Map of life expectancy at birth from Global Education Project.

Sunday, April 30, 2006

Am I missing something here?

Not that it's news, exactly, but people are taking note of the latest report by charlie Savage of the Boston Globe that George W. Bush has proclaimed himself to be absolute dictator, above the law, and unaccountable to Congress, the courts, or the people -- from whom he has the absolute right to conceal any and all information about official actions he takes as Commander in Chief, by which he means Commander in Chief of the United States, not just of the armed forces.

Of course, the administration proclaimed all this publicly a long time ago. This includes the power to do absolutely anything. It includes the power to spy on American citizens, listen to their telephone calls, read their mail and their Internet correspondence, find out what books they have been reading, watch their movements, keep track of their associations, without a court order and without having to tell anyone. It includes the power to make people (including U.S. citizens) disappear into a secret network of prisons, with no possibility of judicial review or even the knowledge of anyone except high administration officials and secret intelligence agents, there to be tortured, even tortured to death, for as long as the Commander in Chief cares to confine, conceal and torture them. These are powers which Mr. Bush proudly proclaims, and boasts of exercising, and the Attorney General has so testified before Congress. The corporate media have treated these claims as an interesting constitutional question, about which scholars have various opinions and may politely disagree. The Democrats in Congress have largely ignored it, or muttered some tepid reservations.

So, uhh, shouldn't people be kind of upset? You know, people like the Majority Leaders in the House and Senate (what are their names again, anyway?), Democratic candidates for President, editors of newspapers, maybe retired presidents (wouldn't you think Jimmy Carter might have something to say? WJ Clinton?), prominent television commentators. I mean, I vaguely remember as a school child being taught that the United States is a democracy, a government of laws not of men (nowadays we'd say people), that we had a constitutional order of checks and balances, a bill of rights, stuff like that. Since none of that is true after all, wouldn't you expect people to at least feel a bit confused? I guess outrage is too much to ask, but a sense of impropriety, at least, could be expected.

I guess not.

Friday, April 28, 2006

Knowing too much

We've talked a few times about the counterintuitive conclusion that screening the general population for common diseases usually does more harm than good. As an extreme example, there are companies that sell whole body CT scans to rich people, who feel that they are doing everything they can to detect cancers, vascular disease, and other potential problems early, so they can live forever, but what they are really buying is likely to be a sack 'o woe.

It isn't just the unnecessary dose of radiation. In the first place, as we've discussed before, even a test with what appears to be a high degree of "specificity" -- that is, 90% specificity means that only 10% of people who don't have the problem will test positive -- will yield more false positives than true positives if the problem exists in a fairly small percentage of the population. This results from Bayes' Theorem, which everyone should understand. If you have a positive test, you end up with additional diagnostic tests, which may be expensive, painful, or dangerous; unnecessary treatment, which may be same as the above; anxiety, lost time at work or whatever else you do, anxiety among friends and family, and wasted resources of the medical system which could have been better applied elsewhere.

Furthermore, many diseases, no matter how dread, may not end up harming you even if you have them, because something else will get you first. Prostate cancer is a good example. Autopsies find that the majority of men over 70 actually have prostate cancer, but few of them die from it or even have symptoms. But, if they had been unlucky enough to have detected it, they would have had surgery, erectile dysfunction, incontinence, all that nasty stuff.

Finally, treatments for many diseases don't work particularly well anyway. An excellent example of that is clinical depression -- which isn't exactly a disease anyway, but a set of slippery, uncertain diagnostic criteria. There is a movement underway in the United States, spearheaded by drug companies, to screen the general population, starting with school kids, for mental disorders. In the UK, the NHS wants to screen everybody for depression. Writing in the British Medical Journal, Simon Gilbody, Trevor Sheldon, and Simon Wessely blow this idea to dust. (Why are half the men in England named Simon?)

a) Most of the people who test positive on depression screening instruments don't have depression, they just happen to be unhappy at that particular moment. They will end up getting unnecessary treatment, stigma, and whatever other badness may ensue.
b) Most people who really do have important clinical depression are going to be diagnosed eventually anyway.
c) Most of the people who really do have depresion aren't treated very succesfully.

Furthermore, Trevor and the Simons say this believing that the common treatment for depression, antidepressant drugs, is actually beneficial. There is some question about that.

So if your doctor suddenly starts asking you a lot of weird questions about how you felt in the past week, such as "I had trouble keeping my mind on what I was doing," or "I felt lonely," or "I could not get 'going'," you might just say, "And how about you doc? Did you feel happy? Did you feel sad? Are you human too?" (All of these questions, except the one about being human, are from the Center for Epidemiological Studies Depression Scale, a common screening instrument.)

Thursday, April 27, 2006

Bizarro world . . .

These days you have to pick and choose your outrages. So first, this is from my friends at the North American Indian Center of Boston:

President Bush has proposed zeroing out Urban Indian Health Programs from the FY 07 budget of the Indian Health Service. The National Council of Urban Indian Health (NCUIH), a Washington DC based urban Indian controlled organization, has issued a statement on behalf of the 34 urban Indian health programs asking Congress to restore funding in the amount of $34,054,000. . .Please contact your Senators and Congresspersons asking them to support restoration of urban funding. At this writing, the FY 07 Appropriations Bill is scheduled to go to the House floor on May 18, 2006 for a vote. In the Senate, the Indian Affairs Committee has recommended restoration of funding for urban Indian Health programs. There is no date set for a Senate vote but one is expected before Congress goes into August recess. . . .

Urban Indian Health Programs offer culturally-competent services including access to Traditional Healing Practices. Behavioral Health/Alcohol Substance Abuse programs provide service treatment/intervention models mirroring Native beliefs and values. Urban Indian patients seek treatment and follow through with service plans at a rate far exceeding those Indian patients who access treatment from non-Indian providers.

The 2000 U.S. census data shows that 61% of the American Indian/Alaskan Native population reside in urban centers. The 1970 U.S. census showed 38% of American Indians/Alaskan Natives living in cities. Targeted government initiatives at assimilation and acculturation of Tribal citizens have been ongoing since the beginning of Federal/Tribal relations. Tribal citizens have been displaced from their homelands, sent to federal Boarding Schools, endured adoption of Indian children at a rate almost 40% higher than the general population, had Tribal religions, and ceremonies banned by government initiatives and were relocated in massive numbers to cities during the 1950’s and 60’s as part of the Relocation Policy. The government’s policy was a ruthless attempt to force American Indian/Alaskan Native people into the melting pot. Courageously, this did not happen and the 34 urban Indian Health program are housed in cities where the Indian community banded together to created local non-profit agencies serving the interests of Indian people.

Okay then, they can just damn well start being white! And the Republicans have a way to help them get started: $100 to buy gas for the uh, Winnebago. Yup, I thought this was satire, but it's the absolute God's honest truth:

Most American taxpayers would get $100 rebate checks to offset the pain of higher pump prices for gasoline, under an amendment Senate Republicans hope to bring to a vote Thursday. . . Our plan would give taxpayers a hundred dollar gas tax holiday rebate check to help ease the pain that they're feeling at the pump," Senate Majority Leader Bill Frist announced Thursday. . . .

Frist said the rebates would go to single taxpayers making less than $125,000 per year, and couples making less than $150,000. Republican senators said they hoped soaring gas prices would inspire Democrats to support their proposals.

"A lot of these other things we're talking about today, supply, like ANWR, have had Democrats oppose them in the past, when gas was $1.25, $1.50. Gas is now $3," said John Thune, R-South Dakota. "I would expect that there would be a lot more bipartisan support for proposals that would increase supply in this country."

Now, this is so completely fucking nuts that my usual talent for invective fails. Cost of the $100 bribe to shut up and keep driving, and pretend that the party will never end? I dunno how many adult taxpayers there are in the U.S. offhand, but it's gotta be over a ten billion dollars. $34 million for urban Indian health would disappear into a billion dollars like a fact into a Republican's brain. Write your own caption.

The New JAMA: The stuff the corporate media didn't cover

One reason I started this blog is because I was continually frustrated by the lack of correlation between the stuff I read in the medical literature that I thought it was important for people to know about, and the stuff that got reported in the general media. After a year and a half of writing the blog, I'm still not entirely sure what it is that makes reporters think something is worthy of your attention.

Anyhow, until I figure it out, here's the latest. The two items in the new JAMA that appear to have gotten some attention are a study about implantable defibrillators, and a study by people at Public Citizen about conflicts of interest on FDA advisory panels. Both of these got spun like tops in the mass media, and therein lies a hint: there are coporate interests (medical device manufacturers and drug companies) with a direct interest in both of these stories. They probably called up the reporters to spin the stories, and then of course the reporters got on them and talked to the authors and/or various potential counterspinners, and they had the "he said/she said" format they needed. Journalists don't tell you what actually happened, that's not their job. They have to be fair and balanced, which means they have to transcribe what other people say, especially people who have a personal interest in the matter and who can be presumed to be trying to manipulate you.

So here is a story that I think is important. Eric Peterson and sufficient collaborators to sing the Coronation Mass looked at 350 hospitals around the country that provided care for people who had suffered heart attacks. As you probably know, there are process of care guidelines for these and other common conditions that are treated in hospitals. For example, people with heart attacks (I won't go into the technicalities of the different kinds of events that are called heart attacks, but we're talking about the common, basic kind here) should be given aspirin and other anti-clotting agents including a relatively new one called a glycoprotein IIb/IIIA inhibitor, and beta blockers. They should also get some of these drugs prescribed at discharge, and get dietary and smoking cessation counseling if indicated. Seems simple enough but on average, only 74% of indicated treatments were provided. Unfortunately, this is typical: for whatever reason, such standards of care are not consistently followed.

