Gap Politics

Breast Cancer

Germania Irredenta

Advice & Consent

Re Steven Stark's "Gap Politics," (July Atlantic): I know of no conclusive historical evidence that "this country long defined its politics by sex far more than did other industrialized nations." But this is a catchy way to open a paragraph. Most of the other "firsts" or sweeping generalizations Stark provides are equally questionable as interpretation or fact. The "first recorded gender gap" in this country probably showed up during early sessions of the Continental Congress, when Abigail Adams's much quoted 1776 appeal to John Adams to "Remember the Ladies" (referring to the lack of rights of married women) and Hanna Lee Corbin's 1777 request to her brother Richard Henry Lee to support voting rights for tax-paying widows were both ignored by those two founders -- and no doubt by all others at the time.

Most important, the Equal Rights Amendment was lost in part owing to the tactical and logistic ineptness of the National Organization for Women but primarily owing to the conservative backlash that set in after the 1973 Paris peace accords. Like previous reform movements in postwar periods, the women's and civil-rights movements could not counter this general backlash. Failure to pass the ERA had little to do with the "anti-majoritarian" aspects of the national legislation that Congress passed under the influence of an eastern-corridor group of female reformers. Likewise, "upper-middle-class activists" were not exclusively focused on abortion before or after Roe v. Wade, for the simple reason that they were the very women who had been able to obtain safe illegal abortions before 1973. Wages and child care were not slighted because of an overemphasis on abortion by liberal women (granted, conservative women overemphasized it), as can be seen in the impressive pieces of economic, civil-rights, and child-care legislation passed by Congress beginning in 1963 and continuing through the 1970s, to say nothing of Supreme Court decisions before and after Roe favoring women's economic equality -- cases often argued and won by feminist attorneys. The first and most numerous cases brought by the Equal Employment Opportunity Commission involving women since the early 1970s have concerned wage discrimination, and both political parties supported quality day care in the 1972 election (even Richard Nixon's unsuccessful welfare-reform bills included federally funded child-care facilities).

Women continue to be disadvantaged in the United States, while men, despite their misplaced anger at affirmative action, continue to be privileged -- in all race and class categories. Disadvantaged people always hold views that differ from those of the privileged, however complicitous their behavior may appear. Although the men's movement in the United States is mentioned only in the last paragraph, the entire article is based on thinly disguised masculine cultural theory.

Joan Hoff

Steven Stark's article about gender politics is thought-provoking, though readers should keep a few things in mind.

1) In the 1994 congressional elections, in which Stark suggests the gap was pronounced, 57 percent of men voted Republican, as compared with 46 percent of women. This does sound like a large disparity, and it is larger than what has occurred before. Nonetheless, let's look at the numbers from the other side: 46 percent of the female population voted Republican, along with the majority of men.

2) Over the years voting preferences have followed economic status much more than gender, and I would argue that it is that trend we now see displayed in the growing gap between men's and women's voting preferences. The more women become (or perceive they have become) members of the underclass, the poverty class, or simply the lower-income working class, the more likely they are to vote Democratic.

3) The reported "white male revolt" is more white than it is male. The black-white gap in voting behavior is huge. Republican candidates never even get into two-figure percentages with black voters. Appreciation for the role of government and adherence to the Democratic Party are nearly monolithic in the black political community. If and when the black-white voting gap closes to the current 22 percent gender gap that Stark points to with dismay, there will be jubilation in the streets! Pundits will crow about how far we've come and how close we finally are in the reconciliation of the races.

In short, the gender wars are not here, though the media and political consultants dearly wish it so. Most women vote like most men on most issues.

Joan Adams

Joan Adams makes a good point: More men and women vote alike than vote differently, and the economic-status and racial gaps are far larger than the ones between the sexes. What makes the recent gender gap different and interesting is that its rise was unforeseen, and it seems to be far more important to our current political debate and the two parties' agendas than the numbers themselves might indicate. This may have the odd effect, as I pointed out in the piece, of widening the gap in coming years and ironically benefiting the "male party" -- the Republicans.

