Map of life expectancy at birth from Global Education Project.

Friday, June 30, 2006

What you don't know probably can't hurt you

At least in some situations, with the benefit of our old friend Bayes Theorem.

My father had surgery a couple of years ago (titanium knees, to be exact) and he had a difficult recovery. The hospitalist (his own primary care doctor was off somewhere doing veterinary medicine, it seems) ordered a scan of the chest to look for pneumonia, among other imaging tests -- which, incidentally, were read by a radiologist in Australia, but that's for another day. He didn't have pneumonia, but Crocodile Dundee saw a lesion on his left lung. The adrenals were just visible at the bottom of the image and he saw lesions there as well. The hospitalist took me aside and told me that they believed my father had metastatic lung cancer.

After my father got out of orthopedic rehab, amid massive anxiety, my parents saw an oncologist who told them it all looked very grim. He ordered a PET scan. My father had scar tissue on his lung and meaningless cysts on his adrenals.

John Stone in this weeks NEJM (you know the story -- off limits) discusses such "incidentalomas." "How many times each day," he asks, "does an incidental finding lead to other tests, additional inconclusive results, and still further testing? What is the effect of incidentalomas on the costs of health care, physician's concerns about being sued, and patient's fears of serious illness." He goes on to tell us that simple (clinically insignificant) renal cysts occur in 12% of people age 50 to 7. And indeed, incidentalomas commonly occur on the adrenals as well. The finding of an adrenal incidentaloma can lead not only to more radiological procedures, as in my father's case, but to biochemical testing and needle biopsies, and even adrenalectomy -- yet only 1 adrenal mass in 4,000 is malignant.

And here's where Bayes Theorem comes in. If you do an imaging test because there are symptoms that lead to concern, the underlying probability that what you are looking for exists is comparatively high. Therefore the fairly non-specific test of a visible lesion on the image is a good indication that you should pursue the matter further. You are really hoping to rule out, rather than rule in. But if there is no prior indication of a problem, a visible lesion that you just happen to see while looking for something else is probably meaningless. But what if you do nothing, and it turns out to be cancer? Major bummer.

This is quite a conundrum, for which I do not have a snap answer. John Iglehart, who shows up here frequently, discusses cost trends and policy developments in medical imaging elsewhere in the Journal. I will get to all that later.

I will be away for a couple of days, but when I get back on Sunday, I'll blog up a storm. In addition to doing Today in Iraq on Monday and Tuesday, we'll discuss: Why Tiger Woods should play more; The vogue for photographing, and even sculpting, pregnant celebrities in the nude; The physics of leaping tall buildings in a single bound - is Superman scientifically credible? (And, why leap anyway if you can already fly?); the economics of converting abandoned factories into office space, as opposed to demolition and new construction.

Or, if we don't discuss any of those topics, we'll do Iglehart and the cost of health care in Massachusetts, and possibly peace, freedom and democracy, being as it's the 4th of July and all that.

Thursday, June 29, 2006

Grossout of the day

From my friend in the uttermost west:

30 Fall Ill from Noodles Tainted with Chewing Tobacco

Authorities in Phnom Penh reported Monday that thirty people suffered from food poisoning after they ate noodles that were contaminated with chewing tobacco, which fell out of the mouth of the cook who prepared the batter. 39-year-old woman Sieng Seng, an employee at a wholesale noodle vendor who supplied the restaurant where people started vomiting from the noodles, said she never knew the wad fell into the ingredients while she talked.

But this is actually an opportunity for me to post what I was gonna post anyway, right now, right here. The WHO has info on tobacco use worldwide by people age 13 to 15. Actually it's based on a survey of students in school, much like our Youth Behavioral Risk Factor Survey here in the US of A, so it probably misses the kids who are most likely to be nicotinic. 17.3% of kids that age around the world use tobacco. The rates are actually highest in Europe and the Americas, where the merchants of death have spent the past century or so corrupting the youth. But Africa, where they're dying of malaria and diarrhea because they can't even afford mosquito netting and clean water, is right behind.

And while we're on the subject of easy questions

A trial, albeit very small, conducted in Norway, compared the drug zopiclone with cognitive-behavioral therapy (CBT) and placebo for adults with insomnia. (Once again, the awesome power of Stayin' Alive is revealed; having grown tired of my ceaseless carping, the good people at JAMA have made this particular article available free to the riff-raff.) The CBT consisted of six individual sessions in which the people learned about factors such as diet, exercise, and alcohol use, light, noise and temperature that affect sleep; were taught to set a schedule for sleeping; taught relaxation techniques, etc.

The drug, zopiclone, is sold inexpensively as a generic medication throughout the world. In the U.S., however, Sepracor got a patent on the active stereoisomer* of zopiclone, and so what is a generic drug everywhere else is an expensive patented medication in the U.S., heavily advertised on television under the brand name Lunesta. Some people who take Lunesta engage in bizarre somnambulant behavior, such as gorging on food or driving while asleep.

In the Norwegian trial, the people who received CBT improved their sleep outcomes at 6 month follow-up, whereas the people who took zopiclone actually slept worse than they did at the beginning.

So, here's your second easy question: Why is Lunesta heavily advertised on television, whereas CBT is not? Bonus question: Your insurer will pay for Lunesta, if your doctor prescribes it. Will they pay for CBT?

* Stereoisomers are forms of a chemical compound which have identical atomic configurations except that they have different arrangements in space, e.g. they may be mirror reflections of each other or be so-called cis-trans isomers, with one or more atoms on the same or opposite sides. Somewhere near the beginning, amino acids with a specific handedness became the stuff of life. Since the chemistry of life has a handedness (by convention, amino acids in living things are called left-handed), many drugs and nutrients that exist in left and right handed forms are active in only one form, but it's easiest to synthesize them without worrying about that. Hence the synthetic Vitamin E, for example, that you buy at the CVS, consists of 50% non-biologically active isomer. So what, just take twice as much. Hence the dosage of Lunesta is half that of zopiclone, otherwise they are completely biologically identical.

Too easy for a hint

If Nuri al-Maliki's national reconciliation plan does not include amnesty for people who have attacked foreign (i.e., American) fighters in Iraq, then with whom, exactly, is he proposing to reconcile?

(Okay, here's a hint. Think back to your school days, and Set Theory.)

Wednesday, June 28, 2006

Not quite victory . . .

but we're winning. I'm talking about tobacco. When I first entered the field of public health, the tobacco companies were successfully polluting the scientific waters with phony research purchased from lowlife whores with Ph.D.s and, incredibly, accusing legitimate investigators of "junk science" with the aid and comfort of "journalistic balance." Everybody except Richard Daynard and John Banzhaf believed that is was impossible ever to successfully sue a tobacco company, and there were full page pictures of happy, healthy, beautiful young people and macho men deriving sexual potency and mysterious allure from their Newports and Marlboros on the back of every magazine and looming on billboards over every city block. The tobacco companies owned Congress and every state legislature, and everybody knew there was nothing anybody could do about it. Smoking was normal. Every celebrity smoked, every movie character smoked, parents smoked, kids smoked, people smoked on airplanes, in restaurants, before, during and after meals. Athletes smoked. People with throat cancer smoked through their tracheotomies. Nurses smoked in hospitals. Teachers smoked in school.

In Massachusetts, in 1992, the voters approved a 25 cent tax on every pack of cigarettes, to fund tobacco control and school health education programs. California did the same thing at about the same time. Several of the states sued the tobacco companies and in 1999 they won a settlement that established some effective constraints on tobacco marketing, scooped up a lot of money for tobacco control programs and nearly as important, forced them to give up a roomful of documents that proved they were liars and murderers. Cities began to pass workplace smoking bans, then whole states. The prevalence of tobacco addiction fell. Fewer kids started smoking. The rate of heart disease and lung cancer started to go down.

Now, the Republican Surgeon General finally announces that yes, there is a scientific consensus that exposure to environmental tobacco smoke is harmful. This is a bullet-proof rationale for banning smoking in public places. Your liberty to swing your fist stops at the end of my nose. Your freedom to poison yourself does not extend to poisoning me. Case closed.

We have not achieved the official national goal of reducing tobacco use to less than 12% of adults, and less than 16% of youth -- in fact we're still at 21% and 22%, and the decline in youth smoking may have leveled off. You can get the full update and current scientific consensus from the National Institutes of Health here. (PDF) But the good news is that more and more jurisdictions are passing workplace bans, and this really helps -- it doesn't just eliminate involuntary exposure, it encourages and helps people to quit. It also means that kids are much less likely to see adults smoking, and so less likely to emulate them. Health insurers are paying for smoking cessation programs. TV and, to a lesser extent, the movies, are much less likely to depict smoking as a normal or glamorous activity. In fact you hardly ever see people smoking on TV any more.

Alas, as I have reported before, the tobacco companies are doing just fine, because their business is growing internationally. A horrible death is too good for Americans after all, but we're still getting rich by exporting it.

You'll feel alive with pleasure, playful as a child.
You've come to where the freedom is.
You're cool and mild.
You'll laugh with every lungful as the change comes over you.

So look up at the billboard.
See her smiling, sexy and tan.
But the only one who's laughing is the advertising man.

-- David Wilcox

Tuesday, June 27, 2006

Now everybody will want one

We've been reading a lot lately about Guidant corporation and its problems with defective defibrillators, but here's a medical device failure you don't hear about every day:

By Ray Henry, Associated Press Writer | June 23, 2006

PROVIDENCE, R.I. --A former handyman has won more than $400,000 in a lawsuit over a penile implant that has given him a 10-year erection. Charles "Chick" Lennon, 68, received the steel and plastic implant in 1996, about two years before the impotence drug Viagra went on the market. The Dura-II is designed to allow impotent men to position the penis upward for sex, then lower it.

