US anthrax buy

The US government is making a big anthrax buy. Not an anthrax vaccine buy. An anthrax buy. They want to buy large quantities of anthrax for the Dugway Proving Ground in Utah, one of the government's germ warfare testing grounds.

The ever-valuable Sunshine Project has discovered contracts for the production of bulk quantities of non-virulent anthrax and associated equipment that can be used to produce large quantities of biological agents.

According to New Scientist,

One "biological services" contract specifies: "The company must have the ability and be willing to grow Bacillus anthracis Sterne strain at 1500-litre quantities." Other contracts are for fermentation equipment for producing 3000-litre batches of an unspecified biological agent, and sheep carcasses to test the efficiency of an incinerator for the disposal of infected livestock.

Although the Sterne strain is not thought to be harmful to humans and is used for vaccination, the contracts have caused major concern.

"It raises a serious question over how the US is going to demonstrate its compliance with obligations under the Biological Weapons Convention if it brings these tanks online," says Alan Pearson, programme director for biological and chemical weapons at the Center for Arms Control and Non-Proliferation in Washington DC. "If one can grow the Sterne strain in these units, one could also grow the Ames strain, which is quite lethal."

The US renounced biological weapons in 1969, but small quantities of lethal anthrax were still being produced at Dugway as recently as 1998.

Neither The Sunshine Project nor New Scientist had any idea what the purpose of these contracts was. The Sunshine Project's Ed Hammond speculated they might be part of a testing process to see how easily the spores dispersed from various weapon delivery systems.

Dugway has said these contracts are still in the "pre-solicitation phase" and no delivery of material has been made as yet. If we believe them. Even if we do, the action is certainly provocative:

Whatever use it is put to, however, the move could be seen as highly provocative by other nations, he says. "What would happen to the Biological Weapons Convention if other countries followed suit and built large biological production facilities at secretive military bases known for weapons testing?"

Once again, Bush's "Biodefense Strategy" makes us less safe rather than more safe. In a special irony, it was alleged evidence that Iraq had these kinds of facilities that Bush used as evidence Saddam had Weapons of Mass Destruction. Presumably this would be grounds for some other country launching a pre-emptive strike on the US.

Or have I got my logic wrong.

[cross-posted at Effect Measure]

Gloss on the below, and administrative statements

Speechless's comment on the previous post is quite apropos: "Isn't it bizaare? As if the system the institution takes on a life of its own that demands primacy over the needs of the patient. The institution comes to exist for its own purpose, and has lost sight of those it was created to serve."

Hospitals are organized and managed for the convenience of the staff, principally physicians and then nurses. Patients are just the raw material they process. It is nearly impossible to get any rest, or a decent night's sleep, in a hospital. Patients' personal needs or suffering are basically just a pain in the ass. Don't get me wrong -- most of my nurses were personally compassionate and caring -- I happen to have described an exception -- but the supply of caring they had available was often insufficient.

Hospital staff see so much suffering that they inevitably become callous, by ordinary standards. My agony would have been perceived as a major emergency anywhere but a hospital. Imagine if it had happened in a workplace, or in front of my family. But in a hospital, the only emergency is imminent death. Intestinal cramps weren't going to kill me, so my situation was just something that somebody would get around to eventually. If it took three hours, so be it, people had work to do.

Now, I am honored to announce that Revere, the editor(s) of Effect Measure will be joining this blog. Revere will make sure that we don't have that downtime on Saturdays, and other times when I am unable to post. We're having technical difficulties as I write this, which I hope we can resolve before I leave the planet today. If that doesn't work out, you may have to wait a bit, but with luck you'll be hearing from Revere this weekend, so please do stop by.

Finally, this is a big news day. I'm always tempted to comment on compelling events, but I think my job here is to try to discover whatever is original or unique that I can offer. I'm sure you'll find all the topical commentary you can handle at Eschaton, America Blog, Talking Points, Today in Iraq, and all the other fine current affairs blogs. But I do need to say that the notion that Judith Miller had to make some sort of a noble sacrifice in order to "protect" Scooter Libby is more ludicrous than giving Henry Kissinger the Nobel Peace Prize. Protect him against what, exactly? Retaliation for doing what Karl Rove wanted him to do? She was "protecting" her confidential source against public scorn, and criminal prosecution. Reporters are not doing their jobs, or serving the public, by giving sources protection against the morally appropriate consequences of their actions. That is the precise opposite of the theory behind the protection of sources. Will Bill Keller ever figure this out?

Ileus . . .

is not a legendary Greek hero.

For those of you who are newcomers to this site, a while back I started to tell the story of my own disemboweling by surgeons who were under the erroneous impression that I had colon cancer. I digressed to tell about the disgraceful and appalling treatment of my Russian roommate, who spoke no English. Now I owe the rest of my story, so here’s the next installment. It's too long for a blog post but that can't be helped.

I’m still hooked up to a urinary catheter, a morphine drip, a nasogastric tube continually pumping out my stomach, and plastic sleeves on my calves that continually inflate and deflate. I haven't had anything to eat or drink for several days.

Normally, waves of contraction travel continuously down the intestines, moving the food along as it is digested, and eventually out the exit. Now think of your distant ancestor whose abdomen is mauled by a saber-toothed tiger. His only hope of surviving is for the system to shut down, so that feces aren't pumped into the abdominal cavity and lacerations have a chance to heal. Actually, it's probably not a bad idea for even the carefully re-sewn juncture created by surgery -- called an anastomosis -- to have a chance to knit free of strain.

Also, my fever was too high. Usually, this is a sign that the patient is failing to clear the lungs, because of shallow breathing and inability to cough. I would just have to cough. Alas, it was impossible.

A woman came with a plastic device that could measure the volume of my inhalations. Every hour, I was to suck on this thing ten times and try to make the little yellow cylinder rise as high as possible. What they didn't tell me was that I would be billed $25 for her 30 second visit and $39 for the plastic doohickey, which was easily worth $4.50. Actually, they billed me for two visits by the respiratory therapist, one of which never happened.

It was a great day, though. The head surgeon came to see me and I asked him to get the damn tube out of my nose. He did it! He told me to take a deep breath then he pulled it right out. Then I asked him to get those damn inflating booties off me. He made a deal with me. He would do it if I would walk. It didn't seem possible, but I was willing to do anything. Nurses came and pulled off the booties. Then they took the catheter out of my penis. They waved a syringe at me the size of a coke bottle, but not to worry. The syringe was to draw out water through a little bypass off the main tube. The principle of the thing turned out to be a water-filled balloon inside my bladder that kept the catheter in place. Once the balloon was deflated, they just pulled the whole apparatus out. The sensation startled, but it was tolerable.

Now the trick was to stand. I still couldn't sit up on my own, but the magic bed could get me into a full sitting position and, with the help of the morphine button, I could get my legs over the side and slide my feet down to the floor. With a nurse pushing the IV pole, I walked down the hall 20 feet and back. I needed someone to lift my legs back into the bed, but you have to admit, all of this was progress. It was painful and strenuous, but was advertised as having multiple benefits. Not only would it prevent blood clots from forming in my legs, then breaking off and killing me, but it was the only known way to encourage the bowels to start operating again. My assigned goal in life now was to pass gas. I should let them know right away if any should depart my posterior.

Then the chief surgeon came again and told me I could have something to drink immediately. He put me on what is called a Full Liquid Diet. He gave me his card. "After you're discharged, I'll want to see you in a couple of weeks. In the meantime, if you have any problems or questions, just call." The card read: "Beth Israel Hospital, a major teaching hospital of Harvard University. Andover G. Knozall, Instructor in Surgery."

Debbie, my regular nurse, was off that day. Nurse Huang gave me a lunch menu. Mirabile dictu! I could order tomato soup, vanilla pudding, cream of wheat. I lustfully circled my choices. Then Ms. Huang told me I could get juice from a refrigerator across the hall.

It turned out the juice came in a little container that looked like a urine sample. I drank some apple juice, trying to be cautious, but it was gone in a minute. I will not try to describe this experience; you can imagine what it meant after nearly a week with nothing getting past my front teeth except a wet sponge on a stick.

I waited a half hour or so and still felt fine, so I went for a urine-sample container of orange juice. I was on my way out of there! I got a little anxious, though, the next time I got up to walk and discovered that my abdomen had blown up into a hard, geometric hemisphere. When my lunch came, I was too bloated to eat. I was sick, getting steadily sicker.

I began to feel surges of pain in my abdomen, always in the same place directly below my navel. As each one subsided, my diaphragm would spasm and acid would burn through my chest and into my throat. My friend Peter, who is a physician, came with his eight-year-old son. JJ had brought me his electronic baseball game, to help me pass the time.

In the end, that people care for you is the meaning of life. But pain, in its time, is the whole universe. The cramps came every minute, and grew stronger every time. They would start in a tight focus just below my navel. Then pain would swirl through my belly and explode into my groin and up through my chest and neck like a cluster bomb, trailing acid fire into my throat. After every attack, I violently gulped the air I would need to make it through the next one. My memory of this whole episode is a blur of agony, but I am sure that my nurse knew that I was in serious distress before Peter and JJ came. She paged the intern on duty right away, but he didn't come for more than three hours. By the end of that time I thought the spasms would break me in half.

