Sorry Doc, you'll have to buy your own Yankees tickets

Those of you with a very long memory will remember that last year, a bunch of people with letters after their names proposed a new code of regulations to stop drug companies from bribing doctors. Well, talk is cheap, but the Pew Charitable Trust has put up real money, $6 million in fact (enough to keep the Iraq war going for an hour or so), to try to actually make it happen.

The Prescription Project is led by my old friend Rob Restruccia, but he didn't approve this message, it's just coming from me. The PP is going to campaign among "academic medical centers, professional medical societies and public and private payers to end conflicts of interest resulting from the $12 billion spent annually on pharmaceutical marketing."

This is a promising development. However, the only real clout behind it is moral persuasion. The drug companies certainly aren't going to cave voluntarily, and unfortunately one of the deep dark secrets about academic medical centers is that nobody is really in charge. Every department is a fiefdom. Similarly, nobody tells individual physicians or group practices what to do, no matter what ethical codes the medical societies propound. Insurers can try to make rules about what prescriptions doctors write, but they have no practical way of enforcing appropriate choices among alternatives, and they have no way of getting inside of doctor's offices and practices to stop them from taking bribes from drug dealers. I fear that without legislation - you know, that evil Big Government -- actually restricting drug company practices, this is going to be something of a cat herding exercise.

But we'll see. You go, Rob.

Your best friend?

Due to an unpleasant personal experience, I was motivated to look into a question that a lot of you, I'm sure, prefer not to think about. It turns out that each year, about 4.7 million Americans are bitten by dogs. That statistic is from a CDC survey done in 1996, so with the increased population of humans and dogs since then, the number is probably greater. The linked site says that's 2% of the population, but actually according to my calculations it's closer to 1.5%. Either way, it's a very common experience. I've actually been bitten twice in my life, which based on those numbers, ought to be about average for a person my age.

Most of the resulting injuries are not terribly serious, but 1 out of 6 -- that would be something like 800,000 a year - require medical attention, including 380,000 emergency department visits. On average, 17 Americans per year die from dog attacks -- most of them children.

This is not the biggest public health problem in the world, but it's awfully sad since nowadays, the main reason we keep dogs is for companionship. (These statistics exclude bites by police and guard dogs, who are acting in the line of duty, by the way.) Any dog may bite -- unfortunately it can occasionally happen unpredictably even with dogs who have not previously shown hostile behavior toward humans. But it turns out that a few breeds are responsible for a highly disproportionate share of attacks. Most of these will not surprise you, but a couple might. The ones that look more suitable to Abu Ghraib than your back yard include Akitas, English bulldogs, Bull mastiffs, Chows, Boxers, German Shepherds, Great Danes, Huskies, and the really bad seed -- Rotweilers and Pit Bulls. Wolf hybrids, of course, are on the list, but anybody who would keep a wolf hybrid is completely nuts. As Merritt Clifton, who compiled those statistics writes, ""Pit bulls and Rottweilers are accordingly dogs who not only must be handled with special precautions, but also must be regulated with special requirements appropriate to the risk they may pose to the public and other animals, if they are to be kept at all."

Estimates of the insured losses (mostly liability, I presume) from dog bites range from $1 billion to $2 billion annually. Most attacks happen at home, and most of the victims are family or friends. The linked resources discuss these issues in more detail, but here's what I have to say. If you own a dog, or want to, you need to take this seriously. You need to be well informed about dog behavior, why and when dogs bite, and what to do about it. Don't take it for granted that your dog is always going to be safe around humans, just because you love it.

Arithmetic

The National Governor's Association has made a bipartisan appeal to the White House to send enough money to keep the Supplemental Children's Health Insurance Program from running dry before the end of this budget year. Fourteen states will have to toss kids off the rolls before the end of the fiscal year, maybe as soon as next month. The total price tag to meet the need? $745 million. That's a lot of money -- it's enough to pay for the occupation of Iraq for two whole days. Over five years, analysts say, the White House budget will leave SCHIP short by $10 to $15 billion.

Obviously we can't afford that, however -- it's enough to pay for the Iraq occupation for a whole week, maybe even ten days.

Regular readers already know that sincd 1992, the FDA drug approval process has been funded by user fees from drug manufacturers. It's not a big surprise that the FDA puts most of its resources into what its funders want -- swift approval of new drugs with commercial potential -- and has starved safety monitoring and approval of generic drugs, that would compete with the FDA's bosses in big Pharma. Marcial Angell, writing in the Globe, points out that Congress could fix this by eliminating the user fees and instead kicking in $300-400 million in public funds, making you, the consumer, the boss once again.

Obviously we can't afford that. It's enough to pay for the Iraq occupation for one whole day.

There is a chorus of alarm in this country about our rotting infrastructure -- water and sewer systems, highways and bridges and dams -- the crisis in Medicare spending, rising numbers of people without health insurance, lack of preparedness for public health emergencies, underinvestment in renewable energy and conservation, lagging educational achievement -- name your own favorite worry. But guess what? For $100 billion dollars a year, we could just about fix everything. And it's not like we don't have the money, it's just that it's spoken for. Somehow we have to pay young people to drive around Iraq in defective armored vehicles and get blown up. That is our number one priority. The rest of that stuff we'll just have to do without.

The Evildoers don't have to attack us. They can just let us bleed ourselves to death.

UPDATE: After I posted this (honest), I came across the following on Josh Marshall's site. He quotes James Fallows as follows (hah!). (Original is subscription only)

Documents captured after 9/11 showed that bin Laden hoped to provoke the United States into an invasion and occupation that would entail all the complications that have arisen in Iraq. His only error was to think that the place where Americans would get stuck would be Afghanistan.