But Lennon can't position his penis downward. He can no longer hug people, ride a bike, swim or wear bathing trunks because of the pain and embarrassment, and wears a fanny pack across his front to hide his condition. He has become a recluse and is uncomfortable being around his grandchildren, his lawyer said.

It seems to me he could solve, or at least ameliorate the problem with a dance belt or some such apparatus, but perhaps in this case, proud Peter will not assume the full upright and locked position. It isn't funny! Okay?

If this tragic tale holds any wider lesson, it is that like Icarus, Victor Frankenstein, or Pamela Anderson, Chick Lennon has paid the awful price for trying to improve on nature. (Come to think of it, has Pamela Anderson paid any price?)

Faith of our Fathers

While you are digesting this essay by George Lakoff and friends, here's an after-dinner mint.

Liberalism began as a movement to affirm individual freedom against the hereditary caste system of European aristocracy. The so-called Founding Fathers of the United States, quite naturally in the context of their times, saw government as the essential threat to liberty. They feared kings and earls, and so designed a government that would be weak and divided. Their rhetoric was universalist, but in fact they were of and for merchants and plantation owners, the rising economic elites of their times whose rivalry with the aristocracy defined European politics and who were the new ruling class in aristocracy-free America. That slaves were not free was troubling to some of them, and we ultimately fought a civil war over it. Economic inequality was not troubling to them. While obviously the poor enjoyed less liberty than the wealthy, their circumstances were responsible, not any identifiable oppressor. And there was always free land to the west for those who were impecunious but ambitious.

Then came the industrial revolution. The yeoman farmer and entrepeneurial artisan became a proletarian. The immediate and obvious threat to the liberty of the masses was not government, but ever greater industrial corporations that made wage slaves of people and dictated their hours of work, their housing, the tasks they would do. Mechanization of agriculture started to drive the small farmers from the land. In the new class struggle of the industrial age, workers organized against capitalists using a rhetoric of freedom, asserting a political philosophy in which government would become the instrument of the common people against the rapacious class of owners. Reformers moved to save capitalism against revolution by imposing some restraints on business corporations during the Reform Era early in the 20th Century, but a new version of liberalism emerged fully after the Great Depression proved that the game of capitalism required rules and a referee. A new role for government was born.

Now, liberalism no longer saw government as the enemy, but as an essential ally. Only government could defend liberty against commanding private interests. This was a bargain the smart capitalists accepted, because they knew their survival depended on it. By providing some protections for workers and the professional classes, a liberal government in the new sense could assure social peace. At the same time, it was obvious to most capitalists that the laissez faire philosophy, that prosperity was assured if the government stayed out of the economy, had failed.

And yet that rhetoric of "free markets" kept creeping back. During the Cold War, "free enterprise" and "free markets" were supposed to be what distinguished our side from the evil commies. After the collapse of the Soviet Union, "neo-liberalism" promised to bring the blessings of free markets to the all the world, and conservatives, of course, had never really given up on laissez faire and the dream of unbridled capitalism.

But reality strikes back. There is no such thing as a "free market." Nothing resembling a free market has ever existed, or ever can. It is a mythological and impossible beast. Markets are social constructions. In complex, post-industrial society, they depend for their very existence on continual, sustained, government intervention. Government creates money, the very lifeblood of markets, and sets its supply and cost by fiat. Government enforces contracts, and at least enough transparency in business dealings to make them possible. Government provides essential economic infrastructure that entrepreneurs will never create, because the structure of markets does not reward them or impedes their creation -- things like roads, bridges, airports, civil order, educated workers. Government regulates use of the commons, so that entrepreneurs upstream cannot, for example, utterly deprive those downstream of use of the river. Government suppresses negative externalities that might destroy even the wealthy and their children, such as air and water pollution. I could go on.

The question is not whether markets are "free." The question is how they are regulated, and on whose behalf. Markets have nothing to do with freedom. The freedom a market gives to one, it takes from another. If I sell you a gun, we both may benefit, until you point it at me and take your money back, or you get it home and find it doesn't work. Liberty can never come from markets. It can only be defended by the community, acting through government institutions. So let us stop using this false and misleading phrase. There is no such thing as a free market. Anyone who utters those words is lying.

Monday, June 26, 2006

And the Awesome Power . . .

of Stayin' Alive is felt once more in the halls of Congress. From the Sexuality Information and Education Council:

New York, NY - In making an effort to help safeguard our nation's youth, Representatives Luis Gutierrez (D-IL) and Jim Moran (D-VA) introduced the Guarantee of Medical Accuracy in Sex Education Act, the GMA. The GMA would prohibit the federal government from providing assistance to any entity whose materials on human sexuality contain medically inaccurate information. This provision would apply to all federally funded health education programs. The GMA stems from the findings of major medical associations and a Congressional review that show that the most frequently used abstinence-only-until-marriage curricula contain medically inaccurate and misleading information about condom efficacy, transmission of sexually transmitted diseases (STDs), including HIV, and pregnancy prevention, among other important issues related to sexual health.

Now, you wouldn't think it would be necessary to pass a law stating that federal funds cannot be used to lie to children. Wouldn't you?

Treading smartly and cautiously down the wrong path?

Sutcliffe and Wong in BMJ view with concern the explosive rise in prescribing of psychotropic drugs to children -- in which the U.S. has set the pace but other countries are catching up. They also anticipate that children will soon become a growing market (sorry about that) for anti-obesity drugs.

They call for high quality clinical studies so that decisions about prescribing to children can be based on evidence that the treatments are effective and that the benefits outweigh the risks. Most of these drugs prescribed for children today have not been tested in children and are prescribed "off label." Maybe more clinical trials are a good idea but as we have argued here many times, "effectiveness" of psychotropic drugs is defined as statistically significant responses to changes in scores on questionnaire scales, usually over a short period of time. Furthermore these effects are compared either to doing nothing, or to other drugs.

Children are not obese because they aren't taking the right drugs, they are obese because they consume too many calories -- often in the form of sugar water -- and don't get enough exercise -- because they are watching television and playing computer games. Similarly, children often present behavior problems because of their family, school and social environment. That could mean either that the environment has caused them to misbehave, or it could mean that behavior that might be okay in a different environment is problematic in the one they happen to be in. (Which of those options you believe in a particular case could be a value judgment, of course.) Children may also indeed have innate deficits in social skills, or difficult personalities, which most people think would be problematic in most plausible social environments.

But in any of these cases, feeding them mind altering chemicals may be a simple-minded option that drives out the right solutions. Since this option is promoted by corporations that stand to make billions of dollars from it, we ought to look at it very skeptically in all cases. They have millions of dollars to spend on these clinical trials which will then "prove" that the drugs are beneficial. But nobody will have spent millions of dollars to try family counseling or different ways of organizing the school environment, or better ways of rescuing kids from abusive circumstances, or teaching children behavioral skills, or promoting physical activity and better nutrition. Changing society and/or healing souls isn't easy, but maybe that means we ought to work harder at it.

Sunday, June 25, 2006

Rah, Rah, Siss Boom Bah

The other day I saw a pasty-faced guy with a serious abdominal adiposity (as we say in the public health biz) heading for the pizza stand. He was wearing a military-style buzz cut and a t-shirt with the Multi-National Force- Iraq logo and the words "Operation Iraqi Freedom" on the front; and on the back, "Ar-Ramadi, Iraq" and the USMC logo.

Now, if this guy ever served in the military, he hasn't done a five-mile march or eaten a MRE for at least ten years. But what does the t-shirt really mean? It's basically no different from the guy in line behind him with the Manny Ramirez number 24 jersey. The guy is a fan. He's rooting for his team, living vicariously through his heroes, manly men like he can never be.

And this is basically what's going on in the political debate over the war. The pro-war crowd doesn't bother to say what, exactly, we are trying to accomplish by staying in Iraq, what the benefits are supposed to be, or what the plan is. In fact, there isn't any plan. The issue is simply that "we" have to "win." That's it. Baseball players never give up, they keep fighting to win until the final out. And that's what "we" have to do in Iraq, because we can't be losers.

Here's what an actual smart person, George Kennan, said about the Vietnam War in 1966:

"There is more respect to be won in the opinion of this world by a resolute and courageous liquidation of unsound positions than by the most stubborn pursuit of extravagant and unpromising objectives."

Unfortunately, our country is led by an idiot.

Friday, June 23, 2006

Public Health 101

Actually, for people who have studied public health, this is the first lecture -- but it seems appropriate at this juncture. I'll try to bring some value-added from my own perspective.

In 2004, in JAMA, Mokdad et al updated a famous analysis from 1993 by McGinnis and Foege. You can read the article here, but you will have to go through a fairly laborious registration process in which you reveal your innermost secrets. It might be worth it because you will then have access to all JAMA content that's more than 6 months old.

Anyhow, here's the basic idea. Doctors code a cause of death on the death certificate. Now, this is always a bit dodgy. In nearly 100% of cases, the proximate cause of death is cardiac and/or respiratory arrest -- your heart stops beating, you stop breathing, Jack you dead. For people on life support, it's a bit more complicated. They are first diagnosed as brain dead, then the techies pull the plug. So in those artificial cases, it's cessation of brain stem functioning. In absolutely 100% of cases, the distal cause of death is birth. We're mortal. We're doomed. It is impossible to save anybody's life.

However, the "cause of death" is supposed to represent whatever disease or trauma the doctor considers to be principally responsible for the person dying at this particular moment. In other words, if you didn't happen to have lung cancer, you would have lived longer. Of course this is often something of a judgment call. People who are sick and debilitated for whatever reason often die of pneumonia, but is pneumonia the cause of death or is it whatever made you so debilitated?

