Map of life expectancy at birth from Global Education Project.

Wednesday, May 31, 2006

I think I'm getting too wonky for my own good

This blogging is a difficult form. You have to be topical, timely, and very succinct. It gives me some appreciation for the challenges faced by traditional media trying to stuff complex issues into their procrustean news holes. Anyhow I think I need to gloss the previous post, which is at once very dense, and somewhat elliptical.

They are talking about a Big Science project, like the project to sequence the entire human genome, which was officially completed in 2003 at a cost of about $3 billion -- although with considerable loose ends -- or the Superconducting Supercollider, which was cancelled in 1993 after $2 billion had been spent.

The Human Genome Project came with a set-aside of a little less than 5% (calculations are complicated, check the link if you really care) for studies of what they called "Ethical, Legal and Social Issues" (or implications) (ELSI) of the project, or more accurately I would say, of humanity gaining the associated knowledge. It turns out, in my personal analysis, that the ELSI of just having a map of the human genome are fairly minor, because by itself, it doesn't tell us much of anything. And indeed, the payoff for biomedical knowledge of having the sequence has been slow in coming.

And this, really, is where the new proposed project comes in. It turns out that converting the data created by the HGP into information which is actually meaningful or useful requires another step, just as large. How do genetic variations actually translate into differences in health and well-being, in the specific context of the physical, economic, and social environment? And of course, other environments have existed, do exist, and might exist, besides the ones in which Americans alive today were conceived, gestated, grew up and live out their lives; and each of us has our own environmental history which is in part unique. So when we do find associations between genes and diseases, is the problem really in our genes, or is it in a society which favors some genes and disfavors others? (Is it in our stars or in ourselves, that we are underlings?) So knowing the genome is like learning the alphabet. That's kindergarten. Now we need to learn how to read. And just as kindergarteners are pretty much amoral, we can't really struggle with the ELSI until we are old enough to read. That's what my previous post was starting to get at.

The ELSI web site is here. The project classifies them as:

  1. Fairness in the use of genetic information by insurers, employers, courts, schools, adoption agencies, and the military, among others.
  2. Privacy and confidentiality of genetic information.
  3. Psychological impact and stigmatization due to an individual's genetic differences.
  4. Reproductive issues including adequate informed consent for complex and potentially controversial procedures, use of genetic information in reproductive decision making, and reproductive rights.
  5. Clinical issues including the education of doctors and other health service providers, patients, and the general public in genetic capabilities, scientific limitations, and social risks; and implementation of standards and quality-control measures in testing procedures.
  6. Uncertainties associated with gene tests for susceptibilities and complex conditions (e.g., heart disease) linked to multiple genes and gene-environment interactions. [Note: This is naively stated. Said uncertainties are ubiquitous; nearly all genetic predispositions are linked to multiple genes and gene-environment interactions. This is what I mean by the pervasively reductionist thinking associated with this entire field. -- C]
  7. Conceptual and philosophical implications regarding human responsibility, free will vs genetic determinism, and concepts of health and disease.
  8. Health and environmental issues concerning genetically modified foods (GM) and microbes.
  9. Commercialization of products including property rights (patents, copyrights, and trade secrets) and accessibility of data and materials.
So, I hope this helps people think about the previous post and begin to see why there are important issues at stake. Tomorrow I'll get back to the psychiatric diseases.

You just might want to know about this . . .

If you think the corporate news media's Operation Ignore on the Clinton/Obama malpractice reform bill has been impressively successful, you'll really be impressed by this one. NIH is considering a large-scale ... excuse me, that would be humongous-scale project to collect genetic samples and longitudinal information on health (i.e., information that tracks individuals over many years) on hundreds of thousands of Americans. If you think about it -- which it appears no politicians or reporters are currently doing -- you will immediately realize that there are quite a few interesting questions associated with this proposal.

Accordingly, the Secretary's Advisory Committee on Genetics, Health and Society (SACGHS), established in 2002 to advise the Secretary of Health and Human Services, has prepared a draft report examining, well, at least some of these issues. I must say that the basic format of the report is to raise objections and then systematically answer them, the conclusion that the study should go forward being a priori. You can download the report -- a 57 page PDF -- from this page. The Executive Summary is not available as a separate download.

It's really not feasible to adequately summarize all of the issues in a blog post. Although the Committee says all the right things about the importance of public participation in decisions about such a study, I'm not sure there is an adequate answer. As they say, "[N]ew issues with strong scientific content sometimes seem particularly ill-suited to one-time techniques for soliciting opinion (e.g., a typical public opinion poll). Because most members of the public will be unfamiliar with the concepts of a large population project, concerted efforts must be made to educate, inform and solicit feedback and input."

That's not the only set of relevant concepts that most members of the public will be unfamiliar with. You can read SACGHS summary, which is too long to reproduce here. But here is my deeper background on this.

Many people -- including, sadly, quite a few who ought to be well informed -- have an inaccurate understanding of the relationship between genes and health. I don't know exactly how much each of my 5 1/2 readers knows about biology, so I'll probably insult some people's intelligence while baffling others, but what can you do? A single gene, in general, constitutes the instructions for making a single chemical called a peptide. Long ones are called proteins, and there are also shorter ones that carry messages within and between cells. That's an oversimplification because genes often code for long peptides that get cut apart to make various molecules. Genes are not only essential to producing the chemicals needed for biological functioning; by a complex dance between genes and messenger compounds that turn them on and off, the developmental process from fertilized egg to adult animal is coordinated. The activation and inactivation of genes continues during adulthood in the process of tissue maintenance and repair, which includes ongoing differentiation of cells from stem cell reservoirs; and in response to environmental cues and metabolic demands.

A common, fundamental error is to view genes in a highly reductionist, deterministic way. It is rarely accurate to say that a variation in a single gene is the cause of a disease. Some people would say it is never entirely accurate although I find that attitude tendentious. It is pragmatically justified to say that Cystic Fibrosis, Hutington's Disease, and some others are caused by specific genetic variations or "defects" if you will. However, development and healthy functioning in general are not determined by genes, but by interaction between genetic programs and the environment. The first environment is of course the womb, and then we live out in the world. Whether a particular genetic endowment predisposes to good health or disease depends on the context. A very important additional complication is that such predispositions are seldom traceable to single genes, but rather depend on complex interactions among multiple genes and the environment, such that teasing out all the strands is difficult, or even entirely unfeasible.

A widely cited example is that Native Americans in the United States have a 2 to 3-fold excess prevalence of Type 2 diabetes. One could say, then, that their genetic heritage places them at risk, and we could solve the problem by identifying the biochemical pathways between genes and disease, and intervening with the appropriate chemical correction. That conclusion would be objectionable, however, because prior to the European invasion, indigenous Americans never developed Type 2 diabetes; and the disease continues to be unknown among indigenous people who live in rural areas of Central and South America and pursue a traditional way of life. When those people move to cities, however, or to the United States, they become at high risk.

So, is the disease in their genes, or in society? Furthermore, what if we do the large population study and discover the combination of gene variants that predisposes to Type 2 diabetes. Do we do genetic tests in order to characterize people's risk of a disease such a Type 2 diabetes, and find that 90% of Navajo, 80% of immigrants from Central America, and 70% of immigrants from Mexico, have the risk profile? Do we charge them more for health insurance, discriminate against them in hiring? Do we do a second crash research program in order to develop the pharmaceutical intervention to correct for their genetic "defect," and then sell it for $3,000 for a yearly supply? Do we target intervention programs to try to get people of Native American heritage to maintain a healthy weight, consume high-fiber, low calorie diets and be physically active as their ancestors were? Or do we try to make fundamental changes in public education, food marketing, the built environment, recreational opportunities and transportation systems so that the entire population is at lower risk?

We can do the latter, even the latter two, without the proposed population study. The value of the study is in making the previous options possible. Is that a good investment of billions of dollars? What are the potential benefits and, yes, risks, of gaining such knowledge? How might the risks be ameliorated, the benefits enhanced? Or does it make more sense to spend the money on something else?

Tuesday, May 30, 2006

Who says the Dems don't have any positive ideas?

