some causes while justifying to yourself that you don’t have enough time/effort/money to put into other causes. Do you go for the bigger national or international causes because they can help more people, or do you support the smaller or local ones because your contribution can have a greater impact? It’s a balancing act that I haven’t even come close to mastering. Perhaps you’d enjoy stretching yourself thin and just support every cause you believe in, while noble, that route isn’t for everybody. Even if boycotting the World Cup was shown to effectively change FIFA policies how many people have the will power to do so? When sympathizing with those being taken advantage of, it’s a tough decision that often gets overlooked. Everyone has that point that no matter how much you love a team or a product, when the company behind the brand does things that outweigh your personal satisfaction with that product, action needs to be taken. How thoroughly do we really want to investigate companies whose products we utilize? For soccer fans like Oliver it’s a cut and dry decision to watch the games, but more needs to be discussed about the struggle to find your own tipping point.

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On Becoming a Bat

I have volunteered in almost a dozen hospitals and clinics on both coasts, worked thousands of hours in the ER, and I’ve been exposed to the hospital setting for just over a decade. But January 24th 2014 was the first time I was there on the other side of healthcare.

I was out to dinner with my girlfriend of over seven years, Amanda, and a med school friend of ours at a little restaurant around the corner from our apartment in Philly. While we were discussing the motivation and the merits of entering the field of dermatology, Amanda turned to me and calmly said that her face was tingling, pointing to her right cheek. Although Amanda has a long history of migraines this was an unusual presentation. As she was describing the sensation the right side of her mouth was drooping in a manner that I will never forget. Her eyebrows curled up towards each other as if to do the expressing of the fear that her brain and mouth couldn’t do for her–something’s wrong and I don’t know what it is. The look cannot be replicated without actually having facial paralysis, and it is the physical manifestation of a neurological haywire. I tried to remember my EMT training and go through the quick physical exam of a possible stroke patient, but we were in a busy restaurant and I could only ask what I believed to be the most obvious questions that came to mind. After about 15 seconds Amanda’s facial droop subsided and she reported her tingling was gone. Luckily we had already paid the check and we were on our way out after bundling up.

As we stepped outside into the 10 degree chill, we knew we were about the same distance away from two different ERs, and actually had the opportunity to choose. Amanda then thought that she should contact her insurance provider to see which hospital would be most appropriate. The fact that this even enters someone’s thought process during a possible emergency is a sad testament to how ingrained debt and healthcare pervade the American public’s consciousness. Amanda instead decided to call her mom, a nurse at one of the hospitals, and she said to just walk to the closest one, which we did.

Upon registering, Amanda and I sat in the clean, quiet, waiting room for a short while until Amanda’s name was called in for triage. Even though I know that patients that exaggerate their symptoms tend to get seen by the doctor sooner, I was hesitant to advise Amanda to embellish hers, because I somehow felt like this is insider knowledge and “tampering” with the doctor-patient relationship. If Amanda didn’t currently have dizziness or tingling I didn’t want her to lead the doctors on a breadcrumb trail of false symptoms so that she can be seen before other patients. She said that she felt like she may have had a stroke, an honest and serious enough problem that would garner immediate attention. After being sent back to the waiting room again, Amanda was called into a “multi-patient room” which I was not allowed access to. Sitting in the waiting room with a loved one not 100 feet away behind giant doors and a giant security guard and having no information as to when I’ll be able to see her or ask her how she’s feeling was absolute torture.

Having limited knowledge on what the possible causes for stroke-like symptoms are, the worst case scenario always runs through your mind. Trying to keep composure in front of Amanda and even claiming that it’s, “surely not that big a deal if it came and went so quickly”, it is much harder to be confident in what modest clinical skills you have when you are isolated. Having waited over an hour with no news on what the upcoming steps are regarding treatment, the only thing between me and insanity is a shitty TNT or TBS or FX movie with the sound off in the waiting room. I finally received a text from Amanda (I had been texting her asking for updates), telling me to go home and feed the cat because she saw the Resident who would be getting the Attending Physician and that it could be “a while”. I took the opportunity to get some fresh air and walk home (we only live a few blocks away) to gather some things that Amanda might want for a long night…and to feed the cat.

