Not to worry . . .

The media here and across the pond are having a massive feeding frenzy over the discover of traces of radiation at various places around London and on British Airways planes, in connection with the investigation into the death of former Russian spy Alexander Litvinenko.

Cancel the apocalypse. The Polonium 210 which apparently killed Litvinenko is an alpha emitter. Alpha particles are helium nuclei. They cannot penetrate a piece of tissue paper, let alone your skin. You could hold a pound of Polonium 210 in your hand and it would not hurt you. Well, actually, that's not quite true -- it would be too hot to hold without getting an ordinary thermal burn. But the radiation would be harmless. Swallowing it is, indeed, a bad idea, because the element accumulates in certain tissues and the radiation can penetrate cells and damage DNA, which is what supposedly happened to Litvinenko.

When the authorities went around to these various places looking for alpha emitters, they no doubt had equipment which could detect incredibly low levels. So they found some. These may or may not have had anything to do with polonium 210 or the Litvinenko case. Various alpha emitters occur naturally, and they are found ubiquitously in rocks and water. The most common is radon 222, which is in the air in many people's basements. Exposure does increase the risk of lung cancer, especially among smokers. Alpha emitters are used in smoke detectors, cancer treatment, and to remove static charges from the air. They are found in mining tailings, and enter the environment from there.

I'll bet if you went into every aircraft and every bar in the world and looked hard for alpha particles, you'd find some in about the same percentage as the British are finding now. My vote: this is a whole lotta nothin'.

Insanity masquerading as dissent

Today's NEJM has the results of a much anticipated study on HIV treatment. (Abstract only, but that's all you want anyway.) Because the antiretroviral drugs used to control HIV can have serious side effects, there has long been interest in the idea of "episodic treatment."

As I assume most readers know, the most important disease process caused by HIV infection is destruction of certain cells of the immune system, called helper T-cells, which display a receptor protein called CD4. The CD4 receptor is the route by which HIV enters the cell. Then it takes over the cells genetic machinery and causes the cell to devote itself to making copies of HIV. Eventually the cell dies. However, the body keeps making more CD4+ cells. Eventually, however, for reasons that are not entirely clear, the production of new CD4+ cells cannot keep up with their depletion by HIV, and the result is the immune deficiency syndrome known as AIDS.

Antiretroviral drugs interrupt the cellular processes by which HIV is replicated. Hence they can prevent the progression to AIDS. But they can also have serious side effects, and so many doctors and patients hoped that they could be used sparingly. Specifically, the idea was to initiate treatment only when the CD4+ count fell below a certain level, and then to stop it when the count rose above some threshold. This study used 250 cells per milliliter of blood as the threshold for initiation of therapy, and 350 as the threshold for suspending it. Unfortunately, it didn't work. The patients using the "drug conservation" strategy got sicker faster, and were more likely to die. We're back to the conventional wisdom: the best thing to do is to treat HIV disease continuously and scrupulously, trying not to miss any doses of the medications and not interrupting treatment. The side effects are unfortunate, but risking them is better than not suppressing HIV replication.

The reason for the headline on this post, and the reason I thought this rather specialized subject was worthy of a post here in the first place, is that this study is yet one more of the innumberable overwhelming and irrefutable proofs that yes, infection by Human Immunodeficiency Virus is the cause of AIDS, the virus causes AIDS by destroying CD4+ cells, and antiretroviral drugs control viral replication and thereby control the disease. In the present study, there was a close relationship between drug treatment and CD4+ levels, and between CD4+ levels and illness and death. End of story.

And yet for some not fully explicable reason, there continues to be a movement, of people who view themselves as somehow being progressive or liberating, who deny these incontrovertible facts. I am a long-time subscriber to Harper's Magazine, which I generally like very much, but in March of this year Harper's disgraced itself and did long term damage to its reputation by publishing an article by one Celia Farber dedicated to denying that HIV causes AIDS, and to the proposition that antiretroviral drugs are in fact the principal cause of the disease. The theory that HIV causes disease was attributed to a conspiracy among scientists lapping up research grants, and drug companies peddling poison. The editors have refused to isue any retraction or to apologize for their astonishing lapse in judgment.

The community of AIDS deniers has done its greatest damage by somehow capturing the heart and mind of the president of South Africa, Thabo Mbeki, who for many years resisted implementing widespread treatment for HIV in that disastrously afflicted country. Now, it's too bad that HIV causes AIDS and that the only available treatments are expensive drugs with serious side effects that don't cure the disease and so need to be taken for the rest of one's natural life. That does indeed mean big profits for drug companies, the need for ongoing expensive research, tough luck for people with HIV, and even tougher luck for people with HIV in poor countries. I very much wish it weren't true. But there you are.

People who want to know the truth about Farber's tissue of lies can read the refutation from leading HIV specialists here. (It is likely, by the way, that first author Robert Gallo took undeserved credit for discovery of HIV, which properly belongs to the French investigator Luc Montagnier. That is not logically related to the question of whether HIV causes AIDS.) If you want all the straight dope, it's here, at the web site of AIDS Truth.

People often try to position themselves as courageous crusaders and progressive revolutionaries by denying what the "establishment" of experts contends to be the truth. (Viz. the despicable Robert Kennedy Jr. and his dishonest, defamatory and deeply dangerous campaign to promote the utter falsehood that vaccination is the cause of autism.) But the progressive revolutionary position in this case consists of advocating for justice for all people infected by or at risk for HIV, including universal access to antiretroviral treatment. That's reality based radicalism.

Blog pimping: Dr. Rick is once again blogging away on Critical Condition. And I have a new post up on the Dialogue. Do check them out if you are interested. (And I can't really have a dialogue without you.)

Juxtaposition

I read this AP story this morning with considerable interest, including this bit:

President Bush called the Afghanistan mission -- which has mobilized 32,800 troops-- NATO's number one operation. Defeating Taliban forces, he said, 'will require the full commitment of our alliance. The commanders on the ground must have the resources and flexibility they need to do their jobs,' Bush said, crediting the alliance for helping Afghanistan go from "a totalitarian nightmare" to stability and steadily growing prosperity.

Then I turned the page, and read this story, which explains the source of Afghanistan's growing prosperity:

By Jason Straziuso, Associated Press | November 29, 2006

KABUL , Afghanistan -- Afghanistan's criminal underworld has compromised key government officials who protect drug traffickers, allowing a flourishing opium trade that will not be stamped out for a generation, a UN report released yesterday said.

The fight against opium production has so far achieved only limited success, mostly because of corruption, the joint report from the World Bank and the United Nations Office on Drugs and Crime said. The findings show a "probability of high-level [government] involvement" in drugs, said Doris Buddenberg, the UNODC's Afghanistan representative and co editor of the report.

The report in particular presented a strong indictment of the Interior Ministry, which runs the country's police, and said Afghanistan's criminal underworld could not operate without the support of the political "upperworld." "The majority of police chiefs are involved," one senior police officer told the report's authors on condition of anonymity. "If you are not, you will be threatened to be killed and replaced."

Without naming officials, the report said it was possible that powerful interests in the Interior Ministry are appointing district police chiefs "to both protect and promote criminal interests." The result is a "complex pyramid of protection and patronage, effectively providing state protection to criminal trafficking activities."

The spokesman for the counter-narcotics ministry said there is no evidence that high-ranking officials are involved in Afghanistan's drug trade. "If there is evidence we welcome the evidence and the arrest will be on the spot," Zalmai Afzali said.

Poppy cultivation and the heroin it produces have become major problems in Afghanistan, providing funds for the Taliban insurgency that has caused the deaths of more than 3,700 people this year.

Opium production in Afghanistan rose 49 percent this year to 6,100 metric tons. The harvest provided more than 90 percent of the world's opium supply and was worth more than $3.1 billion.

Unfortunately, statistics on indicators of heroin addiction and adverse consequences (such as emergency department visits, crime, and mortality) are published at least two years in arrears, and most of the reliable data we have are from no later than 2002 or 2003. So I can't tell you how the fall of the Taliban and the restoration of the Afghan opium crop has affected us -- or at least I can't give you numbers. But my agency has heroin addicts coming in the door every day. Our state's Bureau of Substance Abuse Services has invited us to develop a new residential treatment center because existing services can't meet the demand. Heroin is back, and everybody knows it.

Now, I believe we need a very different approach to this problem, both here and in Afghanistan. I don't believe that pouring more NATO troops into the country is going to stop opium growing, or defeat the Taliban, for that matter. Afghanistan needs the massive economic development projects it was promised, which the U.S. and the international community never delivered. The reason the farmers grow opium is because that's the only way they can make a living and feed their families.