In 2000, the leading cause of death in the U.S., according to death certificates, was heart disease (710,760 deaths, 258.2 per 100,000 population). The following causes were, in order, malignant neoplasm (they could just say cancer but that wouldn't seem so learned), cerebrovascular disease (stroke), chronic lower respiratory tract disease (mostly meaning emphysema), unintentional injuries, diabetes, influenza and pneumonia, Alzheimer disease, kidney disase, and septicemia. Then of course there is the famous "other."

Now, this is already fairly questionable. Our friend Rick Lippin is going to jump all over that "influenza and pneumonia" thing, as well he should, on the grounds that few people die of those causes in the U.S. who aren't already very sick. For example, they might have Alzheimer or cerebrovascular or heart disease. So who qualifies for the I&F cause instead of one of those? It is in part a function of the physician's whim, no matter what anybody tries to tell you. Similarly, many people who die of heart disease have diabetes, which is a risk factor for heart disease. Septicemia -- "blood poisoning" or toxic shock -- may be a sequel of an injury or general debility. It isn't entirely clear what ought to have precedence.

Anyway, what McGiniss and Foege, and their successors Mokdad et al did was to push the causes of death further back, toward factors that mostly lie outside the disease process within the body. Most of these they call "modifiable behavioral risk factors," meaning they are dumb stuff the dead people did that caught up with them.

Their top cause of death is tobacco (435,000 fresh corpses in 2000), followed by "poor diet and physical inactivity," alcohol consumption, microbial agents, toxic agents, motor vehicle, firearms, sexual behavior, and illicit drug use. Now, you should immediately notice some conceptual inconsistency here. The vast majority of those deaths from sexual activity result from microbial agents, or more specifically one, Human Immunodeficiency Virus, but they separated them out. (They also note, in a sop to Rick, that "Because pneumonia and septicemia occur at higher rates among patients with cancer, heart disease, lung disease, or liver disease, some of these deaths really are attributable to smoking, poor diet, and alcohol consumption." But that's just tough shit, they're leaving them in.)

This is what we call a paradigm shift -- from the medical paradigm, whereby disease and death are functions of processes that go awry or organs that fail us within our bodies -- to the public health paradigm, whereby they are functions of our behavior and our environment that can be modified before we ever think of the idea of medicine. It is not a bright line, certainly. I invite everyone to have all sorts of fun nitpicking and deconstructing both lists.

While you do that, I'm going to take one step further back. Why do people smoke? Does the evil lie in the herb Nicotiana tobacum? Does it lie in the fool on the other end of the fire? Or does it lie in the multi-billion dollar business corporations and their investors and executives who persuaded people to smoke through a century-long campaign of manipulation and lies?

We might ask many similar questions. Why do people have poor diets? Why are they physically inactive? Why do so many people die in motor vehicle crashes? Why are we exposed to toxic agents (other than Nicotiana tobacum)? Why is sex unsafe for some people? Why are some people at the wrong end of a bullet? And so on. It is this broader frame, the sociological frame, that motivates Stayin' Alive. So-called health care is one of the many things of value that is unequally shared. But it's not the most important. Furthermore, it is not only of value to the recipient - others benefit, such as physicians who draw income and prestige from their profession; hospital executives, who even when they work for non-profit organizations make enormous salaries; drug and medical device company executives and investors; and so on. Because of these other interests, medical services sometimes do not benefit the recipient at all. The medical institution is embedded in society and is a social institution. It also is subject to sociological scrutiny. So that's what we're trying to do here.

Thursday, June 22, 2006

You get what you pay for?

Our friends Alan Sager and Deborah Socolar are out with yet another killer study. This time they find that the People's Republic of Massachusetts has the highest health care costs in the world. The full report will be available tomorrow or Monday at the Boston University Health Reform Program, and once I've had a chance to read it I will probably have more to say. Meanwhile, you can read about it in this story by Christopher Rowland in the Boston Globule.

Alas, the reason we spend the most is not because we're commies, it's because we aren't. The undisciplined melee of public and private insurance, teaching hospitals, for-profit hospitals, community hospitals, health plans, health centers, physician practices and general what-not sucks up money like a school of humpback whales in a krill field. But are we happy and healthy whales, or are we getting indigestion? (Yeah, sorry, that's kind of an esoteric simile, much too forced.) Some guy named Cutler who calls himself an economist says, according to Rowland, "'Really what's happening is we're buying more stuff, and on average that stuff is good for our health.' Problems associated with the cost of healthcare 'are more than offset by the benefits of living longer, healthier lives.'"

Ahh, no. Here in the PRM we do have somewhat better health status than most of the U.S., but that is entirely explainable by our comparative affluence and high levels of education. All of the comparably affluent countries spend less than half what we do on health care, and their people live longer, and are healthier, than we Massachusettsians. Come to think of it, that's even true of some less affluent countries. And people in many states where they spend less on health care are just as healthy as we are in Mass. So take that, Hahvahd economist.

Again, I'll have more to say once I've had a chance to read the report.

Wednesday, June 21, 2006

They do things differently in the colonies

Jolly old BBC Washington correspondent Matt Frie has droll encounters with the U.S. health care "system."

He gets a toothache, and as his bowler and bumbershoot hang on the rack in the dentist's office, he is given an elaborate presentation describing a two year plan for oral perfection. He passes on the offer, and settles for a root canal. Then he gets a crick in his neck and goes to the chiropractor, who straightens out the kink and then proposes a two year program, at $150 a week, in pursuit of vertebral excellence. Frei stiffens the upper lip and gets on with his life. Then his son notices he is holding the Sunday Times Crossword away from his face so he heads for the optician where he gets prescription glasses. (I buy my old-man glasses at the CVS for $19.95, by the way -- but in many states, that's against the law.) Then his feet start to hurt and he ends up getting bunion surgery. For the next eight weeks he is a certified representative of the Ministry of Silly Walks. I have no idea whether the surgery was necessary, but whatever the merits of the treatment in his case, a lot of Americans get it for largely cosmetic reasons.

Sometimes we hear criticisms of the British National Health Service: that people have to wait several months for elective surgery, and they won't authorize procedures that people who are lucky enough to have insurance routinely get in the U.S. Well, waiting isn't a bad idea. Sometimes problems get better, or after reflection surgery doesn't seem like such a great option after all. And the Brits have an agency, called the National Institute for Health and Clinical Excellence, that actually studies medical procedures and drugs, not just to figure out whether they do anything at all, but whether they are actually worth it. Since they spend half as much on health care as we do, while living longer and being healthier, that's probably not such a bad idea.

Tuesday, June 20, 2006

More on Thinking Backwards

So, if we're thinking backwards from conclusions to evidence, where do we get the conclusions from? In my previous post on running the brain in reverse, I suggested two possibilities: 1) The conclusion is something we would like to be true, because it's convenient, evades the hard work of thinking through complexity, pleases equally backward-thinking constituents, enables us to bamboozle people, or whatever ground of selfishness or wishful thinking there may be; and 2) We just grab a set of beliefs out of the air, for example, "The Bible is the literal and inerrant word of God," and take it from there. The benefit of the latter process is not as obvious, since the belief system could well impose costs and certainly won't avoid hard thinking. The Bible, after all, is riddled with self-contradiction and is manifestly inconsistent with observable reality, so theologians have to do a lot of hard work of obfuscation and sophistry. (For a good time, check out The Skeptic's Annotated Bible.)

But today I want to talk about a third way of generating conclusions as a basis for backward thinking, and that is the reification of hypotheses.(And guess what, I'm back now on the psychiatry thread.) As we've mentioned, you will see advertisements on television explaining that the disease called depression is caused by a chemical imbalance in the brain, which antidepressants correct. Antipsychotic drugs are not advertised on television, as far as I know, but their makers also promote the idea that they correct a different fault in the neurotransmitter system.

You can read a passionate, radical attack on these ideas here, by Robert Whitaker, a journalist and author of Mad in America, and a somewhat more restrained and scholarly dissent here, by a psychiatrist and clinical social worker.

In a pistachio shell, both classes of drugs originated when researchers noticed that people taking antihistamines in clinical trials reported subjective side effects such as drowsiness and agitation. A lot has been invested in subsequent decades to develop antihistamines that don't have these effects, but meanwhile drug companies decided to find out if they could take advantage of them for use in psychiatric disease. The first drugs to result were antidepressants that interfere with enzymes in the brain that break down certain neurotransmitters; and antipsychotic drugs that block a class of receptors for the neurotransmitter dopamine.

These were considered useful because, in the case of antidepressants, slightly more people on the drug than on placebo reported improvement in the short term in formal "rating scales" for depression. These are a series of questions or observations which, when summed up, are supposed to reveal the severity of depression. Here is the most commonly used, the Hamilton Rating Scale for Depression. Note that denying being depressed is considered a symptom of depression. You get 2 points for denying being depressed, but 0 points if you say you are depressed and ill. That's interesting, I'm already part way there, I guess. You also get points for insomnia, lack of appetite, anxiety, agitation, etc. Scroll down to the bottom and notice who paid to print this form and post it on the web.

In the case of antipsychotics, the drugs suppressed the so-called active symptoms -- hallucinations, delusions, disorganized thinking and bizarre behavior. Existing treatments already did this -- the first drug used by psychiatrists for psychosis was morphine, and other sedatives were effective in calming people down. Psychiatrists also used brain surgery -- severing the frontal lobes so that people became tractable zombies -- and electric shocks to the brain or insulin-induced comas which left people groggy and passive. The antipsychotics were considered an advance since they weren't as obviously addictive as opiates and were less violent than other methods.

Noticing that these drugs had effects on neurotransmitter systems led to the hypothesis that the diseases of depression and schizophrenia were caused by flaws in these systems that the drugs were correcting. Hence further drug development research has focused on finding compounds that affect the same systems in more specific ways, or by other mechanisms. Hence the "Selective Serotonin Reuptake Inhibitors," which concentrate their effect on a single neurotransmitter; and the "atypical antipsychotics" which blockade dopamine receptors by a different mechanism.

