Getting somewhat personal

Davison and Simpson, from the Great White North, were able to dodge the flying hockey pucks long enough to do this good qualitative study on advance care planning -- in this case, specifically, for people with end stage renal disease, but the implications are certainly more general.

Health care providers are often reluctant to discuss prognosis with terminally ill people, or to initiate discussions about preferences for care, including terminating futile treatment and do not resucitate orders, well in advance of the time when such decisions will likely be needed. They fear provoking despair in their patients, or other adverse reactions.

Davison and Simpson found that this group of patients generally did want to have these discussions, and that talking about and planning for what was likely to lie ahead actually gave them hope -- not for a miraculous cure, but for more meaningful life and fewer difficulties and troubles in the time they had left.

I feel comfortable with what I am about to say because there is no danger my mother will read this blog - she is unredeemably Internetophobic. As I have vaguely suggested previously, my father has a progressive dementia, which I am pretty sure is Alzheimer's disease superimposed on stroke damage and vascular dementia, although for reasons of her own my parents' neurologist likes to tell them that he does not have Alzheimer's disease, but only vascular dementia. She's the expert, but since he has all the symptoms of Alzheimer's disease, it's hard to figure out how she comes to that conclusion. My mother insists on it, however. For example, she said to me, "People with Alzheimer's disease put the car keys in the refrigerator." It's true that my father never specifically did that. Actually, he doesn't have any car keys because at least we convinced her to stop letting him drive a while ago. However, he puts plenty of other things in strange places, for example putting his pension check in the knife box on the sideboard. For an unconscionably long time, my mother clung to this diagnostic quibble to believe that my father's condition would stabilize.

It did not. His care needs and personality changes are putting her under sometimes debilitating stress. Among other symptoms, he has progressive aphasia and it is already becoming difficult for him to communicate at all. My mother really needs help taking care of him at home, and soon it will be impossible for her, I'm sure. He will need institutional care at some point, I would say within a year at the outside. And then she will have to make decisions about how aggressively to provide medical treatment, since he will begin to develop repeated and chronic infections, probably have additional strokes, and so on.

Well, it just hasn't been possible to get her to start to think about these problems, to learn about options, and to make concrete plans. When I even start to hint at the subject, she deflects it. I would say that it is the neurologist's job to be frank with her, to say, "This is what is likely to happen, and these are the decisions you will need to make," but instead she supports my mother's denial and avoidance. That leaves me with an impossible task, while doing nobody any favors, as far as I'm concerned.

This very painful situation affects more and more families all the time. It is one of the prices we pay for increased longevity. By far the best way to cope with inevitable evils is to understand them, acknowledge them, accept them, talk about them, plan for them. That's where hope lies. Unfortunately, physicians aren't necessarily able and willing to help their patients do that.

On the road again . . .

So no time for serious blogging today. I thought people might be interested in knowing why I'm on the road, and what I more or less do for what is more or less a living. The road trip has to do with a project to convene state governments and community organizations and activists to promote policies to address racial and ethnic disparities in health. Although the federal government pays for most of publicly funded health care, and the CDC is a public health agency for the nation, states in fact control most of the policy levers related to public health and health care. I plan to write about that in more detail in the coming week.

When I'm not doing that, I study physician-patient communication, with particular emphasis on language and culture as factors affecting health related communication, and how people understand and respond to health and illness. I have developed a method, based on speech act theory, for decomposing and analyzing conversation. The primal version, as it were, is specifically designed for understanding communication about medication adherence, but it can be adapted just about any purpose. We have developed software (still in a buggy stage) for implementing the system, and other systems for coding conversation. I have also made an extensive study of encounters with language interpretation, and I'll actually be presenting some findings from that work at the American Public Health Association meeting next week. Again, I plan to write more about this in coming days.

So as you can see, I swing both ways - macro-level health policy, and micro-level medical sociology. I have the interdisciplinary program at the Heller School at Brandeis University to thank for the training, and the inspiration, to span both levels, and particularly the example and encouragement of the late Irving Kenneth Zola, who invented the study of cross-cultural medicine, as well as the study of disability as a sub-discipline of sociology.

Why am I telling you all this? In less than a month, it will be Stayin' Alive's second birthday. I thought it was appropriate, leading up to the massive celebration, to let a little more slip out about who is doing this, and maybe start to bring the blog closer to my regular work. We'll see how that goes, or whether events out in the world will continue to tempt me away from any strong focus.

Thanks again for reading, and responding.

If nominated, I will not run . . .

If elected, I will not serve. Actually, I don't have to worry about it, I'm ineligible for political office in the United States.

It's not because I inhaled -- politicians are now expected to say that, along with the announcement of their candidacy. I'm not gay, I don't have a criminal record, I haven't evaded taxes, and I've never employed an illegal alien.

Nope, the reason I can't run for office is that I'm an atheist.

Candidates are required to discuss their "deep faith," the "centrality of religious belief" to their lives, and to utter little prayers, in every speech. They must be photographed conspicuously attending church every Sunday. A large majority of Americans tell pollsters that atheists are not qualified to hold office.

Now what the hell is this all about? In the first place, whatever religion your member of Congress adheres to, chances are it isn't yours. And if yours is the one true religion, then your representative is just as wrong as I am.

When it comes to making policy, it's pretty obvious that publicly proclaiming your piety, and even being pious in private, doesn't cause a politician to do what's right. After all, if you're like most Americans right now, you think that politicians have been leading the country in the wrong direction -- even though they spend half their breath talking about how God tells them what to do.

I don't go door to door telling you what to believe, or press tracts into your hands at the subway station, or insist on reciting the writings of Richard Dawkins or Paul Kurtz before every high school football game.

If God tells George W. Bush and Joe Lieberman what to do, then God is responsible for their mistakes. I take responsibility for my own. Evidently, Americans think that's a moral failing.

Your religion is your own business, it's not the business of the general public or the government. And that ought to be true for politicians as well.

Quote of the Day

“The modern conservative is engaged in one of man’s oldest exercises in moral philosophy: that is the search for a superior moral justification for selfishness.”

-John Kenneth Galbraith

I have little to add to this .. .

But people who are physicians, want to be physicians, or expect to be patients, might want to read it. I believe I referred to this when it came out, but it's highly relevant here. The editors of NEJM used excellent judgment when they made this essay by Molly Cook and colleagues available to the public:American Medical Education: 100 years after the Flexner report. Let me pull out a couple of quotes that I think are particularly cogent:

From the early 1900s to the present, more than a score of reports from foundations, educational bodies, and professional task forces have criticized medical education for emphasizing scientific knowledge over biologic understanding, clinical reasoning, practical skill, and the development of character, compassion, and integrity. . . .

Theoretical, scientific knowledge formulated in context-free and value-neutral terms is seen as the primary basis for medical knowledge and reasoning. This knowledge is grounded in the basic sciences; the academy accommodates less comfortably the practical skills and distinct moral orientation required for successful practice in medicine. However, Flexner had not intended that such knowledge should be the sole or even the predominant basis for clinical decision making. Within 15 years after issuing his report, Flexner had come to believe that the medical curriculum overweighted the scientific aspects of medicine to the exclusion of the social and humanistic aspects. He wrote in 1925, "Scientific medicine in America — young, vigorous and positivistic — is today sadly deficient in cultural and philosophic background."16 He undoubtedly would be disappointed to see the extent to which this critique still holds true. . . .

The moral dimension of medical education requires that students and residents acquire a crucial set of professional values and qualities, at the heart of which is the willingness to put the needs of the patient first. . . .However, the values of the profession are becoming increasingly difficult for learners to discern; the conclusions they draw, as they witness the struggle of underinsured working people to obtain health care, marked differences in the use of expensive technologies in different health care environments, and their physician-teachers in complicated relationships with companies that make health care products, should concern us. . . .

It has long been observed that assessment drives learning. If we care whether medical students and residents become skillful practitioners and sensitive and compassionate healers, as well as knowledgeable technicians, our approaches to the evaluation of learners must reach beyond knowledge to rigorously assess procedural skills, judgment, and commitment to patients. . . ."

I have many ideas of my own about this. However, it has to begin with the admissions process. Today, medical schools admit largely on the basis of strong academic performance in the sciences, and high scores on standardized tests of scientific knowledge and reasoning ability. Many medical students have almost no background in the humanities or social sciences. Most disturbing, they do not all share the fundamental values essential to compassionate healing, nor the capacity for empathy essential to understanding the lifeworlds of patients who typically come from very different social and cultural backgrounds. It is very difficult, if not impossible, to fix these deficiencies in the educational process. People who do not belong in the profession should not be admitted to medical school in the first place. Let's figure out how to start there.

Racism? Or Personal Responsibility?

No doubt you have heard of the studies in the new JAMA on racial disparities in health care. One, by Liu et al, is free to the struggling masses, while the other, by Trivedi and colleagues is not, but they will graciously allow you to read the abstract. One finds that in California, black patients are less likely to have complex surgical procedures done at hospitals that do a high volume of such procedures, which is known to be strongly associated with greater safety and better outcomes. The other finds that outcomes for ethnic and racial minority patients enrolled in Medicare managed care plans -- outcomes such as good control of high blood pressure, high LDL cholesterol, and diabetes -- are worse for racial and ethnic minority patients than for non-Hispanic white patients.