The question has always been, however, whether these process indicators are really valid, in the sense that they predict patient outcomes. Maybe doctors are using appropriate judgment in not always following them. This study finds otherwise -- in the 25% of hospitals with the lowest adherence to the standards, patients with a documented myocardial infarct (death of heart muscle tissue) were nearly twice as likely to die in the hospital as in the 25% of hospitals with the best adherence. Some of the specific predictors had to do with discharge practices, which obviously could not have caused in-hospital mortality, but are probably indicative of an overall culture of diligence and quality.

This study is observational, not experimental, and hence cannot absolutely prove that better adherence to the standards will improve patient outcomes. There could be other explanations, e.g. the less adherent hospitals are seeing sicker and weaker patients. But the authors beat up the numbers every way they could to try to rule this out and the conclusions stand up to the pounding.

One important observation: the hospitals with inferior quality indicators had a higher percentage of non-white patients. This suggests, as have some other studies, that disparities in health care quality according to race and ethnicity may be at least partly explained by where people get their care, rather than differential treatment within a given institution. That requires more study.

This study gives considerable support for the use of these process of care standards as indicators of quality. That has been controversial, and it still will be to some extent, but I think we'll be seeing more and more attention paid to these indicators, and to figuring out why they aren't followed. (How hard is it to give somebody an aspirin, for crying out loud?) We will see more and more pressure to rate hospitals publicly on these indicators. I have been a skeptic, but maybe this is a good idea.

Wednesday, April 26, 2006

Who will tell the people?

So, the politicians have finally decided they need to do some pandering about the high price of gasoline. Former-failed-Texas-oilman-and-frog-exploder-in-Chief will stop filling the strategic petroleum reserve, "investigate price gouging" (of which I would imagine there is none to speak of) , and suspend environmental regulations on gasoline formulas. That will accomplish nothing except to a) stop the strategic petroleum reserve from growing and b) poison the atmosphere. The Republicans in Congress want to drill in the Arctic National Wildlife Refuge and blame environmental regulations for high gasoline prices in the first place. Bush claims that we wouldn't have these high prices if new oil refineries had been built recently, and blames environmentalists for stopping them.

Actually, the oil companies haven't wanted to build any new refineries. The reason is that they know there won't be any petroleum to refine in them. We could drill for oil in ANWR -- and we'd get enough to last us for a few months.

But the Democrats actually have an even worse idea. Yes they do. They want to suspend the federal excise tax on gasoline (and we all know what happens to taxes that are suspended when it comes time to un-suspend them). Of course, what we really ought to do, and should have done 20 years ago, is to increase the gas tax by four or five times. (We could use part of the money to increase the personal income tax exemption and provide refundable tax credits for low income people, to repair the distributional consequences; and invest the rest in mass transit.)

Evidently there is nobody in political office in this country with the integrity and courage to stand up and tell the people the truth. The price of energy will be volatile -- it will go down a bit, and then up again -- but in the years to come, in the long run, it will just go up. This is a permanent situation, not an abberation or a passing "bottleneck" in supply. We cannot help the situation even one little bit by drilling for more oil, building oil refineries, or making the air even more poisonous than it already is. Our only hope is a national mobilization, on the scale of World War II, to use less fossil fuel -- much less. Starting ten years ago.

I don't hear Nancy Pelosi, Harry Reid, Barack Obama, Hillary Clinton, Howard Dean, not even John Conyers or Henry Waxman, saying anything like that. Like commenter Bo on the previous post says, we are in deep, deep denial. Or, to put it less delicately, we have our heads in a very awkward place.

Tuesday, April 25, 2006

Am I fiddling while Rome burns?

All of this talk about whether people do or do not take their lisinopril and have their nether regions penetrated by fiber optics is important only if one assumes that we will continue to live in a wealthy country where stuff like that determines whether we will one day make it to the shuffleboard court and the early bird special at Denny's, and we should actually care. Consider this:

This is the trend in crude oil prices through the end of last year. As you are no doubt aware, the price has continued on up and is now at about $75/bbl, more than 20% above where it was when this chart was made. The earlier historic spike represents the OPEC oil embargo followed by the political crisis in Iran, but nothing like that is happening now. The OPEC countries are pumping the stuff as fast as they possibly can. Also, as you can see, we are not experiencing a sudden, sharp spike but rather a steady, long-term upward trend in price.

Sure, much of Iraq's potential production is off-line, the Gulf of Mexico has yet to fully recover from last year's hurricanes, there is some loss of production from Nigeria due to a rag-tag insurgency, but those are pretty minor factors. Although the news readers keep telling us that high oil prices are due to "concerns" about Iran's nuclear program, don't you believe it -- this trend started a few years ago. Any specific geopolitical worries just make a little blip.

You need to read this, which is called the Hirsch Report. It's on the Project Censored website because it was done for the Department of Energy which promptly sent it down the memory hole. It's 67 pages plus appendices, but it's written in a very clear, straightforward style. A former cokeaholic fratboy and AWOL Texas Air National Guard Member through whom God speaks might not be able to understand it, but you can. Read it, because it will put important information in your head that you don't have now, even if you think you understand this. Then come back here for some commentary.

(this is to signify the passage of time)
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Okay. The Hirsch report is now more than a year old. It completely omits the not so minor issue of global climate change, and it does contain one fairly egregious error. So, taking those reservations in order:

They cite experts who say the peak happens anywhere from right exactly now, to 2016, plus some outliers who think it's farther away. However, if you read between the lines it's pretty clear that yesterday is probably the best estimate for a few reasons, and more than a year later that's even more clear. First of all, the corporations and governments that have properietary information about existing oil fields all have incentives to highball their estimates of reserves. That brings in investors, increases political clout, fends off conservation efforts, keeps the rabble happy, etc. Second, as they note on page 14, "Because oil prices have been relatively high for the past decade, oil companies have conducted extensive exploration over that period, but their results have been disappointing." Specifically, as shown on page 15, since 1990 that rate at which new reserves have been added has been less than the increase in consumption, at a rapidly increasing rate. And "additions to reserves" doesn't even mean new discoveries: much of it represents increases in calculations of the amount of oil that will be extracted from existing fields based on higher prices, that make more intensive recovery efforts worthwhile. The last so-called "Super Giant" reservoirs were found in the 1960s, and they are now in decline. Since then, only smaller reservoirs have been found. Finally, the price signal that the Hirsch Report says will introduce peak oil may well be here.

The major omission in the Hirsch Report -- the elephant in the bathtub -- is global climate change. Most of the mitigation efforts they discuss consist of making liquid transportation fuel from coal, oil shale, and tar sands. All of these processes pump far more CO2 into the atmosphere than does burning petroleum distillates directly. The major thrust of the report is that if we invest massively in these technologies now, today, we can ameliorate the economic consequences of an oil peak that happens 20 years from now. What they don't say is that we would thereby accelerate global warming. However, if peak oil happens now, or even ten years from now, the economic consequences will be catastrophic, and it's already too late. The technical term is, we are screwed.

They say that greater fuel efficiency can also help, of course, but it takes more than 15 years to replace the auto and truck fleet; and that still won't help all that much. You're burning less gas per mile, but you're still burning it, and of course on present trends humans are driving more and more miles all the time.

(Their egregious error, by the way, is claiming that the U.S. has the world's largest coal reserves. Actually the largest coal reserves are in China and Siberia. But that doesn't matter much.)

Finally, you may have heard that the president has a plan: hydrogen fueled cars. The Hirsch report makes it abundantly clear that hydrogen fueled cars are a) as likely to exist any time in the next 20 years as mobile biological weapons labs are to exist in Iraq right now; and b) hydrogen is not a source of energy, but a method of storing energy, which has to come from somewhere, specifically natural gas. And oh yeah -- that's also about to peak.

Pop quiz:

1) What country is currently the world's largest petroleum producer?

Wrong! It's the United States. But we also consume the most, by a huge margin, and we consume far more than we produce. Saudi Arabia's power comes producing far more than it consumes.

2) Why did the United States invade Iraq?

(Too easy for a hint.)

More boredom: the real problems with health insurance, part I

I know, I know, this week-long vacation in Hartford, Connecticut is the least entertainment we have ever had here, and that's saying something. But it must be done. Maybe we can visit the Mark Twain house once we're done with the tour of the filing cabinets.

Now that we've figured out that health insurance isn't exactly insurance, how does moral hazard apply? Actually, it applies in a completely inverted way. If you are on so-called maintenance meds -- say for blood pressure, or cholesterol, or any other chronic condition -- have you ever wondered why your insurance company only lets you buy 30 days worth at a time (or possibly 90 days by mail order)? Wouldn't it be easier to let you get a big jar that lasts six months, so you don't have to keep hassling with refills? (Most meds don't expire for considerably longer than that.) In fact, most people stop taking their blood pressure pills after a few months, and that's one of the big reasons why -- it's a pain in the neck to have to keep going to the drug store every month, fork over a co-pay of $10 or more, and have to keep getting your doctor to give you refill prescriptions.

