Map of life expectancy at birth from Global Education Project.

Friday, June 24, 2016

Just take a pill!

I've written quite a bit here about chronic pain. As your humble correspondent has written many times, long-term opioid use is not just dangerous, it is ineffective. And most people don't benefit from other pharmaceutical treatments. They might be worth a try, but if you do have chronic pain of neurogenic origin, you will probably need what we call a bio-psycho-social approach. That means learning how not to let pain get the better of you. Physical therapy, graded exercise, cognitive behavioral therapy, all can help.

I don't buy the full menu of non-pharmaceutical options listed by NYT reporters Meier and Goodnough -- acupuncture and chiropractic are bunk -- but I do draw your attention to the basic point. Insurers will pay for pills, but they won't pay for a comprehensive bio-psycho-social approach to chronic pain. I would add that doctors don't really know how to do it either, all they know how to do is write prescriptions.

This is a fundamental problem in our culture. We expect a pill to make everything better, whether we are anxious, or sad, or in pain. But they really don't work for those problems and the idea that what your problem is really bad chemicals that can be fixed by other chemicals is a basic misreading of your situation.

What you suffer from is the human condition. We can work hard to make that better, but there isn't any pill for it.

Wednesday, June 22, 2016

House Republicans roll out plan to screw you

Paul Ryan and his co-conspirators have been talking for years now about their plan to repeal and replace the Affordable Care Act, as soon as they get around to figuring out what that will be. They couldn't figure that out, however, because the ACA is actually working quite well and health care spending has actually grown more slowly than predicted even as the uninsured population has been cut in half. People have discovered that there has not, in fact, been a government takeover of health care and that there aren't any death panels either.

So now Ryan has issued a document which he claims is his replacement plan although it doesn't have any cost estimates or legislative language. Here's how he proposes to make the world better.

Medicare would be replaced by "premium support," meaning old folks would get money with which to buy private health insurance. Note that right now, Medicare is much more cost-effective than private insurance, because it spends far less on administrative costs and marketing, and nothing on profits for shareholders or multi-million dollar compensation packages for executives. So the insurance would be more expensive and presumably the amount government would spend would be less. So if Granny doesn't have big bucks in her 403B, she won't be able to afford comprehensive insurance.

They'll repeal the Medicaid expansion and turn Medicaid into a block grant rather than an entitlement. "Reforming Medicaid’s financing with a per-capita allotment certainly will reduce federal spending," the document says. Right. In other words fewer people will be covered and their benefits will be reduced. Or, as they explicitly say, "Under the House Republican plan, states could also “charge reasonable enforceable premiums or offer a limited benefit package” and use “waiting lists and enrollment caps” for certain groups of Medicaid beneficiaries."

There will no longer be a requirement that people have health insurance. This means, of course, that young and health people won't be in the risk pool and insurance will get more expensive for everybody else.

Insurers won't have to cover pre-existing conditions if you haven't been continuously insured. That pretty much leaves us where we were before.

There's more, but the basic idea is to make things worse for everybody who isn't well to do. Exactly why this is supposed to be better than what we have now they do not explain, but I will tell you: it will enable tax cuts for rich people.

Friday, June 17, 2016

Ho Lee-Fuq

I have seen no mention of this whatsoever in the New York Times, any of the major news networks, or for that matter the liberal blogs and on-line magazines. Only at Climate Progress did I learn that the temperature in Greenland's capital of Nuuk last week hit 75 degrees Fahrenheit, which is the warmest temperature ever recorded there in June. The percentage of the Greenland ice sheet surface that has melted is now 2 standard deviations above normal for June. The arctic sea ice is also on track for a record low.

May was the hottest ever recorded globally, and we're on track for the hottest year ever for the third year in a row. This is serious folks.

To be fair, The Guardian is covering this, even while the Brits are in shock over the murder of a Labor MP by a neo-Nazi. But here in the U.S. of A.? Crickets. Their piece is, if anything, scarier than Joe Romm's. Excerpt:

May was the 13th month in a row to break temperature records according to figures published this week that are the latest in 2016’s string of incredible climate records which scientists have described as a bombshell and an emergency.
The series of smashed global records, particularly the extraordinary heat in February and March, has provoked a stunned reaction from climate scientists, who are warning that climate change has reached unprecedented levels and is no longer only a threat for the future.
Alongside the soaring temperatures, other records have tumbled around the world, from vanishing Arctic sea ice to a searing drought in India and the vast bleaching of the Great Barrier Reef. The UK has experienced record flooding that has devastated communities across the country and scientists predict that the flash floods seen by parts of the country in recent days will increase in future.