Walking back alone around 11pm on the icy streets, a light snowfall began and somehow made Amanda’s diagnosis even more dire in my mind and me feel more isolated and desperate for answers. How could a healthy 28-year-old who doesn’t have any risk factors suddenly develop partial paralysis out of the blue? Was it a brain tumor, a TIA, does something even more serious exist that I just haven’t learned about yet? Should we have rushed right to the ER, were precious moments wasted when we were weighing the pros and cons of our next move? My thoughts turned toward taking care of her if need be. Would this be a longterm thing? If I had to leave school is it even possible to just take a semester off? Would I have to decide to leave immediately or do I get some time, and who do I contact about this anyway? Perhaps my selfishness was getting the best of me, but every scenario concocted pushed me deeper and deeper into this hole of responsibility that I didn’t know how to get a grasp of. I reached the apartment, gathered my backpack, threw in our phone chargers, brought a book to study and the iPad for Amanda to help pass time. It was 11:15 and I received a text from Amanda saying I was allowed to join her in her room in the ER. I flung my backpack over my shoulder and headed out again, this time a thin layer of snow covered the ice on the cobblestones allowing me to step right on them for traction rather than daintily avoiding their glassy palms. Ah shit, I forgot to feed the cat.

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When I met up with Amanda, she was alone in a corner room of a quiet ER, blood already drawn and an empty urine cup beside her gurney. I gave her a hug as she caught me up on this situation. A resident, followed by the Chief Resident then the Attending Physician had been in to see her and asked her many of the same questions that the nurse, registration and triage had asked her earlier. The next step was for Amanda to get a CT scan of her brain. We chatted away as midnight came and went. The worst part of waiting in the exam room is that you have no idea what is going on around you. As far as we knew, ER techs would be coming to take Amanda to get a CT, but we weren’t given a specific time. Working in an ER, I have dealt with patients that want to know what’s going on, and usually nurses and other staff can really only say just sit tight, we haven’t forgotten about you. Although I knew what the answer would be before the nurse told us CT will come by “soon”, the ambiguity of the answer almost made me feel like these people don’t know what they’re doing. The fact that this even crossed my mind made wonder what the lay person thinks, since I know that the staff is often over-worked and usually is buzzing around from patient to patient, but I still had the audacity to wonder if the ER techs were standing around making small talk. This was my foray into the other side and it didn’t sit well.

Techs came and took Amanda to CT in a wheelchair. She was back within 15 minutes and more waiting ensued. Still with no answers in sight we were told after about an hour that the neurologist would be coming to speak with us at some point to discuss the CT results. Is this good or bad, I wondered? I was trying to piece together the clues that would lead me to how serious the doctors thought Amanda’s condition was. Well, she was not under close supervision–that’s good. She also wasn’t hooked up to any monitor for vital signs–I guess that’s good. She didn’t receive any other meds besides Tylenol–that’s also good. At the same time, is this just standard practice in a neglectful, busy ER where patients are always forgotten and maybe even sometimes left for dead? Also, why would a neurologist need to speak to a patient with a completely normal CT scan, couldn’t the ER doctor just tell us the news? I feared that I knew too much in making me wary of the situation, but not enough to recognize that everything was fine and the hospital was just following it’s standard procedures. Does a family that has no medical background and no idea what could be going on take solace in that their outcome is strictly in other’s hands, or does that make it even more nerve-wracking?

What was taking the neurologist so long? Were they verifying the CT with other expert neurologists in the area giving their thoughts on a rare disease, were they debating how best to deliver terrible news? The longer we waited and the more in the dark we were, the worse it seemed. At 1:30am the neurologist came in to speak with us about what they believed happened–which was nothing. The neurologist was 27 years-old, smooth and confident. I’d like to be like that one day, well except for the 27 part, which I can never be again, but I rather like the smooth and confident part. Amanda had what the neurologist believed to be a “complicated migraine”. Nothing serious it seemed, but Amanda would need a follow up appointment. It’s apparently one of those things that can simply happen to someone that has migraines for no explicable reason, and this could be the only incident that ever occurs in Amanda’s entire life. The doctor performed a neurologic exam, asked if we had any questions, then said she would be back with the discharge papers. About an hour later a different doctor came in with the discharge papers for Amanda to sign. While we were waiting we had thought of some questions to ask about her condition, but when it was a different physician that had entered the room we thought that was a little strange. Amanda asked some questions and the resident said he didn’t know how to answer them because he wasn’t a neurologist and that Amanda would have to call them on Monday. But, but, but the neurologist said she’d be back “shortly”, and not only was it not her that came back, it certainly wasn’t “shortly”. I am truly grateful for the attention and care Amanda received and I realize that in these situations, nothing is ever enough. I get it, 30 years ago if you said you could walk up to a hospital, people could take images of your brain, a doctor could look at it and diagnose you, and you’d be out of there in a few hours, you would be incredulous. This is not lost on us.

