kottke.org posts about medicine
Before the Roe v. Wade Supreme Court decision in 1973, most women seeking abortions in the US had to get them illegally. Illegal abortions were often unsafe & painful, and many women died, were injured, or were sexually assaulted by the men performing the procedures. In this video, three women who had abortions before 1973 and a woman who worked at a Brooklyn hospital in that era described their experiences.
“He said, ‘I’m not going to give you any anesthetic’ and he said ‘If you scream, they will hear you.’”
That’s how Connie described the illegal abortion she received in 1953 when she was 16 years old. Now a retired teacher, mother and grandmother, Connie said that after she received the abortion, the man who performed the procedure proceeded to sexually assault her as she lay bleeding on the table.
Each year, Bill and Melinda Gates write a letter about the work they’re doing with the Bill and Melinda Gates Foundation. In 2006, Warren Buffett donated more than billion to their foundation, which effectively doubled its available resources. This year’s letter from the Gateses is addressed to Buffett and details the return on his investment so far.
Bill: If we could show you only one number that proves how life has changed for the poorest, it would be 122 million — the number of children’s lives saved since 1990.
Melinda: Every September, the UN announces the number of children under five who died the previous year. Every year, this number breaks my heart and gives me hope. It’s tragic that so many children are dying, but every year more children live.
Bill: More children survived in 2015 than in 2014. More survived in 2014 than in 2013, and so on. If you add it all up, 122 million children under age five have been saved over the past 25 years. These are children who would have died if mortality rates had stayed where they were in 1990.
Bill calls saving children’s lives “the best deal in philanthropy”. Melinda continues:
Melinda: And if you want to know the best deal within the deal — it’s vaccines. Coverage for the basic package of childhood vaccines is now the highest it’s ever been, at 86 percent. And the gap between the richest and the poorest countries is the lowest it’s ever been. Vaccines are the biggest reason for the drop in childhood deaths.
Melinda: They’re an incredible investment. The pentavalent vaccine, which protects against five deadly infections in a single shot, now costs under a dollar.
Bill: And for every dollar spent on childhood immunizations, you get $44 in economic benefits. That includes saving the money that families lose when a child is sick and a parent can’t work.
Vaccines. And Now my kids don’t die.
From Now This, a short animated history of Planned Parenthood, the origins of which date back more than 100 years.
No woman can call herself free who does not own and control her body.
Voices in the video include Mindy Kaling, Amy Schumer, and Meryl Streep.
I posted earlier about Atul Gawande’s piece in the New Yorker on the importance of incremental care in medicine. One of the things that the Affordable Care Act1 did was to make it illegal for insurance companies to deny coverage to people with “preexisting conditions”, which makes it difficult for those people to receive the type of incremental care Gawande touts. And who has these preexisting conditions? An estimated 27% of US adults under 65, including Gawande’s own son:
In the next few months, the worry is whether Walker and others like him will be able to have health-care coverage of any kind. His heart condition makes him, essentially, uninsurable. Until he’s twenty-six, he can stay on our family policy. But after that? In the work he’s done in his field, he’s had the status of a freelancer. Without the Affordable Care Act’s protections requiring all insurers to provide coverage to people regardless of their health history and at the same price as others their age, he’d be unable to find health insurance. Republican replacement plans threaten to weaken or drop these requirements, and leave no meaningful solution for people like him. And data indicate that twenty-seven per cent of adults under sixty-five are like him, with past health conditions that make them uninsurable without the protections.
That’s 52 million people, potentially ineligible for health insurance. And that’s not counting children. Spurred on by Gawande, people have been sharing their preexisting conditions stories on Twitter with the hashtag #the27Percent.
The 27% figure comes from a recent analysis by the Kaiser Family Foundation:
A new Kaiser Family Foundation analysis finds that 52 million adults under 65 — or 27 percent of that population — have pre-existing health conditions that would likely make them uninsurable if they applied for health coverage under medical underwriting practices that existed in most states before insurance regulation changes made by the Affordable Care Act.
In eleven states, at least three in ten non-elderly adults would have a declinable condition, according to the analysis: West Virginia (36%), Mississippi (34%), Kentucky (33%), Alabama (33%), Arkansas (32%), Tennessee (32%), Oklahoma (31%), Louisiana (30%), Missouri (30%), Indiana (30%) and Kansas (30%).