Thursday, June 16, 2016

Betting Pool

The weeks leading up to the Republican National Convention are bound to be very interesting. Do buy your popcorn now before the shelves are stripped bare! One of the most intriguing questions is who will be the Vice Presidential nominee.

The first, essential criterion is that the person be willing to accept the honor. A desirable quality would be that the individual not be a maniac. The overlap in the Venn diagram for that proposition is very small, so we may have to relax the second criterion. Here is my take on some of the prospects, but I'm not setting odds.

1. Chris Christie. A major advantage is that he has already been thoroughly humiliated and subjugated, so that process can be skipped. He broadens the ticket's appeal to include people who are attracted to vulgar bullies and simplistic world views. Oh wait . . .

2. Ben Carson. The narcoleptic nutcase has pre-humiliated himself, a substantial service to the cause. He might alienate the white supremacist faction of T. Rump supporters. On the other hand, they may be okay with the idea of a house negro.

3. Sarah Palin. An early endorser, she also broadens the appeal to include people who are attracted to incoherent rants and preposterous conspiracy theories. Oh wait . . . . The only candidate who reads all the newspapers. Brings foreign policy gravitas from her nightly examination of Vladimir Putin's head through a small telescope.

4. Louie Gohmert. Stupid enough to think this would be a good idea.

5. Paul LePage.  Could be kept in a simulated campaign environment throughout, so that he thinks he's campaigning but is actually interacting only with actors on a sound stage in between fake flights on a convincing mock up of a private jet that produces sound effects and shows projections on the windows but never actually leaves the ground.

Perhaps you have other candidates to propose.

Friday, June 10, 2016

Legalize Marijuana

There are as we know many unintended effects of prohibiting things that people want. Sure, it's often a balance. Whether we're talking about prostitution, methamphetamine, or 32 ounce sodas there are costs of both legalization and prohibition. It's more complicated than that because various prohibition and legalization regimes are possible. Evidence of the effects of one regime vs. another is generally largely lacking, so a lot of the debate consists of speculation and moral judgments disguised as factual claims.

In the case of cannabis, however, I am fully convinced and I have been for a long time. What we know about alcohol prohibition ought to convince us. I should make it clear that there is evidence -- not definitive but worthy of concern -- that there are long-term risks of heavy use for people under 18 or so. But blanket legal prohibition isn't keeping pot out of the hands of teenagers, and furthermore the causal associations are still impossible to sort out from the evidence. A legal regime that treats cannabis like alcohol -- sold only in licensed outlets and only to adults -- and also regulates potency and labeling (which current regimes in the U.S. don't do effectively, BTW) would do a better job of protecting young people.

We already know about the damaging - and racially discriminatory - effects of law enforcement and punishment. I won't go on about that. But just as outlawing prostitution makes it less safe, outlawing cannabis drives people to alternatives that don't subject them to legal sanctions, but are far more damaging.

Specifically, we have an epidemic of products based on synthetic chemicals that interact with the same neurotransmitter system that THC does, but with far greater potency and unpredictable effects. As the linked NYT magazine article explains, people turn to these specifically because they are readily available in ordinary retail outlets, and won't cause them to fail a drug test. And they can make people batshit crazy, paranoid and violent, as well just plain kill them. Here's a shorter version of the story from Forbes if you don't want to take the time to read the long-form piece.

Here's the thing. It is impossible to suppress these drugs -- spice, spike, "synthetic marijuana" (not), whatever they are called -- because they're easy to formulate in illicit laboratories and the exact chemicals keep changing. But, nobody would want them who could easily and legally obtain real marijuana. The market would disappear. It's that simple.

Wednesday, June 08, 2016

We're Number One!

It turns out that Brown is tied with UConn for the highest number of reported sexual assaults on campus in 2014. Since I work at one and pay taxes to support the other you may think I should be upset, but it's a bit more complicated than that.

We can't say for sure, but this is probably to the credit of both universities. From what I know of the efforts of the administration and faculty here, I think it is. This represents what we call ascertainment bias. At Brown, people are willing to come forward when they experience an assault. (The headline on the story says "rape" but the category is broader.) A university of this size that had few reports would be the one with the bigger problem.

On the other hand, just because we know we have a problem while others don't know it is obviously not where the story ends. We still need to fix our problem, as best we can. It's actually a few different problems.

One is sexual harassment and coercion of students and more junior personnel (such as post-docs, research assistants and junior faculty) by powerful faculty members. That's not pervasive -- and I actually haven't heard of any specific incidents here -- but in many stories from other universities that have become public recently, what we see is that prominent, tenured faculty have enjoyed years of impunity. That must end.

