2015: The Year in Breast Cancer   Leave a comment

BY GEORGE W. SLEDGE, JR., MD

 

GEORGE W. SLEDGE, JR., MD, is Professor of Medicine and Chief of the Division of Oncology at Stanford University. He also is Oncology Times’ Editorial Board Chair. His OT writing has been recognized with an APEX Award for Publication Excellence and a FOLIO: Eddie Honorable Mention award.

Breast cancer remains a fertile area of clinical research investigation, and 2015 revealed numerous surprises, involving local-regional therapy, adjuvant and neoadjuvant therapy, and metastatic disease. It is not a disease so much as it is a universe.

Screening Mammography
While there was nothing particularly new in terms of data in the screening field, screening mammography still made national headlines. The American Cancer Society presented its long-awaited updated screening recommendations, raising the age at which it recommends initiation of screening from 40 to 45. This follows the U.S. Preventive Services Task Forces recommendation to begin screening at age 50. The American College of Radiology, in turn, recommends beginning at age 40.

As all of these groups are operating off of the same data sets, it is important to realize that the differences in these recommendations largely represent differences in data interpretation, in particular the question of, «How many women does one need to screen (or how much money does one have to pay) to prevent a breast cancer death?» That ultimate guidelines committee—the United States Congress—has directed Medicare to ignore the USPSTF recommendations.

The differences between the different groups are confusing to women and physicians. My biases are these: 1) Even with the least aggressive guidelines, a significant percentage of the population does not undergo screening, so we need to improve access and education; 2) We are at the start of a process of diagnostic individualization—call it precision imaging—that will parallel the therapeutic individualization we have seen transform breast cancer. I suspect that a decade from now we will be taking a much more nuanced approach to estimating risk, and therefore a more individualized approach to screening recommendations; 3) As therapy for breast cancer improves, screening will necessarily have a lesser impact on outcome. We do not perform testis cancer screening because it would never be cost effective.

Radiation Therapy
Five years ago I thought I understood what optimal local-regional therapy was. I was wrong. We continue to alter our understanding of both surgery and radiation therapy for local disease. The role of post-mastectomy radiation therapy remains contentious. In 2014 the Early Breast Cancer Trialists’ Collaborative Group published a meta-analysis demonstrating that post-mastectomy radiation reduced disease-free and overall survival in all patients with positive lymph nodes.

This year saw two important new developments. The EORTC published the results of a large (greater than 4,000 patients) trial in women who had a centrally or medially located primary tumor, irrespective of axillary involvement, or an externally located tumor with axillary involvement (NEJM 2015;373:317-27). Patients were randomized to undergo either whole breast or thoracic-wall irradiation in addition to regional nodal irradiation (nodal-irradiation group) or whole breast or thoracic wall irradiation alone (control group). Disease-free survival was improved (for both local-regional and distant recurrence) with what the authors described as a marginal effect (a 1.9% difference) in overall survival.

The NCIC’s MA.20 trial (NEJM 2015;373:307-16), published back-to-back with the EORTC trial, examined whether the addition of regional nodal irradiation to whole breast irradiation improved outcome in node-positive and high-risk, node-negative women. While the additional therapy reduced the rate of recurrence, it had no effect on overall survival. My sense, as a non-radiation oncologist, is that radiation beyond whole breast irradiation appears to add relatively little to long-term outcome, and some real toxicity.

Guidelines committees are re-evaluating their post-mastectomy guidelines. Part of the problem faced by these committees is that systemic therapy has also changed, and reduced local-regional and distant recurrence. Numerous institutional studies, some quite large, are showing lower local-regional failure rates than reported in the Oxford meta-analysis and older randomized trials.

Dem Bones, Dem Bones
Going back now over 20 years, we have had preclinical evidence suggesting that anti-osteoporotic agents (both bisphosphonates and RANK ligand inhibitors) could prevent breast cancer bone metastasis. A large number of randomized trials, mostly underpowered, were subsequently performed. This year saw several decades of work come to fruition.

Let’s begin with the Early Breast Cancer Trialists’ Collaborative Group’s meta-analysis of adjuvant bisphosphonate trials (Lancet 2015;386:1353-61). I have become somewhat uncertain of the value of Oxford meta-analyses in an era dominated (on the one hand) by quite large Phase III trials, and on the other hand by rapidly emerging trials based around small genomics-driven subsets. But this is the sort of meta-analysis that shows the continuing value of the Oxford studies.

To summarize a large body of data, bisphosphonate use reduces the risk of distant metastasis and improves overall survival for early stage breast cancer. The reduction in distant metastasis is attributable entirely to a reduction in bone metastasis, biologically predictable but disappointing to those who felt there might be some spillover effect to other organs. The meta-analysis was composed of an astonishingly diverse array of studies, with differing bisphosphonates, different durations of therapy, and different patient populations. The only subgroup to satisfy a formal test for interaction was menopausal status: all the benefit was confined to postmenopausal women.

We lack a huge database of studies when we turn from bisphosphonates to RANK ligand inhibition. At present we have one drug (denosumab) in one study (ABCSG-18), and that study is frustrating. The Austrians randomized postmenopausal women receiving an aromatase inhibitor to either every six-month denosumab 60 mg or a placebo. The study’s primary endpoint was the prevention of skeletal-related events, with disease-free survival as a secondary endpoint.

The paper on skeletal-related events was published in the Lancet (2015;386:433-43). This was a real success, with denosumab markedly reducing osteoporotic fractures (hazard ratio = 0.50, p < .0001). The fracture rate in the control arm was higher than what we might have suspected, suggesting that we may have been missing AI-induced osteoporosis.

The ABCSG18 investigators next looked at disease-free survival… and that is where frustration enters the picture. Because of the impressive bone result, the study’s data monitoring committee felt there was an ethical obligation to report the results to the patients, allowing those on the control arm to cross over to denosumab therapy, with subsequent pollution of disease-free survival (DFS) results. The trialists (Michael Gnant presented their data at the 2015 San Antonio meetings) performed their analysis at a time that was clearly earlier than one would have liked, and demonstrated a «close but not quite there» p value of .051.

