Mosquito control

CDC is now saying that it has received a few (they don't say exactly how many) reports of relatively young, healthy people who develop neurological complications from West Nile Virus -- partial paralysis of a limb, that sort of thing. It seems that people generally recover, but it can take months or as much as two years. And some people miss a week or ten days of work due to the acute illness. It is still true that the vast majority of people who are infected have no symptoms, or only mild symptoms, but it appears the strain prevalent in the U.S. is somewhat more virulent than the most common strains in Africa.

Now, this is still not really any big deal -- I promise that no matter where you are, you have bigger things to worry about. Nevertheless, this news is bound to ratchet up political pressure for intensified mosquito control efforts. (WNV is spread exclusively by mosquitoes.)

Now, that's where the real danger lies, in my view. Some years ago I did a literature review on the environmental fate of pesticides used in mosquito control, for the Massachusetts Audubon Society. We have an indigenous virus here called Eastern Equine Encephalitis. Every two or three years, two or three humans come down with EEE, which can be fairly serious. For decades, this problem, which I would label as rare, provided the impetus for a very substantial state-funded permanent infrastructure, administered at the county level, which geared up and sprayed our wetlands with a pesticide called malathion every time a case was reported. (The county level administration is one indication of how archaic this program was. The only other responsibility of county government in Massachusetts is the operation of jails.)

It turns out that the situation with pesticides is even worse than the situation with pharmaceuticals. Many approved pesticides have had inadequate testing for human and environmental safety. Most of the research that is done is funded by pesticide manufacturers, and the journals that publish the research are oriented toward people employed in the industry. The spin on some of these research reports is absolutely ludicrous. Malathion is a member of the class of chemicals called organophosphates, originally developed by German scientists during World War II as chemical weapons. Malathion is less potent, but works in exactly the same way, as Sarin, the nerve gas Saddam Hussein was falsely accused of possessing by the Bush administration. There is a substantial body of evidence, based on primate research, that chronic, low-level exposure to organophosphates, which causes no acute symptoms, causes permanent brain damage, and there are lots of case reports of individual humans who suffered acute poisoning from malathion in everday use. Yet the conclusions from these articles always were written so as to downplay the practical importance of these findings.

Well guess what? According to a Reuters report today:

Gardeners should wear protective clothing when using pesticides, say scientists who have concluded in a new study that the chemicals can increase the risk of Parkinson's disease. Researchers at the University of Aberdeen in Scotland have discovered that the more pesticides gardeners are exposed to, the more likely they are to develop the degenerative brain disease. Anthony Seaton and his team in Aberdeen interviewed 767 Parkinson's sufferers and 1,989 healthy people about risk factors for the disease, including their use of pesticides. They found that people with the chronic, irreversible illness were more likely to have used pesticides; amateur gardeners were 9 percent more likely to suffer from the disease than nonpesticide users.

Now this study can't distinguish which pesticides are responsible, but I'm willing to bet a case of Cutter's that organophosphates are the culprit. But wait, there's more. In the U.S. we moved away from use of another class of insecticides, the organochlorines (such as DDT and Methoxychlor) because they bio-accumulate in fish, mammals and fowl. Organophosphates, in contrast, are broken down by enzyme systems in the vertebrate liver. That may be good news for bald eagles, but it's no consolation to every insect, slug, snail, or earthworm exposed to organophosphates. They are completely non-selective and will kill your ladybird beetles and butterflies right along with your mosquitoes. They are also quite toxic to reptiles and amphibians, and oh yeah -- to human children, whose liver enzyme systems have not fully developed.

As Revere helpfully corrected me, the chemical used by the Boston Public Health Commission in response to mass hysteria over the West Nile Virus was resmethrin, which is a synthetic version of rotenone, a naturally occurring compound. Resmethrin is not highly toxic to humans or fowl, but it is extremely toxic to fish -- in fact, it is used by South American Indians as a fish poison. That does make it a rather odd choice for mosquito control. The spraying was done in my neighborhood precisely because I live near a chain of ponds and waterways. And of course, resmethrin is equally non-selective when it comes to insects and other invertebrates.

There are smart ways to control mosquitoes. Malaria is indigenous only to the tropics. Our mosquito born diseases are far less of a concern. Use of toxic chemicals to kill adult mosquitoes is a cure worse than the disease. People who are worried about West Nile Virus (and again, I would say you have bigger worries) can use mosquito repellent, according to directions. (Personally, and this is a controversy we don't have room for here, I would not use DEET on young children. Maybe I'll do that one another time.) Don't allow casual standing water on your property. Ponds can be stocked with fish that eat mosquito larvae, and dragonflies are also helpful. Mosquitoe larvae can be suffocated by spraying ponds with a micro-layer of vegetable oil, which will quickly degrade. There are other tricks available -- in general, it's much better to plan ahead and make the larvae's lives miserable, rather than attacking adults. (Draining swamps, however, is also a cure worse than the disease.) Spraying insecticides around to kill adult mosquitoes is evidence of imprudence, bad judgment, and usually, hysterical overreaction due to mass media hype, encouraged by people with a vested interest.

Heroism

The year I turned 18 happened to be the last year of the Vietnam era draft. I was certain that the war was immoral, pointless, a world historic atrocity, that had been sold to the people by a pack of lies. I knew I could not be involved in killing Vietnamese people for the sake of Richard Nixon's phony macho image, which by then was all that was left of the case for the war . But I was also well aware that if I was drafted and I refused to fight, someone else would have to take my place. As I did not follow any organized religion, it would have been very difficult for me to win conscientious objector status (yes yes, a violation of the First Amendment, but that's how it was), and my likely alternative would have been prison. As it turned out, I drew a high lottery number and I never had to make that hard decision. But something like a million young men did.

One who fought was Col. David Hackworth, who is one of the most decorated war heroes in our history. His funeral is tomorrow, at Arlington National Cemetery, but the nation's top military leadership will not attend. Col. Hackworth was recommended for the Congressional Medal of Honor, for riding a helicopter into the middle of a battle and running repeatedly through a wall of fire to carry wounded men to safety. But he never received the award. In fact, he spent much of his life in virtual exile, in Australia. Reporter Bryan Bender of the Boston Globe explains why:

Hackworth's most enduring foe was not the communists he fought. He earned a a chestful of medals, including two Distinguished Service Medals, 10 Silver Stars, eight Bronze Stars, and eight Purple Hearts. His adversary became the US military bureaucracy, which he railed against for 30 years on grounds that it failed to put the troops first. He also opposed military action in Bosnia, Kosovo, and especially Iraq.

But while the military leadership may be absent from the funeral, hundreds -- and probably thousands -- are expected to attend. The numbers would be larger, except that many who consider him a hero aren't in Washington. Hackworth became a touchstone for soldiers in the Middle East who questioned the Pentagon but didn't feel comfortable raising complaints with superiors.

Col. Hackworth threw his purple hearts away. I wonder how the Swift Boat Veterans for "Truth" feel about that?

I have no right to presume how Col. Hackworth would feel about it, but personally I am very glad that the cowardly liars who are today sending young people to the slaughter for the sake of their megalomaniacal fantasies will not be at his funeral. They would profane it.

Why am I not giddy with excitement?

To quote a journalist with the unusual name of Globe Staff (an alias, I think, for "we're really the New York Times"):

A politically eclectic group has been meeting in secret for months in an effort to craft a proposal that will expand healthcare coverage to as many people as possible.

I always figured that "as many people as possible" meant, like, everybody. But in the faith-based society, it appears that not all things are possible.

The cast of characters for these secret meetings includes the AARP and the AFL-CIO, the American Hospital Association, "America's Health Insurance Plans, the trade association for health insurers," Pfizer, the Blue Cross and Blue Shield Association, and the U.S. Chamber of Commerce. It turns out that "the liberal Families USA and the conservative Heritage Foundation are also participating."

In other news, the Mafia is having a meeting of all the family heads to propose a solution to the problem of organized crime. John Walsh and Whitey Bulger are said to be participating. Most likely the Bush Administration will adopt whatever proposal they come up with.

Can I take Viagra till I need glasses?

Yeah yeah, I'm sure a million people have already used that line but what the heck.

It may well turn out that Viagra does not increase the risk of blindness, but regardless, the latest post-marketing drug safety flap reminds us of something very important. As Paracelsus (1493-1541 wrote, "All substances are poisons; there is none which is not a poison." Pharmaceuticals are, by definition, powerfully biologically active substances. Most of the stuff in your medicine cabinet would kill you if you swallowed only a few grams of it. Indeed, on that basis -- the dose required to kill the average person -- nicotine is 100 times as toxic as DDT. But of course we have banned the use of DDT in the United States, while it is perfectly legal to purchase and ingest nicotine (although not recommended), although DDT has a legitimate economic use and nicotine is simply an addictive drug.

Drugs inevitably come with risks as well as benefits. Our problem is not that the FDA approves drugs which turn out to be unsafe. That can't be helped. The problem is that we often find out about risks of drugs only after they have been approved and widely marketed, and those unpleasant surprises often mean that people would have chosen not to take the drugs after all. This is difficult to avoid entirely, but the problem is greatly exacerbated by our system for evaluating the safety and effectiveness of new drugs. For the most part, the manufacturers pay for drug trials, and they frequently make investigators sign contracts that give the drug companies control over the data and publication of results. They suppres unfavorable information, and design trials so as to show their products in the most favorable light -- as by comparing them with alternatives they already know are not the best available, limiting trial subjects to people with comparatively low risk of adverse effects, limiting the length of follow up, etc.

This system needs to be radically redesigned, to serve the public interest rather than the profit interest of manufacturers of proprietary drugs. We'll discuss some options here in the days ahead.

Why read the book . . .

when you can read the review?

