TRUMP, THE MEDIA, RATINGS AND REALITY

The great American Presidential reality show continues with the media dictating the script. Jay H. Ell maintains that the reality show that they are creating is far from reality. The media creates a situation and then wails at the outcome of their manipulations. Major case in point is The Donald - they cover every flicker of his eyelid and every tussle of his mane and then ask themselves why is he front and central to the debate with all that media attention? They focus ad nauseam on Hillary’s e mails, like anyone really gives a hoot what server they came from, and then rhetorically cry , “Why is no - one reporting on her detailed policy positions?” However the myth that it is all meaningless is off base as their contrived handling creates a reality. 

IT IS THE MEDIA NOT THE MESSAGE

Just to recap Jay H. Ell’s well worn thesis. The media today has one objective that is to increase its ratings as the latter are used to sell advertising. Broadly speaking the media create the news and then report and comment on the news they have created. The Presidential race has been morphed into a reality show with big stakes. The objective is to create a close horse race. The winner becomes the leader of the world’s largest nation. What could be a bigger prize? There is more than a voyeuristic interest in the outcome as the result impacts on viewers’ lives - health care, taxes or whether one’s relatives and friends can stay in the country or not, for example. All this has the potential for amassing big audiences and therefore high ratings and  costly advertisements. The media in some instances favor one side over the other making them very influential players, however all that is secondary to their mission of making money. So carrying on with this argument the last scenario they need is that the winner of the two year Presidential race is a foregone conclusion. The devotees would loose interest and the fourth estate might have to produce their own material instead of being provided with actors and a script, gratis, courtesy of the Presidential contenders and their campaign staff. The tighter that the media can make these horse races the greater the engrossment of the viewership.

THE DEBATES - CARLY FOR PRESIDENT?

Besides the day to day coverage of the campaign there are the debates. These are being conducted in the main by Fox News and CNN. These channels dictate who are going to participate who gets asked what question, who asks them and so on. There have been two Republican Party presidential debates and the consensus is that in both of them the current leader for the GOP Presidential nomination, The Donald, has been hammered mercilessly. If this is indeed so, which Jay H.Ell believes it is, this could have the effect of bringing the GOP contenders closer together thereby heightening the interest, i.e. viewership and thereby ratings. (Incidentally, Jay H. Ell has previously blogged on the control that Murdoch’s Fox News has over the Republican Party).

Now viewing the latest debate the overt agenda was to put The Donald on the spot and create contestants that could challenge him. Then having done so report “objectively” that Trump has received a setback and by implication no longer a shoo in. Carly Fiorina, and Christie faired well and now newly represent challenges to Trump.  CNN’s handling of this second GOP debate was outrageously bad. They were unashamedly into the sensationalism and tightening the race. There was no pretense at allowing equal time for all the contenders. For example two very serious contenders were all but ignored - Ben Carson and Scott Walker. 

 Jay H. Ell believes that the media would welcome a female contest for the Presidency between Carly and Hillary. So Ms. Fiorina was fed the lines and she delivered. Then the selfsame press reported on her sensational success. She was the hit of the evening and has been catapulted into contention. There have been some serious efforts to promote Ms Florina into prime time and this was the latest. A few one liners are apparently enough to turn her into a knockout and even better the President of the United States. When it gets nearer the nomination it will be time to clip her wings and all the tawdry details that halted her senatorial campaign against Barbara Boxer in California will be taken out of wraps. She is a more subtle megalomaniac than the Donald. At Hewlett - Packard  she created a right royal mess from which they still haven’t recovered. Her nickname was “scissors” because her contribution was to fire tens of thousands of employees while buying several corporate jets - The Donald at least has a number of successes amongst his four corporate bankruptcies some of which he had personally signed security for. 

THE DEMS NON RACE

Down at the other end of the scale Hillary, every betting man’s obvious choice to be the next POTUS, is being steadfastly ignored as a serious candidate. The Dem primary issues to date are not centered around income inequality, immigration, foreign policy, women’s rights rather they are about e mails and the like. The same lame media game applies here. All their coverage is on her e mails and then they smugly comment that the issue does not want to go away! Don’t you know that she was secretly dealing with the Kremlin and selling America’s secrets while canvassing for the best recipe on gefilte fish so as to impress her in laws? 

Bernie Saunders, a sweet sincere man, has been drawing crowds like any rockstar does. His message is pure and simple and is bringing great happiness and hope to those who are seeking the holy grail in politics. He is rating prime time coverage juxtaposed next to Hillary who is seen to be shuffling her e mails. Even the media cannot muster enough energy to push the other two Democratic Governor contenders whose names Jay H. Ell can never remember. Of course even the media recognize that grand daddy Bernie is chanceless so what about Joe Biden who in his previous runs couldn’t ever reach ten percent in the polls? Smoking Joe, the man you would like to go pub crawling with should not be encouraged. Term limits are part of the electorate’s unconscious and Joe represents Obama’s third term. Even the most ardent Obama hater has been relieved that Joe never had to take over. 

So here is what is really going 

1. THE TEA PARTY IS THE GOP- ITS OFFICIAL

The big news as to what is going on is that the party of Eisenhower, Nixon, Ford, Reagan and the Bushs' no longer exists. After 8 years of pretending they are all one big happy family the Tea Party faction finally found a credible, (sic), leader - Donald Trump and he unceremoniously hijacked the Party. He unashamedly trumpeted the Tea Party’s social value system, misogynism, immigration policy and xenophobia. Bill O’ Reilly of Fox News has at last found a standard bearer to lead America back to being a white man’s country. Initially the establishment GOP resisted Trump’s ascendency and even recruited Fox News to tame him but he prevailed. More significantly he dragged the whole Presidential field into the Tea Party with him. Unlike in the last election where the establishment’s candidate Romney always lay second in the polls to the Tea party candidate du jour, Donald has remained the pacemaker and between him and Carson, a more kinder, softer and gentler but crazier version of The Donald, they have consistently represented fifty percent of the GOP electorate that were polled. If one adds to that third or fourth placed Cruz it comes to closer to sixty percent. Jeb is less than 10 percent and Carly is even less. 

