Map of life expectancy at birth from Global Education Project.

Monday, October 17, 2016

Providence, RI exercises common sense

Our previous Director of the state health department convened an Emergency Medical Services working group, consisting mostly of fire chiefs and EMS personnel but also including me as the token academic. It was fun. I would wear the firefighter jacket I inherited from my father.

Anyhow, one of the big issues for EMS is what they call Frequent Fliers. I forget the exact percentage, but the majority of ambulance runs transport a small number of people who ride anywhere from once a month to, seriously, one guy who was transported 235 times in 2014. How can this be, you may ask? Well, a lot of them are incorrigible alcoholics. The problem for EMS is that they had no place to take them but the emergency department. There were legal and financial issues involved, as well as the simple lack of an alternative. As you presumably know, emergency departments are expensive and they have a lot of what drunks don't need and nothing that they do need. They'd just sit there until their blood alcohol went down, get kicked out, and come back a few days later.

So, it required an act of the legislature to do three things: protect EMS from liability for transporting people elsewhere than the ED; allow them to be paid for doing so; and create the place to take the drunks. The place hasn't opened yet but it's under construction. The people will get counseling and other services. Whether that will lead to any of them getting sober is unclear, but it will save the city and state some money and who knows, maybe it will actually help some people.

The strange thing is that it took so long to figure this out, and that most cities still operate as Providence has done until now. We just get stuck doing things the wrong way, it seems.

Friday, October 14, 2016

Back to the Knitting

Haven't posted for a couple of days because it felt like, what's the use? The world has gone insane. But what the heck, we're still here and there are still problems that matter so let's talk about some of them.

This week's NEJM puts the focus on serious mental illness -- the people who used to be in what were called "insane asylums" but are now more commonly living on the street or in prison. Lisa Rosenbaum discusses the history and the dilemmas created by the current situation. In a companion essay, Christine Montross discusses mentally ill people in prison.

You probably have heard about conditions in mental hospitals back in the day. They were indeed totalitarian realms in which patients were often degraded and abused. When antipsychotic drugs became available that could control symptoms of severe mental illness, a movement sprang up to move people out of mental hospitals and into supportive community settings. Everybody thought that was a great idea so they largely closed down the state hospitals and moved the people out. However, they didn't do part B, which was to create the supportive settings in the community. Part A saved a lot of money, or seemed to; part B would have required spending money.

So homeless shelters and prisons, rather than group homes, ended up replacing the asylum. Many people with severe mental illness can't behave the way prisoners are supposed to behave so they end up in solitary confinement. People who are (maybe) lucky enough not to be in jail are sleeping on the street. If you live in the city you see them all the time. And no, we aren't saving money. Prisons are expensive, and so are hospital emergency departments which people with serious mental illness land in with sometimes astonishing frequency. (Providence EMS, I am told, transported one individual more than 200 times in 2014.)

We might have a discussion of these issues in our political campaigns, or so you might think.

Friday, October 07, 2016

Threatened Sanity

As I may have mentioned once or twice, I have a long commute. I have what I am increasingly deciding is a bad habit of listening to National Pubic Radio under the misapprehension that I am making some positive use of the time.

Currently they are doing the common lazy journalistic stunt of rounding up random nobodies-in-particular and getting them to talk about why they are going to vote for candidate A or B.. In this case 50% of them are going to vote for the Cheeto dusted megalomaniac.

These people all have one thing in common. They are blithering idiots who presumably are able to dress themselves or they wouldn't be out in public, yet that seems implausible. I discovered that I cannot listen to their drivel so I have to turn the radio off for a couple of minutes until I'm sure it's safe.

Many people are now questioning the viability of our electoral republic. The tolerability of letting idiots vote is dependent on the proportion of idiots in the population and it is evidently much too high. Of course there is a disease vector for the epidemic of idiocy -- the corporate media.