But it turns out that if you bother to look at the actual basic research, there is no evidence that people diagnosed with these diseases have abnormalities in these neurotransmitter systems. In fact, the drugs cause abnormalities. In the case of depression, any compound which has some sedative effect will result in improvement on the Hamilton Rating Scale. And there is no particular reason to think that the effect on psychotic symptoms of neuroleptic drugs is somehow more fundamental than the effects of earlier treatments. If you don't like what the brain is doing, and you broadly suppress some of its activities, you might find the result an improvement, but that doesn't mean either that you now understand the root of the problem, or that you are treating it.

And therein lies the real offense. It would be one thing if antidepressants actually helped people, but there is affirmative evidence that they are in fact counterproductive. The few trials that have been done comparing antidepressant treatment with counseling only, find that people who are treated with antidepressants have a worse long-term course than people who are not. They relapse more often and are more depressed. These conclusions aren't quite rock solid because the studies are retrospective. Nobody wants to fund a randomized controlled trial that might prove this. But it is notorious that in some RCTs, antidepressants have actually done worse than placebo even in the short term. These studies are ignored or explained away.

In the case of antipsychotic medications the story is less clear cut. Some people do have psychotic episodes from which they recover spontaneously; and schizophrenia also tends to remit somewhat in middle age. So it's not necessarily a terrible doom if untreated, although for many people, alas, it is. The question is whether the long-term course of schizophrenia is worse for people who take antipsychotics, and while there is some suggestive evidence for that from international comparisons, I don't think anyone can assert it confidently. Psychosis can be so disabling and unpleasant that desperate measures providing short-term relief are justified. Some people can tolerate antipsychotic medications for the long term and appear to do well on them, but most people can't. The side effects are just intolerable. The new antipsychotics, which some people can take who can't take the older ones due to psychological and motor side effects, cause extreme weight gain, hyperlipidemia and diabetes, which are life threatening.

So, there is a movement which sees these drugs as little more than a fraudulent conspiracy by their manufacturers. I'll tell you what I think just for the heck of it but I won't spend the time today to justify it. My personal conclusion is that these drugs should be a last resort, not a first resort as they are now.

We certainly should not start feeding people antipychotic drugs at the first signs of psychosis, but rather wait to see if the episode remits. They should never be given to children under any circumstances. People who do start taking them might try cutting down or stopping when they reach their forties, and see what happens.

About antidepressants, I have even stronger opinions. They should be used very seldom. There is no such thing as the disease of "social anxiety disorder," and nobody should ever be given a drug for that diagnosis. If there is a "disease" of depression, it exists in only a minority of people who are diagnosed with it. People who suffer from depressed mood and other symptoms such as overwhelming guilt or apathy should try proven methods such as physical exercise, counseling and cognitive-behavioral therapy. Oftentimes the problem can be overcome by changing one's habits and one's thinking, or taking steps to change one's situation in life. People who turn out to have intractable, disabling depression, might elect to try antidepressant drugs. But they have to understand that their problem is not caused by a "chemical imbalance," nor will the drugs fix one.

Monday, June 19, 2006

Res Ipsa Loquitur

From the new Integrity in Science Watch.

"The House of Representatives Science [sic] Committee rejected an amendment to the National Oceanic and Atmospheric Administration appropriations bill that would prohibit NOAA supervisors from punishing employees who disseminate scientific research."

What the CinC meant to say was, "You're either with us, or you're with the scientists."

Thinking Backwards

An essential element of critical thinking is understanding the appropriate roles of facts vs. values in argumentation. For example, it is not evidence for a fact that its truth would be desirable. A second key is tracing the implications of value statements, especially when, as happens ubiquitously, rules or principles collide. And, while there is little or no direct recourse when disputants assert opposing values as fundamental, it often helps to clarify matters when people are willing to think about where their value statements come from and why or how they adopted particular statements as their own.

These good habits are in short supply in much of our contemporary political discourse, perhaps most obviously when it comes to the so-called "moral values" issues (and why they get that label when other issues which clearly are all about moral values do not is one of the keys to our problem), but in most other areas as well.

My recent post about abstinence-only sex education is a case in point. Proponents assert that it is better for teens to abstain from sex, largely as an a priori principle, although they may add arguments about consequences such as emotional vulnerability and exploitation, or leaky condoms. (They may go further and say that people of any age should engage in sex only in marriage, but that's largely beside the point.) They say that most parents agree. Ergo, sex education should instruct young people to be abstinent and not send any "mixed messages" by telling them about contraception and prophylaxis.

But of course the conclusion does not follow. Only if abstinence-only sex education did, in fact, result in higher rates of abstinence and lower rates of adverse consequences than did comprehensive sex education could one call it superior, even on the basis of its proponents stated values. But it doesn't. If you wish to encourage abstinence, you will have to find other means. And, if you don't provide young people with comprehensive information about sexuality and how to mange its consequences, they'll go ahead and have sex anyway but the consequences will be worse.

A further embedded error is that, because proponents believe extramarital sex to be immoral, they promote falsehoods about its dangers. For example, a curriculum promoted by the Department of Education, and the Vatican, both make false assertions about the unreliability of condoms. Some people insist that condoms are far more prone to failure than they really are because they start out believing that people shouldn't use them on moral grounds. They are concluding that what they would like to be correct is true.

Now, even granting the facts, one can still be opposed to extramarital sex. Fundamental moral rules or principles are not susceptible to evidence, at least not in strictly logical terms. You can just say, "It's wrong," I can say, "Not necessarily," and you can say, "Is too," and that's that. But you could ask yourself why you believe that, and you could also try putting the belief in historical context to understand why some people have believed it in some times and places and others have not. For example, you might say, "I believe it because I believe in the teachings of the Bible." But if you were to honestly follow that assertion everywhere it leads, you would find yourself on a journey that few Bible believers are willing to take. The Bible, it so happens, endorses polygamy, concubinage (which is sexual slavery) and the rape of women and girls of people conquered by Hebrews. You might also find yourself in difficulty with your condemnation of abortion, since that is a position which lacks any biblical authority whatever and was not a Christian doctrine until the 19th Century.

But this sort of reasoning backward from conclusions to evidence is characteristic of the contemporary conservative movement in all areas. For example, the Bush administration makes conclusions about climate science based on protecting oil industry profits, on the environmental impact of mercury emissions based on the profits of electric utilities, and about the existence of chemical and biological weapons, and nuclear weapons programs, based on its a priori conclusion that war with Iraq is desirable. It concludes that abortion causes breast cancer because it doesn't like abortion. It concludes that marriage has always been "between one man and one woman" because that's how it wants it to be today. And so on.

Conservative chatterers and supporters of the Administration consistently display these habits of thinking backwards. There is all sorts of good news from Iraq that the media aren't reporting. Eliminating taxation of the wealthy makes poor people better off. Democracies don't try to acquire weapons of mass destruction™, and democracies don't start wars. Saddam wouldn't let in the UN inspectors. No-one could have anticipated that people might try to fly planes into buildings, or that the levees would fail.

But the fact is, they are simply wrong, about everything.

Friday, June 16, 2006

Speaking for Myself

I just posted this on Today in Iraq -- an unusual personal statement.

The discussion, both here and in Iraq, over Maliki's suggestion of a possible amnesty for resistance fighters who have attacked occupation forces, has been truly Orwellian. People in the U.S., including I am sorry to say much of the Democratic congressional delegation and a good part of the liberal blogosphere and chattering classes, apparently do not understand that the United States attacked and invaded Iraq. The Iraqi army fought back. Ultimately much of it went underground and continued to fight in guerilla mode. There has been no peace settlement. In fact, although as far as I know nobody has pointed this out, the government of Iraq never surrendered.

When a war ends and a peace treaty is signed, combatants return to home, and POWs are released. People who fight against foreign invaders are not terrorists, criminals, or murderers. Obviously, if the new Iraqi government ever wishes to end the insurgency and establish a true national unity government, it must come to agreement with the resistance and bring it into the political structure.

This Washington Post story tells the bizarre story of Maliki trying to maneuver between reality and his American masters. On Wednesday, he gave a press conference, in Arabic, which was televised, at which he said, "reconciliation could include an amnesty for those 'who weren't involved in the shedding of Iraqi blood. Also, it includes talks with the armed men who opposed the political process and now want to turn back to political activity.'" Yesterday, he fired an aide who had, in essence, repeated Maliki's own words to reporters, saying "Mr. Adnan Kadhimi doesn't represent the Iraqi government in this issue, and Mr. Kadhimi is not an adviser or spokesman for the prime minister. It is not true what some of the media outlets, including The Washington Post, have said about the willingness of the Iraqi government to talk with armed groups." Not true, except that Maliki said it himself, on television.

Meanwhile, back in the U.S.A., in the warped Congressional debate on Iraq staged by the Republicans, Republican Senators defended the amnesty idea - which I suppose they have to do since the administration line is that the new Iraq government is sovereign and legitimate -- while Democrats and their supporters attack them for supporting amnesty for "terrorists" who have "murdered" American forces "serving heroically in Iraq to provide all Iraqis a better future." Listen folks -- get this straight. It's a war. That's what happens in wars, people try to kill each other. If Iraqi resistance fighters who attack U.S. forces are terrorists and murderers, then by the precise same standard, U.S. troops in Iraq are terrorists who have murdered tens of thousands of Iraqis. You can't have it both ways.

Here is an excerpt from the Democratic press release:


Offer Senate resolution demanding reversal and retraction of reported Iraqi proposal

Washington, DC— Democrats today demanded an immediate retraction and reversal of the reported proposal that terrorists and insurgents who kill American soldiers in Iraq may be granted amnesty by the new Iraqi government.