The reason insurance companies don't let you buy a long-term supply of meds is because you might lose or change your insurance at any time -- because you lose a job, or change jobs, or your employer changes plans. Then they would have bought you some pills for a period of a few months during which they weren't getting premiums for you. They would lose a few bucks. Of course, it might cost them a hell of a lot more if you have a heart attack or a stroke, but by the time that happens, chances are very high that you won't be on their plan. They have figured out that it's in their financial interest to make you refill your prescriptions every thirty days, even if that makes you more likely to have a stroke 10 years from now. Now that's moral hazard!

If you'll look at your co-pays, you may find that the co-pay for a colonoscopy is something like $150. That's enough to discourage a lot of people from getting one. Colonoscopies are fairly expensive to the insurer -- something like $800 or more -- but they pretty much can totally prevent colon cancer, which is far more expensive. However, once again, by the time you are diagnosed with colon cancer, 10 or 15 years after you should have gotten your screening colonoscopy at age 50, they figure you won't be on their plan any more. Now that's moral hazard!

You may have read about an experiment in New York in which people with diabetes received intensive disease management -- frequent examinations; lots of education and support to help them control their blood sugar through diet, exercise, and medications; education and support on foot care and other measures to prevent amputations. It really worked -- it was shown to be cost-effective in the long run, because an amputation costs $30,000 and up followed, of course, by disability and additional expenses. But the insurance companies wouldn't pay enough to make the programs sustainable, even though they are more than happy to pay the $30,000 for the amputations. Once again, they are betting that by the time you need the amputation, it will be somebody else's financial responsibility. Now that's moral hazard!

I could go on and on. There are tons more examples. Wow! This is really dumb! What's the answer?

Universal, comprehensive, single payer national health care. If everyone is in the same pool, and guaranteed to stay there, the financial incentive is clear: prevent disease, promote health. Spend money to save money, and to prevent suffering. What's wrong with that?

Monday, April 24, 2006

The rest of what health insurance is

Okay, so health insurance is partly sorta kinda like casualty insurance. However, 90% of the time that's not what it does for us. It's more like a maintenance contract. It pays for most of the routine and preventive medical services that people ordinarily use even when they haven't just been hit by a bus or collapsed with a squeezing pain in the chest.

Now, some percentage of that is basically predictable -- there are recommended intervals for mammograms, it's recommended that people have their blood pressure, cholesterol and blood sugar checked, etc. Most people get physical examinations every year or two. Then there's is a part of it that varies somewhat from person to person. If you are diagnosed with hypertension, your doctor may prescribed medications, for example. You may have acute diseases that aren't extremely serious but still result in treatment, such as an antibiotic prescription or minor surgery.

Health insurance smooths out the budget for those lesser expenses and also spreads it among individuals and families. There is some benefit in convenience and predictability, and a justice interest, although the justice issue is not as sharp as it is in the case of emergencies or life threatening disease.

However, an even more important reason why it makes sense for people to have this kind of insurance is that spending a little bit of money now can save a lot of money later. Vaccinations are an obvious example of a very inexpensive intervention that has a huge impact on later medical expenses and also prevents a great deal of disability. (You may be too young to remember the devastating effects rubella on fetuses, causing the birth of severely retarded infants; or deafness caused by measles; or paralytic polio.) But there are many other examples. Cervical cancer and colon cancer are almost entirely preventable by screening and early intervention. Control of hypertension and diabetes pay enormous dividends in prevention of disability and the need for very expensive medical procedures.

It has been shown by gold standard studies -- randomized controlled trials -- that when people have to pay out of pocket for such routine care, they often decide not to get these preventive services, or they delay seeking medical attention for symptoms until disease is more advanced and more expensive (if not impossible) to treat. Some people, of course, can't afford them at all; others just decide to do something else with the money. Are they irresponsible, or self-destructive, or crazy? No, they just aren't experts on primary care medicine. They are making decisions that seem right to them at the time, but which they might regret later.

And that brings us to the Ownership Society proposal for health care reform: have people buy really crappy health insurance that only insures against catastrophe, and save up money in tax advantaged accounts to pay for routine and preventive care. This is supposed to control medical costs because if we're spending our own money, we won't be subject to moral hazard. Yup, Chimpy and his friends apparently assume that people are gobbling hydrochlorothiazide, lovastatin, and erythromycin; having lumps in their breast biopsied and tubes stuck up their colons; having their appendices removed and their coronary arteries reamed out, not because they actually need any of these things, but because their insurance is paying for it so they might as be freeloaders.

This is so patently absurd that every human being with common sense should hold them in utter contempt. But Bill Frist and the Decider go around the country spouting this idiocy in front of college educated journalists and even audiences of physicians, and they are taken seriously. Of course, I'm not being fair and balanced, I'm relying on facts and logic.

Sunday, April 23, 2006

Slacker Sunday: The Weirdness File

For some years, I have collected weird shit, to use the technical term. This is an inexhaustible, bottomless well of the inexplicably human -- much of it objectionable, much of it just totally nuts. Today, I'm going to offer a sampling of the nuts. No particular message or theme.

Here's a business card somebody handed me at a reception (name changed to protect the last true Rennaisance man):

Brokerage Business Centers/Management
Education Development Administration Offices of:
Dr. Eustace O. Atwanya

Expert: General Consulting Contracts, Assets Management, Real Estate Investments, Home Buying Services, Loans, Insurance, Travel Services, Social-Political Public Relations Liaison, Negotiation-Medication-Resolution, International Services & Cuisine Finder, Promoter, Advertiser, Caregivers, Research, Edu-Care Technologies, Fundraisers, Training, Recruiting, Financial Services, Career-Employment-Business Opportunities.
We bring the best in business and in human nature!

Solutions Reservoir Executive

Anyone requiring Dr. Atwanya's services should contact me for his number.

Then there was this news clipping from 1996. Perhaps you remember it?

By Reuters
The St. Louis Art Museum has filed a $2.5 million lawsuit against the Whitney Museum of American Art and its security services for a 1993 incident in which a guard drew a heart and wrote romantic messages on a Roy Lichtenstein painting.

"Curtains," a large Lichtenstein canvas, was on from the St. Louis museum to the Whitney when a security guard disfigured it. . . .Mr. Walker used a felt-tip marker to write "I love you, Tushee, Love, Buns" and to draw a heart inscribed "Reggie + Crystal 1/26/91" on the work.

Personally, I view this as an enhancement. Then there was the preacher who handed me this flyer:


PREACHING AGAINST: Adultery, divorce & remarriage, marriage annulment, fornication, common-law living, oral sex, lusting, homosexuality, lesbianism, pimps, pornography, mixed bathing, women wearing shorts, hatred, stealing, cheating, lying, deceiving, gambling, using God's name in vain, dope addiction, alcoholic beverages, tobacco use, smoking, pride, make-up, certain television programs etc., suicide, murder, rape, bribery, extortion, arson, mini skirts, revenge, burglary, rock music, and all the rest that Bible condemns!

Jesus said, you compass land and sea to make a prosylite and now he is ten times more a child of hell. In other words, you made him more wicked than he was before. Listen to what the prophet says and be ready for Jesus' coming. The blood of Jesus cleanses as you repent.

If you want to know what the Holy Ghost said concerning television sets, he said, "Move them out".

Love in Jesus name, "That Prophet"

Unfortunately, I only have an out-of-date Bible.

And now, a classic: Ruth Reichl's most famous restaurant review (edited to go straight to the good parts):

Any sane person would have given up after the asparagus-raisin sorbet.

Not me.

But then I already had a surreal history with Shin's. There was the first visit, when the waitress tok our order and went off, leaving us to sit, foodless, beneath the huge pink rhinoceros . . . ."I'm so sorry," said a pretty woman, coming up 45 minutes later to retake our order. "Your waitress quit." Was it something we had done? She shook her head. "She just didn't speak English." . . .

So here we are, three months later, seated at a corner table. The lights above us are blinking: they get very bright, then dim again, then suddenly blaze on. We want a drink, anything to get warm, but we can't get anyone's attention. "Can we please get a waiter?" we plead. Finally a man with a ponytail comes loping over. We point to the place in the menu that talks about an intriguing fresh sake "exclusive in the U.S. to Shin's." The ponytail nods. He comes back empty-handed. "We don't have that," he says.

We settle for ordinary sake and settle in with our menu. It urges us to order the chef's special omakase tasting dinner, a customized menu that changes every night. We ask the waiter to tell us about tonight's omakase menu. He looks puzzled, as if this is the most exotic possible request. But he dutifully flips out his pad and starts reciting.

Everything he mentions is on the menu.

When we point this out, the waiter has a ready answer. "You see," he explains, "the chef's don't speak English so they can't really tell us what the dishes are." [After a couple of edible appetizers] we are starting to be happy. At that precise moment the busboy picks up a plate and kocks a glass of ice water into my lap. As he tries to sop that up, he knocks over a bottle of sake. By now the tablecloth is a puddle and my clothes are soaked.

[Some dishes follow ranging from uninspiring to disgusting.] Those who have chosen not to experiment with the omakase menu are not doing much better. Chopsticks that break in the wrong place. Soggy tempura. Black cod with the unnerving texture of Cream of Wheat. . . For desert there is aparagus-raising sorbet. Don't want that? You have a choice of berry cottage cheese or banana sorbet. What do they taste like? It is impossible to tell: all three are suffering from freezer burn and all three taste like the refrigerator. Shin's is out of all other deserts.

