Map of life expectancy at birth from Global Education Project.

Wednesday, February 03, 2016

Expect an epidemic of exploding heads in Wingnutistan

I believe I have commented here previously about CRISPR, which is a recently developed method for precise editing of genes borrowed from prokaryotic cells. (If you aren't up to speed on the technical background, that's not really the point of this post. But I will be kind enough to say that prokaryotes are bacteria and archaea, single celled organisms without a nucleus. We are eukaryotes.) It enables scientists to make specific changes at exact sites in a gene, not without some rate of error although they are continually improving the technique.

You don't have to think very hard to see where this could lead. Although we don't yet know enough about the genetic basis of human traits such as intelligence or ability to play basketball, while we're figuring that out we could correct genetic diseases caused by single mutations. If you edit genes in a zygote, the changes will end up in all the cells of the resulting embryo, and so be heritable by the genetically enhanced persons offspring. Yep, supermanperson.

So, this being problematic for many people it is not currently allowed in the U.S. Now the UK has given permission for a single scientist to edit genes in human embryos within 7 days of fertilization, just to check out the methods. Then she is required to discard the embryos.

As you might imagine, I don't have a problem with this. These are surplus embryos from in vitro fertilization, of which thousands are routinely discarded anyway. The anti-abortionists for the most part don't seem to have a problem with that, oddly, even though according to their ideology these are morally indistinguishable from babies. But I expect this will get their attention, not because it's any different by any rationally defensible criteria but because it creates an intuitive offense to moral sensibility, i.e. the embryos are a means to an end.

Since they aren't people, that shouldn't matter. But if you think they are, it must, no?

What will probably trouble many more people is not these particular experiments, but where we might end up in the future. If it's possible to create genetically enhanced humans, it's hard to see how it will never happen.

Thursday, January 28, 2016

A couple of thoughts about Zika virus

Epidemics are scary, and often the fear is exaggerated and leads to all sorts of irrational behavior. All we need is to recall the lunacy over Ebola virus in 2014, which was never a significant threat to the United States. (Of course it was awful where it was epidemic, and the lack of sympathy here in the U.S. for people in the affected regions was at least as appalling as the misguided panic.) The flu pandemic hoax of 2010 was another excellent example.

However, the WHO's alarm over Zika virus does seem proportionate. But this is a complicated story. The virus, which is related to Dengue, has never particularly concerned anyone until now. It is indigenous to tropical Africa and southeast Asia, and was known only to produce mild symptoms. So why is it suddenly thought to be causing catastrophic birth defects in the Americas?

I don't know the answer, but I can offer a pretty good hypothesis. In areas where it has long been endemic, chances are excellent that a woman will have been infected at some time before she ever becomes pregnant, and therefore likely has long-term, perhaps lifetime, immunity. Assuming it is really true that infection during pregnancy causes microcephaly and other serious damage to the fetus, it didn't happen often enough that anybody noticed. Now, a note of caution: we are seeing a coincidence in time of the arrival of Zika in the Americas and an apparent spike in these birth defects. It's only a strong suspicion that they are related, it might be something else we don't yet know about.

In any event, if this is what is really happening, it's a variation on a classic theme. The indigenous people of the Americas were decimated by contact with Europeans because Europeans had all sorts of endemic diseases to which they had evolved relative immunity. But a population naive to an infectious disease is the formula for disaster.

In this case, it shouldn't be a long-term disaster because even as the epidemic of birth defects is raging, girls below reproductive age are getting infected, and presumably their babies will not be at risk. Of course that sanguine analysis depends on the probability of their getting infected before they ever get pregnant, and of a previously uninfected woman becoming infected while she is pregnant. Based on the African experience, we have to presume that the math works out pretty well.

But even an occasional instance of microcephaly is a terrible event. These babies will have very limited existence. So I do hope the vaccine comes soon. Meanwhile, this is a reminder that the prospect of disaster from emerging infectious disease always looms in the modern, densely populated, densely connected world. We need a World Health Organization that is well funded, highly competent, and gets full cooperation from the governments of the planet. We're short of that now.

Monday, January 25, 2016


A blog I occasionally visit, which you might enjoy, is Conscious Entities. The proprietor, who appears to be largely self-educated on the subject, but has done it well, it preoccupied with the so-called "hard problem" -- explaining our conscious experience, our self-awareness, within the modern naturalistic world view.

Of course, I may be the only entity in the universe which has the experience I call consciousness -- maybe the rest of you are zombies. That's one of the hard things about it. The only consciousness we can observe is our own. It seems a fair assumption that since humans are similar to each other in other fundamental ways, we all share the phenomenon of consciousness; and those of us who are not psychopaths are wired to believe it instinctively, through the capacity of empathy. It's less certain with other animals, but that very imponderability leads to all sorts of conflicts about ethics.