Peter did everything he could to help. Even though he is a doctor, it was not his place to intervene. He tried to talk me through a meditation exercise to conquer the pain, but I could not concentrate. I was not simply in pain: I was possessed. My body was no longer my own. I wanted JJ to leave, afraid he would be hurt and disturbed by what he was seeing, but I didn't want to send him away either because I wanted him to know that I liked having him care about me. It was up to Peter, anyway, and Peter let him stay.

Peter urged nurse Huang to page the intern, again and again. She argued with him, defending her own conduct. Finally he threatened to call my attending physician -- Andover Knozall -- at home. Five minutes later, the intern came. His name was Dr. Huang. No relation? I don't know.

"Ileus", he said to Peter, who agreed with him. That's a fancy word for the paralysis of the bowels I'd had all along. Peter had explained to me that the cramps came from the bowels starting to work, but without coordination. One section might start a wave of contraction that met up against another section that was locked up tight. The problem came, ultimately, from the apple juice I had drunk that morning. My stomach was trying to send it on down to intestines that just weren't ready.

Dr. Huang said he was going to pump out my stomach. Peter and JJ left the room. Dr. Huang had a little roll of thin orange tubing. He cut off a piece and dipped one sharp looking end in some vaseline. Then he stuck it up one of my nostrils. It felt exactly as though he had stuck a burning match up there. "Don't do that don't do that don't do that" I yelled. I couldn't yank my head back because it lay against the mattress. I couldn't struggle with him because I was paralyzed by another cramp. The match burned back through my skull and down into me. "Where is it?" Dr. Huang asked.

"My throat my throat my stomach my stomach take it out take it out." Then I gagged and vomited onto Dr. Huang's shirtfront. I vomited again, and a third time. By then, he had a bowl under my chin. The tube came up with the brown glop in my stomach, and I pulled it out of my nose. The cramps eased.

Peter came back in and he helped Dr. Huang change my smock. "Actually," Dr. Huang said, "I'm more concerned about his fever. It should be going down by now. It's still 102." I was lying back exhausted. Peter and Dr. Huang left. I still had cramps, and they still came every minute, but they stayed in that tight little focus under my navel, no longer exploding through my vitals. Every minute, a little surge of pain. But no more cluster bombs, no more back arching and throat clenching.

Nurse Huang came in. "I did everything correctly from the standpoint of nursing. Your friend was wrong to say he was going to call the attending." She leaned over to lecture me. Yes, the nurse actually made a point of coming in to berate me. Now think about it. If this had happened to me on the sidewalk in front of the hospital, somebody would have called 911 and I would have had help within minutes. My mistake was to have a medical emergency in the hospital.

I think we're all bozos on this bus

Health Affairs has a special web issue on the future of Medicare and the health of American elders. And, mirabile dictu, it's open access!

Much of the material centers on a computer simulation by Dana Goldman and colleagues at the RAND Corporation (the folks who brought you the Vietnam counter-insurgency tactics, but we're over that, right?) which with the help of a lot of sometimes dubious assumptions projects the health, longevity and health care costs of the elderly population out to the year 2030. Then they try adding various prospective new medical technologies to the stew to see how it comes out.

The first thing you need to know is that, even as the health of the elderly in the U.S. has been improving in recent decades, the health of younger people has been getting worse, for exactly one reason: the epidemic of obesity and Type 2 diabetes. You can worry about terrorism or bird flu all you want, but this is for real, it's here, it's now, and it's threatening to undo the progress we made throughout the 20th Century in population health and longevity.

Anyhow, for present purposes, the assumptions we make about where the obesity problem is going affect the health status of people turning age 65 and entering the simulation. Less healthy people cost more per year, but they don't live as long. The consequences for Medicare spending tend to cancel each other out, since longer-lived people are still around to spend money on. Eventually they will get sick and die. About 30% of all Medicare expenditures are on people in the last year of life, from which you can run, but you can't hide. As a result, for budgetary purposes, it doesn't much matter how healthy people are when they enter the program. Without assuming any major technological breakthroughs, total Medicare spending increases from about $300 billion today, to $600 billion (in 1999 dollars) in 2030.

But won't those medical breakthroughs reduce the burden of disease and end up saving money? Sadly, no, as the cool kids say. For example, we already have implantable defibrillators. These may be used in increasing numbers of people. They cost about $40,000 to implant. That saves no money to speak of because it stops people from dropping dead suddenly, which is a relatively inexpensive event. At the same time, it causes people to live longer, get other diseases, and cost Medicare more money. Other potential advances may cost less (others cost more), and even reduce the burden of disease and disability, but in the simulation, none of them ends up saving Medicare money in the long run -- even though most of them are cost-effective from the point of view of the individual.

The most cost-effective intervention is a magic pill that extends life by 10 years. If it costs as much as other pills like statins, that you have to take every day, it only costs $8,790 per year of additional life, assuming that those extra years are healthy years. But by 2030, it adds 13.8% to overall health spending, because presumably everyone would take it, and that is the greatest increase in cost of any of the hypothetical new technologies. (If those extra years are unhealthy years, the cost effectiveness is far worse.) Anti-angiogenesis compounds -- drugs that stop cancers from growing by cutting off their blood supply -- cost half a million dollars per year of life added. But they would add only about 8% to total annual costs because fewer people would receive them, and for only a short time, since many of them would soon die anyway.

Advances in medical technology make health care more expensive. That isn't always the case, but it's true in the aggregate. As Goldman and the gang put it, "Many of the new treatments will be expensive and hence will raise the cost of health insurance for the non-elderly, and fewer people will be able to afford comprehensive coverage. In fragmented health insurance markets and incomplete health insurance coverage, the fruits of medical progress will be distributed unevenly. Furthermore . . . if we design cures for the diseases of "rich people" -- as cardiovascular disease once was -- then gradients in health are likely to widen." Indeed. This is already happening. Fundamental reform is unavoidable -- and we will either have rationing by ability to pay, as we do now; or rationing by transparent social choice, as sanely governed countries do.

The Unbridgeable Chasm

That's the one between the reality of Iraq and the political discourse in the United States. I read those eastern elite pointy-headed liberal newspapers, the Boston Globe and the New York Times. I occasionally look in on the TV network news so I'll know what drivel is being fed to the people. I get a sampling of the coverage of other newspapers over the Internet. I listen to NPR quite a bit with at least half an ear.

Then, I get the truth. I read the analysis -- the Informed Comment, as he accurately describes it -- of Juan Cole, with whom I often disagree but who is definitely reality based. I read the admirable news aggregation site Today in Iraq. I regularly visit Iraq Coalition Casualty Count. I read Riverbend's blog. (Which she understandably has had trouble keeping up recently.) I read the reporting of Robert Fisk and Dar Jamail and other courageous, enterprising journalists at Information Clearinghouse. I read the thoughtful, in-depth reporting of such journalists cum social scientists as Mark Danner in the New York Review of Books.

This is the truth. There is no good news from Iraq. The "democratically elected" government is controlled by two Shiite religious parties, with the cooperation of Kurdish representatives whose only long-term goal is independence but who are playing along for now in order to win territory on the cheap. The Shiite parties also envision an independent Shiite theocracy closely associated with Iran's clerical rulers. These factions wrote the new constitution in order to achieve these ends. The only effective units of the Iraqi army are actually militias of these Shiite and Kurdish parties who wear Iraqi Army uniforms, and these are the "Iraqi" soldiers who now fight alongside U.S. forces against Sunni Arabs -- when they aren't commiting atrocities on their own.

Why on earth the United States would be spending blood and treasure to advance these objectives is incomprehensible. Opposing this project through guerilla warfare are secularist Iraqi nationalists, principally Sunni Arabs who were associated with or had a stake in the former regime; and Sunni Islamic factions including Iraqis and a small number of foreigners. The Shiite movement of Muqtada al Sadr, who has a huge following, opposes the present government politically and is allied with the Sunni insurgency against the intended breakup of Iraq. Although his fighters have been observing a cease fire for more than a year now, that appears to be breaking down, and U.S. forces are again skirmishing with his Mahdi Army.

Meanwhile, there is no basic security or civil order in Iraq. Gangs of vicious criminals operate freely, commiting kidnappings for ransom and robberies that have the Baghdad middle class huddling behind closed doors. Women and girls are afraid to leave the house, and the social equality and freedom they enjoyed under the secular Baath regime has been lost. Child malnutrition is widespread. Most people with the means to get out of the country are doing so, notably the physicians and other professionals who would be essential to the rebuilding of Iraqi society. The police and other security forces, as well as the government ministries, are completely corrupt, and loyal to their factions. The police are as dangerous as the criminals, or perhaps indistinguishable from them.

Daily attacks on the oil infrastructure have reduced production to below pre-war levels. Electricity in Baghdad is available for only a few hours a day. Sewage still flows in the streets. The government hides behind 12 foot blast walls in a closed zone of central Baghdad controlled and secured by the American occupiers, to which American "reporters" (actually transcriptionists of Central Command briefings) are confined.