I also don't believe that our practice of jamming more and more drug addicts into our overcrowded jails is anything but utterly insane. For the $36,000 a year or more we pay to incarcerate somebody, we could give two or three people intensive treatment and social supports -- i.e., training and jobs, supportive housing, peer mentoring -- that are proved to reduce relapse and recidivism. For the money we spend on military operations in Afghanistan we could build roads, provide better agricultural technology, develop businesses to process agricultural products and capture more value within Afghanistan and create jobs. That would combat opium growing and the Taliban at the same time. But we can't do those things -- those are liberal ideas, and that just isn't manly, or Christian.

Spinning our wheels

The latest information on health insurance coverage for the U.S. population has recently been released by the CDC. (PDF, but not large.) These estimates are based on the National Health Interview Survey, an ongoing series which yields nationally representative data. (The methodology is similar to that used for the Johns Hopkins study of civilian casualties in Iraq, so according to the U.S. government, obviously you shouldn't believe it.)

Anyhow, the results are about what I would have expected. In order to make sense of it, though, you have to break the results out by age group. Remember, first of all, that nearly everyone 65 and older has insurance thanks to Medicare. It isn't comprehensive insurance, but it is far better than nothing. So changes over time in the percentage of the population who are insured are partly affected by the increasing proportion who are over 65. That's going to automatically tend to drive the percentage who are uninsured down.

First, the snapshot. In January-March of this year, the estimate is that 14.5% of the total population was uninsured at the time of the interview. (That's 42.4 million people.) 18.2% had been uninsured for at least part of the previous year, and 10.1% had been uninsured for all of a year or more. Those numbers have fluctuated only slightly over the past decade. They were actually a tiny bit higher in 1997, then they came down a bit and hit a low point in 2005 -- 14.2% uninsured at the time of the interview, and 17.6% uninsured for part of the past year. Now they appear to have bumped up, but one quarter does not a trend make.

However, this apparent stability masks a lot of change. One of the most important trends is that the percentage of children under 18 who lacked insurance fell steadily from 1997 through 1995, due to the Supplemental Childrens Health Insurance Program (SCHIP), an enhancement to the Medicaid program that enabled families who were "near poor" or medically indigent (i.e., having large medical bills) to buy into the Medicaid program for their children at subsidized rates. In fact, the percentage of near poor children with public insurance coverage increased dramatically, from about 24.3% to more than 52.7%, from 1997 to the present; while the percentage with private insurance fell, from about 55% to 33.9%. Unfortunately, in the first quarter of this year, the expansion of the SCHIP population no longer kept up with the loss of private insurance, the the percentage of near poor children who were uninsured bumped up for the first time in 10 years.

The working age population (age 18-64) has also been losing private coverage since 2001, when 73.7% had it. In the first quarter of 2006, 69.8% had private insurance at the time of the interview. The percentage with public insurance has gone up a bit in that period, from 9.4% to 12.2%, but as you can see, that's not enough to make up the difference.

So, over the past decade, the expansion of SCHIP has enabledthe proportion of near poor children without insurance to decrease slightly in spite of rapid loss of private benefits; while the proportion of working age people without insurance has increased, in spite of more people obtaining public benefits. The overall proportion of the population which is uninsured has fluctuated without much of a trend, thanks to SCHIP and the growing numbers of people turning 65, in spite of the erosion of private benefits. It's too early say, but 2006 may be a turning point, where the uninsured population begins to expand significantly. Most informed observers believe it is indeed happening, as employers continue to eliminate health insurance benefits or require greater contributions from workers and states cut back on Medicaid eligibility.

The bottom line? We've been going nowhere, and now we're starting to slip backwards. Of course, we have more important priorities, like establishing a Shiite theocracy in Iraq at the cost of hundreds of thousands of lives. That noble cause is worth far more than insuring that our own people have health care -- even though we could do it for a small fraction of the cost.

Clearing the in-box: News you can Use

Sorry for the absence, but I warned you. Life is not always compatible with blogging, after all there was no blogging as our ancestors evolved on the African savannah. Anyhow, here are a few items I want to clear away before getting back to the regular rhythm.

1. The new edition of Health United States is out. I haven't had a chance to read it yet -- it's only 559 pages but I guess I'm a little bit lazy. Anyway do check it out if you're interested in how we're all doing. We'll be referring to it often in the months ahead I'm sure. The bottom line, in any event, is no surprise. From the Executive Summary:

In 2003, American men could expect to live 3 years longer, and women more than 1 year longer, than they did in 1990 (Table 27 and Figure 24). Mortality from heart disease, stroke, and cancer continued to decline in recent years (Table 29 and Figure 27). With longer life expectancy, however, comes increasing prevalence of chronic diseases and conditions that are associated with aging.

2. CDC has released the new recommended adult immunization schedule. There are a few important changes. The new Human Papilloma Virus vaccine is recommended for young women; adults should get a tetanus, diphtheria, pertusis booster; you should get a varicella (chickenpox) shot if you aren't immune; some adults should get a mumps booster; etc. I say vaccination is a good thing, and you should check with your doctor to make sure you're up to date on everything.

3. Jerry Avorn, in NEJM, in an article free to the common rabble, kicks the drug industry around the block. Bayer hid evidence, for a long time, that the drug aprotinin, given to prevent post-operative bleeding, caused kidney failure, heart attacks, and strokes. He recites other well-known atrocities: Merck hiding evidence of the dangerousness of Vioxx; and companies making public only the most favorable trials of Selective Serotonin Reuptake Inhibitors (which are still among the most widely prescribed drugs despite being utterly worthless in most cases, IMHO). He drives in the nail with a single blow here:

Many aspects of the aprotinin saga are familiar to observers of the drug-evaluation process: a product is approved because it is more effective than placebo, worries emerge about its safety, few or no adequately powered controlled trials are conducted to address these issues, and payers spend huge sums on the drug, despite the dearth of evidence that it is better than older, cheaper agents. The health care system has a hard time performing drug-safety analyses, in large part because it relies on the pharmaceutical industry to conduct most research on the risks and benefits of medications. It is naive to expect companies to voluntarily fund studies that could sink lucrative products, the FDA lacks the regulatory clout to require them, and despite the $220 billion we spend on drugs each year, we apparently can't find the resources to provide public support for these studies, even if the results could be of great clinical importance and save millions of dollars. Although a large randomized trial would have provided a valid means of comparing aprotinin with other treatments, no such study has been undertaken on the necessary scale.

4. No doubt you have heard or read about the new research on surgery for herniated disk reported in JAMA. The editors have given the public access to the main research report, but not the accompanying editorial by David Flum, which is actually more important. The news reports I have seen aren't much help to the public in interpreting all this.

As you know, lower back pain and sciatica are very common problems, which can be extremely painful and disabling. A hypothesis about the cause, or at least one cause, is that the symptoms result from a rupture and bulge of one of the cushioning disks between the vertebrae, which then impinges on a nerve. I say this is only a hypothesis because X-rays often show such a bulging disk in people with no symptoms, and people can also have similar symptoms without the lesion. Anyhow, spinal surgeons like to operate to remove the bulge, and many people report improvement afterwards.

The new study attempted to randomize people to surgery, or non-surgical treatment such as physical therapy and just waiting. The randomized trial didn't really work out, however, because many people assigned to surgery didn't get it, and vice versa. This creates difficulties for interpretation, because people who chose to get surgery or not to get it might be different to begin with. In a sunflower seed shell, the bottom lines are:

1. People who got surgery and who did not get surgery both tended to get better over time;
   
2. "Intention to treat analysis" didn't show any meaningful difference between people originally assigned to surgery and non-surgical treatment;
   
3. People who actually got surgery reported more improvement in subjective symptoms early on. The differences narrowed over time but persisted. However, there was no difference between people who did and did not get surgery in the percentage who were working after two years.

This could mean that surgery works better, but it is also possible that since people who had more subjective distress were more likely to choose surgery, people who initially have more distress tend to improve more. Dr. Flum emphasizes a problem that many readers may find surprising: there is often a powerful placebo effect from surgery. For example, it used to be common to tie off the internal mammary artery of patients with heart disease, but a study in 1959 found that when patients were anaesthetized and had their chests cut, but with no ligation of the artery, they improved even more! In another study, sham knee surgery for people with osteo-arthritis worked as well as real surgery. Injecting embryonic nerve cells into the brains of people with Parkison's disease worked as well as injecting nothing. And so on and so forth.