And why read the review, when you can come here? Crusading docs Steffi Woolhandler and David Himmelstein, in the new JAMA, review "Uninsured in America: Life and Death in the Land of Opportunity," by Susan Starr Sered and Rushika Fernandopulle (U. of Cal. Press).

As you already are sick of hearing, if you've visited here before, we keep seeing the number of uninsured Americans go up, year after year. Steffi and David review the retrograde politics of the problem: Harry Truman called for national health insurance; Richard M. Nixon, not known as a socialist, called for universal coverage through employer mandates; the Clintons tried to create a byzantine, incomprehensible monstrosity in order to achieve something close to universal health care without having to call it a government program. Today, the Democratic Party's champion John Kerry is way out there on the radical left by wanting to expand Medicaid to cover a few more poor kids.

Today in the culture of life, according to the Institute of Medicine, 18,000 adults die every year because they are uninsured. Yawn. To quote Steffi and David (they wont' mind):

Sered and Fernandopulle's book is an effort to reawaken outrage, to restore the tears that are too often wiped away as people are transformed into statistics. The authors, an anthropologist and a health policy expert, journeyed around the United States interviewing the uninsured and recording their stories.

The suffering is legion, washing over the reader in chapter after chapter of ruined bodies, financial disaster, and families pulled into an inexorable downward spiral—what the authors label a “death spiral.” Even temporary gaps in coverage often breed disability, eg, from untended fractures, untreated psychiatric disease, preventable cardiovascular events, or dental disease, compromising future employability. In some cases a brief spell of bad luck snowballs into a lifetime of disaster, as for a middle class woman whose divorce and consequent lapse in coverage coincided with the discovery of a breast cancer. The case studies are varied: 20-somethings recently dropped from their parents' policies; self-employed carpenters, acupuncturists, even dentists who find coverage hard to come by; factory workers forced off their jobs and out of their coverage by illness or the need to care for a sick family member.

As the docs point out, we squander $300 billion every year on adminstrative costs which are principally directed at denying care and extracting profits. Gosh, with that kind of money, we could even afford to invade and occupy Iraq, which would be a better deal because we could easily kill 5 times as many people. Oh wait, we're already doing that too.

Doing the wrong thing for the right reasons?

The military is having a recruitment crisis for the obvious reason that young people today wish to retain their body parts.

Kos, who is a veteran, is missing the good old days when poor, minority kids like him had a way up and out by joining the army. Indeed, the U.S. military since the days of Harry Truman has ranged far ahead of the rest of our society in combatting racial and ethnic discrimination and operating as a true meritocracy, albeit using a definition of merit that I wouldn't particularly like to see applied elsewhere. It should give us pause that the most prominent minority soldiers and ex-soldiers in the U.S. include such people as Colin Powell (whose ethic of obedience trumped all other considerations of conscience), Ricardo Sanchez (who presided over Torture, Incorporated in Iraq) and Samurai Surgeon General Richard Carmona who considers most sickness to be a result of personal moral failure. (Of course, the military continues to discriminate against women and homosexuals.)

But I also had this to say in response to Kos.

It's also sad when the only opportunity available to many of our young people is the military.

I have to say, there is simply no good reason for the United States to maintain a military even 1/4 as large as we have now. U.S. military spending is nearly as much as that of the rest of the world put together -- and we have no meaningful national enemies at all. The military has very little, if anything, to do with protecting citizens against the kinds of attacks that non-state actors such as Islamic jihadists or Christian fundamentalist fanatics have undertaken. The military we have now is not intended to defend the country, it is intended to project power into the world on behalf of corporate interests.

Rather than being nostalgic for the good old days when a poor kid could join the army as a way up and out, let's have:

• Universal access to higher education, not just for children of the affluent;
• A full employment economy and a guaranteed living wage;
• Safe workplaces;
• Universal health care;
• Affordable child care;
• Investment in sustainable energy and environmental protection;
• High quality, affordable mass transit;
• National investment in culture and in basic science;
• And all the other policies that will create real opportunity for everybody.

The money we are squandering today on the military is more than enough to do all of that, and if we repeal Bush's tax cuts for the wealthy, we can assure the future of social security and Medicare as well.

Remember when this website, The Cost of War, was in the news? The worse the news from Iraq gets, the less we seem to talk about the dollar cost. Those dollars also represent human lives, and the quality of human lives, that we are sacrificing on the altar of Mars.

Demilitarize. Build the great society.

Beyond Anger

Can the United States sink to yet lower depths of disgrace and shame? Now that Amnesty International has called upon governments throughout the world to prosecute the U.S. officials responsible for systematic torture in military gulags, can we anticipate seeing George W. Bush and Donald Rumsfeld in the dock at a Nuremberg style trial in, say, Nuremberg?

George Annas, writing last week in the New England Journal of Medicine, makes it clear where the legal and moral responsibility lie for these atrocities, although he does not fully spell it out. Annas writes, "The road to torture at Abu Ghraib begins arguably with the president's decision in February 2002 that the Geneva Conventions would not apply to 'enemy combatants' jailed at Guantanamo Bay. This decision was made over the strong objections of . .. Colin Powell and without any meaningful input from career lawyers in the armed services. . . . The reasons [sic] given for taking prisoners to Guantanamo was that the global war on terror was a 'new kind of war' that made the Geneva Conventions inapplicable and that Guantamo . . . should be used as an interrogation center . . . that was outside the jurisdiction and . . . oversight of U.S. Courts."

The administration decided that the Constitution and international law were inapplicable in Guantanamo, and Rumsfeld specifically approved torture methods to be used there. What particularly interests Annas, and what is most relevant for this site, is the involvement of physicians in torture practiced by the United States in Cuba, Afghanistan, and Iraq. Rumsfeld's directive specifically said that prisoners must be medically cleared before they were tortured.

Annas doesn't specifically say so, but military physicians are known to have taken part in torture in all three countries, by certifying that prisoners could survive proposed torture techniques, by failing to report torture, and by failing to provide appropriate medical care and pain relief to torture victims. In a case recently exposed by an Army criminal investigation reported in the New York Times, physicians in Afghanistan were evidently mistaken, and two prisoners -- both, if it matters, apparently entirely innocent -- died under torture.

The Bush administration's moral values have corrupted the military, the State Department, and the intelligence services, as well as our public discourse and politics. They have also corrupted members of the medical profession. I would hope that the identities of physicians who have participated in war crimes will be made known, and if the authorities refuse to prosecute them, at the very least state licensing authorities will not allow them to practice medicine any longer. That seems an anticlimactic way to end this post, but unfortunately I cannot be very hopeful that the persons most reponsible -- including the strutting, self-adoring, morally depraved fool who occupies the presidency -- will ever be made to answer.

More News That Isn't Fit to Print

Okay, how many of you already knew that there is a conference going on at the UN right now to review the status of the nuclear Non-Proliferation Treaty? Hands please! That's what I thought.

According to Louis Charboneau of Reuters, "The United States spent the first two weeks of the conference quietly seeking to block discussions of nuclear disarmament-related commitments and decisions reached at the 1995 and 2000 NPT review conferences."

Gee, that's funny. During the 2000 presidential campaign, the current White House occupant called for unilateral reductions in the U.S. nuclear arsenal. According to Newsweek (June 25, 2001), Bush was "stunned" when he was told in May of that year about the size of the U.S. nuclear arsenal. "I had no idea we had so many weapons," he said.

How many? The U.S. currently has about 5,400 nuclear warheads on intercontinental ballistic missiles, both land and sea based; 1,750 nuclear warheads loaded or ready to be loaded on B-2 and B-52 bombers; and 1,670 nuclear warheads classified as "tactical." Surprising as that was to C. Bananas at the time, it now appears he has decided that it just isn't enough after all. He has drastically increased spending on nuclear weapons related research and, oh yes, production. Current spending by the United States on nuclear weapons is now over $6 billion a year. In the Clinton administration, it was about half as much -- and that's adjusted for inflation. One project which has gotten some attention is development of new "earth penetrating" nukes to take out underground bunkers, but there's a lot more going on the corporate media apparently doesn't think you need to know, including a renewed effort to produce tritium for hydrogen bombs. (Fred Kaplan in Slate reviewed the administration's nuclear "posture" and plans about a year ago. Nothing has changed.)

It takes a self-confessed war criminal to tell it like it is. Former U.S. Secretary of Defense Robert McNamara told the invisible NPT conference, "If I were to characterize U.S. and NATO nuclear policies in one sentence, I would say that they are immoral, illegal, militarily unnecessary, very, very dangerous in termsof the risk of inadvertent or accidental launch and destructive of the non-proliferation regime that has served us so well."

Now why on earth should Iran not have a right to develop nuclear weapons when it's perfectly okay for the United States, Russia, Israel, Pakistan, India, France, China and the UK to have them -- and for the U.S. to have more than enough of them to destroy all of civilization, and to be aggressively building more and developing new kinds? And why exactly do we need, or want, these weapons? I can't even think of a plausible lie that could explain it.

I know I don't have to tell anybody who comes here about the effects of a nuclear explosion, the ultimate public health disaster.

Culture of Life! Save the blastocysts! Protect the brain dead!

Tell it to God

Astonishingly, over the objections of James "Savanarola" Dobson and his corps of homosexuality detection experts and ninja bodyguards of the blastocyst, the House has voted to ease restrictions on federally funded embryonic stem cell research. Promising to veto the bill, "President" cuckoo bananas says "there is no such thing as a surplus embryo."

I know that scientific knowledge, including arithmetic, is all a satanic plot, but here's what Satan wants you to know about human embryos. The cell that results from the fusion of sperm and ovum is called a zygote. According to the Book of Falwell (a long-lost sixth book of the Torah, recently discovered but evidently having the authentic signature and hard to counterfeit hologram proving that it was indeed written by G. Almighty himself) the Zygote is a Human Being Whose Life Is Sacred.

