Health Insurance 101

The latest hot right wing think tank meme is that the reason health care costs so much in the United States is that it's mostly paid for by insurance. Since our insurance is paying for it, we consumers aren't cost conscious, and therefore we spend too much. If we could just reduce or eliminate insurance coverage, and make people pay more out of pocket, the wondrous free market would constrain health care costs.

Like everything else that comes out of right wing think tanks, this is of course complete bullshit. The easiest way to prove that is just to take a look around at the real world. Every wealthy country except for the U.S., and even some that aren't so wealthy, has universal health insurance. Furthermore, it's good insurance, better than what most Americans have, with very little out of pocket spending required and very comprehensive benefits. So, all those countries ought to be spending even more on health care than we are, right? Your theory proves it. But of course, the precise opposite is true. They all spend much less, in most cases half as much. And yet their people live longer, healthier lives than we do.

Hmmm. Well, we already know that at right wing think tanks, facts are stupid things. Reality is irrelevant, it's our theories that matter. But here, we're reality based, so we can ask why the theory is wrong.

It's wrong for several reasons but the most important is that consumers do not generally decide what health care to buy; and to the extent they do decide, they don't make decisions in a way that reduces costs in the long run. Except for a very few people with a specific mental disorder called Munchausen Syndrome, we don't obtain health care because we enjoy it, and we don't want as much of it as we can get. In fact, most of what constitutes health care is unpleasant, and we prefer to consume as little of it as we can get away with, even if somebody else is paying for it.

I'm not going to go out and get a kidney transplant, take pills, or even consume minor services like having my doctor thrust a popsicle stick down my throat or stick his finger up my ass just because Blue Cross is paying for it. I'm only going to consume those services because I know I really need them, or more likely, because my doctor tells me I do. Furthermore, the vast preponderance of medical expenses are for goods and services provided to people who are truly, seriously ill. Having to pay a $5,000 annual deductible isn't going to stop me from having cancer surgery or taking antiretroviral drugs; I'll pay the $5,000 and then I'll let my insurance pay the $100,000 balance. If I don't have insurance, I'll spend everything I have and then Medicaid will pay. The third alternative is that I'll die.

Now, this is so obvious and so susceptible to common sense understanding that you would think it would be impossible for any adult to seriously argue otherwise. And yet everyone from John Stoessel to Jeff Jacoby to the White House Occupant is going around saying that insurance is the cause of runaway health care costs and the solution is to make sure people have really crappy insurance that doesn't pay for routine services. Of course, they also claim that C02 emissions aren't causing global warming; that Saddam Hussein was behind the 9/11 attack; and that it's a violation of our fundamental rights to take arsenic out of our drinking water.

Next: The real reasons why health care spending is so much lower in countries with sane political leadership.

Robert F. Drinan, S.J.

As I have never been afraid to proclaim, I'm a humanist, a realist, an atheist, whatever you want to call me. And it is pretty clear to me that religion these days has been, on balance, a very damaging influence on our politics and public policy. I was in fact planning a post on the horrifically destructive influence of Christian fundamentalism on public health, especially during the past six years in which right wing fundamentalists have gained control over every level of federal administration, particularly within HHS, where they have wreaked havoc.

However, Fr. Drinan's death derailed that post. It will still come, but not today. My political ideals and commitment were, in fact, powerfully shaped by preachers: my uncle, who as rector of a large, affluent Episcopal church in Connecticut rose in the pulpit in the 1960s to denounce the war in Vietnam; Martin Luther King, of course; and Robert Drinan, the Jesuit who entered politics, won a seat in Congress, and campaigned forthrightly and unflinchingly for peace, human rights, and social justice. On the House Judiciary Committee, he was among the first to call for the impeachment of Richard Nixon, motivated not so much by Nixon's subversion of the electoral process as by his illegal assault on Cambodia.

Ten years later, the Pope ordered him to retire from politics, and he complied.

I had the opportunity to meet Fr. Drinan about five years ago, when he appeared at an event on behalf of Boston Mobilization (then Mobilization for Survival). I asked him why he had chosen to obey the Pope, and he said simply that he had no choice. I professed not to understand that. He was always guided by conscience, and was never afraid to dissent publicly from church doctrine, as he did on the question of contraception and abortion. Since he did not agree with church teaching on these and many other issues, why did he obey an order to leave a position in which he had real power to promote justice and morality in the world?

I have often puzzled over this question of why people who do not believe in the doctrines of the Catholic Church nevertheless continue to consider themselves Catholics and submit themselves to the Church's authority, when it is explicit Church doctrine that all of its teachings must be accepted and obeyed. I also knew a nun who rejected Church teachings on everything from abortion to the ordination of women and the subordinate position of women in the Church. So why, I asked her, are you still a Catholic nun when you reject the very essence of that role? She really didn't have an answer.

After the grotesque, repulsive truth about the diocese here in Boston was revealed through dogged investigative reporting (back when we had an independent press in this country), that the Church was functionally little more than vast conspiracy to provide child rapists with victims and protection, dissidents formed an organization called Voice of the Faithful to humbly beg for changes. That's all they could bring themselves to do. They couldn't leave the church, they couldn't defy the Bishops, in the end, they couldn't even withhold their donations from the collection plate.

So I mourn the passing of Robert Drinan, who meant so much to me at a critical time in my personal development. And I still wonder why, in the end, he was obedient to an authority he knew to be wrong.

Call me soft on crime

Ask Americans what they’re most worried about and what they want from their elected officials, and consistently over the years a lot of people are worried about crime and want the government to get tough on criminals. That’s not hard to understand – watch your local TV news for a while, and you will quickly learn that assaults, rapes and murders are the principal activities in your home town, and if they couldn't find any locally on that particular day they'll spend the first ten minutes of the evening news talking about violent crimes that happened 600 miles away. The obsession of local TV news with violent crime is second only to their obsession with inclement weather, and it's equally demented. Every time there's the threat of six inches of snow, they're interrupting Bowling with the B-List Celebrities to show us a hatless talking head standing out in the windblown sleet to bewail the coming apocalypse, whereupon the mob strips the grocery stores of milk, bottled water and diapers. It seems the people react similarly to the nightly recitation of carnage, culled by any means necessary from among our 300 million people. So we have mandatory sentencing laws, elimination of parole, an end to coddling of criminals with things like education and job training – why should criminals, who have lost any right to respect or help from society, get a free education when my own law abiding kids can’t?

So who are all these vicious criminals filling our jails? Are they the rapists and murderers of grandparents? Not exactly. Twenty-five to 30% of them have been convicted of drug offenses only, and the vast majority of them are not major traffickers. A full 80% of criminals, including those who have been convicted of property crimes (the largest group), have histories of substance abuse and their offenses are in one way or another associated with substance abuse and addiction. You could look it up. They're in for shoplifting, passing bad checks, stealing car radios, and maybe purse snatchings to get money for drugs. The most violent were usually robbing drug dealers.

But these aren’t just any old addicts – they aren’t the same people who end up in the Betty Ford Clinic or the college counseling program. They’re mostly people with little education, low literacy, no marketable skills. They started doing poorly in school when they were young and their lives just never got going. They might have learning disabilities, they might have come from unstable or abusive home environments – and oh yeah, when they first started to get in trouble, as kids, the system dealt with them punitively, rather than trying to help them. That was much more likely to happen if they were Black or Hispanic. According to the best available data, Black and Hispanic kids don’t use illicit drugs or commit offenses more often than white kids, but they’re much more likely to end up in the juvenile justice system, and from there it's all over.

So the cops find a guy selling dime bags, or writing bad checks, or stealing car stereos, and the judge throws him in jail for a year, then they toss him back out on the street, still without education, job skills or experience, and now with a criminal record. What’s gonna happen?

It has been shown that substance abuse treatment reduces recidivism, and that the best kinds of programs can reduce it by more than 50% -- at a tremendous cost saving to society. However, according to a CSAT consensus panel, “Many offenders are released with no place to live, no job, and without family or social supports. They often lack the knowledge and skills to access available resources for adjustment to life on the outside.” This is happening more and more now because legislators have gotten tough on crime by eliminating probation and parole. In other words, people are made to serve their full sentences in jail, then they are just dumped on the street. For released offenders, treatment is much more likely to succeed if it is integrated with other essential rehabilitative services including education, job skills development, housing, family counseling, etc. But most offenders get none of the above.