As far as I remember, I don’t recall any loved ones having cancer, a dramatic disease, or even getting a phone call about a serious traumatic incident. I am very lucky. I don’t know what it’s like to have someone I love seriously ill, let alone lose someone so close. Every now and then while working in the ER I would come across a patient that would remind me of someone dear to me. A 60-year-old man that has no history of heart problems that suddenly has a heart attack and dies. I think about my father and what it would be like to lose him. Empathy is funny in that it can make you feel profoundly, but that emotion is not genuine. I can think about how sad it would be to lose Amanda, but until I came face to face with that prospect there’s no way to make it real. Every now and then I think of philosopher Thomas Nagel’s paper, “What is it Like to Be a Bat?”, that I read in an undergrad class. The gist is that a human being can never feel what it is like to be a bat, they can only feel like what a human feels like it is to be a bat. This is an important distinction. Prior to getting accepted to medical school I would frequently fantasize about what it would be like to open my mailbox and see a large envelope. Would I jump up and down and shout like a nut, or would I play coy and act like this is to be expected and it’s just a bit of good news? Even when I look back on how happy an event it was, I can never replicate that exact feeling–I can only recall what that feeling felt like–which is not nearly the same thing.

In medical school we are taught and trained to be empathetic and exhibit compassion towards our patients and those that we are providing care for. We spend time in the classroom and watching videos online and writing short essays that exhibit what we’ve learned about how to better understand patients. I have spent countless hours amongst patients in various capacities, and I always thought that I was empathetic towards them, when really I was only sympathetic. I don’t believe it is possible to train someone in empathy. They can learn the tools to becoming empathetic, but without experience we are just doing the best we can. We shadow doctors and even see patients as first year students but unless we have experienced what the patient has experienced we don’t know what it really feels like to be in their situation. Does empathy from a provider really affect patient outcomes, and how would that even be measured? The staff at the hospital Amanda and I went to were courteous, professional, and performed their jobs well. But something in healthcare is missing, and it’s like being a bat. Is spending all the time and resources on trying to get students to become caring individuals actually making better doctors, or better actors? Being on the receiving end of healthcare it is easy to see which providers are going through the motions and which ones are feeling what you’re feeling. Although Amanda and I didn’t admit to each other at the time, while silence filled the hospital exam room between ominous beeps sounding from foreign machinery in the early hours of Saturday morning, we were both terrified. I could describe the feeling to you in as much detail imaginable but you would never know what it was like in that room unless you experienced something similar yourself. And for me, I could try to remember the emotions I felt in the pit of my stomach that night while flipping through a textbook, reading the same sentence over and over again, as I sat next to an energy-depleted best friend–but it will never be as frightening as it was in that moment.

We shuffled home at 3am, hours after we embarked and thankful that nothing serious came about this trip to the ER. Amanda felt fine now, just tired. The heat was left off in the apartment but it was still much warmer than outside. The cat was fed and all was right in the world.

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Something for Nothing

College football bowl season is upon us once again and around this time every year there is the discussion of how screwed up the Bowl Championship Series system is (we’ll be able to argue about the playoff system next year), how corrupt and slimy the recruiting process is, and how college players should or shouldn’t be paid. All collegiate athletes in the U.S. have amateur status, meaning that they don’t (well, a more accurate phrase is “aren’t supposed to”) get paid for playing or from endorsements. The reason there always seems to be so much controversy with college athletics is because the fans are passionate and expect the world from their players, but they are also expected to be students first and athletes second. College athletes straddle the line between the glamorous world in which they are playing in front of thousands of adoring fans, and the drudgery of waking up before sunrise each day for training and conditioning while taking classes and attending practices. With what can seem like the weight of the world on their shoulders they are expected to act like every other teenager at their university. Pro athletes, however, are on an entirely different planet in terms of being pure physical specimens that they are totally and utterly unrelatable both in lifestyle as well as body dimension to the average fan. There is this feeling that college athletes are still pure and similar to the average 18-21 year old, that is until they transcend to the next level where endorsements and fame can take hold. Additionally, with college sports there is a more tight-knit community feel to the local team that doesn’t permeate to the big leagues. Most prominent public school college football coaches are among the highest paid state employees, so whenever you pay taxes you’re doing your part to get your team to a bowl game, or to a 2-9 record.