Second is the general male culture. I actually think, as do many others, that women are probably safer at most colleges than they are in most other settings, but that is obviously not safe enough. Students don't magically change when they cross the invisible borders of the campus. The young men bring with them the attitudes of objectification of women, of conquest as a mark of male accomplishment, of sexuality as predation. They are also immature and can't easily resist peer culture. So the peer culture has to change.

Third is the tendency of most institutions to support their hierarchies, suppress negative news, and avoid disruption. There are perceived costs ranging from bad publicity to loss of otherwise valuable human resources that come with acknowledging inappropriate behavior and it's just easier to sweep it under the rug. So that value equation has to be rebalanced.

Fourth, it takes a substantial investment to establish and maintain rules, guidelines, policies and systems to properly address fraught and contested interpersonal disputes. Universities are not historically well equipped to adjudicate sexual crimes; but they can't just refer these problems to the courts for many reasons. The criminal justice system does a terrible job of prosecuting them, and often puts victims on trial. Violations of appropriate norms, that seriously harm people, are not necessarily legal crimes. So there have to be internal mechanisms to deal with accusations, but we're still figuring out how to do it. Expelling students and firing employees are major injuries to those individuals and the accused have rights that must be protected. So it isn't easy.

So I want people to believe that we are sincerely trying. But keep up the pressure, it's necessary.

Tuesday, June 07, 2016

Not Stayin' Alive

You probably noticed the recent announcement by CDC that the U.S. death rate increased last year for the first time since 2005, and even that was just a blip. This may not mean anything -- sometimes numbers bounce around a bit seemingly at random -- but researchers have actually been predicting it.

First, a couple of clarifications. This is the age adjusted death rate, so it's not a function of the aging population. Second, this is not principally explained by the recently observed bump in deaths among middle aged white women, widely attributed to addiction other social problems. That's too small a group to move the whole population numbers like this.

I'm not sure if this is available to the un-academic rabble, but as David Ludwig explains, what we appear to be seeing is the long-predicted decrease in life expectancy due to obesity. The culprits are heart disease, diabetes, liver disease, stroke and Alzheimer. These are all associated with obesity. (Not so clear why the Alzheimer number went up but it is often associated with stroke and cerebral ischemia so obesity may be at least a partial explanation.) 

Of course we've been Fat Nation for a long time but  Ludwig's argument is that improvements in medical prevention and treatment -- e.g. statins and blood pressure meds, heart surgery, dialysis, etc. -- have masked the deadly effects of fatness, but now medical intervention can't keep up.

All this is so far somewhat speculative but it certainly wouldn't come as a surprise. We'll need to see what happens next year, and as people take a deeper dive into this data, but let this be a wake up call as if we needed one.

And yes, there are culprits and there are important political issues here. Food marketing, walkable neighborhoods, city planning, lots of questions that president Trump could address. We'll keep talking about it.

Friday, June 03, 2016

Not sure what to think about this . . .

I don't recommend that you do this, but if you take a look at the Republican National Committee home page, (and you don't have to because I did it for you) you will see they have a lot to say about Clinton "scandals,"  they're selling George H.W. Bush socks (really!), and they have a section on faith and sections on GOP Hispanics, African Americans, and Asians (nothing about lesbians and gay men, it seems). But they have absolutely not mention and no hint of a presence of their candidate for president.

Tuesday, May 31, 2016

How is this even possible?

Here's Josh Marshall on the incredible outrage of the de facto Republican nominee for president, who is being sued for fraud in the midst of the campaign, going on repeated racist tirades against the presiding judge, before large crowds and TV cameras. Yet the only headline news I can find about the nominee today in the corporate media is his press conference at which he announces making contributions to veterans organizations.

There is a serious problem here which I will call Trump outrage overload. (I may not be the first to use the term.) Before the corporate media can get around to fully reporting one outrage, he commits another, forcing them to pivot. The New York Times ran a fairly brief Reuters article on an inside page, containing this intersting nugget of information:

Legal scholars said that Mr. Trump could face consequences for his criticisms. “Mr. Trump’s conduct could be subject to sanction for indirect criminal contempt of court,” said Charles G. Geyh, a legal ethics expert at Indiana University’s Maurer School of Law. “He has impugned the honesty of the judge in a pending case,” Mr. Geyh said, “and has done so in the context of a political rally that seems calculated to intimidate by inciting anger among his supporters.”
That's all I can find about this in the corporate media. This is a major party nominee for president of the United States, folks. And this isn't even news.

Friday, May 27, 2016

The Economics of Medical Miracles

The Academy Health* blog presents an interesting quandary in health economics. We aren't quite there yet, but the day may come soon when it is possible to essentially cure genetic diseases like cystic fibrosis and sickle cell. That sounds great!