Now you might say, so what if it's the placebo effect? It works. Maybe so but if we could just get people to believe as much in physical therapy and just waiting as they believe in surgery, those options might also work just as well. Right now, we really don't know. So in discussing their options with their doctors, people with sciatica might propose delaying surgery if they can stand it, to see if they can get better without it. They probably will. In fact, consider this, from a short item by Tracy Hampton in the same issue:

When a builder recently arrived at an emergency department, writhing in pain with a 12-inch nail lodged in his foot, nurses carefully removed his boot to find that the nail was harmlessly inserted between two toes. Seeing this, the man's pain suddenly vanished.

(I apologize on behalf of Dr. Hampton for the dangling participle.)

No thanks

As most readers know, I compile the Today in Iraq post on Sundays, and of course I follow developments in Iraq closely throughout the week. This painful avocation often creates a psychological block to my posting here.

How can I get my dander up about how we in this fabulously wealthy, peaceful and safe country don't always do what's right by some of our people, when I continually have the unspeakable suffering of the Iraqi people before me? How can I snicker at the conservative definition of compassion in my shining city on a hill, where learning and healing are the leading industries, when professors and doctors are murdered in Iraq every day, along with hundreds of ordinary people; most parents are too afraid to allow their children to attend school; and the hospitals have no electricity, no antibiotics, and not even clean water?

I don't need to give you links to information here -- visit Today in Iraq if you can stand it. This is what our country has brought about. The motive is not a mystery, the perpetrators proudly proclaimed their intention to invade Iraq, and the reasons why, before George W. Bush even declared his candidacy for president. The reason was to establish large, permanent military bases in Iraq, from which the U.S. could militarily dominate the oil resources of the Middle East. This is not a secret, or a conspiracy theory. It's a matter of public record.

The politicians and pundits who supported the war initially all knew it. The reporters who transcribed Colin Powell's speech to the UN Security Council all knew perfectly well that it was a tissue of lies. If they didn't know right away, all they had to do was read British newspapers, which exposed the entire edifice of fabrication within two days. Hell, I knew it, and I'm just a sociologist, not a professional journalist. John Kerry knew that Saddam Hussein was not building a fleet of unmanned aircraft in order to spray anthrax on east coast cities. Tom Friedman knew that Saddam Hussein had nothing to do with al Qaeda. Christopher Hitchens knew that the Bush administration had no intention of bringing "democracy" to Iraq -- particularly since they proclaimed that a "democratic" Iraq would be an ally of Israel, an enemy of Iran, and would allow American companies to pump its oil. That's a unique definition of democracy. They all knew.

And guess what? The war has gone splendidly. The permanent military bases have been built. They are using them today to bomb Afghanistan. The $591 million palace of the U.S. proconsul, safe behind 20 foot blast walls and rings of armored artillery, is nearly completed. The disintegration of Iraqi society around it all is irrelevant. Who cares? They got what they wanted. And no, we are not leaving. Not in six months, not in twelve months, not in twelve years. Most certainly not if Hillary Clinton is president. (See what better writers than I have to say at Tom Engelhardt's site.)

The cost to all of us is not comparable to the cost to Iraqis, but it's pretty steep. It has sent the American empire on a final path to decline and ruin. Maybe that's what the world needed, though.

Anyhow, sorry about that, but I had to say it. Stayin' Alive will be dark until Sunday -- my family is very primitive, no Internet where I'm going. I do hope to get the next post up on the Dialogue -- a few more verses of Genesis -- and possibly one more here, before I go. And I'll be back on topic. There's a lot of health care and public health news this week, and I will cover it. Thanks for waiting.

Never elect a governor named after a piece of sporting equipment

For reasons too strange and wondrous to explain in the available space,* the People's Republic of Massachusetts has had Republican governors for the past 12 years. That's about to change, big time. Meanwhile, the last of the dying breed, Mitt Romney, is running for president on a platform of moral values, courting the support of right-wing Christians. He may be in for disappointment -- a recent gallup poll finds that 37% of Americans would not vote for a Mormon for president, and the number is much higher among the evangelical Christians he has been assiduously cultivating. (Atheists fare even worse, but I'm not running.)

Regardless of how that works out for him, Mitt's moral values consist of militant opposition to same-sex marriage -- he led a rally at the Statehouse against it this past weekend -- and wanting to outlaw abortion. He was for abortion rights before he was against them, since he never could have been elected governor of Massachusetts otherwise, but he changed his deeply held faith-based principles just in time to run for president.

Anyhow, another one of his deeply held faith-based principles is that people should not pay taxes and that Massachusetts should have a smaller state budget. His assiduous reading of the Bible and the Book of Mormon, and long conversations with God, convinced him that God wanted the toll booths removed from the Massachusetts Turnpike, but only west of Worcester. (Something to do with where the godly vs. ungodly people are to be found in our state.) The $9 billion in funds desperately needed highway and bridge maintenance will no doubt fall in the form of manna from heaven, since God forbids us to raise the money from taxes.

God also told him to cut the funding of the state Department of Mental Health, because God wants seriously mentally ill people to be wandering the streets conversing with the Emperor of Jupiter, rather than immorally requiring fabulously wealthy venture capitalists such as Mitt to pay 5.25% of their income instead of 5% to take care of them. As the Globe reports,

State psychiatric hospitals will stop admitting new patients tomorrow , and 170 Department of Mental Health staff positions will be eliminated in response to Governor Mitt Romney's emergency budget cuts announced earlier this month, according to private hospital groups briefed by state officials.

In addition to the freeze on hospital admissions, the cuts would do away with 37 percent of the staffers who provide care to hundreds of emotionally disturbed children and teens in their communities; cut dozens of inpatient jobs for nurses, aides, and psychiatrists; and reduce funding for medical school research, according to an overview circulated by the Massachusetts Hospital Association.

The mental health agency began sending out notifications on Friday that its hospitals, which have about 850 adult inpatient beds, would stop accepting psychiatric patients who would normally have transferred to them for longer-term care.

Well, I'm glad we're putting a stop to all the ungodly caretaking for sickos and wackos. And Mitt isn't stopping there. If they aren't getting psychiatric care, they most certainly should not have any place to live. After all, Jesus said, whatever you do, don't house the homeless, you'll just encourage them. Specifically, if you don't feel like clicking the link:

Three of the largest public housing authorities in Massachusetts filed a lawsuit yesterday accusing the Romney administration of shortchanging the state's nearly 250 local authorities by millions of dollars, causing housing conditions to deteriorate and forcing the closing of hundreds of substandard apartments. The housing authorities in Boston, Cambridge, and Brookline contend that Governor Mitt Romney violated state law by freezing subsidies for operating and maintenance costs starting in 2003. The move has resulted in a "near crisis" for authorities that run nearly 50,000 apartments statewide for poor, elderly, and disabled residents, the suit said.

"If something isn't done now to fully fund or properly fund these housing units, then the next time the budget process comes around, it's going to be fiscal year '09, and by then the number of units that will have deteriorated and have to be taken off the market is enormous," Steve Young, a lawyer for the three authorities, said in an interview.

As you know, without God, there is no basis for ethics or morality. That is why I am unable to perceive that Mitt is morally superior to me, and you certainly can't trust me to provide moral guidance. I trust that everyone who believes in a moral, Godly government will overlook his membership in a heretical cult and give him their support.

*In a nutshell, the former Dear Leader and Dictator for Life of Massachusetts, House Speaker Tom Finneran, didn't want a Democrat in the Governor's office because that would have diluted his personal authority. So the Democratic party didn't support its own nominees. Weird, huh?

Catching up

Thanks for the comments on the previous post.

Yes Roger, we indeed are planning to try to understand relationships between patterns of physician-patient communication and medical outcomes -- decision making, adherence, satisfaction, and ultimately, better health. As a matter of fact the project started in the context of an intervention trial to try to improve antiretroviral adherence. We have a long way to go, but I have a lot of ideas about possible applications. Stay tuned.

Tanta makes a very good point about a subject that I thought about quite a lot a few years ago. This gets wonkish in a different area -- econometrics -- but it is actually a fairly profound question. Most people probably never really think about how the inflation rate is calculated, but the Consumer Price Index (CPI), the most commonly used measure, is actually based on a bunch of Commerce Department employees going shopping every month, and seeing what it would take to buy a so-called "basket" of typical goods. Really.

A complication, as Tanta notes, is that year after year, the mix of goods that people buy changes, and even goods with the same name -- such as cars and computers -- aren't really comparable. Broccoli and tomatoes don't really change over time -- or rather, if anything, they have gotten somewhat worse due to industrial farming practices -- but computers and cars supposedly get better. Computers also have tended to actually get cheaper, or at least stay at roughly the same price for a much more powerful machine, although cars certainly have increased in price. However, your new Lexus is presumably also worth a lot more than a new Model A was in 1936.