The corporate media, that's who, who ignore ideas put forth by Democrats. The War Criminal in Chief's proposal to cap malpractice awards got plenty of press, but I'll bet a one week subscription to The Wilson Quarterly you didn't know that Hillary and Barack Osama have sponsored legislation called the National Medical Error Disclosure and Compesnation (MEDIC) Bill (S. 1784), in their words "to direct reform toward the improvement of patient safety." Just like the man said, the issue with the malpractice system is not that lawyers are persecuting poor little innocent doctors and juries are making preposterous awards to greedy people who are only pretending to be victims. The problem is that the system doesn't compensate or provide care for the majority of people who are injured due to medical errors, while putting doctors and hospitals in an adversarial position toward injured patients, and creating obstacles to improving safety and quality by creating strong disincenties for doctors and administrators to openly discuss the facts about adverse incidents.

The Senators discuss their legislation in the new NEJM, and as usual, you can't read it because you are just common trash. (Thanks to Gaudeamus for informing us that the NEJM, in a fit of civic responsibility, has made this piece available to non-subscribers.) In brief, it would create a national patient safety database and a new Medical Error Disclosure and Compensation Program. Through grants to hospitals and health systems, it would set up programs whereby participants would agree to make full disclosure to patients who are harmed by medical errors, negligence, or failure to follow the standard of care. They would then negotiate compensation, rather than entering into litigation. The anticipated cost savings -- which have been demonstrated in pilot projects -- would go toward efforts to improve patient safety and reduce errors.

Note that it would still be possible for patients to sue if they aren't happy with the outcome. But experience has shown that this is unlikely. The health care providers will know when they have a case that is hard to defend, and presumably make an adequate offer. At the same time, since patients and their counsel will get full disclosure from the providers of what actually occurred, they will know when they don't have a strong legal case and non-meritorious suits will be unlikely to go forward. This aligns interests the way they should be aligned -- to open disclosure, appropriate compensation, enhanced patient safety, and better quality medical care.

Think we'll read about it in the New York Times?

Monday, May 29, 2006

Bringing the truth home

Every Sunday, for the past few months, I have spent the morning while my neighbors are in church compiling the news of the day from Iraq for Today in Iraq, a web project started by a retired Army officer who had served in Turkey and traveled to other Islamic countries on official business. The people he met admired the United States, and they were friendly and welcoming. When the U.S. invaded Iraq, that changed suddenly and profoundly. He was angry and hurt by the offense to the professional friendships he had made abroad. But Today in Iraq was born the day when draft dodger and deserter George W. Bush said "Bring 'em on," inviting people to attack U.S. troops. Compiling Today in Iraq is a numbing exercise, a weekly litany of statistics -- nearly 2,500 U.S. troops killed, each one represented by the nearly identical, formulaic CentCom news release. The more than 18,000 injured are often not represented at all. CentCom doesn't bother to announce incidents in which U.S. troops are only injured, but none die immediately. We try to find local news stories about them.

I have not served in the military. I turned 18 in the final year of the Vietnam draft, when the U.S. was reducing its presence there and reducing the overall size of its armed forces. I had a high lottery number and I was not called, but after taling at length with adults who I respected and, yes, the minister at my family's church, I had determined that I would not participate in the criminal aggression in Vietnam. My intention was to go to jail. That's easy to say, I never had to follow through.

That summer, I had a job conducting a voter census for my home town. I knocked on one door to ask how many people lived there and the woman broke down sobbing. Her son had been killed. How can an 18 year old possibly know how to respond to that? A friend of our family served in the infantry in Vietnam, and came back with two purple hearts. I've never heard him talk about it but I've heard a bit of his story second hand from his brother. He endured it with apparent equanimity, but he never finished college and I always felt that he fell short of what he might have accomplished in life. A few years later, I volunteered to work for a shelter for homeless men in Washington, D.C. One of the men who stayed there had been horribly burned in Vietnam, and he was badly disfigured. He would wake up screaming in the middle of every night.

I never thought for a moment that our nation could repeat such insanity, but it seems there is a sickness deep in our national soul. Mark Twain sliced through to the abcess in 1904, in The War Prayer, which I recommend reading on this most painful day. For those who may be unfamiliar with it, it begins:

It was a time of great and exalting excitement. The country was up in arms, the war was on, in every breast burned the holy fire of patriotism; the drums were beating, the bands playing, the toy pistols popping, the bunched firecrackers hissing and spluttering; on every hand and far down the receding and fading spread of roofs and balconies a fluttering wilderness of flags flashed in the sun; daily the young volunteers marched down the wide avenue gay and fine in their new uniforms, the proud fathers and mothers and sisters and sweethearts cheering them with voices choked with happy emotion as they swung by; nightly the packed mass meetings listened, panting, to patriot oratory which stirred the deepest deeps of their hearts, and which they interrupted at briefest intervals with cyclones of applause, the tears running down their cheeks the while; in the churches the pastors preached devotion to flag and country, and invoked the God of Battles beseeching His aid in our good cause in outpourings of fervid eloquence which moved every listener. It was indeed a glad and gracious time, and the half dozen rash spirits that ventured to disapprove of the war and cast a doubt upon its righteousness straightway got such a stern and angry warning that for their personal safety's sake they quickly shrank out of sight and offended no more in that way.

You may remember that in 2004, when Marines in their scarlet and blue dress uniforms came to tell Carlos Arredondo, an immigrant from Costa Rica, that his son Alex had been killed in Iraq, Mr. Arredondo doused himself with gasoline and set himself on fire. He was in Florida at the time but the family came from my home town of Jamaica Plain, Massachusetts. (Roslindale, where Mr. Arredondo now lives, is next door.) Alexander Arredondo's funeral was one block from my house. The Latino storekeepers and others who I know from the neighborhood were there. Carlos Arredondo tells his story here.

He says, "And what I learned of Vietnam in my country? I never understood what they was fighting for. Costa Rica, it was my home when I was a boy, and we had the same climate, same weather, and I was afraid the United States would someday come to Costa Rica and do the same thing. So, when my son told me at age 17 that he was going to join the service, I said, "Oh, no," and he said, "Don't worry, Dad." And then:

The day of my son Alex's wake, I was on a stretcher because of the burns. On morphine, so I don't remember many people. I remember hugs, shaking hands. And I remember waiting outside of the funeral home for my ex-wife for two hours, not wanting to see my son's body by myself. When I first approach the casket, I thought it might be hard to recognize him, because we had not been told yet what killed him. We hadn't learn yet that he had a wound in the temple of his head, so that he had a three-inch-wide hole in back of his head. But it was him. And seeing him laying flat in a casket, I thought, he's not breathing and that he looks a little different, a little older. That his hair is a little bit longer. Wanting to reach him I was lifted off the stretcher and climb up to kiss him, to touch his head, his hands, his fingers, his shoulders, his legs, to see if they were still there. I lay on top of the casket, on top of my son, apologizing to him because I did nothing for him to avoid this moment. Nothing.

This must end. And there is one way, and one way only, to make sure it does not happen again. And that is to establish, through the criminal justice system, that people in positions of greatest power in this country also have the highest degree of responsibility. To lead the country into war by lying to the citizenry and the Congress is a crime. And we must deal with the people who did it as criminals.

Sunday, May 28, 2006

Slacker Sunday: More from The Weirdness File

Having just done the Today in Iraq post, I probably shouldn't say what I'm feeling right now, on this weekend which was set aside to remember the casualties of war but is instead reserved, in most cities and towns, for the glorification of war and the celebration of militarism. So here is something that a man placed in the New York Times a few years back, as a quarter page ad. Does he have the answer?

Does the Theory of Relativity Apply to Motions of Society?

The proper combination of about 10^30 terrestrial atoms makes an average human being. Multiplied by 6 billion inhabitants of Eart, it makes a society which exists in perpetual mutual inter-action with its environment-Earth, Sun. Society is thus subject to the general laws of motion of the universe and constitutes a unified physico-economic formation.

Energy required to sustain and develop society comes, first of all, from food which humans produce, no longer collect as animals.

Production presupposes expenditure of human kinetic energy in a more or less organized way affected by the evolution of the instruments of labor. Changes in the content and form of production trigger changes in the content and form of society -- and, medieval, modern, which also display common features:

1) A sum total of humans -- Social Mass (SM).
2) Socially produced necessities of life whose elctro-chemical energy is used in various ways to maintain and develop all aspects of Life -- Life-Sustaining Energy (LSE);
3) Production of a given quantity of goods during a given quantity of time, i.e. Lanbor Productivity (LP) which is but a flow of human kinetic energy transmitted to, transformed, multiplied by hand tools and machines.

Growth, stagnation, collapse of any society depends primarily on the velocity of motion of labor productivity AND its ability to maintain proper relations with distribution and consumption that constantly, relentlessly press for a quantitative and qualitative acceleration of production.