36% uninsurable in West Virginia! You’ll note that all 11 of those states voted for Trump in the recent election and in West Virginia, Trump carried the day with 68.7% of the vote, the highest percentage of any state. The states whose people need the ACA’s protection the most voted most heavily against their own interest.
Update: An earlier version of this post unfairly pinned the entire blame for the lack of coverage of those with preexisting conditions on the insurance companies.2 I removed the last paragraph because it was more or less completely wrong. Except for the part where I said we should be pissed at the Republican dickheads in Congress who want to repeal the ACA without replacing it with something better.3 And the part where we should be outraged. And the part where we regulated cars and cigarettes and food to make them safer, forced companies to build products in ways they didn’t want, and saved millions of lives. We can’t make everyone healthier and raise taxes to do it? Pathetic for what is supposedly the world’s most powerful and wealthy nation. (thx @JPVMan + many others)
In a piece called The Heroism of Incremental Care for the New Yorker, surgeon Atul Gawande argues that our healthcare system is built for and celebrates heroic intensive care over the slower but more effective efforts of long-term primary care givers.
We have a certain heroic expectation of how medicine works. Following the Second World War, penicillin and then a raft of other antibiotics cured the scourge of bacterial diseases that it had been thought only God could touch. New vaccines routed polio, diphtheria, rubella, and measles. Surgeons opened the heart, transplanted organs, and removed once inoperable tumors. Heart attacks could be stopped; cancers could be cured. A single generation experienced a transformation in the treatment of human illness as no generation had before. It was like discovering that water could put out fire. We built our health-care system, accordingly, to deploy firefighters. Doctors became saviors.
But the model wasn’t quite right. If an illness is a fire, many of them require months or years to extinguish, or can be reduced only to a low-level smolder. The treatments may have side effects and complications that require yet more attention. Chronic illness has become commonplace, and we have been poorly prepared to deal with it. Much of what ails us requires a more patient kind of skill.
Testing human blood for tropical diseases like malaria can be difficult in some parts of the world. Centrifuges used to separate the blood for testing are expensive and require electricity. Researchers from Stanford have developed an ingenious human-powered centrifuge made of paper and string inspired by a children’s toy invented 5000 years ago (paging Steven Johnson, Steven Johnson to the courtesy desk please).
In a global-health context, commercial centrifuges are expensive, bulky and electricity-powered, and thus constitute a critical bottleneck in the development of decentralized, battery-free point-of-care diagnostic devices. Here, we report an ultralow-cost (20 cents), lightweight (2 g), human-powered paper centrifuge (which we name ‘paperfuge’) designed on the basis of a theoretical model inspired by the fundamental mechanics of an ancient whirligig (or buzzer toy; 3,300 BC). The paperfuge achieves speeds of 125,000 r.p.m. (and equivalent centrifugal forces of 30,000 g), with theoretical limits predicting 1,000,000 r.p.m. We demonstrate that the paperfuge can separate pure plasma from whole blood in less than 1.5 min, and isolate malaria parasites in 15 min.
A million rpm from paper and string…that’s incredible. (via gizmodo)
My friend Courtney Skott wrote an intense piece about the three miscarriages she’s had, including one just a couple of weeks ago. (Note: you may find the images disturbing, but that might also be a good thing.)
It wasn’t until after that miscarriage that I learned how common they are. But even if you know the statistics — that perhaps 20% of confirmed pregnancies miscarry — they are easy to dismiss. After all, it’s much more likely that you will be in the other 80%, isn’t it? But 1 in 5 is still pretty high, and once you start telling your friends that you had a miscarriage, all the miscarriages around you come out of the woodwork. “My sister had one. My best friend had one. I had two.”
Why didn’t I know that before?
Waaaay more people should know this — I didn’t until, well, you know. Like Courtney says, you don’t realize until you start talking to other people about it and…”out of the woodwork” is right.
Nicola Twilley reports on a relatively new technique being used in a Baltimore trauma center: freezing trauma victims to give the doctors working on them more time to save their lives.
When this patient loses his pulse, the attending surgeon will, as usual, crack his chest open and clamp the descending aorta. But then, instead of trying to coax the heart back into activity, the surgeon will start pumping the body full of ice-cold saline at a rate of at least a gallon a minute. Within twenty minutes (depending on the size of the patient, the number of wounds, and the amount of blood lost), the patient’s brain temperature, measured using a probe in the ear or nose, will sink to somewhere in the low fifties Fahrenheit.