Where does all this leave us? First, we have great evidence for therapeutic benefit with bisphosphonates in postmenopausal early stage breast cancer. But which drug should we use, and for how long and in what dosage? Perhaps the guidelines committees will help us out on this. The RANK ligand data—such as it is—looks similar to the bisphosphonate data, with appropriate caveats. We await more denosumab data, but given denosumab’s track record in the metastatic setting, I doubt it will prove inferior to bisphosphonate therapy. Given its convenience and somewhat better tolerability, it may prove the ultimate winner.

Palbo
Estrogen receptor positive breast cancer had been a sleepy therapeutic area for much of the past decade. That changed in recent years, first with the approval of the mTOR inhibitor everolimus, and now with the introduction of the cyclin dependent kinase inhibitor palbociclib. Basic biologists have known for some time that estrogen’s growth actions require a pathway that includes Cyclin D and CDK’s 4 and 6. Palbociclib blocks CDK4/6, and in cell line models was shown to have striking activity in ER-positive breast cancer cell lines.

In April of 2015 the Food and Drug Administration gave palbociclib an accelerated approval based on the PALOMA-1 results. PALOMA-1 was a randomized Phase II trial (or, rather, a mash-up of two underpowered randomized Phase II trials) comparing letrozole alone to letrozole plus palbociclib. The trial, published in Lancet Oncology (2015;16:25-35), showed a rough doubling (from 10.2 to 20.2 months) in progression-free survival. PALOMA-1 was followed in short order by PALOMA-3, also published in 2015 (NEJM 2015;373:209-219), repeating the same experiment in a Phase III setting with fulvestrant as the endocrine agent. PALOMA-3 demonstrated a significant (statistically and clinically) improvement in progression-free survival, going from 3.8 to 9.2 months.

Palbociclib, as those who use it know, removes some of the joys of endocrine monotherapy. It is obscenely expensive and it adds toxicity to the mix, albeit manageable toxicity. Because CDK 4/6 inhibitors also affect neutrophil production, low neutrophil counts are common and require evaluation and not infrequent dose modification. Though the PALOMA-1 trial saw no neutropenic fevers, out in the real world older and frailer patients get hospitalized with infections.

Two other CDK 4/6 inhibitors are in Phase III trials, and along with palbociclib they cover the entire ER-Positive waterfront. Palbo, in turn, has entered adjuvant trials. These are good things, but I wish I knew more about CDK inhibitors. I have had metastatic breast cancer patients respond for a decade to an aromatase inhibitor. Will I need to give Palbo for a decade as well, and if so, at what cost, both financial and in terms of inconvenience and toxicity? Will we be able to predict who benefits? What are the mechanisms of resistance? How long (assuming it works there) will I need to give a CDK 4/6 inhibitor in the adjuvant setting? If I start a patient on an AI plus Palbo and the patient progresses, should I then switch to fulvestrant plus Palbo? Lots of work for clinical trialists, and lots of questions of importance to patients.

Pertuzumab and Lapatinib
This year saw the updated results from the CLEOPATRA trial in front-line HER2-positive breast cancer (NEJM 2015;372:724-34). This trial compared combination HER2-targeted therapy to trastuzumab monotherapy in the presence of docetaxel. These results are stunning, with an improvement in overall survival from 40.8 to 56.5 months, far more than I would have guessed, and clearly establishing dual HER2-targeted therapy as the standard of care in front-line HER2-positive disease. We can only hope that these results will translate to the adjuvant setting when the APHINITY trial matures.

However, a cost-benefit analysis estimated the cost per quality-adjusted life year of adding on pertuzumab at $713,000 (J Clin Oncol 2015 Sep 8. pii: JCO.2015.62.9105 [Epub ahead of print]).

While the CLEOPATRA results were exceptionally positive, lapatinib disappointed. The long-awaited adjuvant lapatinib ALTTO trial, presented at the 2015 ASCO Annual Meeting’s plenary session (and subsequently published in the Journal of Clinical Oncology), was essentially a negative trial, closing out a decade of work for this kinase inhibitor.

What Do We Do with This Data?
Every year sees some studies that make me wonder whether my hard-won worldview is wrong; there were two of these this year. The first involved the anti-VEGF agent bevacizumab. Bevacizumab prolongs disease-free survival but not overall survival in front-line metastatic breast cancer in numerous Phase III trials. Bevacizumab does not prolong disease-free or overall survival in the adjuvant setting in multiple disease subsets in multiple Phase III trials. The world, myself included (and I devoted a decade of my academic career to anti-VEGF therapy), had given up on bevacizumab for breast cancer.

I was surprised, therefore, to read the NSABP’s trial of bevacizumab in the neoadjuvant setting (Lancet Oncol 2015;16:1037–48). Comparing the chemotherapy alone to the same plus bevacizumab in the preoperative setting, the investigators saw an improvement in both pathological complete response rate and overall survival (though curiously only a trend toward improved disease-free survival). Bevacizumab finally has a positive trial where it counts.

What do we do with this data? Is it real or is it just one of those statistical outlier results that pop up every now and then when one does enough trials with a drug? If it is real, why? I can come up with an explanation involving the use of anti-VEGF therapy in the presence of an intact primary tumor, perhaps with a bow to VEGF’s immune effects. But I am perplexed.

The other «I don’t know what to do with it» trial involves post-neoadjuvant capecitabine. A group of Japanese and Korean investigators, led by Masakazu Toi, MD, presented this trial at the San Antonio meetings (2015 San Antonio Breast Cancer Symposium, Abstract S1-07). HER2-negative patients with significant residual disease after chemotherapy were randomly assigned to post-neoadjuvant capecitabine (in the FDA-approved dose and schedule for metastatic disease) or to the control group. The analysis showed statistically significant improvements in both disease-free (74.1% versus 67.7%) and overall (89.2% versus 83.9%) survival. Benefits were seen in both triple-negative and HR-positive patients.

Adjuvant capecitabine, in several large, well-conducted trials (including the NSABP trial that was positive for bevacizumab), failed to alter the destiny of early stage breast cancer patients. Again, I am perplexed.

