Map of life expectancy at birth from Global Education Project.

Sunday, March 19, 2017


Really, fucking nuts. The news media and politicians of all stripes are struggling with how to respond to a "president" who is manifestly insane.

To be clear, I have absolutely no interest in this ridiculous debate over whether psychiatrists should apply a diagnostic label to him. The very idea that there are entities called "personality disorders" that constitute specific, identifiable diseases is nonsense, as far as I'm concerned. Some people behave in ways that create unnecessary difficulties for themselves and/or others. There is nothing to be gained by declaring that this person has "narcissistic personality disorder," or "psychopathy," or whatever word you care to sling.

But, he does what he does, which is to habitually assert preposterous falsehoods and then refuse to back down in the face of overwhelming evidence and reason; and order his flunkies to participate in his alternative reality. That is insane, in the vernacular use  of the word.

Here is one take from the estimable Josh Marshall. "The real story here is that the President, by force of his office and audacity, was able to inject into the national conversation a preposterous claim which the country has spent two weeks debating. . . . I would say that this ability - both the President's pathological lying and our institutions' inability to grapple with it - is the big, big story." He concludes that "this is a warning case of people in power deciding what's true and false which is a harbinger of free government dying." (I draw to your attention what I believe is the relatively new motto of the Washington Post: "Democracy dies in the dark.")

However, I am more inclined to Simon Malloy's view. The fact is that nobody except for Trump's equally deluded juggalos credits his fantasies. The spectacle of Republican politicians trying to evade forthright comment, or of reporters unable to find the letters l, i and e on the keyboard is disheartening, but none of this will lead to any sort of concrete result. In other words the Justice Department isn't about to prosecute Barack Obama and the U.S. isn't going to recall the British ambassador. (No doubt about that -- there isn't one.)

So for the immediate term, this is basically a distraction. The real danger is that we have a "president" who nobody with any sense will believe about anything. So what happens when there is a crisis of some sort and the nation, and the world, depend on presidential leadership? Congress doesn't have to pass the worst atrocities in his budget proposal, and they won't, but the time will come when a president with no  credibility will be catastrophic.

Monday, March 13, 2017

And another outrage you probably never heard about

A component of the Affordable Care Act which doesn't get a lot of attention is called the Prevention and Public Health Fund. Most of the money goes to CDC which uses it to track disease outbreaks and get vaccines to places where they are needed and vaccinate people who can't afford to pay. It also sends $625 million a year to the states, which using the money for vaccination and other preventive services. The bill in congress to "replace" the ACA eliminates all of this funding.

The BMJ asked the Dept. of Health and Human Services whether this has anything to do with "president" Trump's belief that vaccination causes autism, but got no response.

Now, if you're a Republican, you think that government spending is evil a fortiori because it requires taxation. But you might consider the following information from the linked article:

The $1bn funding also covers all of CDC’s lead exposure testing and risk reduction efforts. CDC estimated that the current rate of lead exposure, with at least 535 000 children with toxic blood concentrations, will cost America $59bn in lost lifetime productivity. Research has shown that each dollar spent on reducing exposure to lead delivers a return of $17 to $221.5

CDC has estimated that vaccination among American children born from 1994 to 2013 would prevent around 21 million admissions to hospital and 732 000 deaths over the course of their lifetimes, with a net savings of $295bn in direct costs and $1.38 trillion in total societal costs.6
But it's more important that rich people not pay taxes.

Tuesday, March 07, 2017

Okay, so why Trumpcare?

Ezra Klein is puzzled. Why are the Republicans in congress proposing an Affordable Care Act replacement that will:

  • Balloon the federal deficit;
  • Take insurance away from maybe 15 million people; and
  • Make it more costly for millions more
  • Destroy the market for individual insurance
Klein says: :

It is difficult to say what question, or set of questions, would lead to this bill as an answer. Were voters clamoring for a bill that cut taxes on the rich, raised premiums on the old, and cut subsidies for the poor? Will Americans be happy when 15 million people lose their health insurance and many of those remaining face higher deductibles? 
Well, the voters weren't clamoring for cutting taxes on the rich, but that's all the Republicans in congress actually care about. But Krugthulu has one additional point:

Obviously, Republicans backed themselves into a corner: after all those years denouncing Obamacare, they felt they had to do something, but in fact had no good ideas about what to offer as a replacement. So they went with really bad ideas instead.
Not to worry, it isn't going to pass as it is. But I still expect something bad to happen.