At this point, the patient, his circulatory system filled with icy salt water, will have no blood, no pulse, and no brain activity. He will remain in this state of suspended animation for up to an hour, while surgeons locate the bullet holes or stab wounds and sew them up. Then, after as much as sixty minutes without a heartbeat or a breath, the patient will be resuscitated.
Brain damage is a risk — as is, you know, dying from hypothermia — but there are many instances of people surviving even after their hearts stop for an hour or two.
Some recent genetic testing of the blood of AIDS patients has determined that the strain of HIV responsible for the majority of the AIDS cases in the US spread from Zaire to Haiti around 1967, from Haiti to NYC around 1971, and from there to San Francisco around 1976 and that Gaétan Dugas (aka Patient Zero) was not responsible for setting the epidemic in motion.
The strain of H.I.V. responsible for almost all AIDS cases in the United States, which was carried from Zaire to Haiti around 1967, spread from there to New York City around 1971, researchers concluded in the journal Nature. From New York, it spread to San Francisco around 1976.
The new analysis shows that Mr. Dugas’s blood, sampled in 1983, contained a viral strain already infecting men in New York before he began visiting gay bars in the city after being hired by Air Canada in 1974.
The researchers also reported that originally, Mr. Dugas was not even called Patient Zero — in an early epidemiological study of cases, he was designated Patient O, for “outside Southern California,” where the study began. The ambiguous circular symbol on a chart was later read as a zero, stoking the notion that blame for the epidemic could be placed on one man.
This is a lovely infographic from Eleanor Lutz of a bunch of different heartbeat EKG waves, from a normal heartbeat to a flatline to ventricular fibrillation (“must be treated immediately with CPR and defibrillation”.) Prints are available.
Thousands of people die every day from malaria, a disease that is transmitted to humans solely through mosquitoes. With CRISPR, scientists can easily genetically engineer mosquitoes incapable of transmitting malaria and using a technique called gene drive, they can force that genetic change into the native mosquito population. So, should we do it?
From the School of Public Health at Johns Hopkins comes this list of 100 things that have “made their mark on public health”, good and bad. Here’s a sampling of the objects:
Horseshoe crab. We all owe a debt of gratitude to the helmet-shaped horseshoe crab, whose ancestors date back 450 million years. From vaccines to needles to pacemakers, any IV drug or medical equipment that will come in contact with the human body must first be safety-checked using a test that comes from a clotting compound in the crab’s blood. This compound can detect even the smallest amount of deadly bacteria and is sensitive enough to isolate a threat equivalent to the size of a grain of sand in a swimming pool.
Vaccines. Immunization is one of the most important public health achievements in human history. Vaccines helped eradicate smallpox globally and eliminate polio in the United States. The introduction of effective vaccines has also drastically reduced deaths from measles, diphtheria, rubella, pertussis (“whooping cough”) and other diseases that sickened hundreds of thousands of Americans in the early 20th century.
American Cheese. Food processing was actually developed to make food safer. Milk is pasteurized to kill harmful organisms, and canning and freezing foods such as meats, fruits and vegetables helps them last longer. But the food industry has taken processing well beyond these early origins. Often, to extend a food’s shelf life, manufacturers increase fats, sugars, and salt and add in chemical flavorings, emulsifiers, and other additives — taking foods that could have been healthy and making them much less so.
Pap smear. Since its introduction in 1955, the Pap smear has reduced death from cervical cancer by more than 60 percent. Invented by Dr. Georgios Papanikolaou, the Pap smear is a diagnostic procedure in which a health-care professional swabs a cell sample from the cervix and sends it to a lab to see if any of the cells are malignant. Before the invention of the Pap smear, cervical cancer was one of the leading causes of death for women of childbearing age in the United States. Today, it comes in at number 14 on the list of cancers found in women.
Spittoons. Spittoons were developed centuries ago as receptacles for spitting — think ashtrays for saliva. These brass or even porcelain repositories were everywhere: In homes, train stations, saloons and even the U.S. Congress. They were meant for men to dispose their chewing tobacco and the abundant phlegm that accompanied the habit. Convenience turned to concern in the late 19th century when a global tuberculosis epidemic took hold and scientists realized that spittoons might actually spread diseases. Some argued that when people spat in the general direction of a spittoon and missed the target, they caused a greater health threat than if the spittoon hadn’t been there at all.