These studies don't give us much information about why this happens. Such disparities are very well documented and were the subject of a recent Institute of Medicine report. There isn't much that's new here. But in my view, the intense focus on disparities within health care systems is too narrow. Disparities in health begin long before people have anything to do with doctors. There are strong socioeconomic gradients in health status and longevity in every society. In the United Kingdom, after the National Health Service was established and everybody had equal access to medical care, the disparities persisted -- although throughout Europe they are less than in the U.S., because there is less inequality to begin with.

Outcomes for poor and minority patients may not be as good not only because there is something inferior about the medical care that they receive, or the interactions they have with providers, but also because people who have worse social environments are less likely to benefit as much from appropriate, or at least similar, treatment. (Equality can be construed to mean giving each person what is right for them, not giving everybody the same thing.) Of course, lack of insurance, or underinsurance, also means discontinuity of care or no appropriate care at all in many cases. It isn't easy for individual physicians to solve these problems, but it's important that they understand them, and make the effort.

While it seems obvious to most people that we ought to be concerned about such inequalities, there are those who disagree. There is a powerful strain in U.S. culture which assigns the blame for poverty to the poor. This is quite distinctive -- you don't find nearly as many people who think that way in Europe or Canada. So-called libertarians believe that measures by government intended to reduce inequality inevitably intrude on personal freedom, and deprive the well off of rewards they have justly earned.

This is an odd belief, certainly. The facts are quite evidently against it. Children are born into rich or poor families, and for the vast majority of them, that seals their fate. Nobody ever earned inherited wealth, or a daddy who could pay for an expensive private education; and no kid ever deserved to grow up with an inadequate diet in a neighborhood where it isn't safe to go outside and play. We don't get to pick our parents, or our genes, or our teachers. Anybody's career in life also depends to a considerable extent on luck, good health, good timing when first entering the job market, all sorts of factors beyond personal control. And while it is true that depriving a trust fund baby of a portion of what Daddy left behind reduces the trust fund baby's freedom, using the money to provide school lunch to poor kids or knee surgery to a construction laborer obviously increases their freedom. Greater equality means more freedom for most people, ceteris paribus, not less.

Many libertarians are under the impression that economics somehow proves that the so-called "free market" (a fiction which never has existed and never can exist) produces a just allocation of wealth, but I don't know where they get this from. There is absolutely nothing anywhere in economic theory that suggests that markets produce distributive justice. People typically work harder at low wage jobs than they do at better paying jobs. If they can't afford health insurance, and they happen to get hit by a bus or be diagnosed with breast cancer, it's not because they lack personal responsibility that they can't pay for treatment.

One person who doesn't seem to understand this is George W. Bush. His Harvard Business School professor Yoshi Tsurumi remembers him well:

Trading as usual on his father's connections, Bush entered Harvard in 1973 for a two-year program. He'd just come off what George H.W. Bush had once called his eldest son's "nomadic years" -- partying, drifting from job to job, working on political campaigns in Florida and Alabama and, most famously, apparently not showing up for duty in the Alabama National Guard. . .

In 1973, as the oil and energy crisis raged, Tsurumi led a discussion on whether government should assist retirees and other people on fixed incomes with heating costs. Bush, he recalled, "made this ridiculous statement and when I asked him to explain, he said, 'The government doesn't have to help poor people -- because they are lazy.' . . .

Bush once sneered at Tsurumi for showing the film "The Grapes of Wrath," based on John Steinbeck's novel of the Depression. "We were in a discussion of the New Deal, and he called Franklin Roosevelt's policies 'socialism.' He denounced labor unions, the Securities and Exchange Commission, Medicare, Social Security, you name it. He denounced the civil rights movement as socialism. To him, socialism and communism were the same thing. And when challenged to explain his prejudice, he could not defend his argument, either ideologically, polemically or academically." . . .

Many of Tsurumi's students came from well-connected or wealthy families, but good manners prevented them from boasting about it, the professor said. But Bush seemed unabashed about the connections that had brought him to Harvard. "The other children of the rich and famous were at least well bred to the point of realizing universal values and standards of behavior," Tsurumi said. . . .

Tsurumi's conclusion: Bush is not as dumb as his detractors allege. "He was just badly brought up, with no discipline, and no compassion," he said.

Unfortunately, people like Bush are not that hard to find in medical schools. The vast majority of medical students come from well-to-do families. Getting to medical school is far more likely for people who start out with advantages in society. And so this disease of affluence -- the sense of entitlement, the completely unearned claim to moral and social superiority -- is nearly as common in medical school as it is at Harvard Business School. While most people who enter the profession are strongly motivated by altruism and a desire to serve, many are principally motivated by the social prestige and monetary rewards. This category of doctor is likely to have contempt for social inferiors, which includes most patients.

And no matter how technically skilled, they make very bad doctors. Healing people is not like fixing cars or dairy cows. People are not just biological entities, they are biological-psychological-social entities embedded in society. Physicians need to be able to interact effectively, compassionately, and constructively with all of those dimensions. Too many of them cannot.

Well said!

A while back I linked to a draft of the Institute of Medicine report on drug safety. Dr. Bruce Psaty and Nurse Sheila Burke take care of us as citizens with a good summary of the issues, free even to the common rabble, in today's NEJM. Their bottom line:

[T]he IOM committee identified a number of serious problems, including a lack of clear regulatory authority, chronic underfunding, organizational difficulties, and a scarcity of post-approval data. Contributing to an urgent need for cultural change in the FDA are a suboptimal work environment, a lack of consistency among CDER [Center for Drug Evaluation Research] review divisions, polarization between the offices responsible for the pre-marketing review and post-marketing surveillance, CDER management's disregard and disrespect for scientific disagreement, and politicization and a lack of stability in the office of the FDA commissioner.

Subtext: The FDA works for drug companies, not the public. This is nothing new -- it is a well-known pattern in the U.S. for regulatory agencies to be captured by the industries they regulate. And it will continue to happen so long as elected officials -- in the Congress and the White House -- are working for the drug companies, not for you. There's nothing libertarian, or conservative, about that. They're just screwing you.

It smacks of creeping socialism

Not that I haven't dealt with this here before, but there are those among us who believe that if we have universal health care, we will a fortiori be slaves to socialism. We will have to gather every Sunday in the nearest football stadium, to participate in pageants extolling the Godlike virtues of our beloved leader, there will be only one brand of toilet paper in the supermarket, and we'll all be forced to wear cheap watches.

It seems odd to me that people believe that, because we don't actually have to speculate. We can refer to reality -- you know, the world that is out there, susceptible to our senses, understandable by our reason -- rather than reading the daily lesson from The Gospel According to Milton Friedman. What do you know? Among the countries that have universal, publicly funded , health care, are Communist dungeons Australia, Canada, Denmark, Italy, Japan, Sweden, the United Kingdom, and France. Okay, okay, the French are all homosexual, brie guzzling, cabernet sipping, effete surrender monkeys, but what do you have against Denmark?

Those countries use various systems to achieve this. In most, only health insurance is public, and most health care delivery is by private entities. The UK operates a national health service, which employs physicians, on the other hand hospitals are mostly private non-profit entities. In Canada, it's the opposite. Physicians are private entrepreneurs, but hospitals are public. The countries also differ in the complementary services for which they provide universal coverage, such as eyeglasses and dental care. So there's plenty of room for tailoring systems to national conditions, whether economic, demographic, cultural or political.

How about efficiency? Administrative costs for Canada's system are, get this, .8%; in France, .2%. (Yes, you read that correctly, that is two tenths of one percent, also known as 2 one thousandths.) In the U.S., administrative costs for the publicly supported part of our system -- Medicare and Medicaid -- are 3.1%. For the private part? 8.3%.

Per capita spending? In 2000, in the U.S., about $4,000. Next highest? Germany, of course, which does not have universal coverage and has the least "socialized" system, after the U.S., with total spending of $2,747. Lowest of all? The most socialized, communistic, totalitarian nation on earth, the United Kingdom, which spent just $1,391 per person in 2000. Of course, one reason is our physicians made $199,000/year, while UK physicians made an average of $52,547. That's not so great, but on the other hand they don't have to pay back a quarter of a million dollars in student loans, because they also have a communistic, totalitarian, soul-destroying system of higher education, including medical school.

Well, at least spending all that money and being free, as opposed to communist slaves like the Danes, makes us healthier, right? Sadly, no. Life expectancy at birth in the U.S.? 77.5 years, actually among the lowest of the wealthy countries. (Average for OECD countries, which include Turkey and Mexico: 78.3 years.)

Anyhow, thank God I live in a free country, unlike those communistic totalitarian brits, where Her Royal Highness Elizabeth the Second, Dei gratia Regina, has the legal power to listen to people's telephone calls without a warrant, and to make people disappear forever into secret prisons, where they may be tortured to death, with no recourse to the courts . . . oh wait, that isn't true. I must be thinking of some other country.

If you want to check out my facts and figures, and learn a whole lot more (for those of you who are interested in stupid things like facts), you don't have to go to the communistic, islamofascist, America hating World Health Organization (although you could). Check out the health data page of the Organization for Economic Cooperation and Development, a reliably capitalist international body dominated by the Beacon of Freedom, Light Unto the Nations, sole remaining superpower, last bastion against the evildoers, USA, where we preserve our remaining freedoms and access to expensive watches by making sure that 45 million people don't have any health insurance.

