Map of life expectancy at birth from Global Education Project.

Monday, March 30, 2015

The Angel of Death


There is plenty of vapid speculation going on about the possible motives of Andreas Lubitz. Lots of people are depressed, and people sometimes kill themselves, but it's obviously uncommon to take a lot of other people along for the suicide ride. Not, however, unprecedented. These researchers found 24 cases of "aircraft assisted suicide" in the U.S. from 1993 to 2012. Most of them were private planes and probably were solo ventures; however the story recounts 4 cases of commercial airline pilots deliberately crashing planes and killing passengers. In no, case, however, did they leave behind an explanation. (One pilot survived, and he was clearly psychotic.)

A somewhat different, but possibly related case, is that of Harold Shipman, a British general practitioner who is estimated to have murdered 236 of his patients, and likely more, by means of fatal injections of diamorphine, which is the name the British give to prescription heroin, which is a thing there. He was convicted of 15 murders and sentenced to multiple consecutive life sentences. He eventually killed himself in prison. Even though they had him dead to rights, he never confessed and never offered any explanation for his actions.

Unlike the murderous airline pilots, self-destruction was evidently not originally on Shipman's agenda. However, though we can only speculate, it is possible that the murder half of the motive was related. Shipman is no the only medical professional who was into murdering patients. Michael Swango is an American internist who murdered as many as 60 patients and colleagues. He murdered his colleagues by poisoning their food, but he murdered his patients much as Shipman did, with drug overdoses. According to an essay by Joseph Geringer (at the link),

Forensic Psychologist Dr. Jeffrey Smalldon (who has examined many serial killers, among them John Wayne Gacy) believes that Swango's drive is "a preoccupation with control and manipulation," including a feeling of control over life and death itself. Sans a formal examination, Smalldon says Swango displays the common threads of a narcissist. . . .


The most chilling evidence was Swango's own diary in which he said he killed for pleasure. He loved the "sweet, husky, close smell of indoor homicide." He claimed that these murders were "the only way I have of reminding myself that I'm still alive." How does one explain a man going through the arduous path of getting a medical degree and then using it to launch a career of murder and assault on the people who entrusted their lives to him? One can almost understand the attributed motivation of serial killers of murdering to have complete power over an individual. But killing for pleasure?
Lubitz, of course, didn't get to savor the pleasure of killing after the fact, but he did take several minutes to enjoy it -- he could have just pointed the plane straight down. I suspect that he wanted to go out with a feeling of power and control. Alas, we will never know.


Friday, March 27, 2015

Don't breathe the air


If you're among my 4 1/2 readers, you've heard about air pollution before. Exposure to indoor air pollution is the fourth leading risk factor for disease worldwide. That's mostly in poor countries where people burn wood or dung indoors for heat and cooking. But outdoor air pollution is the ninth leading risk factor worldwide, and that's not just because of China.

Here in the U.S., the highest exposures occur to people who live near major highways.
There is a very large body of evidence showing that in the United States, non-white and low SES people are more likely to live in proximity to local sources of pollution, including high traffic roadways. We already knew they are at high risk for cardiovascular disease and heart attacks. But now the new BMJ has two papers, one a meta-analysis confirming a high risk of stroke associated with exposure to particulate pollution, the other an observational cohort study finding that exposure to air pollution is associated with anxiety.

You may find the latter observation odd, but it's well controlled. Exposure to particulate pollution is associated with systemic inflammation, and it may be that there is a link to mental health. There are even indications that short-term variation in air pollution is associated with suicide.

Of course, it might be that there are factors such as traffic noise or lack of open space. Nevertheless, whatever the mechanism, this once again is probably the most salient problem of environmental justice in the U.S. When you push a ton of metal at 70 miles an hour down the highway by burning the residue of ancient plants, you are poisoning the unfortunate people who live and work along the route. Maybe we should do something about it.

Tuesday, March 24, 2015

The Inbox


I don't know what I did to deserve it, but I am under a continual bombardment of e-mails from publicists who would have to be out of their minds to think I have any interest other than scathing, boiling contempt for their scumbag clients. The latest is a clown who claims to be the "immediate past president of the Arizona Homeopathic and Integrative Medical Association, and the clinic director of Integrative Medicine of the American Medical College of Homeopathy." He wants me to read his book about how I can detoxify myself from heavy metals through chelation therapy.