There are signs that some editors are waking up to the horrific danger they have created. The New York Times has improved a bit in the past couple of weeks, although they are still gasping desperately for balance, as with a recent long-form piece discussing Bill Clinton's extramarital adventures. But even the victories are Pyrrhic. We're talking about how the candidate insulted a former beauty queen and whether he pays taxes. As Krugzilla notes, we aren't hearing a word about the crisis facing industrial civilization; and I could add, pretty much anything else of substance. Apart from the border wall and the Muslim ban, both of which may or may not currently be operative, the people don't know anything about policy differences. Well, okay, one candidate doesn't really have policies but he will sign everything that Paul Ryan and Mitch McConnell put on his desk and appoint Rush Limbaugh to the Supreme Court.

The discourse is so debased and depraved that it makes you wish for a philosopher king.

Tuesday, October 04, 2016

Why premiums are rising on the ACA exchanges -- and the deeper meaning

Health economist Uwe Reinhardt professorsplains it for you.

There are a couple of moving parts to keep in mind here. The first is that for any given health care service or product, the price is higher in the U.S. than in the rest of the world. It just costs more to deliver the same amount of health care here as it does elsewhere. There are a couple of reasons for this, which I'll mostly leave for another day, but this is a hard problem to fix because obviously those high prices are going into the pockets of people who are politically influential.

The next point, which Reinhardt shows you in graphic form (do lick link) is that 50% of people account for 97% of all health care spending, and the top 10% account for 65%. That's okay -- that's the whole reason why we have health insurance at all, because very few people in the top 10% have even a fraction of the income they would need to pay their own way. Health care is completely unlike other basic goods. We all need about the same amount of food, and the cost of basic shelter and clothing are about the same for everybody.

Now obviously if you're well off you can buy fancier food and clothing and bigger houses, but that's pretty much beside the point. Few of us want to consume more health care than we need -- with the exception of a very small number of people with psychological disorders, it's no fun at all, in fact it's often painful and otherwise unpleasant. And vanity cosmetic surgery is not paid for by insurance so that's also beside the point. Those people who are consuming a lot of health care need it.

So the way civilized countries solve this problem is that they give everybody basic health care coverage and finance it from some sort of a universal levy that has people paying a share they can afford -- simplest is a system funded from a progressive income tax, but some countries use kludgier systems just because.

Before Obamacare, people generally either had coverage through employment; or through government -- Medicare, Medicaid, military service and veterans' benefits. People were eligible for this coverage regardless of their need for health care, which meant broad risk pools including people who consumed relatively little health care, making the whole thing affordable. But people who didn't have coverage through these means couldn't buy insurance if they happened to be sick and actually need it, because it would be very expensive, precisely because otherwise uninsured people who were healthy would not choose to buy insurance and therefore they would be joining a very expensive risk pool.

So the Affordable Care Act forced participating insurers to issue policies to all comers, and to offer them all the same premium. The individual mandate was necessary to force young and healthy people into the pool, but for political reasons, the penalty was set much too low. Therefore insurers discovered that policies sold through the exchanges were costing them more than they expected, therefore they are jacking up the rates (or getting out of the market), which is just going to cause even more relatively healthy people to forego insurance and pay the penalty and so on. This is called the death spiral.


A) Jack up the penalty for not buying insurance. Stat.
B) Pay for universal health care through the tax system. Yes, that means higher taxes but you won't be paying insurance premiums, so you'll actually save money. (And if you get health care through your employer, you're paying for it whether you know it or now.)

But we have a weird, ideological aversion to anything called taxes. We want what they buy, but we don't want to pay for it. Because Freedom.

Wednesday, September 28, 2016

Brave New World?

There has been a lot of yammering but very little explanation or understanding of the baby recently born to a Jordanian couple which is purported to have "three parents." The technique which made this possible is illegal in the United States and apparently for some reason offensive to many people.

The baby does not have three parents, he has two. What he also does not have is Leigh's disease, which is the whole reason the procedure was done. But in order to really understand what happened, you need to understand something about the history of life on earth, which was not created in seven days 10,000 years ago.