We can take a bite out of crime. We know exactly how to do it. But we’re spending billions of dollars building prisons and locking people up, which provides employment for prison guards in depressed rural areas but also increases the crime rate. There’s a better use for most of that money, but when was the last time you heard a politician promising to provide substance abuse treatment, job training, education, housing and family counseling to released offenders? Probably never, because their opponents in the next election would accuse them of "coddling criminals." Guess what. Criminals are people. They got to be criminals mostly because of stuff that happened to them. We can fix that, in many cases. But that would be the liberal solution, and we all know that's a dirty word.

Perverse Incentives

I can't be too specific, but I'm involved in a project to develop pay for performance measures for hospitals with respect to reducing racial and ethnic disparities in health care. There is a whole lot of blogging fodder in this, but I'm going to start with a very basic issue concerning the way our health care non-system is organized.

For this, I'm going to go back to another committee I got volunteered for, which had to do with health care disparities among people with private insurance. I pointed out to the representative of a big health insurance company that they charge a $250 co-payment for a colonoscopy. That's obviously enough to discourage lots of people from getting one, even though colonoscopy can actually prevent -- not just diagnose, but prevent -- colon cancer. (As I assume most people know, during a colonoscopy, the doctor can identify and remove pre-cancerous polyps before they ever have a chance to cause trouble.*) Obviously, colon cancer costs a whole lot more than a colonoscopy, so why doesn't the health plan make them very low cost or even free? Wouldn't they save money in the long run?

Nope. The problem is, the people who are their members this year probably won't be their members 5 or 10 years from now. They will have changed jobs, their employer will have changed insurers, they will have lost insurance altogether, or by then they'll be retired and on Medicare. So the health plan has to pay for their colonoscoy now, but won't have to pay for their colon cancer 10 years from now. Hence, they would rather charge you the $250 bucks in hopes you won't get a colonoscopy which a) costs them more than $1,000 in the first place and b) might find a cancer or other condition that they would have to pay to treat now.

There are a zillion more examples. A while back I interviewed people with HIV about their medication adherence. One problem people have is that their insurance will only pay for a 30 day supply of meds at one time, so they have to keep getting refills, which some people don't have it together well enough to always do on time, or they face obstacles such as transient housing situations so they aren't always near the same pharmacy, etc. I asked the medical director of a leading Medicaid plan why they couldn't give people a 90 or 120 day supply at a time and he said their accountants wouldn't allow it, because the people might not be on Medicaid in a month or two, so they would end up buying meds for people for whom they weren't collecting premiums. Of course, that might end up killing the people, but the finance department, which has the final say of course, doesn't care about that.

Solution? Too easy for a hint . . .

We need universal, comprehensive, single payer national health care. That turns the incentives around. Now the insurer really does have every incentive in the world to keep you healthy. Right now, they don't.

*Did you hear about the dentist who switched to proctology? He was tired of people burping in his face.

Blogroll Change

As we bid a fond farewell to Confined Space, let's have a big, fat, backslapping gladhanding welcome for The Pump Handle, a much higher class public health blog than this one.

Congratulations, Jordan . . .

though with mixed feelings. Confined Space is shutting down, but for a very good reason. Jordan Barab has taken a staff position at the House Committee on Education and Labor. In other words, he's coming in from the blogospheric wilderness to be part of the lawmaking process.

Now, there's still a depraved chimpanzee standing in the road, but at least he isn't driving any more.

Our profound gratitude

To NYT reporters Damien Cave and James Glanz, and photographer Robert Nickelsberg, for risking their lives to bring us a little bit of the truth from Iraq. And of course, everyone else in this weird dream, from the American soldiers to the Iraqi child and even the Iraqi soldiers, at least when they feel like it, is walking through the valley of the shadow with them. The Battle of Haifa St. has been recurring every week or so for a while. Here are some shots from the latest incarnation:

In a miniature version of the troop increase that the United States hopes will secure the city, American soldiers and armored vehicles raced onto Haifa Street before dawn to dislodge Sunni insurgents and Shiite militias who have been battling for a stretch of ragged slums and mostly abandoned high rises. But as the sun rose, many of the Iraqi Army units who were supposed to do the actual searches of the buildings did not arrive on time, forcing the Americans to start the job on their own.

When the Iraqi units finally did show up, it was with the air of a class outing, cheering and laughing as the Americans blew locks off doors with shotguns. As the morning wore on and the troops came under fire from all directions, another apparent flaw in this strategy became clear as empty apartments became lairs for gunmen who flitted from window to window and killed at least one American soldier, with a shot to the head.

Whether the gunfire was coming from Sunni or Shiite insurgents or militia fighters or some of the Iraqi soldiers who had disappeared into the Gotham-like cityscape, no one could say.

“Who the hell is shooting at us?” shouted Sgt. First Class Marc Biletski, whose platoon was jammed into a small room off an alley that was being swept by a sniper’s bullets. “Who’s shooting at us? Do we know who they are?” . . . “This place is a failure,” Sergeant Biletski said. “Every time we come here, we have to come back.” He paused, then said, “Well, maybe not a total failure,” since American troops have smashed opposition on Haifa Street each time they have come in.

Well, okay, they've "smashed" the opposition, even though they don't know who it is or even why they're smashing it, but it seems the opposition is not Humpty Dumpty because somehow or other, it gets unsmashed, and here we are again. But at least the Iraqis are standing up:

The American units in the operation began moving up Haifa Street from the south by 2 a.m. on Wednesday. A platoon of B Company in the Stryker Brigade secured the roof of a high rise, where an Eminem poster was stuck on the wall of what appeared to be an Iraqi teenager’s room on the top floor. But in a pattern that would be repeated again and again in a series of buildings, there was no one in the apartment.

Many of the Iraqi units that showed up late never seemed to take the task seriously, searching haphazardly, breaking dishes and rifling through personal CD collections in the apartments. Eventually the Americans realized that the Iraqis were searching no more than half of the apartments; at one point the Iraqis completely disappeared, leaving the American unit working with them flabbergasted. . . .

In this surreal setting, about 20 American soldiers were forced at one point to pull themselves one by one up a canted tin roof by a dangling rubber hose and then shimmy along a ledge to another hut. The soldiers were stunned when a small child suddenly walked out of a darkened doorway and an old man started wheezing and crying somewhere inside.

Ultimately the group made it back to the high rises and escaped the sniper in the alley by throwing out the smoke bombs and sprinting to safety. Even though two Iraqis were struck by gunfire, many of the rest could not stop shouting and guffawing with amusement as they ran through the smoke.

One Iraqi soldier in the alley pointed his rifle at an American reporter and pulled the trigger. There was only a click: the weapon had no ammunition. The soldier laughed at his joke.

Okay then. We must prevail in this conflict, but we have no idea who we're fighting, or why, or even whether the soldiers of the government we're fighting for are trying to kill us. (Too easy for a hint. Consider the incident in Karbala last week, clearly carried out in collaboration with elements of the Iraqi security forces, if not in fact perpetrated by them.) I would call this insanity but that gives it too much credit. To be insane, you first must first have sentience and intelligence to warp. Even delusions are more coherent than this.

Ed Norton, Man of the Century

As the youngsters among you may not know, Ed (Played by Art Carney) was Ralph Kramden's (Jackie Gleason) sidekick on the TV Sitcom The Honeymooners. He was a New York City sewer worker. Actually, he's the Man of the Century and a half. Readers of the British Medical Journal voted for the most important medical advance since 1840, and sanitation -- yup, sewers -- is # 1. Most BMJ readers are MDs, so I congratulate them -- or at least 15.8% of them -- for recognizing that medical intervention is not, after all, the most important determinant of our health.

It's also not surprising that the medical interventions that did score high are now pretty long in the tooth. Antibiotics -- which date back to World War II -- came in at #2, followed by anaesthesia (19th Century), and vaccines, which technically shouldn't even be eligible since the smallpox vaccine dates to before 1840. However, it wasn't until the 1950s that scientists began to understand how to create new ones from deactivated viruses, so I guess we'll allow it. Some of the other entries aren't interventions or public health measures at all, but basic scientific discoveries (DNA, germ theory, immunology) and techniques (tissue culture, X-rays).

The major lesson to be drawn from all this is that the huge breakthroughs are in the past. The huge investment we've been making biomedical research and development since the 1950s has produced much more incremental progress. The main reason, I would say, is that the conquest of infectious disease (not a complete victory, but a major route) eliminated much of the disease that used to cut people down before they ran into the diseases of aging. Those are not only harder to fight, but we get less benefit from the measures that do ameliorate them because, sad to say, even if we survive our first heart attack, or cancer, we're still getting older.