And then there is the occupation. War is not glorious, or pure, or honorable. It is brutalizing, grotesque, beyond morality. The Americans drop bombs on houses from airplanes, killing people indiscriminately. They fire 50 caliber machine guns at cars that they think have approached them too closely, and at everyone in sight if they have been attacked. They break down doors in random searches of entire neighborhoods, destroy and loot people's property, beat and humiliate ordinary citizens. They routinely abuse and torture people they arrest, and they hold tens of thousands of prisoners, the vast majority on nothing but slight suspicions, under grim conditions. They besiege and demolish entire cities, driving their inhabitants into squalid refugee camps.

They do this even though they do not understand who they are fighting and they have no evident goal or cause. Some of them have taken to posting photgraphs of themselves laughing at the gory remains of Iraqis on an Internet porn site. Ironically, that's about the only place Americans can see for themselves the reality of war, because the television and the newspapers won't show it to us.

The whole world knows all this. But our political leaders, of both parties, and our corporate media, will not confront the truth. There is a cancer on our national soul.

Anybody who isn't paranoid these days is nuts

As we have just seen to our horror, it is important to have it all figured out ahead of time who is going to be in charge in an emergency. The World Health Organization, as those of you know who have surfed on over to Effect Measure, is considerably worried about the prospect of a worldwide pandemic of a particularly virulent strain of influenza, which is currently percolating away among birds, including domesticated fowl in Asia and migratory birds which have now made it to Eastern Europe. Many readers here are familiar with the basics, but it won't hurt to do a brief review.

As a reminder of the technical background, the problem is that this strain of influenza virus has a form of the protein hemmaglutinin on its outer coat that humans have not previously been exposed to. (That's what the "H5" means in the name of this strain, H5N1, with N1 being the form of another protein called Neuraminidase.) That means we have no immunity to this particular strain. So far we know of a few dozen people who have become infected, about half of whom have died, but it appears they either became infected directly from birds, or from very close contact with severely ill people. Unfortunately for people and birds, influenza virus evolves rapidly, both by mutation and by genetic reassortment, including swapping genes with other strains.

Once a variant of H5N1 influenza acquires the means to be transmitted efficiently from human to human, the pandemic will begin. That may be happening right now in Indonesia. In any event, WHO and most experts believe it is only a matter of time. A strain that easily spreads among people will likely be less lethal, but it will be lethal enough. Ordinary seasonal influenza kills people, but mostly people who are already debilitated or immunocompromised. Frail elderly people are particularly at risk. Like the 1918 strain of flu, however, an H5N1 pandemic is expected to be potentially lethal to young, healthy people. And it will make a lot of people very sick.

Far beyond the direct effects of the virus, a pandemic will create enormous social disruption. Undoubtedly countries will try to protect themselves by restricting travelers from abroad, even suspending all air traffic. If many people in essential occupations such as police, firefighters, physicians and nurses, even trash collectors are sick at the same time, public services will be disrupted including health care, just when we need it most. Internal commerce may also be disrupted, shortages of food and other goods could appear in particular cities, and so on. Undoubtedly many people with the means to do so will flee affected cities for what they consider to be safer retreats in the countryside, leaving yet more jobs unfilled. All of this will pass -- the pandemic will sweep through a region and move on in a few weeks -- but it won't be pleasant.

Naturally, the WHO is calling upon all nations to prepare. They've even given us a handy checklist. Here's one item:

1.2 Command and control

In order to be able to make clear and timely decisions and to have a uniform policy that is endorsed by all officials, it is essential to know who is in charge of different activities within communicable disease control, and how that might change if a limited outbreak becomes a major emergency. In addition, it is essential to know who is in charge of key elements in the response (e.g. travel or trade bans, enforcement of quarantine).

As we saw in the recent unpleasantness in New Orleans and points south and east, the federal gummint hadn't figured that out when it comes to natural disasters. Is it CDC, DHS, local officials? Fearless Leader has the answer! It's the army.

Now, you'd think that people at the Centers for Disease Control and Prevention would have the appropriate expertise here; and that FEMA ought to know something about disaster response. What the army is extremely good at is blowing stuff up and killing people. Hey, that's their job. They have also shown themselves to be highly capable at rounding up large numbers of people and imprisoning them. (Not that there's anything wrong with that.) I don't think that's exactly what's needed, although, as WHO also tells us:

1.5.1 Legal issues
Rationale
During a pandemic, it may be necessary to overrule existing legislation or (individual) human rights. Examples are the enforcement of quarantine (overruling individual freedom of movement), use of privately owned buildings for hospitals, off-license use of drugs, compulsory vaccination or implementation of emergency shifts in essential services. These decisions need a legal framework to ensure transparent assessment and justification of the measures that are being considered, and to ensure coherence with international legislation (International Health Regulations).

Well, one possible legal framework would be the declaration of martial law and the assertion of presidential emergency powers. Of course, we can count on that being reversed once the emergency is over, right?

How to get a top job in the Bush administration

He's no Brownie, but:

From Science magazine, May 2002:

Tongues wag as von Eschenbach keeps ties to National Dialogue on Cancer
Three years before Andrew C. von Eschenbach became director of the National Cancer Institute (NCI), he helped create the National Dialogue on Cancer. This amorphous private entity, funded by the American Cancer Society (ACS), brings together VIPs and cancer organizations to talk about how to conquer cancer.
It also attracts controversy. The Dialogue has been criticized as unfocused, as well as being a dosed shop dominated by one sector of the advocacy community. Some detractors have also suggested that von Eschenbach, who stepped down as ACS president-elect when he was nominated to the NCI post, is too cozy with the group.
As vice chair of its steering committee, von Eschenbach says there's nothing mysterious about the group, despite its meetings behind closed doors. "It's nothing but a forum that allows groups, individuals, organizations, interested parties to ... deal with how they might effectively address cancer as a societal problem," he says. Former President George Bush and his wife Barbara are co-chairs of the Dialogue and have hosted gatherings at their home in Kennebunkport, Maine. The 150-some participants range from celebrities such as CNN talk show host Larry King to politicians, federal officials, biotech executives, and prominent cancer research clinicians.

snip

Some prominent advocacy groups have been reluctant to participate in the Dialogue, partly because they say it too closely tracks ACS's views. In particular, some groups chafe at the society's effort to shift the emphasis from research to public health--such as education campaigns encouraging people to adopt healthier lifestyles and be screened for cancer.
The Cancer Letter, a Washington, D.C., newsletter, published a series of articles in the past 2 years questioning some of the Dialogue's activities. These included receiving funds from an ACS government contract with the Centers for Disease Control and Prevention (CDC) that the Dialogue used to fund participants' travel and other expenses. The newsletter argued that the Dialogue was essentially lobbying for CDC, which ACS has asserted should have a greater role in the national cancer agenda. ACS officials dispute that and say there is nothing improper about their use of the funds.
The Bushes are now leading a drive to raise $15 million to bankroll the Dialogue's projects, and yon Eschenbach says that NCI will staff some of these activities. But not everyone is pleased by his decision to commit federal resources. "It's something Rick [Klausner, previous NCI director] would never do," says the leader of one advocacy group. The problem, says the advocate, is that the Dialogue "is really not a shared agenda."--J.K.

It's not what you know . . .

Weird Science

Apparently some people were disappointed with my sarcastic take on the new FDA Commissioner, and were hoping for something more substantive. Well, we don't have a nominee for the permanent job, but we do have a new Acting Commissioner, a urologic surgeon by training who is Director of the National Cancer Institute. According to the Associated Press:

FDA's new acting chief tells of a sea change in care
Predicts more tailored response to patients

By John J. Lumpkin, Associated Press | September 26, 2005

WASHINGTON -- The new acting chief of the Food and Drug Administration, Dr. Andrew C. von Eschenbach, said yesterday that he will be presiding over a transformation in medicine, as scientists understand diseases in a way that could improve doctors' ability to treat patients.

Von Eschenbach, tapped by President Bush as the temporary chief of the regulatory agency, said yesterday that discoveries about diseases at ''a molecular level" will lead to a new kind of healthcare.

Now, doctors treat illnesses based on how well other people have responded to a given treatment. Soon, they will develop a tailored response, built around specific understandings of the patient, the treatment and the disease, he said.

''We are discovering so much about diseases like cancer at the molecular level," said von Eschenbach, who is a urologic surgeon by training. ''Much of what we have done . . . has been based on a model of empiricism." Soon, doctors will be able to intervene with medical treatments more effectively matched to a specific patient's illness.

Preparing the FDA for such a transformation is among his goals, von Eschenbach said.

Hmm. In other news:

Targeted medicines are far off

September 26, 2005

Personalized medicines targeted according to a patient's genetic profile have been over-hyped and their widespread use is still 15 to 20 years away, leading scientists said last week.

The field, known as pharmacogenetics, has made strides in the battle against certain cancers and shows great promise in improving efficacy, reducing adverse reactions of drugs and limiting medical costs.

However, a report by the Royal Society, an independent academy of leading scientists, said more research into the genetics of complex diseases, DNA testing, international guidelines, and investment were needed before targeted therapies would be widely available.

''Personalized medicines show promise but they have undoubtedly been over-hyped," said David Weatherall, who chairs the working group that produced the report.