There's bad news, however. Out of 100 zygotes, about 50 fail to implant in the uterus and uhh, well, there goes a Sacred Human Life down the toilet after the Koran. (Sorry, I retract that.) Of the remaining 50, 30% (that's 15, according to the Satanic Laws of Arithmetic) are simply sloughed off in what appears to be a normal, perhaps late, menstrual cycle and the woman probably will never know that she was preganant. The remaining 35 embryos will last at least 35 days, after which pregnancy may be recognized. Of these, 25% will die in utero, perhaps recognized as a miscarriage. That leaves about 26 of the original 100 zygotes unslain by G. Almighty.

Now that is one hell of a prolific baby murderer.

Perverted Press Priorities

Would you like to know what the really big news is in Massachusetts right now? It was the lead story on every local TV news show last night, with multiple location shots and interviews. It was on the front page of the Boston Globule with a jump to almost a half page inside, featuring interviews with public health officials in two states, and multiple physicians.

Okay, here goes. Three people who received organ transplants from a single donor died from a virus, which the donor had contracted from a pet hamster. This virus (called lymphocytic choriomeningitis virus, LCMV, in case you're interested) is commonplace. It mostly infects rodents but humans can get it. It causes a mild, transient illness, or no symptoms at all. Transplant recipients take powerful immunosuppressive drugs, however, which is why these people died from what is ordinarily nothing more than a nuisance pathogen.

Now, I suppose there is some public interest in this story. It's slightly educational. But what does it mean to us?

• Does it mean we should immediately get rid of our pet hamsters? No, there is no news here whatsoever about pet hamsters or any other kind of pet. This virus has always been around and it has always been a non-problem. It still is.
• Does it in any way change our calculation about whether we should get an organ transplant? No, organ transplantation has always entailed a risk that some sort of pathogen will stow away on the grafts. This incident is not unique and provides no new information about the risk/benefit analysis of organ transplantation.

So why is this the biggest story in New England today? A couple of years ago West Nile Virus was discovered in the U.S. WNV also causes either no symptoms, or mild and transient symptoms in most people. Occasionally, people who are immunocompromised or extremely debilitated will have more severe illness or die from WNV. However, their risk of dying from influenza is thousands of times greater, and more generally, for people in that condition, if WNV doesn't get them something else will.

Yet for a period of more than three months, every time a human being, anywhere in the United States, was diagnosed with WNV, there was a news story about it in the Globe. The Boston Public Health Commission, responding to the public hysteria, drove trucks through the streets of my neighborhood spraying an organochlorine nerve toxin into the air, killing every insect from the ground to 30 feet or more above it, every garden snail and every frog, snake and toad in the park, just in case there were any infected mosquitoes around.

Should the average person worry about LCMV, or WNV? Absolutely not. You should be concerned about keeping your cutting board clean and your refrigerator cold, but cases of home-cooked food poisoning never make the front page of the Boston Globe or Fox News at 10. And as a citizen concerned about public health policy, you should be concerned about the bird flu and Medicaid, which we have not been reading about in the Globule or hearing about on the News at 10. But this incident, tragic as it is for 3 people and their significant others, is of essentially no public policy concern whatsoever.

Why are we given this distorted image of the world? I have my own thoughts, I'd love to hear yours.

A Million Monkeys . . .

Check this out:

Postmodernism generator

Warning: Don't jump to any conclusions about what you are reading till you get to the bottom of the page.

House of Pain

Criticism of commercial television is not normally mah thang, not least because I can't afford the death of so many neurons from watching it. But I was inspired by a review in the British Medical Journal and a Fresh Air interview with the creators to check out Fox TV's hit medical drama House, M.D., and I find I have a professional responsibility to comment.

Dr. House is a senior internist (apparently) at an academic medical center whose defining character traits are relentless arrogance, condescension, insult and psychological sadism directed without fear or favor at colleagues, superiors, residents, medical students, patients, nurses and innocent bystanders. Nobody ever complains, talks back, or even appears to be hurt by this behavior because they all know full well that they are all incompetent idiots while Dr. House is the Greatest Medical Genius Who Ever Lived. Every single patient who comes into this hospital is misdiagnosed, often because they have a bizarre or rare condition that only Dr. House has ever heard of, but always because, as Dr. House puts it, "Patients always lie." Only House's vicious put downs and oozing contempt can torture the truth out of them.

Okay. The writers are indeed holding a kind of funhouse mirror up to nature. Many physicians and observers of the medical institution have described what has been called the "culture of abuse" in medical education. Preceptors and medical school professors do indeed often treat students and residents with scorn and contempt, and many a resident has had as a role model an Aesculapian attending who treats patients like specimens of diseased vermin.

It is also true that physicians should not trust everything that patients tell them. Patients commonly underreport their behaviors that physicians will presumably disapprove, such as tobacco use, alcohol abuse, junk food abuse, etc.; overreport their adherence to prescription drug regimens and other medical advice; and may be either misleadingly stoical about symptoms (perhaps because they would rather not hear bad news), or overly worried or hypochondriacal, for various reasons.

However, it is not conducive to accurate diagnosis or the effective practice of medicine to glorify sociopathic behavior by physicians or to morally condemn patients as "liars." Communication and ongoing relationships between doctors and patients are complex social processes in which powerful influences from within the culture of medicine and from the life world of patients can conspire to thwart accurate understanding, in both directions. The solution is to be found in more compassion, understanding, and sensitivity, and less judgment, not the other way around.

Furthermore, diagnostic puzzles and medical detective stories indeed make up a good part of the case study literature, and some prominent medical journals features such stories regularly. They are fun, and sometimes more broadly instructive, but not actually very common or at all typical of a day at the doctor's office. When they do arise, physicians confer with their colleagues. Dr. House never calls a consult or refers anyone to a specialist. Why should he? He knows everything, from neurology to hematology to psychiatry, and nobody else even knows that the knee bone is connected to the thigh bone.

This show is, I must say, an accurate portrayal of one cultural archetype of the heroic doctor, as a kind of artificial intelligence. But it doesn't work for me.

Weekend list

I'm going to be away for a couple of days on farm and family biz, probably won't use your Internets till Sunday, so I'll leave a couple of items.

First, more on Wayne Chapman. In response to DPR, yes it required a 10-2 majority to decide the case. But the real problem for the offender is that very few jurors are going to take a chance on letting a guy go and having it turn out to be a mistake. For all practical purposes, jurors are going to interpret "likely to reoffend" as "any chance in the delta quadrant of the galaxy." The jurors were troubled about the issues of Mr. Chapman's rights, and denying a man his freedom is a serious burden that we all felt. But who's going to take a chance?

California indeed has a similar facility in Atascadero. It so happens that many years ago I met a therapist who did the penile plethysmography thing there, a very butch lesbian. These places are maximum security prisons, with an added layer of sophisticated psychological manipulation and coercion, including these bizarre sexual practices. One problem -- and it was a major problem for us jurors -- is that there does not appear to be any credible information about the extent to which this "treatment" works, or even what the actual risk is of reoffending even for people who not been "treated." The trial to a considerable extent consisted of dueling "learned treatises," i.e. journal articles, but we didn't get to read the actual articles, we only got to hear the expert witnesses read portions of them aloud and state what they thought it all meant. I knew enough to largely ignore all of that.

Here's another strange feature of this upside down trial. It will come as no surprise that Chapman was horribly abused as a child himself, that he has a low IQ, failed in school, had no job skills, and had a severe drinking problem. In a normal criminal trial, these facts would have been introduced by his defense as mitigating factors, likely getting him a somewhat more lenient sentence. In our looking glass trial, the prosecutors made sure we learned about them, because they made him seem more likely to reoffend were he to be released.

So DPR is right. Wayne was trapped, in part because he isn't very bright. Once he got to Bridgewater, he started denying the crimes. He used the Michael Jackson defense -- he just liked to get into bed with the girls, it was very sweet. (Not even his own expert witness even suggested that he was really innocent, however.) Apparently he thought that admitting the offenses would make it harder for him to get out. Playing the therapy game, convincing the scientists that you are really getting with the program, takes some IQ points that Wayne doesn't have. But whether somebody who is shrewd enough to advance in the program is also being "cured" I have no idea.

The reason I bring all this up here is because it's illustrative of a big problem we have right now as a society. The states have all gotten on the "Megan's Law" bandwagon. Sex offenders now have to register with the police, and their identities and home addresses are in many cases public information. People have been run outof town by mobs, houses burned down. Six Flags has even started printing on its tickets that sex offenders are excluded from its amusement parks. We had a headline on our local tabloid a couple of months ago -- in other words the whole front page -- to the effect that a small town police chief was renting an apartment to a registered sex offender.

I mean look, these guys have to live somewhere. They have to be able to get some kind of job. We aren't prepared to lock every child abuser up for life, it would cost more than the military budget (and we can't afford that either, nor should we). Most of them in fact will not reoffend. Some have worked very hard to overcome their problem and, hard as it is for many people to accept, deserve sympathy. They are often abuse victims themselves or struggle with powerful impulses that are loathesome to them but proved impossible to control. What on earth should we do?

Meanwhile, Revere is very worried about the bird flu. I can tell you on certain information that if Revere is worried, you ought to be worried. As for what you should do about it, that's another difficult question.

Civic Duty

I had jury duty today, didn't end up on a jury and I'm safely home, but it got me to thinking about the time I did serve.

It was an inside out and upside down trial. Technically, it was a civil trial, but the plaintiff was a criminal, whose freedom was at stake, represented by a public defender; while the defendant was the state, represented by two (count 'em two) Assistant District Attorneys -- and they were good ones, obviously the big guns. The jury's job was not to decide what the criminal had done, but what he might do in the future.