For those of who think that metaphysics is dead, the problem of consciousness is an irritant. It feels as though there is some realm outside of the material in which our selves exist. If that is not the case, then we are saying that consciousness is indeed a material phenomenon. Yet we can't detect it, and it seems unnecessary for the evolved functioning of the organism. You could presumably write a lot of instructions that process sensory inputs and generate behavioral outputs that look exactly like a conscious human, but without the consciousness part.

It's a puzzle, and since we can't detect consciousness in others directly, all we can do is talk about it.

Wednesday, January 20, 2016

People are all mixed up

Here is a thoughtful and eloquent essay about the humane practice of medicine from a physician. Dr. Newman, like me, thinks that the biological reductionism of medical practice is not good for patients. He espouses humility in medicine, and understanding the profession as both art and science.

It appears that he also occasionally drugs his patients and sexually assaults them, or so it is alleged, which would seem harmful to the cause. I find this quite mysterious -- certainly I can't see how it is gratifying or why anybody would do that. If you think about Bill Cosby's public persona and his (rather prissy) hectoring about rectitude and respectability, it seems these are kindred spirits.

The Jekyll and Hyde story is archetypal, I suppose. All people are a mixture of good and bad, but some people conceal more than others, and have more extreme polarity. I guess you never really know.

Monday, January 18, 2016

One thing that doesn't get said enough on MLK day

It is not just outrageous, but grotesque, that the FBI headquarters is still named for J. Edgar Hoover. The gay-hating homosexual racist far right blackmailer who, among other crimes against the people of the United States, tried to extort Martin Luther King into committing suicide. Read this and barf.

Members of Congress have tried to get legislation passed to take Hoover's name off the building, but it never goes anywhere. It seems he is still very popular with one of the two major political parties.

Thursday, January 14, 2016

Long Term Problem

John Iglehart, in the new NEJM, does the Cassandra thing with Long Term Services and Supports, also called Long Term Care. (I'm not sure what the public access is to this piece.) The kicker is that right now, this problem is getting essentially no attention from politicians.

Most people who have chronic disabling conditions get most of their care from unpaid family members or friends -- some 40 million people currently in that role. Many of them end up leaving the workforce because they can't handle both jobs simultaneously. What many people don't seem to know is that their health insurance -- whether it's private insurance or Medicare -- won't pay for long term health care, in a nursing home or in the community, and won't pay for essential non-medical services such as housekeeping. It costs more than $90,000 a year to be in a nursing home, and $43,000 to be in an assisted living facility or to get full-time home health aide services. Very few people have that kind of money.

Right now about half the people who need LTSS are over 65 but that percentage, and the absolute number, will obviously increase as the population ages. Not everybody will ever need to pay for LTSS -- some of us are lucky enough to die before we develop severe disabilities -- and others won't ever have to pay for it because we'll be able to rely on family members. But 16% will spend more than $100,000 and few elderly people have that kind of money. I think you know what happens in that case -- you have to spend everything you have, then Medicaid takes over.

It is possible to buy long-term care insurance but it is very expensive and hardly anybody has it. While the Republicans are all promising to repeal the Affordable Care Act, neither they nor Hillary nor Bernie are saying anything about this problem. It's solvable the same way many of our other severe problems are -- tax the rich.

Tuesday, January 12, 2016

Diversionary Tactic

Rita Rubin, in the new JAMA, discusses the relationship between mental health treatment and gun violence. Since we can't seem to get any policies implemented that will actually reduce gun violence, it's fashionable for politicians to use the problem as an argument for improving accessibility of behavioral health services.

I am reluctant to be contrarian about this because I'm all for getting people the help they need. However, this is an excellent example of the way cognitive biases distort our politics. While it is true that mass shooters -- like the perpetrators of the attack on Gabby Giffords and the Aurora, Colorado movie theater massacre -- are disproportionately likely to be seriously mentally ill, such mass killings are a minuscule proportion of all gun violence.

And of course, the vast majority of people with mental illness are not dangerous -- they are far more likely to be victims of violence than perpetrators. And psychiatrists just have no way of predicting who is going to commit violence. So the argument that mental illness is a modifiable cause of gun violence just stigmatizes people who have enough problems already. The real point is to divert attention from what we can do effectively to limit gun violence -- much of which, by the way, is either suicide or what you might call accidental or might not.

After a mass murder in Australia in 1996, that country imposed much more restrictive gun laws. They banned some semi-automatic weapons altogether, and required people to get a firearms license and to show a good reason -- not just "self-defense" -- why they needed to own a gun. They bought back 700,000 weapons which were no longer legal. Since then, the incidence of gun violence in that country has fallen substantially, and there hasn't been a single mass killing. And the Australians do not live under tyranny.