The only breakthrough that could ever rival sanitation, antibiotics and vaccines would be the conquest of aging. That is nowhere in sight.

This duck ain't just lame, he's ruptured

The WaPo actually fact checks the SOTU address. I post this link not because I think my readers need to be disabused of the presidential prevarication, but because this apparently represents a new philosophy of journalism, in which after they say it, and we write it down, we take note of whether it corresponds to reality.

Maybe Stephen Colbert got through to them after all.

Pay no attention to the man behind the curtain

I'm going to ignore the ridiculous health insurance proposal those of you with stronger stomachs than mine are going to hear about tonight because it's DOA anyway, along with the rest of whatever idiotic psychopathy goes down. I thought I'd catch up on a couple of projects I'm working on, in lieu of doing any actual work.

We're going to be participating in an interesting study by our friend William Collinge which involves teaching caregivers (e.g., spouses, partners, siblings) of people with cancer some basic therapeutic massage techniques. It turns out that massage can have huge benefits in relieving pain and stress, side effects of chemotherapy, and other distressful symptoms of cancer. Of course, nobody makes money off of it, so you won't see advertisements on TV telling you to give your sick relative or friend a massage.

I'm also working on a proposal to study the "food environment" near middle and high schools. (I shouldn't give this away because somebody might steal the idea, but what the hey.) I live near a middle school and every morning, when I go to buy the paper, the kids are in the store buying candy, sugary snacks, soda, etc. I have a pretty good idea that in rich neighborhoods, the food choices the kids have are better than in the poor neighborhoods. We did a study a while back that asked the same questions about cigarettes, and it was pretty clear.

We're also finishing up a review of state policy to address health disparities in the New England states. As you may have noticed, health care reform at the state level is all the rage these days -- which I guess it has to be since we obviously aren't going to get anything worthwhile out of the federal government, given that the clowns are running the circus right now. Unfortunately, I'm close to concluding that the states just cannot do very much to solve our problems. They have to operate in the national market and they simply cannot make fundamental changes. As Massachusetts, Maine, Vermont, and now California and possibly Pennsylvania and New York try to work within the given national context, their halfway measures and Rube Goldberg contraptions are doomed to failure, and may even make matters somewhat worse. Why? Because they can't do anything to contain costs, or get control over resource allocation.

It's another one of those long wonkish stories, but I'll try to tell it in coming weeks. Actually, events may speak for themselves. The Massachusetts plan is already running into rough sledding, and it's only halfway implemented. I just hope we all can make it until January, 2009. It's going to be touch and go.

Mass psychosis?

44% of Americans think George W. Bush is honest. Somebody needs to check the drinking water supply, we're in big trouble.

Why would I try to mislead you just because I can make billions of dollars?

In what is generally an interesting business section in today's NYT, Milt Freudenheim does direct-to-consumer (DTC) drug advertising. Unfortunately, while the headline says that a "Showdown Looms in Congress" over the issue, there's precious little evidence of a meaningful showdown in the article. Apparently there will be hearings of some sort, but the only proposed legislation is coming from the pharmaceutical industry.

It may seem paradoxical, but the industry wants to establish user fees from its members to pay for FDA staff to review ads before they are aired (or cabled, or whatever verb describes modern TV technology). Why would they want to do this? I presume it's to head off any more meaningful restrictions or even a ban. DTC advertising is in fact banned outright in every civilized country except the U.S. and New Zealand.

The industry has learned that the law that finances the drug approval process with user fees was very much in its own favor -- he who pays the piper, etc. This system would prevent outright restrictions such as requiring companies to wait long enough after drug approval for safety and effectiveness to be well understood -- a matter of years if we were to be honest about it -- or requiring more extensive disclosure of risks. (Now they can just refer you to their ad in Cooking Light.) They say a ban is unconstitutional, but come on now. The First Amendment is talking about political speech, not travelling snake oil shows. Of course, the Supreme W.* Court hasn't been entirely clear about this.

The drug companies argue that DTC advertising is good because it informs people about products that may benefit them. All I can say is pish tosh. They don't advertise drugs to inform consumers, they advertise drugs to make money. Otherwise we'd see nothing but ads for hydrochlorothiazide, lisinopril, and atenolol. Instead, we see ads for expensive, patented name brand drugs that very few people ought to be taking, and that anybody who arguably should be taking, who has health insurance and is seeing a competent physician, already will be discussing with said physician. If they don't have health insurance, they can't afford them anyway.

And no, I don't want to see thiazide diuretics advertised on TV either. Doctors should be talking with their patients about that sort of thing and they should be making decisions without interference from the manufacturers who are trying to make money off of the deal. DTC ads exist for one purpose only, and that's obviously to try to get people to take drugs. That's the wrong objective. The right objective is to be well informed, to weigh risks, costs, and benefits, and do what makes sense for you in light of expert advice. You'll never get that from an advertisement.

Direct to consumer advertising of prescription drugs should be banned entirely. Period. And there would be an important side benefit: much less incentive to invest drug development money in drugs that are likely to be profitable if and only if accompanied by an expensive ad campaign. That's the only reason that so-called "evergreening" happens -- development of slight variations on drugs that are now in the public domain, that can be sold at high prices under marketing exclusivity but only if ad campaigns can persuade people to pay the extra cost. The money the companies now spend on advertising would also be fed back into real research, or lower overall prices. Total spending on health care would go down. Insurance would be cheaper. Medicare and Medicaid would save money. The creative geniuses in the drug advertising business would have to find honest work, if they can conceive of such a thing. Everybody's a winner.

*My finger still hovers over the "W" key every time I type NYT. We'll see how they cover the 2008 campaign. I recommend The Daily Howler for a daily dose of expose. (Somerby briefly lost my endorsement when he inexplicably started channeling Karl Rove on the subject of Ambassador Joseph Wilson, but he's now transcended that weird brain fart.) But the Supreme Court deserves W every time, when it comes to the invented rights of corporations.

Technical Difficulties

Inexplicably, Stayin' Alive has been crashing Firefox every time I try to view it for the past two days. It works fine with Explorer. Hopefully, this republication will solve the problem, but if anybody else is having difficulties, please let me know. I have no idea what to do about it.

Today in Iraq was about all the blogging I could handle for today. Please do check it out. And then, please join me in writing to your representative and Senators to demand that on Tuesday night, the members of Congress should remain seated when war criminal George W. Bush enters the House chamber, and should withold applause.

I couldn't have said it better myself

I definitely couldn't. Read Harlan Krumholz and colleagues on the Vioxx atrocity. They make the airtight prosecution case. The legal difficulty is that we have thousands of individual lawsuits in which each plaintiff has to persuade the jury that his or her individual heart attack was caused by Vioxx, which is generally not possible to show. What is absolutely possible to show is that a large number of injuries did result from Merck's deceptions, we just can't say exactly which ones. Unfortunately the legal system is not structured so as to assure accountability in this situation.

I'm not going to summarize Krumholz et al's brief, please read it. But here's my value added. The drug companies say that they need to have long-term exclusive marketing rights to new drugs and the opportunity to make billions because that's what motivates and pays for the very expensive process of drug development. If they couldn't make that killing, they wouldn't be able to develop the miracle drugs that save our lives. It's the magic of the market, you see, and the alternative would be socialism, which is never good because people would have to pay taxes and the oppressive institions of government would be developing new drugs, thereby depriving us of our freedom, plus which government is always inefficient.

This sort of mindless rhetoric is sufficient, in our political culture, to carry the day. It's why we have the most expensive, least efficient and least equitable health care in the world, as well as why we have so many dangerous, overpriced, misrepresented drugs on the market. In other words it's bullshit. As a society, we need to grow up and get over it.

At the root of the problem lies the intellectually corrupt academic so-called discipline of economics. College freshmen are systematically indoctrinated by economics professors in a belief system precisely analagous to the ptolemaic universe, a method of reasoning that begins with a set of entirely false assumptions (e.g. the earth is at the center of the universe and the planets revolve around it), and then erects an elaborate structure of preposterous contraptions and devices (crystal spheres, epicycles) to try to wrestle observable reality into conformity with the false explanatory basis. The properties of the economists' theoretical market are no more real than the earth's location at the center of the universe, and it's posited efficiency and benefits to consumers no more real than the crystal spheres.

Here's a quick debunking of Economics 101 using the case example of pharmaceuticals. In the ptolemaic world, transactions are characterized by perfect information. Consumers know what they are buying, they know the costs and benefits of competing products, and they make a decision that optimizes their own "utility" (a tautological concept with no actual referent in the observable universe, meaning that whatever they buy must have been the best possible choice for them). But every pill is indistinguishable from every other. They're just tiny lumps of bitter stuff. The only information we have about them is the information the seller chooses to give us. And obviously, we have no reason to trust the seller except that . . .