Drug development remains mysterious and unpredictable. Focus on what wonderful surprises 2016 will bring.

Posted Φεβρουαρίου 26, 2016 by msofcrete in Uncategorized

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Anyone who thinks Westerners are flocking to Isil because of the Iraq war is a fantasist   Leave a comment

Isil and its jihadist ideology uniquely exploit underlying conflicts and offer the conspiracy theory solution: none of this is your fault.

 

12:11PM GMT 18 Feb 2016

The Telegraph

When Islamist radicals commit some heinous act, they very often try to justify this as a legitimate response to the West’s foreign policy in the Muslim world. The West is the aggressor in “Muslim lands”, oppressing Muslims, so an equally violent response is therefore just and appropriate.

 

I will start by stating the obvious: Western foreign policy in the Middle East has been hugely dysfunctional, and very frequently responsible for very damaging outcomes. The Iraq War is the paradigm example, but this is something that stretches back an entire century. Yet the notion that people both in the Middle East and in the West get radicalised in response to Western interventions in the Muslim world is nonsense.

This claim is nothing more than a rhetorical pillar for the grievance and victimhood “theology” of jihadism. Its purpose is to give colour to their Manichean black and white, Us vs Them worldview which sustains the most horrific excesses of the terrorists as “necessary” in their millenarian battle of “good” vs “evil”: “They are attacking Us! We are merely defending ourselves! We are the good guys here!” Obviously, they must teach young children to kill with callousness and gratuitous brutality in self-defence.

If it were genuinely the case that global Jihadism in its current incarnation was some kind of reaction to Western “imperialism” in the Middle East, you would expect this movement to have certain features, and to behave in certain ways. For example, you would expect the movement to try and unite Muslims, and even non-Muslims in the affected Middle Eastern countries, in a struggle against Western imperialist aggression, targeting specifically Western assets and interests.

 

Yet Isil and their ilk do the very opposite of that. This does get repeated quite often, but it does not seem to sink in with Western audiences: the primary target of Isil and similar groups is not the West. It is other Muslims. Above all, Shia Muslims. But also other ethnic, religious and tribal groups.

The attacks on the West are relatively rare, and small scale relative to what the other groups have to endure. The largest attack against the West carried out by Isil was the Paris attack last November. 130 were killed, and 368 were wounded. A horrific attack by any measure, but compare it with some of the attacks on the Shia, or the Yazidi minority. In October 2014, Isil executed 1,700 Shia civilians in one sitting at Camp Speicher, and a further 670 Shia prisoners in a massacre in Tikrit. By 2015, the U.S. Holocaust Memorial Museum assessed that ISIS had committed genocide against the Yazidis, but also ethnic cleansing and war crimes against Shias, Kurds, Christians, Mandaean and other groups.

Small scale attacks, with fewer than 10 victims are much more frequent. In the West they seem to be happening at a rate of one every couple of months in past last year. By comparison, in the Middle East, random murders of Shia civilians or bombing of marketplaces or Shia mosques happen on a daily basis.

And let us not forget that the attacks that do happen in the West, especially the more recent ones in the United States, only have the most tenuous links to Isil. It often goes no further than one or two deranged gunmen who “pledged allegiance” to Isil in their bedroom, but had virtually no contact with the group beyond that.

For Isil, these attacks are important for PR and marketing. It allows it to recruit foreign fighters for its battles in the Middle East. And Western Media coverage that these attacks ensure give it clout and prestige. But for them, the real battles are against the Shia government of Iraq, the Shia Alawite government of Syria and the Kurds. And any non-Sunni, thus “non-Muslim” civilian minority caught in their “Muslim lands”.

If Isil really was about defending the Middle East from Western “aggression”, why on earth would they attack Indonesia, of all places – the largest Muslim country in the world? Indonesia has had absolutely nothing at all to do with Western foreign policy. Its only “sin” is that it largely practices a very tolerant and inclusive kind of Islam, and does so very successfully. And to the likes of Isil, there is nothing more threatening than a representation of Islam which is at peace with the world, and very successful for it. Indonesia is not oppressed by the Crusaders and the Zionists, and gets along rather well with all kinds of Islamic sects and non-Islamic religions. That is what makes them “un-Islamic” in the warped ideology of the jihadists. They simply do not fit the victimhood and grievance ideology, so they cannot possibly be Islamic.

 

But what about those Muslims radicalised in the West? Young men and women born and raised here, but who nonetheless become radicalised and either carry out attacks on Western streets, or travel to join the fighting in Syria. Are they radicalised by Western intervention in the Middle East?

No. Radicalisation is complex phenomenon. There are as many reasons for radicalisation as there are radicalised young Muslims. Each one of them has their own story with a complex mix of reasons, more or less rational, for why they have come to have the radical world view. Nonetheless, we can also observe some strong patterns amongst those radicalised emerging from the increasing body of interdisciplinary research on radicalisation.

For example, most come from unsafe, unstable social environments and have histories of petty crime, as well as drink and drugs problems. It is also notable that this tendency is especially acute amongst white Western converts. They may feel that their lives lack direction, but also feel disempowered and disenfranchised. They feel that they are not in control of their own destinies.

What an organisation like Isil offers them is instant reception. And moreover, a purpose. A direction in life. You can be an unemployed petty drug dealer one day but if you take a flight to Turkey and cross the border into Syria you are instantly transformed into a warrior of God.

Recruits get guaranteed salvation in the afterlife, but also, the opportunity to establish political utopia on Earth. Something that has not been on offer anywhere in the world since the collapse of communism. They get all that and they get free reign to vent their pent up aggression and their sexual frustration – and the research shows that the recruits have plenty of both. Where else can you get a sense of belonging, a purpose of building paradise on Earth, an opportunity to kill bad guys and sexually enslave as many of “their women” as you can get your hands on? Coming from cultures like ours that glorify sexual prowess, violence, and political utopianism, is it any wonder that so many are seduced by what Isil is promising them?