Leaving, we are handed our coats and an umbrella that isn't ours. For a moment, we actually contemplate making off with it.

Unfortunately, you won't be able to eat at Shin's. For some reason it closed shortly after this review.

Finally, although I could go on for days, here is an advertisement from the Boston Globe. Somebody paid good money for this.


A dead realm ruled by golden radiation
Left haunted by wealth and power
Orange opposes the papal empire
Where true peace can never flower
A piece of red is answered on yellow
Revolving around the fire's glow
Blue lays out the proposed solution
Grey turns to dancing white tango.

Dedicated to my grandfather Chester Kime (Kime and Bonebrake, J.C. & E.K. photographers, Akron.) He broughthis wife Margaret "Peg" C. Marin, a high school classmate of John S. Knight of Knight Ridder, a Willys Knight (whose namesake W.J. Willy died with Joseph Patrick Kennedy, Jr. in 1944. (Joe Jr.'s sister Kick's husband William, Marquess of Hartington, also died that year. (Kick died in '48.))) He died of alcoholism in 1944 (2/2) leaving 3 children: Joseph, Janet and William (of DePere, WI) and saleman for Employer's Insurance of Wausau (dec'd '86.))
Also to C. Nelson Wright (born Nelson in Rittman, OH) who sold tools from the trunk of his car prior to founding Wright Tool & Forge Co. in 1927. He died Easter Sunday, 1972.
Please see my ads in the 3/16/90 Globe; 3/1/91 N.Y. Times (& Harvard Crimson); 3/14/91 S.F. Chronicle/Examiner. Always remember Alice Cooper's "Billion Dollar Babies" and watch out for spiders!

I have taken that advice to heart.

Friday, April 21, 2006

The Decider hears the voices

One thing they tell him, consistently, is that cutting taxes causes faster economic growth, because if the money stays in your pocket, you spend it, so companies can sell more stuff and they hire more people who in turn have more money to buy more stuff with and round and round it goes. "It's Economics 101!" he yells, channelling the voices.

Well, actually, no it isn't. When the government collects tax money, guess what it does? It spends the money! Yup, and when government spends money, it buys things from companies that hire people who . . . etc. And government hires people itself, who spend money that . . . etc. Or government puts money back in people's pockets -- social security beneficiaries and so forth -- who spend the money . . . etc.

In fact, government can spend money in ways that create economic growth, that the private sector will not and cannot do. Government spending, in fact, is absolutely essential to the very existence of a modern economy. Government builds and maintains roads and airports, educates children, pays for basic scientific and medical research on which industry depends for technological advancement, but which private industry would not fund because the company that spends the money cannot monopolize the benefits of the resulting discoveries.

A pre-eminent example is biomedical, public health and clinical research supported by the National Institutes of Health. Guess what? National "defense" spending (the vast majority of which has nothing whatever to do with defending the country) is now $1,600 per person, per year; while federal support for medical research is $97 per person per year. Most of "defense" spending is indeed squandered: it buys bombs and missiles that just blow themselves up along with buildings and people; airplanes that fly incredibly fast but don't transport anything or anyone to anywhere except for those bombs that destroy; tanks and "fighting vehicles" and gas guzzling armored trucks that carry guns around the countryside of Iraq and shoot and kill people and blow stuff up. The economic payoff for all that: negative. It's Economics 101.

Unfortunately, the corporate media doesn't know that. They take it as axiomatic that lower taxes mean higher growth rates. It just is not true, and international comparisons prove it. Overall levels of taxation are far higher in other wealthy countries, but they are not correlated with growth rates. That's just being reality based.

If we raise taxes, eliminate this insane spending on the military, and invest the money in true national defense -- energy conservation; mass transit; renewable energy; universal, comprehensive, single payer national health care; quality public education including universal access to higher education without regard to family wealth; scientific research including medical and public health research; public health infrastructure; early intervention for children with special needs; development of the arts; and whatever you want to add to the list -- we'll be far richer than we are now and more important, we'll stay that way, because right now, we're headed for the worst crack up since Easter Island.

Thursday, April 20, 2006

And another new link

I've also added the Church of Reality to the sidebar. Res ipsa loquitur.

What is health insurance, really?

In our previous episodes, we discussed actual insurance, such as fire insurance and life insurance. Purveyors of these products must confront the problems of adverse selection and moral hazard, and the quandary that the better they do at reducing these problems, the less desirable their product becomes. If they could perfectly match the price of a policy to the individual buyer's risk, their product would be worthless, and nobody would buy it. They survive because the world is still fairly unpredictable, and they are helped by regulation which stops them from competing themselves out of existence in a process called the death spiral.

Is health insurance like casualty insurance? Partly, sorta kinda. It is true that part of the value of health insurance is that it pays for extraordinary expenses associated with catastrophic events, such as severe injuries from a car crash or a fire, or diagnosis with a serious disease, expenses that the policyholder probably could not afford to pay out of pocket. In that respect it is like casualty insurance.

We'll discuss what I'll call the non-casualty dimensions of health insurance in a later post. So keeping in mind for now that health insurance includes very important components that are nothing like casualty insurance, let's just consider the casualty part. Even that part of it is very different from other kinds of casualty insurance from the societal point of view. There are at least three very important differences.

The first is that when people experience severe suffering, or their lives are threatened by illness or injury, the ethical principle called the Rule of Rescue creates a social imperative to save them if possible. We do not feel compelled, as a society, to rebuild the home or business of someone who doesn't have fire insurance, or to restore the income of a widow who loses her business executive husband. (We do provide modest social security survivor benefits, and homeless families may get emergency shelter, but the value of these social insurance benefits is far less than the loss, and they are available only to the destitute.) However, we do not tolerate having people expire on the sidewalk outside of the hospital for lack of financial resources, even if their treatment would cost tens of thousands of dollars. We end up paying for it somehow.

Here's an excerpt from an e-mail I received yesterday:

Hi Joaquin,

I'm in desperate need of help. I am working at the University Hospital in Cincinnati, and I have this 25 year old patient who is an undocumented worker. On Sunday, he was involved in a motor vehicle accident that left him a quadraplegic with very minimal movement of both his arms. Because he is undocumented, has no family here that can take care of him full-time, and no health insurance, one can see the imminent danger once he leaves this hospital in a week. Hamilton county cannot provide him full services as an uninsured patient because he does not have documentation that he has been living in Hamilton County for longer than a month before the accident. He has an aunt and uncle that live close, but both have to work full-time and cannot take care of him. His only family is his mom living near Cancun who may not be able to take care of him, either. What we're trying to come up with is a solution to provide him with the equipment, rehab, nursing care, and prescriptions needed once he leaves this hospital.

Whatever may happen to this young man in the future, the hospital has already spent tens of thousands of dollars on his care. Furthermore, they cannot simply push him out the door and let him die. In this particular case, he may be deported to Mexico, but if he were a U.S. citizen, Medicaid would pay for his care, for life.

So the Rule of Rescue creates a kind of ethical externality -- both related and unrelated people would suffer from torments of conscience if we did not provide catastrophic medical care. But there are additional positive externalities. For example, people who are of working age who suffer curable or controllable conditions -- be it life threatening trauma or chronic disease -- can be returned to or maintained in the labor force, contributing to the support of their families and the common wealth; or providing care to their children, keeping a home, etc. Retired people may have important social roles as grandparents, repositories of wisdom, etc. That is a second difference from other kinds of casualty insurance.

Third, there is very little moral hazard involved in catastrophic medical insurance. While it is conceivable that having such insurance might make some people less diligent about practicing good health habits, there is no evidence for it. Getting lung cancer is sufficiently unpleasant, even if you have insurance, that it is unlikely that health insurance makes people decide not to quit smoking after all. There are much more powerful explanations for our bad habits. And nobody is going to check into the hospital for a heart transplant who doesn't actually need one, just because they have insurance to pay for it.

And that brings us to a final, essential point. The catastrophic part of health insurance is ultimately about social justice. The misfortunes that befall people, which can be ameliorated by medical care, are for the most part a random harvest. To the extent they are not random, they are in fact more likely to befall the poorest and most vulnerable among us. We don't feel compelled to do very much about their poverty and vulnerability, but we are compelled to do something about their imminent death or disability. It's just the right thing to do.

Next time: The rest of what health insurance is.

Wednesday, April 19, 2006

A must-read

The new issue of PLoS Medicine is a theme issue on disease mongering. Go there. Read it.

PLoS Medicine is also a new permanent link on my sidebar. (Firedoglake, which for unknown reasons dropped me from their blogroll, has suffered retaliation. So there.) PLoS, Public Library of Science, is a leader in the open access scientific publishing movement. My readers know that I am continually frustrated by not being able to give you access to the latest literature in medicine and public health which I discuss here. As a medical school faculty member, I have access to nearly all of the leading journals, but the rest of the world does not. That means that information that is vital to your health and well being is information that you can't get, unless you can get access to a medical school library.

According to its mission statement:

About PLoS
Mission and Goals

The Public Library of Science (PLoS) is a nonprofit organization of scientists and physicians committed to making the world's scientific and medical literature a public resource.

Our goals are to:

* Open the doors to the world's library of scientific knowledge by giving any scientist, physician, patient, or student - anywhere in the world - unlimited access to the latest scientific research.
* Facilitate research, informed medical practice, and education by making it possible to freely search the full text of every published article to locate specific ideas, methods, experimental results, and observations.
* Enable scientists, librarians, publishers, and entrepreneurs to develop innovative ways to explore and use the world's treasury of scientific ideas and discoveries.

