Map of life expectancy at birth from Global Education Project.

Friday, May 22, 2015

I commend to your attention . .

this important and eloquent essay by my former student Katie Brooks, a Brown medical student. Unfortunately, JAMA won't let you read the whole thing, but you can read the first page, which is most of it.

If you checked out the talk I posted a couple of weeks back, you'll notice that Katie is telling us that she is being taught, in medical school, all the bad ideas and habits I discussed for our pre-med students: racial stereotyping masquerading as "cultural competence," casual and unreflective discrimination, failure to grapple with the real determinants of health and illness out in the world, oblivious callousness to the problems of the most vulnerable.

They offered to Katie a chance to decline having it published after all, in case she feared repercussions. They patronized the wrong woman.

Wednesday, May 20, 2015

I understand that there are two sides . . .

to the question of physician aid in dying. The California Medical Association has become the first state medical association to adopt a neutral position on a law allowing physicians to prescribe lethal doses of drugs to terminally ill patients. All the others continue to oppose it. In the U.S., it is now legal only in Oregon. Physician assisted suicide is legal in several European countries and, following a recent Supreme Court ruling, in Canada. In the Netherlands it is tolerated. Legalization is contemplated in France and the UK.

Requirements vary. In Switzerland, people don't even need to be terminally ill, they just have to convince two doctors that their suffering is unbearable. In spite of dire predictions, experience is that few people ultimately avail themselves of the option -- though more discuss it and accept prescriptions. Generally speaking, you have to make the decision while you are cognitively reasonably intact, which means this is not an option for people who are severely demented.

I'm sure you are familiar with the many perfectly respectable concerns. People may kill themselves because they are depressed, because they think they are a burden to others, or because they receive in adequate palliative care. Many people argue that with proper palliative care, nobody would really make this choice. And people with disabilities and their advocates argue that there is a slippery slope toward devaluing the lives of people with severe chronic illnesses or disabilities.

Finally, many doctors don't like the idea because they don't want to participate personally and they fear being in the position of having a patient ask for help in dying.

I think that these understandable fears are addressable by a well-thought out legal and regulatory regime. But it is really impossible to draw bright lines here and plenty of dystopias have been imagined around state sanctioned and facilitated suicide. (Including by Kurt Vonnegut Jr. who I greatly admire.)

I am quite confident in opposing the death penalty under any circumstance, supporting reproductive rights for women, and the withdrawal of active life support on the patient's or health-care proxy's choice. This doesn't feel so clear to me. It does stop somewhere, but we need to have a serious, honest public discussion about where. I won't disparage any opinions based on a true set of premises.

(And no, there aren't any death panels in Obamacare.)

Tuesday, May 19, 2015

Must read links

I don't know if this is true, but if it is, you had better start thinking about it. Zack Kanter thinks that autonomous vehicles -- that get from point A to point B with no human operator -- will pretty much take over within 10 or 15 years. That means you won't own a car, you'll summon one. There will be no traffic congestion, almost zero crashes, and you'll get around faster and with less fuel. That sounds great, right? It will also bankrupt GMC, Ford and Chrysler; destroy the automobile insurance and repair industries and the used car market; put 6 million people with driving jobs out of work; and otherwise transform the economy and society massively and unpredictably. Maybe. I was quite skeptical but I'm less so.

Here are the 15 best behavioral science graphs of 2011-2013. The graphical representation of information is essential to both the communication of quantitative data, and to persuasion -- it can illuminate or mislead. These are universally illuminating. Also some bonuses -- there are more than 15 here. You'll learn a thing or two from the content, as well as admiring the presentations.

Friday, May 15, 2015


No, not a bankster or a torturer. Jamie Dimon, Dick Cheney and Donald Rumsfeld still walk free. Still, this guy Kevin Lowe is one sick puppy. He's a physician who ran phony clinics for the purpose of writing prescriptions for oxycodone. One of his physician employees, Robert Terdiman, wrote more than 17,000 scrips in 18 months, totaling 3 million pills, which sell on the street for up to $30. And that's where they were going -- the clinics didn't directly serve addicts, rather they generated supply for a distribution operation. Lowe posted $5 million bail, but Preet Bharara has gotten his man. According to the press release, Lowe cleared $7 million out of the $165 million in total value of the bogus scrips. Twenty four other people have plead guilty, but Lowe chose to go to trial.