Trump has poisoned the well on the Hispanics muting the pussy footing apologists like Marc Rubio and Jeb Bush who needed to go along with Trumpism in order to compete. It is hard to imagine that this demographic can ever be won back this election cycle. Trump’s loutish behavior may result in him not being the contender at the end of the day but he has been the agent for change. To measure the extent of the fundamental shift in the GOP’s center of gravity all that is needed is to reflect on the fact that Reince Priebus, the big pooh bah of the Republican Party, came to visit The Donald to ensure his support for whoever became the elected GOP nominee. By so doing Reince ensured that all the other candidates would back Donald or anyone like him should they emerge triumphant at the end of the Primaries. Put another way everyone would be expected to back a Tea Party standard bearer if one emerged.

This success has emboldened the Tea Party members in Congress who are threatening to shut down the government again if they don’t get their way on Planned Parenthood. The establishment leadership of McConnell and Boehner are resisting with all their might as they know what a no no that is among the whole electorate. 

So the takeover is official.

2. THE GOP CANNOT WIN THE PRESIDENCY IN 2016

Another non media reality is they do not reflect that it is almost impossible for the GOP to win a national election. Memories are so short it is pathetic. Remember that the GOP working party after the last election pointed out their demographic problem but the results of that assessment are being ignored. The reason that Obama beat Romney, to the disbelief of the faithful, is that the demographics were lined up against him. Contrary to the belief of the Anne Coulters’ of the world there are not enough geriatric white males to vote a Republican in in a national election. Coulter a big Donald supporter turned heads when she complained at the attention the Republican hopefuls were giving to Israel by screaming, “How many f … king jews do these people think there are in the United States.” Added to Trump’s tacit support of the demand of a questioner to get rid of the Muslims and his non response to the statement that Obama was a Muslim and not an American has the foreboding of the election turning ugly.

 The main swing demographic that matters is the Hispanic vote. Not only has Obama made Presidential moves to lighten their immigration burden the Republicans have opposed these and as mentioned The Donald has taken the issue to a new xenophobic level. He is going to build a wall to rival the great wall of China to keep them out.  He has made the Hispanics and Hispanicness his and therefore the GOP’s defining electoral issue. Even those Hispanics that prefer smaller government or are against abortion cannot but help feeling offended. In this nation of immigrants can you imagine how the jews would vote if Trump had said the undocumented jews must be deported and believe you me there must be some that are undocumented. Or had he taken on the Indians or Irish, for example, those groups would make his attack the defining issue that would motivate their vote. It is interesting to note that an Hispanic leader maintained that there was a certain amount of apathy amongst the Hispanic demographic but Trump had given them an impetus to vote against the GOP.

Let us even argue that the demographic of women could be neutralized by a Fiorina but even that would not be enough to change the tide. It is incidentally hard to imagine Carly Fiorina doing that as all she has got going for her is that she is a woman. She has done nothing to further women’s issues and all the leading feminine movements support Hillary. Also breaking in Congress is the Tea Party determination to defund Planned Parenthood or close down government. Fiorina is against planned parenthood that has overwhelming female support. If she were for it she could kiss her chances of the GOP nomination goodbye.

The influential LGBT group will stick with the Dems and even if the youth of the Obama coalition split between the two parties it is not enough.

So unless Donald after he deports the illegal  Hispanics disenfranchises the Hispanic citizens as well the GOP has a tough row to hough. 

3. HILLARY WILL WIN THE DEMOCRATIC NOMINATION

The media have all but written off Hillary. They are inculcating a de ja vu Obama feeling about Hillary’s Democratic candidacy. While Hillary is not the most exiting or charismatic candidate and tends to get irritated with the media, (they just simply hate her she maintains), she is still the odds on favorite to win the nomination and the Presidency. Hillary is not terribly good at running for President she just doesn’t feel the beat. By now she should have known when the e mail controversy came out she should have chucked the server at them before they even knew one existed. She is so anxious not to make mistakes that everything looks so contrived. She may even lose Iowa and New Hampshire but she hasn’t got an Obama opposing her and she has taken a leaf out of the latter’s playbook and is sowing up the Southern States delegates. In addition all the Super delegates are going her way. So wah.

4. GOP NOMINATION - HAS IT GOT TO BE JEB?

Before starting there are 20 or so contenders very few that need go away as they are fueled up with money that the Supreme Court allowed them to get. Remember if you are a billionaire you don't need a Derby winner in your stable you need a President! 

The media have got to know that Jeb is the nominee till otherwise proved. Although it is difficult to envisage but at the same time it is even more difficult to believe it won’t be Jeb. If it is Jeb, as all the smart money, including Jay H. Ell’s, believes it will be, it will be a retreaded Jeb. He will have had to have moved so far to the right that he would be unrecognizable. However, for the moment, Jeb is boring and the media will much rather not bolster his persona and so they then can tautologously argue that one doesn't hear from him. For the moment Trump or a look alike is still a very very serious contender.

The GOP nomination is the one area that there has to be uncertainty what with the revolution in the Party going on. So maybe the media has got it right after all. Wall to wall coverage of the GOP race punting and supporting one candidate after another to keep it interesting. And what is more it sells soap and to quote The Donald - he is a ratings machine. By the way Jay H Ell believes Trump is getting bored. While it was reported that he had lost his energy in the second debate it looked more like that he had had enough. As he is not remotely interested in policy positions or preparing for debates he has to run on insults, outrageous comments and the like. It is hard to imagine, hard on him and hard on us to have to hear this all again and again for the next 15 months and if Mr. Trump is correct for 4 years after that. 