“It is shocking that the Iraqi Prime Minister is reportedly considering granting amnesty to insurgents who have killed U.S. troops,” said Senate Democratic Leader Harry Reid. “On the day we lost the 2,500th soldier in Iraq, the mere idea that this proposal may go forward is an insult to the brave men and women who have died in the name of Iraqi freedom. I call on President Bush to denounce this proposal immediately.”

Democrats offered a Resolution demanding that this policy be repudiated, and that President Bush immediately inform the government of Iraq—in the strongest possible terms—that the United States opposes granting amnesty to anyone who attacks American soldiers. The text of the Sense of the Senate resolution is attached below.

“We ask you Prime Minister Maliki, are you willing to have ‘reconciliation’ on the pool of American blood that has been spilled to give your people and your country a chance for freedom?” said Senator Menendez, a sponsor of the resolution. “We reject that notion and are outraged that the sacrifice of American troops and the American people could be so devalued.”

“Terrorists and insurgents shouldn’t be rewarded for killing American soldiers,” said Senator Bill Nelson, of Florida, a member of the Senate Armed Services Committee who also sponsored the resolution.

Excuse me. Did the U.S. prosecute German, Italian and Japanese soldiers after WWII? Confederate soldiers after the Civil War? British soldiers after the war of independence? It's a war, get it? That means people are trying to kill each other. If you start a war, that's what happens. Bunch of fucking idiots.

Thursday, June 15, 2006

Fair and Balanced Science

In case you thought that the Decider had Decided to back off on fixing the scientific facts around the policy, I learn by way of Mike Mitka in JAMA that CDC responded to political pressure by "balancing" a panel at the 2006 National STD Prevention Conference. It seems the panel was originally entitled "Are Abstinence-Only Programs a Threat to Public Health." The panel members had actually conducted research which found that such programs -- "sex education" for young people in which the only alternative to getting STDs is presented as abstinence -- don't work. The reason the research finds that abstinence only programs don't work is that they don't work.

However, the facts weren't good enough for Rep. Mark Souder (R-Ignorance), who wrote to DHHS to demand a more "balanced" panel. He got it. Two of the original speakers were replaced by speakers who support abstinence only programs. But, according to Rep. Henry Waxman (D-CA), Jonathan Zenilman, M.D., the conference organizer, said that "no abstinence-only advocates were selected for the initial panel because no proposals were submitted that offered credible data on the effectiveness of abstinence-only programs."

You can get the Powerpoint presentations from the session here, though I must warn you the server is glacial. If you put up with the wait, you will see that the pro-abstinence only presentations argue that most people don't want adolescents to have sex, and that adolescents shouldn't have sex because it's wrong and it might be bad for them. What they do not show is that abstinence-only sex education programs a) cause them not to have sex or b) are as effective as comprehensive sex education programs at reducing the rates of unwanted pregnancy and STDs. They reason they don't show those results is that the truth is otherwise.

Incredibly, I heard a discussion last night on Christopher Lydon's program on NPR, with the NPR ombudsman, over whether the new standard in journalism should be "truth," rather than "balance." Apparently the ombudsman, and Chris, find this to be a tough call.

State of Emergency

No doubt you have read by now about the Institute of Medicine report on the shortage of Emergency Department resources in the U.S. According to the IOM, ambulances are diverted from emergency rooms that are too busy to accept their cargo every minute.

AP reporter Lauran Neergaard writes "At the root of the crisis: Demand for emergency care is surging, even as the capacity for hospitals, ambulance services, and other emergency workers to provide it is dropping." Well, that's not exactly the root of the problem, it's the stem. The root is money, of course. Emergency rooms are not an economically attractive proposition for hospitals, mostly because they have to treat everybody who shows up with a genuine medical emergency, and some of those people don't have insurance and can't pay. They used to do "wallet biopsies" on people and divert them if they didn't have an insurance card, but it's harder to get away with that now. (Not that it doesn't happen.)

There's a further problem, which the AP report clearly acknowledges. Even if we did maintain adequate emergency department capacity for everyday demand, it would be insufficient for a disaster, whether it's a local catastrophe such as a nightclub fire, or a regional or worldwide infectious disease pandemic. Herein lies a classic problem for human societies, which I have discussed before. We tend to underinvest in preparations for catastrophic events of unclear or fairly low probability. Some people nowadays have even taken to presenting it as somehow a "progressive" position to denigrate concern about possible emergencies such as a flu pandemic, because it supposedly diverts money from immediate needs -- even though in reality, it doesn't. Apparently just taking up a bit of space in the public discourse is a crime.

The truth is that this is not a question of political ideology or leftism or rightism. It's just a puzzle. How much to invest in situations that would be extremely serious if they happened, the timing of which cannot be predicted, is a value judgment. We need to compile the best data we can, get as much information as possible, have an open, public discussion, and then make a decision based on democratic process. Emergency departments are expensive to maintain. Spending the capital needed to maintain capacity above everyday demand means, a fortiori, some form of social subsidy. Presumably, it ought to be more than zero, but how much? I'm not going to tell you the answer, but we need to think about it, and we need to act.

Wednesday, June 14, 2006

Our enemies never stop thinking about new ways to harm our country and our people, and neither do we

Jerry Avorn and William Shrank, in NEJM (and yup, it really is off limits to rabble this time) break another story that your liberal media has once again expended vast resources to utterly ignore.

In a nutshell, the FDA, purporting to fix the incomprehensible and largely feckless so-called "drug labels" (actually those full pages of tiny print that are stuffed into the box, and generally tossed by the pharmacist before the drug gets to you), has promulgated regulations which don't actually do that. However, following the close of public comments, the ever vigilant guardians of the public welfare inserted a paragraph which states that the FDA-approved label, "wheter it be in the old or new format, preempts . . . decisions of a court for purposes of product liabliity litigation." What this means is that it will be essentially impossible for anybody who is injured by drugs to sue the manufacturer. The only way around this would be to prove that the company had intentionally committed fraud in getting the label approved -- something nearly impossible to do.

What happens in practice is that data on the so-called "label" on risks of drugs lag several years behind the known facts. This doesn't require fraud on the part of the manufacturers, just foot-dragging combined with inefficiency and indifference on the part of the FDA. So even if side effects and counterindications aren't on the label, and you are harmed by the drug, you have no legal recourse.

By the way, the industry has been trying to get legislation passed that will accomplish this for years. They have not been able to get Congress to go along. But who needs democracy, when you have a Decider?

You can read about the new regulations here, on the FDA web site. Funny thing, though, the public summary doesn't mention this minor element of the new regs.

Tuesday, June 13, 2006

Disparate Disparities

I'll be at a statewide conference on health disparities all day, so just this quick hit post. Disparities are differences in health status, morbidity and mortality among "population groups." "Groups" means categories like race, ethnicity, gender, sexual orientation, age, and disability. Obviously differences according to age, gender and disability are inherent, but disparities in those cases refers to avoidable differences resulting from correctable inequalities.

This is a major form of discourse in public health these days, inspired in part by the Clinton Administration establishing a national goal to "eliminate" health disparities by 2010. Of course it isn't going to happen. Although I strongly support health equity and structure much of my work around that principle, this discourse says a lot about our politics.

In fact, the most important and best established health disparities are between rich and poor, the well educated and less well educated, people with high occupational status and people with low occupational status. In the health disparities discourse, these factors -- which are closely associated with each other but not really identical -- are usually thought of as exogenous variables that we control for. "Disparities" are what is left over. Such left over disparities are still important and it's well within the egalitarian tradition to study and combat them. But it is noteable that we marginalize socio-economic status.

There seems to be a tacit assumption in the U.S. that class inequality is a force of nature, something we just have to accept as background. We can't do anything about it so why bother to talk about it?

In fact, overall population health status correlates with inequality at the level of the state and nation. More egalitarian countries -- such as the nations of Western Europe -- have healthier populations than the U.S., in spite of lower total wealth. Even a very poor country such as Cuba, which also has low inequality, actually compares favorably to the U.S. on some health status indicators. Social policy - including the structure of the tax system, corporate regulation, and social programs such as universal access to higher education, child care, public transit, job-creating investment and, oh yeah, universal, comprehensive health care -- can powerfully affect the level of inequality in capitalist countries. (Note that health care per se has less effect than most people expect on individual health and longevity. However, providing health care without requiring low income people to pay more than they can afford contributes powerfully to economic equality.)

In research and policy advocacy to combat health disparities, we need to put economic and social equality front and center, not on the sidelines.

Monday, June 12, 2006

Your pathetic media

Even The Mighty Conqueror himself sought to manage expectations about the likely results of the still rather odd and mysterious death of Abu Musab al-Zarqawi, who may or may not have been an important terrorist leader; may or may not have had one leg; could have been captured or killed before the war when he was holed up in Kurdistan, out of Sadaam's reach but within the "no flight zone" heavily patrolled by the UK and US, but wasn't because he was useful as an excuse for the war; who was a convenient scapegoat for much of the violence in Iraq but who we are now assured had not a lot to do with it.

Nevertheless, the corporate media suddenly started saying that a balmy calm has descended over Iraq. For example, today's Iraq round up story in the Chicago Tribune, which also did duty as the Boston Globe's daily dispatch, talked about Zarqawi and renewed threats from al Qaeda in Iraq, but said of the yesterday's violence only: "In the worst violence yesterday, five civilians died in a gun battle between British troops in the southern city of Basra and militiamen loyal to the radical Shi'ite cleric Moqtada al-Sadr." The previous day's Washington Post story, which the Globe reprinted, simply said that there had been less violence in the country on Saturday than usual.