''This is a long-term goal and it will take many years to come to fruition."

It seems to me the Commissioner of the FDA can worry about this Great Transformation later. Meanwhile, they need to start working for us, not the drug companies.

Sabbath day rumination

Yesterday we had to get the exact length of the ridge to install the second segment of the ridgepole. I climbed up onto the gable plate and reached up to the peak to hold the end of the tape. Thirty feet down looks about a hundred times as far away as thirty feet across the room. Believe me, I hugged the framing tight with my left arm.

Later I stood on a piece of 2" X 6" that was lying on the deck, and I said to Mark, "It's hard to explain why evolution gave us this disability. I can jump up and down on this little plank, dance a hornpipe on it, I can certainly walk back and forth on it and I'm not going to suddenly topple over. But put it 20 feet in the air and it's all you can do to stand up. I can see why we'd be averse to heights, but once you're up there, it ought to get easier to balance, not harder."

It is, for some people, once they get used to it. Mark's father, early in his career, was employed as the chief rivet inspector for construction of the Baldwin Bridge over the Connecticut River. That was a truss span bridge, meaning that instead of having towers and cables like suspension bridge or a cable stayed bridge, the roadway was supported by a steel lattice.

Like high steel everywhere, the bridge was built by Mohawks. When the European invasion robbed them of most of their territory and destroyed their way of life, somehow they adopted this specialty, of walking untethered on narrow girders hundreds of feet in the air. One man would work on a platform on a lower level, roasting the rivets red hot, then throw them up to a man on a higher girder who would catch them in a basket, then set them in place with tongs while another man hammered them home. Occasionally the catcher would miss, and a hot rivet might go down his shirt. The wind would gust, the steel would sway, but the Indians wouldn't fall.

Some of you may have seen the film of Felipe Petit, walking on a wire strung between the roofs of the World Trade Center towers. At one point, Petit lay down on the wire and stared up. He saw a bird far above him, and he suddenly thought that he had invaded a realm where he did not belong, so he stood up and walked off the wire.

There is no physical reason why most people shouldn't be able to work in the high steel, but we can't. Our minds won't let us. As David Wilcox put it,

On this high trestle span
The distance down is what
We must ignore

Balance is no harder after all
Out across this bridge so tall
Balance is no harder
Its just that you've got farther
Now you've just got farther to fall.

I hope you don't mind . . .

If I double post, you'll find basically the same jive at Effect Measure.

The people are asking me to "do" the prospects for a new FDA Commissioner now that Lester Crawford has retired. Crawford served with about average distinction by Bush administration standards. I'm sorry for the gross insult, but at least I only used one profanity, specifically the "B" word.

So, possible replacements. Brownie is out of work, and he even has relevant qualifications, having investigated the alleged liposuctioning of a horse's ass.* However, in the present climate, the fraternity president probably can't get away with just pulling another brother away from the washtub full of KoolAid and grain alcohol and giving him a fancy job title. He'll probably have to nominate somebody who looks like he knows what he's doing.

Fortunately for the administration, it would be difficult to find a prominent physician/scientist in the field of drug development who doesn't work for the drug companies, even while being on a university faculty. They can easily come up with a candidate who will please the major corporate campaign contributors and who will also have impressive credentials and sail through confirmation. (David Graham and Marcia Angell are probably not waiting by the phone.)

The problem is not who is sitting in the corner office at the FDA. The problem is the fundamental structure of the pharmaceutical research enterprise. As long as the bulk of the money for developing new drugs comes from profit-making corporations, we're going to keep getting new drugs for common, incurable conditions, drugs that aren't necessarily any better than the old ones but at least have some marginal difference that can be sold as an improvement. Heartburn and GRD, allergy, high LDL cholesterol, high blood pressure, depression, schizophrenia, arthritis, that's where the long green is. These are all real problems, and all about as well treatable by off-patent drugs that we've been using for years and know how to use safely, as they are by more recently developed drugs that are still on patent, that cost 10 times as much, and that are heavily marketed, whose potential dangers we don't fully understand. Sometimes those heavily marketed drugs are actually much worse, and even kill people, and sometimes the drug companies even know it.

Since the medical profession seems unable to resist the siren song of a free post-it pad, a free triangular pen, and a free weekend in Aruba, the only protection we have is from those evil, greedy trial lawyers. Let's hear it for them.

Here's the flu bit, for the folks next door. One consequence of this system is that vaccine development and manufacturing is a very low priority. Drug companies want people to get sick and stay sick. There's no incentive to give them a shot or two that will keep them healthy, when you could be selling them a pill every day for the rest of their lives. And of course once a vaccine is available, the political pressure to make it available cheaply to all those non-paying poor people is going to be very hard to resist. It wouldn't be a major technical challenge to develop a production facility for influenza vaccine using genetically engineered bacteria, that could crank out orders of magnitude more doses than our present chicken egg method, and ramp up for new strains more quickly -- at least not compared to sending human to Mars. But Aventis sure as hell isn't gong to do it.

*True fact. But I'm not going to touch it.

A Debate We Won't Have Soon

I'll be guest blogging again at Effect Measure -- and do get over there if you aren't scared enough already. The gloom and doom thing is getting a bit out of hand, but I suppose we'll just have to push through it and hope to emerge wiser and better on the other side.

Meanwhile, a subject which is difficult but not, at least to me, so depressing but rather, in a paradoxical way comforting if we make the effort to confront it, the United Kingdom will shortly be considering new legislation to permit physician assisted suicide, or perhaps even euthenasia, as the Netherlands has already done. I say comforting because here we are talking about death that occurs at a normal rate and, in most cases, after the span of life we are given, and it's best to consider what control we can and should have over it.

Rather than offer any opinion of my own right now I invite you to consider the pro and con positions in the British Medical Journal, where you will also find additional background and a less tendentious analysis by the Swedish philosopher Torbjörn Tännsjö (who does give his own opinion at the end). Tännsjö's essay is helpful because he presents arguments based on the three kinds of ethical reasoning I have often discussed here: deontological, principled (in this case, a principle of moral rights), and utilitarian. Understanding the differences among these three frameworks is essential if people are not to talk past each other.

There are important distinctions among the kinds of terminal acts at issue as well, which often confuse the discussion. In the U.S. and the U.K., it is already permissible to withdraw life support from people who decline it, including non-communicative people who are presumed not to want it (viz. Terri Schiavo). Competent adults do not even need to be terminally ill or suffering to avail themselves of this right. We can refuse medical treatment.

Physician assisted suicide means that a physician provides someone with the means to actively take his or her own life. This is illegal everywhere in the U.S. except Oregon, but when Dr. Kevorkian practiced it, juries repeatedly refused to convict him. A jury finally convicted the good doctor when he took the next step -- performing a positive act on his own part that brought about a person's death, even though the individual clearly, unequivocally, and competently requested it on videotape, which the jury saw. The moral distinction between the latter two kinds of acts seems almost trivial to me, especially when the subject is paralyzed and unable to carry out his or her own wishes, as was the case with Dr. Kevorkian's crime. But it is obviously very important to most people.

Make up your own mind. The comments around here are getting to be better than my posts anyway, so I hope we'll get some.

Cancer Exceptionalism

Okay, we've got another monster hurricane getting ready to wipe out a city or two, a war in a distant land that has descended past nightmare into the ninth circle of hell, and an imminent global flu pandemic that threatens to set civilization back 200 years, or at least disrupt the NFL playoffs (which should please C. Corax no end). This seems like a perfect occasion to talk about french fries.

I am inspired to this post by an article in the business section -- where else?-- of yesterday's NYWT, by Melanie Warner, but it's not exactly breaking news. French fries are the single biggest selling item in U.S. restaurants, pulling in $4 billion a year for your friendly neighborhood mom and pop businesses such as McDonald's and Burger King. Potato chips, which are basically the same thing in very thin, flat form, are worth $3 billion a year to health food companies like Frito-Lay (owned by the folks who bring you Pepsi Cola).

The outer crust of deep fried potato fragments is saturated with trans-fats, chemicals which are rare in nature but ubiquitous in deep fried foods and mass produced baked goods. Trans fats are much worse than saturated fats at raising your bad (LDL) cholesterol and clogging your arteries. The rest of the product consists of empty calories from simple starches, with no fiber, which makes you fat and diabetic. Now don't panic -- eating fries once in a while isn't going to kill you, but making a habit of it is a very bad idea.

The state of California is suing the food companies to put warning labels on potato chips and in restaurants that sell french fries, but it's not to tell you about heart disease. It's to warn you about a chemical called acrylamide, which is formed when starch is cooked at high heat, which has been shown to be carcinogenic in animals and is present at higher levels in fried potatoes than in any other food. (Warning: it's even worse if you make them at home. Seriously.) It probably contributes to cancer in humans, but nobody knows to what degree or what the dose-response relationship is.

California has a law -- passed by ballot initiative -- that requires warning labels on any product containing a known carcinogen. Obviously the food companies are panicking -- who's going to buy a bag of french fries labeled with a warning about cancer?

But acrylamide is also present, albeit at lower levels, in a host of other foods including prune juice, nuts, grilled vegetables, and whole wheat toast. At the same time, there are naturally occurring carcinogens in black pepper, fresh mushrooms, and other foods, and of course alcohol is carcinogenic.