Said criminal, Wayne Chapman, had a bad habit of forcibly raping little girls, including but by no means limited to his own daughter. He got exactly what he wanted by such subtle methods as punching the girls in the face and threatening them with a knife. I was forced to hear a good deal more in the way of specifics, but you won't be. (By a very odd coincidence, there is a more famous gentleman by the same name in our state whose habit was to rape boys, whose present physical circumstances are exactly the same but whose legal situation is slightly different.)

The Wayne Chapman of my acquaintance had been caught about 15 years earlier. Back then, clinical psychologists had convinced several state legislatures and courts that they could fix people like Chapman. Just let us pop the hood, tune him up, and he'll be ready for the priesthood ... er, well, no, that's not what we meant but he'll be just fine, really. Based, presumably, on his lawyer's advice, Mr. Chapman pled guilty in exchange for a suspended 15 year sentence and civil commitment of one day to life to the Bridgewater State Treatment Center for the Sexually Dangerous.

One treatment at the treatment center consisted of showing the treatees kiddie porn, and making them masturbate until they were sick of it. Another method is to hook them up to a machine called a penile plethysmograph, which measures their erections. Then they are shown the kiddie porn, and if they get a hard on, they receive an electric shock or a disgusting smell. Then they look at pornographic pictures of adult women and masturbate in appropriate moderation. Really weird shit like that. They also do groups, drama therapy, and other non-bizarro psychotherapy.

Every year, a panel of scientists reviews Chapman's case and recommends that he either stay in, or get ten bucks, a cheap suit, and a bus ticket back to Lynn. He also has the right to petition for his release once a year, in which case a jury is called upon to decide if he is "still a sexually dangerous person." Without going into the details of Wayne Chapman's career at the State Treatment Center (I will tell you that he refused to accept penile plethysmography), but to cut to the chase, I do not see how it is possible that any jury will ever allow him to draw a free breath, at least as long as the DA doesn't want him to. District Attorneys are elected officials, and back in the early '90s, several individuals were furloughed from the Bridgewater center who ended up commiting murder. Now the DAs are engaged in an escalating competition to commit more and more offenders -- including picking people up at the jailhouse door as they complete their prison setences and trucking them straight to Bridgewater to be civilly committed. (For people committed a few years after Mr. Chapman, as I understand it, judges now make the decisions about release, not juries. Although the jury system is intended to protect the rights of the accused, in this case it undoubtedly has the exact opposite effect. I can far more readily imagine a judge releasing one of these offenders over the DA's objections, than a jury doing so.)

There were many complexities to this trial, to the legal context, to the jury deliberations, and to my own very painful deliberations as a member of the jury and in fact, as the jury foreman.

This post is already too long, so I'll just propose one quandary. If Chapman had not accepted the plea deal, and been convicted of his crimes, he might have gotten a sentence of 15 years. (Nowadays, it probably would have been stiffer, maybe 25.) He would be walking the streets, not even on parole, as free as Godly men like Bernard Law. But thanks to progressive theories of rehabilitation, he is very likely to die in our deepest dungeon. But one thing is for sure -- he'll never rape another little girl.

More on the ownership society

Despite being the People's Republic, we have a Republican Governor, actually a Mormon from Utah. It's kind of weird, it has to do with the former Dictator of Massachusetts, Thomas "Louis XIV" Finneran, who as Speaker of the House made sure the Democratic candidates for Governor always lost so that he could preside unchallenged over his veto proof majority. Anyhow, King Thomas is gone and Mitt Romney will be soon.

Meanwhile, we're stuck with the slick clown. He's trying to fend off significant efforts at universal or at least expanded health care coverage in Massachusetts with a Bushian proposal. The way "Doctor" Bill Frist (a surgeon who moonlights as a neurological diagnostician via home video) and the rest of the compassionate conservatives want to expand coverage is by making it lousy, and therefore cheaper. By imposing very high deductibles and copayments, and not paying for many services, you can make health insurance "affordable" for more employers and individuals.

The only problem with that theory is that it's only affordable if you don't get sick. Actually this trend has already started without any public policy push. My own employer recently switched us to a plan that, among other curiosities, imposes a $50 co-pay for an ER visit, even if you really do have an emergency. If they admit you, it costs you $250. They also charge $150 for a needle biopsy and other outpatient "surgical" procedures. So, if I'm raising my kids on $30,000 a year, and I have chest pains, I have a decision to make: should I decide it's just indigestion, or should I have it checked out and blow off next week's groceries? Interesting choice. Remember, I do have insurance. Kind of.

Anyhow, Mitt's Policy Director, Tim Murphy, is worried that if hospitals don't aggressively collect those co-pays -- you know, put liens on people's cars and houses and whatever else it takes -- they'll put pressure on insurers to raise reimbursements to cover the bad debt, and on the state to add some subsidies. You can read the Boston Globule article here. The hospital execs don't like this because, well, they aren't actually SOBs, at least some of them. They don't want to squeeze low and moderate income people who just had the bad luck to get sick, or have a sick child, for money they can't afford to pay. It kind of goes against that self image of service to humanity.

Look, this isn't rocket science. Expanding the number of people who have insurance by making insurance inadequate may appear to create more equity but it does not. Wealthy people can afford the co-pays and deductibles, but lower income people cannot. Sickness and injuries are still misfortunes that are not distributed justly by an invisible hand. And if people are discouraged from seeking care that they may actually need, or if they can't make the co-pays on their prescriptions (mine just went up by $15 a month -- it's a lot more for some people), they are likely to end up costing more in the end. And we will have done exactly nothing to control the growth in health care spending or make medicine more rational and efficient. We'll still have multiple payers, high administrative and marketing costs, no consolidated buying power, and we'll actually be discouraging preventive medicine.

We need universal, comprehensive, single payer national health care. That's it. All this farting around has got to stop.

Not exactly on topic, but fun . . .

I'm pretty sure that Sen. Norm Coleman is regretting this morning that he allowed George Galloway to create a new bodily orifice for him yesterday. (I was sufficiently interested in this little drama that I even watched part of The News Hour to see what I could see. They gave George his due, showed all his best bits.) Attaturk, guest blogging for Atrios, also notes that Galloway had a little run-in with our old friend Christopher Hitchens. Here's what I wrote about ole Hitch on an earlier occasion:

Christopher Hitchens, like Lyndon Larouche, used to present himself as a leftist. For many years he had a column in The Nation in which he vied with Alexander Cockburn for the “Most Acerbic” award (a magnificent scarlet inkwell filled with sulphuric acid). Things started to get a little weird in the 1990s when he developed an obsessive hatred of the Clintons. His reasons were partly respectable (triangulating, Dick-Morris-employing betrayers of the revolutionary vanguard) and partly insane (Bill’s serial sex crimes made Ted Bundy look like a boy scout; Whitewater [in which they were guilty, Guilty, GUILTY!) was the financial scandal of the century; Hillary not only murdered Vincent Foster, but conspired with her lesbian lover to seduce, rob and kill dozens of wealthy young fops whose mutilated bodies turned up in seedy alleys all over the DC metro area . .. well, maybe I made up that last one but it’s in the spirit of the thing.) Once he could no longer demonstrate his superiority to the bleating herd of liberal sheep by cheering on Ken Starr, the Iraq war became his next opportunity. His bellicose rantings were enough to drive Dick Cheney to the Quaker meetinghouse. He finally resigned from The Nation, claiming that the refusal of the magazine’s other writers and editors to fall to their knees in grateful acknowledgment of his intellectual and moral superiority on the question of war was proof of their bigotry and hatefulness. He wrote a final hissy fit essay in which he burned every bridge from London to Lompoc.

As some people have noticed, the Iraq war has not turned out the way it was supposed to. Some of the war’s portside chickenhawk supporters have since issued mealy mouthed retractions; others have concentrated on giving Chimpoleon and his pals unsolicited advice about how to do it better. Hitchens, however, has devoted himself to escalatingly vicious and absurd attacks on the war’s opponents. It’s not unusual for polemicists to turn against their own comrades but Hitchens’s case is particularly disgusting and bizarre. I think that chronic alcoholism destroyed brain cells in his cerebral cortex that normally inhibit irrational emotional responses in the limbic system. Something ticked him off around 1994, and the anger just fed into a positive feedback loop that slowly and steadily grows more intense. Eventually, he’ll lose one too many neurons and lapse into a vegetative state.

Happy Anniversary!

Not that I have anything unique or especially profound to say about this, but as a proud citizen of the bluest state, the People's Republic of Massachusetts, I have to recognize this historic anniversary. It's been one year since lesbians and gay men could be legally married in this state. I know that the CW is that our godless Supreme Judicial Court and the sodomite legions they inspired cost John Kerry the election, but I know better -- it was his cowardly, hypocritical vote to authorize the Iraq war and his self-contradictory, gonadless flailing about as he tried to explain exactly what he believed about it and how, if at all, his policy on the war was different from the policy of Napoleon the Wonderchimp.

Meanwhile, something amazing happened in Massachusetts, i.e., not much. People got married. That's all. They are happy. Their kids are happy. They can talk more freely and less awkwardly about their lives with coworkers and their children no longer have to hide in the shadows. Their families and friends have had the opportunity to share their commitment to each other and the important life passage that it represents, just as they have had with their other relatives and friends.

Revere Beach has not turned into Fire Island. The sacred insititution of marriage is still there, same as always. Heterosexual couples are -- miraculously! Glory to God! -- completely unaffected. Boiling lava has not rained down from the sky. True, a lot of Catholic parishes have closed and the rest of the pews are half empty, but that's not because people are getting married. It's mostly because all those priests were raping children, which used to be legal for them, for all practical purposes. (It's true! Ordained clergy and lay church officials were not required to report child abuse to the authorities, thanks to determined lobbying by the Catholic Church over many decades. Oh yeah, we changed that law also.)