So, the Commerce Department attempts to correct for these developments by changing the market basket every few years to match what people actually buy; and by correcting for the supposed quality improvements associated with technological change. Some people even argue that they don't go far enough, and that inflation is overstated.

Actually, I would say that it is understated. What was once a luxury, or even science fiction, is now a necessity. The automobile has profoundly shaped development patterns. Most people live in suburbs where they have no choice but to drive to work, school and the grocery store. If somebody were to start manufacturing new Model As, it would be illegal to drive them. Cars are required to have all those modern safety features. It is nearly impossible to live without a telephone. It is illegal to build or rent out a house or apartment without indoor plumbing, electricity, a refrigerator, central heating. So all of these great things technology has given us may be better than an outhouse, oil lamps, ice boxes and a coal stove - but those are no longer an option. The bottom line is, it costs more to live nowadays than it used to. Whether that makes us better off depends on what you value, I suppose.

Finally, a commenter remarks that evolution is "bad." I'm not sure what to make of that idea -- evolution is why we are here, after all, so it can't be all bad. But funny you should bring that up.

I'm starting a new project, using the Dialogue Concerning the Two Chief World Systems blog, which has been dormant for a while. I'm reading the Bible -- yup, the whole thing, starting at the beginning. I've already done the first five verses. I'm using the King James, because I was raised in the Epispickle Church, so that's what I'm most familiar with. I will post erratically, whenever I have the time and inspiration, probably most often on Sundays. The amount of material I cover with each post will vary -- when we get to the begats, I may take a whole lot in one chunk. It may take me the rest of my life. But I intend to keep going.

Most Bible thumpers, in my experience, are highly selective. Most of what they thump they totally ignore, if they have ever read it at all. Of course, a lot of it would be quite embarassing to acknowledge. But I'm not going to be selective -- I'm going to do it all, every last word.

Others with posting privileges are free to continue to post on the Dialogue blog, and we'll even take applications from newcomers. I don't care whether anybody reads it, but if you do, I hope you'll enjoy it.

Soporific wonkery

As part of my continuing series discussing what I actually do in the real world, I will now confess that about half of what we call my "percent effort" in the eerie netherworld of sponsored research is devoted to a system I developed, with major input from colleagues, to code and analyze the interactions between physicians and patients. Other such systems already exist, the most popular being the Roter Interactional Analysis System. Why do we need a new one?

Well, obviously, any method of categorizing and measuring any components of reality, be they subatomic particles, species of beetles, planets, stars, personalities, national economies, or hate-radio hosts, can answer some questions and not others. The Roter system is concerned principally with the affective and interpersonal properties of interaction, as are most other systems. But my colleague was conducting a trial of an intervention to improve physicians' awareness of the medication-taking behaviors of their patients with HIV, and hence, it was hoped, their discussions of medication adherence with their patients and ultimately the control of their patients' HIV disease. He needed a method that could also provide detailed, specific information about the content of the interaction, that is, what the people were talking about, not just how they were talking about whatever it was.

I also had some ideas about how to make interaction analysis more rigorous and interpretable. Systems such as the RIAA were really developed pragmatically, and don't have a clear underlying theory. They allow only one code to be assigned to each unit of analysis -- and the units themselves aren't defined as clearly as I would like -- and end up mixing together concepts that pertain to what is being discussed (topic), with concepts that pertain, in a loosely defined way, to the process of the interaction.

So, we went back to the beginning and started with a theoretical basis in Speech Act Theory -- a set of ideas developed, in their modern form, by the philosopher John Searle. We can observe that human conversation consists of the exchange of specific kinds of social resources, no matter what we are talking about. For example, I can give you information, express my feelings, ask you to do something, command you to do something, make a promise, ask a question (which is a specific kind of request), praise you, insult you, etc. So we have a unit of analysis -- a completed speech act -- and a way of labeling each of these units. Then, we can go back and code them according to the topic. This is a question by the doctor about symptoms. This is a request from the patient for an analgesic. This is a promise by the patient to quit smoking. And so forth. It's a bit more complicated than that, but you get the idea. Some speech acts are directly about the interaction process -- introducing or closing topics, for example. Some are specifically about interpersonal affect such as empathy and reassurance, but these are actually quite rare.

The taxonomy of speech acts is always the same -- across cultures and languages, I am convinced -- but the list of topics that you use, and how you organize them, depends on what you are interested in. However, for medical visits, it was possible to develop a short list of broad categories, which investigators can then unpack into greater detail as they choose, depending on the current research question. We have also developed software to make it easier to implement the system.

The results will be quantitative data -- numbers of speech acts of various kinds by each participant, cross-tabulated with topics. While I am hopeful that we can learn a good deal about how the content of medical visits is related to certain patient outcomes, I'm still very much aware that all such attempts at quantification squeeze the juice out of life, that ultimately each interaction is a story, a complex, self-contained event that cannot be understood without taking it in as a whole. In order to make sense of human interaction, we need to be able to work between levels, to view interactions through the lenses of both holism and reductionism. Ultimately, interpersonal effectiveness in the healing professions will probably elude complete, rigorous description. But at least we hope to come up with some helpful hints.

Getting hip to HIPAA

One of the reasons they keep me around at my place of employment, in addition to the baba ganouj I make for festive occasions, is that I do the agency's annual training on client confidentiality and HIPAA. It occurs to me that most people really don't understand that HIPAA gives them significant rights, and that a lot of providers still don't really understand the spirit of it.

As readers probably know, HIPAA is the Health Insurance Portability and Accountability Act, which was enacted during the Clinton administration, but took effect in stages. What does an act with that name have to do with patient confidentiality? The original purpose was to make it easier for people to keep their insurance when they change jobs; and to simplify billing for health care services by establishing consistent standards for the relevant information systems. But Congress recognized that in the brave new cyberworld, there are substantial threats to our privacy that did not exist before. Electronic records can be duplicated, searched, sorted, and transmitted around the world instantaneously. They can be hacked and cracked, misused and abused, in ways that paper records cannot. And what the heck, people were concerned about the privacy of their medical information anyway. So they added protections for patients.

For much of the time leading up to implementation of the privacy and security rules, in 2003, health care providers were in a panic. It was going to cost them quadrillions of dollars to comply, it would be impossible to meet all of the requirements, patients would be harmed, yadda yadda. None of that happened, although a certain amount of overzealousness in the early years of the HIPAA regime did create some fairly ludicrous situations. But as it turns out, you can indeed call the person by name in the waiting room. (Unless they ask you not to - which is a reasonable request to grant.)

In fact, I think HIPAA has worked out just fine. Sure, your insurance company sends you that Notice of Information Practices in 6 point type, and don't bother to include the microscope you need to read it. That's a waste of paper. But there are now clear explanations of what health care providers must do to protect your privacy, expressed as a general framework, with the specific measures they have to take based on a standard of reasonableness. If you care to, you can find out exactly what the procedures are that your own providers use, and you can request that they be even more strict in your own case if you like. Here are some of the important rights that you have. And don't take no for an answer.

1) You own your medical records. They are yours. You can see them. You can have copies. If you want to see your medical records (including mental health and substance abuse treatment), your provider will give you a form to fill out requesting them. They have 30 days to give them to you, but it shouldn't take that long.

Your provider can withold part of your record from you for only two reasons: a licensed health care professional thinks that seeing some piece of information will put you in physical jeopardy (probably meaning make you kill yourself); or a third party's confidentiality (not a provider) would be violated. They have to tell you that they are witholding something, and why. Otherwise, it's yours.

2) If you think something in there is incorrect, you can ask to have it corrected. If they disagree, they have to include your rebuttal in the record.

3) You can request additional privacy protections and restrictions on the use of your private information, beyond what is required by law or normal institutional policies. They don't necessarily have to agree to these, but you are also free to take your business elsewhere if they don't.

4) You can ask them if there have been any unauthorized disclosure of your private information, and they have to tell you.

5) They have to insure the accuracy, integrity, accessibility, and security of your private information. They can only disclose it as necessary for providing you with treatment, for billing for their services, and for managing their operations (e.g., staff supervision and quality assurance), and that means disclosing the minimum necessary information to the minimum necessary people in order to get these things done. There are specific requirements about how they have to protect your private information. If they aren't doing it, you can complain, and get satisfaction. Here's how.

So don't say Congress never did anything for you -- at least not back in 1996.