Thus the velocity of motion of ACTUAL labor productivity DEPENDS ON the velocity of SOSCIALLY NECESSARY labor productivity which reflects the energy needs of society.

The relation between the total energy of the social mass, ET,sm; the social mass at rest, SMo; its energy at rest, Eo,SM; the velocity of actual labor productivity, VofActLP; the velocity of socially necessary labor productivity, VofNecLP, appears to be as outlined in the equation below where VofNecLP equals 1 relative to any time of choice.

As VofActLP approaches VofNecLP, mass, Et,sm, grows in quantity and quality. it is therefore a function of velocity of VofActLP. Apparently Einstein's theories link up with socio-economics and merge into relativistic physico-economics.

Eq. 5, a form of the universal law E=MC^2, affects, hence changes all aspects of human life. That is why it emerges as the basic physico-economic law of motion of any society, any time, any place. How could it be otherwise when it constitutes a mere extension of the continuing evolution of non-living physical bodies into living on all fertile planets?

Indeed, how could it be otherwise?

Friday, May 26, 2006

Your Liberal Media

After sleeping off my champagne hangover, I picked up my morning paper to see what it had to say about the conviction of Jeff Skilling and Kenny Boy. As the newspaper industry continues its long, slow slide to skid row, the Boston Globe no longer employs reporters to cover national business news, but the benefit for me is that I get to see what the national coverage is like.

They have a long main story by Carrie Johnson of the WaPo; an analysis by Johnson and Brooke Masters; a biography of Lay by the Associated Presss; and a sidebar on Skilling, with considerable discussion of his relationship with Lay, also by the AP. The coverage totals a full page and half of the business section, plus a quarter page photo and caption on page A-1, and the day's lead editorial.

The only mention of the name Bush comes in paragraph 19 of Johnson's article: "Both Lay, who once mingled with members of the Bush family and earned the name 'Kenny Boy' from President Bush, and Skilling, who during boom years persuaded Wall Street analysts of Enron's genius and his own, took the witness stand . . ." Lay's biography discusses his sojourn among the Houson elite, and says he donated millions to "various causes," but never mentions any specific politician or family.

Fortunately, I don't have to depend on the liberally biased corporate news media any more. This is from Robert Parry for Consortium News:

By the 2000 presidential campaign, Lay was a Pioneer for Bush, raising $100,000. Enron also gave the Republicans $250,000 for the convention in Philadelphia and contributed $1.1 million in soft money to the Republican Party. Not only was Lay a top fund-raiser for the campaign, but he helped out during the recount battle in Florida in November 2000.

Lay and his wife donated $10,000 to Bush’s Florida recount fund that helped pay for Republican lawyers and other expenses. Lay even let Bush operatives use Enron’s corporate jet to fly in reinforcements. After Bush secured his victory, another $300,000 poured in from Enron circles – including $100,000 from Lay and $100,000 from Skilling – for the Bush-Cheney Inaugural Fund.


Once in the White House, a grateful Bush gave Lay a major voice in shaping energy policy and picking personnel. Starting in late February 2001, Lay and other Enron officials took part in at least a half dozen secret meetings to develop Bush’s energy plan.

After one of the Enron meetings, Vice President Cheney's energy task force changed a draft energy proposal to include a provision to boost oil and natural gas production in India. The amendment was so narrow that it apparently was targeted only to help Enron’s troubled Dabhol power plant in India. [Washington Post, Jan. 26, 2002]

Other parts of the Bush energy plan also echoed Enron’s views. Seventeen of the energy plan’s proposals were sought by and benefited Enron, according to Rep. Henry Waxman, D-Calif. One proposal called for repeal of the Public Utility Holding Company Act of 1935, which hindered Enron’s potential for acquisitions.

Bush also put Enron’s allies inside the federal government. Two top administration officials, Lawrence Lindsey, the White House’s chief economic adviser, and Robert Zoellick, the U.S. Trade Representative, both worked for Enron, Lindsey as a consultant and Zoellick as a paid member of Enron's advisory board.

At least 14 administration officials owned stock in Enron, with Undersecretary of State Charlotte Beers and chief political adviser Karl Rove each reporting up to $250,000 worth of Enron stock when they joined the administration.

Lay exerted influence, too, over government regulators already in place.. .


The California energy crisis also was spinning out of control. Rolling blackouts crisscrossed the state, where the partially deregulated energy market, served by Enron and other traders, had seen electricity prices soar 800 percent in one year.

After taking power, Bush turned a deaf ear to appeals from public officials in California to give the state relief from the soaring costs of energy. He also reined in federal efforts to monitor market manipulations.

As California’s electricity prices continued to soar, Democratic Gov. Gray Davis and Sen. Dianne Feinstein voiced suspicions that the “free market” was not at work. Rather they saw corporate price-fixing, gouging consumers and endangering California’s economy.

But California’s suspicions mostly were mocked in official Washington as examples of finger-pointing and conspiracy theories. The administration blamed the problem on excessive environmental regulation that discouraged the building of new power plants.

Again, Lay was influencing policy behind the scenes. An April 2001 memo from Lay to Cheney advised the administration to resist price caps. “The administration should reject any attempt to re-regulate wholesale power markets by adopting price caps or returning to archaic methods of determining the cost-base of wholesale power,” Lay said. [San Francisco Chronicle, Jan. 30, 2002]

Cheney and Bush echoed Lay’s position in their political exchanges with Davis and other Democrats. On April 18, 2001, Cheney told the Los Angeles Times that the Bush administration opposed price caps because they would discourage investment. [L.A. Times, April 19, 2001]

In May 2001, Bush traveled to California on a trip choreographed like a President visiting a disaster area. Only this time, Bush wasn’t promising federal help to a state in need. He was carrying the same message that Lay had sent to Cheney. In effect, Bush was saying: Read my lips. No price caps. “Price caps do nothing to reduce demand, and they do nothing to increase supply,” Bush said. [L.A. Times, May 30, 2001]


In June 2001, the White House went to bat for Enron on another touchy issue, the natural gas power plant that Enron had built in Dabhol, India. The plant had become something of a white elephant. Its cost of electricity was several times higher than what India was paying other providers, which led to an impasse over unpaid bills. Enron wanted India to pay $250 million for the electricity or buy out Enron’s stake in the plant, worth about $2.3 billion.

These sorts of contract disputes between U.S. companies and foreign governments are normally handled by the Commerce Department or possibly the State Department. But Enron’s Dabhol problem became a priority of Bush’s National Security Council staff.

That level of interest over a contract dispute was almost unprecedented, according to former NSC officials from both Republican and Democratic administrations. The administration’s intervention even involved direct appeals from top U.S. officials.

On June 27, 2001, Cheney personally discussed Enron’s problem with Sonia Gandhi, the leader of India’s opposition Congress Party. “Good news is that the Veep mentioned Enron in his meeting with Sonia Gandhi yesterday,” said one NSC e-mail dated June 28, 2001. (I obtained this and other documents under a Freedom of Information Act request.)

Throughout summer 2001, while intelligence warnings about an expected al-Qaeda terror attack went unheeded, the NSC staff met frequently to coordinate U.S. pressure on India over Enron's plant, drawing in the State Department, the Treasury Department, the Office of U.S. Trade Representative and the Overseas Private Investment Corp., which had committed $360 million in risk insurance to the Dabhol project.

While the NSC held no follow-up meetings on the Aug. 6, 2001, intelligence warning entitled “Bin Laden Determined To Strike in U.S.,” national security adviser Condoleezza Rice organized and led the “Dabhol Working Group.”

The working group sought to broker meetings between Lay and senior Indian officials, including Brajesh Mishra, the national security adviser to Indian Prime Minister Atal Bihari Vajpayee. During a trip to India, a senior State Department official delivered a “demarche” or official warning to the Indian government, but New Delhi still resisted the U.S. pressure.

Also in the summer of 2001, Enron was consolidating its influence at FERC. . . .

Ahh, go read the whole thing. Then write a letter to the editor. Vast acreage of ancient forest was laid to waste so they could tell us what amounted to nothing about a small-time land deal in which the Clinton's lost a few thousand bucks. Control of the national energy policy by felons isn't worth a paragraph.

Thursday, May 25, 2006

The Nosology Knows

Before I get to the promised post on the Age of Psychopharmacology, I want to talk a bit about the concept of disease. What I will say here is not at all original.