Aha! There is a government agency which evaluates evidence about the safety and efficacy of drugs and requires that a detailed summary of this information, approved by the government, be included with the drug as it is offered for sale. Alas, we still have a problem. The manufacturer is generating that evidence, and as we have seen, given insufficient dilligence by the government agency, the manufacturer has innumerable opportunities to slant, misrepresent, and just plain lie about it. That's the libertarian paradise, of course -- let the powerful screw the weak.

The solution? Less free enterprise, more democracy. Force the process to be transparent, public, and in the public interest. The profit motive does not work for society.

Dr. Jekyll and Mr. Hyde

Quick, what is the most commonly prescribed drug in the United States? Hint: you will never see it advertised on TV.

It's an opioid analgesic, or more precisely a formulation of hydrocodone and acetaminophen (tylenol). The most common brand name is Vicodin. Bridget Kuehn, in JAMA (Jan. 17) informs us that Americans got 100 million prescriptions for this drug in 2005, and that we consume 99% of the global supply of hydrocodone. Prescriptions of opidoids in general have been increasing dramatically in recent years. Hydrocodone is the most popular because it's relatively short acting and therefore physicians are allowed to give patients refillable prescriptions, which is not allowed with most drugs in the class.

Opioids, of course, are drugs whose mechanism of action is similar to that of morphine, the active chemical in opium. These drugs, starting with morphine itself, are a great boon to humanity. There is still nothing as effective at relieving pain. Without these drugs, many people's lives would be unbearable, much surgery would be nearly impossible, dying would be agonizing for many if not most of us.

Most people, I'm quite sure, have an exaggerated idea of the long-term harms of regular opioid use. People who take these drugs for relief of moderate pain can readily get to a stable dosage at which they get effective analgesia without any disabling euphoria or sedation. About the worst side effect is constipation. Opioids don't rot your brain.

But, they do cause physical addiction and, in some people, intractable psychological dependency. So why do long-term junkies look so bad, have so many severe health problems, destroy their careers and families (if they ever had any), commit crimes, and die young? It's not because they are using heroin and other opioids. It's because they are using them illegally, which means they are hard to get, expensive, and often not there when the junkie needs them. Junkies are continually going through incipient withdrawal; spending most of their time and energy and all of their money seeking the drugs they need; lying, cheating and stealing to get drugs; injecting themselves using unclean needles, containing unknown amounts of heroin along with who knows what else; and neglecting nutrition, hygeine, shelter, health care and everything else in their obsessive pursuit of relief from their uncontrollable cravings.

One answer, which actually works very well, is just to give them the shit. In the U.S., we generally supply it in the form of the long-acting opioid methadone. People on methadone generally go to a specialized clinic where they swallow the juice in the morning, and then get on with their lives, without evident impairment. But we tend to have a moral revulsion against drug dependency, so in many states, people are forcibly weaned from methadone after a period; or they aren't allowed a high enough dose in the first place. Then they relapse and they're back in the life, or in the slammer.

Nowadays, there is strong evidence that abuse of prescription opioids is replacing heroin abuse in North America. Kuehn cites research by Leonard Paulozzi at CDC finding that overdose deaths from prescription opioids now exceed deaths from heroin. The regular national surveys on illicit drug use, although they are of questionable reliability, also indicate that abuse of prescription drugs is more widespread than abuse of illegal drugs such as heroin and cocaine.

I had a friend and colleague who was an HIV positive recovering heroin addict. He was given an opioid prescription for a back injury, wound up relapsing, became erratic in his adherence to his HIV medications, and died. Why did his addiction relapse cause him to stop taking his meds? Again, not because taking narcotics directly stopped him from taking his antiretrovirals, but for the reasons given above: the total disruption of his life and motivational system caused by the relentless pursuit of illegal chemicals. But what might have happened if he hadn't gotten treatment for his back pain? Chronic pain can lead to depression, other somatic symptoms, disability, physical and mental decline, and suicide.

I once interviewed a man with HIV whose doctor had made a deal with him. She'd give him a prescription for morphine if he would take his antiretrovirals. He didn't actually need the morphine for pain, but he needed it to stay away from the dealers, and to stay straight enough to take his protease inhibitor. Technically, I guess, she committed a crime. But she was trying to save his life.

So, what do I have against Rush Limbaugh for being a Vicodin addict? Only that he's a hypocrite.

By the way, I once spent a few days heavily doped up with morphine after surgery. I absolutely hated it. It made me stupid and groggy, and then it made me start to itch and sweat. I asked them to take me off it before they were ready to. Some people aren't so lucky. It makes them euphoric, and they just want more. That's just a curse you are born with.

Is there a political point to all this? Yes, there are a few. But there's some background, now we can get to those later.

Lily claims entitlement to its own facts

C. Corax sends in an article from the Daily Hampshire Gazette out in the Land that Time Forgot, where the mysterious Connecticut River, as yet unseen by civilized eyes, rushes through its impenetrable gorges. Well actually, there are five famous colleges out there and a whole lot of granola, but it seems like it's far far away from here. Anyhow, as far as I know the DHG is not on-line, so here's an excerpt:

BY KIMBERLY ASHTON STAFF WRITER

NORTHAMPTON - A city man who co-founded a mental health advocacy group is among those drug giant Eli Lilly has sought to silence regarding documents leaked about Zyprexa, its bestselling drug for schizophrenia.

Will Hall, a member of the Freedom Center in Northampton - a group often critical of the pharmaceutical industry and that also offers support and holistic alternatives for people with mental illness - is one of 13 people named in a gag order pursued by Lilly.

The order was granted in a federal court in New York Dec. 29 and renewed on Jan. 4. It forbids Hall and others from disseminating or facilitating the dissemination of internal Lilly documents Hall and others say prove that the corporation suppressed information about the side effects of Zyprexa and promoted so-called 'off-label' use.

The documents were originally obtained via subpoena by Jim Gottstein, an Alaskan lawyer, as part of a lawsuit involving Zyprexa. Lilly alleges that Gottstein then disseminated the documents to a dozen mental-health activists who are critical of the drug industry, including Hall.

Hall, reached in Portland, Ore., Thursday, where he is working with another mental health advocacy group, said he has seen the documents, and they show that Lilly knew Zyprexa could cause diabetes and that the company pushed the use of the drug for dementia, although it is not approved for such use. Such marketing is illegal.

Lilly strongly denies the accusations. A spokeswoman for the company said questions about Zyprexa are answered at www.zyprexafacts.com. A Lilly press release on the site says media reports have omitted several facts about the drug.

'From the day that Zyprexa was approved, the labeling provided to physicians identified the potentially clinically significant weight gain that was observed in more than half of all patients treated long-term with Zyprexa, as well as the diabetes-related adverse events observed in clinical trials,' an online Lilly response states.

So is Lilly, like, telling the truth? Er, no. They aren't even twisting the truth. They aren't even cherry picking facts, or taking them out of context, or putting a misleading spin on the matter. They're just, precisely, unequivocally, unambigously, irrefutably, making shit up. Shit that ain't so. Here's Aaron Kesselheim and Jerry Avorn in the Communist-inspired, left-wing moonbat rag Journal of the American Medical Association (the new one, January 17, 2007):

For the antipsychotic olanzapine, studies emerged a few years after its approval linking it to weight gain and diabetes (7. Koller EA, Doraiswamy PM. Olanzapine-associated diabetes mellitus. Pharmacotherapy. 2002;22:841–852.); a series of patient-initiated lawsuits in early 2003 charged that Lilly did not adequately warn about these adverse effects. By September 2003, the FDA required that olanzapine's label be changed to provide a more prominent warning about diabetes-related adverse effects. In June 2005, the manufacturer announced a $690 million settlement of more than 8000 olanzapine lawsuits. The settlement required that documents revealed during the discovery process—including data on the actual rates of such adverse effects—not be disclosed publicly. However, documents recently made public from concurrent olanzapine litigation reveal that Lilly long downplayed and kept secret research that linked use of the drug to weight gain and hyperglycemia, telling its salespeople, “Don't introduce the issue!!!” (Berenson A. Eli Lilly said to play down risk of top pill. New York Times. December 17, 2006:A1)

So there you have it. My point, if any? Gag orders protecting the guilty should not be permitted as part of any civil settlement. Prohibit it by law, and we won't have to put up with this nonsense. If civil litigation is supposed to be a mechanism for protecting the public, it will work best if it includes public airing of the relevant facts and evidence. An outcome in which a few of the people who were injured get compensated, at the cost of keeping the truth from everybody else, is not in the public interest, and it should never be allowed to happen.