Monday, March 06, 2017

The worm Ouroborous

We don't expect the reporters who work for the corporate media to be very intelligent, so let me help them out.

Donald Trump is the president of the United States. If he has information that Barack Obama ordered somebody (presumably the FBI) to "tap his wires," as he put it, for political reasons, he can produce it. It is within his power to declassify and make public any information at all. For him to call for a congressional investigation of this charge is ridiculous. The congress would simply subpoena records which are, at this very moment, in his possession. He is asking them, in other words, to investigate himself in order to force him to produce what he can already produce if he so chooses.

Ergo, no such records exist and he is a big fat liar. But we already knew that. The problem is that our "journalists" can just say so. Oh yeah, then there are those Republicans in congress  . . .

Then there's the case of James Comey, who is screwed, but I have no sympathy for him, it's his own fault. Expect him to be fired shortly. Then the DoJ Inspector General's report will come out . . .

Tuesday, February 28, 2017

Death, doubt and doom loom.

Bazz fazz. (All of the above quoted from Pogo.)

Admittedly we have enough to be worried about but this at least is solvable. The WHO once again raises the alarm on antibiotic resistance. Not that this blog hasn't passed this way before, but the problem isn't going away. We have made progress on improving hygiene in hospitals but that isn't getting a the main sources of the problem which still include feeding antibiotics to livestock and inappropriate prescribing.

If we don't find new ways to combat bacterial infection, and fairly soon, we'll be back to the pre-antibiotic world. Minor wounds and common childhood infections will kill, much of the surgery we do today will be impossible, or at least not worth the risk, and life spans will collapse.

The Free Market™ won't save you, because antibiotics just aren't very profitable for drug companies. People need only a short course of treatment, unlike the big moneymaker pills people take for months or forever. Those are the ones they advertise heavily, along with the ones that cost $100,000 for a course of treatment. In fact, if they do come up with a new antibiotic, it will sell very little because doctors will keep it as a last resort.

This requires government investment. Yes, Big Government. We could take 3 or 4 billion of that $54 billion Orange Julius wants to dump into useless military boondoggles and save humanity instead. What do you want to bet will happen?

Friday, February 24, 2017

Oh no! The politicization of science!

Nothing frosts my pumpkin like these doofi (doofuses? I always have trouble with the Latin plurals) who decry the Scientists' March on Washington because it will "politicize science." Purportedly science needs to remain aloof from politics lest scientists be accused of partisanship and lose the trust of the public.

Wow folks, you are growing with your heads in the ground and talking out of your nether orifices. Science has already been "politicized" and accused of partisanship. EPA scientists are forbidden to release any studies or data to the public without review by political appointees. The CDC abruptly cancelled a long-planned conference on climate change. Cabinet appointees in general deny the reality of anthropogenic climate change, as does the "president." The administration wants the FDA to approve drugs that don't actually work, while the "president" believes that vaccines cause autism. We could go on with this but you get the idea.

It is true that scientists make a claim of epistemological preeminence. We are committed to using a particular toolkit to discover truth. We -- or at least most of us -- agree that there are what Habermas calls different classes of "criticizable validity claims," and that science concerns only one of them. Harking back to Plato, Habermas calls these the True, the Good, and the Beautiful. You can decide for yourself what you think is right or wrong, and what gives you pleasure. But the Truth is out there, to be discovered. It is what it is whether you like it or not. And yes, scientists, through long training and disciplined application, develop expertise that most people -- including most other scientists -- do not have to make truth claims about specific questions.

This doesn't mean we think we're better than you. If you are a skilled plumber, auto mechanic, carpenter or bassoon player, scientists will pay you to do what they cannot. Auto mechanics don't think that chemists or climatologists know as much about automobile repair as they do, but scientists don't resent them for that.