The risk of heart disease from eating french fries and potato chips is almost certainly far greater than the risk of cancer. It's certainly far better established. But for some reason our society is obssessed, out of all the risks to our health, with cancer. Federal law prohibits the addition to food of any chemical shown to promote cancer in animals, to any degree, in any amount. But it is legal to put as much trans fat in food as consumers will choke down. People who don't buckle their seat belts eat only organic food because they're worried about pesticide residues. All I have to say about this is that I wouldn't particularly care to choose among cancer, heart disease, and diabetes. Why single out cancer so disproportionately?

We need to put it all in perspective and remember this: for every single person on this earth, the ultimate cause of death is birth.

Another open door crashed through . . .

Believe it or not (and I know this will seem incredible), kids who watch a lot of TV tend to get fat. According to a new study from New Zealand in the International Journal of Obesity, which followed kids from birth through age 15, "BMI and prevalence of overweight at all ages were significantly associated with mean hours of television viewing reported in the assessments up to that age. These associations were stronger in girls than boys. The associations remained significant after adjusting for parental body mass indices and socio-economic status." The investigators say the effect size is small, but actually larger than those commonly reported for nutritional intake and physical activity.

Meanwhile, there has been controversy about whether TV also makes kids stupid, or more accurately, educational underachievers. The difficulty is in deciding whether kids who just aren't interested in school work to begin with watch more TV, or whether TV watching in fact makes them do poorly in school. And maybe "educational TV" is good for your brain, who knows?

What appears to have been the same cohort was also assessed up to 26 years of age for dropping out of high school and getting a college degree. According to a report in the Archives of Pediatric and Adolescent Medicine (subscription only, sorry):

The mean time spent watching television during childhood and adolescence was significantly associated with leaving school without qualifications and negatively associated with attaining a university degree. Risk ratios for each hour of television viewing per weeknight, adjusted for IQ and sex, were 1.43 (95% confidence interval [CI], 1.24–1.65) and 0.75 (95% CI, 0.67–0.85), respectively (both, P<.001). The findings were similar in men and women and persisted after further adjustment for socioeconomic status and early childhood behavioral problems. Television viewing during childhood (ages 5–11 years) and adolescence (ages 13 and 15 years) had adverse associations with later educational achievement. However, adolescent viewing was a stronger predictor of leaving school without qualifications, whereas childhood viewing was a stronger predictor of nonattainment of a university degree.

These are very strong effects -- and note that they control for IQ. Here's a picture:



Note that about 40% of the kids who watched less than an hour of TV per weeknight graduated from college, while 10% of kids who watched 3 hours or more did so.

So now you know how to make your kids fat and stupid. Glad I could help.

Apologies: I forgot to give the reference to the article. Hancox et al. Association of Television Viewing During Childhood With Poor Educational Achievement
Arch Pediatr Adolesc Med.2005; 159: 614-618.

Will Massachusetts continue to lead the nation?

We are the first state to have same sex marriage -- and it's going to stay that way. We passed a tobacco tax through a voter referendum, and we got tobacco smoke out of 100% of our workplaces including restaurants and bars. Now the Massachusetts Public Health Association and its allies (long, long list in the link) are fighting to stop poisoning our school kids with sugary soda and junk "food." (Link is a PDF.)

We know the "food" industry will fight this with tooth, nail, lies and a storm surge of their ill-gotten dollars. Help MPHA fight back.

Remember, you read it here first.

Well, unless you happened to read it somewhere else earlier. As we have been saying for a while now, antipsychotic drugs don't work very well, and they have really, really bad side effects. The National Institute of Mental Health funded a multi-site, head-to-head study of 5 anti-psychotic drugs, at a modest cost of just $44 million, intended to compare the newer, so-called atypical antipsychotics (brand names Zyprexa, Risperdal, Geodon and Seroquel), which bring in $10 billion a year for their manufacturers, with each other and with and older drug (brand name Trilafon), which costs a fraction as much.

You can read all about this in the newspaper -- NIMH put out a press release and it's gotten considerable coverage -- but the personalized Cervantes take on all this is that it's pretty much the same old story. The older drugs, called neuroleptics, controlled some of the most debilitating symptoms of schizophrenia, called positive symptoms -- hallucinations, delusions, disordered thinking -- and made it possible for people to function at least well enough to stay out of mental hospitals. Unfortunately, these drugs cause serious adverse effects, notably stiffness, tremors and a really bad one called tardive dyskenesia, characterized by uncontrollable repetitive movements, which can be irreversible.

So drug companies got FDA approval for the new class of antipsychotic drugs, claimed they were safer, marketed them with glowing testimonials if they did say so themselves, and charged a fortune for them. But now, says NIMH, "Contrary to expectations, movement side effects (rigidity, stiff movements, tremor and muscle restlessness) primarily associated with the older medications were not seen more frequently with pherphenazine [Trilafon] (the drug used to represent the class of older medications) . . ." And oh yeah, pherphenazine worked just as well. Zyprexa was slightly better in that fewer people taking it were hospitalized for relapses, but it was much more likely to cause serious weight gain and diabetes -- which is a potentially deadly disease. And like the other atypical antipsychotics, it costs 10 times as much as the neuroleptics.

Bottom line? We've been ripped off, again, by the drug companies with the assistance of the FDA. For people with schizophrenia and people who care about them, I'm afraid there's not a lot of good news here, except that doctors will now understand a little bit better what these drugs can and cannot do. People might as well start with the cheap ones and stay with them if they can, which will lower overall health care costs a bit. But the risk of tardive dyskenesia remains and can't be avoided. Maybe they'll find a better treatment eventually, and meanwhile, hang in there. Schizophrenia can remit in middle age. And there's a lot more we can do to help people with schizophrenia make it, especially supported housing, day treatment programs, and family centered support and respite care. There are far too many people with the disease living on the street and in shelters, and there is no excuse for that.

Uh oh . . .

This shows the predicted path turning farther north than the prediction yesterday. Of course we don't know what's going to happen and it still remains less than 50% that southeast Louisiana will take a major hit from this storm. But it might -- or from another one at any time in the next two months.

The reason I post this is because I am troubled that even after all that has transpired, the prevailing attitude is still one of denial. Not only will the jury-rigged Lake Ponchartrain levees fail again in even a violent thunderstorm, let alone a tropical storm, the storm levees south of New Orleans are all completely destroyed. Yet all the talk is about how people are starting to move back in and rebuild. It still seems not to have sunk in what has happened and what the situation is. I'm thinking the best we can hope for is a good, serious scare from this one that will finally break through the concrete between people's ears.

Well Duhhh . . .

From the Commonwealth Fund:

SEPTEMBER 14, 2005 -- The cost of health insurance premiums is rising faster than both wages and inflation, according to results of the Annual Employer Health Benefits Survey released Wednesday by the Kaiser Family Foundation.

And as health care costs have risen over the past five years, the number of businesses offering health insurance to their employees has dropped, the study indicates.

The study found that insurance premiums increased 9.2 percent since 2004. While that is lower than the previous year's growth, it is about three times the growth in workers' wages and more than two times the rate of inflation, the study found.

Annual premiums for family coverage were $10,880 in 2005, which is more than earnings for a full-time minimum-wage worker, which is $10,712, according to the survey.

CWF update

Decline?

Immanuel Wallerstein views the decline of the United States:

The entire world has been following with stupefaction the incredible performance of the U.S. federal government's response to the physical and human disaster of the hurricane Katrina. All the television networks of the U.S. and of many other countries plus all the major newspapers have been following the story in detail. The general reaction has been to ask how could the government of the richest and most powerful country in the world have reacted to this disaster as poorly as, or even much less well than, governments of poor Third World countries? The simple answer is a combination of incompetence and decline. And the results of this disaster will be a further diminution of respect for the president within the United States and a deepened skepticism in other countries about the United States' capacity to put action behind vacuous rhetoric.

But if the U.S. is really starting to resemble a so-called Third World country, perhaps this is not such a startling development as it seems to many people.

Let's begin with this: The average industrialized country spends $2,139/year per person on health care. The U.S. spends $5,267 – almost 2 ½ times as much. The country that spends the most after the U.S. is Switzerland, at $3,336/person.

All of the other wealthy countries (and some of the not-so-wealthy ones) insure 100% of their citizens. We don’t. We have, right now, about 45 million people without health care insurance. And in spite of throwing all that money at the problem, as the ruling party likes to say when the money in question isn't going into their own friends' pockets, we are closer to a Third World than a First World country when it comes to our health status.

The World Health Organization ranks countries in terms of various indicators including:

life expectancy -- the U.S. is 24th:
level of health (based on a complex index) -- U.S. is 72d:
and overall health system performance -- U.S. is 37th.

We have a First World sector, the one you see on television sitcoms and commercials, and read about in the Style Section of the newspaper, the one that people who live in it think is definitive of the United States. Then we have the Third World sector, where those folks live who Barbara Bush was so pleased to see enjoying a luxurious vacation in the Astrodome. Average them out, and you get the kinds of numbers you see above.