Bin Laden also hoped that such an entrapment would drain the United States financially. Many al-Qaeda documents refer to the importance of sapping American economic strength as a step toward reducing America’s ability to throw its weight around in the Middle East.

Ahyup.

There's got to be a better way . . .

If you've missed me lately, it's because I'm still in proposal hell. Non-profit public health and social service agencies spend so much time writing proposals, they barely have the time to do the work they propose. The investment in proposal development and writing is mostly wasted, because only a minority of proposals are funded anyway -- not because they don't deserve to be, but because there are 20 or more applicants for every grant.

The federal government got out of the business of actually making a meaningful effort to ameliorate social problems a long time ago. Instead, the pittance that's doled out through the various HHS agencies goes to "demonstration projects" and "targeted capacity expansion" and "special projects of national significance," meaning that 20 cities get a substance abuse treatment program or a disease prevention program for five years, then the funding gets yanked and the little bit of money goes someplace else. Meanwhile the agencies are in a perpetual chariot race after those ever-receding dollars. When they lose, their clients and communities just get dumped, along with their workers. And most of them, every year, have to lose.

And by the way, the ability to write a good proposal correlates only modestly with the ability to do a good job. The feds intensely monitor the programs they fund, meaning you have to spend 20% on evaluation and reporting, but they don't really care what the data says, they just care about collecting it. But however good you get at doing the program, it doesn't really matter because you'll be cut off in a few years anyway.

This is no way to run a country.

Okay, I'll say something nice for a change

And not only that, it's about the much maligned Fourth Estate, your corporate news media, who I spend a good percentage of my time here clobbering. A few years back, I was quoted in this article by Trudy Lieberman in Columbia Journalism Review. Lieberman beat the crap out of the corporate media for their breathless, credulous, coverage of medical "breakthroughs" and deification of medical researchers --

In the name of news and the desire to build audience, the media are stimulating demand for medical tests and treatments that are unproven and untested, and may even be harmful. The lure of stories about medical breakthroughs and miracles is so strong that the press rushes to report on them even if there is little or no evidence that they are safe and effective . . .

And, a lot of the time, it was the drug and medical device companies that were pushing these stories through their PR firms. They even sent out video press releases to local TV stations, that ran them as if they are real news.

Well, I'm going to go out on a limb here and say that since 2001, when Trudy wrote the story, things have gotten better in this particular department. The political reporters still have their schoolgirl crush on power, and the unskeptical approach to anonymous senior administration officials hasn't changed, but medical breakthroughs are now covered with a good deal more reserve. After the debacles over Hormone Replacement Therapy, COX-2 inhibitors, the essential failure of the artificial heart, and Judah Folkman not curing cancer after all (he never said he would, but his ideas about angiogenesis inhibition were grossly overhyped by reporters), they finally seem to have gotten the idea. Indeed, they have learned that debunking can make a good story too. Our local TV stations hire real doctors who discuss the latest medical research with reasonable caution. (I suppose the station in Ottumwa may still run the video press releases but I'm not there.)


This opinion is not based on rigorous study, and maybe someone will want to contradict me. But I do read the NYT health/science section every week, and their business section too, which is mostly about health care and drugs (that's not a joke), and I look in on local and national broadcast news -- sampling all the networks -- often enough to keep in touch with the zeitgeist. I also did a quick review of the health sections on the major networks' web sites - CBS, ABC, MSNBC, CNN. This week, at least, they're all pretty good. Maybe it's partly because health care news is also business news, and they don't want to get blamed for misleading investors, that they have grown more skeptical.

Anyway, that brings up the $64,000 question: Why can't they learn the same lesson about war and peace?

Immoral Minority

We've long known that Osama bin Laden is the best friend George W. Bush ever had, but George's carnal lust for The Evildoer does come as news. However esthetically unappealing this image may be, in public health we are careful not to pass moral judgment, because it is counterproductive.

Instead, we consider the health-related risks of behaviors, based on evidence, and develop evidence-based methods of risk reduction and harm reduction. In the case of Mr. Bush and Mr. bin Laden, although abstinence might represent the lowest risk, just preaching abstinence does not work. In fact, it is less effective at reducing sexual promiscuity than comprehensive sexuality education -- and just ask Ted Haggard if you don't believe me. Oh well, don't ask him, he is tragically short on insight. But anyway, in other words, we should do our best to encourage Mr. Bush to use a condom when he consummates his desire.

Unfortunately, as you may recall from a few years back, members of Mr. Bush's party have been trying to put a stop to research that would help us do that effectively. NIH grant awards are posted in a searchable database called CRISP, and Republican members of Congress troll through the database in order to find grants they consider politically objectionable -- based on abstracts containing words like "sex worker," "transgender," and yes, Mr. President, "anal sex." As the NYT's Erica Goode reported:

[A] researcher at the University of California said he had been advised by an N.I.H. project officer that the abstract of a grant application he was submitting ''should be 'cleansed' and should not contain any contentious wording like 'gay' or 'homosexual' or 'transgender.' '' The researcher said the project officer told him that grants that included those words were ''being screened out and targeted for more intense scrutiny.''

He said he was now struggling with how to write the grant proposal, which dealt with a study of gay men and H.I.V. testing. When the subjects were gay men, he said, ''It's hard not to mention them in your abstract.''

Resolutely refusing to know what people do doesn't stop them from doing it.

Presidents Day Event

This holiday is celebrated as nothing more than a day off in the middle of the year's dreariest month, which is probably not a bad idea. The only tradition associated with Presidents Day is a sale at the car dealership, but I figured what the heck, I'd acknowledge the official excuse for the holiday here.