Lowe will be sentenced in August and faces up to 20 years. 

Now, here's the thing. He could have made a ton of money legitimately. He was a physician who owned a chain of clinics, most of which were totally on the up and up. Becoming a gangster running a massive criminal enterprise was a choice made entirely freely and with a perfectly good and lucrative alternative. So what is going on with this asshole? By the way, 20 years isn't nearly enough. He should leave prison feet first, as far as I'm concerned.

Wednesday, May 13, 2015

Incidents and Accidents

Charlie Pierce joins a huge chorus taking the opportunity of the derailment in Philadelphia to decry our national neglect of essential infrastructure. It seems likely that this will ultimately be ascribed to operator error -- excessive speed on the curve -- like the Metro North derailment in 2013. However, there will always be human error. The technology to prevent this exists, is not very expensive, and is in fact mandated by the Railroad Safety Improvement Act of 2008. It's called positive train control, and it would have slowed down those trains even if their operators had dropped dead.

However, if you read down to the bottom of the above link, you will find:

PTC systems are eligible for funding under the Railroad Rehabilitation and Improvement Financing Program; however; no railroads have approached FRA for funding of PTC projects using this program. PL110-432 has also authorized Railroad Safety Technology Grants that can be used to support PTC projects at $50 million per year from 2009 to 2013; however, the funds have not yet been appropriated.
 In Europe and Japan, trains routinely travel at speeds in excess of 150 mph, and are one of the safest modes of transportation. (The first high speed rail network, in Japan, started operating in 1964 and has never had a fatal accident.) They are far more fuel efficient than automobile or air travel, and of course emit less carbon. In principle, electrified high speed rail can be zero emission depending how the electricity is generated.

Now, in order to build a modern, super safe, low carbon high speed rail network that will result in enormous economic benefits into the future and help save the planet, we will have to invest money. Which means that people will have to pay taxes -- mostly rich people because yes, they're the ones who have the money. They are also the ones whose wealth depends on the publicly funded highways, schools, airports, law enforcement and other public goods they don't want to pay for. And they are willing to invest millions of dollars in order to buy politicians who will make sure they don't have to.

Update: Less than a day after the deadly Amtrak crash on the Northeast corridor between Washington and New York, lawmakers on the House Appropriations Committee voted down a proposal that would have increased funding for U.S. rail infrastructure. I may vomit.

Monday, May 11, 2015

The Big Lie

Jeb Bush tells Faux News that he would have invaded Iraq in 2003 had he been president, based on the intelligence available at the time.

That's what they all say. Except the "intelligence" was fake, as we all actually know. Paul Pillar, who was National Intelligence Officer for the Near East and South Asia from 2000 to 2005 is probably the right person to ask

The most serious problem with U.S. intelligence today is that its relationship with the policymaking process is broken and badly needs repair. In the wake of the Iraq war, it has become clear that official intelligence analysis was not relied on in making even the most significant national security decisions, that intelligence was misused publicly to justify decisions already made, that damaging ill will developed between policymakers and intelligence officers, and that the intelligence community's own work was politicized. As the national intelligence officer responsible for the Middle East from 2000 to 2005, I witnessed all of these disturbing developments. . . .

The administration used intelligence not to inform decision-making, but to justify a decision already made. It went to war without requesting -- and evidently without being influenced by -- any strategic-level intelligence assessments on any aspect of Iraq. . . .

Official intelligence on Iraqi weapons programs was flawed, but even with its flaws, it was not what led to the war. On the issue that mattered most, the intelligence community judged that Iraq probably was several years away from developing a nuclear weapon. The October 2002 NIE also judged that Saddam was unlikely to use WMD against the United States unless his regime was placed in mortal danger.
Will the corporate media call out Bush on this Big Lie? No, because they were complicit.

Friday, May 08, 2015

It definitely can't happen here

Unfortunately. I don't know how much of this you common riffraff are allowed to read, but a British doc writes a commentary in BMJ asserting that private medical practice is unethical.