What must be done

Okay, yesterday I reviewed Nancy Pelosi's hundred hours pledge and, to auto-summarize, I said okay, better than nothing, if you can even get that done. But here's what the U.S. really, truly must do. None of this is even noticeable on the margins of political discourse, with the possible exception of item number 1.

1. "Yes yes," the people cry, "we know now that the invasion of Iraq was a mistake. [No it wasn't. They did it on purpose.] But how can we extricate ourselves?" Here's how. Get on trucks. Drive south. Get on boats. Come home.

Here is the ridiculous joint press conference of the Military and Administrative Proconsuls in which, despite the headline, they say, in esssence, that Iraqi officials have agreed to a timeline for setting a timeline for making progress of some sort; and that, based on no particular evidence or rationale, Iraqi forces will be able to assume responsibility for security in 2 or 3 Friedmans. Meanwhile, Nicholas Kristoff (behind the subscription wall) reminds NY Times readers of what we have said here many times, the occupation is costing U.S. taxpayers something like $200 billion per year, quite enough to do most of everything else I'm going to mention.

Meanwhile, Gail Collins and the editorial page gang, in a weirdly schizophrenic mega-editorial, say that "even with the best American effort, Iraq will remain at war with itself for years to come, its government weak and deeply divided, and its economy battered and still dependent on outside aid. . . . The tragedy is that even this marginal sort of outcome seems nearly unacheivable now." And it's One, Two, Three what are we fighting for? The Times doesn't actually know, but they want us to keep doing it. They want to fire Ronald Dumsfeld, but otherwise they want to Stay the Course: Demand reconciliation talks (check, viz. today's press conference by the Proconsuls); Stabilize Baghdad using U.S. troops (check, viz. this month's military death toll); and "Acknowledge reality." Okay, I just did. That fixes it.

Time to go. Less is more.

2) Universal, comprehensive, single payer national health care. As Kristoff notes, we could pay for it with the money we're using in Iraq to kill people. (I did the math for him - he said $2 trillion could pay for universal health care for one decade. We're spending $200 billion a year in Iraq, which happens to be $2 trillion/10.) Actually, it would cost a lot less than that, because if we insured everyone, we could actually reduce spending on health care while getting better results. Read the blog Stayin' Alive, by Cervantes, if you aren't yet convinced.

3) Carbon tax. An independent study group here in the People's Republic of Massachusetts recently declared that we have to raise the gasoline tax to pay for infrastructure improvements, and of course that is also the best way, according to conservative economists, to reduce consumption of fossil fuels and save the planet. All candidates for governor, including the Green Party candidate, immediately fell all over each other to utterly, finally and forever repudiate such an offensive, obscene proposal. In fact, the Republican candidate's platform emphasizes suspending (i.e. eliminating) the state gasoline excise tax entirely. Yes, yes, the tax would disproportionately affect low income people. Solution? Using the revenues for a refundable tax credit for low income people and mass transit improvements, which will also benefit them.

4) The massive unfunded liabilities of federal, state, county and municipal government. The feds have Social Security and Medicare to worry about, but state and local government also have unfunded pension liabilities. Universal health care will instantly help, a lot -- it will relieve the states of the burden of Medicaid and health care for retirees. But the country is still headed for bankruptcy. The carbon tax could help there as well. So would eliminating the cap on earnings subject to FISA taxes. So would re-instating the estate tax (Andrew Carnegie, a very famous rich person, thought it should be 100%, because nobody deserves to inherit a fortune), stopping spending $200 billion a year in Iraq, eliminating spending on useless cold war weapons systems, nuclear disarmament (see below) and breaking up the K Street bribery racket that buys bridges to nowhere and museums of the history of shoe buttons with your tax dollars. But we still would have some work to do. Raise marginal tax rates on the wealthy. Encourage older people to stay in the labor force by tweaking the social security benefits formula. All that would about do it. Chimpy wants to eliminate Social Security instead.

5) Nuclear disarmament. 'Nuff said for now.

6) Invest in the future. Better elementary and secondary education, and universal access to higher education. Massive improvements in mass transit. Renewable energy. Redirect biomedical research from drug company profits to improving human health. (Right now these goals are largely incompatible.) Fund sustainable, low fossil-fuel development in the poor countries. High quality early childhood care and education for working parents. Environmental protection and wilderness conservation. Add your own. We can easily afford to do all this if we do the above, in fact it will pay for itself.

Okay, okay, I didn't get into abortion, homosexuality, or Palestine. Those are all trick questions right now, but you already know where I stand on that.

But the rest of it -- that's a real program, a program somebody should run on. It will mean tremendous benefits for working people, and it's easy to explain why. If we did all that, the nation would be much more secure as well. I don't see any Democrats talking this way. Is it really that hard?

Big changes ahead?

With the polls now indicating that the party of Warrior Jesus may lose control of the House, and conceivably the Senate as well, I'm naturally inclined to wonder what the impact might be on public health and health care policy. The Unseen Powers strictly enforce the requirement that political analysts state that the Democrats don't have any agenda of their own, and reporters are required to quote them to that effect in news stories. Of course, like everything else said by pundits and quoted by reporters, it isn't exactly true.

Nancy Pelosi, presumptively the next Speaker of the House, has offered her short list. Now, actually making any of this law depends on the Senate, and should legislation get through both chambers, whether the White House occupant decides to veto it, or sign it and issue a signing statement to the effect that he intends to ignore it, in which case it will be "law" but not the law. Or something. Anyhow, for what it's worth, Ms. Pelosi wants to:

1. "Put new rules in place to "break the link between lobbyists and legislation." That sounds great Nancy! In fact, it will be necessary to get most of the other stuff done. However, it's a) a little vague; and b) ignores the painful reality that your Democratic colleagues, and you, are dependent on the same corporate funders as your colleagues on the other side of the aisle, and you might have trouble rounding up the votes to do anything substantial. We'll see.
   
2. "Allow the government to negotiate directly with the pharmaceutical companies for lower drug prices for Medicare patients." This seems like a good idea, but it's not very specific. Does it mean eliminating the intermediaries from Medicare Part D and folding it into regular Medicare? That would be the right thing to do but it means going up against a now-powerful vested interest created by the original legislation, i.e. the insurance companies that manage the program now; as well as going up against the drug companies. Any real prospect of this happening would depend on Item One, above.
   
3. "Raise the minimum wage to $7.25 an hour, maybe in one step." And then override the veto with 2/3 of the vote in both houses. Okaaaaaayyyy.
   
4. "Broaden the types of stem cell research allowed with federal funds" -- "I hope with a veto-proof majority," she added in an Associated Press interview Thursday." Again, not very specific but let's assume she's talking about having legislators walk in the light of reason and stipulate that a blastocyst is not a human being, which would mean, pretty much, any research that is scientifically sound and holds promise for benefitting humanity should be judged on its merits. This is not by a very long way the most pressing problem facing the country, but I'm not seeing the veto-proof majority.
   
5. And now, the pièce de résistance: "All the days after that: "Pay as you go," meaning no increasing the deficit, whether the issue is middle class tax relief, health care or some other priority."

In other words, Grover Norquist has already won. The billionaire tax relief policies of the past 5 years have led Nancy Pelosi to solemnly swear not to make any effort to solve the horrendous problems facing the country. Thanks Nancy, you've shown us all the true meaning of courage.

ADDENDUM: Here are a couple of suggestions of mine for stuff the Dems might actually be able to accomplish. 1) FDA reform. Fix the drug approval process according to the recommendations we've endorsed here, including establishing effective post-marketing surveillance systems and requiring that the companies fund them and use them; requiring that all trial data be posted publicly, and that results of all trials (not just the ones the companies cherry pick) be included in new drug applications; requiring trials against current best treatment; ban on all advertising, not only direct to consumer but marketing to M.D.s as well, for the first 18 months after approval. 2) Eliminate the cap on income subject to social security taxes. 3) Make the Ryan White Care Act authorization and appropriations increase in proportion to the number of people living with HIV in the U.S., plus inflation. 4) Transfer funding from the DEA to the Center for Substance Abuse Treatment. Subsidize state initiatives to provide treatment on demand, and particularly treatment for released convicts, including a seamless transition from incarceration to the community.

You got any nominees?

All I'm doing is ripping this off

from Buzzflash, but I just thought it was a great work of contemporary art.

I'll be back Sunday, I hope.

Fourth and goal, 10 seconds on the clock, down by 6

Early this year I did one of those Friday hope blogging posts on good news we could hope for in 2006. One item on the list was the eradication of polio. Not to be, at least not this year, but it might still happen.

The campaign went off the rails in 2003 when Muslim leaders in part of Nigeria denounced it as a plot to sterilize Muslim women. (Sigh.) World Health Organization leaders thought they had contained the problem to the affected region but alas, the virus leaked out and surfaced elsewhere. It's also been impossible to immunize all the children in the strife-ridden Afghanistan/Pakistan border region, and the campaign has been poorly run in parts of India. It will be a Major Bummer if WHO can't clean this up and finally eradicate polio -- we'll have to start immunizing children worldwide again, at great cost, and those who do become infected risk paralysis and life-long disability as well as death. So let's all vote for putting in the money and diplomacy needed to finish the job.