Some time around 2 billion years ago (no way to be at all exact) one cell absorbed a smaller one, which survived and reproduced inside it and so the smaller cell's descendants continued to inhabit the larger cells descendants after the larger cell divided. The two cell types then evolved together as a symbiotic community. The smaller cell gradually lost most of its genetic material (some of it may have migrated to the nucleus of the larger cell) and was reduced to specialty functions, most notably as the manufacturer of Adenosine Triphosphate, the cell's energy source. The DNA that remains in the mitochondrion is only what is needed for mitochondrial functioning. It has not influence on the development or characteristics of the organism beyond any effect of defective mitochondrial functioning, an example of which is Leigh's disease.

The nuclear DNA is the DNA that combines chromosomes from the mother and father, and determines everything else about our genetic inheritance. The mitochondria are inherited exclusively from the mother through the cytoplasm of the ovum. You could vacuum out all the healthy mitochondria from a fertilized ovum (gamete) and replace them with equally healthy mitochondria from a different, completely unrelated person and the resulting human would be completely unaffected.

In this case, the mother had some healthy mitochondria and others that had a fatal mutation. She had enough healthy ones that she was not ill, at least not seriously; but there's no telling what the proportion of functional and non-functional mitochondria will be in any of her ova. Unfortunately, she'd had the bad luck to have two babies who were severely affected and who died young. What the doctors did in this case was simply to transplant the nucleus from one of her ova into another woman's ovum from which the nucleus had been removed, and fertilize it with her husband's sperm. Result: baby with two parents and no mitochondrial disease.

It had to be done in Mexico because it's illegal in the U.S. I await an explanation of why this is unethical.

Monday, September 26, 2016

Social Psychology vs. Parapsychology

Hard to say nowadays which is less credible as science. Here's a lengthy post by Andrew Gelman about the so-called "replication crisis," which is a fancy way of saying that the entire field of social psychology is looking like mostly bunkum.

The defensiveness of its practitioners is to be expected, but let's check our own walls for glass before throwing stones. The main problems in the field of social psychology are not ones to which other social sciences or for that matter biomedical research are immune. It's a bit hard to explain if you haven't taken much in the way of statistics or research methods generally, but the keystone issue is the worship and misunderstanding of the concept of "statistical significance."

If I compare two samples from a given population, with an equal (or at least known) probability of being selected at random, and some with characteristic A are more likely to have characteristic X than are those without A, I want to know how likely this is to just be a coincidence. If the observed difference is expected to occur less than 5% of the time when there isn't really a difference in the total population, we say the "p value" is less than .05 and we declare the observation "statistically significant" which is presumed to be more or less synonymous with "true." If the probability is 6% we declare the observation "not statistically significant" which is presumed to be synonymous with "false."

This is so wrong for so many reasons it makes one feel foolish to point them out. One is that the p value depends on sample size as much as it does on the magnitude of the effect. If my sample is too small, I will be likely to get an insignificant p value even if a meaningfully large effect exists. If the sample is large, I will likely get a "significant" p value for an meaninglessly small effect. A bigger problem is that if I make multiple comparisons I will likely find a "significant" value in there just by chance, because you have to multiply the values by the number of comparisons. Cherry picking the ones that are "significant" is basically fraudulent, although it seems most people who do it don't know that.

Other problems are that in social psychology, dependent variables are typically quite subjectively measured and it may be difficult to detect observer bias; independent variables may be associated with other, unmeasured variables that are actually responsible for any effect; there are all sorts of rationales for excluding cases selectively after the fact; and samples are rarely representative of any broader group than (quite typically) undergraduates at a selective university from which they are drawn -- who, by the way, are quite likely to divine the research question and consciously or unconsciously alter their behavior in response.

Gellman points to all sorts of other design flaws but the overall lesson is that it's just too easy to find what you are looking for. These studies get a lot of press because they seem relatable and often directly relevant to our own lives and supposed behavioral predispositions and those of the people around us. But they're largely gahrbahzh. So sad.

Thursday, September 22, 2016

Too many emergencies

Yes, the Trump Foundation and the border wall and birtherism and all of the dreck that spews from Ronald T. Dump should get news coverage.