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Earlier this season the high-profile quarterback for Texas A&M, Johnny Manziel, was accused of accepting money for signing autographs for a memorabilia company, which is considered payment, and therefore strictly prohibited by the NCAA. An investigation ultimately turned up nothing, but the bigger issue about whether or not college athletes should be paid took on a different angle as even former college football stars (who normally keep quiet concerning under-the-table payments) began to openly discuss the temptations to get paid early and the difficulty living on what is essentially a meager stipend, according to Houston Texans running back Arian Foster. In September, Time magazine ran a cover story proclaiming that now is the time that athletes should be paid and even Electronic Arts Sports, maker of the popular NCAA Football video game announced that it would no longer be partnering with the NCAA due to disputes over the use of player likenesses. The game will no longer be manufactured, and when such a big moneymaker has its production suddenly and unexpectedly halted, there must be big changes in the landscape of the college athletics on the horizon. Recent revelations show that the NCAA is now suing EA Sports because they were “unaware” that player likenesses were being used in these games for over a decade.

The NCAA understands that its stars drum up a lot of revenue and earlier this season when searching for a particular player’s name on the NCAA merchandise website it would take the user to the webpage where that player’s number (but not name) would be sold on jerseys and other items. When this was pointed out that the NCAA ended linking players names to their jersey number in order to distance themselves from the idea that they directly profit off of individual players.  It has become obvious that college sports, and more specifically college football and basketball, has too much money at stake and the NCAA is trying to pare any heads sucking at the teat of their revenue stream. Like the hydra, every time the NCAA cuts out one bad apple, two more programs replace it.

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The debate about whether collegiate athletes should be paid or not has been discussed ad nauseam but almost exclusively singles out football among the dozens of other sports, and is generally a very shallow take on the situation. Although football programs are the biggest revenue generator for schools, it only has a small slice of the number of student-athletes overall. What happens to the other students that train just as long and hard at their craft?

Whether or not student-athletes get paid is much bigger than the realm of sports. This has to do with how society views labor and what role universities should play as educational institutes or modes of producing wealth that also aim to educate as an aside. If someone or a body of people are producing a product or service that is not being compensated justly then this is considered exploitation. People will often cite that college athletes have their tuition, room, and board paid for, but what solace is that if they are generating millions upon millions of dollars for their school’s president and board members? This is akin to saying you get a $100,000 salary from your employer and you make your company $100 million on your own, but you should be happy because $100,000 is still a lot of money. This may not strike many people as inherently wrong but it is the definition of exploitation.

The national debate stops at whether or not to pay college athletes- some say yes, others say no- for a variety of well-intentioned reasons. The issue can get very complicated when you try a thought experiment on actually employing the payment of college kids in sports. If I were put in charge of ending the amateur status of college athletes, where do I begin to answer some important questions? First of all, who does the paying? Would the NCAA be in charge of paying the athletes by increasing each university’s entrance fee into the NCAA (a non-profit organization), in which the money then gets pooled together and evenly distributed to the schools to disburse to their students? Some schools are much more profitable than others and also have a much larger endowment from which to pay the players. Does this mean schools that are able to pay more to their athletes actually get to give them larger paychecks? Additionally, does each player on a team get paid the same amount, regardless of whether they are a starter or a backup, and regardless of the position played?

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Secondly, who gets paid? From a business standpoint (and as Temple University can attest to), very few sports teams within a school actually are profitable or break even. Does this mean that only the sports which provide capital for the university should be paying their sports stars? This may drive students from the sport that they love because they will try to pursue a sport in which they receive financial compensation and harms the spirit of intercollegiate athletics.