Of course the Bush administration is doing everything in its power to widen this divide, but it's nothing new. In fact it's deeply embedded in our national character, so much so that there are basic ideas which are taken for granted in most of the world that are marginalized in our political discourse. Anon, I will discuss the question of liberalism vs. libertarianism vs. conservatism. I think that will help to clarify the challenges we face.

Sabbath day reflection

I have a terrible confession. I attended Phillips Academy in Andover, Massachusetts, the same school where George W. Bush evidently acquired the accent of a Wilford Brimley playing Cookie in a 1960s B western. (I really don't think so.) Among other character building exercises (bizarre hazing rituals, drown proofing, and, for seniors, pipe smoking) they required us to attend church Tuesday, Thursday, and Sunday. A dessicated, bow tied teacher of Greek mythology took attendance by assuring that our assigned seats were filled.

My roommate had been raised in a Catholic orphanage and was now the foster son of a Massachusetts cabinet secretary. He told me about the priests who would come to take the boys on outings and molest them. He was a very tough kid and they never laid a hand on him.

One Sunday at Andover they brought in a guest preacher who said that the end times were coming. You could see all the signs as prophesied in the Bible. When they told us all to kneel and pray at the end of the sermon, Dave and I looked at each other. Then we just sat there. They told us to stand and sing a hymn, and we sat. The next week we still had to go to church, but we never knelt, we never prayed, we never stood to sing or chant. The dessicated guy spoke to us sharply after the service, and I said to him, you can make me come here, but you can't make me believe this nonsense.

Oh yeah. They threw me out after my sophomore year. Best thing that ever happened to me.

It's happening.

Get used to it.

A season of Cassandras

Anyone can claim to be reading the zeitgeist, but here's what I perceive.

Cassandra was given the gift of prophecy, and the curse that no-one would believe her. It seems a lot of people are feeling like Cassandra nowadays.

I scarcely need to review the list of prophecies that are just now sneaking into the mass media collective consciousness, but scarcely touching our political discourse.

1. The global peak in oil production may happen tomorrow, or in 20 years, depending on who you ask, although I would say the people who argue for 20 years have an interest in believing that, whereas the people who say "right now" have no obvious bias. Regardless, due to growing demand and extraction from more difficult places, oil is going to keep getting more expensive, and then there won't be as much, period.
2. Meanwhile, the U.S. just continues to import more and more of it, and more and more natural gas as well (that will peak sometime after oil, but not a whole lot later). That means an Amazon of dollars flowing abroad, and serious national vulnerability,
3. which, along with more general national idiocy, causes us to squander hundreds of billions of dollars every year on the most powerful military in human history, equal to the rest of the world combined, invade Iraq and hemmorhage more hundreds of billions, while corrupting our national culture and cultivating the ill will of most of humanity.
4. Unfortunately, peak oil isn't going to slow down global warming (it's too late), and it might even make it worse. There's plenty of coal in the ground to last for hundreds of years (most of it in Siberia and China), plenty of schemes to convert it to gas or liquid to substitute for petroleum, all of which would be much, much worse than petroleum when it comes to every form of pollution, including CO2.
5. That means more violent tropical cyclones (more research confirming this is out today), and rising seas, which threaten more destruction such as we have just seen and the permanent inundation of what are now densely populated and economically important coastal areas,
6. along with drought and ecological disruption and possibly even a catastrophe such as the collapse of the West Antarctic ice sheet or a shut down of the Gulf Stream.
7. Then there is the likelihood of major global epidemics, including the near certainty of a global pandemic of virulent influenza (the H5N1 strain currently infecting birds in large areas of the world), to which humans have no immunity, possibly killing tens or hundreds of millions of people and shutting down global commerce.
8. In the face of these world historical challenges, the U.S. economy is a gigantic ponzi scheme, pumped up with trillions in borrowed money,
9. but the nation's rulers are just planning to borrow hundreds of billions more to buy off the citizens of the Gulf Coast in time for the next election while moving ahead with their plans for yet more massive tax cuts for the rich.
10. Already weakened by Katrina, rising oil prices, and the trade deficit, the economy may well prove unable to withstand the next blow -- another major hurricane, an epidemic, a further spike in oil prices, a significant terrorist attack -- and in any case we are doing nothing to address our problems now and a sane and competent future administration will have great difficulty finding the resources to act effectively.

Oh, I've left out a few things, such as nuclear proliferation and increasing social inequality, but who's got time to keep reading? Now, it isn't possible to assign meaningful probabilities to any particular scenario, and the worst may not happen for 20 years, who knows? I'm not personally a true expert in any of the directly relevant fields, from petroleum geology to meteorology to economics to infectious disease control, I just try to learn what I can about what seems to matter. But lots of people who are experts are having palpitations. It all comes together to mean that the American Century is over, maybe with a whimper, maybe with a bang.

About the only politicians who seem to be taking any of this seriously are fiscal conservatives who are worried about the federal budget deficit and want to cut spending -- not on the military, obviously, and they haven't actually said on what because, uh, actually, there isn't a whole lot else left to cut, unless we go ahead and eliminate Medicaid, Medicare and Social Security, although I suppose we could do without the State Department, FEMA (hey, it's better than nothing, or at least it could be), the EPA, CDC, NIH, and the rest of HHS. Oh yeah, that happens to be exactly the stuff we need if we're ever going to do something about all of the above. Fortunately, we have a president who is strong and resolute, who holds decent moral values, and is willing to bring God back into the public sphere; and heroic journalists who will never betray their anonymous sources named Karl Rove.

There is an opening though, right now. The curtain of censorship has been rent, at least briefly. Maybe there are some honest people in influential positions who will rip it down. I'm counting on it.

The public health system?

Last night I set out to explain to my students the structure and functioning of the public health system in the United States. I even drew a picture on the blackboard. I won't try to reproduce it here but think of a plate of spaghetti and meatballs.

At the top, Congress borrows money from the Chinese which it appropriates to various federal agencies. The majority of agencies having a substantial role in public health, broadly construed, are within Health and Human Services, but by no means all of them. Within HHS we have CDC, of course, which includes the Public Health Service and has a mission which is clearly labeled as "public health." But it has no particular oversight or coordination role with respect to such agencies as the Substance Abuse and Mental Health Services Administration, Office of Minority Health, Health Resources and Services Administration, Centers for Medicare and Medicaid Services (which does more than provide health insurance), or of course NIH and AHRQ, which carry out and fund research. Then there is the EPA, Office of Justice Programs within the Department of Justice, the Dept. of Housing and Urban Development, and oh yeah, the Department for the Defense of the Glorious Fatherland, all with significant or extremely large public health responsibilities and in completely separate cabinet departments. Let's not forget the military services either.

For the most part these agencies carry out only limited public health related activities directly. Most of them (with the exception of NIH) make formula grants to the states, such as the Substance Abuse and Mental Health Services Block Grant and the Juvenile Justice Formula Grant, etc.; and have various discretionary grant programs in which the states compete for funds by writing proposals (and politicking, even if they pretend otherwise.) The states spend some of these funds to implement services directly, but use a substantial percentage of them to purchase services from municipal health departments, community health centers, hospitals, community based organizations, and other vendors. And of course the states -- at least the more affluent and blue-tinged ones -- also use substantial amounts of state tax dollars for public health-related activities, including purchased services.

Federal agencies -- including CDC, SAMHSA, and OMH -- also award funds directly to private organizations, largely the same kinds of organizations that receive state funds, and to municipalities and Indian tribes. Municipal health departments, at least in big cities, pass through some of their state and federal funds to private sector agencies, as well as carrying out programs directly.

Non-profit organizations also receive a small but sometimes impactful amount of funding from national foundations -- notably Robert Wood Johnson, Kellogg, and the Commonwealth Fund -- and from local foundations; from corporations, often with ulterior motives such as drug companies paying for screening programs and health education that they hope will help them sell drugs; from United Ways and similar federated campaigns; and from individual donors.

As the money moves through this tangle of pipelines and pumping stations, people at every level make decisions about how it is to be targeted and applied, usually under constraints from above of varying degrees of strictness.

There are major virtues to this decentralization and complexity. It puts a lot of the funding in the hands of agency that are based in the communities they serve, and really know the communities and the people. In fact, this funding is essential to creating infrastructure and leadership, including in communities with limited resources such as immigrant enclaves and other poor urban neighborhoods and rural areas. It is undoubtedly much more effective than if federal and state bureaucracies tried to operate programs themselves.

On the other hand, it is clear that we are not well positioned for a crisis. For example, if there is ever a need to communicate effectively with the Latin American immigrant community in an emergency, and to coordinate outreach and response of some kind, my own agency would be an excellent choice to do it, but no-one at the city, state or federal level has ever consulted with us about this, included us in emergency preparedness planning, provided us with training, or given us resources. This is highly noteworthy because in our ongoing work, our state, federal and national foundation funders have stayed very close to us, through regular grantee meetings, training, involvement in planning and review committees, and access to funding for capacity building and consulting. We know what's going on at every level, what the policies and plans are of the various state and federal agencies, and what is expected of us. And in turn, they listen to us and depend on us to tell them about the needs of our own communities.