And by the way, there are a lot of people who were abused by priests who will agree with that sentiment, because the same thing happened in the earliest lawsuits against the Catholic Church. The victims got money, but in return agreed to gag orders. And kids continued to be raped by priests. The public has a right to know the truth.

Take your Medicine

We (that's royal, I guess) spend a lot of time here bashing, crushing killing and destroying the pharmaceutical industry and the FDA. We also express reservations about the medicalization of society and the disease labeling of people without symptoms or any experience of illness.

But let's keep in mind that it's a matter of appropriateness, of degree, of costs and benefits. I'm not on a jihad against pharmaceuticals or preventive medicine. Sometimes taking pills is the right thing to do, even for people who aren't sick, and a prime example is high blood pressure -- hypertension.

In Health Affairs, Cutler and colleagues analyze the costs and benefits of antihypertensive drugs, including for people whose only indication is the reading on the sphygnamometer. (Did I spell that correctly? Give me a gold star.) Abstract only available here, unless you're lucky enough to have a prescription.

Hypertension substantially raises your risk for heart disease, heart attacks, and stroke. Although some medications to reduce blood pressure were available in the 1950s, the modern "armamentarium," as the mad doctors call their available drugs became available during the 60s, 70s, and 80s. It was not until the 1970s that it became clear that prophylatic treatment of high blood pressure reduced mortality. By 2000, about two thirds of people over 40 with hypertension -- usually defined as blood pressure higher than 120/90 -- reported taking antihypertensives.

Based on what we know about the benefits of reducing blood pressure, Cutler and colleagues estimate that use of these drugs in 2001 prevented 86,000 deaths. Many of these fatal heart attacks and strokes were not just delayed, but prevented entirely, in other words the people will ultimately die of something else. What if everybody with hypertension took appropriate drugs, adhered to their prescribed regimen, and achieved normal BP? They estimate an additional 89,000 deaths would have been prevented, in other words we're only half way to where we could be. We could increase life expectancy in the U.S. by .5 years for men and .4 years for women.

Antihypertensive therapy yields something like 20 to 50 Quality Adjusted Life Years for each $1 million spent for prophylaxis; for people who are at high risk or have already had heart attacks, the benefits are much greater. That's a much better cost/benefit ratio than we readily accept for treatment of disease. Treating hypertension saves something like $15 billion a year, and we could save even more.

So why is this such a favorable situation? First of all, the important drug classes are now all available as generics. Thiazide diruetics, the first line therapy, cost only a few cents a pill. Second, these medications are very safe, as long as people work with their doctors to achieve a regimen that works without being excessive and causing fainting or other problems. Third, reducing blood pressure has a big impact on some common, serious health problems.

Why do we only get half the potential benefit? People who are uninsured are unlikely to take these drugs, which must be taken every day, till death do me and my pills part. Even people who have insurance, and get prescriptions, often stop taking them or take them erratically, because they don't feel any symptoms and it's a hassle. I have good insurance, but my monthly co-pay for my two generic hypertension meds is still $30, which might seem like too much to some people. Society would benefit substantially if these drugs were given away free to everyone who needs them.

But you don't see these drugs advertised on TV, now do you? Why is that? (Too easy for a hint.)

Slacker Monday

Yes, today is a holiday about which I ought to have something to say. Martin Luther King was an important inspiration to me as a youth. That we have a national holiday in his honor is an indication of how different our political culture was 20 years ago. (At least it seems we won't have to worry about anybody proposing a George W. Bush national holiday.) But I'm having a bad brain day, so I'm just going to offer some links.

Let us never forget what the Noble Cause really is. Iraq to give Western companies oil rights.

And let us never doubt for one second where the Noble Cause leads next. Iran target of US Gulf military moves, Gates says. Well duhh -- Patriot missile batteries and aircraft carrier groups probably won't be much help in clearing and holding Baghdad.

Are they really that crazy? Yup.

Yes, the zeitgeist has changed, and most U.S. elites have recognized that reality will have its way with us in the end, and have turned against these maniacs. But it doesn't matter: they still wield the power of the U.S. military, and as they have made unambiguously clear, the United States is a dictatorship. President Bush, facing opposition from both parties over his plan to send more troops to Iraq, said he has the authority to act no matter what Congress wants.

"I fully understand they could try to stop me from doing it. But I've made my decision. And we're going forward," Bush told CBS' "60 Minutes" in an interview to air Sunday night.

Vice President Dick Cheney asserted that lawmakers' criticism will not influence Bush's plans and he dismissed any effort to "run a war by committee."

"The president is the commander in chief. He's the one who has to make these tough decisions," Cheney said.

The defiant White House stance comes as both the House and Senate, now controlled by Democrats, prepare to vote on resolutions that oppose additional U.S. troops in Iraq. Cheney said those nonbinding votes would not affect Bush's ability to carry out his policies.

"He's the guy who's got to decide how to use the force and where to deploy the force," Cheney said. "And Congress obviously has to support the effort through the power of the purse. So they've got a role to play, and we certainly recognize that. But you also cannot run a war by committee."

It's the Fuerher's war now, and by the Glorious Homeland, he's going to have it his way.

Reality wins a round

I can't remember if I linked to it at the time (I should have, but there's always too much to talk about), but on January 3 the Union of Concerned Scientists issued this report about how Exxon*Mobil adopted tobacco industry tactics by funding phony research institutes to generate phony scientific analysis denying the reality of global warming. (How's that for a Faulknerian sentence?)

From the UCS summary of their report:

Smoke, Mirrors & Hot Air: How ExxonMobil Uses Big Tobacco's Tactics to "Manufacture Uncertainty" on Climate Change details how the oil company, like the tobacco industry in previous decades, has

• raised doubts about even the most indisputable scientific evidence
  
• funded an array of front organizations to create the appearance of a broad platform for a tight-knit group of vocal climate change contrarians who misrepresent peer-reviewed scientific findings
  
• attempted to portray its opposition to action as a positive quest for "sound science" rather than business self-interest
  
• used its access to the Bush administration to block federal policies and shape government communications on global warming

ExxonMobil-funded organizations consist of an overlapping collection of individuals serving as staff, board members, and scientific advisors that publish and re-publish the works of a small group of climate change contrarians. The George C. Marshall Institute, for instance, which has received $630,000 from ExxonMobil, recently touted a book edited by Patrick Michaels, a long-time climate change contrarian who is affiliated with at least 11 organizations funded by ExxonMobil. Similarly, ExxonMobil funds a number of lesser-known groups such as the Annapolis Center for Science-Based Public Policy and Committee for a Constructive Tomorrow. Both groups promote the work of several climate change contrarians, including Sallie Baliunas, an astrophysicist who is affiliated with at least nine ExxonMobil-funded groups.

Baliunas is best known for a 2003 paper alleging the climate had not changed significantly in the past millennia that was rebutted by 13 scientists who stated she had misrepresented their work in her paper. This renunciation did not stop ExxonMobil-funded groups from continuing to promote the paper. Through methods such as these, ExxonMobil has been able to amplify and prop up work that has been discredited by reputable climate scientists.

Well guess what? It took Exxon less than two weeks to throw in the towel. From MSNBC:

NEW YORK - Oil major Exxon Mobil Corp. is engaging in industry talks on possible U.S. greenhouse gas emissions regulations and has stopped funding groups skeptical of global warming claims — moves that some say could indicate a change in stance from the long-time foe of limits on heat-trapping gases.

Next: The Project for the New American Century joins the International League for Peace and Freedom.


*Formerly Esso, but it's still the same old gas.**

**Credit to a forgotten Mad Magazine cartoonist.

Oh crap

President Cheney and his sick, sad ventriloquist's dummy still have their friends at Faux News, plus Mitch McConnell, an old guard of decrepit warriors who are still out for revenge for eating bitterness in Vietnam -- and of course their little band of armchair sociopaths in right-wing hate radio and the badlands of the Internet. But they've finally lost the higher class whore media, the respectable academic war party, the majority of the public which is not insane, and even Sam Brownback. Hell, even Jellyfish Joe Biden has suddenly evolved a spine. (And see my post on the cnidarians for what else he must have acquired.)