However, there is shit happening in the world that is like, really, really important and probably ought to be discussed by the candidates. You know, that little climate change problem, nucular weapons, mass extinction . . .

There is also this. When antibiotics stop working, it's not just those poor dusky-hued people in distant lands currently dying of tuberculosis who will be shit out of luck. It's you. Not only might you die from an infected scratch on your hand, common surgical procedures will be far too risky, women will die in childbirth and children will die from strep throats. Gonorrhea and syphilis will be incurable.

Of course, avoiding this fate requires paying a few cents more a pound for pork, beef and chicken, so we can't possibly afford it.

What are the chances it will come up in the debate on Monday?

Monday, September 19, 2016

San Quintin

Many years ago, I visited the small town of San Quintin in Baja California Norte with my then-girlfriend. There is, or was, a small resort there catering to United Statesian surfer bums and retirees. Pensioners would live there because it's cheap and the weather is always sunny and warm. They never bothered to learn Spanish and would order the staff around arrogantly. (Of course.)

We visited the town which consisted of a few cinder block shacks, a Pemex station, and a fly-infested general store. The people had a few wilting cabbages and starving cows. One guy owned the whole place, he had a farm down the road where the women and old men who hadn't gone north labored in the dust to fill trucks with tomatoes for the journey up the peninsular highway. He had all the water rights so the peasants couldn't irrigate their pathetic gardens. There was a big field with a fence around it and a sign saying "no cazar." (No hunting.) There was a guy sitting on a horse with a rifle to make sure nobody did. Mostly though there was nothing to hunt. More than a mile or so from the ocean was high desert, just coarse sand and the meanest cacti you ever saw.

Oh yeah. The farm had pumped out so much groundwater that salt water was intruding into the aquifer and the water in the resort was spoiled, so they had to use bottled water. It hardly ever rains there. It looks like that's about to change:

The storm is taking dead aim at San Quintin. When we were there I found some old cattle bones sticking out of the sand. The people told me the beast had drowned in a storm some years ago. So, once every thirty years or so they get a tropical storm. I imagine the desert blooms.

Friday, September 16, 2016 (wonky)

Krugman does the "wonky" trigger warning on his blog so I figured I should too. A major problem with biomedical research is what's called "publication bias." This takes a couple of forms. One is that negative findings -- i.e. "A does not cause B" or "is not associated with B" -- are unlikely to be published. Journal editors and reviewers just don't think they're exciting. However, if there are three trials that show that A does not cause B and one that does, and the last one is the only one that gets published, we wind up with a false view of reality.

A second form is that -- oh, did I ever mention that drug companies are evil? They choose not to publish studies that are unfavorable to their products. Same result, we come to believe that drugs are much more effective than they really are.

Another problem is post hoc analysis. If your initial hypothesis isn't borne out, dredge through the data to find some sort of significant association, say with a sub-group or a variable that you originally intended as a covariate rather than an outcome. The problem with this is that the p values are spurious, because if you make a large number of comparisons some associations will appear significant just by chance, when nothing is really going on.

Recognizing these problems, the FDA requires that all clinical trials for drugs be registered in advance, so that a) we'll know what the original hypotheses and protocols were and b)  we'll know about trials that aren't published. The penalty for not reporting your results within a year is supposed to be $10,000 a day.

Surprise! It isn't happening, and the law is not being enforced. We know that results aren't being reported in many cases, but we don't know how many trials aren't even being registered in the first place. Things appear to be getting a bit better, but there are still a lot of drugs being prescribed that probably should not be. This is a huge scandal that is almost completely ignored while we obsess over Hillary's e-mails.

Monday, September 12, 2016

Science for Sale

As my 2 1/2 long time readers have probably noticed, nothing frosts my pumpkin more than corrupt science. Well the gourd has a thick layer of ice right now. Stanton Glantz - a major figure in exposing corruption of science by the tobacco industry, has turned his guns on the sugar industry. They too were paying scientists to say that sugar is good for you.