Western foreign policy? Sure, why not? Sounds like a legitimate argument. They will have it. But is that really what gets anyone out of bed in the morning? If the West “got out of Muslim lands” tomorrow, would anything really get better for anyone in the Middle East? And is there even any possible way for all Western countries to cut ties with the Middle East so drastically that they could be said to have “gotten out of Muslim lands”? In the mind of these zealots, even speaking to “non-Muslims” can corrupt one’s moral purity.

The bottom line is that a lot of this complaint against Western foreign policy is nothing more than an exercise in denial: what the Muslim world, and young Muslims here in our countries, are in denial about is that almost all problems Muslims face in the Muslim world is the fault of none other than the Muslims who live there. Local sectarian and tribal rivalries, regional rivalries between Iran and Saudi Arabia, rampant corruption and chronic economic mismanagement, gross social inequality between most people and a tiny elite who monopolise oil and other key resources, and a bulging youth population with no economic prospects and little to do other than pick up a Kalashnikov. Those are the fundamental problems of the Middle East, and they have next to nothing to do with the West, or its foreign policy in the region. But they do radicalise the local populations.

Isil and its jihadist ideology uniquely exploit and amplify these underlying conflicts and offer the conspiracy theory solution: none of this is your fault. There is a big villain far away who has engineered all your problems. You are good people, and all of this will be magically fixed if we go now and kill the bad people. Who are the bad people? Don’t worry about it, we’ll show you when we get to the battlefront. In psychiatry, we call these denial and displacement respectively. In the real world, we have to call this the instrumentalisation of religion for an ideology of death – and a real tragedy.

Dr Azeem Ibrahim is an RAI Fellow at Mansfield College, University of Oxford and Research Professor at the Strategic Studies Institute, US Army War College.

Posted Φεβρουαρίου 19, 2016 by msofcrete in Uncategorized

DAVID JOHNSTON: Canada’s culture of research excellence   Leave a comment

Contributed to The Globe and Mail

Published Wednesday, Feb. 10, 2016 6:00AM EST

David Johnston is Governor-General of Canada.

His Excellency The Right Honourable David Johnston, Governor-General and Commander-in-Chief of Canada (Dave Chan for The Globe and Mail)

I was born in the town of Copper Cliff, now a part of Sudbury, a city famous for its minerals and for being the site of National Aeronautics and Space Administration (NASA) training missions in the early 1970s. To this day, the reason for those missions is misunderstood: Rather than training in Sudbury because its landscape resembled the moon – as the myth goes – the Apollo astronauts were there to study geology. Specifically, they were studying the Sudbury basin, a two-billion-year-old meteor impact similar to impacts found on the lunar surface. Those astronauts weren’t learning how to moonwalk in Sudbury, they were learning about moon rock.

Why am I telling this story? Not just because I’m a Sudbury native who wants to set the record straight. It’s because I’m in Washington attending meetings on the margins of the American Association for the Advancement of Science – a gathering of some of the world’s top science minds, including numerous Canadians – and Sudbury is again starring prominently in the world of scientific discovery. This time, it’s for what we’ve learned there about the sun.

That’s right, the sun! This time around, the Sudbury basin is the site of the Sudbury Neutrino Observatory (SNO), a lab the size of a 10-storey building located two kilometres underground in Vale’s Creighton Mine.

Recently, the SNO was awarded a prestigious 2016 Breakthrough Prize in Fundamental Physics, dedicated to encouraging physicists studying the deepest mysteries of the universe. The award was accepted on behalf of an international team by Arthur McDonald – himself a co-winner of the 2015 Nobel Prize in Physics for his work at the SNO.

To say the least, it has been a good year for Canadian physicists on the world stage – as well as for all kinds of Canadian scholars. In 2015, no fewer than 24 Canadians won prestigious international awards and prizes in science, engineering, health, medicine, the social sciences and humanities. This is a great achievement, and during my visit to Washington, I’m meeting with scientists and leaders from governments, universities, granting agencies and non-governmental organizations to find ways to build on that record and to further promote Canadian excellence. Because in a world where knowledge is a key currency, nothing attracts talent and resources like success. Global Excellence, an initiative I’ve been working on with academic institutions and government agencies, seeks to recognize and celebrate success so we enhance a Canadian culture of equality of opportunity and excellence.

How do we do this? The story of the Sudbury Neutrino Observatory provides us with some valuable lessons.

One, collaboration – often on a global scale – is critical to success. The SNO involved hundreds of scientists, technicians, institutions and agencies from Canada, the United States, Britain and Portugal. Even Dr. McDonald’s Nobel Prize is shared with Takaaki Kajita of the University of Tokyo, who led an earlier phase of the neutrino experiment in Japan.

Two, whether you’re an individual or community, leverage your local strengths. Think of Sudbury. Who would have thought a nickel mine would be an ideal place to observe neutrinos from the sun? Sometimes the competitive edge we need is literally right under our noses. What makes your community unique?

Three, recognize that Canada is home to some of the world’s brightest minds. We must support and celebrate their success. That means nominating our leading scholars and organizations for the world’s top prizes in the sciences, the arts, social sciences and humanities. Because sometimes the clichés are true: You miss 100 per cent of the shots you don’t take!

Together, in every sphere of activity, let’s build on our momentum and make sure the world acknowledges and celebrates the truly stellar achievements of Canadian trailblazers.

Posted Φεβρουαρίου 10, 2016 by msofcrete in Uncategorized

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Socialism Gets a Second Life   Leave a comment

Why do the young love Bernie Sanders? Because their experience of capitalism is different.

Nashua, N.H.

I was watching Bernie Sanders speak last week at a town hall in Bedford when an early intuition became a conviction:Take Mr. Sanders seriously. He is not just another antic presence in Crazy Year 2016. His rise signifies a major shift within the Democratic Party.

The big room was full, 700 to 800 people, good for 5 p.m. on a Friday. The audience wasn’t raucous or full of cheers as at his big rallies, but thinking and nodding. They were young and middle-aged, with not many white-haired heads. There was a working-class feel to them, though Bedford is relatively affluent.

“Let me disabuse you,” Mr. Sanders says to those who think he cannot win. He quotes New Hampshire polls, where he’s way ahead. He can defeat Donald Trump, he says.

Then the meat. He described America as a place of broad suffering—“student debt,” “two-job families” with strained marriages and insufficient child care, “the old on fixed incomes.”