Perhaps the biggest question of all is how much should these “student-athletes” be paid? Johnny Manziel won the Heisman Trophy (awarded to the most outstanding football player in college) in 2012 and reportedly Texas A&M had fund-raised $740 million that year, surpassing its previous fundraising record by nearly $300 million. Texas A&M Foundation President Ed Davis had this to say regarding the extra fundraising boost in 2012 and its star quarterback:

“People ask me all the time if you have a winning football team, do you raise more money? In normal times, the statistical data wouldn’t support that, but in an era where we are in, effectively, in the news everywhere and you have a young man like our quarterback who has been a media magnet and you have the success you have, I do think that euphoria does spill over into success in fundraising. I’m hoping we can keep it up.”

From jersey sales, ticket sales, merchandising, TV contracts, and national recognition, Texas A&M can attribute upwards of hundreds of millions of extra dollars to their school, athletic program, and research facilities because this 18-year-old kid decided to throw the football in College Station, TX rather than Gainsville, FL or a number of other top tier football programs. While it is true that he will move on to the NFL to make tens of millions of dollars himself, not every National Championship team member or even Heisman winner will even be drafted to the NFL and cash in on their success, yet they will still make millions upon millions for their school. So it is clear that athletics bring in lot of money for schools, but how should these players be compensated? Should they be awarded bonuses specified in their contracts? Because the college players are between the ages of 18-22, many of them will require financial advisors or agents at this juncture because they need to be equipped to handle the pressure and adversity that comes with getting large sums of money as a teenager in college and handling it responsibly. Because the schools are potentially the employers of these students and won’t always see eye to eye on payment amounts or bonuses, these advisors must be third party, which also begs the question, will the student athletes form a union like in every other major U.S. sport, and what kind of structure would it take?

As a strong proponent of fair labor practices, if player A is producing at a higher level than player B and is in turn making more money for the school by his/her performance then I believe he/she should be adequately compensated. However, many sports in college are team sports and require teamwork for success. How would the NCAA or school gauge the value of different players on different teams? Would players sign three or four year contracts or would their salary be negotiated on a yearly basis? If they settle on a 4 year contract, is that money guaranteed if there is an injury, or even if the student performs poorly and is cut? Will academic standards become less rigorous for the athletes to ensure that the school’s investment can spend even more time away from the classroom so that sports will be even more of a main focus?

If every athlete within all schools and within all sports is paid the same amount (let’s say $30,000 a year), then what happens to the extra money raised by star players by the nature of them being on the team? Does this extra money simply go to the school or the NCAA to do whatever it wants with it (with the majority going into the pockets of the higher-ups), and isn’t this still a form of exploitation? Additionally, $30,000 to a student at West Virginia University will go a lot further than $30,000 in a school like Georgetown where the cost of living is much higher in Washington D.C., so schools in urban settings will be at a natural disadvantage in this regard when it comes to recruiting, which I’m sure they would fight against.

How will state schools pay their student athletes versus private schools? As a former taxpayer in New Jersey, I was well aware that I was paying the salaries for all the coaches, trainers, athletic directors, etc. involved in making athletics possible for my state schools. If all college players get paid, taxpayers will be forced to pay the salaries of teenagers to play a sport. I can imagine that a lot of people will have a lot of problems with this. Some state schools are much larger than others, so how can we reasonably expect the smaller schools to afford the salaries of the athletes, or will the state subsidize the shortfalls of these schools? It seems if college athletes were forced to be paid then even more schools would cut sports all together or make conditions nearly unplayable for the players and more team boycotts across the country may ensue.

Lastly, universities are no longer just institutions for higher learning, they are businesses and avenues for making money for those in the administration. Does paying student athletes make it the final straw in making the U.S. college system just a wealth-generating tool rather than a knowledge-generating tool? What does this mean for the psyche of the college student who is not playing a college sport? What would a student who is paying full tuition and saddled with hundreds of thousands of dollars in debt think of the basketball player sitting next to them in the same class learning the same material and getting graded in the same manner but actually making money while sitting there? Of course there is always the big man on campus stud athlete that everyone knows is the star player who you would know if they were in your class, but what about when you don’t know who is getting paid and who isn’t? This is not like a scholarship in which the athlete is getting housing and an education in exchange for their athletic prowess, this is getting paid to be there, which is something entirely different. The argument could be made that because of the athletes, your school is getting more recognition and will hopefully be able to fundraise more money which will go towards improving various facilities (that obviously you won’t be around to see) that will increase the prominence of the school to make your degree more “valuable”. I get that, I don’t necessarily buy it, but I get it.