Nosology means the classification of diseases. Currently, the world uses a system called the International Classification of Diseases-10, or ICD-10. Here's how it begins:

Cholera due to Vibrio cholerae 01, biovar cholerae

Classical cholera
Cholera due to Vibrio cholerae 01, biovar eltor

Cholera eltor
Cholera, unspecified

Typhoid and paratyphoid fevers
Typhoid fever

Infection due to Salmonella typhi
Paratyphoid fever A
Paratyphoid fever B
Paratyphoid fever C
Paratyphoid fever, unspecified

Infection due to Salmonella paratyphi NOS

And so on. As you can well imagine, by the time we get to
Sequelae of complications of surgical and medical care, not elsewhere classified
we've seen one hell of a lot of diseases.

The mental disorders (ICD-10 F00-F99) are also catalogued separately in the Diagnostic and Statistical Manual of Mental Disorders-IV(TR), which includes the criteria for declaring that somebody has, let us say, "Involutional melancholia, single episode or unspecified," as opposed to "Monopolar depression, single episode or unspecified."

In order to do any doctoring, the physician must first make a diagnosis, which means applying to you one of these thousands of labels. People have recognized entities that seem a lot like what we today call "diseases" since biblical times. For example, there is the Diagnostic and Statistical Manual of Skin Diseases in Leviticus 13, which goes on for many pages in this vein (New International Version):

18 "When someone has a boil on his skin and it heals, 19 and in the place where the boil was, a white swelling or reddish-white spot appears, he must present himself to the priest. 20 The priest is to examine it, and if it appears to be more than skin deep and the hair in it has turned white, the priest shall pronounce him unclean. It is an infectious skin disease that has broken out where the boil was. 21 But if, when the priest examines it, there is no white hair in it and it is not more than skin deep and has faded, then the priest is to put him in isolation for seven days. 22 If it is spreading in the skin, the priest shall pronounce him unclean; it is infectious. [Traditionally translated a "a leprosy." Obviously at the time this was written no word for "infectious" existed because nobody knew what infection was -- Cervantes] 23 But if the spot is unchanged and has not spread, it is only a scar from the boil, and the priest shall pronounce him clean.

With no really meaningful exceptions, the classification of diseases -- the fancy word for which is nosology -- continued on the same basis into the 20th Century. Diseases were defined by clusters of signs -- symptoms. Nowadays, however, whenever they can doctors take the symptoms only as a starting point. They are much happier when they can define diseases in terms of an underlying process. In the old days, the disease might have been a "sore throat," but today there are many different sore throats. Instead, it might be "Staphylococcus aureus infection," which more specifically means that a particular species of microorganism is feeding on, and reproducing within, the victim's body. Knowing that, we know the cure: feed the person an antibiotic.

There are many, some of whom operate outside of the epistemological framework of allopathic medicine (the fancy name for the standard kind of medicine that is taught at Harvard, the historical origins of which we can get into later if anybody cares), some of whom are within it or don't promote any particular alternative, who criticize the reductionism of medical diagnosis and treatment. The microbe is ubiquitous, but it's only causing disease in this particular individual. The person is not a collection of tissues and whatever happens to be living in them, but a complete system, that can't be understood by adding up its subunits. This person might have gotten sick because of being debilitated by the wrong diet, not enough sleep, too much alcohol, or some other set of interacting processes, which in turn might be related to social marginalization due to racial prejudice or odd behavior or the sequelae of a traumatic experience . . . In other words, while the biological system cannot be properly understood in reductionist terms, even that system is not self-contained but is part of a bio-psychic system which is in turn part of a bio-psycho-social system.

You get the idea. The reductionist approach to medicine is pretty successful at fixing the immediate problem, but seems to fall short when it comes to promoting health and preventing disease. On the one hand, maybe doctors could accomplish more if they started to pay more attention to our diets, our exercise and sleeping habits, even our social lives and how we relate to other people.

But wait a minute -- I don't want my doctor trying to run my life, and I don't want the medical profession turning every problem into a medical problem. It seems we have a paradox.

I'll take this discussion into the realm of mental "health" (whatever that means) next.

Tuesday, May 23, 2006

I guess I ought to say something

Followers of the public health scene (by which I mean what's happenin', who's down with who and what's up with that) may have noticed some controversy among various people about the magnitude of the danger of pandemic flu in general, and more specifically by a virus strain currently circulating in birds called H5N1. As I'm sure you know, it seldom infects humans, but when it does, it is quite likely to kill them. Many people are concerned that it may mutate into a form which can be efficiently transmittted among people, leading to a destructive worldwide pandemic. Others think this is unlikely.

Among the contestants are Revere of Effect Measure, who has occasionally filled in here while I've been gallivanting about the countryside, and for whom I have filled in while he's been gallivanting* about the planet, and Marc Siegel, with whom I have corresponded and spoken on one occasion at some length. I have been reluctant to say much about this because it's all gotten a bit personal, and I really, truly, want no part of that. But there are issues here that happen to be important to me, so the bullet I must bite.

Marc has summarized his position in the new issue of The Nation. He accuses the U.S. Centers for Disease Control and the World Health Organization of fueling a "worldwide overreaction to H5N1 avian influenza." Revere, in contrast, started raising the alarm about H5N1 influenza at a time when he viewed the CDC and U.S. response, at least, as an underreaction, and the WHO, while not necessarily insufficiently concerned, as having insufficient resources and insufficient cooperation from many national governments.

So this argument is largely a matter of degree. Siegel does not deny that it is possible that H5N1 will evolve into a human pandemic strain, although he considers it very unlikely. However, Marc says, quite specifically, "the priority being placed on it as a potential threat to humans is obscuring diseases that are already worlwide killers: malaria . . . tuberculosis. . . and HIV." He points out that these diseases already kill a lot of people, and that worldwide spending for HIV prevention and treatment is well below what WHO believes is needed. He further notes that the latest administration budget proposes cutting funding for HIV research at NIH, while slightly increasing funding for "avian flu and biodefense" research. He then goes on to talk about the money being wasted on project Bioshield, which is a boondoggle project for terrorism defense.

I am certainly sympathetic to Marc's rhetoric about insufficient global spending on important endemic diseases. I have written about this issue many times, including here and here. But it seems largely a red herring in this context. There is no evidence whatsoever that spending on pandemic flu preparations has displaced spending on other global public health priorities. Indeed, Marc seems to contradict himself by invoking WHO as the authority for saying that spending on HIV is insufficient. If WHO is calling for billions more to be spent on HIV, then how can he say that avian flu has somehow made WHO ignore other priorities?

The Bush administration's determination to squander billions on preposterous defenses against highly unlikely bioterrorism scenarios goes back to well before they had, apparently, even heard of H5N1 influenza. What has happened is that, rather than actually directing any new money to pandemic flu preparedness, they have simply added pandemic flu to the mission statement of their existing biodefense programs. That's actually a step forward, in my view. I have told this story here:

There isn't much in the way of a pandemic flu program per se; rather, states are expected to make preparations using two main sources of federal money, the U.S. Health Resources and Services Administration's National Bioterrorism Hospital Preparedness Program (HRSA-NBHPP) and the U.S. Centers for Disease Control and Prevention (CDC) Public Health Preparedness and Response for Bioterrorism Cooperative Agreement.

The word "bioterrorism" in the names of these programs comes from the days when the Bush administration assumed that bioterrorism was the only infectious disease threat facing the country. In Federal Fiscal Year 2004, when they first noticed the possibility of a naturally caused epidemic, the definition of the kinds of emergencies states were supposed to prepare for using these funds was broadened. Hence the CDC program is now called Cooperative Agreement for Public Health Emergency Preparedness, and the HRSA program's mission statement is "is to prepare hospitals and supporting healthcare systems, in collaboration with other partners, to deliver coordinated and effective care to victims of terrorism and other public health emergencies." [emphasis added.]

So, what happened when pandemic flu was added to the scope of these programs? The funds were cut, rather drastically. The HRSA program peaked in FY 2004, and funding declined slightly in FY 2005. I only have the figures for Massachusetts -- $10,686,180 in FY 2004, $10,256,868 in FY 2005 -- but you can find out about your own state's funding if you like at the HRSA web site. The CDC program really got wacked -- Massachusetts' funding in CDC budget year 8/31/03-8/31/04 was $21,141,965. Since then, it's been less than $18 million. The states use part of this funding to support preparedness by local health departments, and that's how the federal money trickles down to the local level. Obviously, that pass-through funding also peaked in 2004 and has been much less since then.