Many presumably well meaning people have argued that it was a mistake to win this victory in the courts, because the policy is ahead of public opinion and it has just created a powerful political backlash. Clearly it has in much of the country but the opposite has happened here. At first, the majority of Massachusettsians (we don't really have a word for ourselves. Massachusoids? Chusers?) told pollsters they were opposed, and the legislature took the first of two votes required to put a constitutional amendment on the ballot overruling the court. But then that funny thing happened -- i.e., nothing much -- and the mood changed. Most of us now think things are fine the way they are, legislators who ran for reelection based on their opposition to gay marriage lost to their pro-gay marriage opponents, and it is now very unlikely that the constitutional amendment will appear on the ballot. If it does, it will be defeated.

So how does God feel about the whole thing? So far, he's treated us just fine, except for a big snowstorm last January and a cool spring. It seems to be Florida he's beating up on, for some reason. You'll have to ask him what that is.

Medicaid isn't just a nice thing to do . . .

We haven't had a repeat of the Great Depression, and a major reason is the introduction of so-called automatic stabilizers -- originally Social Security and AFDC ("welfare"), later Medicare and Medicaid. These "entitlement" programs make sure that consumer spending by poor and low income people doesn't get wiped out in an economic downturn, thereby creating the liquidity trap that brought on the depression.

From The Commonwealth Fund:

Medicaid Caps Would Increase Uninsured, Erode Recession Buffer, Study Says
MAY 9, 2005 -- Preliminary results of a study released Monday by the Economic and Social Research Institute say if Medicaid had been capped at enrollment levels that existed in the program in 1999, the number of uninsured would stand at 50 million rather than 45 million.

snip

"Medicaid may play a crucial role in helping the country recover from recession," [researcher Stan] Dorn said at a Washington forum sponsored by the Joint Center for Political and Economic Studies. Under Medicaid's entitlement structure, enrollment and outlays rise as the economy worsens, providing a buffer against rising lack of insurance and an automatic economic stimulus to counter a downturn.

But the Free Market Fundamentalists who control the government today practice faith based economics.

It's against my religion . . .

but I'm gonna give a link to the NYWT. Life at the top. (Registration required, I believe, and it only stays up for a couple of days, so get it while you can.)

This story follows three people of varying social circumstances who have heart attacks. It offers decent context concerning what we know about the origins of class disparities in health. Although the article focuses largely on health care per se, it does show how people's social circumstances affect their ability to follow medical advice. It's long, but even the first few paragraphs give a pretty good synopsis of the health disparities issue, at least as far as social class is concerned.

They are not, however, focusing on the racial and ethnic disparities that remain in both health and quality of health care, even after we control for education, income, and occupational status. There are also differences among low income communities that appear to influence the health of their residents, and many other complexities.

The overall theme of justice, in various dimensions, is an effective principle for organizing around public health and health care reform. The issue of health disparities is potentially very powerful because of the constituencies it can unite. While I could be grumpy and say it's about time the NYWT ran such a story, I will just be gracious and say thanks to reporter Janny Scott and the editors.

Now if they would just cover that funny little memo about Tony Blair's cabinet meeting where it turns out Tony and Chimpy were committed to invading Iraq nine months before they actually did it, even though they knew perfectly well that Saddam was not a threat to anyone . . . Well, I guess that's news that isn't fit to print.

Insane, incompetent, immoral, just plain nuts, or you just don't like me?

In the sociology of medicine, we talk about diseases, which are physical traits, states or processes that meet certain criteria. Physicians structure their thinking, planning and action around these entities, conceived almost as embodied enemies. Military metaphors abound in medical discourse -- the armamentarium of therapeutic measures, viruses attacking cells, the war on cancer, etc.

Illness refers to the subjective experience of an individual who experiences physical limitations, pain or distress from some state, trait or process. Illness and disease may correspond very closely. The major distinction between influenza as a disease and as an illness is point of view. We largely define influenza by the symptoms. Although a laboratory test is available for infection by the influenza virus, it is seldom used. Doctors are usually content to tell us we have a flu-like illness, and who really cares, as long as we're back at work in a week or so? On the other hand, doctors may tell us we have the disease of hypertension, hypercholesterolemia, or even breast or prostate cancer when we had absolutely no symptoms and no illness. Once we are given that information, however, we acquire an illness because we now perceive ourselves differently, must take medication or undergo surgery, etc.

Notice I've talked about physical conditions. That was to keep things a little bit simple. What I really want to talk about here is the mental diseases. The vernacular is usually "mental illness" but I want to retain the sociological meaning of that term. Psychiatrists frequently diagnose people who think that they are perfectly alright, so the distinction is very important.

There is no escaping the cultural and moral element in psychiatric diagnosis, which is subtler in the other branches of medicine. Medical conditions which are diseases but not illnesses are classified as diseases because they are thought to put the individual at risk of some condition which will almost certainly be experienced as an illness in the future. My high LDL cholesterol doesn't bother me subjectively today, but a heart attack certainly would.

Most people who present to psychiatrists are in real subjective distress, and do perceive that something is wrong with them. But others don't. Some people who feel just fine and think they're just dandy can be diagnosed with a personality disorder or a psychosis. Other people may be quite unhappy but they don't attribute their unhappiness to facts about themselves, but rather to the way other people treat them. People with so-called Borderline Personality Disorder may be in this category. Some people are distressed only because others condemn them, or because they have been taught to be ashamed of themselves.

Homosexuality is the most famous example of the latter. It was officially a pschiatric disease until 1978; then the Gods of psychiatry eliminated homosexuality per seas a diagnosis, but added something called "ego dystonic homosexuality." Gay activists continued to protest even this diagnostic category, pointing out that it is not surprising that homosexuals are distressed about their nature given that lots of people hate them, but that doesn't mean it's the homosexuals who are sick. They finally prevailed when they proposed that if ego dystonic homosexuality is a disease, then logically, ego dystonic heterosexuality ought to be one as well. The Committee couldn't handle that idea, so homosexuality, dystonic or not, disappeared from the Diagnostic and Statistical Manual of Mental Disorders IV in 1987.

My friend Gary Greenberg wrote a scholarly article comparing the diagnosis of homosexuality to the diagnosis of borderline personality disorder, arguing that both hinge on culturally based judgements about how people ought to be or behave. People with BPD interpret their experience differently from the way their shrinks do - which makes them very frustrating to treat, by the way. I don't really agree with Dr. Greenberg about this particular question, for reasons which are too complicated to get into here. But it's a challenging argument.

So at last we come to the point, antisocial personality disorder, and psychopathy. People get these disease labels because they do bad things. In everday language, any serial murderer is insane. That sort of behavior is just abnormal. Healthy people don't do those things. (But of course they do, if they are soldiers.) In psychiatric language, all such people (who aren't soldiers) are eligible for a personality disorder label, or else they are psychotic, meaning that they act out of delusions. In legal terms, however, they may or may not be insane, although I believe that the legal concept of insanity is nonsensical. Ted Kazcynski was given a formal diagnosis of psychosis and also found legally insane. Friend Gary, who corresponded with him extensively, believes he is neither, and Kaczynski wholeheartedly agrees. I would basically label Ted Kaczynski as a real jerk, but I'm not a pro.

Repost

It occurred to me that something I had put up here before I acquired my present loyal readership is apropos of yesterday's post. Rather than do any actual work today, I'm going to repost it.

He bad

A surprisingly shallow and unenlightening essay yesterday[Feb. 8] in the NYWT about psychiatrists who think they should call some psychopaths evil, instead of or in addition to (it was never quite clear which) giving them a disease label.

I say surprisingly shallow because it is a very short wade to the deep end of this particular pool. The Times reporter just interviewed a bunch of shrinks, some of whom thought that calling Ted Bundy and John Wayne Gacey psychopaths just tends to excuse them. According to these learned gentlemen (no ladies), they were actually just evil but sane (whatever that means, and the question was never even suggested, let alone addressed). Others thought that while you can call them evil, for their psychiatrists to say so would be unscientific.

There was no mention in the article that psychiatry is marbled with moral judgments, even far away from questions of anti-social personality, while paradoxically, any science of the mind has a profoundly problematic engagement with morality. Neuroscience and its handmaiden psychiatry have long ago abandoned the Cartesian dualism of mind and body. The mind, and behavior, are just manifestations of a physical system. Every thought, every feeling, every impulse, is represented by patterns of neuronal activity, which can now be observed in a very crude aggregate and, in principle, could be completely described. Current research into addictions and eating disorders has taken a big chunk out of the illusion of free will, and in the view of many, the rest of it will soon melt away like the snows of March.

No-one created himself or herself. Many people with sociopathic spectrum diagnoses had head injuries as children. Many were severely abused or emotionally abandoned. For others, no such dramatic history can be discovered, but we are all the product of hereditary endowment interacting with the physical and social environment as our personalities got wired into our brains. Our brains are part of our bodies, which bathe them in nutrients and hormones, and supply the sensory input and experiential feedback that our brains process back into behavior. And of course we are all part of complexly interacting social systems. People with no diagnosis of psychopathology, when placed in the right social context, will readily commit evil acts, viz Abu Ghraib and the Nazi holocaust.

I personally do not believe that neuroscience can take us completely "beyond good and evil," because moral feelings and judgments are intrinsic to our subjective experience and are essential heuristics for the functioning of society. But the ontological status of the moral categorization of individuals is questionable at best.

Out with a whimper

Michael Ross grew up on a farm in Brooklyn, Connecticut, not far from where I have some property. This morning, he fulfilled what has long been his ambition. He made history by becoming the first person put to death in Connecticut in 40 years.