So let's not surrender to this diversionary tactic. Yes, let's fix our mental health delivery and payment system. But don't pretend that will do anything to solve the gun violence problem.

Tuesday, January 05, 2016

But, the ACA does fall short

A New York Times survey finds that about 20% of people under 65 who have health insurance nevertheless have trouble paying out-of-pocket medical costs. The problem is that health care in the U.S. is still the most expensive in the world and many insurance plans have high deductibles and co-pays. People who sign up for health care on the ACA exchanges in particular tend to pick plans with high out-of-pocket costs because they are attracted by the lower premiums; but this doesn't necessarily turn out to be a good bet.

We still need universal, comprehensive, single payer national health care. Many of us supported the ACA because we thought it would be the camel's nose under the tent; but if anything it leaves the insurance companies more entrenched. Ultimately, we need a Democratic congress and president who are willing to take them on. I don't know if that's possible any time soon, but it's still the answer.

Tuesday, December 29, 2015

The Alternate Reality Care Act

As Paul Krugman does from time to time, he once again points out that the Affordable Care Act is working at least as well as hoped for, giving a helpful link to the latest Commonwealth Fund report that proves it. He also points out, as he does at the same time to times, that Republican politicians and they're allied scribblers and gibberers willfully refuse to embrace this reality and continue to predict the policy's imminent collapse, or even to claim that it is already happening.

Well he's right, but how can they get away with this? Part of the reason is that most people have been pretty much unaffected by it -- they still have the same employment based insurance or Medicare that they always did, so it doesn't really have anything to do with them directly, but if their congresscritter or favorite yacker is claiming it's a disaster for other people they aren't staring directly at the counterevidence. In fact, since premiums continue to go up, albeit more slowly than before, they can be persuaded to blame Obamacare for a situation that it has actually helped to ameliorate.

It is also true that people with relatively high incomes, who don't quality for big subsidies and chose not to buy insurance before, don't get the greatest deal. They might resent the mandate. There aren't many such people, and what is demanded of them is that they be socially responsible, but lots of people don't want to be. And yes, people who have benefited still have substantial out of pocket costs and their insurance will only turn out to be a good deal for them if they have major medical expenses. But that's true of the homeowners and car insurance too -- that's what insurance is for.

Still, the biggest problem is the corporate media, who won't sort out the truth for people -- not necessarily because of their philosophy of not refereeing fact and falsehood, but because they don't actually understand health care policy -- and the chickenshit Democrats who should have mounted a full-throated defense of the ACA from the beginning, and instead hid under their desks, where most of the remain.

Better Democrats, please.

Wednesday, December 23, 2015

The Golden Age of American Politics

Actually, there wasn't one. The present may seem particularly horrifying but it really isn't. Before 1860, obviously, we had slavery and we were busy exterminating the natives and stealing their land. Then right after the Civil War the freed slaves wound up back in bondage as sharecroppers and terrorists roamed free in the land to assure they didn't assert any political or cultural rights. There was scarcely any objection.

We had the Gilded Age in the 1920s and then yes, we got some progressive measures through in the 1930s but that was only because the circumstances were desperate and that was the only way to save capitalism. The post-war years felt a little better but then we got Vietnam, Nixon, and Ronald Reagan, followed by the triangulating Bill Clinton and He Who Shall Not be Named. Barack Obama had 2 years before racist, reactionary lunatics took over the congress, not to mention most of the states, and now we have the Age of F.F. von Clownstick.

So really, the struggle is never ending. It isn't about fixing our foul stew of plutocracy and racism, it's about keeping up the fight. I intend to do so.

Sunday, December 20, 2015

The River in Egypt

Reading this piece by Elizabeth Kolbert on the coming innundation of much of Florida, specifically focusing on the imminent uninhabitabity of Miami Beach, I found myself profoundly baffled.

The governor of the state and one of its senators, along with the entirety of their political party, maintain that this is not happening, and that the claim it is happening is not just a mistake, but a deliberate hoax by thousands of scientists and allied politicians who are conspiring to rob us of our freedom because of some reason they don't quite get to specifying.

Presumably the politicians who say this know it is completely insane. I don't know about James Inhofe, he is an idiot who might actually believe it, but the delusion cannot possibly be widespread. Rick Scott and Marco Rubio are liars. And what are they planning to say when all of that very expensive real estate disappears? I mean, this isn't happening fifty years from now, after they are dead. It is happening today.

I really do not get it.

Friday, December 18, 2015

Missing the point when it's the size of the moral universe

Here is a very strange essay by physician Vyjeyanthi S. Periyakoil about his interaction with a dying patient, a Vietnam veteran who had never spoken to people about his combat experience. The man finally confesses to the doctor the reason for his long-concealed distress. The essay is all about the terrible burdens carried by veterans.