The mystery is why these con artists aren't prosecuted for fraud. If you take people's money under false pretenses, that's a crime, right? That certainly applies to homeopathy, which is utterly absurd. If you tell me you can improve my gas mileage by attaching magnets to the fuel line or some such, and accept payment in exchange, you have stolen from me and you are a criminal. If you tell me you can cure my diseases by giving me a small vial of water, or by giving me chelation therapy even though I do not, in fact, have heavy metal poisoning, you are trying to steal from me. In fact, you are risking my life and my health, sayeth the FDA:

There are serious safety issues associated with chelation products, which can alter the levels of certain substances in the blood.  Even when used under medical supervision, these products can cause serious harm, including dehydration, kidney failure, and death.  
 
“These products are dangerously misleading because they are targeted to patients with serious conditions and limited treatment options,” said Deborah Autor, director of the Office of Compliance in the FDA’s Center for Drug Evaluation and Research. “The FDA must take a firm stand against companies who prey on the vulnerability of patients seeking hope and relief.”
 
The agency advises consumers to avoid non-prescription products offered for chelation or detoxification. The only FDA-approved chelating agents are available by prescription only and are approved for use in specific indications such as lead poisoning and iron overload. Procedures involving these agents carry significant risks and should be performed only under medical supervision.


This guy is a flat out criminal. He should be prosecuted. That is all.

Monday, March 23, 2015

Happy Anniversary!

to the Affordable Care Act, signed into law 5 years ago. (Has it really been that long?)  The blogosphere is all aflutter with the topic, so above is my value added. There were huge disparities in the rate of uninsurance prior to the ACA. They still exist, but they are much less, especially for African Americans. (Latinos who are not citizens, alas, don't benefit.) So this is real progress in the long struggle for health equity. (Numerically, by the way, most beneficiaries are white, non-Hispanic.) Hopefully all these people will vote, and will vote their interest, which means voting for Democrats.

(click on the chart to enlarge)


























Friday, March 20, 2015

Pharmagangsters

Sidney Wolfe (Nader's health care raider) in the new BMJ tells the outrageous story of rosuvastatin. As you undoubtedly know, there are several medications in the statin class, very widely prescribed for the primary and secondary prevention of heart disease and stroke. They lower LDL ("bad" cholesterol) and probably have anti-inflammatory properties that contribute to their effect.

There is controversy over whether these medications in general are overprescribed, but that's beside the point here. Rosuvastatin was approved much later than other drugs in the class, it's still under patent (I won't mention the brand name) and it is also the most widely prescribed statin in the U.S.

Oh yeah -- according to Dr. Wolfe, it's also the one with the worst risk/benefit profile. It is a associated with a much higher risk of diabetes. Obviously, if you're trying to prevent heart disease, causing diabetes is not helpful. It also appears to present a higher risk of rhabdomyolysis -- destruction of muscle tissue -- and kidney damage.

So why is it the most commonly prescribed statin? Quoth the good doctor:

A prescient answer can be found in an October 2003 Lancet editorial, “The statin wars: why AstraZeneca must retreat.”20 It stated that AstraZeneca’s chief executive, Tom McKillop, “has pledged to do whatever it takes to persuade doctors to prescribe rosuvastatin, including launching an estimated $1 billion first-year promotional campaign. ‘We’ve got to drive the momentum’, he [McKillop] said at a recent investors meeting. ‘You get one shot at launching a major new product. This is our shot.’” 

But McKillop responded with denial, and an advertisement in the Washington Post claiming, utterly falsely, that "The scientists at the FDA who are responsible for the approval and ongoing review of [Brand Name]  have, as recently as last Friday, publicly confirmed that [Brand Name]  is safe and effective; and that the concerns that have been raised have no medical or scientific basis." The FDA wrote a letter to AstraZeneca stating that the ad was false, with no basis in reality, and that the agency had substantial concerns about the product.

Dr. Wolfe concludes, "The patent for rosuvastatin expires in 2016, and with it AstraZeneca’s need to promote it. But for the sake of the public’s health, we must hope that the drug’s disadvantages will lead to a sharp decline in its use before next year."

I conclude, however, that the pharmaceutical industry appears to be largely run by psychopaths. We are talking about people's lives here, which McKillop and other pharmaceutical executives are perfectly happy to destroy for the sake of their insatiable greed. This has tremendous repercussions in undermining public trust in science and medicine, and we must constantly struggle against that mistrust. It's getting very old.

Wednesday, March 18, 2015

Boston's Trials


The city itself, of course, has endured the most snow since record keeping began, which was trial enough. But concurrently, two criminal trials have been runner-ups for local news attention. Both are ritual enactments of substantial civic significance, although otherwise in no way similar.