Ross's story doesn't offer much extra help for death penalty opponents. He was white, privileged (his family's egg farm was successful and he graduated from Cornell University), had no horrific tale of abuse to tell (although who knows if he held some dark secret) and there is no doubt whatsoever of his guilt. He confessed to raping and killing eight girls and young women, and went on fully and publicly avowing his own guilt. And oh yes. He wanted the needle. He said he owed it to his victims' families, but nobody believed he was sincere. He always seemed remorseless, self-centered, and grandiose, wanting to be the center of attention, not caring for expiation.

He abducted his victims from the small towns of Lisbon and Canterbury, where I shop and eat in restaurants. (There isn't any place to do those things in Scotland.) These are still landscapes of woodlands, cornfields and dairy farms, the regional center of Jewett City somewhere between quaintness and decrepitude. Quiet, nondescript towns hardly anyone has heard of, though nowadays some phony Indians have built monumentally garish and inane casino resorts a few miles away, putting people to work at low wage jobs.

Ross got his chance on center stage in January, when he came within a few minutes of getting the needle. In the run up to the fateful date, the local news was about nothing else. At the Green Onion restaurant in Lisbon -- formica tables and a waitress who calls me "dear" -- the people were talking about it. The prevailing sentiment was that they didn't particularly care one way or another. The state can kill him if they want but he isn't worth the cost of the drugs. As it turned out, when the judge realized that his lawyer, in honoring his client's wishes, was working to bring about his execution rather than resisting it, the judge would not let it go forward. Michael's skyrocket was a dud. It took them a few more months to work out the legal kinks.

Today, the main event got less attention than the teaser. A few dozen people stood vigil outside the prison, mostly death penalty opponents, but the folks in Canterbury weren't all that interested. Maybe it's because they knew Michael wanted them to care. I heard some of the victims relatives interviewed on the radio. One said it didn't bring her any peace. Another, who had witnessed the procedure, as they call it, said she had hoped for "closure," but it just made her angry, to see him there sleeping peacefully, after the way her sister died.

I spent the day tilling and planting, building a gate to keep the antlered rats out of my corn and tomatoes. I thought about the teenagers I see walking or riding bicycles down those country roads, how the community -- so far away from the big events of the world, barely noticing that it's no longer 1954 -- would be ravaged and torn if one of those children were just to disappear, and then turn up so violated. Killing Michael Ross, obviously, couldn't bring those girls back. Instead, it just snatched them away again, blotted their memory with the muck of his death, made him important and grand, made us all a little bit like him, just the way he wanted it.

I'm gonna have to bum some folks out . . .

May 18, in addition to being the anniversary of the eruption of Mt. Saint Helens, is HIV Vaccine Awareness Day, sponsored by the HIV vaccine trials network -- in turn funded by the National Institute of Allergy and Infectious Disease.

Sigh. HIV is a slow motion disaster which is much more than you typical everday public health problem. It is a social, political, cultural, ethical, and economic thicket of brambles that messes with everybody's mind, whether they are infected or likely to become infected, or not. The truth about HIV is seldom what anybody wants to believe. In earlier days of the epidemic here in the U.S., factions within the gay community were initially among the most resistant to efforts to promote behavioral change, which they saw as attacks on gay sexuality and freedom. Of course, proprietors of bath houses were also making money off of unsafe sex. The stigma associated with HIV, and the people most likely to be affected by it -- gay men and IDUs -- were major obstacles to an effective public health response and to an adequate investment in medical research. Once we realized that, although the virus happened to take hold in the gay population here, it was an equal opportunity menace, the federal government defined Haitian immigrants as a "risk group," because they happened to be affected by a heterosexually transmitted epidemic, rather than recognizing that it is what people do, not who they are, that puts them at risk for HIV. Churches are often opponents of effective pubilc health measures to combat HIV. I'm so weary of some people's "moral values" that I can't even bring myself to discuss it here.

Then there is the terrible story of HIV in Africa, a continent with more than enough burdens. The threat of devastating breakouts of HIV in south Asia and Eastern Europe. The moral torment of seeing the vast majority of infected people go without treatment because the drug companies don't want any threats to their profits and the Bush administration would rather defend their shareholders and executives than the poor people of the planet. The indescribable pain of seeing friends sicken and die young, in a pointless random harvest.

Of course we all just want it to go away. That is why there is a sort of movement, a political correctness among people who work in the field of HIV that a vaccine is coming soon. Campaigns are underway to convince people to enroll in HIV vaccine trials, to get the government to spend more on vaccine development, and even a widespread conspiracy theory that an effective vaccine already exists but the drug companies are suppressing it so they can continue to sell anti-retroviral drugs.

The cold truth: there is no usable HIV vaccine in sight, and it may even be that an HIV vaccine is impossible.

1. Like influenza, HIV continually mutates and recombines. That means that a vaccine that is effective against one or more strains today may not be effective against other strains that emerge. This is a reallybig problem when it comes to HIV because it would be counterproductive and unethical to give people an only partly effective vaccine. People who believe they are protected, but really aren't, might engage in unsafe behavior and put themselves and others at higher risk than if they weren't vaccinated.
2. HIV infects important immune system cells, called helper T-cells. It is hard to design a vaccine that stimulates the same cells that the virus infects.
3. HIV not only exists as free virus particles, but becomes embedded in the DNA of cells of infected people. These infected cells may be capable of transmitting infection.
4. We really don't know what sort of immune response would be effective against HIV. The body in fact mounts an immune response naturally in response to acute HIV infection, and effectively suppresses circulating free virus for a time. But it can't eliminate the virus, which gradually erodes the immune system until it finally destroys it.

False hope is very dangerous when it comes to HIV, because for one reason or another -- often totally opposite reasons -- people generally don't want to do what is necessary to attack this epidemic.

Sorry for the downhead riff. I hate HIV. But I know we aren't close to beating it.

Incorrections

You may have seen the PBS documentary last night on mentally ill people in prison. This is an important subject, but it isn't exactly news. Some 12 years ago I had the opportunity to visit the maximum security institution in Walpole, Massachusetts with Judge Albert Kramer, who was Presiding Judge of the Quincy District Court (now retired). We toured a cellblock and then we met with a group of lifers. Actually they weren't all doing life, but they all had sentences of 20 years or more.

One of the guys said (warning: Janet Malcolm quotes), "I've been in and out all my life. I started out in DYS when I was 16, and you keep seeing the same people. You know, we're criminals. But now, I see all these guys in here who ought to be in the fucking Pine Street Inn. It's ridiculous." (The Pine Street Inn is a big homeless shelter in Boston. Note that these guys did not claim to be innocent. They said they understood why they were in prison, but they also made a plea to us that they were human beings, whose lives were degraded. What actually goes on in prison is for another time, however.)

Al Kramer said there were two factors at work. First, the legislature had taken up the progressive cause of deinstitutionalization of the mentally ill in the 1970s and '80s, and they had largely emptied the mental hospitals. The idea was to provide intensive community supports, including staffed group homes and integrated mental health and medical care. But after they got done saving hundreds of millions by closing the snake pits, they never got around to spending the money on community based alternatives. So we ended up with people with severe mental illnesses sleeping in cardboard boxes and, of course, commiting crimes out of desperation or delusion.

Second, the public wanted to get tough on crime and they were tired of all those bleeding heart liberal judges coddling criminals, so the legislature passed determinate sentencing laws. Judges no longer had discretion, and Al had to send people to prison whether it made any sense or not.

As regular readers know, I'm not inclined to give GW Bush a whole lot of credit, but he did appoint a presidential commission to study mental health issues in the U.S. (Hey, that's almost as good as actually doing something about a problem, isn't it?) The President's New Freedom [sic] Commission on Mental Health tells us:

[A]bout 7% of all incarcerated people have a current serious mental illness. The proportion with a less serious form of mental illness is substantially higher. People with serious mental illness who come into contact with the criminal justice system are often poor, uninsured, disproportionately members of minority groups, homelss, and living with co-occurring substance abuse and mental health disorders. They are likely to continually recycle through the mental health, substance abuse, and criminal justice systems. When they are put in jail, people with mental illnesses frequently do not receive appropriate mental health services. Many lose their eligibility for income supports and health insurance benefits that they need to re-enter and re-integrate into the community after they are discharged.

So, what do they do? They end up on the streets, disabled and insane. They may start screaming at an invisible interlocutor or taking their clothes off in the middle of Columbus Ave., whereupon the cops will take them to a state mental institution where they will be medicated. After a week or two, they'll be calmed down on the meds, and they'll be discharged -- to the Pine Street Inn. Then they'll destabilize again, shoplift or trespass or perhaps assault someone, and this time the cops will take them to the lockup and book them, and they'll wind up back in jail. By this time they're three or four or five time losers, probably parole violators, and they'll get a long sentence.

And so it goes. I propose that this is completely nuts. In other words, we are all insane.

And in flew Enza

While the corporate media regularly stir up mass hysteria about such very minor problems as West Nile Virus or Eastern Equine Encephalitis, good old flu kills around 40,000 Americans in a typical year. Most of these people are already debilitated for one reason or another, usually advanced in age, and we accept this as part of our condition -- although occasionally young and healthy people succumb, for unclear reasons.

But there is always that possibility of the return of an especially virulent strain of influenza, as in 1918. That world-wide pandemic caused a dramatic spike in the death rate in the U.S. and elsewhere, killing as many as 100 million people.

Michael T. Osterholm in the new NEJM reviews our current state of preparedness. The threat of such a pandemic is substantial, because of animal husbandry practices in Asia in which swine, poultry and humans are in continual contact, giving the virus a chance to migrate among species and undergo continual genetic recombination. There are several problems:

1. Influenza vaccine production still uses a 1950s technology in which virus is incubated in chicken eggs. It takes six months and 350 million eggs to make the 300 million doses used annually. This technology is nearly impossible to ramp up to a larger scale, and slow to respond to new strains.