It is a basic value of science to try to keep an open mind and to be extremely reluctant to call conclusions absolutely definitive and not subject to legitimate question. But as evidence builds for theories, and they integrate seamlessly with broader theories, as multiple lines of evidence converge, some conclusions become unworthy of question. Vaccines do not cause autism. Humans burning fossil fuels add carbon dioxide to the atmosphere which is causing the climate to change with unprecedented rapidity. Particulate matter from motor vehicle exhaust and coal-fired power plants, among other sources, causes serious adverse health consequences. And so on. These are truths. Denying them is political; asserting them is science.

What we are asking is that you base your policies on the truth, in light of your values and preferences. If you believe that it is right and beautiful to destroy civilization in order to further enrich the Koch brothers, then by all means say so. But don't lie and say it isn't happening.

That's what the march is about.

Wednesday, February 22, 2017

Kenneth Arrow, 1921-2017

The death of economist Kenneth Arrow offers an opportunity for me to revisit a subject of great importance, that I have discussed here before. It is perhaps more urgent than ever as the congress prepares to deprive millions of people of health care. You can read an important paper of his here if you like, from 1963, but I will state the case more accessibly, I hope, and also put it in larger context.

A constant refrain of conservatives is that the Free Market® is the best solution to resource allocation. Interfering in the Free Market® is tantamount to depriving individuals of their freedom. The Free Market® is conceived of as a force of nature, existing independent of society and suffering only damage from political interference.

Of course, this theology is invoked only hypocritically. When capitalists want government to do something for them, they forget about it completely for as long as it is convenient.  The conventional wisdom among economists and moderately sane politicians is that "market failures" do exist, such that intervention is occasionally called for; but these are abnormal and require special justification.

This is all completely bullshit. In the first place, there is no such thing as a Free Market®, never has been, and never can be. Markets are social constructions. In modern, complex societies, they require continuous, pervasive government activity in order to function at all. All markets are structured and regulated, the question is not whether this happens, but on whose behalf?

Let us consider the theoretical conditions necessary for the functioning of a Free Market®, and consider whether medical care can conceivably be allocated through such a mechanism. (Note that the Free Market® always fails, for all good and services, and I can prove it. But it's more obvious in the case of medical services so I'll stick to the knitting for now.)

We'll begin with demand. People have a largely predictable need for typical commodities such as food and clothing, and a desire for some other goods such as entertainment that they will satisfy as their means allow. However, we have no idea what medical services we may need tomorrow or next year, and we rarely desire them at all. The need for medical services is an unpredictable misfortune. Furthermore, it is entirely possible that the cost of what is necessary will entirely exceed our means, while our more fortunate neighbor has negligible medical expenses. The only solution is some form of insurance -- a mechanism for pooling risk.

However, for profit insurance companies have an unavoidable incentive not to accept customers who are at high risk, and to try to avoid paying claims if they can get away with it. So in order for health insurance markets to function at all, they must be regulated.

At the same time, to the extent we have to rely on the monetary contributions individuals are willing and able to make to risk pools voluntarily, medical services will be underfunded and underproduced. There are several reasons for this. One should be obvious: transmissible diseases threaten everyone. Disease prevention and treatment benefits everyone beyond the cost for the individual. Furthermore, sick people can't work or take care of dependents to the extent healthy people can, if at all, and having sick friends and relatives, or even seeing strangers suffer, makes at least some of us sad.

Furthermore, as consumers, we are not only involuntary but incompetent. We depend on physicians' expertise to decide what to purchase, or to have purchased on our behalf by our insurer. While the current fashion is to involve patients in decision making, our capacity for that involvement is limited. We still need providers to explain our options accurately, in a way that we can understand and is relevant to us. But they're making more money by some choices than by others. So it matters how these incentives are structured.

There is a good deal more I could say about this, but the unavoidable conclusion is that we need a universal risk pool, regulated medical practice with some constraints on spending, and that people pay no more than they can afford to participate. Universal, comprehensive, single payer national health care accomplishes this. And it makes us all more free. 

Thursday, February 16, 2017

Fiscal responsibility. Also, Freedom.