So they can't get away with this shit any more, right? On the contrary, it looks like they're going all in. Their present predicament has them imprisoned in contradictions. The Iraqi government that they have stood up, that they are arming, which they claim they are proposing to join in "securing" Baghdad has no interest whatsoever in Iraq, and even less in the "nascent democracy" that Chimpy McCarthy talked about last night. It represents Shiite sectarianism, allied with the separatist goals of the Kurdish parties. Prime Minster Maliki and Chimpy's new best friend Abdul Aziz al-Hakim, leaders of the two largest factions in parliament, also happen to be closely allied with Iran, the next target along the Axis of Evil. The only true Iraqi nationalist leader among the Shia, and opponent of Iranian influence, is Muqtada al-Sadr, whose movement and militia are also lined up in the gunsights as the principal target of the proposed escalation of the war.

So what's the plan? They've already raided the Iranian consulate in Irbil, deeply angering the Kurdish government which is their closest ally in Iraq and which is supposed to contribute two brigades to the cleansing of Baghdad.* Somehow they propose to use military force to sever the alliances between the governing Iraqi factions and Iran, while simultaneously continuing to prop up those factions with U.S. arms and starting a new war with the anti-Iranian Sadrists. If this doesn't seem to make any sense, well, it doesn't.

But they intend to accomplish this by bombing Iran from aircraft carriers, and quite possibly from the huge air bases they maintain inside Iraq, thereby proving that you can't mess with them and that the Shiite government had better rethink its alliances, or they might just turn those tank barrels around. It's a play based on pure power and naked aggression. The likely result? I don't want even to think about the worst. But that seems pretty clearly to be the plan.

Is it insane? Absolutely. Can Joe Biden stop it? Absolutely not. As they have already said, they're an empire. They create their own reality. However clear it may be to the rest of us that reality has its own ideas, they still deny it. The only way they can learn, it seems, is the really, really, really hard way.

*The Kurdish leadership is actually friendly with Iran, because of the history of having Saddam Hussein as a common enemy. Iran has apparently been providing material support to the Kurdish army, the Peshmerga, and the Kurds in return are helping to suppress irredentism among the Iranian Kurdish minority. Iran also provides support to the Badr Brigade, which it helped to found. But in so doing, they're just assisting the U.S., which is also supporting both of those organizations in their guise as components of the Iraqi army. It's all completely nuts.

Psychiatrism

In December of 2005, the Army released this photograph of PFC Steven Green heroically shooting the lock off the door of an Iraqi house, accompanied by a panegyric for Green and his buddies bringing peace and safety to the Iraqi streets. As we all know by now, three months later Green and his buddies invaded an Iraqi house, where according to indictments Green heroically murdered the parents and younger daughter and then joined his buddies in heroically raping and murdering 14 year old Abeer Qassim al-Janabi.

That's his own fault, to be sure, but only partially. In the first place, when our brave fighting man joined the army, he already had three misdemeanor convictions. In fact, he spent four days in jail just a few days before he enlisted. The army was happy to have him, even though he was a high school drop out, a drug abuser and a criminal. But that's okay, they gave him a "moral waiver."

The NYT quotes a spokesman for the Army Recruiting Command as explaining, "“A waiver is based on the actuality of the person, the totality of their life, the information we have on them — what have been their shortcomings, what have they done in their life to overcome a previous minor mistake." I'm not sure what Green had done in life to overcome his mistakes, but evidently it consisted of showing up and offering to enlist. And then he found Jesus. A few weeks after enlisting, he got himself baptized at Fort Benning. Jesus and the Army were making a man out of him.

A few days after the photo was taken, Green went to an army "combat stress team" and, according to Ryan Lenz of the AP, told them that he was thinking about killing people. Well, that was his job, actually, but he said more specifically that he was thinking about killing people he wasn't supposed to kill, i.e., he was having "homicidal ideation." The army shrinks are responsible healers, however, so they did something about it. They gave him a prescription for quetiapine, which is an anti-psychotic medication prescribed for schizophrenia and the manic stages of bipolar disorder. Then they sent him back out to do his job and kill people. Lenz writes:

— Three months passed without Army doctors and clinicians from the Combat Stress Team having any contact with Green. He was summoned for a second examination on March 20, 2006 — eight days after the killing of the family. Green was diagnosed as having an anti-social personality disorder and declared unfit for service. The process of discharging him began a week later and he was sent home.

— The Army's own investigation of Green's initial treatment, prompted by concerns he and others would use mental health problems as a defense in trial, is highly critical. Among the most salient findings from a July review of Green's treatment: "Although a safety assessment was conducted, there is no safety plan addressing how Soldier (Green) will keep from acting on his homicidal thoughts."

— Lt. Col. Elizabeth Bowler, a psychiatrist and Army reservist from California who took over the Combat Stress Team with Green's unit in January, recommended his discharge after the second examination in March. Yet she wrote a final evaluation that said Green exhibited no traits that would indicate dangerously erratic or homicidal moods, according to documents viewed by The AP.

It seems PFC Green was angry because Iraqis were killing his buddies. Indeed. That's what happens when you invade and occupy a country and impose a government on it. So ultimately, what's the difference between a political leader who sends young people abroad to kill people and bend the survivors to his will, and a homicidal maniac? At least they both found Jesus.

Have your barf bags ready . . .

because tomorrow night, your stomach contents are going to surge.

It's hard to find anything original or distinctive to say about this grotesque, horrifying situation. Plenty of information, informed analysis, and ranting is available at Today in Iraq, and elsewhere. But I will say this. If that evil, sadistic sociopath gets his way and is allowed to murder a few tens of thousands more people for the sake of his megalomaniacal fantasies, we will finally have to conclude that our constitutional order has failed.

We need to revisit basic issues about the organization of our polity and the rules for both the political process and public discourse in light of the cultural, material, technological, environmental and economic context of the present age. We have to stop regarding the Constitution as a sacred scripture and understand it as a human creation, flawed in its time, improved in important ways since but with many remaining flaws, now seriously out of date.

A few suggestions:

Corporations are not persons, have no rights whatsoever, and exist only at the pleasure of the People's representatives. The People charter them, the People may revoke their charters at any time, and the rights pertaining to people have no relevance to corporations. Corporations are prohibited from donating to political campaigns, to political parties, or to political action committees. Corporations may not employ lobbyists, and may not communicate with elected officials in any way. Obviously, that includes corporations that happen to be in the business of manufacturing weapons or contracting with the military.

So okay, what about corporations that own newspapers, TV and radio channels, Internet sites, etc., that purport to be legitimate journalistic operations? They are common carriers. They must provide access to speech from citizens who they do not employ, and do not control, proportionate to the volume of speech they purvey that they do control. (Yeah yeah, lots of specifics to work out. But right now, freedom of the press applies only to people who own one. That must change. Yes, I have this blog, and in the old days I could have stood on the street corner handing out flyers, but I get to participate in Fox News or the NYT only at their pleasure. There are plenty of creative ideas out there for changing this. Many people thought the technology of the Internet would do the job all by itself, but that, I think, was a bit of a fantasy. Sure, it helps, but it's not the answer.)

Representation in the Senate is proportionate to population.

The electoral college is abolished. Presidents are elected by the plurality of the popular vote.

Congress shall have the sole power to declare war. (Oh, wait a minute . . .)

The tax on estates in excess of 1 million dollars, indexed permanently to inflation, is 100%. That's in the Constitution, it's not a matter of law. Why should dead people have any rights?

The District of Columbia is a state.

So is Puerto Rico, if they want to be.

The president is still Commander in Chief of the Armed Forces, but Congress can issue binding orders by a simple majority which is not subject to veto.

Let's eliminate, once and for all, any ambiguity or debate about the place of religion in society. The political order is secular. It has nothing to do with religion. That means, among other conclusions, that religious institutions are not exempt from taxes, and, as corporations, they have no rights including no rights of free speech. Individual adherents of religion of course have an absolute right to speech. Their adherents may peaceably assemble; say, write or believe whatever they want; and attempt to convince others of the ultimate truth of their beliefs. They get no tax exemption to do so, however. The Constitution guarantees the free exercise of religion -- in the private sphere. There are no prayers in official sessions of Congress, in school-sponsored events, in official military ceremonies, or in any other occasios of state or publicly funded or sanctioned contexts. Members of Congress, soldiers, students and football players are all perfectly free to get together and pray, speak in tongues, or have ecstatic seizures on their own time.

The United Nations Charter, and the Universal Declaration of Human Rights, are the law of the land in the United States.


Any objections? Any other suggestions?

Who calls the tune?