The problem is that these are fairly rare diseases, and that the treatment would be administered only once. So, in order to recoup their research and development costs, the purveyors would have to charge enormous prices -- on the order of a million bucks a pop. That's going to make you think, "Oh, this is like those other moral dilemmas about the allocation of scarce resources. We could use that money to save 50,000 African infants or something instead."

Well, yes, but actually we already are spending it on the people with cystic fibrosis and sickle cell anemia -- actually a lot more than that in many cases. We don't begrudge with CF a lifetime of treatment that may cost $6 million, and they would be much happier getting a single treatment that actually cures them. But somebody has to finance it, which means we need to radically rethink how we organize the financing of medical services.

Then there's Norwegian physician Jarle Breivik who discusses Obama's cancer "moonshot" in the NYT. Apart from the well-known problem that cancer is innumerable diseases and there will never be a cure for "cancer" per se, it is true that we can make progress against the multiple diseases called cancer and maybe achieve something we define as a "cure" for a growing percentage of people. The problem is that the rate of cancer increases relentlessly with age; whoever we cure today is very likely to develop cancer again, either from fugitive cells from the original cancer, side effects of chemotherapy and radiation, or because it just happens. And then we're all going to die eventually anyway. Meanwhile, of course, there are still those starving African kids with diarrhea and malaria.

Medicine, in other words, faces a problem of technological imperative. If we can do it, people will demand it, but we have no fair and reasonable way of sorting out competing demands for scarce resources. 

*Academy Health is the research society in health services and policy. Yeah, yeah, it ought be the Health Academy, but it isn't.

Thursday, May 26, 2016

A Couple of Observations about Wrongdoing

Those of us old enough to remember Whitewater would prefer to forget. In a pistachio shell, the Clintons, while in Arkansas, invested some money in a real estate deal. The promoter turned out to be a sleazebag, and they lost their investment. That is all.

But the New York Times, which for reasons unknown hated the Clintons, produced a long-form investigative piece (written by Jeff Gerth, whose inexplicabe, irrational hatred for Hillary Clinton is as boundless as Donald Trump's ego), which insinuated that the Clintons had somehow been guilty of wrongdoing in the affair. The piece actually made no sense and added up to nothing, but was extremely convoluted and sufficiently difficult to follow that few readers bothered to deconstruct it and figure out that it was a complete nothingburger.

Michael Tomasky tells the story of what happened next. Briefly, a hyperpartisan pathological liar named Kenneth Starr wound up being appointed as a special prosecutor by a panel controlled by ultraconservative judges, and spent 3 years persecuting and tormenting everybody associated with the Clintons and finding absolutely nothing. Then Monica Lewinsky happened, so he switched to that, and we got impeachment.

Starr is now the president of Baylor University. He has suddenly taken to praising Bill Clinton for some inexplicable reason -- to which Clinton's friend say no thanks. He has also (okay, allegedly) swept sexual assaults by Baylor football players under the rug, for which he may (we are all desperately hoping) end up losing his job.*

 Meanwhile, Ronald T. Dump is planning to dredge up the Whitewater hoax as a campaign tactic. Since the corporate media has never accepted that it was, in fact, a hoax, since that would embarrass them, it will probably work.

So, in politics the simulacrum is as good as the reality. Or as Cokie says, it doesn't matter if it's true or not, it's out there.

Turning now to the world of art, a Manhattan gallery sold $80 million worth of works by such modern luminaries as Motherwell, Pollock and Rothko which were in fact painted by a Chinese immigrant in a garage in Queens. Now that this is known, the paintings are worthless. But they are in fact the same paintings they were when they were worth $80 million -- to some of the most discerning collectors on earth.

Think about it, it must mean something.

*Update: They kicked him upstairs. Once you're a big enough asshole, there's no way to fall but up.

Wednesday, May 25, 2016

The Bully

Josh Marshall discusses the Republican presidential candidate's attitude toward women, and his specific attacks on Hillary Clinton, which in Marshall's view are not based on tactical consideration but are rather a direct expression of the Trumpian id. Excerpt:

Listen to Trump's words and you hear repeated lines about hurting Clinton, warning her to back off and not forcing him to hurt her again. Cut and paste them out of the context of a campaign article and they read like dialog from a made for TV movie about a wife-beater. . . .