Not true. Yesterday, as of about noon Eastern Time, (cutting and pasting from my Today in Iraq post), we knew the following:

Bring 'em On: Insurgents fire rockets at British base near Amara, British soldier wounded when sortie to locate the source comes under fire. Hospital says one civilian killed in incident. However, the AP version of this story is different. AP says Iraqi police say insurgents set fire to a vegetable market to lure British troops, 5 civilians killed.

Other Security Incidents

Roadside bomb hits police patrol in northern Baghdad, kills one officer, wounds three.

* Also, gunmen fire on civilian car, killing one
* Police in West Baghdad find body of a security guard for the Health Ministry, tortured and shot in the head.

Reuters has these additional incidents:

* Police found the beheaded body of an Iraqi soldier thrown in a river near Tikrit 175 km (110 miles) north of Baghdad, police said.
* Gunmen wounded two civilians when they opened fire on their car in central Tikrit, police said.
* A joint Iraqi police and U.S. forces patrol raided a house in central Kirkuk, 250 km (155 miles) north of Baghdad, on Wednesday evening and arrested seven suspected insurgents, police Brigadier Sarhat Qadir said on Sunday.
* A roadside bomb seriously wounded a senior police officer, Major General Ali Hussain, in northern Baghdad, police said. A policeman who was driving Hussain's car was killed and another was wounded in the attack. It's possible this is the same incident reported by AP, but the number of wounded differs.
* Gunmen killed a man and a woman in a car in Falluja, 50 km (32 miles) west of Baghdad, police and hospital sources said.
* Gunmen shot dead a security employee of the Kurdish PUK party and another person in central Kirkuk on Saturday, police said on Sunday.
* Gunmen shot dead a civilian and wounded another in a car in central Kirkuk on Saturday evening, police said.
* A roadside bomb targeting a police patrol exploded near the southern Baghdad district of Dora, wounding five civilians, police said.

Kuna has additional incidents:

Two Iraqi civilians were killed in Kirkuk, northern Iraq, on Sunday when unknown militants opened fire on them, and several were wounded in different incidents around the city. Kirkuk police sources told KUNA that three unidentified militants in three cars opened fire in the area of Urouba near a central Kirkuk school, killing the two men.
* The source also said that an Iraqi civilian was wounded in the hand when an unknown gunman shot him in Taza, southern Kirkuk, upon which he was taken to hospital for treatment.
* Furthermore, the source said an explosive device planted in a car had went off on the Kirkuk-Tikrit road, wounding the driver and totally destroying the vehicle.
* Also, a civilian was wounded when a mortar shell fell over a new gas station.
* There were a number of explosions, two of which targeted multi-national force patrol vehicles and another targeting a police vehicle, but no damages were reported.
* Meanwhile, a security source at the joint coordination center said eight civilians were seriously wounded in an attack on a cafe in the city of Khalas, northern Baqouba. The source said the attack took place late last night, adding that the militants were able to escape and that a number of shops in the area were damaged.

In a separate dispatch, KUNA says two PUK members shot dead in Kirkuk. Also:

* Iraqi police said Iraqi forces and Multi National Forces in Iraq were able to arrest seven members of the "Al-Mujahideen Shura Council" believed to have fled Baaqouba following the killing of Abu Musa'ab Al-Zarqawi.
* The Iraqi police in Mosul said five civilians were shot dead by unknown gunmen in Mosul northern Iraq and a headless body was found in the same town.
* An Iraqi police source told KUNA unknown gunmen riding in two civilian vehicles opened fire at six butchers, killing five of them and severely wounding the sixth.

Turkish press says a Turkish truck driver was killed near Mosul on Thursday.

And Saturday was just as bad. Now, this afternoon, DoD suddenly decides to announce the deaths of the following U.S. military personnel (thanks to Iraq Coalition Caualty Count):

06/12/06 DoD Identifies Navy Casualty
Seaman Apprentice Zachary M. Alday, 22, of Donalsonville, Ga., died June 9 from injuries sustained earlier in the day when the vehicle in which he was riding struck a land mine...conducting combat operations against enemy forces in the Al Anbar...

06/12/06 DoD Identifies Marine Casualties
Lance Cpl. Salvador Guerrero, 21, of Los Angeles, Calif., died June 9, of wounds received while conducting combat operations in Al Anbar province, Iraq. He was assigned to 1st Battalion, 7th Marine Regiment, 1st Marine Division...

06/12/06 DoD Identifies Army Casualty
Pvt. Benjamin J. Slaven, 22, of Plymouth, Neb., died on June 9, in Ad Diwaniyah, Iraq of injuries sustained when an improvised explosive device detonated near his HMMWV during combat operations. Slaven was assigned to the Army Reserve...

06/12/06 columbustelegram: Clarks Marine killed in Iraq
Brent Zoucha...19-year-old soldier...was killed last week in Iraq when the Humvee he was riding in exploded after hitting a land mine. His mother, Rita Zoucha, learned of her son's death on Friday. Brent's brother, Dyrek...was not hurt in the explosion

06/12/06 DoD Identifies Army Casualty
Sgt. 1st Class Clarence D. McSwain, 31, of Meridian, Miss., died in Baghdad, Iraq on June 8, of injuries sustained when an improvised explosive device detonated near his convoy vehicle during combat operations...

06/12/06 DoD Identifies Army Casualty
2nd Lt. John S. Vaughan, 23, of Edwards, Colo., died in Mosul, Iraq, on June 7, when he encountered enemy small arms fire during dismounted combat operations. Vaughan was assigned to the 2nd Battalion, 1st Infantry Regiment...

06/12/06 AP: Beatrice soldier dies in Iraq
Twenty-two-year-old Ben Slaven was a member of the U-S Army Reserves. He is the son of Bruce and Julie Slaven. Bruce is a Gage County sheriff's deputy and Julie works in the sheriff's office. Neither were available for comment this morning.

Looks like they were saving them up so as not to take the media spotlight off of their great triumph. It worked, too. Not that the corporate media bothers to report most deaths of U.S. troops anymore anyway. However, the confirmed count of dead now stands at 2,497, and since they have taken to a three or four day lag in announcing U.S. troop deaths, we can presume it has in fact clicked over to more than 2,500. Perhaps that artificial milestone will rate a passing notice.

The basic issue here is that your local fishwrapper or evening news may mention one or two or even five or six violent incidents that occurred in Iraq. They may even run the AP story, which will typically list a half dozen. You will then have the impression that you have been given a complete picture of what happened in Iraq on that day. But in fact, it will be 1/4 or less of the incidents that have been reported, at best. If U.S. troops were injured or killed that day, they probably won't mention it at all, unless one of them happened to come from the local area.

The bottom line? If there is indeed good news from Iraq that they aren't reporting, that's certainly inappropriate. But I've looked high and low, far and wide, and I can't find any. What I do find is that they aren't reporting the vast majority of the bad news from Iraq.

Sunday, June 11, 2006

Almost right can be really, really bad

One of the lesser noted -- but in my view extremely important -- elements of the new health care reform legislation in Massachusetts is a requirement that hospitals collect patient data by race and ethnicity, and that their reimbursement rates be tied to progress in eliminating disparities in health care. The data systems this applies to already exist -- they're the hospital discharge data system, and standard quality assurance systems. What's new is only the requirement for racial/ethnic identification.

If you've been reading for a while, you already know that there is a federal standard, consistent with the census. Because all of the important state public healty data systems feed into federal systems, the states pretty much have to observe the federal standard. And, of course, it's really, really horrible. It's based on long discredited 19th Century theories of biological race, with an awkwardly grafted on attempt to account for the largest "minority" group in the United States, so-called "Hispanics," who don't happen to fit into the race theory. So, as you probably know, people first choose an "ethnicity" - consisting of are you or are you not "Hispanic" -- then they pick one or more "races" -- White, "Black or African American," Asian, Pacific Islander, "Native American/American Indian/Alaksa Native".

The profound, ignorant bogosity of this system has been well described before, here and elsewhere. I won't belabor it, but basically, while the government acknowledges that it has no correspondence to biological reality, they claim that it reflects socially constructed categories. Alas, while it reflects to some extent social constructions of the past, it has little use in the present. The very basic, essential falsehood in the entire edifice is apparent in the assumption that "Black" and "African American" are synonyms. Black is a racial label; African American is an ethnic term, referring to descendants of people brought to the U.S. from Africa as slaves, and people who have assimilated to that ethnic community. There are now innumerable U.S. citizens who are perceived as racially Black, but whose ethnicity is Haitian, Jamaican, Nigerian-American, etc.

Hispanic is also a heterogeneous category. There are huge differences in health status and other social-economic circumstances among, say, Puerto Ricans, Chicanos (U.S. born people of Mexican ethnicity), Mexican immigrants, Salvadorans, Dominicans, etc. Many very important ethnic groups aren't represented in our data in any way, such as Brazilians (who aren't "Hispanic" since Portuguese is the dominant language in Brazil), and Arabs. Pakistanis, Japanese, and Filipinos are all officially "Asian," though what they have to do with each other is a mystery indeed. A Pashtun who steps over the border from Pakistan to Afghanistan to have lunch with his sister's family instantly ceases to be "Asian" and becomes "White." And so on.

So, the Massachusetts Department of Public Health, in collaboration with the Boston Public Health Commission, has developed a draft standard for data collection intended to fix this problem. We still have to ask the official federal questions: Are you Hispanic, and what is your race? But then respondents are to be given access to a large menu of ethnicities: African American, Native American (name your tribal nation), Puerto Rican, Brazilian, Cambodian, Dominican, Chinese, Arab, Pakistani, etc. etc. Also you can pick other and fill in the blank. So far so good.

Now the bad news. One of the available categories is "American." Apparently they intend this to refer to people of the dominant Anglophone European Settler Culture (AESC). At least I so conclude because there isn't any other category that might mean that, and here in the city of James Michael Curley and Tommie Menino they don't Irish- or Italian-American. In other words, American is supposed to mean Gringo, Honky, paleface. European American.