I don't subscribe to the Great Man theory of history, for the most part. We get the presidents we deserve. So, while the presidency has sunk pretty low before, right now we ought to be deeply ashamed of ourselves, as a nation. While the White House Occupant is morally culpable for his incalculable crimes, the Bush presidency is an indictment of some of the most important institutions of our society. It convicts the corporate information media of either grotesque failure or treasonous conspiracy, depending on whether you think the blatherers and scribblers are self-adoring fools, or willing tools of their corporate masters. A little bit of both is a fair conclusion.

We've been over that ground before, and it may largely be barren. They have shown almost no ability for self-reflection or remorse, if indeed they are troubled in the first place by the disasters they have helped to visit upon us. Because they were almost all completely wrong about the Iraq war, they have decided that only people who were wrong are deserving of respect. The structural problems of a capitalist news media aren't going to get any better any time soon, even as the shrinking budgets for real reporting and the ever more incestuous Washington culture are just going to further promote and reward stenography, sycophancy and intellectual laziness in the journalistic "profession." (Katie Couric? WTF?)

But just as troubling to me is the demise of the political party. At one time, parties were mass organizations. People actually belonged to them, it wasn't just a box you checked on your voter registration form. Labor unions, civic organizations, farmer's cooperatives, neighborhood groups, actually constituted political parties, while the parties themselves were organized right down to the city block -- all of this for better or for worse, to be sure, but it meant that people were directly connected to politics and to politicians. Insurgent parties even formed at times from mass organizations, including the People's Party, forged in the 1890s from the Farmers' Alliance and the labor unions, which nearly pulled off a revolution until it was hijacked by the Democrats and William Jennings Bryan.

With the decline of labor unions and mass political movemnts, and the rise of television, that has changed. Parties are not mass organizations, they are loose federations of politicians, established for the purpose of fundraising. Politics doesn't happen in union halls and granges, it happens in the shadow box, a moving pattern of tiny colored dots in each lonely living room. The parties' money is used principally to buy those dots.

The exception, unfortunately, is the church, and specifically conservative evangelical churches dedicated to restoring the society and knowledge base of 2,000 BC.

If we're going to avoid another disaster like the neo-con presidency, and have any hope of digging ourselves out of the pit they've led us into, we are going to need a basic reordering of society. Many people know this, of course, and they are seizing on the new opportunities offered by the Internet to try to build new models of mass organization and do an informational end run around the corporate media. It's even starting to work, a little bit. However, I don't see sitting with your feet up and pecking at a keyboard as a sufficient model for civic engagement. We still need to rebuild popular organizations, start having those meetings again in the church basement and the union hall and the public libarary, have the demonstrations in the town square, build the non-partisan leagues and the third parties, get out there and build movements, and once again build politics upon the polis.

Maybe that way, when we get the president we deserve, we'll be glad for it.

Back, with an observation

Sorry to have disappeared for a couple of days, I have been disconnected from Your Intertubes.

The curse of longevity threatens to become an insuperable burden for society, unless we can find ways of reducing the rate of disability requiring long-term care for elderly people. Dementia is the biggest problem, because people with severe dementia can live for many years, requiring very expensive custodial care. There aren't any major breakthroughs in sight, unfortunately, so we have to find better ways of coping with a growing social and financial crisis.

The vast majority of people who require long-term care do not have nearly enough personal resources to pay for it. Long-term care wipes out innumerable family fortunes -- nursing homes cost on the order of $100,000/year or more -- and most people who require it eventually end up on Medicaid. As I assume my readers know, the cost is shared between the state and federal governments.

In an effort to reduce the burden on the public treasury, Congress has made eligibility requirements increasingly draconian, if not cruel. It has also created some perverse incentives which are both unjust and counterproductive.

Many people with dementia can do very well in non-nursing facilities that only provide support for daily living. However, Medicaid will not pay for such assisted living facilities, even though they cost half as much as nursing homes. Spouses can retain half of a couple's savings as of the date one member applies for Medicaid, which happens when they become medically indigent, i.e. when the person enters a nursing home. This creates an incentive to move from an assisted living facility to a nursing home as early as possible, even though the nursing home is more expensive. The reason is that if the couple waits as long as possible, while continuing to spend their assets on the assisted living facility, there will be less money left over for the non-disabled spouse. Not only does this increase the burden on the public, it forces people into nursing homes who would be better off staying out of them.

The law also punishes people who make gifts -- not only to their children, which might be seen as a way of shielding assets from the state. For example, someone who helps pay college tuition for a grandchild, or niece or nephew, or a deserving but poor neighbor, will be severely penalized when it comes time for her husband to go onto Medicaid. If this happened any time in the past five years, even if the later need for long-term care was not yet anticipated, the state will consider this an attempt to cheat the public and force the surviving spouse to pay the amount of the gift to the nursing home from her half of the assets.

Forcing people into poverty because their spouses develop Alzheimer's disease should not be a goal of public policy. There has to be a better way. Universal, comprehensive, single payer national health care would do it. It would also make a lot more sense to pay for assisted living if it is necessary, including home-based as well as institutional services. But this just makes too much sense.

These kids today, I just don't know . . .

A couple of weekends back I had the chance to party down at Sally O'Brien's, which has kicking bar bands on Saturday nights and a crowd of people who are, ahem, kinda like my age. This was a lot of fun, particularly because every time I go to a club where the young folks hang, at some point during the evening a kid will pass out and try to save himself by grabbing my leg on the way down. Then he barfs on my shoes. The fogies at Sally's, I'm happy to say, might have had a drink or two or six but they managed to stay more or less vertical and did not emit any noxious bodily fluids.