PLoS is funded in substantial part by grants and donations. How many journals can be supported in this way is not clear. Sustainable open access models depend largely on funding by authors -- that is, authors pay a fee for publication, which it has been calculated would be something on the order of $3,000/article to sustain a typical scientific journal. This does not imply corruption or payola -- articles are still peer reviewed and accepted only on merit, and the idea is that the budget for a research project has to factor in the cost of publication, i.e. research grants would include that cost on the front end. If results don't merit publication, presumably that funding would be recovered for another purpose. PLoS journals charge an author fee, but much less than $3,000, because they have that subsidy.

An editorial in the new NEJM (which you can't read, ha ha ha) by Martin Frank disparages this idea, on the grounds that grant funds would be "diverted" to publication. "At a time of shrinking budgets for biomedical research, does it make sense to spend scarce dollars on publication costs instead of on research to develop treatments and cures for disease?"

I got three snappy answers for you Dr. Frank:

A) $3,000 out of a typical NIH grant of anywhere from $250,000 to $5 million and up is chicken feed;
B) Medical schools are already paying the cost by buying all those expensive subscriptions. They could divert that money to support for faculty research. Tah dah!
C) Open sharing of scientific information will speed scientific progress.

Oh yeah -- the NEJM doesn't need subscription or author fees - it makes millions of dollars in profits every year, by selling advertising. NEJM could go open access now, today. They can sell advertising on-line as easily as in print. Hell, they'd probably make even more money. Why don't they? Because the idea of privilege and exclusivity is even more important to them than money.

The End of Evil?

Tracy Hampton in the new JAMA (subscription only)* reports on a February conference called Resilience in Children, sponsored by the New York Academy of Sciences. She discusses work presented at the conference along with earlier published research, in particular work by Caspi and colleagues (relevant abstract here) which finds that of people who are maltreated as children, those who have a certain genotype that confers high levels of the enzyme Monoamine Oxidase A, which regulates the level of a neurotransmitter, were less likely to develop antisocial behavior. Other work by Caspi and colleagues has found an additional effect of a genotype affecting serotonin levels. (Hampton goes on to discuss similar research in animals which finds that variant genotypes can protect against the behavioral effects of deprivation of maternal nurturing. Such animal studies are suggestive, at best, about human social psychology, but do constitute a proof of principle, at least.)

Now, it is well known that mistreated children are at elevated risk of addiction, failure in school and work, criminality and even severe antisocial behavior. The criminal justice system may take a history of child abuse and neglect into account as a mitigating factor in sentencing, but not as an excuse for criminal behavior. And indeed, while it is usually present in the worst criminals, including most candidates for the death penalty, in the case of truly heinous crimes it seems to have little effect on juries.

The most important argument for why being mistreated as a child does not relieve one of moral responsibility for later crimes is that most people who are mistreated do not go on to depravity. But what if this too is just a roll of the dice, attributable to the random substitution of adenine for guanine in a single gene, or in any case some combination of genetic polymorphisms? Even without this knowledge, of course, thoughtful people have already recognized that there must be an additional element of luck involved, such as encountering a caring, effective adult at a crucial time.

There are also some sociopaths, such as Michael Ross (whose case I have discussed before) who do not have any known history of maltreatment. The gene variants that fail to protect abused children do not, apparently, cause any elevated risk of antisocial behavior for children who are well nurtured, but no doubt there are other explanations, in genes or environment, for the Michael Rosses and Ted Bundys of this world. Functionalist arguments can still be made that there is a social need for punishment, stigmatization and retribution, but a complete science of the mind renders these actions ethically suspect. In effect, everyone is innocent, and the commission of evil is merely a misfortune for the perpetrator as well as the victim. What then, is the morally defensible response to intolerable behavior?

* I will have more to say soon about open access publishing, and will link more to PLoS Medicine as well.

Tuesday, April 18, 2006

More apocalypse . . .

Just so you know we're fair and balanced, Eric Pianka believes that the probability of an emergent infectious disease (or perhaps more than one) causing a human population crash is substantial:

Some politicians, economists, and corporations want us to believe that technology will come to our rescue. But we have a false sense of security if we think that science can respond quickly enough to minimize threats from emerging diseases. Microbes have such short lifecycles that they can evolve exceedingly fast, much faster than we can respond to them. Many bacteria have evolved resistance to most antibiotics, and viruses are resistant to just about anything. Defense always lags behind offense. So far, modern humans have just been lucky. A reactive approach to problems isn't enough, we also need to be proactive and anticipate problems before they become too severe to keep them from getting out of control.

I'm still skeptical about that, but he does make the point that since the globe is far more crowded with human beings today than ever before, and since travel around the globe is possible in a few hours, a plague would not be limited to a single continent, as the Black Death was to Europe or the demographic disaster caused by smallpox was to the Americas. I will just reiterate what I have said here many times: we need to take the problem of antibiotic resistance very seriously, and we need to develop new vaccine manufacturing facilities based on cell culture techniques that can ramp up manufacturing of novel vaccines quickly and in large quantities.

And then, yes, we need to work to reduce the human population over time, by making contraception universally available and raising the status of women. We need to do whatever we can to reduce the use of fossil fuels, since global warming increases the dangers from infectious diseases. We need to build strong public health infrastructure around the world. We need to provide everyone with clean water. We need to change our methods of animal husbandry (and eat less meat while we're at it.) Whether an emerging infection kills 1%, or 10%, or 90% of the population, it won't be pleasant. Pianka isn't exactly wishing for it, as he has been unjustly accused. But he seems to see that 90% event as inevitable. Let's make sure he's wrong.

Kicking them while they're down

Around this time last year I mentioned that our friend here, Pharmy, from the Prescription Access Litigation Project's Bitter Pill Awards, would likely be paying us visits from time to time. So here he is again, to promote this year's awards. Stop by and make a nomination for most outrageous drug company advertising tactic!

We're also beating up on Big Pharma over at Critical Condition, in connection with another PAL campaign. So I might as well get in a few more knocks here. Those of you who pay attention to these issues are no doubt aware that drug prices are much higher in the United States than elsewhere -- hence all those criminal senior citizen smugglers taking bus trips to Canada and Mexico. Big Pharma, with strong endorsement from the current compassionately conservative administration, claims that they need the high prices to pay for research and development. Supposedly, people in those other countries where the pills are much cheaper are "free riders" on the miracles of Yankee innovation. The Commerce Department even called for other countries to raise their prices on patented medications. (Now that's compassionate!)

Is it any surprise that this is, er, not true? Donald Light and his colleague Joel Lexchin, in the British Medical Journal (abstract only available to the common folk) prove it. Actually, their desire to use the "L" word is almost palpable.

  • Drug companies in countries with lower prices, such as the UK, invest a higher percentage of their revenues in R&D than do U.S. companies;
  • Drug companies in lower price countries fully recover their R&D costs from sales and make high profits;
  • Drug companies in lower price countries spend as high a percentage of GNP on drug R&D as does the U.S. (Specifically the U.S. is at about the median, investing .24%, compared with .55% in Switzerland and .35% in Sweden, for example.)
  • European companies are just as innovative, proportionate to their share of the world market. The U.S. accounts for 48% of world pharmaceutical sales and discovered 45% of new drugs* that were introduced in 2003; Europe accounts for 28% of world sales and introduced 32% of new drugs.
Light and Lexchin go on to point out that drugs are sold in a global market, and it doesn't make any difference where the revenues come from, i.e. whether domestic revenues cover a company's R&D costs is irrelevant. Drug companies invest 3 times as much in marketing, advertising and administration as they do in research; if they really couldn't afford their R&D costs, they might look to cut funds there before they cut back on R&D. Furthermore, fixed costs such as research have little influence on prices; marginal costs are much more important, and the marginal costs of actually manufacturing drugs are almost trivial. The marginal costs that are important for the U.S. industry are marketing costs. As the authors conclude, "The pharmaceutical industry and the U.S. government want to blame other developed countries for these higher prices rather than make drugs more affordable."

* Meaning real new drugs, so-called "new molecular entities," not including reformulations of old drugs intended to maintain exclusive marketing rights.

Monday, April 17, 2006

Apocalypse please?

The Christian millenarian movement (those folks who expect to be raptured up to the heavenly kingdom while the rest of us have to deal with the tribulations and the reign of the Antichrist and the battle of Gog and Magog and what not) justly get a lot of attention, because they vote for Republicans and support insane policies like invading Iraq, expelling Palestinians, and stoning homoexuals to death. But there's a lot more of that end-of-the-world stuff going around. Or at least close-to-the-end-of-the-world stuff.

The survivalist movement of the 1990s is still a fresh memory. Supposedly computers wouldn't be able to tell the difference between the Year 2000 and 1900, and the result would be the collapse of civilization and the death of billions in famine, plague and war. Since I've started blogging, I occasionally get e-mails from people who have absolutely figured out that within a year or two there will be a global currency crisis that will destroy civilization resulting in the death of billions in famine, plague and war. (I can save myself and my family by hoarding silver, or joining their society which is going to issue its own currency, or heading to the hills and developing a self-sufficient lifestyle.)