Dzokhar Tsarnaev's lawyers have already declared that he is one of the two perpetrators of the marathon bombing, along with his brother, although he has not as far as we know confessed himself to law enforcement. That's pretty much of no consequence because his guilt is beyond question. Yet we are having a full trial to prove guilt, complete with witnesses' unbearable, inexpressible pain and the most horrific of images. The reason for this technically is that a plea of guilty cannot be accepted in a capital trial. But the prosecutors could get to a guilty verdict with much less theater of cruelty. The real reason is that they want to kill the defendant and they believe that putting the jury through this ordeal will help them achieve that.

Those witnesses who have said anything in public away from the witness stand appreciated the opportunity to confront the defendant and tell their stories, although most have not spoken out of court. So prosecutors can use that as justification. But Tsarnaev's lawyers have indicated that they will accept life without possibility of parole, which is the only other possibility given a guilty verdict, and the Department of Justice will not agree.

Why is it so important to snuff out Dzokhar Tsarnaev? Will it fix anything?

Former New England Patriots tight end Aaron Hernandez, in contrast, is charged with a tawdry murder over what appears to be a trivial slight of some kind, although the motive is so far not publicly known or even suggested. His lawyers are trying to get an acquittal or a lesser charge, but presumption of innocence granted, so far the matter does not look good for him. He has also been charged with another pointless murder of two strangers, is subject to a civil suit for a non-fatal shooting, and it's been pretty well demonstrated that he never left behind the small-time hoodlum culture of Bristol, Connecticut from which he emerged in spite of his fame, glory, and millions of dollars.

This trial, while it's obviously about guilt and innocence from the point of view of the defendant, is about our culture of athlete worship from the standpoint of the rest of us. If the prosecutors are painting a true picture, this guy is a sadistic psychopath whose natural athletic endowment let him get away with a total lack of self-discipline or serious effort and whose only purpose in life is immediate gratification. But 10 year old boys were wearing his name on their backs. 

Monday, March 16, 2015

A puzzling incident


While in the hypnagogic state recently, I recalled something that happened as I started my freshman year in college. A recent Harvard graduate got accepted to Swarthmore, telling the admissions office that he had been in the army to account for his years after high school. (I'm not sure how he dealt with letters of recommendation and what might have seemed a strange transcript request to his high school. Evidently it didn't occur to them to ask for his service record.) He lived in a dormitory and attended classes for a few weeks before they discovered the ruse. Alas, I don't remember the dude's name.

I actually met him during freshman orientation. We were on the sidelines of an event we both obviously found bemusing, specifically folk dancing, so I tried to strike up a conversation. He was aloof, understandably. I mean, he doesn't want to get to know people and then have them start asking him about army life, of which he is utterly ignorant. People who had classes with him remarked that he seemed exceptionally well prepared.

There was no e-mail back then, which is what colleges use today to inform the community about weird shit like this. The deans issued a statement of some sort and there was a brief item in the student newspaper -- necessarily brief because how much is there to say? The grapevine had it that his explanation was that he wanted to write a book. That would be impossible, I should think, without massively violating people's privacy and trust, and demonstrating himself to be an asshole.

I imagine we all fantasize about going back and doing it over knowing what we know now. He probably imagined himself impressing the freshman girls with his maturity and erudition, acing all the courses, dominating the dormitory bull sessions. But surely he didn't expect to follow through on this for four years, graduate summa cum laude and be the commencement speaker, while having to keep his secret from everybody he knew. How he swung this financially in the first place is also a mystery. He must have had a trust fund.

Presumably Swarthmore and Harvard communicated about this, which would create a problem for him if anybody requested his Harvard transcript. That would no doubt keep him out of graduate school but would probably not be a problem for employment. In my life, no employer has ever requested a transcript from me at any level, and that includes my current position as university faculty, no less. So he probably pretty much got away with it. I don't think they tried to prosecute him.

Anyway, it was strange. Anybody have a clue what was in the guy's mind?

Thursday, March 12, 2015

Why is the ACA so unpopular?


This is a question about which I have expressed my puzzlement here from time to time. Economist Gail Wilensky, in JAMA, has a go at it. Her central proposal is that Obama's notorious repeated statements that "If you like your plan, you can keep it," and that you could also keep your doctor, turned out not to be true.

Well, yes, not literally true. Actually the vast majority of people could keep their plans, and as for not being able to keep your doctor, that was already a possibility before the ACA. It's insurance companies, not the government, that decide what docs they want in their network.