I cannot begin to express how profoundly offensive this is. Obviously it implies that all those other people aren't American. It also happens to be the case that America consists of two continents plus the islands of the Caribbean, of which the United States is a small part, and from which all those exotic Dominicans, Mexicans, Jamaicans, Haitians, and Brazilians actually come. Not to mention those Native Americans. (Duhh.) Furthermore, if we are labeling ethnic groups by their geographic origins, the geographic origin of what they mean by American is England.

Yet the Division of Health Care Finance and Policy, which will enforce the new regulations, intends to adopt this standard. They are having a public hearing on Tuesday, June 13, after which every single person who receives care in a hospital in Massachusetts will be asked whether they are Haitian, Brazilian, Pakistani, Arab, Jamaican, Puerto Rican, etc., or, instead, alternatively, in contrast, are American.

This, my friends, shall not happen. The correct choice is "Euro-American" or "European American." Pick something more specific if you like.

Friday, June 09, 2006

Ready or not?

The somewhat less than optimal emergency management performance in the Hurrican Katrina disaster last year got the attention of state officials, at least here in the People's Republic. I attended a meeting yesterday sponsored by our state Department of Public Health, where supposedly knowledgeable persons such as YT were asked to make recommendations about emergency preparedness for so-called "Special Populations."

As far as I can decode the concept, you're considered special if you might for one reason or another present problems for the authorities which are somehow different from the problems posed by affluent, healthy, anglophone Euro-American men between the ages of 18 and 55 who are news junkies, trust authority, and always keep their Escalade's full of gas. (Only the lack of an Escalade makes me special, but I do own a functional pickup truck.) However, some populations are more special than others, and we did focus on the specialest.

Specifically, the special folks who I purport to know something about include people with limited English ability; people with serious mental disorders; people with other chronic diseases or disabilities, cognitive or physical; people with substance abuse problems; socially marginalized and very poor people including homeless people; undocumented immigrants; cultural minorities; and all the possible combinations and permutations of the above. To oversimplify a bit, the problems these special folks might pose in case of a public health emergency (e.g., contaminated water, an infectious disease epidemic, widespread radiological or chemical contamination) or natural disaster or, I suppose, war or terrorist attack, include:

  1. Not getting critical information being broadcast to the public -- where to go, what to do -- because of not understanding English and/or not monitoring broadcast media;
  2. Inability to comply with instructions due to, for example, lack of transportation (viz. New Orleans), disability, lack of other resources (e.g., money to buy emergency supplies), etc.
  3. Unwillingness to comply for cultural reasons, mistrust of the authorities, fear of deportation or other consequences;
  4. Difficulty in communicating with individuals directly at shelters or emergency dispensing or decontamination sites due to language, cultural or cognitive barriers;
  5. Specific needs for medication, mental health services, or other supports which are disrupted in a disaster;
  6. Cultural requirements, ethnic conflicts, behavioral problems or privacy needs which might arise in a shelter or evacuee situation (we aren't supposed to say refugee for some reason).

It's good that they are thinking about these problems. They all came up in New Orleans, and everybody wants to do better next time. But it turns out that while there are various specific plans and resources authorities can put in place to address some of these problems, there is one major concept that makes most of the difference.

Emergency preparedness and response are primarily the responsibility of local authorities. Counties, in those states that have strong county government, and cities in towns. In New England, we don't have much in the way of county government, so it all comes down to the towns, including very small towns. If cities and towns expect to be able to respond effectively to the needs of their special populations, they need to start talking with the people, in two-way conversations, ahead of time.

In other words, the Board of Health in East Boysenberry needs to find out who lives in or is present in the town -- be it Somalis, Hmong, Mayans, Uruguyans, Nigerians, Pakistanis, or the insular community of Believers in the Second Coming of Christ in the Person of Henrietta Glockmyer, residents of a therapeutic community, or migrant agricultural workers from Central America and Jamaica who are in town to pick the Boysenberries in October. They have to learn what languages those people speak, what channels of communication exist to reach them, what organizations exist in their communities-- whether formal community based organizations, religious congregations, sport or social clubs -- and what their resources may be, and what special needs they may have. They have to include all those people in planning, and make them part of the communal life and political process in East Boysenberry, before the excrement hits the ventilator.

Can we do that, in most of this country, especially in the current climate of nativism and cultural hegemonism? We'll see.

Thursday, June 08, 2006

Technical Difficulties?

Help! I happened to look at this blog, for the first time in months, using the browser of the Evil Empire. It was totally bejabered -- the sidebar was not on the side, but at the top. You had to scroll down to below the sidebar to see the posts, which were crammed awkwardly against the left margin.

Other blogs I checked looked fine, as does this one using Firefox. Do other people have this problem? I need to know! If so, does anyone have the geekish powers to tell me how to fix it? (Blogger support is completely useless and never responds to inquiries.)

Tuesday, June 06, 2006

Dichotomous Dualistic Dilemmas

A guy I knew in college* said that the way to get an A on a paper was to begin with an irrelevant quote from Alice in Wonderland, and use the word "dichotomy" in the first paragraph. So here goes.

`Get up!' said the Queen, in a shrill, loud voice, and the three gardeners instantly jumped up, and began bowing to the King, the Queen, the royal children, and everybody else.

`Leave off that!' screamed the Queen. `You make me giddy.' And then, turning to the rose-tree, she went on, `What have you been doing here?'

`May it please your Majesty,' said Two, in a very humble tone, going down on one knee as he spoke, `we were trying--'

`I see!' said the Queen, who had meanwhile been examining the roses. `Off with their heads!' and the procession moved on, three of the soldiers remaining behind to execute the unfortunate gardeners, who ran to Alice for protection.

`You shan't be beheaded!' said Alice, and she put them into a large flower-pot that stood near. The three soldiers wandered about for a minute or two, looking for them, and then quietly marched off after the others.

`Are their heads off?' shouted the Queen.

`Their heads are gone, if it please your Majesty!' the soldiers shouted in reply.

Okay. Please don't get me wrong. I'm not anti-psychiatry. Some of my best friends are psychiatrists. Really. In fact, now that I think about it, most of my best friends are psychiatrists, or psychologists. A signficant chunk of my professional responsibility is the evaluation of mental health treatment programs. I'm in this thing up to my hippocampus. What I am doing here is trying to highlight some of the dichotomies that psychiatry wrestles with. Yesterday, it was the dichotomy between an agency of healing, and an agency of social control.

But perhaps this is a false dichotomy. Maybe they're really on a continuum. As our typically incisive commentators indicated, you can't necessarily do one without a little bit of the other.

Then there is the dichotomy between repudiating a dichotomy -- mind/body dualism -- and celebrating it, which I highlighted previously. On the one hand, Cartesian dualism is seen as archaic and unscientific. On the other hand, the concept of mind as a distinct entity is the very foundation of psychiatry. Without it, psychiatry would disappear into neurology, as indeed some of its former territory has already. But perhaps this is a false dichotomy as well, and this is really about levels of analysis -- holism and reductionism.

Then there is the dichotomy between rationality and morality, manifested as disease vs. evil. We have glanced at this problem in the cases of Michael Ross, who haunted my second hometown in Windham County; Ted Kaczynski, who was proclaimed insane not because of his antisocial behavior, but because of his radical beliefs; and Wayne S. Chapman, the rapist of little girls upon whom I was called to sit in judgment as a juror, who condemned himself to imprisonment by refusing to undergo penile plesythmography. Once again, however, perhaps this is not a dichotomy but a complex phenomenon. Just as healing may sometimes involve coercion, force or fraud, disease may consist in part of subjective distress, and in part of social disability or deviance. After all, we are social beings; our status in society is a part of what we are. But whose job is it to define deviance, to ordain that it be corrected, and to carry out corrective action? Where does the authority come from?

And so a final dichotomy, between medical and social problems. Is there something wrong with this patient, or is there something wrong with the world in which this patient lives? If our diagnosis is the latter, what should we, as soul healers, do about it, if anything? It is in the context of these -- perhaps not dichotomies, but tensions, or dilemmas, or creative principles, yin and yang -- that the era of psychopharmacology developed and continues.

*I ran into him a year or so after graduation at my cousin's house in New Haven. He was in the foyer playing the piano, which he did very well, along with being fluent in classical Greek and able to solve differential equations in his head. He said to me, "Guess what Cervantes? I'm not an asshole any more! I used to be an insufferable jerk, but I've changed. I'm a nice guy now." And you know what? It was true, every word.

There are pills that make you large . . .

But I'm going to begin by talking about the pills that make you small. Thomas A. Ban, in "Pharmacotherapy of Mental Illness -- A Historical Analysis" (Progress in Neuro-psychopharmacology and Biological Psychiatry. 2001;25:709-727) writes:

The first widely used therapeutically effective drug in psychiatry was morphine. Alexander Wood's finding in 1855 that morphine, administered by "hypodermic needle," promptly relieved neuralgic pain, led to the introduction of subcutaneously administered morphine during the 1860s, for the rapid control of agitation and agression, in psychiatric hospitals.

The second widely used therapeutically effective drug in psychiatry was potassium bromide . . . . The third . . . was chloral hydrate. . . . The judicious use of these three drugs provided the necessary means for day and night-time sedation. It also allowed the replacement of physical restraint by pharmacological means in behavior control . . . . By the dawn of the 20th Century subcutaneously administered morphine and scopolamine . . . became the prevailing treatment modalities of excitement and agitation in psychiatry. They are still among the most reliable and effective treatments for rapid control of behavior.

