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The Reality of War

Brian Mockenhaupt’s “The Last Patrol” (November Atlantic) clearly conveys the futility and waste of U.S. efforts in Afghanistan. Focusing just on the people we send there in infantry positions, one sees a sickening toll on these troops’ bodies and minds from fighting a so-called U.S. enemy while hampered by political limitations on military engagement. The Taliban fighters have no such limitations.

Repeatedly putting troops in frontline situations with inadequate preparation, supplies, and support and nonsensical rules of engagement constitutes heinous behavior on the part of our political and military leaders. What are they thinking when they expend the lives and mangle the bodies of the young men who carry out such infantry patrols?

I knew the situation in Afghanistan was bad, but I did not realize it was so intractable for the infantry soldiers. My heart goes out to them and to their families.

Michael L. Wood
Atlanta, Ga.

Brian Mockenhaupt’s article about the soldiers in C Company of 2-508 was superb. I received it from a friend with whom I’d been deployed out of Fort Lewis for a couple years back in ’06–07. The cold emotion of entering combat that the writer conveyed, which is oh so familiar, took me back to a place I had left three years ago. For a while after you leave combat, you forget about the reality of war. Sometimes, someone like Mockenhaupt brings it all back for us.

Chuck Rogers
Naperville, Ill.

How to Evaluate Medical Research

We applaud David H. Freedman’s “Lies, Damned Lies, and Medical Science” (November Atlantic), having long been admirers of professor John Ioannidis. We too evaluate medical evidence and train physicians and others in how to analyze studies for reliability and clinical usefulness. However, we believe the problem is larger, and the consequences of applying the results of misleading science more deleterious, than implied.

Low-quality science significantly contributes to lost care opportunities, illness burden, and mortality. For instance, in the 1980s, observational studies “reported” dramatic tumor shrinkage and reduced mortality in women with advanced breast cancer who were treated with high-dose chemotherapy and autologous bone-marrow transplant. But these studies are highly prone to bias; valid randomized controlled trials are required to prove efficacy of therapies. More than 30,000 women underwent these procedures before randomized controlled trials showed greater adverse events and mortality. And we believe less than 10 percent of such trials are reliable.

Individual biases have been shown to greatly distort study results, frequently in favor of the new treatment being studied. Yet few health-care professionals know the importance of bias in studies, or the basics of identifying it, and so are at high risk of being misled. In an informal tally, roughly 70 percent of physicians fail our basic test for critical appraisal, which should be a foundational discipline for all health-care professionals.

Sheri Ann Strite
Michael E. Stuart, M.D.
Delfini Group
Seattle, Wash.

David H. Freedman states, “Much of what medical researchers conclude in their studies is misleading, exaggerated, or flat-out wrong.” This inflammatory lead-in, and the article itself, are dangerously specious.

Freedman centers on John Ioannidis, whose principal research tool is meta-analysis. This method, Ioannidis claims, has uncovered widespread flaws in all types of clinical research. Freedman fails to mention, however, that meta-analysis itself has major problems, and is not accepted as a rigorous method of analysis by many leading statisticians. A major prob­lem is the pooling of data from different sources, which include different populations, ways of conducting clinical trials, and ways of appraising the results. This heterogeneous pool of information is blended into a statistical mayonnaise of strong studies and weak studies, for an analysis that is often impossible to evaluate with any degree of certainty. Ioannidis may claim to have mathematical methods that can account for these differences, but there will always remain doubts that he can deal with the inherent problems of meta-analysis.

The devastating consequences of untreated hypertension, the connection between type 2 diabetes and obesity, the prognosis of certain death in childhood leukemia, and poor survival in HIV/AIDS are just a few problems we no longer face because of high-quality clinical research. None of these achievements, or any others, were mentioned by Freedman, who went on a cherry-picking expedition in a field he doesn’t seem to understand.

Robert Schwartz, M.D.
Boston, Mass.

David H. Freedman replies:

Robert Schwartz has a right to consider my article inflammatory, but he offers no evidence that any of it is wrong, let alone specious. What’s more, he seems oblivious to the trap that anyone who tries to dismiss John Ioannidis’s work immediately falls into: if we are to maintain such a high regard for prominently published research findings, then we must take Ioannidis’s findings seriously, because they are prominently published; and if his work is negated by methodological flaws, then those same flaws negate most published findings. Ioannidis’s work is in fact frequently cited and even lauded by medical researchers of all stripes, including—contrary to what Schwartz implies—statisticians, with relatively few objections. The medical community should indeed be esteemed for its successes with the disorders Schwartz mentions. Tragically, there would not be space in this entire magazine to list the disorders that continue to plague us.

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