You may recall that we had a consensus for a couple of decades that the way to avoid heart disease was a low fat diet. It's taken a couple of decades more to eradicate that falsehood and it's still clinging to life. Food manufacturers touted their "low fat" products as healthful while they were full of toxic sugar. What we're finally getting around to understanding is that dietary fat -- other than transfats -- and dietary cholesterol do not cause atherosclerosis. But sugar does, and it also causes a glycemic spike in the blood which contributes to diabetes. Plus it makes you fat. The entire edifice of nutrition science from the late sixties right into the nineties was a fraud erected by the sugar industry and its scientific prostitutes in academia.

That's really evil.

Thursday, September 08, 2016

Celebrity Jeopardy

So one way I dispose of 1/2 hour of unneeded consciousness from time to time is by watching Jeopardy! For those of you who aren't familiar with the program, they have special tournaments for categories such as high school students, college students, teachers and what not. They also do a celebrity tournament every year which features people who for one reason or another are famous. As it turns out famous people tend not to be very smart so they make the questions really easy.

This year many of the players as it turns out are "journalists," among them Chuck Todd and Anderson Cooper. Apparently the only reason they agreed to go on the show is because of the Dunning-Kruger effect. As it turns out they are both astonishingly ignorant of the most basic facts of history (e.g., Cooper thought that Alexander the Great presided over the golden age of Athens, and also couldn't figure out that "tank" is a word that means both an aquarium and a war fighting machine) and incapable of the simplest deductive thought. They revealed themselves to be total airheads. Louis C.K., on the show with Jonathan Capehart and Kate Bolduan -- who are maybe a small notch above Cooper and Todd but not much when it comes to gray matter -- destroyed them both. I will venture to say that comedians in general are probably much smarter and better informed than journalists.

The way you get to be a talking head on TV is by being pretty and having good diction. Being an idiot who will read whatever drivel and propaganda your corporate overlords put in front of you is how you rise to the top and make millions of dollars.

Tuesday, September 06, 2016

Rapid Testing

Reading between the lines -- and not very far between them -- it appears the whole Theranos corporation thing was never anything but a scam, although as with most cons it is likely that CEO Elizabeth Holmes on some level believed her own bullshit.

For those who don't know, this was a silicon valley start up that promised to do a whole suite of medical tests from a drop or two of blood. No more getting the needle and giving up vials. The company attracted billions in venture capital and Holmes was briefly recognized as the world's wealthiest female entrepreneur. Turns out, the technology doesn't work and the billions have melted away like the snows of March.

What you may not know is that this probably didn't seem preposterous to investors because in fact you can get some reliable test results from a fingerstick, in just a few minutes. Many large practice now have on-site rapid testing for blood lipids -- i.e. cholesterol -- and what is called the HbA1c,* which is an indicator of what your blood sugar has been over the past few weeks and is the standard for monitoring diabetes control.

When practices have these things, it makes diabetes care better, easier and cheaper. You come in for your visit, the medical assistant pricks your finger and gets a drop of blood for the HbA1c and a small pipette for the lipid test. Then she (yeah, usually it's she, that's the real world) goes down the hall, sticks them in a machine, and in a few minutes has the numbers to give your doc before the visit. The alternative is for the doctor to give you a test order and for you to make a second visit to a lab, in which case the doctor won't have your test until after the visit when obviously it's much less useful. Plus which you might not bother to get the test at all.

Unfortunately, other than simple blood glucose that's all we've got right now. Other tests require more blood and can't all be run by one machine either. It is probably impossible even in principle. But what the Theranos story tells us is that with sufficient audacity and a convincing act, even smart rich people can be conned. Viz. Bernie Madoff and Ken Lay, among too many others to name.

* Stands for hemoglobin A1c, and the way it works is that the glucose in your blood gets attached to the hemoglobin in your red blood cells. The more glucose, the more of it is attached. This is also called "glycolated hemoglobin."

Tuesday, August 30, 2016


Clostridium dificile is a bacterium which is an opportunistic pathogen in humans. Specifically, it infects the intestines and causes severe diarrhea, which can be fatal but is always indescribably unpleasant. Much C. dificile is now antibiotic  resistant as well.