Vaccines. And now my kids don’t die.
James Hamblin, the dishy brainiac doctor who does those entertaining and informative videos for The Atlantic, is coming out with a book in December called If Our Bodies Could Talk. He calls it “a FAQ about human bodies”.
Now, in this original and entertaining book, Hamblin explores the stories behind health questions that never seem to go away — and which tend to be mischaracterized and oversimplified by marketing and news media. He covers topics such as sleep, aging, diet, and much more:
Can I “boost” my immune system?
Does caffeine make me live longer?
Do we still not know if cell phones cause cancer?
How much sleep do I actually need?
Is there any harm in taking a multivitamin?
Is life long enough?
Perfect eyesight. Curing cancer. Designer babies. Super-soldiers. Because of CRISPR, genetic engineering might make tinkering with life as easy as playing with Lego.
Imagine you were alive back in the 1980’s, and were told that computers would soon take over everything — from shopping, to dating, and the stock market, that billions of people would be connected via a kind of web, that you would own a handheld device orders of magnitudes more powerful than supercomputers.
It would seem absurd, but then all of it happened. Science fiction became our reality and we don’t even think about it. We’re at a similar point today with genetic engineering. So let’s talk about it.
Relatedly, I’m finishing up Neal Stephenson’s Seveneves right now and while it starts out as space science fiction, much of the book is concerned with the sort of genetic engineering issues discussed in the video.
After The Man freaked out back in the 60s, LSD and other psychedelics were banned and criminalized. But slowly, scientists are experimenting with psychedelics to treat depression, anxiety, and other ailments.
In the 1960s, a psychologist and former Harvard teacher named Timothy Leary coined the phrase ‘Turn on. Tune in. Drop out.’ The slogan was inspired by advertising jingles, but Leary wasn’t pushing a product, he was promoting a drug: LSD.
But today, scientists are studying psychedelics once again, in the latest twist in the long, strange story of LSD.
Even outside of a therapeutic setting, many people extolled the beneficial effects of psychedelics. Former Apple CEO Steve Jobs recalled in his biography by Walter Isaacson:
Taking LSD was a profound experience, one of the most important things in my life. LSD shows you that there’s another side to the coin, and you can’t remember it when it wears off, but you know it. It reinforced my sense of what was important — creating great things instead of making money, putting things back into the stream of history and of human consciousness as much as I could.
Check out the NY Times companion piece and the archival footage of LSD experiments on cats, spiders, and goats.
Errol Morris has made a short film about the world’s remaining stocks of smallpox virus 1 and the debate between those who want to eliminate the virus forever and those who want to keep it around.
In the story from classical Greece, Pandora was warned: Don’t open the box. She opens it anyway. The various pestilences are unleashed on the world but Hope remains at the very bottom of the box. Today there are microbiologists who want to continue to research smallpox. If they are given a free hand, what might they unleash?
There are those who insist that these residual stocks of smallpox should not be destroyed because some ruthless super-criminal or rogue government might be working on a new smallpox, even more virulent than existing strains of the virus. We may need existing stocks to produce new vaccines to counteract the new viruses. New viruses, new vaccines. New vaccines, new viruses. An escalating arms race with germs.
Keep this video in mind when you read about the latest advances with CRISPR.
The latest video from Kurzgesagt is an explainer on antibiotics and superbugs (drug resistant bacteria).
What would you say if we told you that humanity is currently making a collaborative effort to engineer the perfect superbug, a bug that could kill hundreds of millions of people?
Amos Dudley wanted to improve his smile but didn’t want to pay thousands of dollars for Invisalign, so he 3D printed his own orthodontic aligners.
I took a mold of my teeth with some cheap alginate powder, Permastone, and a 3d printed impression tray, to get a better picture of what was really going on. Notice LI-r (right lateral incisor) projected outward, and CI-r (right central incisor) depressed inward and overlapping.
At the time of writing this, I’m an undergrad, which means that a) I’m broke, and b) I have access to expensive digital fabrication tools - definitely an unusual dichotomy. I was researching [name brand clear-aligner treatment], and I ran across a photo that caught my eye.
Those look like the layer striations from a 3D print!
What is to stop someone, who has access to a 3D printer, from making their own orthodontic aligners?
Update: Unsurprisingly, orthodontists feel that DIY dentistry is not such a great idea.