So what's going on? The new annual survey sponsored by NIDA, called Monitoring the Future (not out yet, but described by Bridget Kuehn in the new JAMA, off limits to you worthless rabble, I'm sorry to say) explains. It covers adolescents but these are the people who go on in five or six years to hang on my pants in night clubs. It turns out that while the rate of self-reported illicit drug use among the youth of today is down (which mostly means fewer of them admit to smoking pot), abuse of prescription medications is way up. And we're talking, get this, hydrocodone, in other words pharmaceutical junk, brand name Vicodin. Almost 10% of 12th graders told a survey interviewer they had used Vicodin in the past year, and more than 3% said they had used oxycodone, which is even more powerful. Youch. One has to presume those numbers go up through the college years and beyond. Combine that with a few rum and cokes and you're puking on my shoes in no time.

Kuehn writes, "Another troubling aspect of teens' medication abuse is that they often take the drugs in combination, and the users themselves may not know what the combinations are, [NIDA Director Nora] Volkow said. She explained that teens may dump tablets they have acquired into a bowl at a party, and they and their friends sample the drugs."

Now I have to admit that in my college days we tried this and that, but the idea of taking something without knowing what it was would have seemed insane to us. Furthermore, nobody but a few major losers would go anywhere near opioids. We had certain standards, and we considered that shit just plain scary. Who wants to be a junky? I might also add that it just wasn't around. Ten percent of high school seniors doing Vicodin? I mean, we're talking a huge volume of consumption here, more, I would have to think, than the volume of legal use. The drug companies have to know where it's going. And how is it getting there? Something just ain't right here.

A necessary digression

I listened to Christopher Lydon's show last night -- it's called Open Source, and it's because Lydon already had the name that Pajamas Media was forced to stay undressed. He had on MSNBC pundit Lawrence O'Donnell and The Nation's John Nichols, among others, to talk about the Libby trial.

Appropriately, the discussion wandered into the case for war in Iraq and Colin Powell's notorious speech before the UN Security Council. O'Donnell zealously defended the performance of the U.S. news media at that time, claiming that they could not possibly have been expected to know that Powell was full of crap. Lydon and Nichols pointed out that British newspapers effectively debunked Powell's speech the following day, but O'Donnell insisted that The Guardian and others didn't find any "smoking gun" to prove that Powell's claims were false and that U.S. reporters had no choice but to simply transmit them.

Right. I'm just going to give you a couple of highlights of my personal experience on that fateful week in February. One of Powell's claims was that there was a facility in Iraq, where al Qaeda was training its operatives in the use of chemical weapons. He showed satellite pictures of the "chemical weapons training facility." So, British reporters decided to go there. The chemical weapons training facility, first of all, was located in Iraqi Kurdistan, in the "no fly zone" protected by U.S. and British warplanes from incursions by the Baathist regime. Since it was outside of Saddam's control, it was easy for the reporters to get there. Out in the desert they found a decrepit, abandoned village of cinder block huts with no electricity, no water, and no chemical weapons or for that matter, weapons or "facilities" of any kind. This went completely unmentioned in the United States. I read it in The Guardian about two days after the speech.

Powell also stated that a terrorist group called Ansar al-Islam was operating "in Iraq," and that it constituted a link between al Qaeda and the Saddam Hussein regime. Powell implied that the leader of Ansar al-Islam was Abu Musab al Zarqawi. I was curious, so I spent about five minutes doing research on the organization. Like the chemical weapons training facility, Ansar operated exclusively in a remote area of Kurdistan. Its leader, Najeddin Faraj Ahmad, whose nom de guerre is Mullah Krekar, was not in fact Abu Musab al Zarqawi, although it was indeed associated with al Qaeda. The principal goal of Ansar al-Islam was the overthrow of Saddam Hussein. I also learned that, according to Kurdish Media, a reasonably reputable though fervently nationalist news service, Saddam Hussein had provided weapons to the Patriotic Union of Kurdistan on condition that they use them to attack Ansar al Islam. Even though Saddam and the PUK were enemies, this is plausible because Ansar al-Islam was also at war with the secular PUK. Alliance and animosities in that part of the world can be very complex.

So yes, Saddam and Mullah Krekar were indeed "linked," in that they were trying to kill each other, but I don't think that was what Powell was trying to imply. I wrote a letter to the Boston Globe detailing these findings, which of course they did not publish. I also wrote to the ombudsman pointing out that the paper was not providing its readers with essential, readily available information even as their government was taking them to war. They ignored me. This information, which any citizen with an Internet connection could have discovered in five minutes, was never mentioned, as far as I can tell, in any mainstream media in the United States including the New York Times, Washington Post, NBC, ABC, CBS, CNN, or anyplace else. In fact, as far as I know they still haven't mentioned it. A curtain of censorship had been drawn over North America. Hell, I even met the Executive Producer of PBS's Frontline at a party and I told him. He scoffed at me.

These people, who consider themselves professionals and make substantial salaries, are "reporters" in the same sense as court reporters. They are transcriptionists. There have been some minor self-critcisms from some of them about how they didn't dig hard enough, but the truth is, they did not tell the public basic facts that they surely must have known to be true. O'Donnell is a pompous, airheaded ass.

Haloscan problems

Haloscan is acting up -- it's telling me I have posted a comment, but it does not appear. I also see on my Haloscan account some comments by others (hi Neolotus) that don't seem to be showing up publicly. I hope this will be fixed soon, if you've had problems, sorry.

Give me liberty and Give me death

C., in commenting below on companies pushing toxic sugary stuff at kids, reminds us obliquely of the tradeoff we frequently encounter in the public health biz between what in the first analysis at least appear to be liberty interests, and our goals of population health. For example, many people object to laws requiring use of seat belts and motorcycle helmets as infringements on personal freedom. There are some highly respectable counter arguments -- for starters, brain injured people are a substantial burden on society, and my liberties are infringed when I have to pay taxes to take care of them and their dependents. You can probably take it from there yourself -- but these laws remain controversial and vary from state to state depending on local politics.