It can't happen here for a few reasons, not least of which is that unless you want to work for the military or the VA, there isn't much of an option. British M.D.s, as I assume you know, are mostly salaried employees of the National Health Service. However, some people with money think they get better service if they pay a physician out of their own pockets so doctor set up private practices to get themselves richer. But, says Dr. Dean:

[L]et’s face it: the whole business is largely a con. Patients think that paying must mean higher quality medicine, but—like paying more for shampoo with added vitamins—the promise is far greater than the reality. Rich and famous people may use private facilities to shelter from the public gaze; for most “ordinary” private patients, though, the main advantage is simply to jump the NHS queue. Private hospitals are like five star hotels, but for the most part they are no place to be if you are really sick.
And why aren't the rich people getting higher quality medicine? Easy:

The business of medicine and the practice of medicine are at odds. Private medicine encourages doctors to make decisions on the basis of profit rather than need. When confronted with a choice between two treatment pathways in equipoise—one that earns the doctor no money and the other with a fat fee attached—that conflict is stark. I cannot say, with hand on heart, that I have never chosen the second option.
In short, as I have explained here many times, the idea that the mythical "free market" is an appropriate way to organize health care is utterly nonsensical. I can go on at much greater length why that is so, but this should be enough.

The entire U.S. health care system is unethical, and everybody who works in it is part of an unethical structure. It's about vacuuming up money first, and taking care of people somewhere down the list. How to fix it? Socialism, baby. Just like the Brits.

Wednesday, May 06, 2015

Too much news

Two British welfare recipients, about whose existence I do not give a rat's ass, had a baby. In even bigger news, they named her.

It seems the military is planning to take over Texas, in collaboration with Walmart and the Chinese army. That sounds like an excellent plan to me. In fact it's long overdue, I hope they'll get on with it.

NASA has been experimenting with an engine that purportedly can accelerate a vessel in space without throwing off reaction mass. According to the known laws of physics, that is impossible -- but that's actually good news, it means they can use cold fusion as the energy source.

Monday, May 04, 2015

I used to be a skeptic

I admit that I wasn't thrilled about the Affordable Care Act when it first became law. I had the same objections that most of us with a portside list had. It didn't do enough to contain costs, it left the insurance companies leeching on the system, it was just a gravy train for hospitals and medical suppliers and long-term affordability was highly doubtful.

So far, however, so good. The latest Commonwealth Fund survey finds that it's been a major success in reducing the number of people who are uninsured, reducing the number of people who delay care because of cost, and reducing the number of people who have trouble paying bills or who have medical debt. It's working to make life better for millions of people.

But how about cost? In fact the growth in health care spending has been well below recent experience. There's debate about the reasons for this, but clearly the ACA did not cause an increase in cost. I am now cautiously optimistic that there is simply no politically plausible path for Republicans to destroy the ACA, and given that it is becoming more and more entrenched, the only way forward for Congress is to improve it. As Medicare demonstrates effective reforms in the structure of reimbursement, those changes can be made widespread in the private insurance market as well. If we move from fee-for-service to Accountable Care Organizations, we'll get better health care for less money. And the ACA has created a platform for doing that. Doctors and drug companies and hospital execs may howl, but it will be impossible to take this away from people and that means it has to be affordable. That's the political dynamic ahead of us, I (confidently?) predict.

Thursday, April 30, 2015

More on The Opioid Abuse Epidemic -- it's really serious

Mostly what we hear about the epidemic is overdoses and overdose deaths. In Massachusetts, as the linked article tells us, the incidence of opioid-related deaths jumped by 33% from 2012 to 2014, and in fact killed more people than car crashes and guns combined.

This has happened due to an unfortunate confluence of two events. Back in the early '90s, the zeitgeist pendulum swung (I made up that phrase but I think it's okay) toward a perception that physicians had been too reluctant to prescribe opioids, backed by a factual belief that when people took them for pain, addiction rarely resulted. Alas, it does result unacceptably often if prescribing is not carefully managed and monitored. It is now contrary to consensus guidelines to prescribe opioids for chronic non-cancer pain, but it still happens quite often.

The second unfortunate event was the U.S. invasion of Afghanistan. The Taliban had banned cultivation of opium resulting in a constricted world supply, but once they were removed from power, Afghans started growing more opium than ever. As a result, heroin is abundant and cheap. It's expensive and relatively difficult to obtain illicit prescription opioids, so addicts often turn to heroin. But, you don't know the purity of what you buy on the street so overdoses are common.