As recent events have made clear, there has been no comparable effort to knit together the various agencies and actors that will have to be mobilized in emergencies. We don't have a clue what the local, state and federal health agencies plan to do in the case of a serious epidemic or other catastrophe, nor do they seem to have thought about what we might do to help. That seems unfortunate. We now know that coordination and collaborative planning at higher levels have been comparably deficient.

Tongue tied, mind boggled

I have a couple of posts I'm working on but it seems almost feckless to talk about routine matters today. I feel we are at a critical moment in many ways, and I'm trying to organize my thinking.

Meanwhile, I'm guest blogging over at Effect Measure. Check it out if you're interested. (I'm using some recycled material, which is important for blogospheric sustainability.)

Can we do two things at once?

The Resident says he can (although we know he can't even do one thing right), but the corporate media apparently cannot. One attack in London that killed 55 civilians dominated the front pages and the newscasts for days, and of course hurricane K has filled 90% of the news hole for two and a half weeks now.

The situation in Iraq, for which my store of adjectives fails me, is now apparently permanently relegated to page 17 of the Boston Globe, no matter what happens. I checked the web sites of ABC, CBS, CNN, and MSNBC. Two of the four (CBS and MSNBC) have headlined the events in Iraq yesterday, but the other two just have inconspicuous text links under the "world" category, as if this has nothing to do with us. The NYWT, to their credit, has headlined Iraq.

Even so, none of these appears to understand what is really going on there. The "Iraqi" troops working with the U.S. in Tal Afar are Kurdish and Shiite militias, attacking a town that consists predominantly of Sunni Turkomen. The Globe story yesterday (also in the back pages) described the fighting based on the Centcom press release. The last sentence of the story mentioned that thousands of the inhabitants are living in refugee camps. The horrific attacks today have been claimed as payback to the Shiites for the assault on Tal Afar -- which was also horrific, because it included dropping 500 pound bombs from airplanes, which killed unknown numbers of civilians. Doctors at the local hospital said they had seen 17 civilian corpses. However, this was not mentioned by most U.S. news media.

The Sunni Arab politicians who had been invited to participate in drafting the constitution have now finally rejected it, and are vowing to see it voted down in the October referendum. The political process in Iraq is failing and the country is descending into civil war and chaos. The security situation is worse and worse, and even the Green Zone is no longer fully defensible. For truth:

Today in Iraq

Juan Cole

Iraq Coalition Casualty Count (with a link list down the right that is truly painful to peruse).

I wonder when the Resident will take responsibility for that? That is, if the federal government has failed in any way.

Enjoying your tax cut?

By Associated Press | September 13, 2005

NEW YORK -- The nation's employers are struggling with close to double-digit increases in health care costs in 2006, and consequently will be shifting more of that burden to their employees, according to a new survey of more than 1,800 firms.

"Employees are bearing more of the costs because double-digit increases are unsustainable," said Blaine Bos, a Minneapolis-based health care consultant for Mercer.

To keep a lid on costs, Bos said many employers are using a tactic called cost shifting, which demands employees to pay higher deductibles, premiums and co-payment fees. Employers are also limiting workers' choice of insurance plans.

"We used to think of cost-shifting as something you could do only every so often," said Bos. "But we're seeing a new willingness on the part of employers -- born of desperation -- to shift cost in successive years to achieve acceptable cost increases."

But it's no problem -- you can pay the premiums with the money you're saving thanks to the lower capital gains tax.

A View From Afar

The British medical journal The Lancet (warning: highly annoying registration process required) tells us what the corporate media here in the U.S. still haven't completely figured out. Subverting public health to the so-called War on Terror is killing us.

From the lead editorial:

Since 2001, fears for the future safety of the US population have focused on one thing alone: the potential dangers a bioterror attack could unleash. This obsession catapulted the issue of America's decaying public-health infrastructure from a state concern to a crisis that involved the entire nation. The worry was justified.

A damning report issued in 2002 by the Institute of Medicine claimed that governmental public-health agencies had long suffered “grave underfunding and political neglect”. It criticised the country's “obsolete and inconsistent laws and regulations” governing public health, and derided the fragmentation of health responsibility, shared among officials at all levels of government. The uneven distribution of resources within the “increasingly fragile” health sector meant, the report claimed, that the health system would be unable to manage a large-scale emergency.

snip

Significant boosts to funding for public-health infrastructure followed 9/11, along with plans to better coordinate emergency responses and improve communication between all levels of government. Crowning these efforts was a National Response Plan purporting to provide “the means to swiftly deliver federal support in response to catastrophic incidents”. It was released in January this year, under the auspices of the Department of Homeland Security and its subsidiary the Federal Emergency Management Agency.

Last week marked the plan's first real test. It failed. While the central themes of the plan strongly emphasise fighting terrorism and national leadership, three key areas of administrative difficulty have been all but ignored.

[The editorial describes the jurisdictional problems between federal and state authorities, and civilian and military leadership, which were revealed by the disaster.] The reason behind this bureaucratic tangle is that health responsibilities are dispersed through numerous federal departments. Key emergency health responsibilities come under the jurisdiction of the Department for Homeland Security, rather than their perhaps more natural home at the Department for Health and Human Services.

The third, and perhaps most concerning issue, is the ongoing confusion over what public-health preparedness should be preparing for. Public-health officials are divided over whether to prioritise all-hazards preparedness or specific plans to counter a bioterror attack. Bioterrorism is clearly the government's priority, but this focus, and the funding bias that goes with it, limits states' flexibility to choose a broader approach to protecting public health. States also claim that if priorities are set nationally, their specific vulnerabilities will be ignored and responses will be slow and unwieldy. They are probably right.

Would Hurricane Katrina's aftermath have been less fraught had these issues been addressed? It is impossible to say. For not only did the USA shy away from a national priority list of public-health threats, it also failed to define what should constitute “prepared”. Assessment criteria to test states' compliance with national obligations have been criticised as meaningless and impossible to measure.

A well functioning public-health system protects human life when disasters occur. Just how much the neglect of the US system hindered an effective response to Hurricane Katrina should weigh heavily on the shoulders of George W Bush, as he views images of stadia crammed with New Orleans' many homeless and hears the final counts of the dead.

I will simply add that it is very doubtful that anything will ever weigh heavily on George W. Bush's shoulders. His life is nothing but a relentless litany of failure, for which other people have always paid the price, and he has never been accountable. That our political system elevated an ignorant, incompetent sociopath to its highest office is our real national disgrace.

Finding the Bottom Line . . .

and more on the rule of rescue.

What should be the goal of public health? According to the constitution of the World Health Organization, to which the United States and nearly all the countries of the earth are signatories:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

and,

“The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”

Wow! I guess we should all step up and claim our fundamental right to complete physical, mental and social well-being! While we all were waiting for whoever is responsible for honoring our fundamental right to come through, the family of brain dead Susan Rollin Torres kept her body alive on life support for three months in order to try to save the life of her fetus, which was surgically delivered after seven months gestation, and died about five weeks later. Supporters around the world mailed the family $600,000 to pay for this effort.

Meanwhile, during those 4 months plus, more than two million children under five (already born) died from malnutrition. The family of Ms. Rollins Torres, like the family of Terri Schiavo, is devoutly Christian. They believed it was their duty as Christians to raise the $600,000 to save their fetus. Left over funds will be used to establish a college savings fund for Mr. Torres's two children.

Obviously, nobody takes the WHO constitution seriously. The definition of health -- as well being -- is circular. What, then, is well-being? If health includes social well-being, it is logically contradictory to say that everyone has a right to it without regard to their social condition. If everyone has a right to the highest attainable standard, who decides what that is? The Torres family had their own definition, but obviously, the resources used to provide the highest attainable standard for one person will not be available for the next -- and resources are not infinite.

Nevertheless, the WHO constitution does force us to think about justice. The rule of rescue -- the seemingly instinctive impulse that humans have to make any sacrifice, expend every resource, to save one or a few people in desperate circumstances -- conflicts with utilitarian ethics, because when we obey the rule of rescue, we deprive innumerable other people -- some of them not desperate, others perhaps equally so -- of resources that could improve their well being or even save their lives. This is an ancient puzzle but now, more than ever perhaps, it demands our attention.

Some info relevant to the below

It's not only people with behavioral health problems, obviously, but all of the low income evacuees -- including people who didn't used to be low income but have now lost their jobs and had their homes destroyed -- who need to worry about Medicaid eligibility. This is a huge problem, however, since a) it's not clear that they legally reside in the states where they are now located; b) they have no documents or means of proving their eligibility; and c) the state bureaucracies wherever they happen to be are likely to be overwhelmed by displaced persons.

The Commonwealth Fund has some info.

SEPTEMBER 9, 2005 -- State Medicaid officials said Friday they want "simple and straightforward" answers from the federal government about financial reimbursement for health services provided to Hurricane Katrina victims.

They need to know, for example, how to proceed with Medicaid eligibility for Katrina victims whose Medicaid status cannot immediately be verified and for individuals who now qualify for the program due to losses suffered in the hurricane, Ohio Medicaid Director Barbara Edwards said Friday during a telephone news briefing sponsored by the Kaiser Commission on Medicaid and the Uninsured.