Also too, the Robert Wood Johnson Foundation and the Urban Institute find that it really wasn't all that many people who couldn't keep their insurance -- and not only that, but most of those who couldn't probably didn't like it. In 2013, the first year of the ACA, 18.6% of people with non-group insurance were told that their existing plans would no longer be offered because they weren't ACA compliant. Note that this does not mean that they lost their health insurance. What it means is that they had to buy a different, better policy, and if they were eligible for a subsidy it likely wouldn't even cost them more. That was about 2.6 million people, some percentage of whom were no doubt disgruntled, but still, that would not drive the overwhelming unpopularity of the ACA.

In 2014, that problem pretty much went away. Based on survey data:

[P]olicy cancellations caused by noncompliance with the ACA were uncommon in 2014 in both the nongroup and ESI markets, and the number and rate of cancellations in the nongroup market in 2014 was far smaller than in 2013. The nongroup market has historically been characterized by high volatility: an analysis of pre-ACA nongroup coverage patterns from 2008–11 shows that only 42 percent of nongroup enrollees retained their coverage after 12 months (Sommers 2014). It may still be the case that insurers chose to cancel policies for business reasons, such as low enrollment, so some cancellations are to be expected for reasons other than ACA compliance. The nongroup cancellations caused by unknown reasons may be explained by such business decisions.
Note the additional implication: It was not necessarily the case that if you liked your plan, you could keep it, even before the ACA. The only people who are not demonstrably better off under the ACA are:

  • Affluent people, who do not quality for subsidies, who do not get employer-provided or other group insurance, who are healthy, and who therefore chose to buy really crappy insurance. They no longer have that option and they may have to pay more, but for better insurance. If they should be hit by a bus, they will realize that they are not, in fact, worse off. How many such people are there? Very few, I'd wager.
  •  Extremely wealthy people who had their taxes raised by a tiny bit. 
That's it. The reason people don't like the ACA is because they have been told they're supposed to hate it, and they don't actually know what it is.

Tuesday, March 10, 2015

Boys on the bus

I presume you don't think that the big news is that there are racist frat boys, in Oklahoma of all places.

No, the news is that audio-video recording devices are now ubiquitous. It wasn't news that Mitt Romney thinks half the population are moochers, either. It was just news that he got recorded saying what everybody already knew he believed.

Speaking of ubiquitous recording devices, whatever happened to that NYC cop who was recorded shaking down a citzen for $1,300? I never did see the denoument. Of course, if he had just shot the guy dead, no problem.

Monday, March 09, 2015

Cooking Lesson

This is a bit off topic, but maybe somebody who has worked in a kitchen can explain it to me.

While snowed in recently, I saw Alton Brown demonstrate how to make french fries. Like all of his processes, it's a bit elaborate, but I figured, what the heck, I'll try it.

Here's what you do. First, I cut a russet potato into full length strips, about 1/4" square. I left the peels on, they're the best part. Then I soaked them in water for a few minutes, which apparently dissolves some of the outer layer of starch and is considered an essential step. Put them on a rack and thoroughly dried them.

Next, a couple of minutes in relatively cool oil, 325 degrees. Take them out, let them drain and rest, then crank up the oil to 350. (Yes, you need a fat thermometer. I used canola oil, and a dutch oven, which is fine). Cook them till GB&D. Drain them and salt them.

They were great! Really crisp on the outside, creamy on the inside, great potato flavor, non-greasy. But here's what's odd. They were actually much better than any fries I can remember getting in a restaurant, even a good one. Restaurant fries are typically limp, not really crisp, don't have that inside/outside textural contrast, and don't taste like potatoes. Why not? They're supposedly doing it professionally, and they should have the process down. But they don't.

Friday, March 06, 2015

An instructive (and fun!) presentation . . .

. . . from Uwe Reinhart (who in case you don't know is a health economist at some snobby institution in New Jersey). This is a very good basic educational piece on the history of Medicare, how powerful vested interests made it not-so-great at first (quite like the ACA, although he doesn't make the analogy), how it gradually got better more-or-less out of necessity, how in spite of its flaws it's far better than not having it at all, and how it has a perfectly secure future if we just don't sabotage it.

Also, he makes funny jokes.

Thursday, March 05, 2015

Bumper Stickers

Proud to be an American

You seem to think that's an achievement, something you earned by hard work and merit. I'll bet 100 to 1 you were born here. It's just a circumstance in which you found yourself, fortuitously if that's how you feel about it. I don't see how it's anything to be proud of. As a matter of fact, I would also wager that people who actually did achieve the status are people you don't particularly like.