Belli notes, “He moved these teeth in only 16 weeks. You can cause a lot of problems with that. If you move a tooth too fast, you can actually cause damage to the bone and gums. And if you don’t put the tooth in the right position, you could throw off your bite,” leading to additional damage and wear on the teeth.
John Hofsess helped eight people die and just before he died late last month at an assisted death facility in Switzerland, he wrote this piece.
I was horrified anew in 1999 when the gifted conductor Georg Tintner, who was dying from a rare form of melanoma, jumped from the balcony of his 11th-floor apartment in Halifax to end his agony. Many Canadians would hear such news, shake their heads, utter a few sympathetic platitudes and move on. But I couldn’t just sit back and wring my hands. That year, I went from advocating for assisted suicides to facilitating them. Let’s not mince words: I killed people who wanted to die.
On the most recent episode of Last Week Tonight, John Oliver argues against many US states’ anti-abortion laws. This was super funny and also made me really angry.
In an all-white room, mosquitoes are mated and the resulting larvae divided by sex. Workers whisk at stray mosquitoes with electrified tennis rackets — the kind you see in novelty stores, but which have sold out in mosquito-obsessed Brazil.
MIT Tech Review takes you inside the mosquito factory that could stop Zika and other diseases. (Add “working in a mosquito factory” to the list of jobs I’m glad I don’t have…)
For an episode called The Fix, Radiolab explores what anti-addiction drugs are available and why they aren’t more widely known and used to treat alcoholism and drug addiction.
Reporter Amy O’Leary was fed up with her ex-boyfriend’s hard-drinking, when she discovered a French doctor’s memoir titled The End of My Addiction. The fix that he proposed seemed too good to be true. But her phone call with the doctor left her, and us, even more intrigued. Could this malady — so often seen as moral and spiritual — really be beaten back with a pill?
We talk to addiction researcher Dr. Anna Rose Childress, addiction psychologist Dr. Mark Willenbring, journalist Gabrielle Glaser, The National Institute of Health’s Dr. Nora Volkow, and scores of people dealing with substance abuse as we try to figure out whether we’re in the midst of a sea change in how we think about addiction.
Neoantigen vaccines use the DNA from a cancer patient’s own tumor to, hopefully, eradicate the cancer.
For some 50 years, cancer biologists have tried to incite the immune system to attack cancer by targeting molecules that commonly stud the surfaces of malignant cells. These “antigens” act as homing beacons that immune cells find and lock onto (much as antigens on viruses attract the immune system, the basis for preventive vaccines such as that for measles).
Trouble is, normal cells sometimes sport the same antigens as tumors, and the immune system is programmed not to attack antigens found on healthy cells. As a result, revving up the immune system to target common tumor antigens hasn’t worked, leading to a number of failed experimental cancer vaccines.
That led biologists to a different approach: siccing the immune system on antigens found only on cancer cells — and only on the cancer cells of a single patient. “It’s highly unlikely that any two patients have the same neoantigens,” said Dr. Catherine Wu of Boston’s Dana-Farber Cancer Institute. “That’s why we have an opportunity to make cancer vaccines truly personalized, loaded with patient-specific neoantigens.”
Over the years, there’s been a growing consensus that suggests being happy is correlated with living a long life. Well, you can wipe that smile off your face because a massive study published in The Lancent makes it clear that no such correlation exists. So what about all those studies suggesting that stress and joylessness hastened death’s arrival? According the new study’s co-author:
In our view, the previous studies haven’t been well done. All that’s going on is ill health actually was causing unhappiness and stress.
In other words, your unhappiness is going to last longer than you thought.
Retro Report looks back on the story of the boy in the plastic bubble.
The epitaph on David Phillip Vetter’s gravestone observes correctly that “he never touched the world.” How could he have? From a few seconds after his birth until two weeks before his death at age 12, David lived life entirely in one plastic bubble or another. Touching the world would have killed him in fairly short order. Even his two weeks outside a plastic cocoon were spent in a hospital trying, futilely, to stave off the inevitable.
There was never a child quite like David Vetter. Americans above the age of, say, 45 may remember him not so much by name as by a phenomenon of the 1970s and early ’80s: “the boy in the bubble.” The Retro Report series of video documentaries, exploring major news developments of the past, returns to that era through interviews with, among others, David’s mother and one of his doctors. More than just a look backward, the report examines medical strides that now give hope to the once-hopeless, coupled with ethical questions long part of the “bubble boy” story.
