Pie in the Sky?

Sandro Galea and George Annas, in the new JAMA, repeat the familiar lament that we invest proportionally far too much in curing people with medical intervention and far too little in keeping the population healthy through public health measures. They see health as a fundamental right and they want to adopt the Universal Declaration of Human Rights as the ethical basis for public health.

Actually they seem to fall a bit short in their understanding of what public health means. For example, they say "Public health is not alone, sharing funding and infrastructure deficiencies with transportation, education and even public safety." In fact, all of these are part of public health. Education probably the single most powerful contributor to population health, particularly education of women and girls. Mass transit, cleaner and safer motor vehicles, fire and crime prevention -- these are all public health.

The problem in the U.S. right now is that public health is all about social justice, and fixing the problems that the mythical "free market" cannot. Therefore it is unpopular with the plutocrats who run things, who would have to pay taxes to make the planet better for the rest of us.

That's why the UN's new sustainable development goals, which were formally promulgated at the beginning of this year, seem unrealistic. If the wealthiest country on earth isn't interested in investing, it won't happen. The goals include ending poverty, ending hunger, quality education for all, gender equality, affordable clean energy, climate action -- you know, all that commie stuff. Unfortunately, we have an entire major political party, that controls most of the levers of power, that doesn't want any of that to happen. So let's tell it like it is.

Darwin Day

Yes, it so happens to be his birthday, following the announcement yesterday of yet one more (kind of unnecessary) vindication of general relativity. It's worth noting here that it was general relativity, and the subsequent discovery of the expanding cosmos, that led straight to the modern understanding of cosmology and the horribly named "big bang" theory. I prefer to call it the Initial Singularity, or IS theory, because there was no bang.

Anyway, the have a deep philosophical connection, not in a positive sense -- they don't need each other to be true -- but in a negative sense, which is only important to humans right now. Between them, they dispose of God. They don't exactly make God impossible (especially since the concept is not consistently defined) but they make he/she/it completely unnecessary.

The trouble is, the more we learn about the universe the more pointless it seems, from our point of view. Which indeed it is. It isn't about us at all, we just happen to find ourselves here. I'm not sure why that's so difficult for so many people to accept. It doesn't bother me at all, we still are what we are and what is meaningful to us still matters -- but only to us. That's good news! We don't have to worry about how a merciful God could give us earthquakes and evildoers, or what we're supposed to put on the altar. We can go about explaining earthquakes and evildoers without any bother about that nonsense. And we don't have to ask "Why me?" when something bad happens to us. No particular reason other than the reasons you can observe.

So let's celebrate.

A long time ago, in a galaxy far, far away . . .

. . . two orbiting black holes spun closer and closer and finally merged, sending ripples in space-time across the universe which were observed on Sept. 14, 2015 by some talking apes inhabiting a coating of slime on a speck of dust. By a long time ago I mean about 1.3 billion years ago, which is just another way of saying how far, far away it was.

The physicists who made this observation are saying it's a very big deal. Welllll . .. .kinda. It doesn't change anything at all about our understanding of the universe, it just confirms what has been understood for (coincidentally) just about 100 years before the observation, when Einstein published the theory of general relativity. In the years since, it has been confirmed by every test, including one that indirectly confirmed the existence of gravitational waves. Einstein himself didn't even think they would ever be detected because they are too subtle. So in that sense it's not a discovery at all. It is for sure an astonishing feat of technology. And it should lead to future detection of cataclysmic events, including some of much smaller magnitude that occur closer by.

But the real implications are philosophical. Again, nothing that many people -- but not most -- don't already understand. The scale of the universe is completely beyond the intuitive grasp of humans. This event happened, according to counting logarithms on my fingers, on the order of 10^20 kilometers away. According to the investigators, each of the black holes weighed about 30 times the mass of the sun; the event momentarily generated more energy than the entire light output of the universe, an impossibly tiny fraction of which humans just detected. You would not have wanted to be up close and personal. That tiny fraction represented a displacement smaller than the charge diameter of a single proton.

The very weird thing is that it only took 3 pounds of mush inside the heads of some of those talking apes to figure out how to look for these waves, and to find them. We pack about 86 billion neurons into that mush, which is all it takes to operate the body, eat fuck and fart, and discover a universe in which we are absolutely nothing. It's really no wonder that lots of people just don't want to believe it.

Facts are stupid things

One of the many spiritual costs of spending a lot of time behind the wheel is having to read the bumper stickers on the battered vehicles of my struggling neighbors. Yesterday's soul-rotting annoyance was

Keep Working. Millions of welfare recipients are depending on you.

It was a rusty truck belonging to a tradesman of some kind. Then there was the National Pubic Radio interview with a couple of enthusiastic Trumpistas in New Hampshire who said that they were tired of illegal immigrants getting free cell phones and free health care. Of course NPR didn't bother to point out that illegal immigrants get absolutely no government benefits whatsoever. As always, they just let the falsehood sit there. (As Cokie articulates the policy, it doesn't matter if it's true, it's out there.)

As for the millions of welfare recipients, basically there aren't any, at last as my guy with the bumper sticker understands the concept. From Center for Budget and Policy Priorities more than 90% of government benefits (not counting tax breaks and subsidies for the rich, obviously) go to people who are elderly, disabled, or live in working households where the Walmart wages won't pay for the groceries. Almost all the rest goes to unemployment benefits, survivor benefits (you know, widows and orphans), and medical care (as opposed to paying for it some other way, as we have always done rather than let people expire in the hospital parking lot). In other words, the bumper sticker guy's mother, and himself if he's out of work (which he probably has been). 

But Republicans get away with making people think there's a super secret kind of welfare that all the dark people are getting that they don't have access to. And the corporate media aren't going to set them straight on it because of Cokie's rule. That's where things stand.

Trying to locate the evil

Anna Marie Barry-Jester at 538 tries to tell us what went wrong in Flint. She doesn't get very far, it seems to me. Yes, she chronicles how responsible officials ignored and belittled citizen complaints, and cooked the books on testing the water. But she doesn't explain why they did this, and she doesn't go more than two links up the chain, either, pretty much sticking to the actions of flunkies.

I'm not going to speculate about where the true responsibility lies here -- apparently the FBI is on the case and maybe they'll make some headway through the zone of plausible deniability. But the fact is, this is a crime so vast, and so horrific, it's difficult for the mind to encompass. People get 20 years for armed robbery and life in prison or the needle for murdering one person. But I will be very surprised if anybody even pays a fine for poisoning an entire city, damaging the brains of thousands of children, diminishing their prospects, and shortening their lives.

Our conception of justice is horribly distorted.

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.

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.

Consciousness

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.

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.

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.

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.

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.

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.

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.

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.