Siegel makes a case for investing in vaccine research and manufacturing facilities, which is one thing that Revere has also advocated for. Marc then decries the mass culling of poultry in response to outbreaks. I tend to agree with him that this is not helpful and takes a huge toll on the welfare of poor people who depend on poultry for food and income. Revere happens to agree.

Marc then criticizes the ABC movie Fatal Contact: Bird Flu in America, for "capitaliz[ing] on fear." Well sure. It's a disaster movie for crying out loud, that's what they do. There was a movie last night about an earthquake ripping North America in half. There are ridiculous, over the top disaster movies about volcanoes, tornadoes, extraterrestrial invasions, asteroids hitting the earth, giant monsters emerging from the bottom of the ocean, you name it. So what?

Finally, Marc says: "Sadly, hyperbole is not a method of discourse exclusive to TV drama; a public health blog for bird flu fanatics recently suggested that the United States should pull out of Iraq and use the resources we save for bird flu preparation. On the surface this sounds like a terrific idea. On further reflection it seems clear that going into Iraq in the first place was based on the same kind of argument -- in which a remote but scary risk is exaggerated so it appears to be looming -- that has characterized the public health reaction to bird flu."

Now, I must say I don't get this at all. I haven't heard of any blogger recommending that we spend the $2 trillion being squandered in Iraq on bird flu preparation, but it is certainly true that if we weren't wasting that money we could make adequate preparations for just about every possible disaster and make huge strides toward solving our more immediate problems as well. On the other hand, I don't see how anybody can make a credible claim that vast resources are being wasted on bird flu preparation. (And we certainly aren't killing hundreds of thousands of people and destroying a whole society in the process.) On the contrary, we are spending trivial amounts on these preparations, almost all of which Marc Siegel supports -- in fact he wants to spend more on vaccine resarch and development! His complaints about Project Bioshield are completely off topic and irrelevant.

Virologists and epidemiologists disagree about the likelihood that the specific viral strain H5N1, currently panzootic in birds, will evolve into a form which is readily transmissible from human to human. They disagree about the likely consequences if it does -- what the infection rate will be worldwide, how many people will become seriously ill, and how many will die. People also disagree on the extent of economic damage and secondary public health consequences -- from such causes as temporary shortages of health care workers, disruptions in the food supply chain, etc. -- that are likely to occur. But it would be grossly irresponsible to dismiss the possibility of a very destructive event. Nobody actually knows how likely it is, they merely have opinions.

Furthermore, no-one disputes that it is entirely possible that someday, one or another strain of virus will cause an emergency, be it worldwide or limited to a region or a continent. Influenza -- H5N1 or another strain -- is one possible candidate, but it could be something else. Nobody can actually assign a probability to an event of any given magnitude, or say when it will happen, but it almost certainly will. Humanity has endured destructive epidemics innumerable times in the past and we haven't repealed the principles of biology. It is prudent to make preparations for such an event. Preparations are not specific to H5N1 influenza. Whatever plans and infrastructure we put in place will be equally relevant to any other infectious disease outbreak. It is entirely reasonable for people to advocate for such investments, and equally reasonable to keep a watchful eye on H5N1.

So, the bottom line is, I really can't figure out what this argument is all about. Can you?

*Gallivanting seems to exist only in the present participle. Nobody ever gallivants, or gallivanted, but many are gallivanting.

Thinking ourselves sick?

This subject may not be exciting the masses, but I will press on. In our last episode, as you may recall, Sigmund Freud had provided psychiatry with theories, tools, and a direct link to physical illness through the "conversion disorders."*

Beginning in the 1930s, psychiatrists sought to further advance their prestige within medicine by extending beyond the concept of functional disorders to create the field of psychosomatic medicine. In a functional disorder, a psychodynamic process causes the patient to experience a physical symptom such as paralysis, numbness or blindness. However, no organic disease process can be discovered. In a psychosomatic condition, in contrast, organic disease is found; for example, a gastric ulcer or coronary artery disease.

In the early theories of psychosomatic illness, organic syndromes were thought to be linked to psychodynamic processes according to a sort of narrative logic. For example, ulcers were related to conflicts over the symbolic meaning of food in connection with a patient's relationship with the mother. Based on such theories, psychiatrists of the 1930s and '40s claimed to be able to cure a variety of diseases through psychoanalysis.

The development of psychosomatic medicine contributed to dramatic advances for psychiatry within the general medical establishment. During the 1930s, psychiatrists increasingly found jobs in general hospitals and medical schools. The Rockefeller Foundation made numerous grants to establish psychiatric liaison programs in university teaching hospitals. For example, one grant given in 1932 to the University of Colorado placed a psychiatrist to teach in the departments of obstetrics, medicine, surgery and pediatrics, "to demonstrate to the students the applicability and usefulness of psychiatric knowledge and the importance of regarding the patient as possibly an individual with mental maladjustment or disease as well as physical illness."

World War II brought further advances for psychosomatic medicine as the psychological stress and trauma of the battlefield frequently led to physical manifestations. However, in the 1950s, according to Okun, "the bubble burst". The use of psychoanalysis to treat physical syndromes simply could not be empirically confirmed, and the field became discredited.

Since then, it has made something of a comeback, but in not quite the same form. There is plenty of evidence that chronic emotional stress, by affecting the secretion of hormones, is associated with hypertension and vascular disease. (For what it's worth, however, a recent study finds that chronic stress actually reduces the risk of breast cancer in women.) Chronic anxiety and post-traumatic stress disorder are associated with physical symptoms such as shortness of breath and heart palpitations and need to be considered when diagnosing such complaints. The little understood syndromes of fibromyalgia and chronic fatigue syndrome are hypothesized to be associated with PTSD and/or feedback processes involving the cerebral cortex, and are susceptible to behavioral treatment. The hypothesis that the powerful link between social status and general health is somehow driven by the brain is very popular, but it has not been proved and the exact mechanism is unknown. Unfortunately, proposals that optimism and emotional tranquillity improve outcomes and survival in cancer now appear very shaky, at best.

The bottom line is that, while the duality of mind and body is becoming obsolete, the connection between mental states and physical health now appears to be largely non-specific. Stress, of whatever origin, broadly influences health. Psychiatrists get a piece of the resulting action, but it is not really in the medical major leagues.

Next: The mind in the body and the age of psychopharmacology.

*For today's post I acknowledge a substantial debt to Donald Okun, "Liaison Psychiatry (Liaison Medicine)". Adv. psychosom. med., Vol. 11 pp. 23-51 (Karger, Basel, 1983)

Monday, May 22, 2006

Okay then

You need to read this.

A quick summary of the import is here.

Saying what I feel like

Since I've just done my blogostic duty and posted something long, in-depth, and on-topic, let me take a moment to say that I have been following with interest and befuddlement the weird drama of the Jason Leopold "Rove has been indicted story." I presume that anyone who visits here already knows all about this, but on May 13, Jason Leopold, a reporter with a checkered past who is now working for the Internet magazine Truthout, appeared to have gotten the biggest scoop since, uhh, well, since Dan Rather got the goods on GW Bush being AWOL from the Texas Air National Guard. Supposedly Fitzgerald had gotten an indictment of Karl Rove on Friday, May 12, and was going to announce it publicly by last Wednesday.

This is starting to look suspiciously like another one of Rove's favorite ju jitsu's -- planting a negative story about a client, or in this case himself, just to discredit the story and those who report it. That may be what happened to Dan Rather, and Rove has been caught doing it in the past. Rove engineered a miraculous last-minute comeback for Texas gubernatorial candidate Bill Clements in 1986 by finding a bugging device in his office and claiming it had been put there by the Democratic candidate. It turned out Rove had put it there himself.

Fortunately, hardly anyone bit hard on the Leopold story. People noted it with appropriate skepticism and reservations. If Rove really did plant the story, hoping to engineer a meltdown of the liberal blogosphere, he has largely failed. It could pretty much do in Truthout, but that's not going to rearrange any tectonic plates. Meanwhile, Truthout is standing by it, which either means they really have something, or they are suicidal. We'll see.

However, what is really interesting about all this is that the corporate media views the whole thing with a yawn. They didn't make any serious effort to find out what happened in the CBS/TANG debacle, they haven't held Rove to account for his previous dirty tricks, and they are determined to see this as nothing but a screwup by a marginal news operation. The campaign tactics used by Rove against John McCain in the 2000 Republican Primary, against John Kerry (Rove was clearly behind the Swiftboating smears), and throughout his career, ought to have made him a pariah. But for the corporate media to really investigate his past and present, and to make an issue of his consistent use of dishonest tactics, would only be to embarass themselves, because they have been duped by him repeatedly. Rather than admit that, they just let him get away with it.