One thing is for certain the casino mogul has no plan B. Maybe someone else will emerge from the pack?  Is it possible that the media kingmakers will give Chris Christie another chance for prime time? Surely BridgeGate is water under the bridge by now. Jay H. Ell’s GOP choice John Kasich makes too much sense to put his name up in lights. He and Hillary will put us all to sleep with practicality and lower the ratings. Carly, who knows? but when the going gets tough she has to wilt. Rubio, Cruz and Paul - no buzz to keep the crowds off their seats. Walker looks as if he has already shot his bolt, Huckabee’s stick resonates but has been heard before so maybe its just gotta be Jeb. Get him talking about his brother and his father and his mother there is a lot of interest there. Also he can discuss his Hispanic wife whom The Donald approves of.  There is an argument that the US should return to hereditary rule and the Bush dynasty is already in place. So maybe the smart money is right…… The Media can plan a coronation spectacle and hire the Queen’s carriage to drive him up Pennsylvania Avenue. Those spectacles also bring in high ratings and Donald would look good in a Gold Carriage…..

BEHIND THE SYRIAN REFUGEE CRISIS

Behind the 500,000 pitiful Syrian refugees that have poured into Europe in the first 6 months of this year and the total of 4 000,000 souls displaced since the start of this Middle East turmoil this year, lie a host of other issues that crowd the room like a ton of gorillas. First and foremost is the battle against the Sunni extremist ISIS waged by an odd coalition of forces some of whom are at war with one another. Adding another wrinkle to the emergence of ISIS is the fact that they have been successfully recruiting Muslims from Western countries and have openly admitted that they mean to use the refugee crisis to send sleepers into Europe and America. Then, secondly, there is the civil war between the genocidal and totalitarian Syrian Premier against his own people which is the immediate reason for the European refugee invasion. Overlying these two major conflicts is the life or death power struggle for control of the Muslim world, led on the one hand by the Gulf State Sunnis and on the other the Iranian Shia. Also the perception that the Muslim world is controlled by terrorists hangs over the plight of the refugees. 

On top of all this is the predominant belief in that Middle East that the balance of power has shifted to Iran as a result of the recent controversial nuclear deal. This brings into focus another gorilla skulking in the shadows of the room - the fight to destroy Israel lead by newly empowered Iran and its surrogates, designated terrorist groups Hamas and Hezbollah. Not to forget that Syria’s Assad is a key partner in this imbroglio against Israel and it is from this country the refugees emanate. On the world stage yet another shifting of fortunes as Russia, by arming Assad, brings itself closer to creating a de facto power block between it and the Shia world controlled by Iran. This like everything else in the volatile Middle East has unsettled Israel who to date relied on Putin as an ally and as a result Netanyahu has scurried off to Moscow to plead with the unpredictable Russian Premier. Obama too is weighing up his options in relation to Putin’s blatant opportunism. The ripples of the refugee catastrophe are felt everywhere and are in contention in the upcoming US Presidential election for example. 

THE SYRIAN REFUGEES AND THE MUSLIM WORLD

Before moving onto the existential predicament the refugees have landed Europe into let us see how the world around Syria is coping. Three and a half million of the 4 million rooted from their Syrian homes that are still in the Middle East. The bulk is in Lebanon, (1,100,000), Jordan, (620,000), Turkey, (1,600,000), Iraq, (223,000) and Egypt (143,000). All these countries are stretched to the maximum with this flurry of humanity and are targets for destabilization.  Now it does not take a rocket scientist to realize these countries are all predominantly Shia. So where are the Sunni Gulf States in this desperate crunch? On its face the Gulf States are culturally most suited to settle these fugitives. The Gulf States have the same religion, legal system and the equivalent language but they have steadfastly refused to lift a finger to help. Kuwait, presumably in a crude attempt to deflect attention from the obvious sectional reason for their shameless neglect, have argued that their country is too rich for the Syrians. (It is also interesting to note that the evacuees are not clamoring at the Gulf States’ borders either). There are nearly sixty Muslim countries in the world and no others have volunteered to settle even a thousand. 

Assuming that this behavior, particularly by the Gulf States, is not just callous indifference it sends a message to all concerned of the deep divisions in the modern world between Sunnis and the Shia - a circumstance that will have profound implications in the predicted tussle between Iran and IsraeI. One could tritely refer to Israel and the Gulf States relationship as an unholy alliance!  Needless to say this neglect of the Syrian plight by their Sunni brethren has not past unnoticed and is used as an argument by many in Western countries not to become involved.

THE EUROPEAN DILEMMA

It is fair to say that Europe has been in an agitated ambivalent state ever since the refugees began pouring in. The humanitarian dimension of what was unfolding resonated in a continent that had stood by in the thirties and forties when a genocide was taking place. There have been desperate scenes of frantic scrimmaging everywhere interspersed with 71 dead bodies in a truck, drownings and most poignant of all a dead three year old young boy being dragged out of the water. The European Union is meeting regularly, anxious not to repeat their inhumanity exhibited at their infamous meeting at Evian, France in 1938 when every participant refused to take in any Jewish refugees. In the forefront of the relief effort is Angela Merkel, Chancellor of Germany who has argued, “If Europe fails on the question of refugees, its close connection with universal human rights will be destroyed”. Merkel initially pledged support for the placement of 800,000 fugitives. Other countries were far more circumspect - UK 20,000, France 24,000 and Spain 15,000. 

The real Gorilla in this room is the fact that Europe has already experienced Muslim immigration and has witnessed a failure by that community to integrate into their societies. Also isolated terror incidents and flagrant antisemitism by Muslim extremists has left more than a sour taste. Interestingly enough Holland and Belgium have not agreed to any settlements. Issues such as communities demanding Sharia law abound throughout Europe and women and chid abuse related to custom are a challenge to local authorities. However, other than Hungary’s right wing Prime Minister claiming that he was not going to allow the Christian fabric of his society to be torn by a massive Muslim presence the Muslim identity of the homeless has remained in the closet. 