There isn't any logical place to draw the line with that argument. It seems to invite unlimited paternalism. Why not tell people what to eat, require them to get a minimal amount of exercise, ban rock climbing or diving? On the other hand, most people support the prohibition of cocaine and heroin, consumer product safety regulations, and other measures that are justified on essentially the same grounds.

The common sense view is that it's a matter of degree, of striking a balance. How serious is the infringement on the liberty of the fool or the adventurer, and how great is the risk to society and their dependents of their choices? (This calculation backfires on proponents of prohibition of recreational drugs, because the burden on society might well be less if drugs were decriminalized. But that's a digression.)

When it comes to children, however, we are much less protective of the liberty interest. We expect to practice paternalism toward children. Hardly anyone objects to laws prohibiting the sale of tobacco, alcohol, or firearms to children, even when they fiercely protect the right of adults to buy these products.

Yet it strikes me that most people would absolutely reject restrictions on selling sugary soft drinks to children -- even if we could show that these are as dangerous as cigarettes, which may indeed be the case. Of course we all drank soda as kids and many of us still do, because social norms didn't just permit it, they encouraged it. So it seems inconsistent with the culture. And of course we would, logically, have to extend the ban to candy, which we all remember as the child's equivalent of sex and a major currency that adults use to buy children's love. Furthermore, in the old days, kids were much more physically active, so most of them could handle the occasional sugar blast. We remember eating lots of sugar and we didn't necessarily get fat.

But nowadays that's changed, and a lot of kids are seriously imperiled by excessive sugar consumption. Furthermore, we're all going to have to pay for it. So why is it different from banning sales of tobacco and alchol to minors? I'm not trying to answer the question, I'm just posing it. It's just something to think about.

Proposal Hell

Sorry for the light posting, but people in my line of work spend much of their professional lives in this horrible purgatory. No research proposal has ever been completed more than 17.5 seconds before the deadline. Why that is, I cannot tell you for sure, but it's as inevitable as tasteless beer commercials.

Anyhow, what I'm working on now is something we don't think about a whole lot, and that's the neighborhood food environment for kids. If you go into a small grocery or convenience store, you will see advertisements for soda, massive displays of candy at the checkout counter, coolers promoting so-called "energy drinks" (which are just a way of marketing sugar water), and of course a whole lot of twinkies and hohos prominently displayed. On their way to school, the kids in my neighborhood stop in and buy breakfast, consisting of soda, candy bars, and those nasty little shrink-wrapped pastries. It would be great to convince the merchants to tone some of this down, or even try to push healthier food choices (not that the kids would buy an orange and a low-fat milk instead of a Snickers and a coke, but hey, you could try.) But, that's how they make their money. The margin on those items is good, the distributors give them incentives to advertise them and place them prominently, and they're giving the people what they want.

There have been substantial efforts to fix the food environment inside the schools, where the authorities have control. They can get the soda and junk food out of there, and they are starting to do it. But it's a free country. We can't control what goes on inside the bodega or the 7/11, but maybe we can find incentives to influence it. So, that's what I'm working on. Is it radical? Is it even political? Is it hopeless? We've got to do something because we have 12-year-old kids developing type 2 diabetes. There is a public health disaster in the making.

Death, doubt and doom loom . . .

Bazz fazz

Now this really frosts my pumpkin

Owen Dyer in BMJ (subscription only but you can read the first 150 words here) writes that "A new public relations campaign to be launched by the American Association of publishers will equate open access to scientific journal articles with government censorship." This news was originally reported in Nature magazine by Jim Giles, but they give non-subscribers only about 25 words. So that's kind of ironic, now isn't it? Anyway, they don't get a link because they won't allow it, so Mr. Giles will just have to let me leech off of him, by leeching off of Owen Dyer. But that's what they want, isn't it?

Last summer the academic publishers Elsevier (which has published some of my work) and Wiley, and the American Chemical society, met with PR mad dog Eric Dezenhall, who, according to Dyer's summary of Giles's report, which I am in turn summarizing here, "Mr. Dezenhall . . . advocated 'bypassing mass consumer audiences in favour of reaching a more elite group of decision makers,' arguing that 'it's hard to fight an adversary that manages to be both elusive and in possession of a better message: free information.'" Uhuh. He advocated developing simple messages such as "public access equals government censorship," and "government is seeking to nationalize science and to be a publisher."

Apparently the extremely strained logic behind this Rovian campaign is that open access publishing depends on the cost of publication being included in research grants, including government grants. The actual journals, of course, are not government organs at all, but independent, private non-profit organizations. Right now, the financing for scientific journals comes from two main sources: outrageous subscription fees that only well endowed libraries in wealthy countries can afford; and advertising, most of it from drug and medical device manufacturers. (See my earlier post on the $20 million dollars a year or so in drug ads taken in by JAMA and NEJM -- most of which goes to finance lobbying by doctors, some for good causes to be sure, and some in defense of their obscene incomes. In spite of this bounty, they still charge hundreds of dollars a year for subscriptions.)

Of course, these publishers want to keep their own profits and executive salaries, at the cost to society of limiting access to the latest scientific research to people connected with universities in wealthy countries. There isn't a single good argument in favor of their entirely self-interested cause, so they hire a professional liar to try to bamboozle the scientific community for the sake of their socially destructive privileges.

Well, at least we have the news media to interpret science for us, even if we aren't allowed to read the journals. I think I'll go see if Anna Nicole Smith is still dead.

UPDATE: Commenter Frank reminds me that I shouldn't assume that everybody is reading all the posts here in order. (This medium still takes some getting used to, even after more than two years.) No, I don't think that physicians in general make obscene incomes. Here is what I really think, from a few days ago.