2. The U.S. has little or no "surge" capacity to respond to a pandemic. We have only 105,000 mechanical ventilators, most of which are already in use at any given time. Ventilators would not be available for the tens or hundreds of thousands who would need them in a repeat of a 1918-style epidemic.


3. We have inadequate plans for creating, equipping and staffing the temporary hospital space that would have to be set up in such places as high school gymnasiums.


4. If a deadly flu were to emerge in Asia, most countries would close off international travel to try to contain it. World commerce would grind to a halt and the economic effects would be devastating. Only the ability to quickly create and distribute millions of doses of vaccine, or to attempt containment using antiviral medications, could persuade countries to allow international flights to continue.

But (and now this is Cervantes talking, not Dr. Osterholm) all our time and money for emergency preparedness is going into these preposterous bioterrorism drills. The states have been given federal grants to pretend that somebody sprayed anthrax (which is not contagious) around and everybody for miles around has to show up at a particular hospital to get a dose of ciprofloxacin. These drills are controlled by public safety officials -- police and firefighters -- not public health and medical officials. They focus on issues like what to do when 10,000 cars show up at a 300 space parking lot, and people start fighting to get to the head of the line. This activity does absolutely nothing to enhance our capacity or our readiness to respond to events which are actually likely in the real world.

Oh right, 9/11 changed everything. Reality is so last century.

Don't get me wrong -- ethics is hard work

Now that the Terri Schiavo circus has packed up the elephants and headed out of town, we do need to have a serious, public discussion about end of life and beginning of life ethics. Not that there is any real hope of that happening.

The new British Medical Journal (link is a PDF) brings two items of news from across the pond that we here in the colonies might want to think about.

The British Law Lords (equivalent to our Supreme Court) have ruled that British law does not forbid parents from intentionally selecting embryos that are a tissue type match for existing children who require a tissue donation, in other words the creation of so-called "savior siblings." (That's "saviour" in the UK, but I prefer to conserve my "u"s if at all possible.) Actually it's a bit more complicated than that because UK law has established a Human Embryology and Fertilization Authority that actually regulates such practices, however the authority has evidently approved it in the case at issue.

There has been at least one such case in the U.S. already, which received fairly limited attention. This strikes me as odd because the cult of life folks ought to be absolutely appalled. These couples are perfectly capable of reproducing without use of in vitro fertilization. They deliberately create multiple embryos, have them tested for compatibilty with the sick sibling, implant the one that matches and destroy the rest.

Those of us who do not believe that embryos are "human life" or have the moral status of human beings nevertheless have other grounds for being disturbed by this practice, in particular the question of whether the baby so created is truly a wanted child and what it might mean for the child, the family and the rest of us if we sanction bringing children into the world for the purpose of donating their bone marrow to someone else.

The second case is from the Netherlands, where physician assisted suicide and euthanasia are legal under strict conditions. A Dutch physician provided the means for suicide to a man diagnosed with Alzheimer's disease, who was in the early stages and far from terminally ill, but who did not want to endure the later stages of the disease and repeatedly asked for help to commit suicide. The committee that oversees assisted suicide ruled that the patient was indeed "suffering unbearably," presumably just from the prospect of advanced dementia, and was competent to choose, therefore the assisted suicide was permissible. Note that if this patient waited until his dementia was more advanced, he would have become technically incompetent to choose, and the option would not have been available to him.

This is also troubling to me, on various grounds, although I support the general right for people to choose the time and manner of their passing, and it is possible that in the same circumstances, I personally might have the same wish as this patient.

What do others think about these cases?

Public Health and Contemporary Politics

Medicine is the discipline that addresses health at the level of the individual. Public health addresses the level of populations. Public health is inextricably entwined with politics. As it is continually concerned with public goods and market externalities, it finds itself in fundamental conflict with free market fundamentalism and conservative views of the proper role of government.

The Congress and presidential administration now in power represent private interests -- oil companies, investment banks, multinational manufacturers and industrial food producers, and weapons manufacturers prominent among them. Public health practitioners and scholars have always found themselves in conflict with such interests, in advocating for environmental and safety regulation, food labeling, and other measures which restrict capitalists in the name of the public good. More subtly, public health advocates, based on scientific proof of the relationship between material deprivation and inequality, and ill health, have tended to be advocates for the social safety net and for investment in human development. And of course, for universal health care.

The association of public health with these sorts of policies goes back to its origins in the late 19th Century. Public health was an essential froce in progressivism and the so-called Age of Reform, helped to energize the New Deal, and was a vital force in the post-war era right up to the Reagan Administration. Public health measures were always resisted by the powerful business interests that stood to lose a few dollars off the bottom line, often with considerable success. The most obvious example is that the insurance and drug companies have successfully blocked universal health care. Environemntal and safety regulations are still far weaker than they ought to be, and we still have children who are ill-nourished, ill-housed, and ill-educated. But we made a lot of progress during the 20th Century. No-one should doubt it.

Now that the obscenely rich are in total control of the federal government, we have been moving steadily backwards. There is no need to start reciting the horrors here. But this is an old struggle, between commanding private interests and the public good. What is most disturbing about the present situation is the introduction of a new conflict, between truth and fantasy, between science and faith. Public health contains a set of social objectives, but just as important, it is a scientific discipline, or rather the cross-disciplinary application of epidemiology, biology and medicine, sociology, psychology and behavioral science, and environmental sciences. Whatever their loyalties and passions, public health practitioners bow to scientific truth.

But the ruling Republican Party rejects truth as a basis for ordering our affairs. We do not decide based on reference to observable reality and logic. We decide based on the interests of our wealthy constituency, and then we declare the science to be whatever supports the chosen policy. This ruling cabal has made a cyncial alliance with religious cultists who reject science and reason on principle, in favor of the superstitious beliefs of pre-literate nomads. Wherever their obsessions are not immediately threatening to the greater enrichment of the plutocracy, the cabal is happy to overrule science in favor of these religious fanatics as well, even at the cost of thousands or millions of lives. Here the global HIV epidemic clearly reveals what is at stake for the future of humanity.

Sorry for such a long post, which really doesn't say anything new. But as we go about our lives we often forget the profound crisis and the stark choices that we face. This is a terribly dangerous moment in our national history.

At long last, have you no shame?

The FDA is charged with protecting the health of the public by assuring the safety of food, drugs, medical devices, and cosmetics. It is supposed to base its decisions on scientific -- in other words, truthful -- evidence. We have seen how the FDA has been corrupted by the pharmaceutical industry, at the cost of thousands of lives. Unfortunately, it is not unusual for regulatory agencies to be captured by the industries they regulate. Political scientists have long observed this phenomenon.

But now it appears the FDA has been captured by bigots. On May 25, according to the Associated Press, new FDA guidelines will forbid sperm donation by any man who has had sex with a man in the past 5 years. Ostensibly, this is to protect against the possibility that donor sperm will be infected with HIV, but that is a transparent fraud. To quote from public comment submitted by the Gay and Lesbian Medical Association, Human Rights Campaign, Lambda Legal Defense and Education Fund, Rainbow Flag Health Services & Sperm Bank, Sperm Bank of California and the National Center for Lesbian Rights:

It remains our concern that the guidance will simply adopt, as to sperm donors, the 1994 CDC guidelines, which ban any men who have had sex with men (MSM) within the preceding five years from being blood or tissue donors. The designation of MSMs as unsuitable donors operates regardless of the results of any HIV test, the sexual behavior of the potential donor and with no accounting for the fact that the blood of the donor can be tested, and that semen, unlike other types of tissue, can be stored in quarantine for six months until the donor is retested. Simply put, we believe that the guidance should not designate MSMs as unsuitable sperm donors without adequate scientific support. Moreover, in reviewing the guidance document, the FDA should consider the reliability of current mechanisms designed to prevent the transmission of HIV through reproductive tissue donation, including the quarantine and re-test procedure.

That is awfully restrained and polite of them. The FDA rules do not forbid men who have sex with female prostitutes from being sperm donors. They do apply to men in monogamous same sex relationships. Being gay does not cause people to become HIV+; having unsafe sex does. This rule is simply bigotry. It is indistinguishable from forbidding Black or Arab men from being sperm donors, as far as having any rational scientific basis. I'm guessing that the real motive is eugenic. The good Christian folk at the FDA just don't want gay men to reproduce. Of course they know that being gay is a choice, a moral failing, but just in case there's a bad seed involved, here's a chance to purify the bodily essence of God's chosen nation.

Immunization

Robert Rinsky, editor of Public Health Reports, is happy! And, with a bit more reservation, I share his ecstasy. Says Bob, in the new issue, "I have one of the most amazing documents of modern times in front of me. An indescribably huge triumph of Public Health. Almost incomprehensible. It is the March 21, 2005 Morbidity and Mortality Weekly Report announcing the elimination in the United States of rubella and congenital reubella syndrome. . . "

Okay, he could use a thesaurus. But he's right. When I was a child, a family close to us had a child born deaf, blind and retarded because of rubella, who spent his life in an institution. I'm not old enough to remember when the country was terrorized by polio, but my aunt had it and suffered some lifelong effects. I had a schoolmate who wore heavy braces and walked with crutches, and I have already written about my friend and mentor Irving Kenneth Zola. Smallpox, one of the great scourges of humanity, has been eradicated from the earth. This is a case of humanity coming together, cooperating at the highest levels of national power, to eradicate a biological species, but I've never heard even Earth First! objecting. (They probably do, but it's not likely to be a winning issue for them.)

People younger than 60 or so can scarcely imagine existence before the modern vaccine era. Life was far less certain. Any child could be snatched away at any time in a random harvest, or maimed for life. We take for granted now that children will become adults. Believe it or not folks, that is a luxury our grandparents did not know.