A new study by Tolia et al identifies another ugly consequence. The proportion of babies born with "neonatal abstinence syndrome," i.e. born addicted to opioids due to their mother's use, increased from 7/1,000 births in 2004 to 27/1,000 in 2013. They didn't use a total national sample and they don't calculate the dollar cost, but neontal intensive care units are really expensive and the babies spent an average of 19 days there in 2013, accounting for 4% of NICU days, and more than 20% in some centers. (BTW, just to bust the stereotype, 76% of the mothers were white.)

Now, do get a grip. In the past there has been excessive hysteria over this. The babies generally recover without lasting harm, although their social circumstances may compromise their future health and well-being. They used to take the babies away from the mothers, but as far as I know doctors and child protection agencies are wiser now. In fact the rate of breast feeding in these circumstances has increased, according to the study. The babies do better when they are breast fed and that also implies that the mothers are immediately gotten into treatment. But . . .

That prevalence is really shocking. In more familiar terms it is 2.7%, in other words almost 3% of women giving birth in the U.S. are exposing their unborn babies to opioids. To me, there is definitely a wow factor to that.

Tuesday, April 28, 2015

Trials and tribulations

The good people of metropolitan Boston just saw two highly publicized trials end in guilty verdicts, while another is just beginning in Colorado. These are very different cases.

I didn't have much to say about the Aaron Hernandez trial. It was only a headline event because of the fame of the defendant. The mountain of commentary on the guilty verdict either consisted of rants on the obvious -- yes, he's a bad guy -- or preposterous overinterpretation that implied collective guilt of all New England Patriots fans or some such. Get a grip. Nobody knew that he was a psychopathic murderer until he got caught at it, upon which the Patriots instantly severed all ties with him and the fans lined up to dump their replica jerseys. This isn't even an object lesson in athletes getting coddled and having impunity -- he didn't get into any serious trouble at the University of Florida nor was he a disciplinary problem with the Patriots. His coaches thought he was immature and impulsive, so they watched him carefully. They knew he was a pothead but obviously that wasn't hurting his athletic performance. So this is just a one-off story of a warped individual.

Dzokhar Tsarnaev's guilt was never in doubt, so now we're in the phase when the jury has to decide whether to give him the needle. Seventy percent of Massachusetts residents don't want him to be snuffed. His lawyers even made the argument before the jury the death is preferable to life in the supermax, so why go easy on him? They're probably right, in fact. Don't click on this link if you are prone to nightmares. The question, then, is why the prosecutors are so determined to get him killed ten or fifteen years from now instead of letting him go insane and kill himself in twenty? It's a mystery.

In the case of James Holmes in the Aurora movie theater massacre, the issue is legal insanity. Here too, I'm kind of missing the point. He is indisputably insane in the vernacular sense. Everybody agrees on a diagnosis of paranoid schizophrenia. But there's this weird philosophical issue with not guilty by reason of insanity, which doesn't have to do with whether he is mentally ill but with whether he could "appreciate the wrongfulness of his actions," whatever that means. Who cares? He's obviously dangerous and he needs to be locked up but what's the point of killing him? I don't get it. The state is wasting millions of dollars on this absurd exercise.

Monday, April 27, 2015

The Merchants of Death Won't Die

I'm not sure whether you common rabble are allowed to read this (I have a cookie on my computer that gets me in whether it's subscription only or not) but anyway, Jonathan Gornall in the BMJ updates on the status of the tobacco industry. While smoking prevalence is down considerably in the wealthy countries over the past few decades, the industry is finding new customers elsewhere. In 2012, 2.47 trillion cigarettes were smoked in China. And the U.S. is still a profitable market, with 287 billion smoked that year. That's not to mention cigars and smokeless tobacco.

The industry counterattacks fiercely whenever governments propose tobacco control measures, such as plain packaging or tax increases. They use both lawsuits and political cronyism. Gornall reports that since 2010, 38 British member of parliament have been guests of Japan Tobacco International, one of the big 4 companies that dominate the global market, at pop concerts, cricket games, Wimbledon tennis, and other events. Eighteen members of the House of Lords are members of a cigar club through which they are regularly entertained by the Tobacco Manufacturers Association.