We can turn it around if we make clear to “the billionaire class” that income inequality “is not moral.” The economy is “rigged.” Real unemployment is not 5% but twice that. “Youth unemployment is off the charts.” He wants job-training programs for the young. The minimum wage is “a starvation wage.” Raise it to “a living wage—15 bucks an hour.”

The audience is attentive, supportive. “Yeah!” some shout.

He speaks of Goldman Sachs, of “banksters” and of a Republican Party owned by “the oil industry, coal industry.”

“Health care is a right of all people, not a privilege.” He asks if any in the audience have high-insurance deductibles. They start to call out: “$4,000,” “5,000,” “6,000!” Someone yells: “Nothing’s covered!”

No one mentions ObamaCare, but it seems clear it hasn’t worked here.

Mr. Sanders says people don’t go to the doctor when they’re sick because of the deductibles. “Same with mental-health care!” a woman calls out. “Mental-health care must be considered part of health care,” he responds, to applause. He is for “a Medicare-for-all, single-payer system.”

How to pay for it all? “Impose a tax on Wall Street speculation,” he says, briefly. He does not elaborate and is not pressed to.

Mr. Sanders’s essential message was somber, grim, even dark. It’s all stark—good guys and bad guys, angels and devils. But it’s also clear and easy to understand: We are in terrible trouble because our entire system is rigged, the billionaires did it, they are the beneficiaries of the biggest income transfer from the poor to the rich in the history of man, and we are going to stop it. How? Through “a political revolution.” But a soft one that will take place in voting booths. We will vote to go left.

As the audience left they seemed not pumped or excited, but satisfied.

I listen to Mr. Sanders a lot, and what he says marks a departure from the ways the Democratic Party has been operating for at least a generation now.

Formally, since 1992, the Democratic Party has been Clintonian in its economics—moderate, showing the influence of the Democratic Leadership Council. Free-market capitalism is something you live with and accept; the wealth it produces can be directed toward public programs and endeavors. The Clinton administration didn’t hate Wall Street, it hired Wall Street. Big government, big Wall Street—it all worked. It was the Great Accommodation, and it was a break with more-socialist approaches of the past.

All this began to shatter in the crash of 2008, not that anyone noticed—it got lost in the Obama hoopla. In March 2009, when Mr. Obama told Wall Street bankers at the White House that his administration was the only thing standing between them and “the pitchforks,” he was wittingly or unwittingly acknowledging the Great Accommodation.

The rise of Bernie Sanders means that accommodation is ending, and something new will take its place.

Surely it means something that Mr. Obama spent eight years insisting he was not a socialist, and Bernie Sanders is rising while saying he is one.

It has left Hillary Clinton scrambling, unsteady. She thought she and her husband had cracked the code and made peace with big wealth. But her party is undoing it—without her permission and without her leading the way. She is meekly following.

It is my guess that Mr. Sanders will win in Iowa and New Hampshire. But the tendency he represents—whether it succeeds this time or simply settles in and grows—is, I suspect, here to stay.

A conservative of a certain age might say: “No, he’s a fad. Socialism is yesterday! Marx is dead, the American economic behemoth rolled over and flattened him. Socialism is an antique idea that rocks with age. America is about the future, not the past.”

I disagree. It’s back because it’s new again.

For so many, 2008 shattered faith in the system—in its fairness, usefulness and efficacy, even in its ability to endure.

As for the young, let’s say you’re 20 or 30, meaning you’ll be voting for a long time. What in your formative years would have taught you about the excellence of free markets, low taxes, “a friendly business climate”? A teacher in public high school? Maybe one—the faculty-lounge eccentric who boycotted the union meetings. And who in our colleges teaches the virtues of capitalism?

If you are 20 or 30 you probably see capitalism in terms of two dramatic themes. The first was the crash of ’08, in which heedless, irresponsible operators in business and government kited the system and scrammed. The second is income inequality. Why are some people richer than the richest kings and so many poor as serfs? Is that what capitalism gives you? Then maybe we should rethink this!

And Mr. Sanders makes it sound so easy. We’re rich, he says; we can do this with a few taxes. It is soft Marxism. And it’s not socialism now, it’s “democratic socialism” like they have in Europe. You’ve been to Europe. Aside from its refugee crisis and some EU problems, it’s a great place—a big welfare state that’s wealthy! The French take three-hour lunches.

Socialism is an old idea to you if you’re over 50 but a nice new idea if you’re 25.

Do you know what’s old if you’re 25? The free-market capitalist system that drove us into a ditch.

Polls show the generation gap. Mr. Sanders does poorly among the old. They remember socialism. He does well among the young, who’ve just discovered it and have little to no knowledge of its effects. A nationwide Marist poll in November showed Mr. Sanders already leading Mrs. Clinton, 58% to 35%, among voters under 30. She led him among all other age groups, and 69% to 21% among those 60 and older. By this month a CBS/New York Times poll had Mr. Sanders up 60% to 31% among voters under 45.

Bernie Sanders is an indicator of the Democratic future. He is telling you where that party’s going. In time some Democrats will leave over it, and look for other homes.

It’s all part of the great scrambling that is happening this political year—the most dramatic, and perhaps most consequential, of our lifetimes.

Posted Φεβρουαρίου 7, 2016 by msofcrete in Uncategorized

Μεταξύ Μπανγκλαντές και Μοζαμβίκης στον Παγκόσμιο Δείκτη Οικονομικής Ελευθερίας η Ελλάδα   Leave a comment

Μεταξύ Μπανγκλαντές και Μοζαμβίκης στον Παγκόσμιο Δείκτη Οικονομικής Ελευθερίας η Ελλάδα

 

Στην 138η θέση υποχώρησε το 2015 η Ελλάδα στον Παγκόσμιο Δείκτη Οικονομικής Ελευθερίας που καταρτίζει το Heritage Foundation, καθώς, όπως υποστηρίζει ο Οργανισμός, «έχασε τον έλεγχο» στην οικονομική και νομισματική πολιτική.