Here's a link with more of the emetic biography of Karl Rove.

More on the Sociology of Mental Illness

I know, I know, there's a federal law that if you have a blog, you can't take a break. Sorry about that, anyhow I'm back. As promised, I want to spend some time on this whole question of the social construction of mental illness and the ontological status of the DSM labeling system, etc. There are some other matters I need to deal with, so as usual these posts will be interspered with others, but I'm going to try to make it add up to a coherent discussion.

So, here is some historical background.

Psychiatry has always occupied a somewhat uncomfortable place within the medical institution. Indeed, psychiatry's origins are substantially separate from those of the other medical specialties. But we are talking about the post-Englightenment era: the dichotomy between healers of the body and "soul" (the literal meaning of psychiatry is "soul healing") is a product of modern philosophical and social developments.

The ancients viewed the mind and body as a single entity. Hippocrates was thus able to write with equal authority about diseases we would today classify as physical and mental. "Hysteria", for example, was caused by movement of the uterus, and depression by an imbalance of the humours. In extant traditional cultures, we find a similar holism. In Haiti, for example, diseases such as mouvais sange, in which the blood rises in the body producing all sorts of physical symptoms, may be caused by emotional shock or stress; while a variety of syndromes with both physical and behavioral manifestations may be caused by sorcery, or by improprieties of diet or bathing, sexual abstinence, etc.

Modern positivist philosophy, often traced to Descartes, has forced a splitting apart of mind and body. From Descartes' time until very recently (if at all) the inner workings of the mind have not been readily susceptible to empirical investigation by the standards of positivist science. Hence investigation of the mind was relegated to the province of philosophy rather than science.

Perhaps Cartesian dualism contributed to the separate development of the institutions that cared for the mentally ill in the Western world from the rest of the medical institution. Whatever the reasons, during the 18th and 19th Centuries this is clearly what happened. In England, the profession of psychiatry was founded when physicians took over the operation of madhouses. Asylums run by physicians became popular in the United States in the 19th Century.

According to Paul Starr, as the asylum became the preferred setting for treatment of the mentally ill, the general hospital remained the least desirable setting for those with other forms of illness. Says Starr, "Although by the 1840s, most superintendents [of mental asylums] were doctors, they kept aloof from other physicians. And, increasingly, as mental hospitals shifted from therapeutic to custodial functions, psychiatry became primarily an administrative rather than a medical specialty."

At that time, the remainder of physicians, who delivered their services in patients' homes and, increasingly, in their own offices, could do no better than psychiatrists at curing the diseases which came their way. However, that all changed with the development of the germ theory of disease. For the first time, this gave physicians an empirically supported theory of disease processes. This understanding allowed them to undertake surgical procedures with a somewhat lower chance of killing the patient. Ultimately, it led to effective antibiotic therapies which gave physicians real power over many of the most feared diseases.

Psychiatry, however, did not benefit from the empirical advances of the early 20th Century, even though one important condition which had been within the domain of psychiatry, general paresis, was explained and conquered at this time. Paresis, formerly nearly indistinguishable from schizophrenia, was found to be the terminal stage of syphilis. However, psychiatry gained no lasting prestige from this discovery because the consequence of effective chemotherapy for syphilis was that paresis would not occur in the first place. Hence the disease passed from the psychiatric domain to that of general or internal medicine.

Furthermore, even when individuals do present with paresis or other syndromes of brain disease or trauma such as epilepsy, stroke, or tumor, as soon as the organic disease process is identified, the claim of psychiatry on the case is largely undermined and it passes instead to neurology or another specialty. The domain of psychiatry has continued to be defined by mind/body dualism. Only for so long as a pathology of mind could not be explained by a phenomenon of the body could psychiatry retain its claim.

Sigmund Freud was, of course, the most influential individual in shaping modern psychiatry. Although the empirical support for his theories was limited to anecdote, he provided psychiatry with a generally accepted toolkit for treating the mind. Furthermore, by discovering the conversion disorders, he forged a link between psychiatry and what I will for now call "physical" medicine which psychiatrists could exploit to try to enhance their prestige within the medical community. At last psychiatrists had something to offer other physicians in the diagnosis and treatment of "real" diseases. Finally, Freud's work got psychiatry out of the ghetto of the lunatic asylum and gave psychiatrists the opportunity to set up private practices and treat paying patients, like other doctors.

Nevertheless, Freud's work, if anything, contributed to the influence of dualism in shaping psychiatric practice and its relationship with the remainder of medicine. While the theory of "functional" disorders did forge a link between mind and body, nevertheless the etiology of such disorders lay in psychodynamic processes, the still insubstantial stuff of mind. A psychiatric diagnosis will be used to rule out "organic" causes of illness and lead to a patient's being transferred to a psychiatric ward; hence the disorder is no longer seen as a "medical" problem.

Next: The era of psychosomatic medicine.

Friday, May 19, 2006

I'll be away for a couple of days . . .

but I'll leave you with this. I probably should have had more to say about this whole immigration flapdoodle before now, so here's something. I think this letter to the editor of today's Globe is quite revealing. (It refers to an earlier op-ed, so I've edited it lightly so you won't have to go back and read that essay.)

Yes, we Americans are nearly all descended from immigrants. Most of us acknowledge the struggles [of immigrants]. Most of us welcome immigrants; it is illegal immigrants we oppose.

People . . . who lump the two in one category insult our grandparents and great-grandparents who came to this country legally, endured a rigorous health screening at Ellis Island, and never dreamed of asking for welfare, unlike many of the illegals. Wouldn't he like to know that when he eats in a restaurant, the immigrants who work there have been screened for communicable diseases? And after Sept. 11, who wouldn't wish to be careful about illegals who may pose security problems?


Now, the rhetoric around this issue does tend to focus very much on the question of legality. People who are in the country illegally are "lawbreakers" and we shouldn't tolerate lawbreaking. But of course that is perfectly circular. It was once illegal for Black people to ride in the front of the bus. The question is what the law ought to be. The laws concerning immigration into the United States have changed drastically and repeatedly throughout our history. Originally there were no restrictions whatever. Anybody could just walk in. Then restrictions were imposed, motivated by racism - people worried about too many Chinese or Eastern European people coming here and polluting our culture.

This cartoon is from the 1860s.

Fear of cultural contamination is very prominent in today's anti-immigrant hysteria, of course. The Senate just passed a resolution proclaiming English to be the national language. This terror of the language of Cervantes is inexplicable to me. Spanish is the indigenous language of Puerto Rico, whose citizens are also U.S. citizens; the entire southwestern United States was once part of Mexico, until it was taken by conquest in 1849. I speak Spanish and as far as I know, that does not make me in any way dangerous to the people around me. Nobody has accused me of threatening their way of life by saying buenos dias.

The letter write is also worried about infectious disease. What makes her think that the native-born citizens working in restaurants have been screened for infectious diseases? (I am not aware of a single incident of customers catching an infectious disease from an undocumented restaurant worker in all of history.) As for welfare, I'm sorry to have to disabuse Ms. Sakellaris, but innumerable legal immigrants and their descendants have indeed received welfare. However, illegal immigrants cannot. As everyone knows, what is going on is that desperate people are coming across the Mexican border looking for work. They no perfectly well that they cannot receive welfare. It's just like the man from Fishtown told me back when I was a community organizer: They're all on welfare, and they're taking all the jobs.

Finally, Sakellaris raises the issue of security, Sept. 11, yadda yadda yadda. This is something I have a hard time imagining: Islamists terrorists decide to get into the United States by going to Mexico and then trekking across the desert. It would make more sense to do it the way they did it in reality, which is to come in on student or tourist visas. If they can't get one, it would probably be a lot easier to enter the U.S. via Canada -- which some have in fact done (viz. the guy who came through Vancouver in 2000 hoping to attack the LA airport), although none has ever, to my knowledge, tried to come in via Mexico. So why aren't people worried about the Canadian border? Obviously, the Latino immigrants who are the target of the hysteria are Christians, typically more devout than most Americans, and they certainly aren't terrorists.

Here's a Thomas Nast cartoon from 1889 depicting an Irish immigrant.

I could have shown you cartoons of Jews, and Slavs, from the same era, but that's enough bandwidth for one day. You can see lots of cartoons here.

Thursday, May 18, 2006

And while we're on the subject . . .