More on the reification of constructs

I'm on the list to take on-line surveys by Polling Point, and I often do it, more out of curiosity to see what they're up to than a desire to contribute to the advance of social science. Yesterday I took their "post-election" survey.

First they asked an open-ended question: What's the single most important issue facing the country? Actually I couldn't give them a straight answer, because I believe we have some inextricably entwined major problems: looming environmental catastrophe, the unsustainable budget and trade deficits and vast unfunded liabilities of the federal government, the catastrophe in Iraq (which along with the insanely bloated military budget in general just makes the previous item all the more intractable, among other grievous harms), and the erosion of the constitutional regime and rule of law without which we cannot mobilize to solve this Chinese puzzle of crises.

Another task they put before me was to indicate, on a continuum, where I came down on the tradeoff between protecting the environment, and protecting jobs and our standard of living. I had to skip this question, because like all sane people who know their ass from a strip mine, I know that there is no such tradeoff. Protecting the environment is one of the highest priorities if we want to have any chance of preserving jobs and our standard of living.

They also asked me to make a similar choice between raising the income tax and raising sales taxes in order to close my state's budget deficit. Again, I could not answer, this time because, while I prefer a progressive income tax to most sales taxes, I do believe that there is an urgent need to increase the gasoline tax in Massachusetts -- as responsible, non-partisan analysts have proposed -- because we have an urgent need to maintain and improve our transportation infrastructure and face a huge shortfall in needed funds. At the same time, a gasoline tax is one of the best ways to reduce fuel consumption and begin to make progress toward limiting climate change. Part of the revenue could be used to provide a refundable tax credit for low-income taxpayers, offsetting the cost to them, while improvements in mass transit will greatly benefit poor and low income people. Well, there was no way for me to explain all that by clicking at a point on their scale.

I could go on at some length, but the general point should be clear. Polling data on issues is often misleading because the pollsters frame the issues according to the world views imposed by sound bite politics. Are moral values among the most important reasons why I choose candidates? You bet! Moral values like not starting wars of aggression, and not letting greedheads market toxic pseudo-food to children. But I know that if I answer "yes" to the question, they'll presume that I mean that homosexuals shouldn't be allowed to teach in public schools. And so on.

I'm not sure what to do about this. The polls merely reflect actually existing political discourse. If I were writing the questionnaire, I might do it differently, but I expect the professional bloviators and political consultants wouldn't find my results very useful, since they wouldn't fit into their prefabricated categories.

At least Polling Point does give you the chance to tell them what you thought of the survey. Assuming anybody actually reads that part, they might do better next time.

What the hell . . .

I am a little bit shy.

Equity and equality . . .

Not necessarily the same thing, depending on what you mean by them. I'm posting late today because I was at a forum sponsored by our state's Attorney General's office, intended for hospital managers. (I crashed it, sorta kinda, because the policy issues are up my alley.) In most states, hospitals' legitimate claim to not-for-profit status is not taken for granted. They compete, obviously, with for-profit hospitals, and they have to justify their tax exemption by establishing that they do good stuff that a for-profit hospital wouldn't necessarily do. Attorneys General monitor non-profits and issue guidelines for non-profit hospitals' so-called "community benefits," which is how they demonstrate their goodness and untaxableness.

Whoa, this was supposed to be a short story, and it's already got an expository first act. Anyhow, another thing that's going on right now in the People's Republic of Massachusetts is that we have a new requirement that hospitals report data by race and ethnicity, and that they do so according to a new standard that includes, in addition to the Five Official Races and the One Official Ethnicity, a full menu of ethnicities, from Brazilian to Bosnian. Good. The seminar was on how to use this wonderful data to fulfill the community benefits requirement -- which pretty much came down to identifying and working to eliminate racial and ethnic disparities in health care. Which they are going to want to do because our new health care reform legislation, starting in 2008, is going to tie their reimbursement rates to as-yet-to-be-defined progress in reducing disparities.

I'll talk more about the whole community benefits thing, and the problems of measuring disparities in health care, and all that, another time. Today I just want to pick up on a snippet of today's conversation. One presenter mentioned that when she goes to talk to groups of doctors about health care disparities, they'll say, "Other providers may have a problem, but I treat everybody the same."

Here's my answer to that, which I also hear all the time.

That's your problem. You treat everybody the same (or at least you think you do), but everybody is not the same. In fact, everybody is different. Differences in language, culture, level of formal education, life experience and circumstances, all directly effect communication, decision making, adherence to your advice, understanding what you say, you understanding what they say, making the correct diagnosis, offering the right treatment -- and they require that you treat people, not the same, but rather equally appropriately, according to their specific needs and resources. If you treat everybody the same, as a health care provider, you are discriminating, in favor of people who are most like you, with whom you communicate with the least difficulty. Think about it.

Special post for some of our doubting friends.

Here is the ranking of countries by life expectancy at birth, from the new United Nations Development Program Human Development Report. You won't actually find the countries listed in this order anywhere in the report, they're alphabetical or ordered by the net score on a complex "Human Development Index." But thanks to the powers of Excel, it's easy to generate this most interesting view of the world, from this table.

"The number of years a newborn infant would live if prevailing patterns of age-specific mortality rates at the time of birth were to stay the same throughout the child’s life."

>1 Japan 82.2
>2 Hong Kong 81.8
>3 Iceland 80.9
>4 Switzerland 80.7
>5 Australia 80.5
>6 Sweden 80.3
>7 Canada 80.2
>8 Italy 80.2
>9 Israel 80
>10 Spain 79.7
>11 Norway 79.6
>12 France 79.6
>13 New Zealand 79.3
>14 Austria 79.2
>15 Belgium 79.1
>16 Germany 78.9
>17 Singapore 78.9
>18 Finland 78.7
>19 Cyprus 78.7
>20 Luxembourg 78.6
>21 Malta 78.6
>22 Netherlands 78.5
>23 United Kingdom 78.5
>24 Greece 78.3
>25 Costa Rica 78.3
>26 United Arab Emirates 78.3
>27 Chile 78.1
>28 Ireland 77.9
>29 Cuba 77.6
>30 United States 77.5

GDP per capita, 2004, measured by purchasing power parity (PPP)

U.S. -- $39,676
Cuba -- $5,700 (est.)

I will leave further comment to those who wish to explain why the United States has the highest quality health care in the world, and why this is the greatest country on earth.

Talking about talking . . .

about talking about talking.

C. Corax astutely asks whether it is ever appropriate for medical interpreters to engage in behavior other than interpreting. Many people answer "Yes." They argue that if it is the job of the interpreter to facilitate communication, they should intervene when they observe miscommunication due to cultural barriers between physician and patient. The most commonly cited examples are discordant health beliefs and practices, essentially the typical subject matter of medical anthropology. Maybe the parents believe their baby has empacho, a sickness believed to be caused by a ball of food lodged in the digestive tract. (The doctor would probably diagnose colic.) Maybe they consult a curandero, or believe that they have been cursed. The doctor, meanwhile, may be assuming knowledge about entities such as viruses or abnormally dividing cells that they do not have.

Well, yeah, occasionally stuff like this comes up. Every time I start to talk about cultural competence, somebody brings up the book The Spirit Catches You and You Fall Down by Anne Fadiman, which tells a tale in which differing health beliefs between physicians and a Hmong immigrant family in California caused major problems. No doubt there are occasions when interpreters might contribute to mutual understanding by helping to explain such alternative viewpoints to the parties.

However, after reading transcripts of hundreds of medical encounters between immigrants and non-immigrant physicians, and interviewing more than 200 immigrants about their health and health care, I can say confidently that for Latinos, at least, such so-called "folk beliefs" are of very minor importance to culturally competent health care or cross-cultural communication. And to the extent that they are significant, you don't need an interpreter to achieve mutual understanding -- the doctor just has to ask. After all, I understand that people from California -- that magical LaLaLand where the sun always shines and everybody gets around on rollerblades -- believe in the healing power of crystals. However, I don't hear that east coast docs need to learn all about this in order to take care of them.

The fact is that all medical encounters are cross-cultural -- between the culture of medicine, and the culture of the real world where human beings actually live. I don't take the credit for that discovery, by any means. One of the most compelling explorations of the canyon between doctor and patient was made by Elliot Mishler, whose Discourse of Medicine is back in print. (It's not exactly beach reading -- quite academic.) Elliot (with whom I am acquainted) distinguishes between the Voice of Medicine and the Voice of the Lifeworld. He finds patients continually thwarted in their efforts to tell their stories, and to place their experience of health and illness in the context of their lives. Instead physicians, who remain imperiously in control of the agenda and process of the medical encounter, relentlessly deflect the discourse to the biomedical conception of the patient they have acquired through socialization in medical school and residency.