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The technical questions related to providing coverage for Katrina victims who relocated from their home states, made more complex by the numerous differences among the states' Medicaid programs, demand "simple and straightforward" answers from the feds.

Ruth Kennedy, Louisiana's deputy Medicaid director, said during the briefing the hurricane damage was sure to increase the demand for Medicaid-provided services. For example, elderly people previously cared for by family members at home will now require nursing home care. Evacuees have significant health needs and must be enrolled in Medicaid coverage as quickly as possible, Kennedy said.

"Time is of the essence," she said, adding that the more days that pass before state officials know what Medicaid will pay for, the more difficult it will be to provide needed health services.

While President Bush said Thursday that states would be reimbursed for "showing compassion" to Katrina victims, Edwards said it remained unclear how state Medicaid programs and their health providers would be compensated for delivering care to hurricane victims. Bush, in his remarks, said he would work with Congress to reimburse states for providing Medicaid services.

Democrats in the House and Senate have offered legislation that would provide full federal funding for Medicaid services to Katrina victims without requiring them to pass the program's asset or income tests.

Scottie says the administration is working on it, promises to open the money spigot some time. I hope somebody is watching.

An oddly ignored fairly big problem

We hear a great deal about how people affected by natural disasters often suffer trauma and may have long-term symptoms. Oddly, it is very seldom mentioned that the population of the evacuated regions of the Gulf Coast included what is presumably a typical proportion of people with serious mental illness, mental retardation, addictions, adult onset dementia and neurological disorders such as traumatic brain injury. People with such problems were also certainly among disproportionately among those who could not evacuate on their own ahead of the storm and ended up in the chaotic public shelters.

The late Irving Kenneth Zola, whose work I often refer to, was assigned to produce an ethnographic documentation of Boston's West End, before it was destroyed as part of the '60s campaign of Urban Removal and its residents scattered. Irv found that the rate of psychiatric crises, hospitalization and institutionalization went up sharply among the displaced residents, but he also had a surprise for us. This had almost nothing to do with previously healthy people being traumatized. The vast majority of people who showed up in those statistics had long-term mental illness or disability, but they required relatively little professional support and certainly did not require institutionalization, because their families and community provided an environment in which they could function. With their extended families broken up, the neighbors dispersed, the corner store and the pizza parlor and the barber shop where the proprietors knew them all gone, they could no longer function successfully.

The mental health care systems in places with large numbers of evacuees are under tremendous strain. People with mental illness, cognitive impairments, neurological disorders, when suddenly placed in unfamiliar environments, often decompensate and may become severely delirious. Many went for long periods without their medications. They are now separated from their mental health providers, and it is undoubtedly impossible right now to get their records or contact those providers in most cases. The people need to be reassessed, rediagnosed, given new prescriptions, housed, re-enrolled in disability or SSI if they are eligible (probably with new representative payees found to manage their finances), counseled. Some may need supported housing or even institutionalization now that their natural supports are gone. I expect quite a few will fall through the cracks -- or more likely the gaping chasms -- and wind up homeless in unfamiliar cities, or dead from suicide, victimization, or misadventure.

The only resource I have found that is seriously trying to report on and discuss this problem is Dr. Peter Kramer's Infinite Mind radio program. As my thousands of loyal readers know, I disagree sharply with Kramer about some issues (he's the Listening to Prozac guy), but he's doing a public service here. We worry about so-called "surge capacity" for hospitals in cases of disaster, but there is little or no discussion about mental health and substance abuse treatment. (Oh yeah, what about all those folks cut off from their methadone? Their counselors and 12-step programs? There's a whole other set of major problems. . . .)

Raise high the roofbeam . . .

Even for the secular, Sunday is good to have as a day of rest and reflection, so I'm going to take it easy and reflect. (I'll have to use some vocabulary not all readers will understand. I'll explain in comments if anybody asks.)

Yesterday I went to O.L. Willard & Company in Willimantic and bought two 2X10" pieces of straight, flat douglas fir, one 12 feet long and one 14 feet. These are the ridgepole of my house. At the building site, Mark had looked up the rafter specifications for a 9 pitch roof and the span of my house, carefully laid out and cut a pattern rafter, then used it to produce a twin. He had also constructed a staging platform a little less than 9' high out of scrap.

My brother Tom arrived. We erected a 16' pole dead center and vertical at the south gable end, and used it to simulate the ridgepole as we temporarily placed the prototype rafters and clamped them to the top plate of the gable wall, which we had deliberately left a bit long. We confirmed that the rafter pattern was accurate, we scribed the plate for cutting and took down the rafters and the pole, then cut the plate as scribed. Mark laid out the rafter locations on the top plates of the side walls and the ridgepole, then started cutting rafters from the pattern, which Tom and I hauled up to the second floor. Once we had a good supply, Mark and I got up on the staging while Tom stayed below. Tom passed up the 12' section of ridgepole, then laid a rafter approximately where it would go, across the top of the east wall with the head on the staging. I supported the ridge pole as Mark nailed it to the rafter head with 12 penny cement coated nails. We attached a second rafter on the same side about 8' down, then Mark and I picked up the ridgepole with both rafters attached and lifted till the birdsmouths seated properly on the plate. Tom located both rafters on the marks and toenailed them to the plate, then he moved around to the other side and passed up a rafter at about the midpoint of the section of ridgepole. I supported the entire assembly on my shoulder (I think I may be a couple of inches shorter today) while Mark nailed on the third rafter and Tom toenailed it to the plate.

That was it. With three points of support, the ridgepole was now in the air, and I could get out from under. We installed the second gable rafter, and nailed both gable rafters to the gable plate. We installed plywood sheating to tie the roof to the gable wall and stabilize it, then we just started installing rafters. I had to shoulder the pole a couple of times more to tighten the birdmouths against the plates, but what the heck, I can take a compression load. Next week, we'll erect a pole on the north gable wall as a temporary support for the second section of ridgepole, gusset it to the section already installed, and place the rest of the rafters. We'll install the remaining gable studs, sheath the roof, and the house will be structurally complete.

This is a commonplace achievement. There is no saying how many tens of millions of houses have been built around the world using similar techniques. Mark is highly skilled, of course, but his profession is not considered highly prestigious. Carpenters make a living, but they don't get rich.

Now just stop for a moment and think how clever is our species. Over thousands of years of civilization we have learned methods for building with wood. We know exactly how to make warm, dry houses that can stand for hundreds of years. We understand footings and foundations; how to nail together a stiff, strong structure to withstand compression load and wind shear; insulation and ventilation, solar gain and the need to vent the attic -- all of it inside the heads of people like Mark who didn't learn any of it in school or see it written down, who just absorbed it from their predecessors. To be sure, it is written down and you can learn it in school if you want to, but most people don't.

We're still improving on our methods. My house incorporates a lot of manufactured wood products, starting with plywood of course which replaces the boards used to sheath my parents' old farmhouse, but also microlaminated beams and manufactured floor joists. Most roofs today are not built using our stick framing technique, but with factory built trusses lifted into place by a crane. The windows I eventually install will have double panes of glass with argon gas between them. Unlike us primitives, professional builders seldom use hammers any more. They drive nails with compressed air.

We know more than we did last century, last year, last week, and we know how to do things better. In many respects, my house will be better than my parents' house, which was built in 1835. It will be much better insulated, in fact it's a passive solar design that will hardly need to be heated at all. It was certainly much easier to build, using power tools and modern materials. Then again it won't have the same charm, at least not until 135 years from now.

But here's the bad news. My parents' house is better than the homes of at least 95% of the world's population -- much, much better than most of them. So will mine be. Even though we know more and more all the time, and we know how to do things better, in some of the most important ways, we don't. Are we making progress? Is our ever accumulating knowledge making our human society better, our planet happier? I'm not sure. Lots of people say no. So what are we not learning that we need to?

Culture of Life XXXXIII

There is a great deal I could say about this picture but I'll keep it short. We only see two independent variables here -- "race" and sex. Black people have lower average incomes, educational and occupational status than white people, and those variables are very important influences on life expectancy. If you control for them, the disparities are reduced, but not entirely eliminated.

Women live longer than men. That's partly constitutional but it's also because men are more likely to have dangerous occupations, are more likely to smoke, and are more likely to be murdered.

We only see these two artificial "race" categories on the diagram, because data on more socially meaningful ethnic groups -- such as African Americans (which is not a synonym for Black), Puerto Ricans, Navajo, and Chinese Americans -- are not good enough.

The calculation of life expectancy at birth is based on projecting current death rates for five-year age cohorts into the future. It doesn't correspond to any real person's actual predicted life span, because the underlying assumption is certainly false. So this is really telling us something about the chances that people who are already alive will die prematurely.

What is the full causal story of these disparities? That's very complicated and we don't know all of it, not even close. But the hurricane disaster is instructive. Staying alive requires all sorts of resources -- personal wealth, a safe environment, the benefit of formal supports from society, knowledge and skills, and it helps considerably to have a lot to live for. We allocate all of these very inequitably, and life and health are inequitable in corresponding measure.

Top priority for the administration and Congress once the recent unpleasantness recedes: permanently eliminate the estate tax, thereby assuring that the inheritances of people whose parents possess more than $20 million are not reduced by 17%.