So, the use of drugs in psychiatry is firmly rooted in the problem of controlling patient behavior that personnel in mental hospitals found difficult. Drugs replaced the strait jacket. This is a powerful metaphor for a fundamental philosophical and ethical problem in psychiatry. Psychiatric "diseases," as we have seen, consist of nothing more than clusters of behaviors. The patient may or may not wish to change these behaviors. If the patient does not wish to change, then any form of treatment must, fundamentally, be coercive. Even if they do wish to change, and come to psychiatric treatment of their own volition, they may end up submitting to a coercive process.

I am not going to begin to discuss the extent, ethical and practical implications, and possible resolution of this problem in this post. I'm just raising it. Here are a couple of examples to think about.

Consultation-liaison psychiatry consists of psychiatrists who work on general medical or surgical wards and assist the physicians there who have primary responsibility for patients. They are frequently called because of patient management problems. Typically, the diagnosis and treatment of illness is not even at issue. There is considerable discussion in the literature about what determines when a psychiatric consult is called, and it is clear that, at least as far as C-L psychiatrists are concerned, the suspected presence of psychiatric illness is not the most important independent variable. Joan Gomez (Liaison Psychiatry: Mental Problems in the General Hospital. Free Press) says that the most common reasons for referral include "the staff are under strain over this patient."

George B. Murray writes that "Not infrequently the psychiatrist is called when there is a management or behavioral problem with a patient .... [M]any patients are quietly demented, delusional or delirious ... since these patients perdure quietly in their disorder, presenting no problem to the managing staff, the psychiatrist is never called." Murray receives support from Olson ("Depressed Patients who do and do not Receive Psychiatric Consultation in General Hospitals". Gen. Hosp. Psych. 13, 39-44 (1991)), who, through a chart review, found that many inpatients identified as depressed by their attending physicians never receive a psychiatric consultation. On the other side of the equation Hengewald, et al, ("Management of Patient-Staff and Intrastaff Problems in Psychiatric Consultation." Gen Hosp. Psych. 13, 31-38 (1991) based on a standard 30 item database used in the Netherlands, found that in that country, approximately 1/3 of psychiatric consults called in general hospitals, excluding suicide attempts, concerned patient-staff or intrastaff conflicts.

Shorter version: This patient is a pain in the ass, let's call the shrink and give him a shot.

Now, from today's Boston Globe, a story that you may find astonishing, but to those of us who work in the field, it isn't even particularly noteworthy.

By Scott Allen, Globe Staff | June 6, 2006

A 50-year-old woman filed a federal lawsuit against Beth Israel Deaconess Medical Center yesterday, saying she was forcibly undressed by five male security guards there last year after she refused a nurse's order to take off her clothes. . . .

Sampson said she went to the hospital for treatment of a severe migraine headache, but was moved to a psychiatric unit when she admitted struggling with self-destructive impulses. She said she pleaded to be allowed to keep at least her pants on before the strip search, but the nurse refused.

``Go ahead and rape me; everybody else has," Sampson said she cried out as the guards unbuckled her pants and removed them. ``They left me there with my underwear showing and my johnny up to my chest . . . I was crying, and [the nurse] said, `That's what you get for not listening to me.' "

In a letter to Sampson, hospital officials said they were sorry she had such a terrible experience, but stood by their strict policy of searching psychiatric patients for their own benefit. Yesterday, Beth Israel Deaconess officials declined to comment further, saying they can't talk about pending legal matters.

So, this is very simple. Woman goes to hospital for treatment of headache. Mentions that she is being treated for a mental disorder. Is thereupon unceremoniously abducted and assaulted. That's right -- under normal circumstances these actions constitute kidnapping, unlawful confinement, aggravated assault and battery, and sexual assault. But it's for her own good, and the hospital stands by its policy. It is not clear to me why this is not a crime. I'm unaware of any relevant legal exception to the laws that govern the fundamental norms of civilization. Can anyone help me out here?

Monday, June 05, 2006

Slacker Monday?

As is no doubt already clear, I've been a bit busy lately and I haven't gotten up a lot of material here in the past few days. I hope to have more on psychiatry later today, but meanwhile let me rip off the Center for Science in the Public Interest which has been kind enough to put me on its "Integrity in Science Watch" mailing list. It is the fate of the blogger, especially one with a specialty, to end up on a minimum of 5,487 e-mail lists. Since I'm already on several lists for enlargement of a specific body part and people who need $2.5 discreetly transferred out of Sierra Leone, it's a lot to wade through. However, I do give this one the occasional interested glance.

CSPI has been around for 30 years now fanatically defending the purity of our precious bodily fluids, principally as they may be affected by food and water. Sometimes they seem like the environmentalist equivalent of Rev. Dimsdale, but somebody needs to stake out the border march.

A couple of notably depressing items from this week's Integrity in Science Watch:

Public Employees for Environmental Responsibility gets ahold of notes from a meeting between OMB officials and pesticide industry representatives one month before the administration approved new rules which, while purporting to ban pesticide testing on pregnant women and children, actually allows it through loopholes. Excerpts from the notes:

• “Re kids—never say never” (emphasis in original);
• “Pesticides have benefits. Rule should say so. Testing, too, has benefits”; and
• “We want a rule quickly—[therefore] narrow [is] better. Don’t like being singled out but, speed is most imp.”

Then there is this one, quoting ISW: "Two of the U.S. Appeals Court judges who ruled against allowing the Environmental Protection Agency to regulate carbon dioxide emissions failed to disclose on their financial statements that they attended an all-expenses-paid, six-day conference on the topic financed by the corporate-funded Foundation for Research on Economics and the Environment, Eric Schaeffer, director of the Environmental Integrity Project wrote Sunday in the Washington Post. . . " We've got to do something about those activist judges.

Anyhow, it's a good project, do check it out, direct link here.

Sunday, June 04, 2006

Whisker's Roundup of the Wounded

I normally post these for Whisker on Today in Iraq on Sunday, but today's post was so long that I decided to put it here instead. It's obviously relevant to public health, in this case under the heading of intentional injury. Thanks Whisker, for all you do.

Army Sgt. 1st Class Juanita Wilson is one of 11 women injured in combat so far in the war on terror, having lost her left hand in Iraq on Aug. 21, 2004, when a roadside bomb detonated under her vehicle. She was treated at Walter Reed Army Medical Center in Washington, D.C., and given a prosthetic limb.

Sgt. Joey Bozik lost his right arm, left leg above the knee, and right leg below the knee when the Humvee he was riding in was struck by a roadside bomb on Oct. 27, 2004.

Pvt. Jacob Brown was a Danville native who suffered a mangled leg, mashed wrist and a damaged spleen.

Lance Cpl. Jeremy Trakimowicz 27, was severely wounded on the left side of his head when a roadside bomb detonated in Fallujah on June 24. He is assigned to the 6th Motor Transport Battalion of Red Bank.

Natasha McKinnon 23, of Ashtabula, was wounded Oct. 4 when the Humvee she was riding in was hit by a roadside bomb in northwestern Iraq, near the Jordan border. The injuries were extensive, and her left leg was amputated just below the knee.

On December of 2004 Sgt. James "Jay" A. Dolph. was trying to open the hatch of a humvee but was standing on the hitch, wearing a 140-pound pack — and he slipped off the hitch. The weight of the pack and the door of the Humvee all came down on his ligament and snapped it. The sound it made was so loud his Army buddies thought he had been shot. Moreover, he passed out immediately because of the pain, and that furthered the assumption that it had been a shot. And even now he's still walking with a cane and doesn't know if he'll ever be able to do without it

Kortney Clemons A former Army medic, Clemons, 26, of Little Rock, Miss., was a couple of weeks from returning home in February 2005 when his patrol came across an overturned vehicle in Baghdad. While trying to transport a wounded soldier into a helicopter, a roadside bomb exploded, killing three other medics and peppering Clemons' legs with shrapnel. Doctors severed Clemons' right leg from the mid-thigh down.

Lance Corporal James Crossan suffered a broken back and other injuries when the roadside bomb blew up his Humvee.

Lt. Col. Timothy Maxwell was a tough son of a gun on his third tour in Iraq who thought nothing could rattle him. Then mortar shrapnel pierced his brain. Surgeons picked the metal and ruptured bits of skull from his brain and transferred him for long-term care to a Veterans Affairs hospital in Richmond, Va.

Sgt. Jonathan Brown had his arm had been shredded by a friendly fire missile during the November 2004 raid on Fallujah.

On Memorial Day, David Gonzalez, an Army specialist, was driving a Humvee that was struck by a remote-controlled improvised explosive device on the main road leading north out of Baghdad, his father said.--suffered a badly broken leg and a damaged colon, his father said. An artillery shell also “took a chunk out of his left buttock,” Michael Gonzalez said, adding his son nearly died from the initial blood loss.

The 22-year-old from Glen Ellyn is in critical condition, recovering at a hospital in Germany. His family says his Humvee was attacked while on routine patrol in Baghdad on Memorial Day. "He turned to the sergeant next to him and said, 'I'm paralyzed,'" said David's father, Mike Gonzalez. Added David's mom, Katherine, "He said he reached down and put his hand on his hip and said he felt blood."

At least two pieces of shrapnel pierced the leg of Army Sgt. Joshua Mattson, a 1994 Swartz Creek High School graduate, when an improvised explosive device was remotely detonated last month. The metal remains in his leg, but he's been released from the hospital and is still in Iraq.

Spec. Maxwell Ramsey lost much of his left leg in March when a shell buried in a road exploded as his Humvee passed.

Master Sergeant Christopher Self got caught in a firefight in Iraq in December-- bullets that tore through both of his legs.

Joey Bozik An Army sergeant with the 118th Military Police Company in Iraq, Bozik was riding in a Humvee October 2004 when it struck the mine. He was severely wounded, losing his right arm, his left leg below the knee and his right leg above the knee.