Yet those of us who happen to speak English don't have an interpreter with us when we see the doctor, to explain to us the significance of Coombs titers and help the physician understand that the patient's ability to follow a diet or a medication regimen is constrained by family and work responsibilities. The problem is more complex, to be sure, when the cultural distance between doctor and patient is particularly great. It is likely that distance is greater between a former Salvadoran peasant and a North American doctor whose own father probably went to Harvard too, than it is between that doctor and an Irish-American auto mechanic -- but the difference is not as much as most people think.

Asking interpreters to step in and try to fix this problem is to call for a great deal of skill and judgment. Whether it really results in better communication, more satisfactory relationships, and better medical outcomes, is an empirical question for which we have essentially no data. Perhaps it just introduces more problems than it solves, and interpreters generally should stick to trying to be a "black box" translator.

However, that doesn't really work either. True equivalence of meaning between different languages does not exist. In fact, it is impossible to define, because we can only think using language. The only way to judge that statements in different languages are equivalent in meaning is to ask a bilingual person for an opinion -- and such opinions may differ. What is more, meaning depends on context, and on the hearer. What I am writing here will not have exactly the same meaning to every listener. (In Speech Act theory, we call the response evoked in the hearer or reader the perlocutionary force of the utterance. More on that later.) Interpreters can't just translate everything literally, because that often just doesn't work.

Sometimes, of course, an interpreter may confront a genuine emergency, a situation in which ordinary human ethics demand intervention, regardless of what professional codes of ethic we may write. For example, the interpreter realizes that a child is in danger, and that the doctor does not. My personal view, pending more data, development of better training and standards for interpreters, and better understanding of how communication in general can be facilitated and improved, is that interpreters should be very restrained and cautious about stepping out of the role of simply converting meaning, as best they can, from language A to language B. But if they do go beyond that, they must make their behavior fully transparent to both parties, interpreting everything they say as well as everything the parties say. In the data I described in my last post, they did not do so.

More from Clark Kent

Okay, I said I would talk more about what I do for a living. Now that we have that little election thing out of the way, I'll continue with the series.

At the APHA meeting, I was on a panel on Latino access to health care, sponsored by the Latino caucus. It was a great pleasure for me to be a part of a panel that really came together coherently around some important issues.

Tilly Gurman from Johns Hopkins found that Latina mothers giving birth at a certain hospital experienced major failures of communication with their doctors, including not understanding lab tests and discharge instructions, and only half of providers felt truly competent to serve Latinas. Nevertheless, the women consistently expressed a high degree of satisfaction with their care. I was nodding my head as she spoke because we consistently find the same thing -- we observe really atrocious processes of care, but Latina mothers give the clinic outstanding marks on patient satisfaction surveys.

There are a combination of reasons: a cultural norm of appreciating that people at least appear to be making an effort and not offering criticism unless you are asked repeatedly; favorable comparison of facilities and resources in the U.S. with those of the poor countries from which many of these women come; respect for authority; and of course, not necessarily realizing that there has been a failure of communication. (As Rummy says, there are the known unknowns and the unknown unknowns.)

Antonio Estrada spoke about barriers to care among HIV+ Latinos in the Mexican border region. While there were various problems, about 8% of the respondents indicated that difficulty crossing the border and the presence of the border patrol specifically were an obstacle. These are individuals who for one reason or another spend time on both sides. This is a reminder that for the population of the region, the border is an artificial construct. Mexicans of that region did not cross the border, it crossed them, when the U.S. seized the territory by force in 1848. To this day, members of extended families live on both sides. The Hispanic population of the Southwest does not consist, for the most part, of immigrants, but of people who found themselves in an Anglo dominated country while staying right where they were.

Mara Youdelman of the National Health Law Program discussed promising practices for providing language access in health care settings. For people who are interested in their excellent work on this subject, you can find out all about it here.

Vilma Enriquez-Haass discussed her dissertation research, based on an analysis of a survey of Latino day laborers. (This is a subject I wrote about a while back when I covered for Jordan Barab at Confined Space. I wish I'd had Vilma's findings available then.) Day laborers, who assemble to find work at places such as Home Depot parking lots, often do construction and landscaping work, but they don't have the benefit of worker's compensation and health insurance. Men who are injured on the job may get acute care, but no follow-up or rehab, and certainly not any short-term disability. In other words, if they can't work because they are injured on the job, they don't get paid.

Finally, I spoke about role exchange in medical interpretation, using data from pediatric clinics where doctors and nurse practitioners are communicating with limited English speaking mothers. We've observed that nurses and social workers who are called on to interpret often conflate their professional roles with that of interpreter. They may substitute their own judgment for that of the physician, edit what the mother says because they think they have a better idea of what the doctor ought to hear, and take over the interviewing process. Interpreters with inadequate training engage in inappropriate socializing with the mother, take it upon themselves to provide health education -- not necessarily accurately or coherently -- and also edit mother's remarks for what they consider to be biomedical relevance. Medical interpreting is a profession that requires high ethical standards as well as skills that go beyond just being bilingual. (Thanks to my colleagues Kari White and Rachel Heckscher for their contributions to this work.)

Now, I know there are a lot of folks out there who think that the real problem is that there are too many immigrants in this country, especially people who haven't yet fully mastered English and people who aren't here legally. I will discuss those issues at greater length and I hope we can have some dialogue about it. But meanwhile, whatever you may feel about the situation, these are the facts.

Editor's note: We're glad that Dr. Rick is back in circulation. Stop by Critical Condition for his return to the blogosphere. We hope that CC will get back to regular updates. I should be back Sunday.

Big changes?

So what can we hope for from the Democratic Congress between January, 2007, and the start of the next campaign season,* after which little will get done? I'm afraid we'll need to temper our expectations for a cornucopia of public health goodness.

As far as the political balance of power, even as the former world bestriding colossus and Emperor of Mesopotamia shrivels up like bacon, he still possesses the constitutional power of the veto, and under the new order, he may well use it. Just as important, the congressional Democrats are highly fractious, with nowhere near the unity and party discipline of what is now the opposition.

As far as the nation's circumstances are concerned, we're bankrupt. We can reasonably expect the new congress to be generally more inclined toward supporting essential public health infrastructure including CDC and its grants to the states for programs such as cancer control and emergency preparedness -- the latter, one hopes, with a more realistic focus on natural disasters and epidemics, rather than implausible bioterrorism scenarios. We can hope that programs of the Health Resources and Services Administration, such as the Ryan White CARE Act; the Substance Abuse and Mental Health Services Administration, including their formula grants to the states as well as support for community based treatment providers, will at least keep up with inflation and growing need, although the essential public interest in treatment on demand will not come close to being satisfied; and that formula grants to the states in these areas will also no longer be squeezed.

But even those modest improvements will be hard to achieve. The Democratic leadership has promised, quite appropriately, to institute pay-as-you-go financing. Any increases will have to be offset by cuts in spending elsewhere, or revenue increases. Whether they can stick to this pledge remains to be seen, but the fact is the country faces a long-term catastrophe if they can't, should the Chinese and Saudis decide to call in their loans. Stopping the hemmorhaging of billions of dollars every week in Iraq, starting to shut down the global military imperium and ending boondoogles on weapons systems designed to fight the Soviet Union in the 1980s would free up tons of money. But as the always on-target Tom Engelhardt spells it out, that is not likely, indeed, except for Iraq, it isn't even part of the public discourse. And no matter what the public mood and its expression in the election, we are going to be stuck right where we are in Iraq for a long time to come.

The Democrats have proposed to raise the minimum wage, and the Incredible Shrinking President has signaled he would sign a bill subject to certain conditions. The Dems also say they will give Medicare the power to negotiate directly with drug companies over price, but it isn't clear whether the veto pen comes out on that one. Even if it doesn't, presumably any savings go to shrink the doughnut hole, at best, or more likely just get written off to cost control, so there isn't going to be any free money coming out of that one. Whether it happens at all still depends on whether enough Democrats are sufficiently free of drug company entanglements to actually pass it.

Ted Kennedy will become chair of the Senatorial committee that oversees the FDA, and we may see some progress toward more effective drug regulation, although to give credit where it's due Sen. Grassley hasn't been bad in that area. The problem is that the agency needs a pretty radical redesign, which requires comprehensive legislation that the drug companies will fight with everything they've got; and new leadership, which only the White House occupant can appoint. It also needs, yup, more money, which has to come from somewhere.

