This seems like as good a day as any to write about the PP/Komen controversy (Komtroversy?). And it seems like a reasonable place to start is agenda-setting theory, riffing on Michael Reich’s riff on Kingdon’s agenda-setting streams. My basic understanding is this as follows. Kingdon identifies three agenda-setting streams: problems, policy, and politics. The political stream includes events, opinions and symbols to which problems can be attached or detached by stakeholders to raise or lower the priority of a problem. Reich has identified four currents that run within this stream — organizational, scientific, symbolic, and economic.
As far as I can tell, symbolic and organizational politics have trounced science, with economics being a bit of a wash in setting priorities — or in this case, “winning” a debate.
A basic issue seems to be that the organizations - Susan G. Komen Foundation (SGK) and Planned Parenthood (PP) – have both set themselves up to represent women: Komen by pink-washingeverything in sight (also here) and PP by being a major provider of reproductive health care — and primary care in general. Simplistically, women funding women makes sense; women de-funding women seems bad. Whether one group seems to represent a (toothless? intolerant?) feminist approach while the other has “declined…into a parody of conventional femininity” is another argument – though an important one in teasing out the symbolism of the debate. Still, the women v. women gloss may help explain why this debate seemed more explosive than, e.g., Congress voting to de-fund PP.
The background politics don’t help, namely, the political stances of the head of SGK and SGK in general and the politics of abortion (George Karlin on abortion, fyi). It’s silly to pretend that this “just” became political or that only one side of the political spectrum is responsible for this. It seems that SGK’s CEO has given ample amounts of money to GOP campaigns and that Ari Fleisher was instrumental in the hiring of new head of communications at SGK — and that PP was key in the hiring decision and has been to SGK’s internal politics for some time. It is also true that, as a small set of a wider suite of services, PP (proudly) provides abortions (not with public money, although that is the crux of the federal investigation in question, which itself seems to be a political stunt.)
The reality of the funding seems to be that SGK was always going to honor existing grants through their end-dates (end-2012) but then not take any more applications from PP – or any organization under federal investigation (of which PP was really the only one — this must have seemed like such a good storyline at some meeting). Now, SGK says PP can still apply for funding and have tried toclarify the investigation criterion.
What I really don’t understand is why SGK took the route they did to distance themselves from PP and pro-choice-ness (which does seem to be the underlying intent). Another bizarre approach, which was suggested, would have been for SGK to say that they were going to cut-off PP because they wanted to remain apolitical and opt-out of any abortion debate. Things were already plenty political.
But is unclear if, given a goal of cancer detection, PP is the objectively best place to give money and this seems that it could have been a reasonable argument to make to redirect funding streams. First, the US government no longer endorses clinical breast exams or breast self-exams (or says it is an individual decision) and recommends mammograms for women aged 50 and over. Meanwhile, about 85% of PP’s clients are aged 35 or under. While many organizations (including PP) still support clinical breast exams, from a resource allocation perspective and focusing on mammograms – which PP refers-out to do – it may well make sense for SGK to move funds to organizations providing mammograms directly (and, indeed, this was the second storyline they tried on, though who knows if they will actually reallocate that money to mammogram services). Also, SGK funded less than 5% of clinical breast exams performed by PP over the last 5 years and less than 10% of mammogram referrals in the same period. Not all PP affiliates received SGK money for their services. So, losing SGK money might curb services but it is not going to end breast cancer screening and referral at PP. And, in the backlash of this blow-up, PP has already made up enough money to replace lost SGK funds.
If the goal is not merely breast cancer detection but accessible and affordable primary health care (for women) and ‘saving women’s lives,’ and doing things that are ‘in the best interest of women’ – then giving money to PP or other community health clinics makes sense and SGK pulling their money makes less sense. It is true that a lot of women rely on PP for comprehensive health care.
In part, the problems with symbolism represent a fundamental problem with disease-specific funding streams, especially when they have no obligation to engage in systems-strengthening or capacity-building. However, I suppose, this whole thing also represents the potential dangers of a disease- (or body part)-specific organization engaging with the wider health system — you’ll eventually be pulled into debates about what health and health care should entail and you’ll have to be ready to deal with them.
I’d be curious:
- based on what we know about breast cancer detection, should money (in general) go to clinical breast exams? that is, is scientific recommendation being trounced by symbolism in this case?
- should we – and how should we – be moving away from disease- and body-part-specific funding? is it different for funding research versus funding screening/care?
(update: 13 Feb, speaking of symbolism)