Quick tip

We've talked quite a bit about Ritalin here, so I figured I'd pass this on. This seems to be a fairly commendable example of science journalism, it's a non-bylined AP report on the publication of results of a trial of methylphenidate in pre-schoolers. The anonymous reporter did a good job of getting critical perspectives on the journal reports, which they usually don't bother to do.

I have little to add right now because I have only been able to read the abstracts. (My university library doesn't have an electronic subscription to the journal.) There are actually five different articles reporting various aspects of the trial results, so it's going to take some work for me to get a firm understanding of the total picture. I did manage to glean that Ritalin stunts kids' growth and has many other side effects that aren't very nice. Based on the instruments they used to measure effectiveness, 21% of kids with serious symptoms who got speed, and 13% who got placebo, had complete remission. So you have to stunt the growth of 100 kids to get 8 of them to sit down and shut up. Even on taken at face value, that sounds like a questionable proposition. But unlike your favorite radio talk show host, I won't criticize what I haven't read. More later, I hope.

Doctor Evil

Unfortunately, despite my vast influence, the editors of the New England Journal of Medicine have yet to heed my entreaties that they make material of general public interest available to the little people. So you can only read the first 100 words of this rather important exposé by Peter Q. Eichacker (yeah, he must have had a rough childhood), Charles Natanson, and Robert Danner. This has gotten some coverage in the corporate press but I haven't found it very clear or edifying so I figured I'd offer my own.

The rising calls for evidence based medicine, and measures of quality in health care, have been accompanied by the increasing popularity of "consensus guidelines" or cookbook recipes for how people with particular diagnoses and symptoms are to be treated. For example, there are guidelines for when to initiate antiretroviral therapy in people with HIV that have to do with CD4+ cell counts and symptoms of immunodeficiency. This is a good thing in that it gives physicians an accessible, practical summary of what a panel of experts thinks the available evidence tells us about the best approach to a situation.

There is some controversy about holding physicians strictly accountable to such guidelines in quality assurance efforts, because people aren't cakes or casseroles and the same recipe isn't necessarily right for all of us. For example, a physician might choose not to prescribe a drug because it is clear the patient won't adhere to the regimen. Nevertheless such guidelines do represent one method of helping to assure that people get the most appropriate, effective and cost-effective care.

Well, sure enough, they are also just one more target for drug company manipulation. I wrote a while back* about the Texas Medication Algorithm Project, which was funded by drug companies and touted in the President's New Freedom Commission report on mental health (a lot of "compassionate conservative" BS from early in the Chimpoleon administration that went nowhere, of course). It's a "decision tree" that by an amazing coincidence, leads to drugs manufactured by the project's sponsors -- and it was based on the expert opinions of drug company consulants, not evidence. (See also here for a perspective from a chapter of the National Alliance for the Mentally Ill, with some additional links.)

In the latest outrage, Eli Lilly got a drug called Xigris approved for treatment of sepsis in 2001, even though half of the advisory committee members who reviewed the drug voted against it. (Sepsis is essentially a bacterial infection that overwhelms the immune system. Adverse consequences of the immune response cause as much trouble as the infection itself -- these include fluid in the lungs, and shock, which is essentially a catastrophic fall in blood pressure.) Later trials established that Xigris increases the risk of bleeding and did not save lives compared with older, cheaper drugs. Oh yeah -- a treatment with Xigris costs $8,000.

Obviously, under the circumstances, Xigris was not selling well. So what did Lilly do? Invest its profits in coming up with a better drug, as John Stossel assures us is their only reason for making a profit in the first place? Sadly, no. Among other ploys, they hired a group of experts to create practice guidelines for treatment of sepsis -- including many who had other, existing financial relationships with Lilly -- that included use of Xigris. They also hired a public relations firm to tout the results. Their justification for endorsing Xigris was that it had been tested in randomized controlled trials, whereas the alternatives -- antibiotics -- had not. But you can't test antibiotics in controlled trials because it would be unethical -- we already know they work, so you can't compare them to placebo. And the clinical trials of Xigris showed it to be dangerous.

There are more details and complexities to all this, which I won't go into. But here's my bottom line: experts who sell their opinions are far worse than prostitutes. They are, in this case, quite possibly murderers. Yet they occupy prestigious positions in universities, enjoy huge incomes, and presumably the esteem of their colleagues. They should be outed, and disgraced.

*Or at least I thought I did, but the post appears to be saved as a draft only. Somehow I never put it up. Oh well.

The real divide in American politics

No doubt you've seen this elsewhere, it's gotten a bit of blogospheric circulation. United States Senator Rick Santorum explains the Iraq war this way: "As the hobbits are going up Mount Doom, the Eye of Mordor is being drawn somewhere else. It’s being drawn to Iraq and it’s not being drawn to the U.S. You know what? I want to keep it on Iraq. I don’t want the Eye to come back here to the United States."

Then there was the falafel master mustering his vast knowledge of medicine to reassure us that pregnancy never has any life-threatening complications; the bizarre finding of Jeff Stein, as reported on the NY Times op-ed page, that the vice chairman of the House intelligence subcommittee on technical and tactical intelligence, and the chair of a House intelligence subcommittee charged with overseeing the C.I.A.’s performance in recruiting Islamic spies and analyzing information, don't know the difference between a Sunni and a Shiite or which is which. Then there is Republican educational policy -- that children must be taught the controversy about whether the earth is less than 10,000 years old or not, which I have also wasted all of our time talking about. And of course yesterday I discussed the profundity of RNC propagandist John Stossel on health care policy. I could take this straight to the top of the banana tree (see portrait, above), if I wanted to, but you get the idea.

So that's it then. It's not about red states and blue states, or liberals and conservatives, or values voters and coastal degenerates, or who is "serious" when it comes to foreign policy. It's about the people who have a clue, vs. those who don't know their ass from Crater Lake. It's about having one neuron to rub against another. The election on November 7 is between people who have at least a vague grasp of reality, and people who don't. This, in the most powerful nation on earth.

Lying, ignorant blowhard of the week award

Who else but ABC's resident reality-challenged conservative idiot John Stossel? Here he is on yet one more subject about which he knows less than nothing, health care economics. Stossel has already been caught dead to rights committing journalistic fraud -- lying to his public, claiming he'd had organic produce tested for pesticides, when he, well, to be precise, had done no such thing. He should have been fired and forever barred from the profession, but no, ABC continues to give him a prominent platform to spout his torrent of lies and illogic. If you've been reading, you don't need me to deconstruct this, but here goes anyway.

Stossel:

Suppose you had grocery insurance. With your employer paying 80 percent of the bill, you would fill the cart with lobster and filet mignon. Everything would cost more because supermarkets would stop running sales. Why should they, when their customers barely care about the price? Suppose everyone had transportation insurance. The roads would be crowded with Mercedes. Why buy a Chevy if your employer pays?

C'mon John, do you think we're all as stupid as your fans? Health care is nothing like groceries. I'm not going to go out and get a Coronary Artery Bypass Graft or a bowel resection just because my insurance pays 80% of the cost -- I'm going to get those operations because I have heart disease, or cancer. And I'm not going to decide on my own that I need them -- my doctor is going to tell me.

Stossel:

People have gotten so used to having "other" people pay for most of our health care that we routinely ask for insurance with low or no deductibles. This is another bad idea. Suppose car insurance worked that way. Every time you got a little dent or the paint faded, or every time you buy gas or change the oil, you'd fill out endless forms and wait for reimbursement from your insurance company. Gas prices would quickly rise because service stations would know that you no longer care about the price. You'd become more wasteful: jackrabbit starts, speeding, wasting gas. Who cares? You are only paying 20 percent or less of the bill.

Utter nonsense. When I get health care, I don't have to fill out any forms, or wait for reimbursement: my provider bills the insurance company. And what makes you think that I could do a better job of driving a bargain than my insurance company can? My insurance company has 1 million times the buying power I do, and employs professionals who negotiate with providers. In fact, doctors and hospitals charge much more to individual buyers than they do to insurers.

When asked about "consumer directed plans," "nearly eight in 10 Americans think that allowing people to shop around for their own medical care would be an effective way to control costs."

Yeah, and they don't believe in evolution either. We don't decide what's true by taking a poll.

This is not to say that we don't need insurance. We need it to protect us against financial catastrophes that could result from a stroke or heart attack. That's why health savings accounts, which cover smaller out-of-pocket health expenditures, are paired with high-deductible catastrophic insurance. That's a good thing. But today's demand from people that insurance cover everything from pets to dental work puts us on a slide toward bankruptcy.

I don't know where he gets tbe bit about pets from, but it's precisely those smaller out-of-pocket expenditures that you don't want to force people to make -- those are the preventive services like screenings and early intervention that save big bucks later on, that people forego when they have to pay for them. They're a very small part of overall spending, that saves money in the long run.

In other terrifying news from the poll: "Three-quarters like the idea of expanding Medicare, the government program that covers retirees." Great, let's bankrupt America even faster! Medicare already has an unfunded liability of $32.1 trillion — that's how much more money the politicians have promised versus the amount the Treasury has to pay for it. The Medicare Trust Funds report says expenditures "are expected to increase & at a faster pace than either workers' earnings or the economy overall."

True! The cost of Medicare is rising. So we have two choices: let Grandma die, or set up a universal insurance program that can actually gain control over costs. This is a little bit of a complicated story, which Stossel is too dumb to understand, but I've discussed it here at length. In a nutshell, the taxpayers who pay for Medicare would spend less for their own health care under a single payer system, making it easier to take care of Grandma as well.