One of the most popular methods for not stayin' alive in the U.S. is the motor vehicle crash. You may have heard about the sharp reversal of the long-term trend in traffic deaths over he past two years.

This cuts against improvements in the safety features of vehicles and the design of highways, which had helped bring down the fatality rate over decades. We don't have the hard core evidence to explain the reversal, but experts offer a few suggestions. Yes, we have more ways to be distracted by our gadgets. However, sayeth the Sage of 41st St.:

Government officials and safety advocates contend, however, that more than anything else, the increase in deaths has been caused by more lenient enforcement of seatbelt, drunken driving and speeding regulations by authorities and a reluctance by lawmakers to pass more restrictive measures.
In Alabama, crashes are up only 5% but fatalities are up 25%. That's because more people are speeding -- obviously the faster you're going the more  deadly your crash will be. Continuous budget cuts have reduced the number of state troopers -- now there are only 2 on duty at times in entire counties. Texas has raised its highways speed limits to 85. Seat belt laws are unenforced, where they are in place in meaningful form at all. Other approaches to improving safety, such as traffic monitoring cameras and ignition interlocks for people convicted of DUI, are also contrary to Ayn Rand.

Libertarian claims about traffic safety legislation are obviously nonsensical because you aren't necessarily just killing yourself. But even if you were, crashes, deadly or otherwise, cost the rest of us money. They block traffic, they cause lifelong disability with enormous cost, they destroy property, they deprive children of parents and I could go on and on.

Driving is not a right, and any freedom to drive is constrained by the freedom of the rest of us not to be endangered by you. It is a privilege in return for which you owe it to the rest of us to be responsible. And that must be encoded in the law, and the law must be enforced.

I will just mention that I witnessed a crash on Rte. 6 in Johnston, RI a few weeks ago in which two teenagers were killed, and it could have been a lot worse. A bystander car was also struck, and driven into a gas pump, which exploded. Fortunately, the driver was inside paying. So yeah, I've been thinking about it.

Monday, February 13, 2017

Simple Arithmetic

Making affordable health care available for people with low incomes costs money. It has to come from somewhere. The Affordable Care Act is financed by taxes. The Republican congress wants to eliminate those taxes, because they fall mostly on wealthy people. (There are some additional levies on insurance and pharmaceutical companies that pay for parts of the act that are really side issues.) But they also know they will pay a political price for eliminating health insurance for millions of people, and specifically for sick people who really need it.

There is no way to square this circle. But most citizens don't understand this basic fact. Many of them don't even know that Obamacare and the Affordable Care Act are the same thing. And:

[O]nly 61 percent of adults knew that many people would lose coverage through Medicaid or subsidies for private health insurance if the A.C.A. were repealed and no replacement enacted. In contrast, approximately one in six Americans, or 16 percent, said that “coverage through Medicaid and subsidies that help people buy private health insurance would not be affected” by repeal, and 23 percent did not know.

It's no wonder that no legislation has moved yet in the Congress. There is no alternative to the ACA that won't kick millions of people off of the insurance roles, make insurance worse for most other people, and won't require taxes. Therefore the Republicans will never be able to do what they have promised to do.

What will they do instead?

Tuesday, February 07, 2017

Global impact

Sorry for the absence. Frankly, I've felt that writing about quotidian subjects is somehow futile or beside the point. Truth and logic no longer matter in the making of policy. But, I suppose life must go on.

We Americans are often too self-obsessed and don't bother to know or understand much about the rest of the world. On the other hand, the U.S. does matter, a lot. Reading the new BMJ (British Medical Journal) illustrates the point. It's as much about the U.S. as it is about Britain.

For example, there's Travel ban threatens medical research and access to care in the US, medical groups warn. This tells the story of a resident physician at the Cleveland Clinic who was refused re-entry because she holds a Sudanese passport.

Nitin S Damle, president of the American College of Physicians, said that foreign physicians and medical students working in the US have to be “thoroughly vetted” to obtain their visas. The order was “discrimination based on religion” and should be rescinded, he said. “If the executive order is not permanently rescinded, blocked by the courts, or reversed by Congress, it will hinder the free exchange of information and travel among doctors around the world,” he said.