Also it is patently obvious that this is not Europeans perpetuating genocide while the world stands by. For example, the Europeans never put the hapless refugees in trucks they were put there by shameless exploitative thugs. All the Europeans are trying to do is wrestle with the nightmare that has landed on their doorstep. When caseloads of weapons are discovered in boxes captioned “Humanitarian Aid”, when opposition forces in the country cry enough is enough, it is understandable that there is concern by Governments. In contradistinction even in Hungary the plight of the damned has been embraced by individual citizens who empathize with the Syrians and have provided them with clothes, shelter, food and warmth.

PULLBACK ON REFUGEES

As the days roll on and the numbers of fleeing souls increase exponentially the brake mechanisms go into effect. Hungary has put up a fence making it extremely difficult to enter their country en route to migrate to the richer nations of Germany and Austria. They are even using tear gas and water hoses to control the mob. Germany pulled back too on their generous financial aid given to emigres and have replaced it with food coupons. Germany too is about to put up a fence on its border. There is little doubt that Europe cannot resettle what could be millions of people and somehow they are going to have to find a compromise between humanitarianism and reality. The initial planning EU meetings have morphed into emergency meetings on how to cope with this flood of humanity not how to integrate it.

The United States at the moment are going through their own contortions on the subject. Immigration per se has been made an issue front and center by the current GOP frontrunner, Donald Trump, for the Presidential nomination. The latter wants to deport 12 million Mexicans that are in America illegally. Ironically the United States is the country in the world that has been able to integrate peoples from all countries and persuasions into their melting pot. However, with Immigration a hot button election issue it is unlikely that Obama is going to make any sizable gesture. Thus far he is admitted just over a thousand Syrian homeless and has an objective of about 10,000 for a year. It is not only Trump who is sounding the alarm the number two contender on the Republican slate at present, Ben Carson says that no one can come in until they have had a comprehensive security check, which as it is not possible now, no one can seek asylum. It would be a brave Presidential contender in this climate to propose a major contribution to alleviate the crisis.

(All this immigration bluster is so much hot air because there is no way that 12 million Mexicans are going to be sent home as they are integrated into the economy. The quicker they are legalized the better as they are generally younger than the overall population and one needs a tax base to support the baby boomers who are going into retirement. Also no one cannot even hazard a guess at the true USA illegal situation as there are millions and millions of undocumented workers from other countries. For example there are a 100,000 illegal Greeks that have found there way to the US since their economy collapsed. Nothing will happen to these individuals till legislation is passed that punishes the employers - a policy not favored by the big donors of the GOP).

There is little doubt that Angela Merkel and some of the other European leaders had the adding of large numbers of young workers to their countries in mind in addition to their altruism. Their populations are aging and this is yet another gorilla in this overcrowded room. 

COMPROMISE ON ALTRUISM AND POLITICAL REALITY

The religious leader who has been in the forefront of the type of compromise needed is former Chief Rabbi Lord Jonathan Sacks. He believes that solidarity and empathy needs to be displayed towards the victimized Syrians. He has just completed his book “In God’s Name” where he explores the causative factors of those who effect violence in God’s name. He believes in the biblical edict, “Love the stranger as you were once strangers in Egypt”. He states that if one cannot have empathy for the plight of the Syrian displaced there is no hope as the world then loses its moral compass. At the same time he recognizes the limitations imposed on the European countries and as he is being interviewed left right and center to put a number on the refugees the UK should accept he has come out with the figure ten thousand. The precedent he relates to derives from the project initiated by Sir Nicholas Winton who brought in 10,000 Jewish children from Nazi Germany into the UK. He believes that, “….Sometimes small humanitarian gestures can pierce the darkness and light a flame of hope”.

Pope Francis’s message of hope and solidarity is for every Catholic parish to open its doors to one Syrian family.

AT THE END OF THE DAY

Jay H. Ell has tried to show that even if Europe was able to absorb all the Arab refugees the underlying problems would still need addressing. He would also hope that all those gorillas in the room could be openly discussed. It is not wrong, for example, for a people to discuss their fears such as infiltration by ISIS so they can be realistically answered. Also the Middle East mess needs sorting out. The West has  a moral duty to help resolve the chaos as their imperial meddling has more than contributed to it.

The major military decision that needs clarification is how to take on ISIS without supporting Iran and Abbas because all that does is push the can down the road. In case the US and the other 5 major powers hadn’t noticed Iran has become more belligerent since the nuclear deal. The central decision to be made by the Muslim world is to take on terrorism before the extremists take over the religion. Already they have hijacked the platform and the whole theism is being identified with the murderers.

The West also need to remember who their only real ally is in that region and who operates from their value system. Israel too has made what should be considered a humanitarian gesture as the Israeli Defense Force has treated over 1500 injured Syrians regardless of what side they were on in this latest conflict. Abbas’s contribution has been to invite the 4 million displaced Syrians to settle on the West bank. Not surprisingly the refugees did not make a beeline to his and Hamas’s democracies and headed straight for Europe. They did need to become cannon fodder in yet another fracas.

One should be grateful that at least one is not hearing that if the Israeli Palestinian confrontation would be resolved than all these problems would go away. 

To be continued as anything can happen for this powder keg to explode…. 

SERENA - THE TALE OF TWO AMERICAN SISTERS

The US Tennis Open, which has to be the greatest spectacle in sport with its gladiatorial contests that can go on late into the night and early into the next morning. A single shot can decide a game, a set, a match and a Championship and will be accompanied by roars that echo into the heavens. Fittingly the major battles are played out in the Colosseum like stadiums named after Arthur Ashe and Louis Armstrong. Ashe was the first African American to win the US, Wimbledon and Australian opens, a victim to Aids via a blood transfusion and a winner and pioneer in so many arenas. Louis “Satchmo" Armstrong was a beloved native of New York and one of the trailblazers of jazz and arguably its greatest exponent.The whole tennis complex with its numerous courts was recently christened the Billie Jean King US Tennis Association Center in honor of yet another tennis great this time renowned for her struggle for equality for women’s tennis, gay rights and her tireless efforts for these and other causes. So this battle for world tennis supremacy has as its backdrop a gigantic complex that celebrates excellence as well as championing the underdog and those who have overcome adversity. The screaming fans, no polite clapping here, whose support oscillates between the excellent and the underdog reflect this culture.