One wonders whether equivalent corruption is going on in the U.S. But in any event, there isn't any other legal product which, when used as directed, kills half of its consumers. There will never be any shortage of psychopaths to serve as executives of the tobacco companies, but they are murderers. Let us be clear.

Thursday, April 23, 2015

Is one of these things not like the other one?

As you are no doubt aware, federal prosecutors have spent the past few days trying to convince a jury in Boston to order the snuffing of Dzhokhar Tsarnaev. (The defense will try to convince at least one juror not to go along with it starting on Monday.)

I followed the proceedings pretty closely, because I lived in Boston more than half my adult life and worked just a few blocks away from the scene. Had I not moved away just that year, I might have been there. So it is kind of personal. And I do have to say, if there's every a case where prosecutors can get a death sentence from a jury, this is it. The testimony of the injured, and loved ones of the dead, was horrific and heartbreaking. The utter depravity of setting off bombs, packed with shrapnel and designed to maximally maim and kill, in a festive crowd of completely innocent strangers is as far out as it gets. Tsarnaev appears to have no remorse, did not look at the witnesses, and showed no emotional reaction at all to the agony and terror paraded before him.

On the same day, the administration announced that a drone strike on the Afghanistan-Pakistan border (they don't say which country it was actually in) back in January killed two hostages, and American and an Italian, who they did not know were present. Okay, it's a tragic accident, they only meant to kill some other people of who's identities they weren't sure. (Turns out they also killed a couple of other U.S. citizens who were al Qaeda members, but they didn't know they were there either.)

Now, you might argue that there is no moral comparison. The Tsarnaev brothers intended to maim and kill innocent people, whereas when the U.S. does it it's collateral damage, not intended at all. Sure, the U.S. in Afghanistan has had a bad habit of bombing wedding parties and kids gathering firewood and blowing up houses full of civilians, but it's an accident.

Here's the thing: if you know that among the consequences of your actions will be a substantial number of "mistakes" that kill and maim innocent people, then you do in fact intend it. Any consequence of your actions that you can predict will happen, you intend. And you are responsible.

Wednesday, April 22, 2015

A talk some guy gave last week

In case you're interested. It's about cultural competence in health care. Sponsored by our Minority Association of Premedical Students.

Tuesday, April 21, 2015

What is to be done?

Julia Belluz, in Vox, struggles with how to respond to frauds, quacks and cranks such as Oz and RFK Jr. The problem is well known and I have discussed it here. Debunking them on the facts is ineffective in dislodging their followers. In fact, confirmation bias is so strong that telling people why their beliefs are wrong just makes them believe more deeply. And when you try to debate the fraudsters, it a) gives them attention and publicity and b) gives them an opportunity, as Oz is threatening to do no his program, to actually legitimize themselves by creating a simulacrum of legitimate controversy.

She asked for advice from various people, but I'm not sure how helpful it is in the end. They call for the corporate media not to create a false impression of balance ("Shape of the earth: views differ") but I'm pretty sure they're going to keep doing it. It's a reflex. One calls for shaming the enablers, e.g. Oprah viz a viz Oz, but that's not going to work. Oprah is in his corner.

They warn against creating martyrs, but that's the whole problem in the first place. Then there's this:

Just last week, Robert F. Kennedy Jr., a well-known vaccine denier, attended a Sacramento viewing of an anti-vaccine documentary, and told his audience that mass inoculation is akin to "a holocaust."

I asked Dan Kahan, a professor of law and psychology at Yale, how he would suggest covering this event. He said it was important to consider the broader context here: "The fortunate truth of the matter is that there's tremendous confidence by the American public in vaccines," he said. "We have had 90 percent coverage for well over a decade. There are enclaves of people who are concerned. But most parents vaccinate and don't give it a second thought."

So any reporting on vaccine deniers like RFK Jr. should reflect that this is a minority view, Kahan explained. Otherwise reporters risk creating an appearance of significant conflict when there isn't really any — signaling to the unconcerned that they should potentially worry, which could have a negative impact on vaccine rates.
Well sure -- but to report on it, even while calling it a minority view, is to run into all of the above problems. I mean, that's how Kennedy presents himself -- as a brave crusader against a corrupt establishment. He'll be the first to tell you he has a minority view, that's what he's proud of.

But, I can't give up. Truth is the greatest cause.