The threat of emerging infections is real enough, but there are those who seem convinced that we aren't just talking about a disruptive event with a lot of sick people, economic losses and a spike in mortality, but the collapse of civilization resulting in the deaths of billions in famine, plague and war. Sometimes these fears are concatenated -- the flu pandemic brings about the currency crisis, leading to etc. etc.

One starts to suspect that, at least in the case of many people, these are expressions not of fears, but of wishes. Certainly that is true in the case of the Christian millenialists, but is the psychology of the secular apocalyptics similar? Do they yearn for a better world on the other side of the Great Dying?

Ecologist Eric Pianka of the University of Texas gave a speech at the Texas Academcy of Sciences in March in which he warned of plague that might kill billions. He was falsely accused by creationists and other nut cases of advocating this, and even of trying to manufcture pathogens. However, it does seem that Pianka thinks the world would be better off with something like 10% of the human population we have now.

Now personally, I don't think there is anything outrageous or immoral about having that opinion. The earth once had a much smaller human population, and perhaps it will again one day, and people on the whole might be happier in a world with fewer humans. It is perfectly logical and ethically defensible to like humans in the particular but to believe that humanity in the mass is a destructive force. However I do not think it is ethically defensible to want to get there by slaughtering vast numbers.

I don't know exactly what Pianka hopes for, I have never communicated with the man and published excerpts of his remarks don't make it entirely clear. This is not about him or his bizarre case. But it is about the phenomenon of actually hoping for some form of acpocalypse, either consciously or unconsciously. I think that a human population crash could result from nuclear war, although given the present distribution of nuclear weapons it would have to be a war between the U.S. and Russia, which is not at all likely. (That could change, some day.) A war between the U.S. and China could be nearly as horrific, but seems an extremely remote possibility. A regional nuclear war, involving such nuclear powers as Israel, Pakistan, or India, is more probable. It would be locally devastating and might have very severe economic consequences, particularly by eliminating much of the supply of petroleum. But a global depression will not cause the human population to crash. After all, we had one in the 1930s, followed by the most terrible war in history, and the population just kept growing.

Similarly, even the worst infectious disease outbreak that is in any way plausible would not cause a human population crash. The 1worst flu pandemic in known history, in 1918, caused a transient spike in mortality but scarcely interrupted the upward curve of human population. The Black Death, the most destrutive known plague of any kind, killed perhaps 1/3 of the population of Europe over a generation or so, but that was before people understood pathogenicity. We have the knowledge today to far more effectively control such an event, even in the case of a novel pathogen for which we lack a vaccine or a pharmacological treatment.

So it seems to me that predictions of apocalypse are either paranoia, or wishful thinking, and I'm inclined to believe that the latter is more prevalent. A decline in the human population is desirable, in my view, but we are very unlikely to get there by a massive spike in the death rate, and we certainly should not wish for that. A long-term decline in the birth rate will get us there, although there are certainly great difficulties to be overcome from the epoch of radically aging population through which we would have to pass. That is a surmountable challenge, though, and we ought to be thinking about how to take it on.

And for all the wishful thinkers out there, if civilization does collapse and 90% of the people die, you should not expect to see the utopia on the other side -- even if you do stockpile a year's worth of biscuits.

Friday, April 14, 2006

Don't wait up for me . . .

I will probably be away from Your Internets for a couple of days while I do some construction work and study up for my Jeopardy! audition (seriously -- I'm going to be memorizing all the presidents, state capitals, and Foods that Begin with the Letter Q).

Meanwhile, my friends have asked me to be constructive and positive about the new Massachusetts health care legislation. Okay. The deal is, what happens from here, over the next couple of years, is what really matters. This is the beginning, and we're starting on the top of a very steep ridge. We could fall off to either side. It's because he hopes we'll fall to the wrong side that the Republican governor and candidate for president supported the bill. It's because they hope we'll fall off to the right side (which I suppose would be the left side) that Health Care for All, unions and other progressive organizations supported it.

The wrong side is that there isn't enough money to make the subsidized plan for low income people really affordable, and the "affordable" plan for moderate income people is crappy insurance that still isn't affordable; while employers continue to bail out of providing decent insurance because they can dump people onto the subsidized and "affordable" plans for only $295 a year. Most people end up with high-deductible insurance that they are forced to buy, that doesn't cover their routine and preventive care, for which they now pay out of pocket. Poor people are forced to buy insurance they can't afford, and the political pressure forces the legislature to make that insurance worse and worse -- less comprehensive, with higher cost sharing. Massachusetts enters the Cato Foundation utopia.

The right side is that the subsidized plan really is affordable and comprehensive. Because a much higher percentage of the population is in the public insurance pool, the state gets a real handle on health care costs, by gaining the leverage it needs over hospitals while promoting good quality care and giving people at risk the prevention and early intervention services that will really save money in the long run. At some point, the legislature raises the $295 assessment on employers that don't provide insurance and turns it into a payroll tax with an exemption for the first $10,000 or so in pay per employee, so that it is both progressive (instead of the regressive job tax we have now) and provides enough incentive that employers won't stop providing insurance. Eligibility for the public plan is extended, so that moderate income people can buy in at full price instead of buying the crappy "affordable plan," and the public plan is affordable for them because it has buying power and can effectively control costs while maintaining quality care. We start to move toward where we really want to go.

Can that work in a single state? Therein lies a real and possibily insurmountable problem. More on that later.

Thursday, April 13, 2006

Boooooooooorrrrrrinnnnnng . . . .

Yup, I'm talking about insurance. Hartford, once the "Insurance Capital of North America," was not so much celebrated as mocked for that distinction. "America's file cabinet" was one popular epithet.

It's painful I know but I'm going to press on. As you will recall, in our last episode, we discussed Fred's Insurance Company and his problem with people buying life insurance because they figured they were about to shuffle off this mortal coil, whereas people who figured they had plenty of time left to make their fortune and write their novel weren't likely to pony up. That is called adverse selection -- people who really need the insurance are more likely to buy it, which is not good for John Hancock's profits.

As a commenter pointed out, another problem that Fred has is called Moral Hazard. Basically, if you know you have fire insurance, you might not be as diligent about fire protection. You might not be as inclined to buy fire extinguishers, to clear the brush from around your house, to make sure your chimney is cleaned, etc. Of course you have other incentives not to let your house burn down -- danger to life and limb, loss of articles of sentimental value, major inconvenience. But on the other hand, if your house is old and crummy, or you can't pay the mortgage, you might be tempted to set a fire -- the ultimate form of moral hazard. Most people with life insurance won't be more likely to die because they have it, but people who are desperate about being unable to provide for their families might -- as in Death of a Salesman.

Note that we still haven't said anything about health insurance. As I said before, health insurance isn't actually insurance, at least not if that term is supposed to refer to the kind of product we have been discussing. Unfortunately, a lot of supposedly smart people, including the denizens of conservative think tanks and the Republicans in the executive branch and the Congress, are confused because health insurance and fire insurance have the same last name. They know all about the moral hazard problem, so they think it must be a big problem with health insurance. Therefore, they want us to have high deductibles in our health insurance policies so that health insurance companies won't be subject to moral hazard.

What's wrong with this picture? Tune in next time, when we actually begin to discuss health insurance.

Wednesday, April 12, 2006

WaPo Bombshell is old news

The "bombshell" in today's Washington Post, showing that U.S. intelligence had known since May 2003 that the "mobile biological weapons labs" in Iraq were just hydrogen generators for filling weather balloons was reported in the United Kingdon in June, 2003. Here's the story from The Guardian.

Iraqi mobile labs nothing to do with germ warfare, report finds

Peter Beaumont, Antony Barnett and Gaby Hinsliff
Sunday June 15, 2003
The Observer

An official British investigation into two trailers found in northern Iraq has concluded they are not mobile germ warfare labs, as was claimed by Tony Blair and President George Bush, but were for the production of hydrogen to fill artillery balloons, as the Iraqis have continued to insist.

The conclusion by biological weapons experts working for the British Government is an embarrassment for the Prime Minister, who has claimed that the discovery of the labs proved that Iraq retained weapons of mass destruction and justified the case for going to war against Saddam Hussein.

Instead, a British scientist and biological weapons expert, who has examined the trailers in Iraq, told The Observer last week: 'They are not mobile germ warfare laboratories. You could not use them for making biological weapons. They do not even look like them. They are exactly what the Iraqis said they were - facilities for the production of hydrogen gas to fill balloons.'

The conclusion of the investigation ordered by the British Government - and revealed by The Observer last week - is hugely embarrassing for Blair, who had used the discovery of the alleged mobile labs as part of his efforts to silence criticism over the failure of Britain and the US to find any weapons of mass destruction since the invasion of Iraq.

The row is expected to be re-ignited this week with Robin Cook and Clare Short, the two Cabinet Ministers who resigned over the war, both due to give evidence to a House of Commons inquiry into whether intelligence was manipulated in the run-up to the war. It will be the first time that both have been grilled by their peers on the Foreign Affairs Select Committee over what the Cabinet was told in the run-up to the war.

The curtain of censorship over North America at the time, however, meant that we never heard about it here. (I screamed and yelled about this at the time, wrote letters to the editor, etc. Got nowhere, of course.)

An absolutely literal post

requiring no sense of humor to understand.