All this by way of introduction of the hype and near hysteria that this year surrounds the number one women’s seed Serena Williams and to a far lesser extent her elder sister Venus Williams. Serena at the time of writing is on her way to history. If she wins the US Open she will have a calendar slam, having won the Australian, French and Wimbledon Opens this year. This last calendar slam was achieved by Steffi Graf in 1988. In addition Graf has won the most open slams in the “Open Tennis Era”, 22. And if somehow you have been in a coma these past two weeks if Serena wins this 2015 US Open she will equal Steffi’s magical number.

THE MEDIA BLAST

The blast involves all the media from the internet to the published media of all sorts all backed by a flood of advertisements featuring the Golden girl Serena. Chase Manhattan have featured her almost incessantly on TV and the Internet while Gatorade commissioned twenty one murals in Brooklyn NY featuring her winning each one of her slams to date accompanied by a touching advertisement tribute. She has been featured on several magazine covers. To give some idea of the coverage that Serena has evoked let us look at the reportage of Day 5 of the US Open in the media and internet:

Firstly there is extensive reportage of the previous days match such as “Serena loses first set but rallies to beat Mattek Sands" and ” Serena reaches her third step to history - four more to go”.Then there were articles as to how ok it was to be nervous and articles as to why she was nervous. (Maybe she had just been following the media who to date had not commented as to what the world would be like if she didn’t win - presumably fearful of the emptiness the hopelessness that such a catastrophe would evoke.) Then there were at least 10 videos on the internet on highlights from game three the round where  64 players had entered. In addition it was thought appropriate to run videos of previous slams.

The headline that put it all into perspective was run on the ESPN website - “ Day Five - Five developments not involving Serena”.

WHY THIS MEDIA FOCUS?

Before we go much further Jay H. Ell agrees with the unanimous assessment that Serena is not only the greatest women tennis player ever but the greatest women athlete. The question that needs answering is why the most comprehensive wall to wall coverage is being meted out that is usually reserved for the issue to du jour such as a hurricane disaster, a mass school/cinema murder, Shandra Levy’s disappearance, 9/11…. .  No sports event ever amasses this type of continuos coverage - not the baseball or basketball play offs and sometimes the Super Bowl. Jay H. Ell was around when Steffi not only won the calendar slam in addition she triumphed with the Wimbledon Gold Medal and while the media covered this feat appropriately it was still considered very much business as usual. So why this frenzy?

THE CAREERS OF VENUS AND SERENA AS COMPARED TO FEDERER

Could it be the greatest record in tennis that has unleashed the floodgates?

Since 1997 to this day one or other Williams sister has dominated the women’s tennis scene. Serena has won just in case you missed it earlier in this piece, 21 Grand  Slams and Serena 9. As partners they have 13 Doubles Grand Slams. While for the large part Venus dominated the earlier part of their careers their victories have been interspersed, The first of their trophies was the 1997 US Open won by Venus and Serena won in 1999. Venus last victories in Slams were at Wimbledon in 2005, 2007 and 2008. In the latter tournament she beat Serena and in 2005 and 2007 Serena was on the injured list. A large part of both their pilgrimages have been punctuated by illnesses or injuries.

All in all pretty impressive but if you were seriously looking for a feature on the basis of performance it would had to have been Federer. Federer is also pushing the mid thirties has had two main rivals, every step of the way of his career, Nadal and Djokovic who between them have won 23 Slams. Venus and Serena’s most serious rivals were each other. In fact over the past three years when Serena has won 8 of the 13 Slams she has played a host of opponents and along the way her challengers have been shortlived.  Federer’s consistency over the decade and a half has been amazing having been World number one for the longest period of any player and has the highest recorded number of slams in mens tennis 17. In addition he has won the World Tennis Championship 6 times and has won a record 295 Grand Slam matches and been in more consecutive semifinals 23 and quarter finals 46 than anyone else. He has been consistently ranked first, second or third spot for nearly his whole career. Serena’s rankings over her nearly twenty playing years have been all over the place. There is little doubt that he is the greatest tennis player of all time and arguably one of the greatest athletes of all time. He is playing the best tennis having just won the US Open dress rehearsal in Cincinnati beating Murray and Djokovic. The tennis world, for what it is worth, is watching his progress in an extremely tough mens field with greater interest.  By contrast Serena’s best competition in this open was Venus. For the rest they are in and out with no one but no one stamping themselves as a great.

So as impressive as Serena’s record that is not the reason for getting the Katrina like treatment.

THE AMERICAN STORY

As Jay H. Ell has blogged American aristocracy derives from money, and those that are cheered and revered are regarded as winners and or victims. Celebrities from the entertainment world, especially where a ball is involved, are adored.  The Williams’ have all these attributes in addition to a story that is remarkable. It is their rags to riches log cabin bit that brings tears to everyone’s eyes. Even more important Serena is American and her supportive, loyal and friendship relationship with her older sister is endearing - apple pie and mother’s milk.