I am not sure why, but immunization has always been shadowed by skepticism. Ever since Jenner developed vaccination to prevent smallpox, there have been popular movements against the practice. Many people are simply determined to believe that immunization is dangerous, ineffective, of an active conspiracy of some kind against their ethnic group or their religion. Recently, a polio outbreak in Indonesia is believed traceable to a traveler to a region of Nigeria where religious leaders have opposed polio vaccination as a plot to render Muslim women infertile. In the U.S. and the U.K., a determined movement of parents has insisted that their children's autism was caused by the Measles-Mumps-Rubella vaccine, or more specifically a preservative used in some doses that contained mercury. (Very careful study has absolutely ruled this out.)

Many people in the U.S. continue to refuse to allow their children to be immunized based on religious ideas or pseudo-scientific beliefs. There are principles of civil liberties at stake of course, and most states allow conscientious objection to immunization requirements. It is easy to permit this because of herd immunity -- if most children are immunized, an epidemic cannot take hold, and even those children who are not immunized are protected. But that is a matter of percentages. Too many objectors would find their children at risk of dangerous diseases.

Opposing immunization is not progressive, populist, or liberating. It's just a mistake. There have been a couple of incidents in which vaccines that turned out to have unacceptable side effects, and needed to be withdrawn. For most, there may be rare adverse effects, usually mild and transient, or more common mild side effects such as a one day fever. But believe me, these are well worth the benefits. It's a lot easier to be a Christian Scientist nowadays, when you can take a free ride on everybody else's sensible choices.

A Blogging Masterpiece

American hero Matt* over at Today in Iraq has put up a post, a couple of days late, commemorating the second anniversary of the Scourge of God prancing about on the flight deck of the U.S.S. Abraham Lincoln with a wad in his pants, declaring Mission Accomplished. The CinC's speech is reprinted in its entirety, sound bite by sound bite, along with the relevant news since that date.

I'm going to comment on what is on topic here: the public health situation in Iraq today. Iraq is a humanitarian disaster of the same order of magnitude as the Asian tsunami. We all know of the Johns Hopkins study, published in The Lancet, that estimated 100,000 excess civilian deaths since the invasion. While U.S. officials have dismissed the study, they have not provided any counterargument or evidence. Instead, they simply say that they don't bother to count the Iraqi dead, which is apparently answer enough for Americans. Independent reviews have concluded that the study methodology is sound. Due to limitations on data collection posed by the security situation, it is undoubtedly an underestimate.

The majority of Iraqis killed by U.S. forces, through direct acts of violence, have been women and children. There have been plenty of incidents of children being killed and maimed by American bombs that have been photographed, lots of fully documented and proven incidents of innocent people gunned down by U.S. troops at checkpoints, or just because the happened to be on the highway near a convoy. Those of which some form of public record exists are obviously a small minority of all that occur. These may get a mention in the New York Times but they are of no apparent concern to any of our political leaders, television news producers or most of the public.

Far worse, in the long run, but less dramatic, is the damage being done to the current generation of Iraqi children. An estimate reported by the Washington Post is that 7.7% suffer from "acute malnutrition," which means protein-calorie deficiency, which means, if they are lucky enough to survive, stunted growth and permanent neurological damage. Far higher numbers suffer from chronic, less severe malnutrition. The public water supplies in major cities are contaminated (when the water flows at all), sewage flows in the streets, and the hospitals lack equipment, supplies, and drugs.

Freedom is untidy, it appears.

*Who works for the U.S. Army, an experience entirely unknown to the architects and most of the defenders of the Iraq war. (Correction to earlier post, Matt is a civilian DoD employee, stationed abroad. He's a hero because of his work on the blog.)

Red States and Blue States and the Social Determinants of Health

I've had some fun showing correlations between ill health, and numbers of uninsured people in the various states, and the percentage of the vote that went to the moral values candidate in 2004. His own state of Texas is worst on one measure and close to worst on another.

However, correlation is not evidence of causation. Obviously, those people didn't vote for the Dear Leader because they are uninsured and have low life expectancies. (And actually, to presume that the people who voted that way are themselves uninsured and fated to die young is to commit another fallacy, called the ecological fallacy. But this is not a course in research methods so I won't get into that right now.) Instead, these facts about the states presumably go together because of other, underlying causes that aren't in our model so far.

It is well known that so-called Socio-economic Status (SES), which is some mixture of level of formal education, income, and occupational prestige, is strongly related to health status, and that access to medical care does not explain the relationship. (And in fact, providing universal access as most wealthy countries have done does not reduce it by very much.) It is true that lower SES people are more likely to use tobacco and to be obese than are higher SES people. But after you control for the readily observable behavioral factors disparities still remain. It has also been found that the disparities are related to the overall level of inequality in society, in other words societies with a lower average level of wealth, but low inequality, tend to have healthier people than do wealthier societies with high levels of inequality. Welcome to the USA, where we are less healthy than the Western Europeans and also far more unequal.

Various causal stories can be told about the correlations I have noted here. The red states tend to be poorer on average and to have lower average levels of educational attainment than do the blue states. That makes their people sicker, but it doesn't directly make them vote for a faux Texan whose main political agenda is to further impoverish them. These states also have more conservative political cultures, obviously. Does that make them have more inequality, more poverty, and lower education, or is it the other way around? What do you think?

More Red State/Blue State Fun

As I'm sure everyone knows because the buzz has been about nothing else, this is national Cover the Uninsured Week (not an official federal event, to be sure). The Robert Wood Johnson Foundation has issued a report based on the Behavioral Risk Factor Surveillance Survey (BRFSS) showing the percentage of adults 18-64 in each state without health insurance in 2003. (This is cross-sectional data; larger percentages were without insurance at some time during the year. The BRFSS is a telephone survey that so it actually underrepresents poor people.)

The highest percentage of uninsured adults was in, ahh, Texas (27%). Competing for the top spot were Louisiana, New Mexico, Nevada, Oklahoma, Florida . . . Bringing up the rear, with the lowest percentage of uninsured adult residents, were Minnesota, Hawaii, Delware, DC, Massachusetts, Wisconsin, Vermont . . .

Is anybody starting to see a pattern here? At Stayin' Alive, we always take a rigorous, scientific approach, so I fired up my trusty SPSS and ran a correlation between the percentage of the presidential vote in 2004 that went to what his name -- you know, that guy whose wife said last night that he tried to milk a male horse -- and the percentage of uninsured adults.

Another major sociological discovery for this site! The correlation coefficient (Pearson's r) for this relationship is .344, p=.014. The unstandardized regression coefficient is .574, which means that for every one point increase in the percentage of uninsured adults, the horse yanker got a little over half a percent more in the 2004 vote. It appears he has drawn the conclusion that the more uninsured people there are, the more popular he becomes, because his new budget will cut spending on Medicaid and insure that that the number of uninsured people gets larger. That's got to drive up his approval ratings, right?

The Other Nucular Option

We've heard an awful lot about Weapons of Mass Destruction™ during our long national nightmare. You know, horrific weapons like the sarin gas that a faith-based organization used to kill 11 people in the Tokyo subway, and the weaponized anthrax that one of the tireless defenders of America's freedom took from a secret U.S. military laboratory and used to kill 5 people.

I have wasted a lot of time, megabytes and inkjet toner, before and after the glorious conquest of Mesoptomia, arguing that nerve gas and non-contagious pathogens are in fact no more inherently massively destructive than the high explosives and projectile weapons used by the defenders of freedom to, among other humanitarian triumphs, reduce the city of Fallujah to rubble. Not long after the Aum Shinrikyo attack in Tokyo, a man in Seoul killed hundreds of subway passenger with a milk carton full of paint thinner. Thank God we got rid of Saddam before he gave a bottle of turpentine to Osama bin Laden.

But there is of course a category of weapons which are about as massively destructive as they can get. From a public health point of view, a nuclear explosion would definitely be an incident to be avoided. Unfortunately, a certain rogue state in North America possesses a few more of these weapons than it is likely to need for legitimate purposes of self defense. Specifically, 10,000 nuclear explosive devices, 7,000 of which are actively deployed on submarines, land-based ballistic missiles, and long-range bombers. The purpose of these weapons is to uh, uhm, errr, ahh . . . come to think of it nobody has actually explained what they are for. I don't recall hearing any discussion about this.

Lawrence J. Korb, former Asst. Secretary of Defense for the spineless, America-hating liberal president Ronald Reagan, points out that Emperor Chimpoleon the First's budget calls for spending $11 billion next year on maintaining these nuclear weapon delivery systems, and another $6.6 billion to develop, test and build new ones. I mean, you can never have too many, right? This traitor proposes reducing our aresenal to 1,000 weapons, which would still be plenty to destroy all of civilization and would save us about $10 billion a year, which we could use for good purposes, such as keeping all the people in persistent vegetative states alive forever. Maybe you can think of a different use, but the point is, in order to protect rich people from godless taxation, we've run up this little budget deficit and it's causing a few little problems.

Korb and his colleagues can be found at the Center for American Progress. Meanwhile, it's pretty obvious to me that there is no reason why the Iranians should feel shame and guilt about their own nuclear weapons-related research when it's perfectly alright for Israel to have at least 100 nuclear weapons and the U.S. to have 10,000. Not to mention the Russians, Chinese, Pakistanis, Indians, British, and French. Non-proliferation is not going to make any sense to most of the world unless we make serious steps toward reducing nuclear arsenals. As Korb says, the U.S. could give up 90% of its nuclear weapons tomorrow, and we would be instantly safer and more prosperous. We could move toward an effective, international nuclear arms reduction regime, and ultimately elimination, from there. That's the single most important step we can take to lift the cloud of terror from humanity.