Όπως επισημαίνει η βρετανική Telegraph, η Ελλάδα χαρακτηρίζεται «ως επί το πλείστον ανελεύθερη» χώρα και η θέση της επιδεινώνεται διαρκώς μετά την προσφυγή της στην τρόικα που υποστηρίζει ότι προωθεί μεταρρυθμίσεις για να κάνει τη χώρα αποτελεσματικότερη, με μεγαλύτερη διαφάνεια, πιο σύγχρονη και ανταγωνιστική, αλλά στην πραγματικότητα εισπράττει χρέη για λογαριασμό των βόρειων πιστωτών της χώρας.

Η Ελλάδα έπεσε στην 138η θέση της κατάταξης -ανάμεσα στο Μπανγκλαντές και τη Μοζαμβίκη- ακριβώς επειδή «έχασε τον έλεγχο» σε επίπεδο οικονομικής και νομισματικής πολιτικής, ενώ σε αυτό συνέβαλαν και τα capital controls που περιόρισαν ακόμη περισσότερο την οικονομική ελευθερία.

Η κατάσταση στην Ελλάδα και ο παγκόσμιος μέσος όρος

Η κατάσταση στην Ελλάδα και ο παγκόσμιος μέσος όρος

Σε πιο στενό γεωγραφικό επίπεδο, η Ελλάδα κατατάσσεται στην 41η θέση στην Ευρώπη, με δυνατό σημείο της την ελευθερία των εμπορικών συναλλαγών και αδύνατα σημεία τη διαχείριση των δημόσιων οικονομικών, τη διαφθορά και την αποτελεσματικότητα των ρυθμιστικών αρχών.

Η συνεχιζόμενη έλλειψη οικονομικής ελευθερίας έρχεται να προστεθεί στο πρόβλημα που αντιμετωπίζει η Ελλάδα με την ανταγωνιστικότητά της και στην πολιτική αστάθεια, επισημαίνει το Heritage, προσθέτοντας ότι πρέπει να γίνουν τολμηρά βήματα για να αποκατασταθεί η δημοσιονομική βιωσιμότητα, να γίνει ελαστικότερη η αγορά εργασίας και να αντιμετωπιστεί η διαφθορά.

Σημειώνεται ότι πρώτο στη σχετική λίστα έρχεται το Χονγκ Κονγκ, με τη δεκάδα να συμπληρώνουν η Σιγκαπούρη, η Νέα Ζηλανδία, η Ελβετία, η Αυστραλία, ο Καναδάς, η Χιλή, η Ιρλανδία, η Εσθονία και το Ηνωμένο Βασίλειο.

Όπως επισημαίνει σχετικά το Heritage Foundation, η Ευρώπη κατέστη λιγότερο ελεύθερη οικονομικά το 2015, με παράγοντες όπως το κόστος των κανονισμών εργασίας και οι υψηλές φορολογικές επιβαρύνσεις να πλήττουν την ανάπτυξη.

Το αξιοσημείωτο στον δείκτη του 2016 είναι αυτή ακριβώς η σοκαριστική διαπίστωση της «ανελευθερίας» που χαρακτηρίζει την Ευρωπαϊκή Ενωση, όπου σήμερα υπάρχει μία ελεύθερη ζώνη στα βόρεια, η οποία εκτείνεται γύρω από τη Βρετανία, την Ιρλανδία, την Ολλανδία και την περιοχή της Βόρειας Θάλασσας και της Βαλτικής, ενώ η Ελβετία βρίσκεται πάντα κοντά στην κορυφή αλλά ασφαλής από τα «νύχια» των Βρυξελλών και τη ρυθμιστική ασφυξία.

Κάπου μέσα σε αυτό το πρώτο μπλοκ βρίσκεται και η Γερμανία, η οποία βρίσκεται στην 18η θέση της παγκόσμιας κατάταξης.

Την ίδια στιγμή, υπάρχουν άλλες δύο «ομάδες» κρατών με σοβαρά προβλήματα: μία φτωχή ομάδα στα ανατολικά με εύθραυστο κράτος δικαίου και οι υπερχρεωμένες χώρες του ευρωπαϊκού Νότου που αντιμετωπίζουν σοβαρά οικονομικά προβλήματα.

Όπως φαίνεται από τον δείκτη οι χώρες της ΕΕ είναι κατά μέσον όρο λιγότερο ελεύθερες από άλλες χώρες με συγκρίσιμο κατά κεφαλήν εισόδημα και επίπεδο ανάπτυξης.

Το επιτυχημένο παράδειγμα της Βρετανίας

Η χώρα που φαίνεται να διαφοροποιείται εμφανώς είναι η Βρετανία, η οποία άφησε μάλιστα πίσω τις ΗΠΑ στον Παγκόσμιο Δείκτη Οικονομικής Ελευθερίας, κερδίζοντας τρεις θέσεις, με αποτέλεσμα να τερματίσει 10η παγκοσμίως. Η επιτυχία αυτή αποδίδεται στο γεγονός ότι η χώρα μείωσε τη φορολογία για τις επιχειρήσεις, ενώ η συνεισφορά του Δημοσίου στο ΑΕΠ συρρικνώνεται. Επιπλέον, στη Βρετανία είναι πολύ εύκολο να ιδρύσει κανείς μια νέα επιχείρηση και οι νόμοι που διέπουν τα εργασιακά είναι ελαστικοί.

Posted Φεβρουαρίου 4, 2016 by msofcrete in Uncategorized

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Jon Favreau, Speechwriter “For the first time, Obama sees it and he’s like, ‘I actually don’t have that many edits’.”   Leave a comment

I started writing speeches for John Kerry when I was 21. And I basically only got the job because I was a press assistant on the campaign, and we were losing to Howard Dean, and the campaign was running out of money and there was a big shake-up and all these people got fired, and they needed a deputy speechwriter and at that point they couldn’t really afford to hire a real one. No one really wanted to join what looked like a sinking ship. He went on to have a whole general election, but throughout that whole time, I always sort of thought that I had landed the job by accident. As a writer, you can never tell if you’re good anyway without doubting yourself.