The Traveler's Dictionary

Many visitors to the United States are unfamiliar with the idiosyncratic version of English we speak here, and may become confused. As a follow-up to yesterday's post, I thought I would offer a small phrasebook of common American locutions, with their translations into standard English. Readers are invited to add to this.

I'm not racist, but . . . : I'm racist.

I'm not racist in any way, shape or form: I hate the mud people more than I love life.

Liberal media: Reporters who slip up and describe elements of observable reality inconsistent with conservative ideology.

Bipartisanship: Resolutely support the glorious revolutionary line of Dear Leader, the People's inspiration, from whom storm clouds shrink as he passes.

Centrism: Foaming at the mouth right wing radicalism.

Moral values: Hatred.

Human life begins at conception: Human life ends at birth (and is resurrected at brain death).

Weapons of Mass Destruction: Emptiness; the void that binds.

National security: Weapons of Mass Destruction.

Support the troops: Make as many 19 year old pregnant widows as possible.

Big government: Grandma's next meal.

Liberty: Sanford Weil's next Lear Jet.

Well, that's probably enough to study for one day. After several weeks, you should be able to master American English. Enjoy your visit!

UPDATE: I should have included this one in the first place. Sorry.

Dead insurgents: Dead children.

U.S. says 13 rebels killed in airstrike.

Police and hospital officials in the area offered a conflicting account, saying the airstrike hit the village of Zaidan south of
Abu Ghraib and flattened four houses, killing 45 people, including women, children and old people.

An Associated Press photo showed the body of a boy in the back of a pickup truck at the nearby Fallujah hospital and people there said he was a victim of the Zaydan airstrike. Other photos showed several wounded children being treated in the hospital.

Thamir al-Dulaimi, a doctor with the Fallujah Public Hospital, said 20 other civilians from the village were being treated, while a highway patrol officer said civilian cars were being used to bring the wounded to the hospital.

It's the same old song.

None so blind

Jellyfish Joe Biden's recent macaca moment reminded me of an amusing (in a black comedy sort of way) inicdent a few years back. I don't think the protagonist in the Barack Obama role in this story would mind my telling it, but I haven't had the chance to ask him so I'll change his name to Ezekiel. I forget the name of the Joe Biden character anyway so I'll call him Mike.

I was hired by a small city to a minority needs assessment study, and Ezekiel, who managed a social service agency, was appointed chair of the committee that oversaw my work. There were plenty of issues concerning the schools, the police, municipal hiring, etc., but we also paid attention to community attitudes and private behavior. People had been complaining that a local night club discriminated against black and Latino patrons, barring them for alleged dress code violations that were not enforced against white customers. So Ezekiel and I went to meet with the night club manager.

We sat with Mike in a booth in his club. Mike put his hand on Ezekiel's shoulder, and pronounced the magic incantation that summons inexorable doom. "I'm not racist at all." Ezekiel and I exchanged the subtle here-it-comes cringe. "I mean, I see you sitting here in a suit and tie, you just seem like a normal person. I don't even think of you as black."

"But I am black," Ezekiel sighed.

"I know, but I don't see you as black, I just see you as a normal person."

Ezekiel asked me to please explain to Mike what was wrong with his attitude, and I tried, believe me. I was constructive, I was patient, I tried to take it one step at a time. Mike was making a distinction between what he apparently regarded as normal black people, and normal people. He was implying that if Ezekiel was not wearing a necktie, his blackness would make him abnormal. He was presuming that black people in neckties were somehow deviant as black people, but achieved honorary whiteness. He was stripping Ezekiel of his blackness, making him into somebody he was not, in honor of his necktie.

None of these points made any sense to Mike. "But Ezekiel, I'm paying you a compliment. I'm sayin', I'm not racist. I just think of you as a normal person." He could not be swayed. He deserved credit for his open-mindedness, which we were twisting into a perverted blame.

For people like Mike, and Jellyfish Joe, racism is so deep in the structure of their mentality that they have no perspective from which to look at it, they cannot step off of it to examine it, it is foundational. There are many other common delusions that are as deep in the souls of many of us, of course. Perhaps we can mature as a society and bring more of them to the light of day.

Health Literacy for Medical Doctors

Long time readers may remember my friends Bert and Madge, a retired couple. Bert unfortunately has progressive dementia, and has had a stroke. He cannot dress or bathe himself, is incontinent of urine and feces, and has other difficulties with activities of daily living. He also has a fairly profound aphasia, in other words he has great difficulty finding words and formulating what he wishes to say.

A few weeks ago, Madge just could not take care of him any longer, and placed him in an assisted living facility. It's not a nursing home -- it provides only custodial care. In order for him to stay there, he must be able to walk and cooperate with his caregivers. At first, he adjusted well to the change and seemed quite happy. But then, just a few days after he moved in, he suddenly became unable to stand or walk, started drooling, and otherwise had severely impaired motor control. Madge and the facility staff were both afraid that he'd had another stroke, and would have to be moved to a nursing home.

But then Madge looked at his medication list and saw that he'd been prescribed Risperdal (risperidone), an anti-psychotic medication. He is definitely not psychotic! She also remembered that when he had been hospitalized a few months back, the hospitalist had given him Haldol, a similar drug, and that a friend of hers who happened to know about these things told her not to permit anyone to prescribe antipsychotics for him in the future.