As P.J. O'Rourke says, "Think medical care is expensive now? Watch how expensive it gets once it's free."

Oh, that's convincing -- your "expert" is a racist comedian. And of course this is a ludicrous self-contradiction - health care can't be both expensive and free at the same time. The payer will still be paying for it -- and controlling costs in a way that individual consumers cannot do.

When third parties pay, regardless of whether it's government or private insurance, people find it easier and more tempting to cheat. No one spends other people's money as carefully as he spends his own. But "profiteering?" What the heck does that mean? Every company wants to make as much profit as it can. If an insurance company makes "excess" profit, other insurance companies will rush to compete in those areas; therefore prices will fall quickly.

Well, that must already be happening then. So insurance is the best way to contain costs after all. You're contradicting yourself John, but we're supposed to be too dumb to notice. Actually, if we had non--profit insurance, then it would cost even less, wouldn't it?

And frankly, I want drug companies to make lots of money. The more they make, the more they invest in drug development that may someday cure my disease or ease my pain.

If you had even a passing acquaintance with the subjects you yell and scream about, you would know that drug companies spend most of their R&D budget on "me too" drugs and minor modifications of existing formulations so they can hold onto marketing exclusivity. A lot of the studies they finance are rigged, and when the studies make their drugs look bad, they keep them a secret. Then they plow even bigger bucks into advertising and marketing in order to get us to take the ineffective, unsafe drugs they have bribed or bamboozled the FDA into approving. A single payer system could stop doctors from prescribing inappropriate medications.

Finally, the worst news on the poll is that "56 percent support a shift to universal coverage." Universal coverage sounds so nice — no worries, no paperwork. Mommy and Daddy, usually in the form of government as single payer and manager, just take care of everything. Universal coverage in Canada and Europe is popular because no one has to worry about paying directly or filling out forms. But like all well-intended schemes of collectivists, it is becoming a cold, bureaucratized machine that does not serve people well.

Just because you say it doesn't make it true. Actually, it's a good bet that if you say it, it's false. Various studies -- such as the one I discuss here, and this one, show that people in those commie pinko countries with universal health care get better service and better quality care than we do. Stossel tells stories about English people pulling their own teeth because they can't stand the wait, which as far as I know he just made up, but the fact is, most Americans don't have dental insurance at all, so they just have to wait forever.

I doubt that ABC employes this clown because he attracts viewers. They just pay him to bamboozle and defraud the public on behalf of their wealthy owners and executives, who don't want to pay taxes and don't care what happens to you or your grandmother. Stossel is a very unfunny joke.

And oh yeah: If having universal health care will automatically make the price go up, how come the countries that have it spend half as much on health care as we do, while managing to cover everybody, give them better service (the actual, you know, fact, is that people in Europe and Canada have shorter waits to see a doctor than we do), and end up living longer and being healthier? But that's the great thing about being a conservative these days -- you can spew fact-free, irrational, self-contradictory horseshit, and be given a prominent platform and a multiple six figure salary. You are completely unaccountable, you don't even, apparently, have an editor. It's a good life.

Plugging the Competition

If you get tired of me, you might want to check out the blog at PLoS Medicine. In this entry, Virginia Barbour cogitates on "What are the "fundamental unanswered questions in medicine?" She gets props from me because her proposals are social and political, rather than biomedical quandaries: how are we going to pay for the high tech care that people in rich countries have come to think is their right? Why don't we invest proportionately in the diseases of the poor countries? Why are so many people willing to trust "alternative" treatments for which there is no evidence, while distrusting well established, safe and effective interventions like vaccination? Why don't people get more upset about the death toll from motor vehicles? [And, I might add, other important causes of premature death such as gun violence, while they are very worried about unlikely or far less severe problems such as terrorism.] Etc.

Not surprisingly, the first commenter is disappointed and wants to propose biomedical questions. In my view, at the present state of socio-medical development, these are far less important. When it comes to medicine, we need to let our wisdom catch up with our knowledge.

Also, check out Counterspin, a new addition to my blogroll.

Back to the wonkshop

Sigh. Despite the fecklessness of it all, I shall again take up the banner of health policy as is my mission.

One reason conservatives, or whatever those people ought to be called, are actually mad at the White House Occupant is that he supposedly betrayed God's command to send old and poor people out into the woods to die by championing the Medicare prescription drug benefit. You may have heard that the 2003 Medicare reform package actually provided a windfall to the drug companies by forbidding Medicare to bargain with them over price and farming out the drug benefit to private companies. True enough, but you may not know that it also squanders your money in another way.

Since 1983, Medicare has included an option to enroll in managed care programs. The way these plans work is that Medicare pays insurance companies a fixed amount for each enrollee, which is supposed to be a bit less than the average cost per Medicare beneficiary. The idea is that the plans could provide the care for less by limiting choice of providers, paying their provider panel members a bit less in return for a guaranteed level of business. They would also, obviously, "manage" their care, assuring that cost effective procedures were used. People would join these plans because they could offer a bit more to the consumer -- such as prescription drug coverage -- while keeping their costs down. In the middle was their profit.

The problem with this idea is that, (and if you've been reading Stayin' Alive for a whiel you guessed it), it's mostly the younger, healthier beneficiaries who sign up, because of targeted marketing, and because peope who need less care are less bothered by the limited choice of physicians. As a result of this "cherry picking," the people enrolled in managed care plans actually would cost Medicare less if they were in the standard fee-for-service program, while the fee-for-service program (which still serves the large majority of beneficiaries) is stuck with the older, sicker, and more expensive beneficiaries. In other words, the plans waste taxpayer money and siphon it into the profits of insurance companies and the salaries of their executives.

So, what did the Medicare Modernization Act do about this problem? Again, you should have guessed by now: it raised the reimbursement rate for Medicare Managed Care plans. Now we overpay for enrollees in these plans by 11% -- that's $4.6 billion of your money every year, almost enough to kill people in Iraq for two weeks.

You don't have to take my word for, Families USA has the lowdown here. (PDF)

Once again, the Alcoa sombrero

It often feels futile writing about public health and health care policy when we all know that these issues are not going to be seriously addressed, at least on the federal level, in the current political context. And of course, I'm talking about the most pressing problems facing the country: the profound social structural and economic challenge posed by an aging population and relentlessly rising costs for health care; the entwined crises of petroleum depletion and global warming, and the radical economic challenges of the coming new energy age; the gathering clouds of wider war over energy resources amid the proliferation of nuclear weapons; the threats of microbial drug resistance and emerging infectious diseases.

But we aren't even seriously contemplating these issues as a nation. Our political culture is all about tribalism, fanaticism, and kleptocracy. The party in power uses political ideas -- if you can call its empty sloganeering, fear mongering, bullying and bigotry "ideas" -- only as a means to the end of power and personal enrichment.

The artificial TV world in which American politics now happens is a perfect habitat for these tactics, but finally, the polls are showing, more and more people are seeing through the lies. The consensus expectation is for a major shift away from Republicans in November, and likely Democratic control of one or more chambers of Congress. But we also know that the ruling cabal despises democracy and the constitutional order, has absolutely no scruples when it comes to holding on to power, and cannot afford any serious investigation of its rule. So, this has a lot of people worried. I happen to be one of them.

It is essential that we be prepared for even the most shocking possibilities. We can expect massive vote suppression and fraud, and tens of millions of dollars poured into slanderous attack advertising at the last minute, when there is no time to respond. That will happen. But we also might see war with Iran, a trumped up terrorism crisis, something, anything, to terrorize the people and further hammer at the foundations of the republic. And remember -- our constitution is not our friend. They only need one more vote in each chamber to hold on to absolute power. And then what?

Another open door crashed through . . .

But sometimes it pays to point out the obvious. There are intellectually respectable objections to the gold-standard Randomized Controlled Trial (RCT) as the only kind of evidence one ought to accept for choosing health-related interventions (see, for example, Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials, by Gordon Smith and Jill Pell.) Nevertheless, if a new drug can't show its superiority to alternatives which are cheaper and/or known to be safe in an RCT, there isn't likely to be much justification for using it.

As everybody who wasn't born yesterday ought to know, drug companies sponsor most of the clinical trials on which drug approvals are based, and guess what, there are lots of ways to rig those trials to make their drugs look good and guess what, they do it. One strategy to combat use of slanted trials, and cherry picking of favorable ones, in order to sell drugs, is called the systematic review. Ideally, authors of such reviews first try to find all of the studies on a subject such as a specific drug; then they evaluate them for quality according to specified criteria; then they add up the results of the good ones ("meta-analysis") to come up with a better estimate of the effectiveness of the drug than any single trial can produce.

The Cochrane Collaboration is a non-profit organization which for many years has been compiling a database of such systematic reviews done according to its exacting standards. However, reviews are also regularly published in journals. Some of these reviews are sponsored by, guess who? Yup, drug companies actually pay for reviews of trials of their own products, many of which trials of course they themselves paid for. So, some Danish guys did a Review of Reviews (yeah, I know, next we'll need a review of reviews of reviews) and I'll bet you'll never guess what they found out?

When there was a Cochrane review and an industry-funded review of the same drug within two years, the industry-funded review always recommended use of the drug without reservation; the Cochrane review never did. The industry-funded reviews were of much lower quality and often incorporated studies which had serious deficiencies. Conclusions? "Industry supported reviews of drugs should be read with caution as they were less transparent, had few reservations about methodological limitations of the included trials, and had more favourable conclusions than the corresponding Cochrane reviews." Well duhhh.