I am sorry that The Atlantic published David Plotkin's article "Good News and Bad News About Breast Cancer" (June Atlantic). Disseminating this type of biased polemic in a lay periodical has the potential to misinform thousands of women whose health and in some cases lives will be jeopardized.

The vast majority of the increase in breast-cancer incidence relates to an aging population and mammographic technology. The number of menstrual periods that women experienced prior to the Industrial Revolution is unknown. What is clear, however, is that a contemporary woman will live longer than a medieval one did, on a statistical basis, by approximately forty years, and this clearly has more to do with her risk, menstruating or not.

The proportion of highly aggressive as opposed to slow-growing, less aggressive breast cancers being detected has not changed because of menstrual activity. Most important, the aggressive carcinomas have not disproportionately diminished in number, so this does not explain the relatively better current cancer survival rate. However, the size of breast cancers has changed, most dramatically on the basis of mammography. When I started practice, in San Francisco in 1972, the average size of an invasive breast cancer was 30 mm (1.2 inches). By 1994 the average size of an invasive breast cancer was 14 mm, and of one detected mammographically 11 mm (about two fifths of an inch).

In 1972, 40 percent of women with invasive breast cancer suffered a recurrence or died of their disease within five years, whereas of the patients with mammographically detected 11 mm invasive breast cancers, only 10 percent will have suffered a recurrence within five years. Most of those who die of breast cancer remain older women, who are reluctant to have breast examination or mammography, and who present with much larger cancers at higher stages. In my present practice, with a population with an average age of sixty-nine, the average size of invasive breast cancer is 28 mm -- not significantly different from what it was a quarter century ago in the same city.

Dr. Plotkin's comments suggest that pathologic grading of invasive carcinomas is imprecise and subject to a great deal of inter-observer variability. This is not the case. A standardized system of grading of invasive breast carcinomas has been available since 1970. This system is simple to use and highly reproducible. The grade established by this system more accurately reflects disease-free survival than does the receptor status (the measure of estrogen- and pro-
gesterone-receptor protein in the carcinoma). One of the senior investigators in a clinical trial in which Plotkin participated (B. Fisher) noted little difference between estrogen-receptor-positive and -negative status and outcome (Fisher et al., 1986). Not a few high-grade (aggressive, poorly differentiated) invasive carcinomas are estrogen-receptor-positive and still grow quite rapidly.

Plotkin expends considerable effort trying to impugn the now widely accepted benefits of screening mammography. Virtually every study has shown a significant reduction in breast-cancer mortality among the women screened, and the most recent data indicate a similar benefit for younger women (forty to forty-nine). These recent data will require the National Cancer Institute to revise, yet again, its recommendations regarding the interval between mammographic examinations. "Lead-time bias" implies that a woman whose breast cancer is detected mammographically years prior to its possible clinical detection would have the same eventual mortality. In fact, as numerous trials of screening mammography and also my own personal experience testify, this is not the case. A cancer detected at 11 mm is associated with a very different outcome at ten years than a cancer of the same specific type 30 mm in size. Although recurrences will continue after ten years for the 11 mm cancers, they are less frequent than among 30 mm cancers. Clinical trials to test the efficacy of mammography have as their end point a reduction in breast-cancer mortality. To call the Kopparberg trial bootless because the lives saved from breast-cancer mortality were offset by cardiac disease is absurd.

Michael D. Lagios, M.D.

I and other members of the Women's Health and the Environment Network (WHEN) were glad to see your June cover article on breast cancer. However, when David Plotkin discussed "the change in women's hormonal environment," he talked about it strictly in terms of lifestyle changes, such as delayed and fewer pregnancies, and women in the work force.

Dr. Plotkin left out what many of us believe to be the biggest change in our hormonal environment -- the huge increase in hormonally active synthetic chemicals in our environment. These chemicals mimic estrogen or alter the way the body processes its own estrogen. These environmental estrogens are adding to the total estrogen load we carry and pass on to our children. Many now suspect that these chemicals are among the causes of increased rates of breast cancer (and of reduced sperm counts and other problems).