However, what the good doctor fails to observe is that the soldier's burden is that he murdered a pregnant teenage girl in cold blood, a peasant who just happened to be in the wrong place at the wrong time, because she had seen him and might have given away the presence of U.S. troops in the area. This is the doctor's take on it:

What would I have done if I had been in his shoes, I wondered. I could have let the girl go, but maybe the mission would have been compromised and my entire platoon would have been killed or taken prisoner of war.
Er, no. Evidently this was the policy of the United States army the time, but this was in fact a war crime. I remember during the war reading an outraged essay by a conservative writer about how Viet Cong propaganda was claiming that U.S. troops murdered young women with knives. What do you know, it was true. And how weird that the New England Journal of Medicine would publish this essay in this form. These sorts of personal musings are actually peer reviewed (I have done it myself), so this was read by at least three people in addition to the editors.

Thursday, December 17, 2015

And the Terrorists Have Won

Now all you have to do is send an e-mail, and the second largest school system in the country will close, keeping 650,000 children home. If you think that's ridiculous, you have forgotten about the world's second most ridiculous human, Chris Christie, who said this in the "debate."

"The second largest school district in America in Los Angeles closed based on a threat. Think about the effect that that is going to have on those children," Christie said during his opening statement at the fifth Republican presidential debate in Las Vegas. "When they go back to school tomorrow wondering, filled with anxiety about whether they're really going to be safe. Think about the mothers who will take those children tomorrow morning to the bus stop, wondering whether their children will arrive back on that bus safe and sound." The governor then suggested the Obama administration was to blame for failing to address the threat.
Uh, governor, it was a hoax, by somebody who doesn't even know how to make a convincing impression of a Muslim. But basic logic and obvious facts are irrelevant to Republican voters, so he'll probably get a bounce in the polls.

Monday, December 14, 2015

The Paris climate agreement

Joe Romm actually has a positive view of the Paris accord, which surprises me a bit. If you haven't had a chance to get familiar with it, the 186 participating nations each have pledged what's called an "intended nationally determined contribution" toward a goal of limiting the global mean temperature rise to 2 degrees Celsius. However, the existing intended contributions aren't enough to get there -- they will need to be reviewed and ratcheted up going forward.

That sounds great but there is no enforcement mechanism. It is meaningful that essentially all of the world's nations agree that yes, there is a problem, and yes, we need to do something about it. The symbolism is powerful and it may help politicians in some countries establish more effective policies. To my mind, however, that is speculative. The agreement is purely rhetorical. It doesn't actually do anything. The economic forces driving fossil fuel consumption are unchanged.

The only really effective measure, which happens to accord with brown shoe economic theory, is a tax on CO2 emissions equal to their social cost -- which means enough to drive them to zero within a few years. In other words, we need to make investments in essential technology and infrastructure pay off. That includes energy storage, and  a "smart" electric power grid, which are necessary to make renewable energy viable. A carbon tax can also provide subsidies to low-income people so that they are not economically harmed in the short run, and subsidize energy conservation and adoption of renewable energy sources.

And yes, it will have to be global.

If the nations of the world can't come together to do that, or something very much like it, the agreement is just so much hot air. And given that one of the two major parties in the nation with the world's largest economy denies reality, we're a long way from doing anything meaningful.

Here's Bill McKibben's less enthusiastic take on the accord.

Thursday, December 10, 2015

On becoming a physician

JAMA this week is a semi-theme issue on the evils of medical education. Most of it is behind the paywall but they are letting you read this on the high rate of depressive symptoms among physicians in training.

It isn't really surprising. I've had a couple of friends go through it and, first of all, the all consuming demands on medical students and residents lead to a lot of breakups with spouses and partners. Second, there are those all consuming demands themselves. And, perhaps most important, there is the unprecedented encounter with suffering and loss. All day and night you're working with sick and dying people, and watching them die, and telling them they will die, and seeing their loved ones suffer, and sometimes you think you screwed up and it's your fault and sometimes you really did screw up.

On top of that, as the issue also recounts, there is still a tendency for preceptors to be abusive and to humiliate trainees. It's just very hard to root that out of the culture.

The huge challenge for physicians is to compartmentalize -- to really be compassionate and empathic when dealing with patients and families, to really care, and then to leave it behind, at least enough to live with yourself and have a happy life. Not everyone can do this. Physicians sometimes burn out, and in addition to depression, they are at risk for addiction (the drugs are right there) and suicide. Yeah, they make the big bucks, or at least bigger than most. (Less so primary care doctors, who also work very hard.) And its no excuse for misbehavior or mistreatment of patients.

But it's not an easy job. Never forget that.