The president and chief executive of the Association of American Medical Colleges, Darrel C Kirch, said that international graduates played an essential role in US healthcare, accounting for 25% of the workforce, and that the ability of the US to attract top talent to its medical centers had helped make it a global leader in medical research. “Because disease knows no geographic boundaries, it is essential to ensure that we continue to foster, rather than impede, scientific cooperation with physicians and researchers of all nationalities, as we strive to keep our country healthy,” he said.
Then there's this, on the proposed of a bilateral trade deal between the U.S. and Britain which the "president' is pushing to facilitate the breakup of the E.U. Doesn't sound like a bad thing, right? Well, it's a bit complicated, but it could be very bad for Britain, given the highly unequal negotiating power between two economies of such disparate size. Read if you want to get a little more sophisticated about trade.

Then there's the global gag rule. Republican presidents always forbid U.S. funding of agencies abroad that make referrals for abortion or even discuss it with patients. But the "president" has gone beyond George W. Bush's version to extend it to all U.S. departments and agencies, not just AID, including the CDC, NIH and FDA.

The administrative burdens of implementing this rule, on both US agencies and aid recipients, could be very large. Such rules are likely to prevent the US from effectively tackling a problem like the Zika virus.

The consequences of this action can be expected to be widespread and contrary to the stated intent of the rule. If the goal of this policy is to reduce the number of abortions worldwide, then it will fail. Countries exposed to the gag rule show a rise in abortion rates when the rule is in effect and a reduction when it is not.2 Policies that curtail investments into comprehensive family planning programmes reduce the outreach of these programmes to the rural areas where the majority of people in sub-Saharan Africa live.

By limiting women’s access to modern contraception, the rate of unwanted pregnancies rises. In this situation women will often turn to abortion.
Reducing access to abortion and contraception results in shorter birth intervals, which negatively impact the health of women and their children and result in higher levels of child malnutrition.3 Rather than improving the health of women and children in the world’s poorest countries, the global gag order increases maternal and child morbidity and mortality.
In short, making policy based on ignorance and prejudice is usually not a good idea.

Tuesday, January 31, 2017

It's personal

Syrian doctor studying in U.S. stuck abroad, while his pregnant wife is here in Providence. Specifically, he's Khaled Almilaji, who is a student in our School of Public Health of which I am a faculty member.

He says the United States is enriched by many cultures and that would be a sad thing to lose. The 35-year-old Almilaji received a scholarship to earn a master’s degree in public health at Brown University. He moved to Providence in August on a student visa with his wife. Almilaji coordinated a campaign that vaccinated 1.4 million Syrian children and provided medical care during Syria’s civil war.

Thank God we're safe from him.

Friday, January 27, 2017

There's more to the ACA than health insurance

It's amusing to watch the Republicans continue to flail as they try to figure out how to screw millions of people out of health care without getting blamed for it. But they can do a lot to make health care in the U.S. worse without it being so obvious.

For example, the ACA includes funding for the Center for Medicare and Medicaid innovation, which supports demonstration projects to find way of delivering better care at lower cost. If you read this blog, you know that we pay a lot more for health care than other wealthy countries -- yeah, the ones who cover everybody because of socialism -- and we get worse results. Because freedom. CMMI is trying to bend the cost curve down while getting better results. But of course you have to spend money to do that, so socialism.

The ACA also established a fund for public health programs to prevent chronic diseases. Oh yeah -- it goes to the states. But that costs money too, so socialism.

Then there is the Patient Centered Outcomes Research Institute (which, full disclosure, has funded some of my research). PCORI compares treatments to learn which are better. Of course, that also costs money, which comes form a tax on insurance premiums, so socialism.

If they repeal all this, it will just make us less healthy in the first place, we'll pay more for health care, and we'll get worse results. But that's better than socialism. Oh wait, I mean it's better than making rich people pay taxes.