Catherine Miller

I am extremely disappointed by The Atlantic's publication of an inflammatory and misleading article on breast cancer. David Plotkin has taken some very complex and contentious issues and put the most negative spin on them possible. Let me take just one example among many -- his paragraph on radiation therapy. Modern-day techniques do not result in tissues that feel "thick, hard, even wooden -- a strange, unpleasant sensation." Plotkin also states that radiation may promote lung cancer in the irradiated side of the body. What is missing is any recognition of the very positive data available on current radiation techniques and of long-term follow-up studies that show no increased risk of cancer in women treated with breast irradiation. A very frightening message has needlessly been sent to any women contemplating breast conservation (and therefore radiation therapy). In many other ways Dr. Plotkin casts current management strategies, whether of screening or of treatment, in a light suggesting that they are either worthless or harmful. At a time when patients' trust in the medical field is challenged from so many directions, this message is particularly harmful.

Lynn C. Hartmann, M.D

The huge increase in life expectancy since the Industrial Revolution is attributable largely to agro-industrial and public-health advances. Getting rid of puerpual sepsis flipped the men-to-women ratio of 100 to 95 seen early in this century. A tremendous reduction in infant deaths was the single largest factor in increasing the length of the average life.

The average doubling time of mammographically discovered breast cancer is greater than 260 days -- about three times as long as the average doubling time of metastatic breast cancer. This fact alone can account for the improvement in the five-year survival rate, with the number of deaths per 100,000, age-adjusted, staying remarkably stable.

The widely accepted benefits of screening mammography are based on only two randomized trials, both conducted twenty-five to thirty years ago and both very possibly flawed. The inability of a more modern randomized trial to confirm even the purported small decrease in mortality reported by these old trials justifies skepticism.

When Michael Lagios says that a group of women with tumors 11 mm in diameter has a better five- or even ten-year survival rate than a group with 30 mm tumors, he is supporting the influence of lead-time bias. If the proliferative rate in the 11 mm group is slower than that in the 30 mm group, the longer-term mortality will also be better. Omitting measurements of proliferative rate from the analysis of primary breast tumors introduces the likelihood of test and control groups that are not equivalent. In the old randomized trials we did not have such readily available technology. Today we are able to conduct trials in which apples are truly compared with apples.

If, as Catherine Miller asserts, a "huge increase in hormonally active synthetic chemicals in our environment" has occurred, Idon't see the evidence. The use of postmenopausal estrogen-replacement therapy is the one clear change in the lives of women, aside from the much expanded period of fecundity.

I believe that the excessively prolonged action of "normal"estrogen on breast tissue is far more strongly implicated in the rising incidence of breast cancer than synthetic estrogenic toxins, whose presence is relatively minor. Women menstruate until their ovaries stop making estrogen. Only if estrogen-replacement therapy is prescribed do they resume menstruating. If the toxins are playing a role, it must be very small.

Lynn Hartmann, like other radiologists and radiation therapists of years past, wants to play down the toxicity of radiation. The advocates of radical surgery, now largely in the past, and the current promoters of aggressive cancer chemotherapy tend not to want to acknowledge the deleterious effects of the treatment provided by their specialty. In the past, relatively few long-term survivors of cancer received radiation therapy as a primary treatment. Those patients had radiated tissues that, when I encountered them, felt quite abnormal to me. Obviously, the majority of patients treated with radiation therapy fifty to twenty-five years ago died of the cancer or some other illness before the long-term effects of radiation could be assessed. With the more widespread use of radiation therapy in large numbers of patients with acute leukemia, Hodgkins disease, testicular cancer, and slow-growing breast cancers, we will see more long-term complications of radiation therapy. Some acknowledgment of this should be given to patients who are making treatment decisions.

Hans Koning's article "Germania Irredenta" (July Atlantic) deserves an answer from someone who, even fifty-one years after the capitulation of the German Wehrmacht, considers himself a Reichsdeutscher, a Reich German.

Koning's last three paragraphs show the illusions under which those whom I call the "anti-Germans" suffer: they try to obfuscate a matter of realpolitik with an emotional issue that will have absolutely no impact on the future development of the issue -- namely, the return to Germany of ancient German territory.