In the beginning daddy Richard Williams trained his two phemons on public courts. With virtually no tennis experience in a world where there are tennis academies and high priced coaches he did it all from scratch. He wrote a seventy eight page plan for their training and future and carried it out. As Serena opined with only two players he produced 30 Grand Slam wins a feat rarely achieved by the most prestigious coaches with several proteges. John McEnroe,  marveling at his achievement, questioned incredulously, “How does he do it?”   Richard kept them out of the Junior Tournaments as he felt there was racial prejudice so they were robbed of early acclimatization to competitive tennis. When finally they entered the professional ranks the young girls were not part of the club and kept very much to themselves. In 2001 at a time when there were repeated unsubstantiated accusations of match fixing by their father, an injured Venus pulled out of the prestigious Indian Wells Tennis Tournament in her semi final match against Serena. The angry crowd booed and jeered Serena throwing out racist slurs. A shattered and frightened Serena never returned to Indian Wells till 2014 when under the influence of Nelson Mandela’s philosophy of the power of forgiveness returned. Over the years in spite of a few high profile court incidents she carved out for herself a resume of charity foundation work and a reputation for guts and perseverance and ultimately serenity. 

Venus, too, gaining in confidence with every year on the tour, became a much admired role model, an activist for women in a quiet and dignified manner. Both of them had other interests and become more and more admired for all their activities. Most significantly their touching supportive relationship and friendship when on the court they were fierce competitors has been featured more and more in the media. Both of them endured ongoing injuries and long periods away from the game. Serena suffered a life threatening pulmonary embolus and Venus was recently diagnosed with an energy sapping autoimmune disease. Yet both of them publicly express gratitude at their blessings. Both of them have come to terms with their tennis points of compass - Venus  - that Serena is the better player - Serena,  - as Victoria Azarenka has observed, that unlike everyone else rather than wanting to win, - just refuses to lose! 

They are moneyed winners who have overcome adversity and Serena shows unbelievable guts and tenacity having won 10 of 11 grand slam matches when she was a set down. They operate on a world stage and as Americans they have dominated for 15 years. 

THE AMERICAN STORY CONTINUES

At the time of writing the story is ongoing. As if scripted, Serena, in the quarter finals, beat her only realistic competition, 35 year old Venus, in this the 2015 US Open. She did this after losing the second set to Venus, 6 -1. The two hugged endearingly at the net after the match played to a packed crowd in the crucible of the Arthur Ashe stadium. Donald Trump having been bumped off the media focus by Serena, also as if scripted, arrived to watch the Serena  - Venus quarter final. Donald also is a quintessential New Yorker and why shouldn’t he bask in the Williams’ limelight, especially as he is running for President?  Maybe he is a tennis fan? This all adds up to be show business which is makes zany America tick. And New York, where The Donald is unlikely to garner too many votes, included him in on the night that belonged to them.The drama is being enacted in the stadium where the Williams sisters love to play, in their own American Open which is their favorite tournament where they are embraced by all Americans - as everyone witnesses the Great American Dream come true. If the masses needed any assurance that the Dream was not a myth they are once again being reminded by the fairy tale story of the Williams’ playing out before their very eyes. 

Serena is the leading lady in a sensational heart tugging story that whichever way it ends the ending has been declared happy. To join in the metaphorical madness she has two more mountains to climb in her seven step journey to history. The nation watches stroke by stroke to the beat  of the commentaries of icons of former years, John McEnroe, (how can anyone not take it all in when the maven McEnroe tells you how privileged he is to watch Federer again), and Chris Evert  both of whom are willing history on. To keep in the idiom just watch when Serena crowns her achievement on Saturday. The very private Steffi Graf, now an American citizen, will be persuaded, if she hasn’t been already, to present Serena the trophy and we will all go ballistic because we will know that all is well in the USA and therefore the world…..

And finally if Serena wins the Founding Fathers will at last have something to celebrate ............

BREAST CANCER MAMMOGRAPHY - WHY THE CHAOS?

Women have to be confused with the plethora of papers that seem to question the value of mammography as a screening technique in symptomless patients and those not at increased risk for breast malignancy. While there seems to be very little controversy over the management of clinically detected breast cancers there is a continuos swirling debate around preventative mammograms that gets more and more intense every day. Ductal Carcinoma in Situ, (DCIS), where the cancer cells are limited to the breast ducts and not in the breast tissue, and which entity is predominantly diagnosed by mammography, is the most recent breast disease to have its management strongly challenged. How can this all be? Surely scientific medicine has certainty?

HOW DO DOCTORS DECIDE TREATMENT?

To understand it all one has to analyze how medical knowledge is obtained and how the discipline of medicine decides on treatment options. Some therapeutic choices in the not so distant past such as blood letting and leeches were based on belief and nothing else. One would dearly like to believe that medicine has progressed beyond that, which it has, but it has not nearly the scientific precision that some of its practitioners pretend it has. The dream that Flexner had when he revolutionized the study, practice and education of medicine has not fully materialized. His report, which had the imprimatur of the American Medical Association, was published at the turn of the twentieth century and had as its objective to make medicine a purely scientific discipline. To effect this he had the medical schools that had no scientific emphasis to medicine shut down. The reformer never took into account the variables of doctor and patient that go into defining disease and its management. 

EMPIRICAL DIAGNOSES

So to return to what predicates medical decisions. A large number of treatments, especially surgical, are pragmatic and commonsense. These are deemed to be empirical and have not been subject to rigorous scientific assessment. For example, the field surgeons in war learned pretty fast if you didn’t amputate a highly compromised limb, gangrene would set in and result in death. So that is what they did with no scientific trials to prove them right. That principle holds to this day although with modern medicine and anesthesia one can battle more successfully to save many limbs. Likewise surgeons did not have to stand around and watch too many appendices burst with subsequent death to realize that removal of the appendix was the way to go with symptoms and signs of that condition. 

Other medical disciplines also got the message through observation or obvious commonsense. Anesthesiologists didn’t need too much cajoling to use chloroform as opposed to alcohol and holding the patient down in surgery. The penny dropped in obstetrics when they finally put two and two together noting that puerperal sepsis was occurring in mothers that delivered in the hospitals and not in the community. Semellweis who made this observation linked it to hand washing. He was spurned by his colleagues as he had no scientific basis for his theory but he was proved right. 

But not all instances of empirical, intuitive and commonsense approaches turn out to be correct.