Now what should we do about the good doctors who get paid to write drug industry propaganda and publish it in medical journals?

Do no harm

Since we've been thinking about The Lancet the past couple of days, I was reminded of Steven Miles's essay two years ago, on the legacy for military medicine of abu Ghraib. (Access is free, fairly painless registration required -- I recommend you go for it.) Funny thing about that, this got little or no attention in the U.S., as far as I know. Miles, by the way, has just come out with a book expanding on this work: Oath Betrayed: Torture, Medical Complicity, and the War on Terror (Random House).

In the Lancet piece, he catalogs the horrors of Abu Ghraib and the prison camps in Afghanistan. Okay, we've heard it before. But his focus is on the participation of medical personnel in the torture and degradation of prisoners, including condoning medical neglect, active participation in torture, and issuance of false death certificates to cover up murder by U.S. military and civilian personnel. Here are just a few examples:

he medical system collaborated with designing and implementing psychologically and physically coercive interrogations. Army officials stated that a physician and a psychiatrist helped design, approve, and monitor interrogations at Abu Ghraib.15 This echoes the Secretary of Defense's 2003 memo ordering interrogators to ensure that detainees are “medically and operationally evaluated as suitable” for interrogation plans.6 In one example of a compromised medically monitored interrogation, a detainee collapsed and was apparently unconscious after a beating, medical staff revived the detainee and left, and the abuse continued.22 There are isolated reports that medical personnel directly abused detainees. Two detainees' depositions describe an incident where a doctor allowed a medically untrained guard to suture a prisoner's lacertation from being beaten.22,23

The medical system failed to accurately report illnesses and injuries.34 Abu Ghraib authorities did not notify families of deaths, sicknesses, or transfers to medical facilities as required by the Convention.34,36 A medic inserted a intravenous catheter into the corpse of a detainee who died under torture in order to create evidence that he was alive at the hospital.37 In another case, an Iraqi man, taken into custody by US soldiers was found months later by his family in an Iraqi hospital. He was comatose, had three skull fractures, a severe thumb fracture, and burns on the bottoms of his feet. An accompanying US medical report stated that heat stroke had triggered a heart attack that put him in a coma; it did not mention the injuries.38

Death certificates of detainees in Afghanistan and Iraq were falsified or their release or completion was delayed for months.24,39 Medical investigators either failed to investigate unexpected deaths of detainees in Iraq and Afghanistan or performed cursory evaluations and physicians routinely attributed detainee deaths on death certificates to heart attacks, heat stroke, or natural causes without noting the unnatural aetiology of the death.40,41 In one example, soldiers tied a beaten detainee to the top of his cell door and gagged him. The death certificate indicated that he died of “natural causes … during his sleep.” After news media coverage, the Pentagon revised the certificate to say that the death was a “homicide” caused by “blunt force injuries and asphyxia.”24

In November, 2003, Iraqi Major General Mowhoush's head was pushed into a sleeping bag while interrogators sat on his chest. He died; medics could not resuscitate him, and a surgeon stated that he died of natural causes.42 6 months later, the Pentagon released a death certificate calling the death a homicide by asphyxia.42 Medical authorities allowed misleading information released by military authorities to go unchallenged for many months.24 In 2004, the US Secretary of Defense issued a stringent policy for death investigations.43

Finally, although knowledge of torture and degrading treatment was widespread at Abu Ghraib and known to medical personnel,13,41,44 there is no report before the January 2004 Army investigation of military health personnel reporting abuse, degradation, or signs of torture.

Although there have been calls over the years for prosecution of the physicians and other medical personnel involved in these crimes, there have been none. The names of any physicians and other licensed providers (such as nurses) who may have participated have not been made public, although I read in a review of Miles's book that he does name at least a couple. The relevant state licensing authorities should investigate and, if the allegations are confirmed, revoke the licenses of any guilty personnel; and there should be assurances that they cannot subsequently be licensed in any other state, as too often happens with incompetent or unethical doctors.

Before joining the military, physicians have already taken an oath. Military service does not in any way change the ethical obligations of physicians, nurses, or paramedics. Orders to a military physician to violate ethical requirements are unlawful and must not be obeyed. According to the Geneva convention, as quoted by Miles, "Although [medical personnel] shall be subject to the internal discipline of the camp . . . such personnel may not be compelled to carry out any work other than that concerned with their medical duties." If the military can't live with that, however quaint, it can't employ physicians.

Finally, Miles notes that most of the results of Army investigations of these abuses remain classified. The prisoners already know what was done to them. The only people they're keeping this information from are you and me.

Old death in the new Iraq

Okay, the Lancet doesn't come out until tomorrow but you can already get the manuscript of the Johns Hopkins/Al Mustansiriya/MIT study on excess deaths in Iraq here. (PDF) Since we're already hearing that it's just a political stunt, not reliable, etc., I figured I ought to offer my take on it.

As readers of Today in Iraq know, there are daily death tolls reported by the Baghdad morgue, the police, and stringers around the country who feed information to the major news services who have offices in Iraq -- AP, AFP, Reuters, KUNA (the Kuwait news agency) and Xinhua (the Chinese agency) provide the bulk of the available information. Many people assume that the reports they read in the newspaper, usually from AP, or the daily Reuters "fact box" report that many bloggers (including Atrios and Juan Cole) often repost, are more or less complete descriptions of the day's violence. In fact, they don't even come close.

By combining information from all of the available sources, we always come up with at least two or three times as many violent incidents as you will find in any one source. Even so, it's pretty obvious that most deaths by violence in Iraq never get noted by the police, the morgue, or the news services. Out of deference to their masters, the Iraqi authorities generally don't try to count people killed by the occupation forces. Much of the country is off limits to journalists. Many people who are shot dead never end up in the morgue and there certainly isn't any reason for Iraqis to make police reports. (Police or other security forces, or people dressed like them, are responsible for most of the murders in the first place.) Muslims bury their dead quickly and relatively unceremoniously, and, while the health ministry issues death certificates, it has no system for aggregating and reporting vital records data.

So, the researchers set out to estimate deaths by means of a household survey using area probability sampling methods. This is a method used all the time in health surveys. It's a method I have used myself, in fact. To begin, you just need census data -- it actually doesn't even have to be highly accurate as long as any errors are essentially random, or unrelated to your study questions. Then, you pick geographic areas based on probability proportionate to the population they contain. This is usually done in stages. In the Iraq study, they first determined the number of clusters they would select in each province based on population size (Baghdad, with its population of over 6 million, got 12; Muthanna, with a population of 570,000, happened to get none.) Then, towns, blocks, and starting households were selected at random. For each household selected, the 39 nearest houses were also included. This survey had a total of 47 clusters, including 12,801 persons.

The researchers interiewed adult household members between May and June, 2006, to learn about births, deaths, and migration since January 1, 2002. They also asked people to report if an entire neighboring household had been wiped out, to account for households with no-one left to speak for them. They report that for 92% of reported deaths, the respondents were able to produce a death certificate. A substantial omission in the report, I must say, is the failure to state the response rate. The investigators also refer to procedures for substituting areas which were too unsafe to visit. They do not say how often this happened, but if anything, it would tend to bias the results downward.

To arrive at an estimate of total deaths for the country, they simply multiply the deaths in the study population by the appopriate weights for the number of people each cluster represents (i.e., the inverse of the probability that a person living in that province would have been selected). The clustering does not directly affect the estimates, but it does affect the so-called confidence interval. Since people living in a specific area are at greater or lesser risk of violent death than average, the statistical power of the study is less than it would be for a single stage probability sample of 12,801 persons, because of the possibility that the selection of clusters introduced sampling error. Although the manuscript does not discuss the specific calculations that were done to adjust for this, I am willing to give investigators from these institutions the benefit of the doubt that they did it correctly.

It is conventional to report 95% confidence intervals. The researchers find that there is a 95% probability, assuming no systematic biases in their data, that there have been between 426,369 and 793,663 excess deaths from violence among Iraqis since the invasion -- i.e., deaths that would not have occurred had the death rate continued as before. (There were very few violent deaths in Iraq prior to the invasion. The famous mass graves date from the era of the Iran-Iraq war, and suppression of Kurdish and Shiite rebellions associated with that era.) The investigators also estimate that there have been about an additional 54,000 deaths from non-violent causes, mostly in 2005-2006, as Iraq's health care and public health infrastructure severely deteriorated.

The steady increase in violent death rates is quite appalling, from 3.2/1,000/year in March 2003-April 2004; to 12/1,000/year from June 2005-June 2006. Not surprisingly, the deaths are concentrated in Baghdad and the predominantly Sunni Arab areas of the country. The three provinces of autonomous Kurdistan have been peaceful. 31% of violent deaths were caused by coalition forces, 24% by other actors, and in 45% of cases the perpetrators were unknown to the respondents. Even if none of these were caused by coalition forces, it results that U.S. troops have killed about 200,000 Iraqis, with perhaps a modest contribution from the British.