The Dems are going to be extremely timid about any "revenue enhancements." As a matter of fact, they have proposed tax cuts. It is possible that some of the sunsetted cuts -- such as the estate tax and capital gains -- will be allowed to expire after all, but that won't help until 2010. So the kind of money needed to expand Medicare or Medicaid and insure more people, and to begin to solve their long-term financing problems, is nowhere to be seen.

The most important new policy of all, a carbon tax, which would help save the world while providing desperately needed revenue, is not even remotely possible. Other than that, it is conceivable that there could be legislative overrides of some of the EPA's most egregious rule making of the past few years -- on mercury, arsenic, particulate matter, etc. -- but even that would take a knock-down, drag-out fight.

So, except for some possible incremental benefits, the most I'm hoping for in the short term is that the space for public discussion of our real problems will begin to open up. If we can at least start to honestly confront the profound multiple crises before the nation, there is hope that in another two years, we will start to work on them seriously.

Don't get me wrong -- that's a hell of a lot better than the situation last week. We are no longer doomed. But we have taken only the first step on a long, hard march.


*Approximately February, 2007.

Addendum: I meant to mention rolling the pork barrel out of the Capitol. That would indeed free up a few bucks for better things, but I have no particular reason to expect the Dems to do that either. Bringing home the bacon gets the votes for both parties.

Hangover blogging

Well, mild hangover. Actually I think it's more insufficient sleep. In any case, I believe I am coherent enough to comment.

What impresses me the most, and lets some optimism for the longer term get its nose under my tent, is that most voters repudiated the Thousand Year Reich even though the corporate media hasn't changed a bit. They still believe that balance means giving equal credence to truth and falsehood, they still go howling off in a pack after trivia, they cling fiercely to their manufactured political narratives and stereotypes, they are incapable of self-reflection and impervious to criticism, and they live in the same bubble of power, wealth and status as the political and economic elites who they write about. Cokie's lacerating pain last night was obvious, and disturbing.

But like the citizens of the Soviet Union, Americans no longer take our Pravdas at face value. It does have something to do with the new media created by your Internets, not because people get their basic information from sources outside of the corporate media but because bloggers and web projects like Media Matters have created some new accountability and broken down some of those rigid frames. It also has to do with the ineluctable force of reality. No matter what kind of balance ABC News tries to enforce between Dick Cheney's fantasies and the reality of Iraq, people know when there's a funeral in their town for a 19 year old Marine and they know what their cousin in the National Guard tells them when he finally makes it home. Whatever they may think about the right to life, they know when they don't have it because they don't have any health insurance. Whatever the business pages trumpet about the "record high"* in the Dow and low unemployment, they know when they're having a hard time putting food on their families. However much credibility the networks extend to extremists and liars like James Dobson and the Vulgar Pigboy, those guys are self-evidently repulsive. And in spite of the bizarre enthusiasm of the hand picked crowds, it's pretty obvious that George W. Bush is a halfwit.

As the newspapers continue to lose circulation and the TV news loses eyeballs, maybe they'll start to think about this: people may actually pay attention to them again if they try telling the truth.

*That was probably the most absurd spasm of pack journalism of the entire year. Stock market indices are supposed to set "record highs" every day. That's why people invest in the stock market: on the assumption that it will go up, and they'll earn a return on their investment. Actually, thanks to inflation, the Dow hasn't even come close to its highest ever value, and it's only a very small segment of the stock market anyway. The vast majority of stocks are worth less than they were in 2000, even in nominal dollars. But it would be too complicated for them to explain that.

The politics of public health

The vast multitudes who attend APHA -- and I mean that sincerely, it's a huge convention, with something like 15,000 registrants -- are not exactly a revolutionary vanguard. They are state and federal bureaucrats (by now, more than half of them appointed or hired by Republican governors or the Emperor of Mespotamia); scientists in many disciplines, most of whom study narrow problems with no obvious political content (such as my own work on physician-patient communication, although there might be some politics in there after all); practicing physicians and other kinds of health care providers; health educators who teach people how to eat or exercise or take their pills; and yes, a few community organizers and public health outreach workers and advocates whose work is to a greater or lesser extent bound up with social change or compels them to activism.

Nevertheless, since John Snow took the handle off the Broad St. pump in 1854 (or maybe he didn't, but it's the idea that counts), thereby ending a cholera outbreak, the public health community has been reality based. And as we all know, reality has a liberal bias. In the first place, fundamentally, there is a strong gradient in health status and life expectancy associated with the construct called socioeconomic status. People with more money, more education, higher social status, more authority in the workplace, live longer, healthier lives. Ergo, reducing social inequality means a healthier population. And no, it doesn't happen at the cost of worse health for the rich. There are fewer of them to begin with, and they have more than enough. The greater equality of European countries compared to the U.S. is one reason why their populations are healthier.

Second, public health depends on public goods. These include clean air, clean water, clean food supply, open access to information, safe neighborhoods, well educated children, control of infectious diseases even among people who can't pay for medical care on their own, and a whole lot more than markets don't supply, and powerful interests such as corporations and rich folks who don't want to pay taxes don't want us to have.

Third, moral sanctimony founders on the rock of truth. Your "moral values" may lead you to demand abstinence-only sex education, but the truth is that it doesn't cause abstinence, doesn't prevent sexually transmitted infections, and doesn't prevent unintended pregnancy. Moral condemnation of homosexuality doesn't do anything to cause people not to be homosexual or not to engage in homosexual behavior (just ask Ted Haggard) but it does cause young people to experience shame and anguish, to be shunned by their peers, sometimes to kill themselves, sometimes to develop substance abuse problems; and it makes it impossible to provide people with information and resources to stay healthy. Declaring that obesity or abstinence from tobacco are matters of personal responsibility doesn't fix the toxic food environment or the trillions spent by corporations to manipulate us into eating and inhaling poison.

And, obviously, war is bad for children and other living things.

So, that reality base forces public health researchers and practitioners to favor one party over the other in the current U.S. political scene. There's just no getting away from it. Will the prospects for public health change dramatically if one party rule ends in the United States? No. But it is possible that in the years ahead, they'll start to look up a little bit. Maybe we'll even catch up with Cuba, in a few decades.

Odds and Ends

* Don't get me wrong, I am far from despairing. In fact, I believe in the possibility of progress and the long-term prospect for humanity. But I'm talking really long-term. The next 50 years, at least, will be a rough patch, to say the least. The disaster was largely avoidable, but the capture of state power in the world's most powerful country and largest economy (by far) by a gang of murderous, thieving sociopaths has put the planet in a hole we won't get out of for a long time, no matter what happens to U.S. politics in the days and years ahead. Disturbingly, the latest polls show the Republicans making something of a comeback. Why is beyond my comprehension. It appears now that they will retain the Senate, maybe lose only two seats. As a nation, we are sick down to our very soul.

* The Annual Meeting of the American Public Health Association is in Boston, starting today. For any of you who will be there, I'll be presenting on "Role Exchange in Medical Interpretation" at a session on Tuesday at 2:30, sponsored by the Latino caucus. Like last year, I'll try to do some blogging on interesting sessions I attend. APHA is huge, overwhelming, and impossible to cover adequately, but I'll do what I can.

* If you haven't seen any comments from me on your own blogs lately, it doesn't mean I haven't been visiting -- I've been in a silent way lately. Maybe the words will start flowing soon. Also, for those who have sent me tips and story ideas, please keep doing it -- even if I haven't used them yet, I still may, and I often read with interest. It's hard to decide what to write about every day, and sometimes a story that would be a good fit here just doesn't happen to fire up the right synapses on the day it happens. I have a big file, and I keep working through it. I always appreciate getting your e-mails.

Monday I will probably post in the evening, due to the APHA meeting.

The Dark Crystal

My master's degree thesis was titled "Which Way is Up? Social Welfare and the Ideology of Progress." I wrote it just about exactly 20 years ago. Back in that dimly remembered historic epoch, progress -- historic, current, and inevitable -- was the animating conviction of American culture. Each generation was better off, and better, than the last. Technology hand in hand with capitalism had banished our vulnerability to nature, was ending enslavement to need, and soon to want, and then would open up a world without material limits. Medicine would banish disease, and then even death. Morally, we had very nearly conjured our founding ideals into reality, conquering slavery, then patriarchy, segregation, and soon even poverty, sexism and war. Humanity was about to spill from its earthly cradle and conquer the planets and the stars.

To be sure, people had varying views of exactly how far we had come and how fast we would progress, but few doubted that we were going somewhere good. Even the fiercest social critics and champions of the oppressed, after all, were true believers in progress, the central dogma of Marxism and its descendants. Conservatives as well, despite the label and their claim to defend tradition and the greater glories of the past, did so in the name of an even more glorious future in which ancient values would come to actualization in a world of abundance, and all conflict would end.

