New York City

Sheryl McCarthy, in “Behind the Abortion Color Line” [April 27], is correct that women who cannot get effective, affordable birth control are more likely to have unintended pregnancies and abortions. Most women will spend about thirty years trying to prevent pregnancy, making contraception a critical component of healthcare. In my practice, women tell me every day that they cannot afford birth control; nor can they afford to miss work to wait all day for free supplies. Is it so surprising that nearly half of US pregnancies are unplanned, with little change over decades?

We physicians need to do our part: medical education must improve to enable honest conversations between doctors and patients. Few physicians receive comprehensive training about birth control–as little as one lecture in medical school. Medical schools and residency programs should increase evidence-based training about the range of contraceptives available and how to discuss sexuality with patients.

The wider public also needs to learn about the benefits and risks of contraception. The benefits of contraception far outweigh the risks, especially compared with the risks of pregnancy and childbirth. McCarthy highlights the side effects of hormonal contraception; women should also know that hormonal contraception prevents ovarian and uterine cancer, and improves acne and menstrual cramping. Some women have trouble with one contraceptive but are able to use another. I’ve helped hundreds of women find birth control that works for them, whether IUD, pill, patch, ring, injection, implant or tubal ligation.

Of course, education alone won’t prevent unintended pregnancies–economic factors and lack of health insurance also contribute to the problem. But widespread knowledge about contraceptive options–among patients and physicians–would be a step in the right direction.

ANNE DAVIS, MD, MPH, medical director Physicians for Reproductive Choice & Health

Healthcare: Radical Reform Needed

Baltimore

I was a member of the Health Care Reform Task Force in the Clinton White House, and I have difficulty accepting that the reform proposal failed because it was too radical, as Lester Feder claims in “Fighting for Our Health” [April 27]. In my book The Politics of Health Policy, I present a long list of reasons the reform failed. Feder’s reason is not on that list. Far from being too radical, the proposal was much too accommodating to the health insurance industry; it did not dare to confront it. Grassroots Democrats, already disappointed and angry about President Clinton’s approval of NAFTA, could not be mobilized to support the reform proposal.

Without a clear mobilization in the country, such as we saw in the civil rights era, we are not going to see true healthcare reform. Feder’s recommendations to give more money for technology and research (to investigate how doctors can practice better and more cheaply) and to subsidize premiums for those who cannot pay are exceedingly unambitious. They don’t even come close to the root of the problem: the enormous power of the insurance-medical-industrial complex.

VINCENT NAVARRO, MD, PhD Professor of health policy The Johns Hopkins Medical Institutions

Health ‘Insurance’: What Is It Good For?

Washington, D.C.

Kate Michelman, in “A System From Hell” [April 27], asks “if ‘health insurance’ does not pay for healthcare when people need it, then what exactly do those words mean?” Indeed, our healthcare system is a relic of another era. Insurance is designed to cover risk, not certainty. Fall off your horse and need a doctor to set your arm; get struck down with smallpox and need a doctor to treat you–in both cases, the need for care (and therefore coverage) could not be predicted or anticipated. That is the nature of insurance. However, modern medicine deals in large measure with chronic conditions and preventive care, neither of which fits the antiquated “insurance” model. So when a health insurance company knows for sure that you will need care, it withdraws it on the grounds that it is no longer covering risk. That is a perfectly logical system, but it is tragically obsolete.

MICHAEL McCARTHY

Consumer Society Healthcare?

Fort Bragg, Calif.

Why is it that virtually every discussion of healthcare speaks of “insurance,” of “coverage”–universal or otherwise? Is this another of the perversions of the “consumer society,” the “market economy” that is disintegrating before our eyes? Gone, it seems, is the intrinsic goal of healthcare–to provide ways and means to foster a level of health quality that will permit our citizens to live productive and satisfying lives.

With the energy and funds we expend on balance-sheet accounting we could immensely expand and improve services that prevent diseases; that strengthen infant, child and family health; that implement individual and community health education; that stimulate biomedical research and technological innovation. A bottom-line mentality is antithetical to human health values.

HOWARD ENNES

TVA: Cool Clear Water?

Knoxville, Tenn.

Kelly Hearn’s April 20 “Tennessee’s Dirty Data,” about Tennessee Valley Authority water sampling after the coal ash spill at a TVA power plant, plays to people’s fears using uninformed speculation. Certified results consistently show public and private drinking water supplies in the vicinity meet state and federal health standards.

The five sampling locations Hearn characterizes as evidence of an attempt to manipulate sampling are floating stations positioned to monitor turbidity from dredging. They are one small part of the comprehensive water-quality monitoring program. Hearn’s misinformed speculation could have been avoided had he asked TVA.

The TVA has sought since the spill occurred to ensure that air, water and soil samples are representative of environmental conditions and are analyzed by certified laboratories. These monitoring networks were reviewed and approved by the US Environmental Protection Agency and state officials to ensure comprehensive, representative sampling.

To date, TVA and the Tennessee Department of Conservation and Environment have collected more than 800 river water samples, and the sampling continues at a rate of fifty to sixty per week. All samples are analyzed by the state health department or certified independent laboratories. In addition, the state has analyzed more than 100 samples from private wells.

TVA stands by the integrity of the sampling and testing performed at the spill site. The data are posted at tva.com along with detailed information about the recovery project. Our primary commitment is to protect the health and safety of the public and our employees, who work and live in the community. We are fulfilling that commitment through certified professional environmental monitoring conducted with oversight from state, local and federal officials.

ANDA RAY, senior vice president Office of Environment & Research Tennessee Valley Authority

Hearn Replies

Buenos Aires

It is not true that I failed to ask TVA about the water-testing sites listed in the dredging permit. I did, and I documented as much in an e-mail to Gil Francis, a TVA spokesman. I told Francis that experts were basing their criticisms of TVA’s water-contamination data in part on the five sampling sites listed in the dredging application. TVA had ample opportunity to respond to my statements and queries or to clarify any misinterpretation.

Rewinding a bit, The Nation made a request in February to see the GPS coordinates for water-quality testing sites. That request was met only recently, after my article was published. In its letter, TVA still refuses to make sense of why its sampling produces “safe” results while third-party sampling finds extremely toxic levels of arsenic and other metals.

KELLY HEARN

A Day That Does Not Live in Infamy

Matinicus, Me.

Thomas J. Sugrue, in his review of two biographies of Franklin Roosevelt [“The Hundred Days War,” April 27], says that FDR “repealed Prohibition.” As strong as his desire may have been to do that, Roosevelt lacked the authority. Repeal was effected by the passage of the Twenty-first Amendment, on December 5, 1933.

BILL HOADLEY

Clarification

Katha Pollitt says in her May 18 “Subject to Debate” column that Douglas Feith is a visiting scholar at the Belfer Center of Harvard’s Kennedy School of Government. He is an adjunct visiting scholar.