You may have read about the study in PloS Medicine by Lesser and colleagues (including our friend Merrill Goozner at the Center for Science in the Public Interest) who find that studies funded by the beverage industry are more likely to be favorable to the beverages in question than studies with neutral funding.

Some readers will just say, "Well duhhhhh," but others may find this unsettling, or somehow disparaging to the claims of science to unique epistemological authority. Don't scientists claim that properly conducted investigations are merely revealing a reality which is "out there," independent of the ideology or preconceptions of the investigator? How then could the funding source influence scientific conclusions?

Well, scientists do sorta kinda make that claim but it's not that simple. I'm not going to address the question here on a profound level -- I've already taken a flyer at that here and here, among other places. But on a common sense level, there are several reasons why funding sources can affect conclusions, that don't take us down to the question of the fundamental privilege of scientific inquiry.

The most egregious abuses have been limited in recent years by the cleansing action of sunlight and somewhat stricter policies, but in the past it was common for industry funders of research to retain absolute editorial control over the findings. That meant that if the company didn't like the results of a study, it could prevent the investigator from publishing them; or it could edit the report to its liking. Selective release of findings still goes on, but there is movement to require that drug companies make all clinical trials available for public scrutiny, while universities are not allowing faculty to sign contracts which surrender their autonomy. This problem is far from solved, but it has been ameliorated.

Even so, there is a lot of power in simply picking and choosing what questions to ask in the first place. By the time you go into a large scale, expensive study, you generally already have a pretty strong hypothesis. A company will simply choose not to go where it doesn't like the lay of the land. It's also easy in many cases to set up a study to come the desired conclusion. For example, drug companies compare their new drugs to placebo, rather than existing drugs that are already known to be effective. That way, they don't have to show that their products are better than the alternative. They also often test their products against sub-optimal doses of competing products, or otherwise rig the trial.

Then there is the problem of subtle bias. In any complex study, there are countless decision points. Is the data for this case valid, or should we throw it out? What are the cut-off points for classification? What constitutes a clinically significant effect size? How should this questionnaire item be phrased? It's very easy to consistently make these decisions in a way that favors a desired conclusion, without being consciously aware of it. Of course, you could also cheat on purpose. But psychological research has shown that people's decisions can be powerfully influenced by very modest incentives and feelings of obligation to a sponsor, even when they emphatically believe that they are completely objective and fair.

Of equal importance is the way in which an existing body of knowledge -- which is usually beset with contradictory findings or complexities of interpretation -- gets summarized in review articles. Reviews in major journals can define the ways in which issues are conventionally understood, but it turns out that these reviews have often been written by drug company flacks, rather than the prestitious authors whose names are attached, who merely sold their reputations for money and an extra dollop of fame. I think these prostitutes should have had their tenure revoked and been fired, but in fact there have generally been no repercussions and their careers have sailed on unaffected. Medical journals now have policies against ghost-written articles, and they require disclosure of conflicts of interest, but that obviously doesn't stop this scam. There is no way to tell if the putative author really did the work, and just disclosing conflicts doesn't do anything to stop them from having their full effect.

The bottom line? Science is what it claims to be, an attitude toward the world and a tool kit for revealing reality. But, like every human enterprise, it is corruptible, and frequently corrupted. The solutions are structural. Ultimately, it really does matter who pays the piper.

Deflating Conflating

The Commonwealth Fund, which I love and which also loves me, offers the Top Ten Health Policy Stories of 2006. There's nothing wrong with this list (albeit it is a bit Commonwealth Fundocentric) except for the title.

These are in fact a Top Ten Health Care Policy Stories. As I have attempted here to hammer like a spike into the reader's brain, health care (which I would prefer to call medical services anyway) is only a minor determinant of health, even in wealthy countries where it does make a substantial contribution to longevity. In poor countries, except for certain very basic interventions that don't even require an M.D., it's well down the list of priorities. Yet this habit of thought is so powerfully ingrained that even among sophisticated interlocutors we find ourselves focusing on health care when we meant to be talking about public health and health disparities.

Any top ten health policy stories of 2006 ought to include the extension of workplace smoking bans to more cities and states; the growing movement to improve the nutritional quality of foods available in schools; the NYC ban on trans fats in restaurant foods. On the downside, the failure to eradicate polio as predicted in January; the ongoing destruction of the public health infrastructure in Iraq (meaning nutrition, potable water, and of course public safety, as well as the deterioration of the health care system); the controversy over EPA standards for airborne particulates, mercury and other pollutants; rising rates of violent crime in the U.S.; and many other developments would have to merit consideration.

But the Commonwealth Fund gives us only stories about the organization, financing and provision of health care. One reason is, of course, that so-called health care is the largest industry and the largest public enterprise (outside of war and its sequelae) in the United States. A lot of money falls off that gravy train into the laps of policy analysts, researchers and consultants, including people who work for foundations and write reports. Public health beyond the realm of medical services is diffuse and unprofitable, because it's mostly about public goods that nobody owns, and nobody makes money from. They make us all better off, but they don't support lobbyists and they only get a little bit of think tank attention because of the oddball philanthropist or two.

I'm going to make more of an effort in 2007 to be fair and balanced when it comes to medical services, and everything that really makes us healthy. Don't be afraid to call me out if I seem to be succumbing to the usual intellectual sloppiness.

Everybody talks about the weather, but nobody ever does anything about it

I always thought Mark Twain had first said that, but after a bit of googling around I find it isn't clear whether it was Twain, or his friend Charles D. Warner. In any case, it isn't funny any more. We're talking about the weather more than ever, and we could be doing something about it, but we aren't.

I'm not any sort of a meteorologist or climate scientist, but I have a bit to say about the current bizarre weather from the standpoint of an educated lay person who tries to keep up with the latest, and a student of society who thinks about how people are likely to respond to events.

Here in New England, this has been the winter that wasn't. Yesterday the new Governor of Massachusetts was inaugurated out of doors in his suit jacket, without an overcoat. Many in the crowd were in shirtsleeves. Dandelions are blooming, and robins have forgotten to fly south. For the past few nights, we have had no frost. A January thaw is not unusual here, but this is not a thaw because there hasn't been any freeze. After the warmest December since systematic record keeping began, we are already well on our way to an even warmer January. The long range forecast has a cool down to closer to normal temperatures next week, but nothing that will make up for the extraordinary warmth so far.

The official line is that the earth has warmed only about 1 degree farenheit in the past 50 years, which doesn't seem like much. Of course that's the global mean, which includes the oceans and the less volatile tropics. Certainly New England has warmed more than that. Still, we've had plenty of cold winter weather the past few years, and the scientists haven't predicted that we won't still. Rather, when a warm weather pattern sets up, it will be a bit warmer than usual, and a cold weather pattern won't be quite as cold. We really wouldn't notice if the lowest daytime high in January was 17 degrees instead of 15, or if the highest temperature was 54 instead of 52. Rather, we expect the effects of climate change to be observable through indicators on a longer time scale: the date the pond freezes and thaws; the date of the first and last frost; the extent of snow cover over North America on February 1.

But this winter had been really different. They tell us the jet stream is further north than usual, keeping the arctic air under house arrest. No doubt it will eventually spill south and shock the hell out of us. But us lay people are now starting to worry about those positive feedback loops. We're well past the solstice now, and the sun is creeping north, where it gets to work on bare, unfrozen ground and open water instead of snowbanks and ice covered lakes. That means even warmer air, and when that arctic air does head south, it will be much warmed up by the time it gets to Boston. If the snow cover never forms, or retreats more quickly in the spring than usual, does that mean all the more heat to be stored in the oceans and the ground, and a warmer summer and a warmer next winter?

If this does signal a faster pace of warming than expected, that's important. But just as important is how people will respond to this. So far I don't think many people are complaining, other than skiers and maple syrup producers. It's saving folks a bundle on heat and it's making life a lot lazier and easier. Will people in the northeastern U.S. be inclined to see this as a problem? Will it worry them? Will they feel compelled to take serious action? I have to be honest, most people around here seem to be enjoying it and psychologically, it's just a lot to expect that people are going to clamor to make serious collective sacrifices in order to bring back hockey games on the pond in lieu of roller blading around it. Our Mayor for Life wants to build a new City Hall down by the waterfront, and I'm just afraid we're going to have to see it under water before people really start to pay attention. So far, the winter that wasn't is just a pleasant curiosity, to the public and the press.

Sayonara

to weird sicko (or sick weirdo) Rick Santorum, who will now be able to devote full time to worshipping his pickled fetus. Adios as well to Bill Frist, who can give up his schtick as Karnak, the Magnificent Psychic Diagnostician and go back to defrauding the taxpayers through his family business at Hospital Corporation of America. And to many a wackjob, thief and liar. So long, goodbye, don't stand in the doorway letting the cold air in.