This graph, which I have posted here before, shows trends in life expectancy at birth in the U.S. for white and Black men and women. (Other groups are not shown because of lack of adequate historical data, and the complicating effects of immigration.) As you can see, women live longer than men, and white people live longer than black people. By coincidence, the effects cancel out so that white men and black women have about the same life expectancy. (Life expectancy is an artificial construct based on the idea that everybody born today will have the same probability of dying when they are 1, 5, 10, 15 . . . 80 years old as people in their demographic category do today.) Although life expectancy overall has been increasing, the disparities have remained.

The greater longevity of women holds throughout the wealthy countries. It didn't used to be true, in large part because of the risk of dying during childbirth. Fortunately, in the 1850s, Ignaz Semmelweis discovered that by having birth attendants carefully wash their hands and instruments, the risk of women contracting fatal post-partum fevers could be nearly eliminated. He was scorned at first, but eventually his ideas were accepted. Subsequently, medical technology greatly reduced the risk from other complications of childbirth as well, notably pre-eclampsia and hemmorhage.

Female longevity is thought to be a basic characteristic of our species. The shorter male life expectancy is partly caused by higher rates of smoking, and a far greater risk of death by violence. However, even accounting for known, controllable factors, the relative fragility of the male remains.

In much of the world, however, until recently women did not expect to live as long as men. The continuing danger of maternal death among poor women in poor countries explains much of the phenomenon. In much of Asia selective female infanticide was of major importance. Also, in times of scarcity, again particularly in Asia, boy children would tend to be favored. Given the presumed biological advantage of women, that women now at least equal male life expectancy in all the world does not mean they do not continue to suffer from discrimination, so it is actually a somewhat meaningless milestone, but there it is.

The UN, among its other millenium development recommendation, proposes some readily affordable ways to make childbirth safer, and to raise the status of women generally, which is essential to eradicating poverty.

Still, I presume most people will agree that it is not good news that men are doomed to be outlived by their female friends. Perhaps it isn't really true after all, and there is something we are missing about male aging. The tendency of men to develop heart disease earlier than women is a major factor, and that may well be preventable. The important thing, in any case, is not to try to live forever, but to have a good life and enough life span to achieve what matters to us.

Tuesday, April 11, 2006

Call me an old grump . . .

. . .but for some reason I'm just not joining this celebration as enthusiastically as I should.

According to Anna Barford and colleagues, editorializing in the April 8 BMJ, "The year 2006 should not be allowed to pass without at least a quiet celebration that this is the first year in human history when -- across almost all the world -- women can expect to enjoy a longer life expectancy than men. . . . Almost 30 years ago, amid much fanfare, the eradication of smallpox was announced. But when it becomes certain that women everywhere can expect to live longer than men, also a remarkable achievement, a similar announcement is unlikely."

I dunno, I can't quite put my finger on it, but it seems to me there's bad news in there somewhere . . .

The Immigration Wars . . .

What's going on right now -- a campaign driven largely by bigotry to purge the country of "illegals" -- those people who according to CNN anchor Jack Cafferty "are becoming ever bolder. March through our streets and demand your rights. Excuse me? You have no rights here, and that includes the right to tie up our towns and cities and block our streets. At some point this could all turn very violent as Americans become fed up with the failure of their government to address the most pressing domestic issue of our time."

It is never clearly stated how these people are supposed to be harming the United States, just that they are "criminals" and guilty of "bad behavior" for being in the country illegally. Of course, their criminal bad behavior is motivated by a reprehensible desire to feed their children.

We've been through this before, again and again. The last time was in 1996. A very good friend of mine wrote about it back then. I couldn't have said it better myself.

The full dimensions of the crime

will never truly be known. We won't necessarily hear from our TV news about the full toll of assassinations, car bombings, roadside bombings, firefights, drive-by shootings, massacres, mortar strikes and air strikes in Iraq every day, but there are news outlets that do their best to keep track of these. (As usual, I have to tout Today in Iraq, but there are other places you can go as well, including the excellent Reuters AlertNet Foundation). However, death by violence doesn't begin to tell the story of the carnage and suffering in Iraq.

We are often told that the problems are exclusively in the Baghdad region and the so-called Sunni triangle in the middle of the country, with the Shiite south, along with Kurdistan, being peaceful and enjoying all that "progress" -- newly painted schools, re-sodded soccer fields, and so forth. But now representatives of the European agency Saving Children from War have visited the southern city of Basra and found the following:

As a result of water-borne diseases and a lack of medical supplies, infants born in the southern city of Basra are subject to abnormally high mortality rates, say officials of an international NGO devoted to child health issues.

"For weeks, there were no I.V. fluids available in the hospitals of Basra," said Marie Fernandez, spokeswoman for European aid agency Saving Children from War. "As a consequence, many children, mainly under five-years old, died after suffering from extreme cases of diarrhoea."

Fernandez went on to cite a number of problems facing local hospitals in Basra, which is located some 550km south of the capital, Baghdad. "Hospitals have no ventilators to help prematurely-born babies breathe," Fernandez said. "And there are very few nurses available, so hospitals often must allow family members to care for patients."

Many doctors in the area say that the local health situation has deteriorated markedly since the US-led invasion of the country in 2003. "The mortality of children in Basra has increased by nearly 30 percent compared to the Saddam Hussein era," Dr Haydar Salah, a paediatrician at the Basra Children's Hospital, pointed out. "Children are dying daily, and no one is doing anything to help them."

Fernandez added that, for the last three years, the Maternity and Children's' hospital in Basra had not received any cancer drugs from the health ministry. "In all of Basra, a city with nearly two million inhabitants, there's no radiotherapy department available," Fernandez complained.

Khalid Ala'a, spokesman for local NGO Keeping Children Alive, said that Basra hospitals lacked many essential drugs and antibiotics used to treat infections common to the area. "We've asked for help from the Ministry of Health, but they only tell us they don't have money to supply hospitals," Ala'a said. "They tell us we must wait for investment, which could take months."

Iraq, which once had a highly advanced public health and medical system, and population health status and life expectancy commensurate with the developed European states, is now in a condition comparable to the most impoverished parts of rural Africa. Weapons of mass destruction, anyone?

Monday, April 10, 2006

It's hard work

If the long and winding tale of the recent Massachusetts health care legislation teaches us anything, it's that most people basically don't understand what exactly the heck is going on here -- and that includes state legislators and even quite a few activists who have been pushing for something vaguely defined as universal health care or universal coverage. It's always my goal here to provide the entoxicatingly delicious bite-sized chunk of wisdom that will produce immediate enlightenment about the pressing issues of the day, but when it comes to health care policy, I just can't do it. It's complicated, the standard vocabulary is misleading, a lot of different parts have to be fitted together to make sense of it all, and it's just wonkish, and boring, and it makes your head hurt, and that's all there is to it, so there.

So I've decided to take this in pieces. First I'm going to talk about insurance that isn't health insurance. The product or service we call health insurance is only partly insurance, and to the extent that it is insurance, it is unlike other insurance in very important ways. But the mere fact that we call it insurance muddles things up. So for now, let's not even talk about it. Let's talk about automobile insurance, homeowner's insurance, and life insurance.

Insurance, in the original and still most common sense of the term, is a financial instrument for spreading risk. Most people would have their lives utterly ruined if their house were to burn down, but fortunately, only a few people's houses ever do burn down. A lot of people will willingly pay a sum they can afford -- these days typically less than 1,000 dollars a year -- for the peace of mind of knowing that if their kid plays with matches and their little Blandings Castle burns down to the root cellar, they'll be given the money to rebuild. If people have a mortgage, the bank will insist that they have insurance, because they want their collateral protected. Life insurance and automobile insurance are basically similar -- they compensate you or your heirs for an unwelcome eventuality.

Liability insurance has this function, plus one more -- it protects others who might be injured by your negligence. Therefore it is also required in some circumstances, for example in order to legally operate an automobile.

Okay then. Let us suppose that Europeans land for the first time on an island in estuary of the Hudson River, kick out the local oyster gatherers, and build a city of 8 million people. Suddenly, in 2006, Fred invents life insurance, and Fred's Insurance Company enters the virgin market. Now, Fred could figure out the percentage of adults in Manhattan who die every year -- let's say it's 1% -- and sell a $100,000 life insurance policy for $1,001 dollars a year. (We'll ignore the income he makes on the money he holds on to before he has to pay out claims -- that's important to Fred but it doesn't really matter to our point.) If he sells 100 policies, he collects $100,100, and at the end of the year he makes one $100,000 payout. He's made a hundred bucks, just for sitting on his keister signing deposit slips and writing one check. Of course, he could be unlucky and have two people die that year, or be lucky and have nobody die, so he evens it out by selling many hundreds of policies and doing it for many years -- it should work out in the long run, right?

Nope. If Fred tried that, he'd be very sorry, because a whole lot of people with terminal cancer would have bought his policies, while all those twenty-somethings jogging in the park would never even consider it. If Fred wants to make money, he's got to try to figure out the individual customer's chances of kicking the bucket in the near future, and then by some combination of differential pricing and selective sales get enough people to buy policies and not die to pay him for the customers who expire.

But wait a minute -- I thought the purpose of insurance was to spread risk. Now you're charging more to the risky people, or refusing to sell to them at all. In fact, if Fred can do a very good job of predicting your life expectancy, his product will become worthless. If he knows you are going to die in exactly 3 years, 4 months, he'll charge you exactly enough to cover the cost of the payout at that time in the future, plus his expenses and his profit, minus whatever investment income he expects to make on your premiums. Your heirs would be better off if you just invested the money yourself and didn't pay Fred.