Are these results reliable? They are in fact the most reliable information we have about this subject. Particularly powerful confirmation comes from the very close match in this survey between deaths reported to have occurred in 2003-2004; and the results from a similar study conducted by the team in 2004. That of course had an entirely different sample of households, but used the same methods. People often misunderstand the concept of the confidence interval. It is far more likely that the true number of violent deaths is close to 600,000, than that it is close to 427,000. People also do not understand how a sample consisting of such a small percentage of the population can give us confidence in saying something about the entire population. But that results from the laws of probability, which assure that state lotteries and casinos will always win.

Was the release of this report politically motivated? Possibly the authors made a special effort to get it out before the election, but that has no relation to its truth.

Finally, as I have said many times, Iraq Body Count should go out of business. They are doing positive harm to the reality based community by giving the perpetrators of this world historical crime cover for saying that the death toll is only 10% of what it really is. That is not helping the Iraqi people.

UPDATE: Thanks to a tip from Whisker, here's an article that shows that innumerable violent deaths in Iraq go unreported.

A conspiracy so immense . . .

Serious wing nut Cliff Kincaid, of extremist media attack dog Accuracy in Media, blames l'affaire Foley on a homosexual conspiracy that has infiltrated the Republican party. "House leaders permitted homosexuals to infiltrate and manipulate the party apparatus while they publicly postured as friends of family values and traditional marriage."

Kincaid concludes, "For the sake of honest and open government, not to mention protection of the children, the secret Capitol Hill homosexual network must be exposed and dismantled. But only Republican leaders can do that. Their failure to do so suggests that the network may go higher and deeper—and have more power—than even the New York Times article indicated."

So at last we know the real reason for the failures of Republican government in Iraq, New Orleans, Afghanistan; the immense federal budget deficits; the disloyalty of scientists in federal employ who insist that burning fossil fuel causes global warming and FDA-approved drugs are dangerous; the polling data that shows that Republican control of congress is threatened. It's not the commies any more, and it's not the Jewish financiers (although Kincaid still things George Soros just might have had something to do with this), it's not even the appeasers of terrorists who cruelly and deviously subjected Joe Lieberman to the reprehensible indignity of an election. It's the homos, directed from their secret HQ at Mr. P's near Dupont Circle. Ken Mehlman really needs to do something about this.

Somebody else must have caught this . . .

But I haven't noticed it anywhere before. Dennis Hastert hasn't issued any press releases since late September, but here's his last release from August:

Hastert Drives Effort To 'Keep Kids Safe In Cyberspace'

Congressman leads Community Meeting addressing Internet safety

ST. CHARLES – Congressman J. Dennis Hastert brought national experts together with community leaders and parents on Tuesday for a 14th District Community Meeting to share information and insights on protecting children from Online predators.

Held at St. Charles North High School, “Keeping Kids Safe in Cyberspace,” included representatives of local police agencies and a panel of national Internet and law enforcement experts highlighting efforts to make the Internet safer for children. A private question-and-answer session followed, where parents addressed specific concerns and situations with police and web providers.

“Recent news stories remind us that there are predators using the Internet to target children,” Hastert said. “And just as we warn our children about ‘stranger danger’ when they are at the park or answering the door or telephone, we need to be aware of potential dangers in Cyberspace.”

Recent arrests in the Chicago area and throughout the nation have highlighted the danger of Internet predators. According to a recent Justice Department study, one in seven children using the Internet has been sexually solicited and one in three has been exposed to unwanted sexual material. One in 11 children have been harassed.

Hastert highlighted efforts underway in Congress to protect children on the Internet, including recent House passage of the “Deleting Online Predators” Act, which requires schools and libraries to limit access to social networking and pornographic websites, and calls on the Federal Trade Commission to launch a tips and information website for parents. Panelists representing MySpace.com, Comcast, Microsoft, the National Center for Missing and Exploited Children and the Naperville Police Department Internet Crimes Unit also addressed their organizational efforts to promote safety.

You can't make this shit up.

A Moral Enigma

Amy Friedman points out, in the new BMJ (subscription only) that in the United States, it is generally perfectly legal for people to sell their blood, semen, and ova, and for women to rent their uteruses for surrogate pregnancy and, in Nevada, to rent their bodies for sex. People can also be paid to participate in clinical trials of drugs, in other words to rent out their bodies for experiments.

However, it is illegal to pay people for donations of kidneys or parts of their livers. People can donate these body parts for transplantation out of altruistic motives, but they can't even be compensated for travel costs and other non-medical expenses associated with the procedure. Since many people suffer and die from lack of suitable organ grafts, a market in organs from living donors would enhance the supply while providing an economic benefit to people who choose to take advantage of it.

Although, as Friedman notes, many people object that paying for organs would exploit the neediest, she points out that we pay for military service, which disproportionately attracts people with limited job prospects, and may be riskier than organ donation.

Yet there is something about this idea that just doesn't feel right to most people. Why is that? What, if anything, is wrong with this proposal?

fighting them over there so we don't have to fight them here.. .

Sorry to go off topic, but as regular readers know I do the Today in Iraq post on Sundays, so Iraq is on my mind -- which it should be anyway.

You won't get any insight into what's going on there from TV news or even your local newspaper, so here's a simple truth. The U.S. Army is now engaged in a low-grade war with Shiite militias, particularly those associated with the Sadrist movement, which is part of the Iraqi government and was a key ally of the U.S. in installing its desired candidate, Nuri al Maliki, as Prime Minister. Elements of Sadrist militias are a major component of the Iraqi security forces which the U.S. is "standing up," supposedly so we can "stand down" -- I guess that's after we get done exterminating them. These groups are mortal enemies of al Qaeda and its sympathizers, which consider them apostates and are engaged in killing Shiites in Iraq in large numbers, while the Shiite militias are trying to kill them. The Sadrists major grievance with the United States is that it is occupying their country and attacking and killing them.

This is why our young people are dying and getting their limbs blown off. For the sake of utter, pointless insanity. The really bad news is that even if the Democrats take one or more chambers of congress in November, the maniacs behind this murderous folly will still control the armed forces and will continue without any meaningful opposition -- unless it comes from an aroused citizenry.

Critical Condition still in business

Unfortunately, as I mentioned some time ago, Dr. Rick has been unable to continue with the Critical Condition project for personal reasons. Our best wishes to him and I hope we'll see him back soon.

Meanwhile, Critical Condition is still open for anyone involved in health care or the healing professions who has something to say. I have just put up a lengthy post by Dr. Alan Lewis, who wanted to respond to a statement by Dr. Ezekiel Emanuel that I quoted here some weeks ago. As I note in my introduction to his post, his approach to healing is somewhat dissident in the present environment, in which reformers are calling for restricting the autonomy of physicians through stricter standards of practice and so-called "evidence based medicine." We'll see if Dr.Mr. Lewis draws any responses.

Meanwhile, if anyone wishes to contribute to Critical Condition, just send me your submission by e-mail (see the sidebar) and if it isn't toxic, obscene, or fattening, I'll put it up for you. And no, I don't have to agree with it.

Evil?

I've done a little netsurfing to see what people are saying and wondering about Charles Roberts, the guy who murdered the Amish schoolgirls. As far as his family knows, it came out of nowhere. He was a kind, peaceful, law abiding man. How could such evil lurk in the shadows?

As far as I can tell, and much to my surprise, no-one in the media or law enforcement has mentioned the strong likelihood that he had an organic brain disorder. The fact is, people don't just suddenly change into psychopaths after a lifetime of empathy and sociability. The molestation he said, and evidently believed, he had committed at the age of 12 apparently never occurred. It appears he was delusional. I'm going to pull a Bill Frist here and diagnose frontotemporal dementia. Although the behavioral changes in this case appear to have had an unusually abrupt onset, it is possible that people did not recognize earlier, gradual changes as pathological since they can be subtle. He may also have had a brain tumor, or even some uncommon and unknown organic disease process.

In any case, it is believed that frontotemporal dementia is underdiagnosed. Many people who have it are no doubt in jail, their condition unrecognized. What is the moral status of such people?

I will ponder that until Sunday, when I will return here.

Smackdown!

I'm really sorry that this is subscription only, it's definitely the sort of thing that the greedheads at the AMA (which gets most of its revenue from advertising in the journal) should make available to the public. But a lot of it is fairly technical, and I suppose it wouldn't have quite the endorphin-releasing effect on the general public that it does on me . . .

Anyway, I'm talking about hero whistleblower FDA scientist David Graham, who is now far too firmly in the public eye for them to get rid of him, as desperately as they want to. In the new JAMA (link for reference purposes only, you can't read it without a password), the good doctor lays waste to drug companies, the FDA and the congress (yup, like I said, they actually have a real job to do) over COX-2 inhibitors. Merck and Vioxx get the BFH (which the carpenters among you know stands for a particular category of Big Hammer), but the rest of them get a pretty good wacking with a 2x4. I shall summarize.

Our story begins with aspirin, which in spite of its miraculous properties is in the public domain and therefore impossible to make obscene profits off of. What to do, what to do . . .Aha! Aspirin does have one side effect, not extremely common but potentially worrisome, which is that it can cause gastric bleeding. It turns out that its anti-inflammatory and analgesic effects result from inhibition of an enzyme called cyclooxyenase (COX)2, while the gastrointestinal complications result from inibition of COX-1. So if you can design a drug that inhibits COX-2 but not COX-1, maybe you can get the good effects without the bad. You can also patent it, get exclusive marketing rights, and make a killing. (ha ha)

Of course, you also have to convince people that it's worth spending the vastly greater amount of money for patented new drugs. That requires advertising. And there is one other teeny weeny little problem. COX-1 inhibition slows blood clotting and relaxes the blood vessels, which is why aspirin protects against heart attacks. COX-2 inhibition opposes these effects, which might increase the risk of heart attacks.