Unfortunately, there are quite a few of these rabble left in the Congress, from Brownback to Inhoffe to go, Virgil go, Virgil B. Goode. So as health policy reporter John Iglehart predicts in the new NEJM, we probably should not expect anything dramatic in the health care reform department for the next couple of years.

As Iglehart points out, the Democrats' promise to institute "pay as you go" rules for any new spending, along with the availability of the filibuster to Senate Republicans and the veto pen to the White House occupant, sharply limit the possibilities for significant expansion of health insurance coverage. Expanded federal funding of stem cell research may pass the Congress, but will probably hit the veto wall. Allowing Medicare to negotiate with drug companies for lower prices might pass, but that doesn't mean the administration will actually have to do it.

A few days ago I posted about the overpayments to so-called Medicare Advantage plans. These are the Republicans' pet scheme to save Medicare dollars, but of course they have the opposite effect, lining the pockets of private insurers at your expense. Iglehart doesn't seem to have an opinion on whether Congress will do anything about this. Given that Big Insurance has been moving to hire Democratic lobbyists and will no doubt be dangling campaign contributions in front of the new majority party, I'm not holding my breath.

As for expanding health insurance coverage, Iglehart thinks the "Blue Dog" Dems -- who are strongly committed to balancing the budget -- will probably stop anything major from happening.

As with the expecation of most observers about the occupation of Iraq, which the Democrats have pre-emptively pledged not to defund,* Iglehart expects the most excitement to come out of oversight hearings. He expects new FDA Commissioner Andrew von Eschenbach to spend a good deal of his time on the hot seat before various congressional committees. I would add that Medicare, CDC and other HHS programs may be in for a good, hot roasting. What all this will ultimately mean for public policy, however, is not so clear. I'm afraid that our long national nightmare will not be over for at least a couple of years, although we may at least be emerging into lucid dreaming and the hypnogogic state.

*The standard Democratic negotiating position starts with, "You can have everything you want. Just please don't be mean to us."

Ali, Ali, Ali!

Last night while I was reducing the wine sauce I switched on the Tube of Boobosity and caught the opening ceremony at a college football game featuring the University of Louavul. (I think I may have misspelled it but I know how to pronounce it.) Muhammad Ali, who was born in Louavul, was there as an honorary coin tosser, but he was too debilitated by Parkinson's Disease to do anything but stand there.

When I was a youth, I admired Ali for many reasons. He was an astonishingly gifted athlete. He violated everything the crusty old guy in the dusty old gym tells the golden boys trying to punch their way out of the ghetto, by carrying his hands low and standing up straight -- deliberately confronting his opponent with his guard down. He could do this because he was so much quicker, able to flick punches away with his forearms or slip them by moving his head, while leaving the opponent defenseless against attacks to the ribs and powerful upward jabs.

But he really became popular, and world famous, because he showed that he was more than a braggart and a rabble rouser when he refused induction into the armed forces during the Vietam war. Nobody could accuse him of cowardice, obviously -- not only because he had proven his physical courage in the ring. It was obvious that the army would not have sent him into combat but rather would have used him as a good will ambassador, yet he sacrificed his career and willingly endured prosecution and the risk of imprisonment. (He was convicted but the Supreme Court ultimately vindicated him as a legitimate conscientious objector.) He said very openly that the war was contrary to his religious principles, and that it was not being waged on behalf of his people. "No Viet Cong ever called me nigger," he provocatively remarked .

He was banned from boxing for three years and when he came back, he had lost something. He regained his championship but he depended more on guile and psychology than sheer athletic superiority. He was a great hero to African Americans, and to oppressed people everywhere. He became the most famous person in the world.

Like many former members of the Nation of Islam, he converted to orthodox Sunni Islam. Since his retirement from the ring, he has pursued a life of piety and good works. But his physical disability has prevented him from continuing as a public figure. There is no proof that his parkinsonism was caused by repeated blows to the head, but it seems a pretty good bet. It is terribly sad to see this proud, intensely charismatic man, once the epitome of physical beauty and grace, trapped in a dysfunctional shell of a body.

From a public health point of view, boxing is not a huge problem, at least not directly, because relatively few people engage in it. Actually, at least according to my perusal of the unacceptably scant epidemiological data, compiled here, amateur boxing is not notably less safe than other contact sports. However, professional boxing is another matter altogether. As everyone knows, Ali's situation is not unique. In fact, he may be lucky. More than a few boxers have died in the ring, and many others suffer from blindness and dementia. Ali's faculties remain intact, only his motor control has been damaged, albeit severely.

Many argue that people who choose to pursue a career in boxing are exercising personal freedom. They are presumably aware of the risks and accept them. This might be countered with the observation that professional boxers are overwhelmingly from disadvantaged backgrounds, and in fact may not have a lot of other chances in life. Suzanne Leclerc and Christopher D. Herrera discuss some of the ethical arguments here. They don't conclude that boxing should be banned, but they do conclude that physicians should not participate as ringside "fight doctors." (This is rather like the AMA position against physicians participating in torture, without specifically condemning Bush administration policies.)

The liberty argument for permitting professional boxing hinges on the presumption that only the participants are harmed. That presumption dodges the issue of the socio-cultural effects of a spectacle in which men* attempt to win money and glory by rendering an opponent unconscious through repeated blows to the head. While many people believe that such spectacles provide a catharsis of violent impulses that spectators might otherwise channel into antisocial behavior, Daniel Goleman, in Emotional Intelligence, argues the contrary: that research has shown that spectators become more agressive after witnessing boxing matches.

In the case of Muhammad Ali, it is impossible to say what he might have become without boxing. Perhaps he would have excelled at another sport, but it is more likely that he would have died in obscurity, and the world would have been deprived of a public life that was not only entertaining, but deeply meaningful. Would Ali himself trade his fame and fortune for a healthy old age? I doubt it. But I personally no longer watch professional boxing and I do wish that it would fade away.

*Women now box, of course, including Muhammad Ali's daughter. It is said that he disapproved, and tried to discourage her. But when she wouldn't listen to him, he ended up giving her his blessing. What else is a father to do?

Tip

The British Medical Journal, in a fit of holiday beneficence unto the poor and unschooled, has made it's current issue free to all. It's partly whimsical, partly frivolous, and partly serious. It may amuse and/or enlighten to various degrees.

I'd just like to single out Joseph Stiglitz's contribution. As you are bored of reading about here, the system whereby drug companies get exclusive marketing rights to compounds they develop as a reward for their investment in research doesn't work very well. Without reciting once again all of the inefficiencies, distortions, and anti-social consequences, I'll just say that one consequence which is particularly offensive to Stiglitz is that the drug companies have no interest in diseases which principally affect poor people in poor countries, who can't pay big bucks for their products. Stiglitz proposes a prize fund for new remedies for these diseases. The winner would scoop up the prize, but the product would then be available for generic manufacture and inexpensive sale to the people who need it.

Sounds good to me. But of course, that would require use of tax moneys and action by government, which according to the Republican Party is immoral, at least when it benefits poor people. So we'll have to think of something else.

Am I missing something here?

I read that GW Bush is to give the eulogy at the funeral of Gerald Ford. That this is even possible, let alone that the politicians and the corporate dictators of public opinion in the mass media find it perfectly ordinary and to be expected, is proof of the pathological incapacity of Americans for self-reflection.

George W. Bush as eulogist? He is a habitual and remorseless liar, a war criminal, a mass murderer, the public face for a gang of vicious thieves who have betrayed not just their country, but all of humanity for the sake of nothing but insatiable greed. The proper place for him is locked in a cage, for the rest of his life, so that he can't hurt people any more. And yet we give him the leading role at a solemn occasion of state.

The Democrats have already pledged not to impeach him. Not a single prominent writer or social critic, to my knowledge, including the editorial staff and columnists for the publications that hold down the left edge of our political discourse, including The Nation, has called for him to be tried for his crimes, or even for those crimes to be called what they are and for the Congress to act accordingly. He continues to be treated with respect and deference and the supposed opposition party has even promised not to do anything that would effectively impede the escalation of his crimes.

Do Gerald Ford's family and friends have no shame? Have they no respect for the late president, that they would allow his memory and his name to be so drenched in filth?

The only way for the United States to begin to recover its national honor is to impeach both George W. Bush and Richard Cheney; remove them both from office; and prosecute them for their crimes. That is what we must do.