Now, the insurance industry can't precisely predict your life expectancy, but in order to compete with each other, insurers need to do the best they can. If you are young and healthy, you're going to look for a company that will sell you cheap insurance. If you know you are sick, the insurance companies better be on the lookout for you or you'll take them for everything they've got. So insurance companies need to be able to sell cheaply to low risk customers and charge more to high risk customers, or their competition will get all the desirable sales and they'll lose their shirts.

So it's fortunate for the insurance industry that they can't precisely predict people's life expectancies, or they'd put themselves out of business because their product would become worthless. At the same time, they continue to work as hard as they can at predicting individual risk in order to keep up with the competition.

This is one reason why insurance markets are highly regulated. In order to accomplish some of the social purposes of insurance, insurance companies have to be restricted from segmenting their customers as thoroughly as they can -- and actually, insurance companies appreciate those restrictions, even if they won't admit it, because their business would be much more difficult without them. It would be impossible to buy affordable homeowner's or automobile insurance in some neighborhoods, for example, if states didn't force insurers to put customers into relatively broad pools. This does have the effect, however, of making people in relatively safe neighborhoods subsidize the insurance costs of people in dangerous ones.

Sorry to bore you. Now you can entertain yourself by thinking about ways in which health insurance is similar, and different, while I prepare to discuss that very subject.

Sunday, April 09, 2006

The memory hole.

No doubt you will recall April 9, 2003, when the television newscasts all led off with film of a crowd of jubilant Iraqis pulling down a statue of Saddam Hussein, with the help of U.S. Marines. The front pages of all the newspapers had a shot of the joyous scene the next day, so reminiscent of the statues falling in the former Soviet Union, and the crowds hammering away at the Berlin Wall. Iraq had been liberated and was greeting the triumphant Marines as heroes!

Sadly, no.

Army report confirms Psy-ops staged Saddam statue toppling
by Jon Elmer

July 3, 2004 – An internal Army study of the war in Iraq has confirmed that the infamous toppling of the statue of Saddam Hussein in Firdos Square in central Baghdad on April 9, 2003 was stage-managed by American troops and not a spontaneous reaction by Iraqis. According to the study, a Marine colonel first decided to topple the statue, and an Army psychological operations unit turned the event into a propaganda moment.

At one point during the stunt Marines draped the statue of Saddam Hussein with an American flag. When the crowd reacted negatively to that gesture, the US flag was replaced with a pre-1990 Iraqi flag, missing the words "God is Great," by a sergeant from the psychological operations unit. The Marines brought in cheering Iraqi children in order to make the scene appear authentic, the study said.

Allegations that the event was staged were made in April of last year, mostly by opponents of the war, but were ignored or ridiculed by the US government and most visible media outlets.

So, what do we read today, on the third anniversary of this phony event?

The Associated Press

Iraq police and soldiers bolstered security in the capital to prevent attacks on "Freedom Day." The holiday marks the April 9, 2003 event in which a huge crowd of Iraqis cheered as U.S. Marines hauled down the statue of Saddam Hussein on Firdous Square, marking the collapse of his regime.

Don't believe anything you read in the newspapers, and TV news lies.

Friday, April 07, 2006

And the walls come a tumblin' down

Bill Blakemore at ABC News notes that the corporate media have finally gotten around to teling us that, yes, global warming is real, it's caused by humans, and it's a big problem. He notes that this same corporate media has spent the last couple of decades telling us that the whole subject was controversial and did not represent a scientific consensus, because they were happily bamboozled by a disinformation campaign run by the oil companies. And oh yeah, GW Bush and the administration were co-bamboozlers.

Major corporate media reported on the discovery of the fossil of a transitional creature between fish and amphibians, and just flat out said that it was over 300 million years old and enhanced our understanding of the evolution of tetrapods. Yeah, they featured rebuttals from creationists, which is kind of like giving equal time to the flat earth society every time there's a satellite launch, but they made it pretty clear who was full of oats processed through a horse on this one.

We've had plenty of coverage of regulatory agencies failing to protect the public because they are beholden to industry -- the EPA in the case of arsenic and mercury, the Nuclear Regulatory Commission in the case of nuclear power plant security being two recent examples.

Career civil servants in the Department of Justice are ripping the K Street project to shreds along with the Republican one-party state, and reporters are actually covering the story, so Gonzales can't do anything about it, at least he hasn't so far, as far as we can tell.

Poor Scottie is getting the crap beat out of him every day over illegal surveillance and lying about it, those historic lies about the imminent threat from Saddam's Iraq, the manipulative leaks of classified information, and all that sordid stuff.

A good part of the talking headocracy, for reasons which are not entirely clear, continues to serve as the Office of the Imperial Panegyrist, and editors still don't want us to really understand what is happening in Iraq, but one gets the impression that reporters at least, as a class, are actually starting to do their jobs. Why now, and not last year, and especially why not in 2004? Who knows. It's too little, too late, but we'll take it.

The Good News

The corporate media aren't telling you the good news out of Iraq, which is that it is still possible to get accurate information about what's going on there even though they don't want to tell you about it.

That's not to say it's a secret -- AP, Reuters, AFP and independent journalists continue to do their best to provide a window into daily events in that most unhappy of countries, and Arab media in English are available over the Internet as well. But the TV news has stopped transmitting most of it, and for that matter so have many newspapers, at least the ones I read. The Boston Globe, in particular, has decided to stop reporting news from Iraq almost entirely, including the deaths of U.S. troops.

So, please read Dancewater's post today at Today in Iraq. It's painful, terrifying, discouraging -- definitely wouldn't be good for ratings to actually tell people all of this. Who wants to hear that? It's much more inspiring to listen to the president vowing to win total victory. We have to do that, after all, because we are good.

I'll have a post here on another subject later today.

Thursday, April 06, 2006

Ju Jitsu?

Universal "coverage" -- however defined -- is not the only issue in health care policy. It's essential to meaningful reform, but there are ways to do it that just make matters worse. The conservative movement, led by the White House, wants to force everybody to buy really crappy health insurance that doesn't pay for basic and preventive care, but only kicks in if you have catastrophic expenses. We would have to pay for ordinary services out of pocket, which is supposed to make us "owners" of our own health care. There are tax breaks which make it even easier for rich people to afford, and don't do much for the rest of us. This system leaves the private insurance industry in control of our money, skimming off their 25% or so, and does nothing to control costs or bring rationality to the allocation of resources. On the contrary, it encourages people to skip preventive care and subsidizes expensive interventions after people have become seriously ill.

The day after celebrating their great victory in getting what is touted as nearly universal coverage passed in Massachusetts, progressive forces are waking up with a nasty hangover and a sneaking fear that they've been taken advantage of. Here's what crusading docs Steffie and Dave have to say. Excerpt:

The legislation promises that the uninsured will be offered comprehensive, affordable private health plans. But that’s like promising chocolate chip cookies with no fat, sugar or calories. The only way to get cheaper plans is to strip down the coverage – boost copayments, deductibles, uncovered services etc. Hence, the requirement that most of the uninsured purchase coverage will either require them to pay money they don’t have, or buy nearly worthless stripped down policies that represent coverage in name only.

Third, the legislation will do nothing to contain the skyrocketing costs of care in Massachusetts – already the highest in the world. Indeed, it gives new infusions of cash to hospitals and private insurers. Predictably, rising costs will force more and more employers to drop coverage, while state coffers will be drained by the continuing cost increases in Medicaid. Moreover, when the next recession hits, tax revenues will fall just as a flood of newly unemployed people join the Medicaid program or apply for the insurance subsidies promised in the reform legislation. The program is simply not sustainable over the long – or even medium – term.

It appears they may have a point. Liz Kowalczyk of the Boston Codfish Wrapper finds out that the premium that families above 300% of poverty (that's about $50,000 a year for a family of three) will have to pay will be around $700 a month, and that won't cover prescription drugs and will have over a $1,000 a year deductible. Meanwhile, there just isn't enough money in the legislation to begin to provide an adequate subsidy for poorer people, and how much they will have to pay to buy into the state-subsidized plan that's supposed to be available for them is still unknown.

Worst of all, there is no reason to think this will encourage more employers to cover their employees. Au contraire, as far as I can tell, if they're paying workers less than $50,000 a year -- which is where the vast majority of uninsured people are already -- they'll have less incentive than ever to offer coverage. The state is promising to subsidize coverage for those folks, so why not dump them? $295 a year is all they'll have to pay, much cheaper than health insurance. It wouldn't be bad in principle for more of the population to be in the state-sponsored plan, but it's bad if you haven't taken care of the financing, which they haven't. The only way to pay for it now is to make people pay most of the cost out of pocket, in other words it's regressive.

In fact, people near the 300% of poverty limit would presumably have to pay nearly full price for the state-sponsored plan, and they won't be able to afford it. In order to avoid a huge fine, they'll have to buy the crappy "affordable" plan that won't pay for their routine care or prescription drugs. Depending on how much money the state can come up with, there's no telling how far down the income scale this will go. If more and more employers drop coverage, and costs keep rising, maybe right down toward the bottom. Sure, we could solve the problem in a trice by raising the income tax, but is that going to happen?

In case anyone has any doubts, the conservative Republican governor Mitt Romney is planning to run on this accomplishment in the Republican presidential primaries. The Heritage Foundation helped write the bill.

I sure hope I'm wrong but we may just have sent our bank account information to a deposed Nigerian prince.