For the medical industry, additional bad news is that it is mostly iatrogenic. While community acquisition occurs, the most likely way to get C. dficile disease is to be in the hospital, wherein it lurks, and to receive a massive antibiotic bomb that wipes out our normal intestinal microbia. C. dificile then moves into the abandoned territory.

What to do? How about restore the intestinal microbia. How to do that? Well, don't think about it too hard. What you need is a shit enema. So that's what they are doing, and it works. Adding to the unpleasantness, if you have recurrent infection it works much better to use donor poop than your own, which obviously has not been up to the task. (You may only be able to read the first paragraph.)

I note this not to gross you out, particularly, but because it points as dramatically as possible to our evolving understanding of ourselves not simply as clonal colonies of eukaryotic cells derived from a single zygote, but as ecosystems including not just those, but also a much larger number of prokaryotic organisms. Our eukaryotic genome has co-evolved with the rest of the ecosystem such that it supports beneficial  symbionts that not only are essential to digesting our food but also protect us from unfriendly organisms and quite possibly do other stuff we don't yet understand.

That doesn't mean that the stuff you buy at the GNC that purports to be probiotic will actually do you any good. We're still just beginning to figure this out and  come up with evidence based interventions. But it will become a bigger deal in coming years, I hereby predict.

Thursday, August 25, 2016

Have I ever mentioned that drug companies are evil?

They aren't really of course -- corporations aren't people nor are they moral agents. But human beings do act on their behalf. With price gouging by pharmaceutical manufacturers all of a sudden in the news (despite it has been going on forever), some of our friends from Hahvahd, aka World's Greatest University, explain some of the ins and outs of drug pricing wonkery (and wankery).

Some of the main points are:

  • The U.S. grants long periods of monopoly over new drugs, and let's companies use various loopholes and fancy tricks to extend their monopolies.
  • Even when they lose legal monopolies, they often have practical monopolies for various structural reasons in the industry. The simplest is that if you are in a competitive market for generic drugs, there isn't much profit there in many cases, so you don't get a lot of competition.
  • Medicare is not allowed to negotiate drug prices, and drugs can't be imported, even though they're cheaper everywhere else in the world.
The companies claim they need to haul in the big bucks to pay for R&D, but that's a total crock. They conclude:

High drug prices are the result of the approach the United States has taken to granting government-protected monopolies to drug manufacturers, combined with coverage requirements imposed on government-funded drug benefits. The most realistic short-term strategies to address high prices include enforcing more stringent requirements for the award and extension of exclusivity rights; enhancing competition by ensuring timely generic drug availability; providing greater opportunities for meaningful price negotiation by governmental payers; generating more evidence about comparative cost-effectiveness of therapeutic alternatives; and more effectively educating patients, prescribers, payers, and policy makers about these choices.
The problem is, of course, that the companies own congress, so none of this is going to happen.

Monday, August 22, 2016

The Party of Ignorance

A United States senator says that there is no need for college professors, students can just watch documentaries. He specifically proposes watching the Ken Burns documentary instead of paying some egghead to teach Civil War history.

By the way, this clown has a college degree.

Burns is a Republican, He is not from the South, but I presume he must know that many of his colleagues and their constituents actually wouldn't like that proposal because they think the Civil War was actually the War of Northern Aggression and it was all about state's rights and the preservation of heritage and tradition. How do universities deal with these differences in point of view?

Unless they are Liberty or Bob Jones university, we expose people to basic facts, often in the form of a textbook; and to various interpretations and viewpoints on those facts through diverse reading assignments. We then encourage them to discuss and debate the issues, along the way teaching critical thinking skills and the technique and etiquette of adversarial dialogue. Then we ask them to express their own ideas and conclusions through written essays, which we evaluate and critique.

In other words, we don't just stuff them full of single viewpoints on complex issues. We develop the capacity to learn and think for oneself. A capacity sadly lacking in Ron Johnson.