I have only scratched the surface in discussing the challenges and questions that face an impending sea change in college athletics. This is a very complicated issue that is much bigger than sports. I have not even considered how paying college players will impact tuition rates, which could be an essay all on its own. The bottom line is that the NCAA and universities across the country are making billions of dollars off of their pupils on the sports field and this simply doesn’t sit right with me. It’s not as if the money is going back into the school system to promote better research facilities or libraries. Rather, the money is going to those with prominent roles in the university, and it is also going towards updating the athletic facilities in order to recruit better athletes in order to get better on-field performance in order to get more money from ticket sales/merchandise/TV contracts in order to line more pockets with money. How to go about implementation towards rectifying the situation is riddled with more ethical and logistical questions, but no doubt committees and other layers of bureaucracy will be involved. I would love to hear thoughts on any of the issues or questions raised in this post and what the ideal situation may look like for the future of college athletics.

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The Prisoner’s Dilemma

“I used to be fast, man. I’ll race you to that gas station.”

There is only one group of American citizens that are constitutionally guaranteed the right to medical services, and you may be surprised to find that it isn’t politicians, law enforcement, the elderly, or even veterans—it’s prisoners. The U.S. has always had a love-hate relationship with its law-breakers. We romanticize the old-timey gangsters, the outlaws, and the reclamation stories about overcoming turmoil and coming out stronger in the end (plus, when was the last time that there was a U.S. president that didn’t admit to ingesting illegal drugs?). And we hate the inner-city gun violence, gangs, and “thug culture” that seems so pervasive in the media today. The prison-industrial complex has been getting a lot of flak in the U.S. for well over a decade (and rightfully so). Often lost in the talk about profit motives and unjust penalties for petty crimes are the effect it has on the prisoners themselves once they are released into a different world from when they last left.

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I began running with Back on My Feet (BoMF) a couple months ago. Back on My Feet is a non-profit organization that aims to combat homelessness by having daily runs at 5:30am in which residents of homeless shelters are grouped together with non-homeless runners, and they run about 3-5 miles around Philadelphia. The program is designed for former drug users, ex-convicts, or otherwise down-and-out types to get a regiment centered around fitness and a routine. There are milestones that once reached entitle the members to new goods – new shoes, running equipment, etc.—and services—resume editing and interview workshops. The shelter that I run with is Ready, Willing, and Able (RWA), and consists mainly of ex-cons that are being reintroduced into society.

I don’t normally like waking up early. In fact, I only do it when I have to. It’s even harder to wake up early when it’s cold out, which it always is at 4:45am. When I first began running with BoMF I basically tried to get each session over with quickly so that I could go back to the friendly confines of my own bed. I soon realized that no matter how fast I ran to the meeting place, or how fast I sprinted during our morning jog with the RWA members I would still get home at the same time. I might as well try enjoying this I figured. Soon waking up early was still difficult, but rather than lament that I felt like I was one of the only people awake on the east coast I felt that I should embrace it. As I leave my apartment and jog towards the meet up I will frequently stop to walk and look at the sky above me. There are stars out and lots of them. Just about all of the neon signs are turned off in Philadelphia in those early hours and I can see as far into the universe as my contact lenses allow me. There is something quite surreal about looking up and seeing distant, tiny lights that you have never noticed before through your own warm breath walking alone in a city of one and a half million. Perhaps it is this feeling of isolation and quiet that allows strangers to share things about their life, or perhaps it is just frustration.

Technically the program is designed so that one has no idea who are the ex-homeless and who are there for support—but it’s pretty evident who’s in each camp. I met ‘Steve’ during my first session of BoMF and we exchanged the usual pleasantries that are the norm for a “res-member” (someone who is a resident of one of the shelters), and a “non-res-member” (someone like me, just an outsider looking to run). At about mile 2 we had exhausted talk of weather and sports and so we just ran side by side quietly. My body had acclimated to the temperature by now but Steve was sweating profusely, his balding head spewing a trail of steam in his wake as we glided alongside the Schuylkill River. He turned to me asked if I had any plans for the end of the year. I wasn’t really sure what he meant by that but I could tell it was his way of asking me to ask about his own plans. Steve then began to discuss how hard it is to find a job that pays well enough to allow him go back to school. Already equipped with a GED, he always wanted to go to a technical school to become a certified mechanic in a two-year program. This December he was finally moving out of the halfway house and onto another phase of his life, but it did not come without plenty of meetings with social workers and temp agencies.