LIMITATION OF INTUITION, COMMONSENSE AND EMPIRICAL MANAGMENT IN TREATMENT SELECTION.

Two examples where practical commonsense and intuition have failed dramatically in management options relate to the prevention of coronary heart disease. Working on the assumption that women do not suffer from Coronary Heart Disease till their menopause men were given female hormones as a prophylaxis with disastrous results. Likewise it was the conventional wisdom that females after menopause should be put on supplemental hormonal therapy as they would be cardiac protective and decrease cancers. After years of comparative research studies the consensus was that coronary artery heart disease, breast cancer, stokes and thrombotic events were all increased. So intuition and logic is not enough to advocate a medical treatment. 

So we see that empirical treatment plays a big role in medical management. However except in obvious situations the empirical hypothesis needs scientific evaluation otherwise the outcome cannot only be of not be any use it can do harm.

The two commonest ways to scientifically evaluate an empirical management or any hypothesis for that matter is either by an observational trial to see outcome of treatment over a long period of time or a comparative study to compare the new management with either nothing or another established approach. There are several variations to these two types of research and this is not the place to discuss them other than to state that the more rigorous the study is the more reliable the result. 

THE ROLE OF MAMMOGRAPHY IN THE PREVENTION OF BREAST CANCER AND HOW WE GOT THERE.

Let us look at the current controversies on breast cancer management and see how we got there. Breast cancer is the commonest female cancer occurring in one in eight women during their life time with over two hundred and thirty thousand women diagnosed each year. Even today empirical intuitive treatment still plays a major role in management decisions and this to a certain extent has created the dilemma that has occurred in the recommendations for mammogram screening and treatment of DCIS. 

Introduction of Mammography.

Mammography is a relatively new concept that was introduced in the 1960’s. It was based on the logical assumption that if one was able to diagnose breast cancer, early, before it became clinically evident, then one would be able to treat it earlier and thereby prevent the spread of the cancer and therefore death. The introduction of routine screening of women throughout the world has been tremendously successful with in some areas nearly an eighty percent success rate. This tour de force has coincided with the introduction of more and more sophisticated and powerful mammography of the breast tissue. Like so many medical interventions the compelling nature of the rationale of the approach resulted in wholesale adoption before scientific evaluation had taken place. Not only was the actual concept not assayed neither was the sophisticated technology, with the latest being the 3 - D mammogram, evaluated as to its impact on the disease. The more sophisticated the screening technique the higher the detection rate of cancer or DCIS.

Evaluation of  Screening Mammography.

The impact and outcome of mammography screening has now been extensively and scientifically evaluated. The results have been to put it kindly, disappointing. The number of breast cancers diagnosed have increased but the number of deaths from the disease have almost remained constant. The Cochrane Collaborative Group, which is the most prestigious group for evidence based medicine maintains that there is no quality evidence that mammography has decreased the death rate from breast cancer. They have taken their argument one step further and maintained that it is uncertain whether the screening does more good then harm.

Four types of cancer types have been recognized:

1. Slow growing so even if detected late does not impact outcome.
2. Fast growing so that even if detected early it cannot influence outcome.
3. Cancers that are so slow growing that should be left as patients will die with them.
4. A small number of cancers detected that benefit from earlier detection and treatment. 

It appears that there is a positive impact of screening mammography in the age group of women between 50 and 74 years of age where cancers are detected that will benefit by early treatment.  In a review article in Medscape in 2009 it was cited that mammograms in the age group between 50 to 74 would save 1.8 lives of a 1000 women screened over a period of 15 years. The Canadian Task Force had similar results starting that screening 720 women for 11 years would prevent 1 breast cancer. 

That respected Cochrane research group stated that if screening mammography started at 40 years of age, 50,000 women would need mammography over 15 years to save one life at an additional projected financial cost of $6.5 billion. 

Risks of Mammography Screening

Assuming the Cochrane group is more or less on the money and cost isn’t taken into consideration, why wouldn’t society want to save one life in 50,000 screened over more than a decade? It boils down to the risks. David Newman in his book “Hippocrates Shadow” argued that, on balance, the mass screening produces cancer phobia and unnecessary surgery and treatment. The anxiety and even panic that mass screening produces is immeasurable but a constant as any practitioner will relate. However there are a number of measurable side effects such as false positives, over diagnosis and radiation.

1. Over diagnosis is rated as the biggest hazard of mass screening. In effect this relates to operating on patients that do not need surgery. The number in this category varies according to the study but in 2012 the UK Cancer Research Group stated that 1 in 5 breast cancer cases were over diagnosed. A much higher figure, one in three, was quoted in s study published in the British Medical Journal in 2009. Analysis was from several countries including the UK, Canada, Australia and Sweden. The American Cancer Society rates the figure between 0% to 30%.
2. False positive results occur when the initial mammography screening results indicate a cancer and further tests such as a biopsy prove them wrong. According to the American Cancer Society that of the ten percent of women who are diagnosed as positive on mammography a half to three quarters have not got the condition on further testing. This results in unnecessary anxiety and expense all over the whole board. 

3. Radiation is really a big cancer risk in the younger patients. Above 50 years it is minuscule. 

MAMMOGRAPHY SCREENING AT THE END OF THE DAY

There appears to be a consensus that mammography is most cost effective when performed every second year in women between ages 50 to 74. The US Preventive Services Task Force, (USPSTF), are in line with this approach but this is such a hot political potato that Congress overrode their 2009 recommendation insisting that insurance companies pay for annual screenings from forty till death. As a public health economic issue the cost with 70% of eligible women participating is $7.8 billion per year. If the target 85% screening rate would have been achieved the tab would have been $10.1 billion. (Annals of Internal Medicine 02/04/14).