There is no reason why a German of East Prussian ancestry who was born in the West should feel animosity toward Russians living in his parents' home in Königsberg right now. Certainly these Russians bear no responsibility for the fact that the Königsberg Germans were driven out or murdered in 1945. The same goes for the Poles now living in Breslau, and the Czechs in Eger.

Königsberg was founded by the Germans in 1255 A.D.; the beautiful city hall of Breslau was built by its German population in the fourteenth century; and Eger has been an integral part of the Reich (up to 1919) since about the year 1000 A.D. I mention these facts only to show that the German Eastern territories were not just recent acquisitions, as are Hawaii by the United States and Chechnya by Russia.

Will the Sudetenland, Silesia, Pomerania, and East Prussia become German again? I would say yes. Koning believes that the Germans ought to consider 1945 a clean slate, and forget everything that went before. Such a view is unrealistic and even ahistorical. The real obstacle to the return to rightful borders in East-Central Europe is first and foremost the United States, and then the governments of England, France, and Bonn.

Koning put much emphasis on the facts that in 1945 many millions of East Germans were removed from their ancestral homes (one of the greatest war crimes in history) and that in the meantime perhaps as many millions of Poles, Czechs, and Russians have taken the place of the former German inhabitants. Does this fact reduce German claims? Is it a hindrance to the eventual reincorporation of these territories into a reconstituted Reich (or whatever name is eventually chosen)? In both instances I think not: except for the time from 1919 to 1945, the Reich was always a multi-ethnic European entity. Perhaps that will eventually be its role again.

Hans Schmidt

Hans Koning's "Germania Irredenta" is the kind of anti-German trash published during the world wars. The Second World War "really started with those Sudeten Germans," according to him, but this is historically inaccurate, because the problem began with the Treaty of Versailles, which denied the Sudeten Germans their basic rights of self-determination, as promised in Wilson's Fourteen Points, and thereby led to their just and rightful desire to unite with Germany.

After the Second World War the Sudeten Germans were victimized for a second time by the criminal forced expulsion from their homelands. Crimes against humanity are clearly defined by international law, and the Sudeten Germans clearly were victims of such crimes. Crimes cannot be relativized.

Koning states that "the best that reunited Germany can ask for . . . is a clean slate." Yes, this is true, but the clean slate should require that all the other states of Europe own up to the crimes they committed against Germans after the war.

Don Heinrich Tolzmann

I have received letters from readers who express doubt that any Germans are still taking the border claims of the former deportees seriously. Thus I am grateful in a way for letters such as those by Hans Schmidt and Don Heinrich Tolzmann, among others, which prove that such arguments do persist.

The Slavic-Teutonic border in Europe has moved east and west over a span of a thousand years, a gauge of the relative power of its neighboring peoples. The challenge of the German destruction-invasion of 1941 (not ordinary defeat of the Slavs but their destruction was the German plan) was so absolute that in its response the Soviet Army, which was then a second-class force, became the most powerful army of its time. That this border should now be moved east again, even if Germans did build the fourteenth-century city hall of what was then Breslau, makes no sense historically. As for the moral issues at stake . . . but I'd better stop here.

I feel I must correct the impression given in "The Paradoxical Case of Tony Blair," by Geoffrey Wheatcroft (June Atlantic), that the BBC was swayed by political pressure from the Labour Party into giving Tony Blair's keynote speech more prominence than the O. J. Simpson trial verdict.

The suggestion that the BBC did as it was told is ludicrous. The editor of the news did not even know that Blair's office had contacted the BBC at the time the decision to lead with Blair was made.

Political parties regularly attempt to put pressure on BBC news programs, but our judgments are made independent of any outside influence or interference.

Richard Sambrook

EDITORS' NOTE: The credit line for Conor Cruise O'Brien's cover story in last month's issue should have noted that the book from which it was drawn, The Long Affair: Thomas Jefferson and the French Revolution 1785-1800, will be published next month in the United Kingdom and in Europe by Sinclair-Stevenson.

The Atlantic Monthly; November 1996; Letters; Volume 278, No. 4; pages 8-18.