Wednesday, January 25, 2017

Repealing the Enlightenment

PZ Myers reviews the "president's" war on science. Go ahead and read it. Here's my personal stake:

The lunatics who have taken over the country seem to want to undo the Enlightenment. That isn’t actually possible but they can cause horrible carnage. I’m an NIH-funded researcher and our entire school of public health largely depends on federal funding — and a lot of it is stuff that Republicans don’t like. They don’t want to know about social determinants of health, inequities, health of people they don’t like such as gay men and drug addicts, marketing of drugs for useless or unsafe purposes, hospitals raking in money for useless procedures, and a whole lot else. So yeah, I’m worried.

Monday, January 23, 2017

Objectively Evil

I don't know if you remember, but the popular vote loser in the recent presidential campaign promised repeatedly that he would not cut social security, Medicare, or Medicaid. Purportedly that helped him get votes from people who don't normally vote for Republicans.

Uh huh. His nominee for secretary of HHS wants to cut Medicare and Medicaid spending, by a lot, and in his confirmation hearing he refused to say that he would honor Trump's promise. No surprise, Trump's flunky KellyAnne Conway now says yup, he wants to convert Medicaid to a block grant, which is just a path to cutting it.

If you're like most people, you probably think that Medicaid spends all its money on welfare queens in Cadillacs trading food stamps for vodka. Actually 21% is spent on elderly people (much of that going to people in long-term care in nursing homes who have exhausted their assets); 42% on people with disabilities; and 21% on children.

When the money goes away, what happens? I'll bet you can figure it out.

Friday, January 20, 2017

System and Lifeworld

That's the subtitle of the second volume of The Theory of Communicative Action, by Jurgen Habermas. It's very heavy going so I don't necessarily recommend that you try to read it. But it seemed like a good title for this post.

Our modern, complex society is nothing like the kind of societies in which humans evolved. People lived in bands in which everybody knew everybody else, in fact they had varying degrees of kinship, and they communicated face-to-face. Many people are still part of communities like that, to some degree, although for most of us they are more diffuse. We're mobile, we don't see most of our kin regularly. Most of our daily interactions are in the form of narrow role relationships -- worker and boss, customer and server, teacher and student, colleague. And of course there is a vast system of mass communication that is our only window into a world far wider than the village or band, that affects us in ways that are often mysterious, in the face of which we feel largely helpless.

People's brains aren't really built for this. It's not hard to understand why people who are frustrated about the conditions of their lives would have mistaken ideas about what is causing their problems and what to do about it. It's perhaps a bit less obvious, but I hope it is now that I point it out, that messages may come through the system that people perceive as slights, or offend their sense of propriety. But in the old days any such message would come from a person you could have a conversation with. You could tell them how you felt, hopefully work out an understanding, or choose to avoid that person in the future. But people can't talk back to their televisions.

NPR has devoted about half of its news content of late to interviews with Donald Trump supporters. I can't even listen any more, I turn off the radio during my commute whenever they do this. It's just too disturbing to realize that we wound up with a malignant narcissist, authoritarian blithering idiot as president because these people are so deeply incapable of critical thinking. But as Chauncey DeVega explains, perhaps with a subtext less sympathetic than I would like, the shit will hit the lifeworld.

No, they won't get well-paying jobs bolting cars together or mining coal. If the Mexicans all get shipped back to Michoacan, their food will get more expensive. In fact, more of it will be imported and a lot of the local farms will go out of business. If we throw up high tariffs, everything in WalMart will cost more and our export industries will decline. If they repeal the affordable care act, a lot of them will lose their health care and it will get more expensive for the rest of them. And those are just the promises Trump made that they thought they liked. He's going to trash their public schools, make them breathe toxic fumes, cut their social security benefits, and oh yeah, their taxes will go up even as their wages go down.

The dirty secret is that federal taxpayer funds flow from states with liberal electorates to Republican states. As DeVega writes:

As philosopher Henry Girioux has repeatedly warned, the “dead zone of capitalism” will only be expanded by Donald Trump and the Republican Party’s obsessive advancement of predatory capitalism and austerity. “Red State” America is already economically unproductive and parasitic, largely dependent on the taxes and economic activity generated in “Blue State” America. As such, Trump’s policies will disproportionately punish his greatest supporters.

So what will happen when they look around in a couple of years and find themselves worse off? We'll find out.