Best not to think about that. In fact, there were indications of cardiovascular risk in the very first application to the FDA for approval of VIOXX, in 1998. But the FDA requires "complete certainty" before worrying about safety concerns. Indeed, in 1999, shortly after VIOXX was approved, the now-famous VIGOR study found a 500% increase in (in lay terms) heart attacks in people taking VIOXX, compared with people taking the aspirin-like naproxen. The company just claimed that naproxen protected against heart attacks, and that VIOXX wasn't actually causing them. It kept right on advertising the drug to consumers. Not until 2004, when another trial showed an increased risk when compared with placebo, did Merck withdraw the drug. It turns out, as everyone should have known, that naproxen has no cardioprotective effect. Meanwhile, Pfizer's rival drug celcoxib was found to increase cardiac risk in 2000, but Pfizer didn't tell anyone until 2005.

Merck claimed in 2004 that its trial showed that the increased risk of heart attacks didn't begin until people had been taking Vioxx for at least 18 months, but that turned out to be either a very stupid mistake or a big fat lie, which they finally admitted in 2006. (I won't go into the technicalities.)

Here's Dr. Graham's bottom line:

What should physicians do? For most patients with arthritis or other conditions who require chronic pain relief, naproxen appears to be the safest NSAID choice from a cardiovascular perspective. For patients at high risk of NSAID-related gastrointestinal tract complications, naproxen plus a proton pump inhibitor is less costly and as effective, and probably safer, than low-dose celecoxib. . .If COX-2 inhibitors cost substantially more, confer substantially greater cardiovascular risk, and offer no unique and meaningful gastrointestinal tract benefit over generic naproxen plus proton pump inhibitor, is there any point to the continued use of these drugs? Another critical area for research relates to the use of low-dose aspirin in the setting of COX-2 selective and nonselective NSAID use. It is unclear whether aspirin mitigates or abolishes NSAID-related MI risk, and, if so, how it may affect gastrointestinal tract risk. The concomitant use of aspirin would appear to contradict the premise underlying selective COX-2 inhibitor use.

Another key issue is to account for the long delay in defining the risks and benefits of COX-2 inhibitors. Part of the problem lies with FDA policies, practices, and procedures that lead it to ignore potential safety problems. Despite a priori concerns and disconcerting evidence in the preapproval application, the FDA approved rofecoxib, stating it lacked “complete certainty” that the drug increased cardiovascular risk. Such a standard does not protect consumers, is prejudicially favorable to industry and its financial interests, rewards drug companies for not aggressively pursuing safety questions, and guarantees that some drugs with major safety problems will be approved and, once approved, will remain on the market, even in the face of extensive patient harm. The failure to immediately withdraw high-dose rofecoxib from the market following publication of the results of the VIGOR trial, and to study quickly and intensively its cardiovascular risks at lower doses, increased the number of patients harmed by the drug as well as the profits made from its continued marketing. Only Congress can help prevent this from happening again by enacting legislation to create a separate and independent Center for Post-Marketing Safety within the FDA, empowered with the authority to identify and effectively deal with unsafe medicines and the companies that market them.

But guess what kids? Merck is now coming back with an application for approval of yet another COX-2 inhibitor, while Pfizers celecoxib (Celebrex) continues to be sold. Merck's claims on behalf of its new drug, as Graham shows, are based on cynical manipulation, using a trial designed to get deceptive results. They have no shame. Will the FDA?

By the way, Congress actually has a function

You probably think that the main responsibilities of the United States Congress are to provide an internship opportunity for young people while protecting them from creeps; and to retroactively authorize the president to do whatever he is already doing, regardless of its legality. But those are actually a very minor part of their responsibilities. No doubt it will come as a surprise to even the most dedicated news junkie, but the Congress also passes statutes creating government programs, and appropriates money to operate them.

So I'll just change the subject for a teeny weeny moment and note that Congress adjourned without getting around to reauthorizing the Ryan White CARE Act, which provides essential services to people living with HIV. No doubt the lame duck Congress will pass the reauthorization after the rigged election in November. Right now, there is a proposal passed by the Republican House. (Democrats aren't allowed to participate in developing legislation.) It would authorize annual increases at about the rate of inflation, but since the HIV epidemic continues to spread beyond its original concentration in urban areas, that means there won't be enough money to go around. The Republican solution is to take money away from those Sodomite Democratic cities and give it to the honest Republican Christians of Kansas and Idaho.

According to the linked report from the Kaiser Family Foundation, "Some legislators from states with large urban areas -- including California, New Jersey and New York -- have opposed measures that would change CARE Act funding formulas, saying they could harm HIV/AIDS programs in areas with higher HIV prevalence." Indeed. But this is an issue of public policy, scarcely something that voters should be interested in.

Donning the ALCOA Sombrero

I'm sure most readers have become at least vaguely aware that the U.S. is in the midst of a major naval deployment to the Gulf that dare not speak its name. Time Magazine has mentioned it, and various bloggers have offered tidbits here and there. This article at Global Research has details, which include extending the deployment of the U.S.S. Enterprise carrier group, deployment of the U.S.S. Eisenhower carrier group (which the Global Research article calls a "battleship," perhaps because the author's first language is not English), along with submarines, a group called Expeditionary Strike Group 5, which appears to be configured for amphibious assault, and Coast Guard vessels. (The Coast Guard possesses ships that are extremely formidable in comparison with the assets of Third World navies, including 200 foot cruisers with artillery fore and aft and batteries of 50 caliber machine guns amidship.) Canada has also dispatched warships to the region. And no doubt you have read speculation about Cheney administration intentions to bomb Iraqn [I'm as bad as the Washington Post], possibly using nuclear weapons -- much of which is backed up by tidbits of evidence.

This article was the subject of a Kos diary that attracted numerous comments from knowledgeable readers, if you are interested in seeing a discussion about this. The author, I think, is glaringly ridiculous in proposing that the Lebanon peacekeeping operation is actually a fig leaf for deployment of NATO forces to the eastern Mediterranean in support of the coming war with Iran, although I suppose European leaders could see it as a reasonable precaution in case a conflict expanded unpredictably.

As I'm sure you also know, this massive naval deployment has received almost no attention in the corporate media. It's a secret from nobody except the American people. Of course, there's a story about sex right now, which even though it has nothing to do with public policy, is bound to be far more important. The Cheney administration has already declared its intention to attack Iran. Although the corporate media assure us that this is just a stick to back up negotiations, that's what they told us about the military threat against Iraq.

It has become, in the words of Malcolm X, "incandescently clear" that this gang will do absolutely anything to hold on to power. If there is any important public policy implication to the Foley scandal, that is it. Now there is a looming possibility that Democratic control of one or both houses of Congress could occur in January. While I have no illusions about the courage or integrity of the typical Democratic member, nor about the ability or willingness of the party to seriously challenge the one-party rule of plutocracy, a Democrat controlled chamber could make things very inconvenient for the current ruling clique and steer much of the vigorish away from its friends.

They will stop at nothing to prevent that. Nothing. Perhaps the Nightly News should feature some consideration of the possibilities.

What are you afraid of?

I need hardly point out that statistically, the odds of you or your children being murdered at random by a homicidal maniac are extremely remote, in spite of recent incidents that have dominated the news. In fact, present company excepted, the most likely killer of a child is a parent, as I have discussed before, with mother's boyfriend right up there. But when a parent or babysitting boyfriend or relative kills a child, it isn't ordinarily news.

Now, I can't blame CNN and the rest of the show biz gang for intensive focus on the recent incidents in schools. These are more interesting than run of the mill murders precisely because they are unusual, and of much more use to television producers because they happen in public spaces where they can get lots of footage. Without film, it isn't news either. And we certainly can't blame them for making huge stories out of terrorist attacks, even though, as with school shootings, we could have an attack of the magnitude of the Sept. 11, 2001 attack every month, and it would make a scarcely discernible bump in the death rate. Yet even a ridiculous rumor of a possible future terrorist attack gets far more media attention than all the ways people die that they don't have to.

This is probably unavoidable -- the news biz is show biz, and people just aren't going to deliver their eyeballs to advertisers in exchange for a daily recitation of the tawdry and tragic facts of everyday life. Domestic violence merits attention when the people involved are famous, because everything celebrities do is interesting. It also merits some attention when the people happen to be white and live in the suburbs or the country, because we are supposed to think there is something unusual about that, I suppose.

But the distinction between what is news, and what are the actual facts of life, means that people just don't have a realistic basis for thinking about the appropriate priorities of public policy. The real dangers -- the kinds of events that are most likely to kill or injure you or people you are about -- are scarcely in consciousness, while the remotest possibilities loom large. Right now, of course, the political leadership is deliberately manipulating these misperceptions, which doesn't help. But the fundamentals of the news business make that very easy.

Responsible journalism in the public service would require a concerted, ongoing effort to correct that imbalance by providing in-depth coverage of the facts of public health. But, as I just commented on the great blog of Jordan Barab, Dick Cheney should join the nearest Quaker meeting and George W. Bush should become a monk and take a vow of silence. Which is most likely?