As I've written in similar contexts, when we look at the messaging of a national political campaign we should be listening to the score, not the libretto, which is, like in opera, often no more than a superficial gloss on the real story, mere wave action on the surface of a deep sea. You're missing the point in trying to make out the logic of Trump's attacks on Clinton. The attacks are the logic. He is trying to beat her by dominating her in the public sphere, brutalizing her, demonstrating that he can hurt her with impunity.
I think that this, as much as his racism and xenophobia, his hyper-aggressive nationalism, and his anti-intellectualism, explains his appeal. Many working and middle class white men are stinging from loss of privilege. Even as their economic status is stagnant or declining, the racial and gender privileges they once took for granted are eroding. The election of Barack Obama obviously drove home the loss of racial privilege, and we have seen the intense backlash. Now along comes the prospect of a woman president and it's the end of the inheritance to which they felt entitled.

The nation, and the world, are in grave danger. I am sufficiently distressed by this that it's been hard for me to post here. I'll get back to it.

Thursday, May 19, 2016

The Visible Hand

Jonathan Alpern and colleagues in NEJM discuss the plague of pharmaceutical locusts that is depriving some of the most vulnerable people of health and life. Yes, there have been a couple of famous examples, such as the psychopath Martin Shkreli who bought the rights to a decades old drug and then jacked the price up 500 times. It turns out, however, that this sort of scam has become commonplace.

As Alpern discusses, the targets are typically treatments for relatively uncommon infectious diseases, such as tropical diseases and opportunistic infections. This is because the market for the drug is small enough that it isn't likely to attract competitive manufacturers. These are people who cannot afford high out of pocket costs and may be uninsured or underinsured. As Alpern et al explain:

It seems that a new business model has emerged: companies are acquiring drugs in niche markets where there are few or no therapeutic alternatives in order to maximize their profits. Unlike new brand-name drugs, the patents of the drugs being targeted by this model expired years ago. These companies seem to have no interest in adding value to the health care system by developing new drugs. . . .

What makes this business model particularly disturbing is that vulnerable patients — such as immigrants, refugees, and people of low socioeconomic status — are often disproportionately affected, since many of the medications are for tropical or opportunistic infections. These patients often have limited or no access to insurance, or have access only through public programs, so already stark health disparities are compounded.
This is a problem only in the United States. In Europe, drug prices are regulated. The reason they aren't regulated here is because the obscenely wealthy psychopaths who have bought the U.S. political system -- including politicians, the corporate media, and economics departments -- have brainwashed us all into thinking that letting rich bastards screw us is the definition of "liberty." So that's what congress does.

Monday, May 16, 2016

The collapse of civilization

Yes, it has happened in war zones, but it's also happening in Venezuela right now due to gross misrule and the collapse of oil prices. The Gulf monarchies prepared for this eventuality by putting money away. They won't be able to live on their savings forever, but the Saudis have acknowledged that the end of the era when money gushes from oil wells is coming, and they have vowed to diversify their economy. Norway, though not as dependent on petroleum as the Saudis, is also preparing for the gravy train to end.

Alaska and Louisiana did not plan; nor did West Virginia plan for the collapse of the coal industry. All three states are in financial trouble, although of course nothing like Venezuela. (It helps that they have the federal government to help them out, although of course their political leaders won't admit that.)

The point is that it is very difficult for people to contemplate that their long accustomed way of living will have to change. The depth of denial can be astonishing. Joe Romm walks us through the climate shock we are experiencing right now. Not thirty years from now -- right now and starting last year. Scientists who specialize in this area are by constitution conservative in what they will say publicly, but obviously the positive feedbacks in the climate system are terrifying -- disappearing sea ice, burning forests, melting permafrost all amplify the process. What we are seeing now is consistent with an accelerating trend which is on the highest end of the projected range.

This is a global emergency. But it's much more important to bully and humiliate transgendered people, because that's what Jesus wants us to do.

Wednesday, May 11, 2016

We already knew this, but it's disturbing

Gillis and Fountain in the NYT discuss the fate of the boreal forest. That is the vast coniferous regime that wraps the earth south of the tundra, across Siberia, Alaska and Canada. Something like 1,000 square miles of it just burned in Alberta, which made the news, but it's burning more and more everywhere. You already know why: hotter temperatures, earlier snowmelt, pine bark beetles.

You may also ask why there was a city of 80,000 people by the banks of the black-fly infested Athabasca river in the desolate arctic forest -- you know, the one the people just had to flea before the conflagration. It's because they were occupied in mining tar sands, ultimately to pump the C02 into the atmosphere which was responsible for destroying 10% of their city. There's worse news, which is that if the forest keeps burning like this it will cease to be a carbon sink and will become a net emitter of carbon.

Joe Romm makes it crystal clear. We can't afford even the 2 degree warming target. We can't delay action, wait for a technological fix or afford ourselves the luxury of time. The time is now.