He seemed to have done the math thoroughly because he was spouting out figures on how much he would need to make per week, per day, and per hour in order for him to pay for technical school. He said that he was beginning to look at rent in different areas in Philly for when he leaves RWA. He also said that a lot of the places he was looking at were in areas that are too expensive and so he would have to choose between living in a decent area but barely having enough money left over to eat after savings, or to live in “the ‘hood” but have some extra money. He went on to say that living in the latter areas is what led him to prison in the first place, and that going back there would be a recipe for disaster. I asked what he thought he would do and he said that he would try to live in a nicer area but try to take lots of side jobs and see how much money he could save for a year or two and hopefully he could gauge the probability of him going to school. We made that final turn down Bainbridge St. and headed towards the Hess station that was light up like E.T.’s spaceship in the forest that is Broad St. at 6am.

How does someone get out of a cycle like this? Steve is lucky in a way—he has no kids, no child-support, and no wife, but he will still face an uphill battle for the foreseeable future. Just supporting himself and hitting the reset button will take the better part of a decade, and for a forty-something year old with a history of drug abuse and living a hard life, that’s looking to be on the other side of the halfway point. It is easy to talk about statistics to report how our prison system is failing on so many levels. And how (like many other things in our society) the profit-motive doesn’t align with the mission of the industry, which is namely to rehabilitate those that are incarcerated, and should therefore be taken out of the hands of those that seek to make the profit. We are so inundated with numbers and reports that they have virtually no meaning. What is the number that will create outrage? 2.3 million adults are currently incarcerated, which is about 740 per 100,000 people or 0.7% of the US population. Prison private telecom systems, health insurance contracts, and the bail industry are making profits in the billions each year. Does it matter if it is 1 billion, 2 billion, or 50 billion? At what point do we stand up and say something is wrong here when nearly 40% of those incarcerated are African-American? Is it when the percentage creeps up to 43, or how about a nice round 50%? These are people, plain and simple. It’s easy for me to say this now only because I have met some of these people, but this system is self-sustaining and every generation that has a high percentage of its members in jail will surely have even higher percentages in the next generation. There are some members of RWA that are in their early 20s that have multiple children who they no longer see. Where are these kids going to end up in 15 years?

The black sky was finally half purple, with what almost looked like blue along the Ben Franklin Bridge. For all the things not going his way, Steve doesn’t seem to mind as much when he’s running. He beat me to the gas station—by a lot actually—then turned around and gave me a big smile while I gasped for the frigid air that was no longer being warmed by my throat sufficiently. This isn’t about me realizing that if there’s a will there’s a way. This isn’t a “things will get better if we work at it” story and it certainly isn’t Jim and Huck. This is about awareness and understanding. This is about making the connection from Steve’s life story to the millions of others who are similar only because they are all victims of the prison industrial complex. This is about realizing that even a positive ending to Steve’s story, which we’re all hoping for, is insignificant compared to the systemic changes that are needed to avoid creating millions more down-and-out Steves generation after generation.

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The Mural Capital

I consider Philadelphia my city. I have never lived in it or attended school there, but I have worked there and have family that reside all throughout its various far-reaching sections. Some of these family members will even order a “wooter” when they go to a restaurant from time to time, so that’s all the justification I need to feel one with the city. Just over a month ago I moved to Philadelphia and was offered the opportunity to go through a “mural bus tour” through Drexel (my school). This bus tour is designed to acclimate new students not from the area to get a feel for what some of the underserved areas of Philly actually look like by using the many murals that dot the city as points of interest.