So Madge took Bert to the doctor and asked him to look up the side effects of risperidone. Most doctors would probably get offended at that point and tell her where to put her side effects, but this doctor did it. Uh oh!. "Risperdal may impair judgment, thinking, or motor skills." Also, "The most common side effects include anxiety, uncontrolled movements, constipation, nausea, upset stomach, runny nose, rash, vision changes, saliva increase, abdominal pain, inability to control urination, weight gain." And there's one more thing:

FDA Alert [4/11/2005]: Increased Mortality in Patients with Dementia-Related Psychosis

FDA has determined that patients with dementia-related psychosis treated with atypical (second generation) antipsychotic medications are at an increased risk of death compared to placebo. Based on currently available data, FDA has requested that the package insert for Risperdal be revised to include a black box warning describing this risk and noting that this drug is not approved for this indication.

Don't you think it would be a good idea for doctors to look up the side effects and the indications before they prescribe the fucking drug, not afterwards? And why did he prescribe this "medication" in the first place? Bert often has what might be called delusions. For example, he often believes that the assisted living facility is a ship -- perhaps he's back reliving his days as a naval officer. So what? Who cares? Let him believe that. And that belief is not due to psychosis, and there is no reason to believe that an antipsychotic medication will suddenly make him believe that he's on dry land.

In fact, these medications were never approved for use in dementia, but they have been widely prescribed to demented people. The reason is that drug companies managed to convince doctors that it was a good idea. How many people who are in nursing homes, immobile, incontinent, uncommunicative, are that way because of the drugs the doctors have pumped into them? A lot. Here's something I wrote a few years back:

With the increasing availability of pharmacological agents for the treatment of more and more conditions, elders, who experience high rates of morbidity, have experienced marked increases in drug prescribing and exposure to pharmaceuticals.

There are many reasons why prescribing to elders is problematic. Elders have higher rates of adverse side effects from some drugs. Furthermore, since elders often experience multiple illnesses or symptoms, they are likely to have many prescriptions. In U.S. nursing homes, residents are prescribed an average of about 7 or 8 different medications. Studies have found that elders in general use an average of 2 to 6 prescription medications, and from 1 to 3.4 non-prescription medications. This situation presumably creates a high risk of adverse drug reactions and interactions.

This is bad. It must stop.

The good news? Two days after stopping the drug, Bert was walking just fine, alert, communicative (to the extent he was able) and in excellent spirits. He still thought he was on a ship. And maybe he is on a kind of voyage.

On the Road

I'm going to be away from your Internets until Monday evening, so probably no post until Tuesday. No, it's not a Superbowl party and a day long hangover, but personal business, relevant nevertheless to the subject matter of Stayin' Alive.

Remember to make the most of your day.

A hundred billion here, a hundred billion there . . .

pretty soon it adds up to real money. Of course I'm referring to The Emperor's new budget, which wants $245 billion to continue the program of world conquest while cutting $70 billion out of Medicare and Medicaid.

Obviously, if we just held on to the $245 billion all the rest of our problems would be a lot less daunting, but let's separate the questions for now. Yes, publicly financed health care is costing more and more and we're going to have to come up with some combination of more revenue and cost savings. As you know if you've been reading the best way to save money is to actually expand these programs to cover everybody, but that's dreamland for now. The Administration proposal includes raising premiums for wealthy Medicare beneficiaries, which seems to make sense; and cuts in reimbursement rates for providers, which is a more complicated story.

Continuing our discussion of why health care costs so much more in the U.S. than it does in civilized countries, one of the most important reasons is that inputs cost more: we pay more for drugs, medical devices, and physicians' salaries. We'll deal with the drugs and stuff later, but today let's talk about the docs with the horse farms. Docs in the UK make less than their U.S. counterparts, but more than docs on the continent, and the Brits tend to think it's too much, although presumably most British M.D.s don't agree. There are a couple of reasons why European physicians accept lower incomes than American bone sawyers. First, there is less economic inequality overall in Europe, so in general people don't feel they need immense incomes in order to feel appreciated. Higher education, including medical school, is heavily subsidized, so docs don't graduate with a quarter million dollars in debt. (That's the number one excuse I hear when I bring up the question of physicians' incomes with members of the profession.) That also means, of course, that Europeans don't need to make huge incomes in order to help pay for their own children's education.

Physicians have a lot of responsibility, obviously, and they work hard. They have to invest a lot in their training, and it's a very demanding road. They don't start making a substantial income until their late 20s, at best, while their business school counterparts are out there making the big bucks three or four years earlier. But the truth is the really big bucks are concentrated in certain specialties, whereas primary care physicians make the least, and are losing ground. Now that's a big problem. There is a looming shortage of primary care docs, even more so ones who specialize in geriatrics, and those are the kind we need the most, especially if we want to help control costs by better prevention.

So the issue is not to just squeeze providers, but to reconfigure reimbursement to better reward primary care physicians and the institutions where they practice; while ratcheting down the ridiculous overpayment of some specialists. That's going to be tough. Once people have something, they feel entitled, they feel as though they deserve it. But really, $300,000 a year is just too much.

More on Right Wing "Think" Tanks

A couple of posts back I said something snide about how right wing think tanks are not reality based. Actually, they're where failed academics go to get jobs that don't require them to do any actual research or make any sense. But you don't have to take my word for it. From The Guardian:

Scientists and economists have been offered $10,000 each by a lobby group funded by one of the world's largest oil companies to undermine a major climate change report due to be published today.

Letters sent by the American Enterprise Institute (AEI), an ExxonMobil-funded think tank with close links to the Bush administration, offered the payments for articles that emphasise the shortcomings of a report from the UN's Intergovernmental Panel on Climate Change (IPCC). . .

But AEI "experts" get tons of face time on TV news gabfests, NPR, and your local birdcage liner's op-ed page, while people who actually know what they are talking about and tell the truth -- real scientists and policy experts who do original research, write peer-reviewed articles, engage in honest debate at scientific conferences, and who look for answers out there in reality instead of in the checkbooks of their corporate sponsors -- do not.