God Bless America

So apparently as far as you know God has no plans to bless America, but you're hoping he'll see your bumper sticker and say, "What the heck, let's throw them a blessing." Is that really how he works?

Obama Sucks

Yeah, I really did see that one. So what exactly does it mean? He used to smoke cigarettes, but I don't think that's it. And I'm pretty sure he's not homosexual. So evidently this is just a generic term of derision. But why? Can you please tell us exactly what it is you are unhappy about?

Choose Life

Okay, so you want to provide everyone with high quality health care, make sure that every family is securely housed and every kid has enough to eat, and that the food is safe and the air and water are clean, that are good work opportunities for everybody and people with disabilities and old folks are cared for. You want the U.S. to contribute a fair share among the wealthy nations to combat malaria, TB, HIV,  diarrheal diseases and malnutrition that kill millions of kids every year in the poor countries; and of course you want to abolish the death penalty. I'm with you!

Wednesday, March 04, 2015

Not getting what the constituency is . . .

As we wait to see whether John Roberts will join Roger B. Taney in the annals of Supreme Court infamy, let's see who lines up in support of the Affordable Care Act, and who lines up against it.

For: Hospitals and health insurance companies, physicians, most academic researchers in health economics and health services (believe me, I know that first hand), the 10 million or so people who have gained insurance because of the act, the major foundations that address health care and public health, drug companies (they're actually complaining that it's pharmacy benefits should be more generous but they certainly don't want it to go away) . . . Lots of those people and groups have lots of money and even have traditionally supported Republicans.

Against: The Koch brothers and Fox News. And I don't even get what their problem is, frankly.

That's enough for the entire Republican party and Nino Scalia. It just doesn't make sense.

Monday, March 02, 2015

When will this idiocy end?

Sorry for the light posting, been busy. Anyway, a new survey of pediatricians finds that 93% of them say at least one parent asks not to adhere to the recommended schedule of vaccines in a typical month, and 21% say more than 10% of parents make this request. The ostensible point of the published article is that most pediatricians say they accede to this, but I find that baffling. I mean, they have to -- they can't go ahead and inject the kid without the parents' consent.

But obviously, resistance to vaccination is very widespread in the U.S., and I am going to give you the 4-1-1: it is nonsensical. There is no evidence whatsoever, not even suggestive evidence, that giving kids "too many" shots in too short a time is harmful or dangerous in any way. Nor that any given vaccine creates any substantial risk of anything serious for healthy children. This is not controversial, it is not an issue, it is not anything at all other than a mass delusion.

But I find it quite mysterious. There are wackos out there making all sorts of ridiculous claims, but most of them are generally ignored or ridiculed. There are people who claim that cancer is caused by radio waves, but almost nobody declines to use cell phones, even though the assertion got a lot of publicity for a while. Why is this particular version of idiocy so hard to kill?

Thursday, February 26, 2015

Sí, es muy difícil


Actually it's not Spanish for "difficult," it's Clostridium difficile, an intestinal infection which, take it from me, you want to stay a light year away from. It causes diarrhea which is beyond description, and I know because I had it.

It's been a few years, I think, since I discussed my personal history here, but while George Bush the First was busy bombing Iraq, I was in Beth Israel Medical Center in Boston having my ascending colon removed. It's a long story with many interesting lessons, but it was now almost 25 years ago so some -- though not all -- of the lessons are no longer operative. Anyway, the surgery was unnecessary, I did not in fact have cancer. I would rather still have the ascending colon, however.

I was in the hospital for 11 nights, due to various complications, C. diff being one of them. This is an opportunistic infection that happens when your symbiotic intestinal microbiota gets wiped out by antibiotics. Back then, it was pretty much limited to hospitals and nursing homes, but as the linked report in NEJM says, that's no longer the case. Only about 25% of cases have their origin in hospitals. The authors estimate, based on regional surveillance, that there were 453,000 incident cases in the U.S. in 2011, and 29,000 deaths. That's not a big bar on the cause of death graphic but it's particularly disturbing since it's mostly iatrogenic, and the problem appears to be getting worse.

Again, folks, I cannot emphasize this enough. When you need antibiotics, you may really, really need them. But do not take them if you don't need to. Make sure to have this discussion with your doctor; do not demand antibiotics if your doctor doesn't think you need them. And wash your hands, with soap.