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As I’m sure many of you know, Philadelphia has the most murals of any city in the world. There was a presentation by a member of the Philadelphia Mural Arts Program to demonstrate how these filthy, crime-ridden intersections of seedy parts of the city can be transformed into magnificent centers for culture and the arts. Well that wasn’t exactly how it was presented but the mural projects were certainly framed in a way that made them seem as if they really could solve many of the problems plaguing these areas. The goal of the Mural Arts Program has many facets. Chief among them are to de-stigmatize mental illness and to advocate for at-risk people to seek help sooner rather than later, and to use the actual painting of the murals by ex-cons as a form of restorative justice that can bring them closer to their communities and ease them back into society.

This is all well and good. Who wouldn’t want a city beautified by some of the area’s most talented artists that could turn an abandoned building into something awe-inspiring that can also have many beneficial side effects? But then I began to think. Even in the areas with the most murals, crime statistics have seen an increase in the last five years, more people are on food stamps, fewer students are enrolled in high schools despite a larger population, etc. In other words, things look bleak for those who don’t need any more bad news. In cities like Rio de Janeiro the government has similar art projects in their slums in order to mask how decrepit and miserable life is in these areas. Are murals simply putting lipstick on a pig?

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The Mural Arts Program was initially a component of the Philadelphia Anti-Graffiti Network. The Anti-Graffiti Network’s aim was to redirect graffiti artists towards creating murals rather than “destructive graffiti”. In a somewhat literal sense, the program was designed to cover up poverty and make the lives of those in the lowest socioeconomic strata somewhat more palatable by giving them something pretty to look at on their way to their minimum wage job (if they are so fortunate). In a sense, graffiti is an indication that the area has negative socioeconomic indicators and is more of a symptom of a failing system, not a cause of it. Does covering up the graffiti actually do anything to ameliorate these factors? Will it put food on the table, pay a medical bill, or put a roof over a family’s head? It seems that it may provide hope to some but in all likelihood it will not get at the root of the problem.

After the presentation it was time to head to the streets to see the areas that would help us become compassionate physicians. The (mostly white) students piled into the two buses while we drove through unfamiliar territory that we would only find ourselves in if we accidentally made a series of wrong turns. It almost felt as though we were on a Six Flags Wild Safari tour. As long as we kept our arms inside the vehicle we could pass by inconspicuously, rather than drawing attention to what is essentially our “Privileged White Kids Tour through Poverty presented by a Medical School!”

We eventually got off the bus somewhere in North Philly to take a tour on foot of some of the current mural projects. As an African-American woman passed the throng of kids staring at a mural in progress, cynically and unprompted, she asked, “What is y’all doing here? You just gonna make us some more paintings, huh?” If this is a pervasive sentiment in Kensington, then it seems that the murals may end up doing more harm than good in the long run. Do these communities want their streets to be made beautiful so that they give the guise of economic self-sustainability, when in fact things are getting worse? Will the people in these areas end up being more resistant to outside help if it seems that it isn’t really help at all?

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While noble and perhaps just, murals do not attempt to eradicate the major factors contributing to the high incidence of mental disorders and gun violence. Perhaps the Mural Arts Program is only designed to be a safety net and to catch those that fall rather than prevent people from falling. I truly want to believe that the program is doing the most that it can to alleviate the issues that plague these communities. I am very interested to see the outcomes and conclusions of the Yale School of Medicine study of these programs, which is in the last of a 3-year study. If, for instance, the murder rate in the area of murals decreases does this mean that more murders are just happening a few blocks away? Correlation does not imply causation, because if murders are less likely to occur at intersections with a mural, then every city block in every major U.S. city should have them. Worst-case scenario is that not only do murals not contribute to fixing the underlying problems in these communities, but they divert resources away from other worthwhile community-building projects.

Philadelphia is indeed my city and I truly want what’s best for its citizens. It may be a point of pride to proclaim us at the Mural Capital of the World, but it seems like a hollow title. Projects like the Mural Arts Program seem to implicate an air of “things are getting better”, and with a little more elbow grease we can turn this place around one street corner at a time. Perhaps their optimism should be applauded, but I am generally skeptical of programs that put all of their resources toward glossing over why a problem exists and instead focus on how to make it better after the fact. Not that programs like these aren’t necessary, but they should viewed in the light that they can help rehabilitate a community, but not get at the factors that drive a community to the point of collapse– mainly income inequality. I’ll leave you with some anecdotal evidence about how little the denizens of these impoverished street corners care about their murals.

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