The Experts Speak

The corporate media, as we all know, will report undeniable, observable individual facts, but is generally reluctant to assemble them into a coherent view of reality. When it comes to explaining what the hell is going on, their job is to channel the pronouncements of the powerful -- and furthermore, if powerful people happen to make an assertion that is contrary to some of those undeniable, observable individual facts, they generally don't bother to point it out.

So it's important that today we get two summaries of expert opinion that they can channel, which do try to assemble a coherent view of reality, and which are as far as I can tell reasonably non-tendentious, although I do have to exercise proper skepticism about the first one, which is the non-classified summary of the National Intelligence Estimate on Iraq. (We'll get to the second one, the Intergovernmental Panel on Climate Change report tomorrow, I hope.) Sure, the Directorate of National Intelligence must have faced pressure from President Cheney to fix the facts around the policy, but Mr. Negroponte, while he has shown himself unafraid to do evil, knows that the reality in Iraq is going to bite his ass very hard if he doesn't tell something at least vaguely like the truth here. So, shorter NIE:

• Prospects for the emergence of a viable Iraqi state are close to nil. The document does throw President Cheney a bone or two in the form of "If X happens things might get better," but it makes it pretty clear that X is not going to happen.
  
• Violence in Iraq will likely increase.
  
• Yes, Iran and Syria have some involvement in Iraq but that has little to do with the problems there.
  
• Iraq's neighbors all have interests and concerns in Iraq and the chaos there could easily widen into regional conflict.
  
• If the U.S. withdraws quickly, the level of violence will probably get worse faster, and it will take a few years for Iraq to sort itself out. On the other hand, if the U.S. doesn't withdraw, the same thing will happen.

Here's how it ends:

A number of identifiable internal security and political triggering events, including sustained mass sectarian killings, assassination of major religious and political leaders, and a complete Sunni defection from the government have the potential to convulse severely Iraq’s security environment. Should these events take place, they could spark an abrupt increase in communal and insurgent violence and shift Iraq’s trajectory from gradual decline to rapid deterioration with grave humanitarian, political, and security consequences. Three prospective security paths might then emerge:

• Chaos Leading to Partition. With a rapid deterioration in the capacity of Iraq’s central government to function, security services and other aspects of sovereignty would collapse. Resulting widespread fighting could produce de facto partition,dividing Iraq into three mutually antagonistic parts. Collapse of this magnitude would generate fierce violence for at least several years, ranging well beyond the time frame of this Estimate, before settling into a partially stable end-state.
  
• Emergence of a Shia Strongman. Instead of a disintegrating central government producing partition, a security implosion could lead Iraq’s potentially most powerful group, the Shia, to assert its latent strength.
  
• Anarchic Fragmentation of Power. The emergence of a checkered pattern of local control would present the greatest potential for instability, mixing extreme ethnosectarian violence with debilitating intra-group clashes.

So alright. What does this mean for policy? Pretty much what every sane person already knows: Iraq is a disaster that cannot be rescued by American warriors. There isn't even anybody for them to fight, except for everybody. The goal of U.S. policy now must be to contain the problems, to support -- and note that does not mean impose, or manage, or try to control -- some form of regional solution among the neighboring states that will avoid wider conflict. U.S. interests have already been irretrievably damaged by the insanity of invading Iraq in the first place. They cannot be recovered.

As for the people of Iraq, they are pretty well screwed too. I would say that after the conflict there has exhausted itself and some form of order appears, we will owe them big time, and I hope we will pay -- for real, competent, honest reconstruction this time, not an excuse for Halliburton and DynCorp to walk off with billions of taxpayers' money. But right now, that's just impossible.

Support our troops. Bring them home.

Rationing Rationally

One of the common objections we hear to single payer health care or other universal systems is that it will mean "rationing" of health care. To ration means "to supply, apportion, or distribute," and it's related to the word rational. Both are derived from the Latin word for "reason." So why is that bad?

People fear that it means they won't get services they need. They point to comparatively long waits for some elective procedures in Canada, and to the United Kingdom's National Health Service declining to provide certain procedures to people beyond a given age, or to pay for drug treatments that are approved for use in the United States.

Of course, we have rationing of health care right now in the U.S., but it's irrational rationing -- rationing by uninsurance. People with the right kind of insurance may get a heart transplant costing half a million dollars, whereas people with no insurance don't get basic care that can prevent heart failure. But is it wrong to set limits at all?

The UK has established an agency called the National Institute for Clinical and Health Excellence (NICE -- the "H" for health came letter and the old acronym is, well, nicer), which provides the National Health Service with guidance on what to pay for and what not to pay for. For example, here they recommend not giving memantine (brand name Nimenda) to people with mild or moderate Alzheimer's disease. This drug is approved and heavily marketed in the U.S. for just those people, so the drug companies are mad at NICE about this and other guidances.

And yes, in coming up with its recommendations, NICE takes cost into account as well as effectiveness. Measuring effectiveness is somewhat subjective, of course. Treatments can extend life, or relieve symptoms. Longer life can be of little value if people are in great pain, or severely disabled, or severely demented or even vegetative. So while there are methods for attempting to quantify the value of treatments, such as Quality Adjusted Life Years, public participation, openness, and political accountabilty are necessary, and NICE offers all of these. But the bottom line is that a day or a week or a month of life is not of infinite value after all. The money that might extend a very sick person's life could also feed a hungry child or nourish the souls of millions. Ultimately we must have a way of making these tradeoffs and saying that enough is enough.

So, there are many reasons why the UK and other rationally governed countries spend much less on health care than the U.S., but rationing, yes rationing, does contribute. Is this a terrible, immoral idea that our Culture of Life could not accept? What do you think?