Inspired by Tardigrade's comment on the previous post, I will say something about today's news on the speciation of humans and chimps. The Boston Globule headline had it "Humans, chimps may have bred after split," while CBS has it "Study: Chimps, Humans Mated," and I'm sure other headlines are similar.

Of course, every visitor to this site knows that we have always maintained that living proof of human-chimpanzee hybridization is before us. However, we didn't mean it seriously. I think.

I'm afraid these sloppily written headlines are going to drive some people even deeper into denial, simply because of the yuck factor. The creatures in question were, of course, not humans and chimpanzees, but ancestors of the two species who were much more closely related than we and the president are today.* If the hypothesis of Drs. Reich and Patterson is correct, some interbreeding occurred for a period sometime after initial speciation, until about 5 1/2 million years ago. That would be no more strange than the interbreeding which occurs today between, for example, wolves and Canis domesticus, although paleontologists are finding the hypothesis a bit surprising because of the anatomical differences between the creatures in question, the direct human ancestors being fully bipedal.

Whether or not this hypothesis survives, it reminds us that one reason people reject science is because its truths are often unsatisfying, uncomfortable, or downright unpleasant. It doesn't feel good to be one among millions of species of eukaryotic organisms (not to mention probably billions of species of prokaryotes), extinct and extant, fucking and shitting and farting for barely more than an instant in a layer of slime on a dust mote in the midst of the unimaginably vast, cold dark. Or at least it apparently doesn't feel good to some people. I find the whole thing quite impressive, and fascinating, if annoyingly inexplicable (so far). But it is the unexplained that drives us on. Even though we're nothing, we're a kind of nothing that it is interesting to be.

*Sorry. My irrational Bush-hatred got the better of me.

I have good news . . .

and, of course, bad news. The good news, according to an ongoing series of surveys by the National Science Board, is that the proportion of U.S. adults who are considered scientifically literate has doubled since 1979. The bad news is that it is now 17%. This survey program, directed by Jon D. Miller of Northwestern University, is discussed by Liza Gross in PLoS Biology.

It is only because people do not understand basic scientific ideas, in fact do not understand the nature of science and how scientists think, that they reject science in favor of biblical literalism. According to Miller's research, 1/3 of Americans think that evolution is "definitely false," most aren't sure, and only 14% believe it is the true explanation of human origins. In an international survey of 34 countries, the U.S. ranked 33rd in the proportion of adults who believe in evolution, ahead of Turkey.

Gross reports that Miller finds that 43% of Americans agree with all three of the following statements: the Bible is the actual word of God and is to be taken literally; there is a personal God who hears the prayers of individual men and women; human beings were created by God as whole persons and did not evolve from earlier forms of life.

Whew. We have a very serious problem here. I have to tell you the truth -- I grew up in the United States, I have lived in many different cities, and I have worked in many different kinds of jobs and workplaces. I attended two different high schools, and three colleges or universities, and I have taught at three. Oh yeah, as a youth I attended church and Sunday school, and my uncle was an Episcopal minister. I have never, to my knowledge, met a single person in my entire life who does not believe in evolution. Now obviously I must have, but it never came up. Whenever it has come up, every single person in the room took it for granted that yes, of course the earth is billions of years old and all of life evolved from a simple common ancestor by the process of mutation and natural selection. That's just common knowledge, it's like knowing that the earth is roughly spherical and it goes around the sun.

I knew that many years ago, there were laws in some states against teaching evolution in the schools, but that was all settled in 1925 when the state of Tennessee put high school teacher John Scopes on trial for open and flagrant evolutionism and Clarence Darrow made a fool of William Jennings Bryan on the witness stand. Out of the blue sky, well into my adulthood, I hear that this question is still politically controversial, and that people all over the country are campaigning to have the biblical story of creation taught in science class. To me, this was like discovering that 50% of Americans have two heads and I'd just never seen one of them. What the hell (pardon me) is going on here?

Well, maybe I shouldn't be surprised because it is also the case that I never knew a single person who voted for Ronald Reagan, and he was elected president twice, by substantial margins, I am given to understand. There is, clearly, an extraordinarily powerful cultural assortment process in our society. I don't try to avoid people who disagree with me about fundamental issues. I don't avoid talking about science and politics -- on the contrary, those are two of the subjects I talk about the most, even with people I've just met. Somehow, without any manifest social barrier -- no caste signal such as pigmentation, clothing, accent, or any other visible sign -- I inhabit a completely different world from the majority of my fellow citizens. This is a very disturbing, very weird discovery. I really need to find out how this is possible.

Wednesday, May 17, 2006

Driving us nuts

Mental illness, mental health, the realm of psychiatry and psychology -- whatever you want to call it -- presents some of the problems in the sociology and philosophy of health and illness in particularly high relief. I'm going to touch on some of the highlights now, which is all I can do in a single blog post. I've written about some of these specific issues in more depth before, for example here where I discuss the apparent "epidemic" of mental illness and explain it as a growing availability of diagnostic labels; here, where I discuss the problem of evil in the context of biological theories of the mind; and here where I discussed the very different kinds of criteria that can lead to a diagnosis of mental illness -- personal distress, disability, or the disapproval of others.

But now I'm just going to take a quick look around from the treetops. Psychiatry has always been in an uncomfortable relationship with the rest of medicine. Whenever the specific, biological basis of a formerly psychiatric disorder is fully understood, the disorder tends to leave the realm of psychiatry and become the province of neurologists, or possibly some other kind of doctor such as an infectious disease specialist. I mentioned recently that tertiary syphillis used to be conflated with schizophrenia. Now that we know it is an infectious disease, it is no longer considered a psychiatric disorder. Similarly, the dementias associated with aging used to be considered "insanity," but today people with Alzheimer's Disease and vascular dementia see neurologists, not psychiatrists. (The neurologists can't do anything for them either, but we still pay for visits.)

Psychiatric diagnoses depend, not on X-rays or blood tests, or feeling lumps or hearing odd sounds from the viscera, but on checklists of behaviors. If you have two from column A and three from column B, you have the disease. There are several problems here, of which the most basic are:

  1. Somebody has to decide that the behaviors in question are undesirable or pathological;
  2. Somebody has to decide that a certain amount of them, in a certain combination, constitutes a "disease";
  3. Somebody has to decide that Hermione Hassenfeffer does, in fact, manifest the necessary combination of behaviors in sufficent degree to merit the diagnosis.

I try to be pragmatic, rather than profoundly philosophical about this. Sometimes the reality of psychiatric disease is not worth disputing -- it can be like Justice Potter Stewart's definition of pornography: "I know it when I see it." People who are walking down the street having loud, incomprehensible conversations with entities who are not there are either schizophrenic, or they are cell phone users.

However, even in this case I must acknowledge recent commenter Spiritual Recovery, who experienced a psychotic break and then recovered without the usual drug treatment. This can certainly happen -- it happened to Kurt Vonnegut Jr.'s son Mark, who wrote a book about it. One question is whether jumping in immediately with antipsychotic drugs can actually exacerbate the situation. Would more people recover spontaneously if we didn't start messing with their brains? Maybe, who knows? There is also the question of whether there are cultural contexts in which people who we would consider mentally ill may have a useful social role to play as shamans or visionaries, which enables them to channel and manage their hallucinations. I have heard of this idea before, I don't have any personal knowledge as to its validity. Certainly it doesn't apply to everybody who we would label as schizophrenic -- people who are severely disabled by schizophrenia-like symptoms who up just about everywhere, as far as I know.

But the general point is a strong one. The existence of schizophrenia certainly does depend on the social context, at least at the margins. Ted Kaczynski was diagnosed with paranoid schizophrenia (thereby sparing him execution) although he does not have hallucinations or hear voices. His conviction that industrial civilization is bad for humanity was ruled delusional by the court appointed psychiatrist. Hmm. Exactly what constitutes a delusional belief system is, inevitably, in the eye of the beholder.

But other diagnoses are far less certain and stable than the diagnosis of schizophrenia. I've said a lot about depression. Everybody knows that the difference between the normal human experiences of sadness and grief, and the disease of depression, is a matter of judgment. There are extreme cases where almost everyone would agree that there is something intractably and disturbingly wrong with a person; and there are probably many more cases that people would argue about.