I met with Obama after Kerry lost and Obama won the Senate seat. Robert Gibbs had recruited me for this job because he was my boss when I was with the Kerry campaign. And he’s like, “Look, Obama’s never worked with a speechwriter before in his life — he’s written all his own stuff. But now he’s a senator; he’s going to need to learn to work with someone, whether he likes it or not.” And when I met with Obama he was unbelievably nice, we had a great conversation, it was the most easygoing interview I’ve ever had. And at the very end he said, “Well, I still don’t think I need a speechwriter, but you seem nice enough, so let’s give this a whirl.”

So I start with Obama through the Senate, thinking, you know, I had been at the convention when he gave that speech in 2004. That was all him, and that hung over my head the entire time I started writing for him. Because I thought, Never will I help write a speech like this, right? He is the master — I was there when he gave one of the best speeches I heard, and he wrote it. And his first two years in the Senate, I think we wrote some decent speeches together, and then he announced for president, and — it’s hard to remember now — but for most of 2007, he was badly trailing Hillary Clinton. And on the stump, he would go and give 40-, 50-minute speeches in Iowa that were long and sort of rambling and workmanlike, and he’s better than that but it was a tough race, and when a race gets tough there’s more pressure and everyone starts yelling at you, you start just going out and saying all kinds of different things and making your speeches longer. The knock against him was “Oh, she’s all substance and you’re all style.” So to counter that I think Obama went out and tried to show everyone just how smart he was on every issue, and the speeches became very long and involved. And, you know, I’m Mr. Speechwriter in the campaign, and I’m like, “Well, I’m not fixing this, so I’m sort of a failure here.”

And so now it’s like October of 2007, and there’s literally headlines that say — I had one hanging up from the New York Post that said, “Hillary Ready for Her Coronation.” We were down in Iowa, and our last chance there is the speech that Obama’s giving at the Jefferson-Jackson Dinner in Iowa. A couple of us that had been with the Kerry campaign in 2004 remembered that that was the speech that Kerry gave that sort of turned the race around and helped him beat Dean in Iowa. And so we looked at the speech the same way. Now, the interesting thing about this speech is, all the candidates deliver this speech. It’s the last time that all the candidates deliver a speech one after another before the caucusing begins, and the whole media’s there — national media, local media. There’s no prompter, and there’s a time limit of about ten minutes. So you have to deliver a ten-minute speech without a prompter and you have to make your best case for your candidacy. All the pressure was on this speech; everyone was like, “This is our only hope here. Maybe we can pull even with Hillary after this or catch up in the polls.” And because there was so much pressure on it, writing and drafting were impossible — there’s a million conference calls with everyone saying, “Emphasize this, emphasize that.” Me and Ben Rhodes and Adam Frankel probably went through ten, 15 drafts of that speech, staying up till three in the morning, having them rejected the next day by people because everyone was so involved. Obama didn’t know exactly what he wanted to say, and Axelrod didn’t know, and there was all kinds of calls and meetings.

The president’s notes on his second inaugural speech.

So, finally, there was a speech planned a couple weeks before the JJ that we sort of just made up — it was basically a year before the actual election, right? Like the anniversary of the year before the real election. And no one on the campaign was really paying attention to that speech because everyone was so focused on the JJ. So what I did is I pretty much wrote a speech that I thought he should give at the JJ. I kind of snuck it in there. But I always remember now: The night that he was on SNL, I had a bunch of people over at my apartment in Chicago. He was supposed to give that speech that I had written, the practice speech, that day. I hadn’t heard how the speech went but I had a bunch of people over at my apartment to look at the SNL skit. It’s like 11, 11:30. And suddenly I get a call from Axelrod and he said, “Obama just gave the speech — totally blew up the place. He loves it and he says that that’s what the JJ needs to be. But the trick is, he needs you to cut this 20-minute speech down to a ten-minute speech so he can start practicing, and he needs you to do it by tomorrow morning.” So I was in my apartment with everyone over, I’ve had a beer or two, but immediately I kick everyone out, I change over to Red Bull and coffee, and I walked down to the campaign at midnight and stayed up all night until about 10 or 11 a.m. the next day, and I wrote the JJ speech. And I finished the draft and for the first time, you know, Obama sees it and he’s like, “I actually don’t have that many edits. I think it’s a pretty good speech.” So he practices that speech, practices memorizing that speech more than I had ever seen him do before, because he’s never really had to memorize a speech word for word. Like when we were at a hotel in Des Moines a couple weeks before the speech, if you walked by Obama’s hotel room you could hear him practicing the speech to himself and the mirror, just trying to memorize it.

There are two important moments in that speech. One paragraph distilled the whole race of why Obama and not Hillary at the time, right? Which was like, “This part of Jefferson and Jackson and of Kennedy and Roosevelt knows that we’re better off when we lead not by polls but by principle; not by calculation but by conviction. And that’s what this party’s about.” Something like that. And then there was this nice thing at the end that a lot of people didn’t notice in the campaign just because it wasn’t central to the message against Hillary, but he sort of quieted down at the very end of that speech and he said, “I’ll never forget that I would never be where I am right now unless someone somewhere stood up for me when it was hard.” You know, when it wasn’t easy. “And then because that one person stood up, a few more stood up, and then a few thousand more stood up, and then millions more stood up, and because they stood up we changed the world.” And that was sort of the first time we linked the history of him possibly being the first black president and civil rights with a message of the campaign, which was grassroots organizing to make a difference. And that’s sort of how we ended that speech, and that was always pretty meaningful to me.

So we get to the JJ, and somehow, by the luck of the draw, the order of the candidates’ speeches was that all the other candidates go first, Hillary goes second to last, and Obama goes last. So all these candidates go, get out of the way. Hillary gives her speech and the crowd’s all quiet for Hillary because she’s obviously the front-runner. And she gives a speech that is like all … I mean, you could tell there were a lot of slogans that were shopped around in her campaign. So the speech was something about “Turn up the heat, turn America around,” and all the supporters in the stands were supposed to yell, “Turn up the heat!” It didn’t work that well. And then there’s a pause and then Obama gets up there and he delivered — way better than it was written — the JJ speech. I was sitting there watching all the reporters, and all the reporters were like, “That’s it — that’s the speech. This is something big.” The crowd went completely insane. Even some of the other candidates’s supporters were going nuts.