Several studies lead the USPSTF in 2009 to change their recommendation as to who  should be screened and how often. Their principal recommendation was for screening for women between ages 50 to 74 every second year. This would bring down the cost to $3.5 billion a year. Bearing in mind that 50,000 women over 40 years of age screened annually will save one life but leave in its wake all the morbidity and even possible mortality that are adverse effects of the screening must surely make the medical world and the Public Health authorities relook at the current strategy of routine annual screening of all women over 40 years of age.The additional cost of including the 40 to 50 year old sector is $6.5 billion.

MAMMOGRAPHY’S DISEASE - DUCTAL CARCINOMA IN SITU. (DCIS)

With the introduction of routine mammography screening a new disease DCIS was defined. The latter rarely presented as a clinical entity. Put another way, in by far the majority of cases there is no mass in the breast, no nipple discharge or skin changes so without routine mammography the diagnosis of DCIS would not have been made. The irresistible inference was that DCIS, where the cancer cells are just in the ducts and not in the breast tissue, was the precursor to invasive carcinoma. With more and more sophisticated technology being developed the diagnosis was made more and more often. About 60,000 cases were diagnosed in 2014. The treatment of DCIS is essentially the same is Stage 1 invasive carcinoma. That includes lumpectomy, (removal of the area where DCIS is with wide margins), mastectomy, radiotherapy with or without lumpectomy or unilateral or bilateral mastectomy. This is pretty radical treatment to institute on the basis of “intuition”.  

Now the radiologists make this diagnosis on the basis usually of patterns of calcification. As there is no mass in the breast the most efficient way to do the biopsy to confirm DCIS is by stereotactic core needle biopsy. The latter uses x-ray equipment and a computer to analyze pictures of the breast. The computer then pinpoints exactly where in the abnormal area the needle tip needs to go - a complex and costly procedure. Up to three quarters of biopsies are negative.

MAIN FINDINGS OF RECENT DCIS STUDY.

With the scientific studies now emerging the intuition on DCIS has been challenged in a number of areas. A major study published in the Oncology Journal of the American Medical Association involved the follow up of over a 108,000 women who had been diagnosed and treated for DCIS. The follow up was for 10 to 20 years and yielded many important findings: (Whether these will change doctor or patient behavior is another matter). 

1. Regardless of the management of DCIS, which ranged from bilateral mastectomy to simple lumpectomy with or without the radiation, the outcome was the same.

2. While the risk of death from breast cancer was higher in the DCIS group the significant predictors of mortality were women under the age of thirty five and black ethnicity. The women under thirty five were obviously not diagnosed by screening and must have had clinical indications for the mammogram. The risk of dying was greater at a young age being 17 times greater in women under 35 as compared to 1.4 in those over 65.

3. Prevention of invasive carcinoma in the breast with treatment did not prevent death from breast cancer. However the deaths were due “secondaries” just as if these DCIS were invasive carcinomas to begin with.

DILEMNA ON DCIS

This paper has evoked responses across the board ranging from DCIS must be treated like Stage 1 invasive breast carcinoma, (which for practical purposes it currently is), to it should not be treated at all and just watched with repeated mammograms. Bearing in mind that DCIS has the same prognosis and natural history as invasive carcinoma and treatment of DCIS did not prevent the latter there is a strong argument for the wait and watch approach till if and when the invasive carcinoma presents. This would prevent the vast majority of DCIS patients being treated unnecessarily. Close on sixty thousand women are diagnosed with DCIS and the majority could be being over-treated, at great cost with endless morbidity, as a result. It is apparent as well that there a subgroups with DCIS that must be at more risk than others and while age and ethnicity have been identified studies of those with hereditary predisposition, estrogen receptors status and histology for example need to be evaluated. Surely all workers must agree if this group is to be treated that all radical treatments must be out.

AT THE END OF THE DAY

* The death rate from breast cancer has remained virtually static for decades. What improvement there has been is generally accepted to coincide with a decrease in hormone replacement therapy which had been shown to be a cause of breast cancer. It is thus obvious that all this activity needs a dispassionate review and scientific assessment rather than continuing these visceral judgements in the management and screening of breast cancer.  Society has to decide whether they wish to modify the criteria for these costly and radical treatments that show little benefit and high adverse effects. 

* The problem is that standing in the way of the rethink is doctor and patient behavior - two variables that are never taken into account yet it is doctor bias that has got into this mess in the first place. The medical profession now sanctimoniously argues that the pros and cons of treatment should be discussed with the patient so they can make an informed choice in situations they probably would not have been in if there had been the appropriate studies in the first place. On the other hand patients don’t see the necessity of scientific studies either if they are persuaded by the “logic” of the treatment. When, in 2009, the USPSTF made its recommended changes for routine mammogram screening at the age of 50 years there was an outcry second to none. The US Congress had to step in and decree that medical insurance companies regard 40 years as the age that would recognize and pay for.  Society swallows buckets of pills, with only anecdotal evidence of efficacy, that they intuitively believe will help. Recently pressure groups even influenced the FDA, society’s gatekeeper to keep science in medicine, to reverse their decision to register a medicine that supposedly increases a female’s libido. In studies the medicine has shown doubtful effectiveness coupled with unacceptable side effects and its registration had twice been denied by the FDA. 

* Costs do matter. If one recognizes that Planned Parenthood that performs over 10 million women services per year do so at a  cost of about $200,000,000 then $6.5 billion is a lot of money. They perform 10 million services and a million of those are for breast and cervical cancer testing that otherwise would not be done. They diagnosed 85,000 cancers, provided 4 million birth control encounters and 2 and a half million sexually transmitted screenings or treatments.

* As far as mammograms are concerned the US Preventive Services Task Force’s recommendations on mammography which include routine screening of symptomless between 50 and 70 years of age should be reconsidered. With regard to DCIS found on screening a study needs to be designed to evaluate the difference between watchful waiting with repeated mammograms versus lumpectomy versus lumpectomy and radiation. 

To quote Dianne Rehm on her influential Public Radio morning show, where she was trying to make head or tail of the experts’ opinions on the recent DCIS study, that should she be diagnosed with the DCIS at this stage of her life she would do nothing.