There were some smudges of smoke on the psychic horizon. The threat of nuclear war was probably the most ominous, and there were those cassandras moaning about a population bomb and resource depletion and a silent spring. Robert Heilbroner's Inquiry into the Human Prospect was a very dark vision of the future which college students were generally made to read. The vast majority of speculative fiction gave humanity scarcely imaginable powers and galaxies as playgrounds, but John Brunner's Stand on Zanzibar and The Sheep Look Up saw us destroying our planet and ourselves. The undercurrent of repressed anxiety was strong enough that the most perspicacious even said we were not really in an age of triumph at all, but rather an age of anxiety. But few took these bum trippers seriously. The inevitable technological breakthroughs would fix everything.

The point of my thesis was that, in fact, in many ways we were worse off than our hunter-gatherer ancestors, and that our wisdom was running a long way in arrears of our knowledge. Nowadays, not many people need a professional curmudgeon to tell them that. Faith in progress is blowing away with the New American Century in the desert wind. We're finally awakening from the hallucinatory triumphalism that gave us, in the guise of world historic statesman and visionary, a dimwitted psychopath prancing around on a warship with a sock in his pants. Now it's just a bleak, cold evening and we've got nothing but a tattered flag to wrap around our shivering shoulders.

Maybe, in the coming years, we'll finally start to confront our real problems, and maybe, if we have an acute attack of honesty, self-knowledge, and true courage, we can beat the worst of them. But it might even be too late. After all, John Kerry might tell another lame joke.

Dissertation topic

For all you MPH students looking for a thesis, here are some research questions.

1) Has anybody, anywhere, ever responded to spam e-mail and purchased a penis enlargement product?
* Describe this population in terms of age, ethnicity, level of education, actual penis size, and other parameters of interest. (For that matter, are they all male?)

2) When people sent in their money, did they actually receive something?

3) If the folks in Indonesia or wherever they are actually do send a product, does it contain any biologically active ingredients?
* What are these ingredients? Are they safe?

There should be a good prospect of funding for this. Let me know if you need help with your proposal.

No data, no problem

Okay, I said I'd talk about my day job so here's installment number one.

It is a national goal (established by Bill Clinton, although it's much more important that he was adulterously fellated) to eliminate racial and ethnic disparities in health by 2010. Ain't gonna happen, obviously, but just like VICTORY in Iraq, it's still the goal. One essential precondition for achieving a goal is knowing how far away you are, in what direction it lies, and whether you are making progress or not.

Unfortunately, the information we need to pursue this particular goal is woefully inadequate. Much of what we do know I have discussed here previously, for example here and here. But what we don't know is considerably more vast.

The vast majority of available data on health disaparities -- from important sources including vital records (birth and death certificates), disease surveillance systems, and programmatic databases of state health departments -- use the federal standards for racial and ethnic identification. These are the familiar 5 races -- White, Black, Native American, Asian and Pacific Islander -- and two "ethnicities" -- Hispanic and not Hispanic.

Today, the 19th Century concept of race on which these classifications are based has been discredited. The races were essentially thought to be biological sub-species of humanity, in which the highly visible traits used to define them – principally complexion – were correlated with other important genetically determined traits, such as intelligence and temperament. It is now understood that the division of humanity into these five groups, and various schemes of sub-groupings, was based on socially determined prejudices, not scientific data. Genetic variation within the "races" is far greater than the variation between them; and the selection of different traits as the determining factors would result in entirely different sets of "races."

Particularly absurd is the Asian "race," which includes Japanese, Chinese, and Filipinos. The Philippines, of course, are not located in Asia. They are literally Islands in the Pacific. What is more important, the nation is multi-ethnic and, to the extent one wishes to accept the racial construct, multi-racial. Inhabitants of the Philippines include indigenous people, descendants of Spanish colonialists, and Chinese and other settlers. Only some of these people are arguably of Asian "race." Furthermore, it is conceptually troubling to invent, as the census has done, Chinese, Japanese, Pakistani, and Indian "races," which only compounds and elaborates the error of thinking in racial terms. Step across the border from Pakistan to Afghanistan, by the way, and you instantly turn "White."

The separate "Hispanic ethnicity" category co-exists awkwardly with the race classifications. "Hispanics" are also asked to choose a "race," but the plurality (42%) chose "other" in the 2000 census. It is difficult to see why a person may be of Chinese, Filipino, Black, Native American or Hawaiian "race," but can only be of "Hispanic" ethnicity. Important, ethnically distinct immigrant groups such as Brazilians, Haitians, and persons from the English speaking Caribbean are entirely invisible in this system. Haitians may choose Black as their race, but they are culturally quite distinct from descendants of slaves brought from Africa in the 18th Century - the ethnic group African Americans. Brazilians, in fact, don't exist in this system at all, anywhere - they aren't "Hispanic" (they speak Portuguese). Immigrant groups from Africa, Arabs (who are officially White, whether they like it or not), Cape Verdeans -- none of them exist.

The Hispanic category is also constructed by the dominant culture. Nobody is "Hispanic" until they arrive in the U.S. They are Argentinian, Mexican, Colombian, Salvadoran. They may belong to ethnic groups within those countries, such as Argentinian Jews, Quechua speaking indigenas, or Chinese-Dominicans (such as one of my former research assistants). But now they are all just "Hispanic." There are huge differences in health status and experience in the health care system among these groups.

Then there are the very important systems in which there is no racial or ethnic identification at all, or it is highly unreliable, or it consists only of "black" and "white." Examples are the hospital discharge systems (which record diagnoses), HEDIS (health plan and hospital quality assurance data), some important large-scale health surveys, and others.

But, if we can't see the problems -- whether in social determinants of health, access to health care, quality of care received, or outcomes of care -- they might as well not exist, from a public policy point of view. We won't have to do anything about it. That is very convenient.

Most people think the solution to this problem must be very difficult. It isn't. More on that soon.

The liberal media

I pay a lot of attention to the news, so I know what's important. The front page of the New York Times, CNN and the rest of the cable news networks morning noon and night, NPR on the same schedule, all of the corporate media web sites, have made it very clear: the most important issue before the country, and the voters, as the mid-term election approaches, is that John Kerry told a joke which some people construe as implying that if you don't study hard, you'll have to join the army.

They are so right. I was going to vote for Democratic candidates on Tuesday but now I know better. I was paying too much attention to trivial matters such as the disastrous geopolitical consequences of the grotesque failure of the U.S. invasion and occupation of Iraq; the murdered children among the among the hundreds of thousands of dead Iraqis; the tens of thousands of young Americans killed and maimed; the trillions of dollars your great grandchildren will still be paying back, if the United States survives this catastrophe; the destruction of Iraqi civil society; the disgrace and shame of the United States before the world for degradation and brutal torture in its dungeons.

I thought all of this was important, and that the people responsible for it -- such as George W. Bush, Richard Cheney, Donald Rumsfeld -- should be accountable. But of course I don't have the wisdom and experience of leading professional journalists. They understand what really matters, what really ought to concern me, and how I should exercise my franchise. John Kerry screwed up a joke, and he's a Democrat. That's all I really need to know.

UPDATE, Nov. 2: So, how long can they keep this going? Last night, Sen. Kerry's mal mot was the lead story on all the local news stations here -- in spite of a gubernatorial debate that had happened last evening, among other options. This morning, it was the subject of a screaming front page headline in both daily newspapers. The Globe featured of photo of President Cheney, captioned with this clever quotation from the great statesman, "He was for the joke before he was against it," and three -- yes three -- long staff-written articles on the alleged "controversy." The content of the articles was defensible on its face -- essentially that this was all theater, that Republicans scour the wires for remarks by Democrats that they can criticize, taking them out of context or overinflating their importance if need be, and that the press falls for it. But, er, Globe editors -- you fell for it. That's what you told us all was the most important story of the day, that's what you assigned your reporters to write about, that's what you put on the front page. This entire story merited nothing more than a one paragraph "in brief" item in the first place. Instead, you take up half the newspaper talking about how it doesn't really matter, which, obviously, means it must matter after all, or else why are you talking about it?

Meanwhile, our old friend John Boehner blames the disaster in Iraq on the military officers in charge. Harold Dean tries to create a comparable hooplah, and the very same corporate media ignores it. The biggest idiots in all this, after all, are the sycophantic fools who went to journalism school. The profession is contemptible. Apparently a qualification to be a senior editor of a major newspaper is to be a tool, and proud of it.