But at least depressed people generally speaking don't like being depressed and want relief. There is another category of diagnoses in which the allegedly sick person feels just fine, thank you. Homosexuality used to be one of them. To the extent homosexuals felt they were diseased, it is because that is how other people treated them. They felt guilty, rejected, humiliated -- but they liked having sex with people of the same sex. Now the APA has been persuaded not to call homosexuality a disease, and even if it's no picnic being gay in Kansas, you can move to the South End or Greenwich Village and everything will be just fine.

The personality disorders which remain on the list also tend to be questionable, although in different ways and perhaps to a lesser extent. Sociopaths have something wrong with them because the rest of us say so. Generally speaking, they do not agree. What kind of a "disease" is it that the victim doesn't mind having? People with so-called borderline personality disorder drive the rest of us nuts, but they think it's our fault. They are usually quite unhappy, but they attribute to the people around them, not to themselves. Well, we aren't about to change to make them happy, even if it were possible. But these "diseases" are matters of degree, they manifest in enough different ways that it isn't clear that they are always the same "thing," if they are a thing at all, and it isn't clear that they ought even to be called diseases.

It is common to justify the concept of mental illness in terms of functional impairment and disability. If people can't hold a job, can't have stable and satisfying relationships with others, can't maintain their personal hygeine, and so on, something is clearly wrong. But again, that may be a consensus, but it's a matter of context, and opinion. Not everyone holds a job, after all, and we don't consider non-working spouses to have anything wrong with them. Quite possibly many of them would not be able to hold a job, were they put to the test. What about the people we used to call hobos, migrants who may take odd jobs but are content to be homeless and camp out in out of the way places? There are many people with odd behaviors, who might merit a diagnostic label, who live on the margins of society but seem reasonably content.

Psychiatrists want to be credible within the medical profession. In the past, there was little or no demand that psychiatric treatments be proven efficacious by the methods used for medical treatments. For that matter, medical treatments didn't have to be shown to be effective either, but psychiatry came to the evidence-based game comparatively late. The theories used by psychiatrists were firmly held and passionately defended, but they were largely speculative and often quite fungible and vague. Psychiatrists used to be convinced that schizophrenia was caused by suppressed conflicts and desires, and that autism was caused by emotionally distant mothers. Now they give drugs for schizophrenia and autism has been handed to the neurologists.

Oh yes, drugs. Although psychiatric disorders, almost by definition, are of unknown etiology, in order to be considered "scientific" psychiatry needs randomized controlled trials. It's a lot easier to do one for a drug than it is for talk therapy. For one thing, drugs are perfectly standardized -- a specific dose of a specific chemical. Counseling is very difficult to package as a standard product in a standard dose. For another, although psychiatrists nowadays like to talk about "rewiring neural circuits" by talking to people, they don't really have any way of proving that they have done so. Even if nobody knows how the drugs work, at least everybody believes that they are doing something concrete and biological.

Having said all of this, let me be absolutely clear. However problematic the concept of mental illness, there really are people with mental illnesses, who really do suffer, and who are best served if we agree that they are sick. There should be no more stigma associated with mental illness than there is with influenza, heart disease or diverticulosis. There should be equal access to appropriate, comprehensive treatment. There should be an equal commitment to making sure that treatments really work. But we need to understand mental illness correctly, and that requires a very critical, skeptical examination of the current set of concepts, the system of care, and treatments.

That's something I will try to do more of here. I'm very interested in hearing people's ideas about all this.

Tuesday, May 16, 2006

'Nuff Said Department

From my old friend* Marc Rodwin, in the latest Health Affairs:

As Marc concludes:

To paraphrase Mark Twain’s comment on reading his obituary in a newspaper, the reported recent demise of medical practice as a result of rising malpractice premiums has been greatly exaggerated. The perception that increased malpractice premiums cause a crisis is at odds with evidence from the AMA surveys. These surveys indicate that premiums have consistently been a small percentage of total practice expenses . . .Claims that the level of malpractice premiums justify a tax credit to prevent physicians from leaving the practice of medicine are hyperbole, especially when physicians’ income is viewed compared with that of others. Average physician income in 2003 was between the ninety-fifth and ninety-ninth percentiles for all Americans.

I got nothing to add. The AMA and its paid representatives in Congress need to start worrying about other issues.

*I was his TA for a course in health policy many years ago.

Just thought this was interesting . . .

While I'm too busy to post anything substantive right now (proposal writing) here are the "top stories" from the CNN web site as of 12:25 pm, Eastern Time:

# Powerful quake reported near New Zealand
# Gunmen storm garage in Baghdad
# Horses tread back-high flood to safety
# King warns Saudi media about women's pictures
# Adopted dog helps save girl with cracked skull
# Teen jailed for her own safety, prosecutors say
# Bubonic plague found in mice at campground
# Zoo visitors shocked as bears eat monkey
# Report: U.S. cultural treasures could be history
# 'Da Vinci Code' prompts parody from albinos
# Paris Hilton's Mother's Day gifts stolen
# Bars require fingerprints to get a beer
# Bonds says he's haunted by Babe Ruth

So yeah, okay, there is at least one legitimate story in there. The NZ quake was near some uninhabited islands and did no damage, but you now, it's an earthquake! While the gunmen were storming the garage, four (4) U.S. troops were being killed in Iraq (bringing the daily average of dead coalition troops this month to 3.25, the highest since January of 2005 -- but hell, who's counting? -- there's still no Iraqi government, Iraqi children are starving, and a couple of hundred Iraqis are blown up, tortured to death, or shot every day -- maybe they'll get around to reporting on some of that. But Paris Hilton's Mother's Day gifts -- now that's news we need to know.

Monday, May 15, 2006

And I have more to say about this . . .

Like most psychiatric diseases, bipolar disorder is diagnosed based on a set of behavioral symptoms. Nobody knows what the underlying biological process or abnormality is in BPD, or for that matter whether there is only one -- in other words, whether it is really one disease. (In the past, doctors thought that schizophrenia and tertiary syphillis were one disease. They still don't know whether what we call schizophrenia is one disease, but it probably isn't.)

The basic description of bipolar disorder is cycling from periods of what looks like clinical depression to periods of unusual self-confidence and exuberance which can pass over into an irrational state called mania in which self-confidence turns into grandiosity, racing thoughts become divorced from reality, and assertiveness may turn into aggressiveness. Some people stop short of the extreme manic state. The milder form, called hypomania, may actually be desirable -- a period of creativity and joy.

Well, four and five year old children are like this naturally. One moment they are calm and quiet, then they are exuberant and creative, then they have a tantrum, then they sulk. In their exuberant, creative phases they indulge in fantasies which they seem fully to believe. In their tantrums, it is impossible to reason with them.

In school, children are required to spend long periods quietly focusing on tasks which are often not very interesting. They are required to speak only when they have permission. They may play energetically only during brief, specified periods. Most children do not like to do these things, and some simply will not. In the old days, when children didn't conform, their teachers would smack them on the back of the hand with a ruler, beat them on the buttocks with a rod or a paddle, or make them sit in the corner wearing a bizarre, humiliating hat. Parents usually demanded comparable conformity at home, and used similar measures to enforce it.

I presume these methods were at least somewhat effective, or they would not have been so widely used for so long, but clearly they had pernicious secondary effects, as we say. Nowadays they are out of favor. When children fail to conform their behavior to the demands of adults, we label them as diseased and drug them. Reasonable people may disagree as to whether and under what circumstances this is appropriate, but there is very widespread concern that far too many children are being drugged and that it ought to be a last, desperate resort.

Like physical violence against unruly children, the drugs have side effects. The most widely prescribed are amphetamines, which are among the most dangerous of addictive drugs and can even produce psychotic states. For children diagnosed with bipolar disorder, as I wrote below, lithium and Depakote are the common prescriptions. These drugs also have side effects.

But anti-psychotics are another matter entirely. These drugs are so toxic that even desperately ill adults often cannot take them. They are associated with severe weight gain, hyperglycemia and diabetes, and hypercholesterolemia and heart disease. They can cause severe neurological complications, damage the liver and kidneys, and cuase a life-threatening metabolic disorder. The "clinical trial" for quetiapine in 4 and 5 year olds is a "phase IV" trial which is supposed to test the safety of the drug in a new population. There is no need for such a trial. We already know the answer. The drug is not safe. It is not safe in adults, albeit it is sometimes the lesser evil. To give it to children, whose brains are still developing and whose liver enzyme systems are underdeveloped; children who are not physically ill but whose behavior is troublesome, who may or may not have some completely unknown neurological abnormality, is grotesque. The purpose of this is for a drug company to try to sell more pills and make more money.

That's my opinion.