The last time I had been in a room where he gave a speech like that was 2004, when I was a kid working for John Kerry. And to have been there in Iowa at that moment when I had helped work on the speech and just help sort of see, you know, history unfolding in this arena, it was incredible and it was the first moment in my life that I thought to myself, Okay, maybe I got the hang of this. From then on it felt like something clicked and then we had the Iowa victory speech and the New Hampshire speech, the “Yes We Can” speech and all that other kind of stuff. And it worked out from then on, but the JJ was sort of the first moment that I was like, Okay, I think I might have something to contribute here. I think I can be of use. That to me was probably the breakthrough.

It was also the first time I thought we would win. I mean, when we started, we thought it was a long shot — “Who knows?” — but then August, September roll around, October even, and we’re like, “I don’t know if we’re gonna do this. It seems we might come up short.” And then he gave that speech and it was great because most people from Chicago were in Des Moines that night, the whole campaign was there, and we — a couple of us had driven out from Chicago to go see the speech, me and my friend, just to be there. And you know, it was the first time that I thought, “It’s gonna happen. It could actually happen and turn this around.”

But it didn’t really resonate for me then. Not yet. It didn’t until we won Iowa. But I remember the first time I saw him after we won Iowa, he came out of his hotel room after editing that speech, and he just looked at me and he goes, “Speeches, man.” And he gave me a big hug and I was like, All right.

Posted Ιανουαρίου 15, 2016 by msofcrete in Uncategorized

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The Real Victims of Victimhood   Leave a comment

Arthur C. Brooks

 

BACK in 1993, the misanthropic art critic Robert Hughes published a grumpy, entertaining book called “Culture of Complaint,” in which he predicted that America was doomed to become increasingly an “infantilized culture” of victimhood. It was a rant against what he saw as a grievance industry appearing all across the political spectrum.

I enjoyed the book, but as a lifelong optimist about America, was unpersuaded by Mr. Hughes’s argument. I dismissed it as just another apocalyptic prediction about our culture.

Unfortunately, the intervening two decades have made Mr. Hughes look prophetic and me look naïve.

“Victimhood culture” has now been identified as a widening phenomenon by mainstream sociologists. And it is impossible to miss the obvious examples all around us. We can laugh off some of them, for example, the argument that the design of a Starbucks cup is evidence of a secularist war on Christmas. Others, however, are more ominous.

 

On campuses, activists interpret ordinary interactions as “microaggressions” and set up “safe spaces” to protect students from certain forms of speech. And presidential candidates on both the left and the right routinely motivate supporters by declaring that they are under attack by immigrants or wealthy people.

So who cares if we are becoming a culture of victimhood? We all should. To begin with, victimhood makes it more and more difficult for us to resolve political and social conflicts. The culture feeds a mentality that crowds out a necessary give and take — the very concept of good-faith disagreement — turning every policy difference into a pitched battle between good (us) and evil (them).

Consider a 2014 study in the Proceedings of the National Academy of Sciences, which examined why opposing groups, including Democrats and Republicans, found compromise so difficult. The researchers concluded that there was a widespread political “motive attribution asymmetry,” in which both sides attributed their own group’s aggressive behavior to love, but the opposite side’s to hatred. Today, millions of Americans believe that their side is basically benevolent while the other side is evil and out to get them.

Second, victimhood culture makes for worse citizens — people who are less helpful, more entitled, and more selfish. In 2010, four social psychologists from Stanford University published an article titled “Victim Entitlement to Behave Selfishly” in the Journal of Personality and Social Psychology. The researchers randomly assigned 104 human subjects to two groups.

Members of one group were prompted to write a short essay about a time when they felt bored; the other to write about “a time when your life seemed unfair. Perhaps you felt wronged or slighted by someone.” After writing the essay, the participants were interviewed and asked if they wanted to help the scholars in a simple, easy task.

The results were stark. Those who wrote the essays about being wronged were 26 percent less likely to help the researchers, and were rated by the researchers as feeling 13 percent more entitled.

 

In a separate experiment, the researchers found that members of the unfairness group were 11 percent more likely to express selfish attitudes. In a comical and telling aside, the researchers noted that the victims were more likely than the nonvictims to leave trash behind on the desks and to steal the experimenters’ pens.
Does this mean that we should reject all claims that people are victims? Of course not. Some people are indeed victims in America — of crime, discrimination or deprivation. They deserve our empathy and require justice.

The problem is that the line is fuzzy between fighting for victimized people and promoting a victimhood culture. Where does the former stop and the latter start? I offer two signposts for your consideration.

First, look at the role of free speech in the debate. Victims and their advocates always rely on free speech and open dialogue to articulate unpopular truths. They rely on free speech to assert their right to speak. Victimhood culture, by contrast, generally seeks to restrict expression in order to protect the sensibilities of its advocates. Victimhood claims the right to say who is and is not allowed to speak.
What about speech that endangers others? Fair-minded people can discriminate between expression that puts people at risk and that which merely rubs some the wrong way. Speaking up for the powerless is often “offensive” to conventional ears.

Second, look at a movement’s leadership. The fight for victims is led by aspirational leaders who challenge us to cultivate higher values. They insist that everyone is capable of — and has a right to — earned success. They articulate visions of human dignity. But the organizations and people who ascend in a victimhood culture are very different. Some set themselves up as saviors; others focus on a common enemy. In all cases, they treat people less as individuals and more as aggrieved masses.

Robert Hughes turned out to be pretty accurate in his vision, I’m afraid. It is still in our hands to prove him wrong, however, and cultivate a nation of strong individuals motivated by hope and opportunity, not one dominated by victimhood. But we have a long way to go. Until then, I suggest keeping a close eye on your pen.

 

 

Arthur C. Brooks is the president of the American Enterprise Institute and a contributing opinion writer.

A version of this op-ed appears in print on December 27, 2015, on page SR19 of the New York edition with the headline: Real Victims In the Victimhood.

Posted Δεκέμβριος 27, 2015 by msofcrete in Άρθρα

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