I remember very clearly watching the news reports about “the boy in the bubble” when I was a kid. Now, as an adult and a parent, the ethical concerns hit me somewhat harder. (via @DavidGrann)
Today, the NY Times is running an editorial by Dr. Bennet Omalu called Don’t Let Kids Play Football. Omalu was the first to publish research on CTE in football players.
If a child who plays football is subjected to advanced radiological and neurocognitive studies during the season and several months after the season, there can be evidence of brain damage at the cellular level of brain functioning, even if there were no documented concussions or reported symptoms. If that child continues to play over many seasons, these cellular injuries accumulate to cause irreversible brain damage, which we know now by the name Chronic Traumatic Encephalopathy, or C.T.E., a disease that I first diagnosed in 2002.
Depending on the severity of the condition, the child now has a risk of manifesting symptoms of C.T.E. like major depression, memory loss, suicidal thought and actions, loss of intelligence as well as dementia later in life. C.T.E. has also been linked to drug and alcohol abuse as the child enters his 20s, 30s and 40s.
The story of Omalu, his research, and its suppression by the NFL is the subject of Concussion, a movie starring Will Smith that comes out on Christmas Day, as well as a book version written by Jeanne Marie Laskas.
Update: Dr. James Hamblin shares the findings of a new paper on how repeated head trauma can affect the brains of kids as young as 8.
In the journal Radiology today, an imaging study shows that players ages 8 to 13 who have had no concussion symptoms still show changes associated with traumatic brain injury.
Christopher Whitlow, chief of neuroradiology at Wake Forest School of Medicine, wanted to see how head impact affects developing brains. His team studied male football players between ages 8 and 13 over the course of a season, recording “head impact data” using a Head Impact Telemetry System to measure force, which was correlated with video of games and practices.
But for the love of Julia Child and the sake of every other soul in the restaurant, particularly the underpaid line cooks sweating their way through another Saturday night shift, please, please stop describing your food preferences as an allergy.
Neil Swidey on why food allergy fakers need to stop.
In 1948, contact lenses were huge hunks of glass that don’t look at all comfortable. And the fittings started with a plaster cast of your eyeball. Ok, probably not plaster but still, ew. (via @FastidiumSum)
It’s getting more difficult for new painkilling drugs to be approved because the rate of effectiveness vs. placebos in drug tests is falling. But oddly, the drop is only being seen in the US.
Based on patients’ ratings of their pain, the effect of trialled drugs in relieving symptoms stayed the same over the 23-year period — but placebo responses rose. In 1996, patients in clinical trials reported that drugs relieved their pain by 27% more than did a placebo. But by 2013, that gap had slipped to just 9%. The phenomenon is driven by 35 US trials; among trials in Europe, Asia and elsewhere, there was no significant change in placebo responses. The analysis is in press in the journal Pain.
Concussion, starring Will Smith, is about Dr. Bennet Omalu, who discovered the link between football and CTE (Chronic Traumatic Encephalopathy) and will be out in December.
The movie is based on the 2009 GQ article, Game Brain.
Let’s say you run a multibillion-dollar football league. And let’s say the scientific community — starting with one young pathologist in Pittsburgh and growing into a chorus of neuroscientists across the country — comes to you and says concussions are making your players crazy, crazy enough to kill themselves, and here, in these slices of brain tissue, is the proof. Do you join these scientists and try to solve the problem, or do you use your power to discredit them?
Saw someone on Twitter saying that maybe this will be football’s The Insider. Let’s hope it moves the needle.
Update: From the NY Times, Sony Altered ‘Concussion’ Film to Prevent N.F.L. Protests, Emails Show.
In dozens of studio emails unearthed by hackers, Sony executives; the director, Peter Landesman; and representatives of Mr. Smith discussed how to avoid antagonizing the N.F.L. by altering the script and marketing the film more as a whistle-blower story, rather than a condemnation of football or the league.
“Will is not anti football (nor is the movie) and isn’t planning to be a spokesman for what football should be or shouldn’t be but rather is an actor taking on an exciting challenge,” Dwight Caines, the president of domestic marketing at Sony Pictures, wrote in an email on Aug. 6, 2014, to three top studio executives about how to position the movie. “We’ll develop messaging with the help of N.F.L. consultant to ensure that we are telling a dramatic story and not kicking the hornet’s nest.”